Reader

Below is our draft of an illegal harms risk assessment for our Mastodon service. I am publishing this in its current form as a means to share our approach to this activity. This document is not final and is subject to change, but it may be helpful in considering your own approach to assessing your service.

Preamble

Tŵt Cymru / Toot Wales (“Tŵt”) operates a small Mastodon service “toot.wales” that allows persons to request permission to create hosted accounts on the service (subject to our terms of service and account approval process) and/or create hosted accounts without approval for post priori account review; and to then publish text and media to public and private feeds. The service further allows approved users to find and follow content from a wide variety of world wide web sources, predominantly using an Internet protocol “ActivityPub” that allows third-party services using the same protocol to interoperably exchange messages with our service.

Of particular note, there are no “virality” mechanisms that would increase the risk of harm to a large number of users, as the service is predominantly user-configured chronological feeds. There are a small number of recommendation algorithms that are curated by our moderation staff and take into account all local and third-party user and domain “limits” and “suspensions”, service settings which partially or wholly block access to accounts and domains. In short, while Tŵt is a social media service, it is extremely user-centred and does not enable or facilitate viral marketing or reach.

The Tŵt service is therefore a user-to-user service, hosted in the United Kingdom with its primary audience being United Kingdom residents (“Wales and the Welsh, at home and abroad”).

The service is administered and moderated by volunteer staff who take actions on actors, behaviour, and content subject to service policies and process manuals, which are available as listed in the table below.

The service is operated and administered by the New York tax-exempt charitable incorporation “Toot Wales Inc.” with the EIN 83-4296652.

Key information

The service to which the risk assessment relates	https://toot.wales
Service size	11,226 registered accounts
The named person responsible for the risk assessment	Jaz-Michael King
The findings of this risk assessment have been reported and recorded through appropriate governance channels	This document will be made available as required and appropriate
Date of this risk assessment	February 17th, 2025
Next scheduled review date	March 1, 2026

Content	Risk factors	Conclusion	Rationale	Measures
Terrorism	1a, 4a, 5,b, 5e, 7b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting. In addition, the service follows alerts issued by IFTAS from the SW-ISAC account (https://mastodon.iftas.org/@sw_isac), which recommends specific sources of Advanced Persistent Threat and Terrorism and Violent Extremist Content for blocking.	None
Child Sexual Exploitation and Abuse (CSEA): Grooming	1a, 2, 3a, 4a, 5b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The service prohibits user accounts created by persons under the age of 18, and we are unaware of any accounts that are operated by or for a person under the age of 18. In addition, the service follows alerts issued by IFTAS from the SW-ISAC account (https://mastodon.iftas.org/@sw_isac), which recommends specific sources of CSEA and CSAM for blocking.	None
Child Sexual Exploitation and Abuse (CSEA): Images	1a, 2, 5b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service. The service uses industry-standard hash and match technology to review media files stored on the service to identify images or video of child abuse and/or sexual exploitation, and to date no media has resulted in a positive match. In addition, the service follows alerts issued by IFTAS from the SW-ISAC account (https://mastodon.iftas.org/@sw_isac), which recommends specific sources of CSEA and CSAM for blocking.	None
