Right now the gender community is about where the gay community was around the time of Stonewall. At that time, homosexuality was formally classified as a mental illness, and there were clinics where thousands of people were treated with electroshock therapy to be "cured" of being homosexuals. Internalized homophobia was so embedded in the gay culture that many people couldn't even see it.

There are those who say that the DSM-IV, the Standards of Care, and the present network of gender clinics and therapists are a foundation for much the same kind of smothering atmosphere of self-hatred. Certainly it is true at some clinics that the only way to get corrective surgery is to prove that you hate your current life. Then the let you pay for the privilege of having your body mutilated, and they send you out the door with your self-hatred intact.

Is it a body modification, or is it mutilation? That question has come up in other contexts, including piercing, tattooing, and cutting, and it really comes down to the reasons why you do what you do. If a transsexual woman hates her penis, and has surgery, how do you classify it?

The most common surgical technique is penile inversion, sometimes including a skin graft to provide additional depth. With a good surgeon, there is about an 80% chance of retaining sexual sensitivity--meaning that there is a 20% chance that you won't. An inverted penis does not self-lubricate, and it does not have any sort of immune system barrier.

I am a strong believer in informed consent, and I have nothing against any person having corrective surgery, if it is their choice to do so. But what does informed consent mean? I haven't been to any of the conferences where surgeons present a discussion of their work, but I have seen (and have copies of) the literature that two of the top surgeons in the US send to prospective clients. Everything focuses on the surgery itself. And that's where my problems with surgery begin.

Yes, at a cosmetic level, the surgery is very effective. It is my understanding that even a doctor who does not know what sie is looking at may not be able to tell the difference between a genetic woman and a post-op. But the surgery should not be about cosmetics; it should be about living a better life. Is a cosmetically correct vagina a reasonable trade-off for loss of sexual sensitivity? That is an individual decision, and I do believe that most people seeking surgery are aware of that risk.

What about the risk of complications? They can be very serious, including tissue death from swelling and sutures, vaginal-rectal fistulas, and collapsed or prolapsed vaginas. Part of the risk here lies in specific surgical techniques; each surgeon works differently, and their experience and skill do vary. It is possible to find out exactly what techniques each surgeon uses, but getting information about complication rates and types is nearly impossible, unless I've missed out on a major source of information. Informed consent? How do you find out if your surgeon is a butcher?

And all of this is directly related to surgery. What is life like after surgery? Some people have good lives. Some people have miserable lives, but would never admit it. Some people scream about being mutilated for the rest of their lives. Figuring out accurately which category a person fits into isn't always easy. Figuring out the numbers about who is really happy is a whole lot harder. There are no usable statistics, and anecdotal evidence can only lead you astray. Informed consent?

I recently heard something which I found truly horrifying. I was told--by a gender activist, who is a non-op, but who has been around for a long time, and certainly has access to more data than most of us--that it is common for post-op transsexual women to bleed during intercourse. (No natural lubrication, remember?) I've had no other confirmation of this, but it is also the kind of thing that would get hushed up as a dirty little secret. With no sharing of this kind of information, how do you find out what life is really like after surgery? Informed consent?

This same person told me about a study of HIV infection in prostitutes in Italy. The genetic women had an infection rate that was around 20% to 30%. (I don't remember the exact number.) Horrifying? Yes. Was that the worst finding of the study? No. The post-op transsexual prostitutes had an HIV infection rate of 85%. That's eighty-five percent, no typos. Why? No natural immune barrier, no natural lubrication, and a tendency to bleed if whatever lubrication is available is insufficient, and you are beginning to get closer to an explanation. Informed consent? Where do you ever hear about things like this? I've been out for three years, and this is the first I've heard of it. Now, how do I try for an independent confirmation?

BTW, around a third of the transsexual community is involved in prostitution. The highly functional transsexuals you see on the Internet are not exactly typical. (And again, try to get a confirmation on this, or even a single study with any kind of believable statistical foundation.) But I have had my gender therapist confirm that I am an exception in so many ways--ability to function in life, self-acceptance, openness--that I cannot be taken as representative of the community. I'll never be the TS poster child.

