Jennifer George

I finally broke through some gatekeeping.

As I approach my 2d anniversary of hrt, I felt that the next step I would like to take on my journey would be an orchiectomy. I’ve wanted them gone for as long as I can remember. They never felt right.

I haven’t socially transitioned yet for a myriad of reasons, but this is something I can do to further my transition without coming out to the world.

I talked with my therapist and she supported the idea. At my next appointment with my endo, I talked to her and she also supported the idea. I spoke to my wife, I had mentioned the idea probably a year ago, and told her I was now ready. She has some reservations, mainly the usual risks of surgery. She is supportive, but still doesn’t fully understand the reality of being trans. She said she wants me to be happy and agreed to go with me to see the urologist.

I am a patient with the Gender Clinic at a large University Hospital near me. They are great, but there is just one urologist in the clinic. I had seen him when I began my journey for the possibility of Lupron treatments. So I made an appointment with him. I had to wait 6 weeks.

My wife and I went to the appointment. The result of the appointment was that he wasn’t sure about doing the procedure. I hadn’t socially transitioned and he usually looked for a full year of living in your correct gender. He referenced the WPATH Standards of Care and their recommendations for this surgery.

Also, my wife was not enthusiastic. She was supportive, but she worries about the risks. So we ended the appointment, agreeing to meet again in a month. He was going to talk to my therapist and psychiatrist. I walked out to my car and broke down and had a good cry.

Over the next few days I thought about the appointment and realized I had been totally unprepared to argue my case. I had thought that it was just a matter of expressing an interest in the procedure and being an established gender clinic patient. I didn’t expect the gatekeeping.

I decided to send the doctor a note through the clinic’s patient portal. Immediately after the appointment, I sent the following:

Dr. Xxxxxx, thank you for meeting us today. I appreciate your time and your concern and cautious approach. I just wanted to add to our discussion concerning the WPATH Standards of Care. They do not call for a year of living fully transitioned for orchiectomies. They do recommend that for vaginoplasty, but not orchiectomy.

I’ve attached the relevant pages if you are interested.

I will see you in August.

He replied:

Thank you for continuing a thoughtful discussion with me. I appreciate your point, but will also point you to the following paragraphs (see copied below, my emphasis), which has led me think carefully about your situation. While “technically” not part of orchiectomy criteria, it has become part of my general criteria, which I think you would agree is reasonable given the permanency of the procedure. I try to appreciate the patient perspective always when making medical decisions and I understand this is something you have been working on for many years. I appreciate your courage with your transition as it is often more complicated than what you want alone. Let's continue the discussion. Best regards, Xxxxx

The criterion noted above for some types of genital surgeries—i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity—is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. As noted in section VII, the social aspects of changing one’s gender role are usually challenging—often more so than the physical aspects.

Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation

The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).

Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable.

I was unsure about how to interpret this reply, was this a positive position or not? I was not encouraged and wanted to say more, so I took a few days to draft a reply. It is too long to add here, so I will post it as another blog.

To be Continued…….