Child Sexual Exploitation and Abuse (CSEA): URLs	7b	Low	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is low. The content is prohibited by our terms of service. Over the past six years, two instances of URLs purporting to be links to third-party destinations where CSEA may be available were removed from the service. As we have no access to a database or directory of CSEA URLs, we respond to user-generated reports and/or moderator review to remove this content reactively. If such a database were available, we would implement a filter to disallow these URls from appearing on the service.	None
Encouraging or assisting suicide	1a, 5e, 5g, 7b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Hate	1a, 3a, 5e	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting. Further, the service makes use of several databases and lists of services that are known to allow this content, and we routinely defederate (disconnect and block access to and from) such services. At time of Risk Assessment the service blocks 969 domains.	None
Harassment, stalking, threats and abuse	1a, 3a, 4a, 5b, 5e, 5g	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting. Further, the service makes use of several databases and lists of services that are known to allow this content, and we routinely defederate (disconnect and block access to and from) such services. At time of Risk Assessment the service blocks 969 domains.	None
Controlling or coercive behaviour	1a, 4a, 5b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting. Further, the service makes use of several databases and lists of services that are known to allow this content, and we routinely defederate (disconnect and block access to and from) such services. At time of Risk Assessment the service blocks 969 domains.	None
Drugs and psychoactive substances	1a, 3a, 4a, 5b, 5e, 7b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Firearms, knives or other weapons	1a	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Human trafficking	1a, 3a, 5e	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Unlawful immigration	1a, 3a, 5e	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Sexual exploitation of adults	1a, 3a	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Extreme pornography	1a, 5e	Low	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is low. The content is prohibited by our terms of service, and our proactive and reactive content moderation processes severely limit the accidental availability of such content. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Intimate image abuse	1a, 5b, 5g	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and our proactive and reactive content moderation processes severely limit the accidental availability of such content. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting. The service hashes and matches all images and video sent to the service and compares it to industry standard hash databases, and no instance of CSAM has ever been flagged as a match or a near match, further limiting intimate image abuse (as related to minors).	None
Proceeds of crime	1a, 3a	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Fraud and financial offences	1a, 3a, 4a, 5b, 7b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Foreign interference	1a, 3a, 4a, 5e, 5g, 7b	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Further, the service makes use of several databases and lists of federated services that are known to allow this content, and we routinely defederate (disconnect and block access to and from) such services. At time of Risk Assessment the service blocks 969 domains. In addition, the service follows alerts issued by IFTAS from the SW-ISAC account, which recommends specific sources for blocking.	None
Animal cruelty	1a, 5e	Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. The content is prohibited by our terms of service, and in six years of operation no such content has been published by our hosted accounts. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.	None
Other illegal content		Negligible	The likelihood of a visitor encountering this content, or the service being used to facilitate or commit this offence, is negligible. All harms as described in https://connect.iftas.org/library/iftas-documentation/shared-vocabulary-labels/ are disallowed and/or subject to moderator action. Where such content may be encountered from third-party web sites that can be viewed from within the service, we routinely block access to such third-party sources when notified by user reporting.