Now, let's get back to that self-hatred business.

DSM-IV classifies this as a disorder. To be a disorder, there must be a diminished ability to function normally in life. Well, I do have some news on that front; I function quite well, thank you very much, and so do a lot of other transgendered people. The "disorder"--dysfunction, whatever you want to call it--comes from having to stuff your identity for a huge portion of your life. The "disorder" is due to the closet, and keep in mind that most of us go into the closet at around age five.

DSM-IV classifies this as a disorder based on the opinion of one person. He has no studies to back up his analysis of who we are, or how we function, or why. Now would someone kindly explain to me how this is different from the inclusion of homosexuality as a mental illness, up through 1973? Homosexuality was removed from a reprint of DSM-II in 1973 because it was no longer possible to sustain the myth that homosexuality diminished anyone's ability to function in life.

It is time for the gender community to fight for declassification, and that struggle has begun. But it's going to be hard, because a significant part of the community will be fighting against it. Yes, you read this correctly. There are too many people who don't want to see the system changed because they think they know how to work it, and they are afraid of what might replace it. All they care about is getting what they want.

At this point it's time to drag in the Standards of Care. These standards were put in place in 1979, and have been revised three or four times since then. The standards basically do two things. One is to set ethical standards for medical and mental health care providers who work with the gender community. This part is important, because there have been and continue to be abuses. The other function is to set the standards that must be met before treatment is "given." This is where the problems start.

In order to get access to hormone therapy, one must see a qualified therapist for three months, and get that therapist to make the recommendation. Basically, you have to prove that you are transgendered, that you are serious about changing your gender role, that you are aware of the risks and the irreversible nature of changes from hormones, and that you are not otherwise psychotic. This is the minimum.

Not every therapist or clinic treats this as a minimum. There is a practice called "gatekeeping," in which a therapist--or worse, a review committee--withholds approval while the candidate jumps through a never-ending series of hoops. There are clinics which require that a person transition first, and live full-time for one month, before getting approval for hormones. This, in spite of the fact that transition is far riskier, with farther reaching immediate effects than hormones. This, in spite of the easily verifiable fact that many of us could not transition successfully without having been on hormones for several months.

I know, from my own abuse recovery work, that the only way that a psychotherapist can work to help a person is to be a guide and companion on a difficult journey. What the Standards of Care has done is to create an adversarial relationship. It is transsexual versus therapist. People learn what therapists want to hear, and don't tell them anything else. For too many of us, there is no healing of wounds by this therapy, only the creation of new barriers. Informed consent? How do you get information through this wall? Is it consent when your mind is made up before you question any of the evidence?

Even so, the gender therapists and clinics are a far friendlier environment than that which a transgendered person encounters going to a therapist who has no experience with transgender issues. These people are all too often inclined to "cure" something which (1) is not really a disorder and (2) cannot be cured. These people may endure years of frustration to get what the Standards of Care promise (more or less) in three months. And there is always, always, always, the fear that the therapist--any therapist, even one who works with the community--will deny that we are transsexuals, and thus take away a massive part of our identity.

There is virtually no trust between the gender community and the mental health community. In no other environment have I ever seen the word "therapist" split into two words: "the rapist."

So far we've only talked about hormones. The requirements for surgery in the Standards of Care are much tougher. One year on hormones. One year of living full-time in the new gender role. Two recommendations from therapists, one of whom must be a Ph.D., and one of whom must have had an extended clinical relationship with the candidate. The candidate must prove the she (far more M2F's reach this point than F2M's) has wanted to get rid of her genitals for a continuous period of two years.

In other words, you have to prove that you hate your body, or at least part of it. It is a form of self-hatred, and fixing the body doesn't necessarily fix the self-hatred. Because of the walls between transsexuals and therapists, there isn't a chance for many people even to become aware of their rage. Because the Standards of Care has created an adversarial system, there is virtually no way for a therapist to reach through those walls. One of the things that truly enrages me is that this amounts to a psychiatric endorsement of self-hatred.

