My Orchiectomy Journey Part II

As I mentioned, I took a while to draft a letter supporting my position. I said:

Dr. Xx, thank you for the thoughtful reply. I do appreciate your caution in taking on such a permanent procedure.

I feel that I may not have presented myself in the best light at our recent appointment. As you know, I began this journey in April, 2021, over two years ago. At that time I began on the anti-androgen Spironolactone. I underwent the lengthy process of getting Cardiologist clearance and I was finally able to begin estrogen therapy in October, 2021. I have seen Dr. Yy on a regular basis since then

I have put together a great team of doctors to help me through this phase of my life, Dr. Yy, Endocrinology, Dr. Zz, Internal Medicine, Dr. Ww, Cardiology, you as Surgeon, Dr. Hh, Dermatology to help me recover my hair, Dr. Pp, Psychiatry, and Dr. Tt, Psychology. They have all been incredibly compassionate and supportive.

I have been consistent and devoted to my transition. At my last appointment with Dr. Yy in April, I brought up my interest in the next step of the medical transition, an orchiectomy. We discussed my motivations, including the medical benefits and the mental health benefits, especially the easing of dysphoria. She expressed her support, and I contacted your office for an appointment.

You have expressed your personal guidelines that patients should have 12 months of a “real life test”. I previously sent you some pages from the WPATH Standards of Care showing that they did not recommend a real life test for orchiectomies, just a year of hormone therapy. That was in fact from Version 7 of the SoC. Version 8 has reduced the recommendation to 6 months of hormones, and seems to have removed the real life test completely and several articles cited put doubt on the value of the real life test.

I note that SoC 5.6 recommends 6 months of hormone therapy before a gonadectomy.

In any event I would like to explain my transition and motivations. Your main concern seems to be the possibility of regret following a permanent procedure, and that a real life test will demonstrate the patient’s commitment and seriousness. I can understand the concern that younger patients may not be fully aware of the reality of their transition, and other patients may be struggling with a mental illness manifesting itself as gender dysphoria.

I am well aware of the permanence of the procedure. Concerns about fertility are not an issue. I’ve had my children and have no interest or need for more. Sexual desire as a male hasn’t been an issue for years. I acknowledge that there may be a need in the future for Testosterone supplementation and I expect to maintain my relationship with Dr. Yy. In fact I discussed this issue with Dr. Yy this week and she told me that very few of her Trans patients need Testosterone supplements.

I can begin by pointing out that I am 58 years old. I am not a 19 year old diving into this with abandon. I have known that I was a woman since the age of 9. That feeling has never wavered. I suppressed and denied it for decades, as many Trans people do, but there has never been a time I didn’t feel this way. SoC 5.3a recommends marked and sustained gender incongruence and I believe I fit this criterion with flying colors. I have also been in therapy for over a decade. My therapist is fully supportive of the diagnosis and supports the procedure.

SoC 5.4 also addresses the issue of surgery without social transition, noting that in some cases it may not be a feasible option and that this should not be a bar to treatment.

“Everyone’s transition is different” is a common statement in the community and I feel mine is unique. The first issue is that I am 6 foot 2 inches tall and in my life have weighed over 400 pounds. This presents a big impediment to a successful social transition, but I think I can overcome that eventually. The biggest impediment to my transition at the current time is familial and financial.

Unlike that 19 year old, I have a wife and 2 grown children. You’ve met my wife and she is supportive, but has strong feelings about the effect of my transition on the children. I don’t agree with her concerns, but I respect her wishes. In addition, I am essentially a small family business owner in a partnership with my father. My livelihood relies on personal relationships with my clients; I have no question that many clients would leave should I transition. Such a loss would affect not only myself and my family, but also the other people associated with the business including my father and our employees. I feel a heavy responsibility to my family and the possibility of harming them and their lives is a scary prospect. I am working on expanding and re-focusing the business to be more LGBT+ focused. Until then, I have some serious and practical impediments to full transition.