Duties and approach

Duty	Toot Wales Approach
To prevent individuals from encountering priority illegal content by means of the service	Our preventive measures include the use of IFTAS’ Do-Not-Interact and IFTAS’ “CARIAD” databases, a service that monitors bad actor services and recommends defederation. A range of IP and domain blocks are applied at the service level using industry standard IP and domain reputation metrics. The service uses industry-standard hash and match technology to review media files stored on the service to identify images or video of child abuse and/or sexual exploitation.
To effectively mitigate and manage the risk of the service being used for the commission or facilitation of a priority offence	New user accounts are reviewed, including but not limited to the IP address (geolocation and IP reputation score where appropriate), email domain, and “reason for joining”.
To effectively mitigate and manage the risks of harm to individuals	No additional actions planned
To minimise the length of time for which any priority illegal content is present	For the time period Mar 1, 2024 through Feb 15, 2025, our moderation team have responded to a total of: 58 service-hosted account reports (reports about our hosted users), resulting in 46 user account suspensions (predominantly for spam) in a timely fashion concordant with our Moderator Content and Account Action Process Manual. 69 reports received for third-party accounts (reports about accounts hosted by third-parties) visible from our service, 39 of which resulted in moderator action. 1,924 third-party accounts suspended for violations of our policies after moderator review. During the time period specified, we received ten appeals for our moderator actions, two of which were upheld, eight rejected. Of the eight rejected, the outcomes were six suspensions, one freeze, one limit. Our severity approach ranks actors, behaviour and content into one of three tiers with a corresponding target time-to-action: Severity: Takedown within 60 minutes Severity: Takedown within 24 hours Severity: Warning within 24 hours Regardless, three strikes leads to takedown and/or account suspension. In general, we follow the harms classifications and definitions found at https://connect.iftas.org/library/iftas-documentation/shared-vocabulary-labels/ unless local law preempts or further defines such harms.
Where the provider is alerted by a person to the presence of any illegal content, or becomes aware of it in any other way, swiftly take down such content	As above.
To have in place regulatory compliance and risk management arrangements	This document
Design of functionalities, algorithms and other features	We prohibit the use of certain hashtags, removing content bearing these hashtags from our recommendation engine. Our domain blocks remove any associated listings from our “trending” or recommended content function. Our account suspensions in turn suppress listings from the account recommendation function.
Policies on terms of use	Code of Conduct Content Guidance Automated and Bot Content Policy Federation Policy News Media Publishing Policy Spam and Inauthentic Activity Verified Accounts
Policies on user access to the service or to particular content present on the service, including blocking users from accessing the service or particular content	https://blogs.toot.wales/toot/twt-community-code-of-conduct
Content moderation, including taking down content	https://blogs.toot.wales/toot/twt-community-code-of-conduct
Functionalities allowing users to control the content they encounter	The service provides content in several contexts: a personalised chronological (“home”) timeline that will only show content the user has elected to “follow” either by account or by topic; a public timeline of locally-hosted user-generated content; a public timeline of third-party user-generated content that is not otherwise prohibited or removed by our content reviewers; Notifications; Conversations Account users can use the following features to control the content they encounter: Filtering posts (drop or hide) by keyword or phrase These filters can be applied to each of the above contexts individually Hiding “boosts” (allowing content from a followed account, but not allowing that followed account’s reposts or boosts) Account muting Account blocking Domain (entire server) blocking Reporting harmful content to our staff Full technical specifications for these options is available at https://docs.joinmastodon.org/user/moderating/
User support measures	Users can message the staff account (teamtoot) or email our help desk help@toot.wales
Staff policies and practices	All staff sign and agree to a Moderator Agreement and Code of Conduct. All staff are trained on and are directed by the Toot Wales Content and Account Action Process Manual. All staff undergo annual safeguarding training.
To include provisions in the terms of service specifying how individuals are to be protected from illegal content	https://blogs.toot.wales/toot/twt-community-code-of-conduct
A duty to apply the provisions of the terms of service consistently	As above
A duty to include provisions in the terms of service giving information about any proactive technology used by a service for the purpose of compliance with a duty set out in s10(2) or 10(3) (including the kind of technology, when it is used, and how it works).	https://toot.wales/privacy-policy
A duty to ensure that the provisions of the terms of service are clear and accessible	All policies are written in plain speech, reviewed annually, and linked to from various pages and account profiles on the service and our related web properties.

Ofcom reference	Measure	Comment
ICU A2	Accountable individual	Jaz-Michael King
ICU C1	Content moderation function	Service staff will review and assess suspected illegal content
ICU C2	Take down	Takedowns occur subject to the Moderator Process Manual.
ICU D1	Enabling complaints	Complaints can be received in-app by messaging the teamtoot account, or via email help@toot.wales
ICU D2	Easy to find complaints information	Service about page, service web site.
ICU D7	Appropriate action for complaints	All complaints are reviewed by staff
ICU D10	Appeals	All appeals are reviewed by staff
ICU D11	Proactive technology	Thorn Safer - CSAM hash and match IFTAS FediCheck - domain blocking
ICU D12	Appropriate action for complaints	All complaints are reviewed by staff
ICU D13	Manifestly unfounded complaints	All complaints are reviewed by staff
ICU G1	Terms of service	https://blogs.toot.wales/toot/twt-community-code-of-conduct https://toot.wales/privacy-policy
ICU G3	Clarity of terms	See ICU G1
ICU H1	Proscribed organisations	The service will block any account and/or domain if we become aware that they are a member of a proscribed organisation.

Thanks to the great people at The Social Change Nest, we are now officially live on the Open Collective platform:

Tŵt Cymru / Toot Wales Collective

Along with our recent server move to Mythic Beasts, this places us firmly in the UK and will allow Jaz to wind down the New York-based charity that has operated toot.wales until now.

Budget

Our services include the Mastodon server, a web site, and our domain names. The annual cost of running the services is currently £3,954, which works out to £329.50 each month.

Although we don't pay our moderators, we'd very much like to get to a point where we can provide a little something each month for the effort and energy our moderators put into keeping Tŵt running.