Gatekeeping occurs at this stage, too. Who is to judge whether the one-year "real-life test" of living in the new gender role is successful? Not the transsexual who is living it. It is up to two therapists, this time, and possibly also a review committee.

There are more subtle traps, too. Spironolactone, a blood pressure medication which has a side effect of suppressing testosterone, is given to many people to aid the effectiveness of estrogen. Because of its direct effect on blood pressure, it can have fatal side effects. Because it is a diuretic, it can cause dangerous potassium buildup. It can have serious side-effects on the central nervous system, including mimicking bi-polar disorder. Any of these side-effects, if not recognized as side-effects of spironolactone, can be used to permanently block a candidate from surgery. Who makes this decision? Not the transsexual. And not the endocrinologist who is monitoring hormone levels, either. It is the therapist, the transsexual's adversary, who now feels a professional obligation to fulfill that adversarial role and deny surgery, in the client's best interests.

Informed consent? Who is even thinking about the issues at this point? The transsexual, who has to bull her way through a system that was created to support her and is all too often used against her? The therapist, who can't get through the walls created by the adversarial relationship? The surgeon, who really doesn't understand anything except the surgery?

Before anyone starts to scream that this is a one-sided view, I acknowledge that I have outlined a lot of worst-case scenarios here. The problems are two-fold: First, it frequently does work this way. Second, these are the stories that circulate within the community, out of proportion to the success stories. The process starts with therapists, and virtually everyone I've ever talked to had fear in her heart, walking into that first appointment. For some, that fear is more than justified.

All of this to cure a disorder that is not a disorder.

This system creates myriad other problems within the gender community. The community is often split, crossdressers against transsexuals. The assumption is that their needs are so different that neither one can possibly understand the other. In fact, we all seek a workable solution to fundamentally the same single issue: that the gender of our bodies does not match the gender of our minds. It is a caste system, with transsexuals placing themselves above the crossdressers. (Every time I hear someone say, "I'm just a crossdresser," I want to scream.)

Because of this split, it is more difficult for people to obtain both the information and the diversity of experience that is necessary to understand the issues, and for anyone to come to a personal solution that is right for that person. Instead, there is tremendous peer pressure to be a transsexual, and to have surgery at the earliest possible time. If that costs you your marriage, or your children, or your job, well, that is the price you have to pay for being a transsexual. Yes, you really hear these things.

Informed consent? How can you learn enough to be informed? How do you resist the peer pressure enough to know that you are making up your own mind, and not just following in someone else's footsteps? How do you know that the person egging you on is not secretly horrified by the mess she's made of her life, and needs you to make the same decision that she did, just to validate her own decision? Informed consent in this maelstrom?

Self-hatred and regrets? Let me tell you a true story, about a transsexual who had surgery. She was seriously diabetic at the time of her surgery, and should never have climbed onto the operating table. As a diabetic, she has to be involved in her own day-to-day health care, and should have known this. But she did it anyway.

There were complications, and possibly medical negligence. Whatever the case, there was tissue death from swelling and sutures, and from the poor blood circulation typical of diabetics. In order to demonstrate tissue death, she gave herself cigarette burns on her genitals.

I am not making this up. This is taken from court records from the malpractice suit. And the only records I have read are those of the plaintiff.

Only now--only now--can I begin to introduce you to soc.support.transgendered, the only newsgroup on Usenet that's worth bothering with for transgender issues of any kind, unless you're interested in personals or continual flame wars. Even s.s.tg can be extremely dangerous to the unaware, and sometimes even to those of us who have been around for a while.

Earlier this year we weathered a flame war that makes anything I've seen in other newsgroups look like a picnic in the park. It was driven by a small handful of post-ops who were deliberately trying to split and destroy the community. All the language of the flaming was based on deeply entrenched transphobia. The people who drove the worst of the flames attacked anyone who was not committed to surgery as a man and a transvestite--someone who dresses as a woman for sexual pleasure. These attacks violate the most basic courtesies of the gender community, and the flamers knew and counted on this. They were also filled with sexual innuendo as well as accusations, and again, this was done with the intent of hurting people. This went on for months, not only in s.s.tg but with stalking by email, some of it even traceable to posts in other newsgroups. The war also spilled over into alt.config, as the separatists tried to create their own newsgroup.