Two other examples of my moving my transition forward are that for the last two years, I have attended a bi-monthly support group, in my female presentation. They know me only as Jennifer. As part of that group I met with [Senior State Attorney General Officer], to discuss gender inclusivity in state legislation. The second example is that I was a panelist in an LGBT Patient Perspective Panel with Doctors from [Hospital], mostly attendings and residents from the Emergency Medicine Department. I helped provide a Trans patient’s perspective on a visit to the ER and how they could improve their interactions with Trans patients.

You also seemed concerned that I would not be satisfied by the results cosmetically. That is not the primary objective, but it is a welcome effect. The removal of the testes will reduce the size of the area and will help the appearance, but the main objective is to get rid of them to ease my discomfort. They feel wrong, they do not belong there. Having them gone will improve my mental health.

I have been focused on moving my transition forward and am frustrated by the slowness of things. I believe an orchiectomy is a positive step I can take that would not be obvious to the outside world. It would allow me to move forward and take another step without harming my family.

So, I didn’t hear anything from him until the appointment. My anxiety was through the roof for days leading up to today. My wife couldn’t come to the appointment due to work commitments, so I went alone.

We started out with pleasantries and he said he hoped I understood that his message was supportive and I said I hoped I hadn’t sounded obnoxious in my letter.

He then opened by saying he was on board with the procedure and he thinks it will be a positive thing for me. My relief was palpable. We then talked for a good half an hour about the procedure, the scheduling and so on. He is currently scheduling surgery 4 weeks out, but I still need to get a short letter from my therapist, that she has already agreed to provide and a note from the cardiologist. He has to get approval from the insurance company, which he says is routine. I hope so.

I have now spoken to his office and we have a surgery date. I am incredibly excited.

I have mixed feelings about this experience. I understand his concern about doing permanent procedures that a patient might regret in the future. On the other hand, I object to his outdated standards that lag behind the current standards of care.

The Standards of Care are evolving positively. The old Harry Benjamin Standards of Care were first published in 1975 and amended several times, up until 2001. It had a very paternalistic attitude and was proscriptive. It had strict requirements to qualify as “transsexual” which was amended to “transgender” in later versions. These included crossdressing and real life experience. So, a patient had to really take potentially dangerous steps before getting treatment.

Those standards were supplanted by the WPATH Standards of Care and as I described above, they are much more patient focused. They now believe the patient and don’t make the patient jump through hoops to prove themselves.

My urologist still isn’t so enlightened. He says he is half way between the WPATH SoC 7 and 8. I think he is still being paternalistic, but he is improving. He doesn’t like the concept of “informed consent” where the patient asks for something, signs a waiver, and gets what they want.

I hope my experience has helped soften his position a little.

Having doctors in my family, I know very well how arrogant and paternalistic some doctors can be. They know best what is good for a patient. To some extent that is true, but they need to understand that the patient is the one in charge of their own lives. I don’t know my urologist’s age, but I am at least 15 years older than him. I know what I want and what I need in my transition. He doesn’t.

A doctor is trained to diagnose physical problems and provide treatment. Outside of psychiatrists, they are not trained in mental health. In my case a urologist is implementing a course of treatment requested by the patient. He hasn’t been involved in the diagnosis of the condition and doesn’t have a history with the patient. When a patient who has been working with a team of doctors and has been following a plan with those doctors, a new doctor should not step in with a new requirement and block the patient’s progress.

At the most, I would expect a doctor in this situation would want a letter from the Endocrinologist and Therapist. They should not be introducing new obstacles or setting up their own criteria for the procedure.

While his attitude is paternalistic, I can understand some of his caution. He is being asked to remove healthy tissue. There is no disease or injury to the testicles that would otherwise justify their removal. That idea goes against many doctors’ ethical mindset. He also has concerns about liability. There is not just the usual risk of malpractice, but also regret from that patient who then may try to turn around and blame the doctor. Again, letters from other doctors and waivers should cover that concern.

To conclude, I have my surgery date and I am looking forward to being free of the offending body parts. I hope it all goes well and I will report back after.