We very occasionally produce postcards and flyers and such, and may incur a small cost here and there for sundry items. We may also choose to host additional services.

With the arrival of the Online Safety Act we may have to pay for some advice and/or some third-party services to ensure our compliance.

Please note: we pre-paid the server bill for a year, so there won't be a major payment for some time, but we need to raise the money in time for a few smaller bills and the next annual payment in December.

Governance

These recent changes mean we will be moving away from a board-governed charity and instead operate as a fiscally hosted collective. All income and expenses will be public, transparent, and published on our opencollective.com page. The Collective is administered by Jayne, Jaz, and Mark, you can view their profiles on the Collective page.

Our organisational policies remain the same, and can be viewed at https://blogs.toot.wales/toot/croeso-i-twt

As we close down the NY charity we will pay any and all bills we need to before shutting down, we have a small surplus that we will use to prepay the domain names and any other services we can legally spend the money on subject to NY and US charity law.

Paypal

If you were previously donating using a Paypal account, please consider switching over. We will close the Paypal account later this year. To cancel your Paypal recurring payment:

• Go to Settings.
• Click Payments.
• Select Automatic payments.
• Select the merchant. We should be listed as “Toot Wales Inc.”
• On this page, you can cancel the automatic payment.

A Note From Jaz

When I started this project in 2018, I made it clear it needed to be something that can survive without my direct support, that success would be defined as Tŵt being able to stand on its own two feet. In many ways, I think we've achieved this goal.

I sincerely believe social networking should be a non-profit, community-driven activity, and our success growing toot.wales is testament to those of you who agree with me.

I am heartened not only by our collective community, but the thousands of other communities around the world that we connect to, similarly ad-free, community-managed, allowing 15 million people to connect to each other in a people-powered network owned and operated by the people using it.

We are seeing a shift in mainstream social apps that are allowing if not encouraging the toxicity and intolerance we work so hard to prevent. It's never been more important to offer the alternative vision that so many of us in the Fediverse believe in.

I understand not everyone can put their hand in their pocket to support our little corner of the Fediverse, so I humbly remind everyone that there are two ways you can help us continue to offer this valuable service: donate your money, or spread the word.

If you enjoy the experience toot.wales and our larger network brings you, tell five friends. Tell your colleagues. Tell your local newspaper or radio station.

You don't need to sell people on open source, mastodon, no nerdspeak. Just let everyone know there's a social network you use that is growing rapidly, is not owned by billionaires, has no advertising, no addictive algorithms, it's just a big collection of apps that can all connect and talk to each other.

Pick any app, pick any server. They all work together.

You know. Like a world wide web.

https://jointhefediverse.net/ is a great link to share, simple and easy to understand.

To everyone who uses our services, supports us, or uses and supports a different part of the open social web – thank you. The future is federated, and we intend to continue to be a leader in this space.

We are still crunching the database indexes and are aware of ongoing issues with loading replies and posting new toots. Please bear with us until everything is completed before we can fully assess if there are any underlying issues not related to the migration we need to address.

The backlog is fully processed and service is at normal levels. The only task remaining is an indexing of the database for the advanced search function, which will take a while to complete. Search is functional but may be slow, buggy, or missing posts.

We are slowly coming back to normal service. The Local Feed should be moving along nicely, but we have over 100,000 backlogged messages in the queue, so your Home Feed will be disjointed and delayed while that queue gets processed. You may see messages out of order, or delayed. Highly technical, scientifically-proven guesstimation says 2 hours or so until we are fully caught up (9pm-ish GMT). Thanks for your patience!

It’s been two weeks since I had the procedure and I feel good.

The procedure was scheduled for Friday and I got the call Thursday telling us to be at the hospital at 7:30 am. The procedure was to be done in the ambulatory surgery area of the hospital. My wife was coming with me for support and to drive me back home. The hospital is about a 45 minute drive, so we left at 6:30 and arrived in good time.

The check-in procedure was very smooth and I was taken back in short order. I was seen by several people, the nurse coordinator, the OR nurse, a P.A., the anesthesiology residents and the anesthesiology attending. Finally the surgeon appeared and we discussed the procedure and made sure I still wanted to go through it.