The residue of that flame war is still with us, in wounds, in the good people driven out of the community, in the people who continue to push the same arguments, although the most vicious of the flamers has moved on. One is still with us, and she still browbeats us with the statement that a "real transsexual" will do anything to obtain surgery at any price. As I understand it, this person is still living as a man, years after her surgery, and is afraid to go out as a woman. As far as I'm concerned, she has paid a greater price for her surgery than another woman I've heard about, who died of a blood clot the day after her operation. (Clotting is one side-effect of the high estrogen dosages we take until surgery or castration.)

There are other hazards there, too. Other post-ops come through who still haven't dealt with their self-hate. There is the outspoken long-term activist who flames anyone who crosses her. There are the people who think that the community has done nothing for them, and that they owe nothing to anyone or anything in return. I often find myself in a difficult position there, with compassion towards some, rage at others, and a decreasing patience with all the short-sightedness, the labeling, and the cross-fire.

To be honest, the community has achieved a lot in terms of awareness and acceptance, and the ethical conduct side of the Standards of Care has been a blessing. In some areas, there is even progress in legal rights, but we still have a long ways to go in that area. But so many people are so wrapped up in their own issues that they can't see any of this, either progress or problems.

And then there's the closet. It is hard to come out of this particular closet, and before anyone can begin to make reasoned decisions they must deal with some combination of rage, self-hate, shame, fear, and self-doubt. People who begin their coming out process in s.s.tg are all too often blown about in the wind, if not in actual flames. Although some of us stay there to offer the help that we can, it is in fact one of the most dangerous places I know of for coming out. I have heard of people who have looked at that newsgroup, and decided not to transition because they did not want to be like those people.

Yes, Usenet can be a dangerous place, but I've found very few newsgroups that engage in this kind of cannibalism.

Informed consent?

With a bit of awareness, however, s.s.tg is a place where one can learn about gender politics, and the need for changes and reform, as well as for a continual push towards acceptance in the outer world. For all the flames that go through there, you will also see tremendous pain and heartbreak, and there are many success stories as well. It is for those people that I stay there, except for the times when I, too, can't deal with it all any more. Subtracting out the hazards of Usenet, it is a microcosm of the gender community as a whole.

It is against this backdrop of politics, struggle, pain, and destruction that one must read about the gender community. I have not read Transsexual Empire by Janice Raymond, but it is on my reading list these days. I have read one extremely bitter attack against that book, but that same letter was filled with the same self-hatred directed against the world that I have seen too much of already in the gender community. I would suggest keeping an open mind while reading this book, along with the awareness that it has created controversy. But then, it is a time and a place where strong controversy is needed to bring the problems of the community to some resolution.

There is other reading that I would suggest. I would start with Kate Bornstein's Gender Outlaw, which is both her personal journey and her political stand on community issues. I would read some biographies, starting with Conundrum by Jan Morris, which is a thoroughly middle-class experience. You might also read My Story by Caroline Cossey, which is full of her pain, her rejections by the British legal community and by her fiancees, her abuse at the hands of the British tabloids, as well as her experience working as an exotic dancer to pay for her transformation. There is Second Serve by Renee Richards, a book which has driven at least one transsexual back into the closet. I have not read Transgender Warriors, yet, although it is next after Stone Butch Blues (both by Leslie Feinberg). For a very different perspective, one that shows how to live a good and decent life without all this rubbish, there is The Spirit and the Flesh, by Walter Williams.

Welcome to my world, if I haven't scared you away by now.

I am moving now towards gender activism, and this is the community that I will work for. It will not be fun, with flames and bullets coming from behind, and apathy and loathing ahead. But I am going to leave this community in better shape than I found it.

Yes, bullets. In at least one case, real ones. Activists are not always appreciated by those whom they represent.