The anesthesiology resident started my IV and gave me some sedative and I got wheeled to the OR. I remember moving myself from the stretcher onto the table and that’s about it.

I don’t have a strong memory of the early time in recovery. My recovery nurse was wonderful. As my head cleared I was visited by many of the same people I saw before the procedure. I was told it went perfectly.

We waited until my head cleared. It took a while for my blood pressure to chill out. My nurse kept asking me if I needed any pain meds and I kept saying no. Finally I started to feel some discomfort and agreed to some meds. She gave me some oxycodone. This was the first time I ever had it and it seemed to work.

Finally I was given the ok to go home. On our way I we picked up some oxycodone that had been prescribed. We got home about 12 hours after we left. I settled down for some tv and to relax. I wasn’t in pain but the area was quite swollen. I should have been icing the area, but I didn’t. By bed time I decided to take some Tylenol. I never touched the oxy.

Saturday and Sunday I just lazed around the house. The swelling decreased every day. It was sensitive and my skin was a painful. I also felt the feeling I expected. That feeling you get after you get kicked in the groin, not the initial pain, but the later nausea and discomfort. I felt that constantly. It slowly waned over 4 or 5 days.

The incision was glued closed, so there are no stiches. I was told to just go easy on the area. Don’t scrub it in the shower. It has been quite secure and not painful at all. It feels like there is some harder tissue right under the scar which I assume is more glue or scar tissue. It too is getting smaller with time.

That was the way it was, just getting better each day. Now, 2 weeks later, I had a follow up appointment with the Urologist. The swelling is almost all gone. There is no pain. The incision is healing well. No infection. I’m cleared for most activity, except riding a bicycle.

The whole process was easy and not painful. I really hope the swelling continues to go down and the all the stuff down there continues to shrink. All in all it was a generally easy experience.

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.

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…….

An online friend on Mastodon posted the following:

Some cis people mourn who a person was when they transition.

What they don't seem to grasp is that we mourn too.

In much the same way you might mourn if you woke up to learn that you were in a coma for two or three decades.

You're awake and alive, and existing now, but what of the life that would have been?

@sasha_strange@tech.lgbt

This is so important to understand. This topic usually comes up in the context of a parent mourning the loss of a son or daughter who is transitioning. The parent may feel that their son has died and have trouble recognizing their new daughter. This is a completely natural and understandable reaction. How the parent deals with it is the big issue. Does the parent deny the daughter? Does the parent welcome the daughter with joy and open arms? Does the parent have compassion for their child and help them through the transition, love and support them and think of their child’s well-being before their own. Do they have the maturity and self-confidence to realize that their child is not doing this to hurt the parent or embarrass the parent. Does the parent have the ability to deal with their own feelings while also helping their child?

As a parent my instinct is to protect my child against every danger in the world. My kids are grown and have moved out on their own, yet this instinct remains and I have to restrain myself from trying to fix everything and let them do it and learn how to be confident and self-reliant adults in the world. But I am always there for them.

A parent who thinks that their own feelings about their child are more important than the child’s own feelings about itself are narcissists. I can hear the phrases, “Why are you doing this to me?”, “What will the neighbors think?”, “What do I tell Aunt Karen?”, “Why are you being so selfish?”, ”You killed my son.”, “My son is dead”. None of these things do anything other than hurt the child.

I feel a better way to frame it is to realize my child has been suffering for so long. If they had any other long term medical issue, I would not be angry at them. I would not try to talk or threaten them out of being sick. I would seek professional help and do everything I could to help my child.

Much of this attitude comes from ignorance. Ignorance just means not knowing something and is understandable, as long as they seek to learn the truth. A parent that refuses to learn, or refuses to accept the truth of gender dysphoria is directly harming their child.

But, few people understand that the trans person also mourns. They mourn the loss of what could have been. If you are lucky enough to have realized your reality at an early age and were encouraged and supported in your gender exploration and presentation, you don’t have as much to miss.

Those of us who were unable to face their gender issues until adulthood, in my case, my 50s, have missed plenty. I grew up a boy. I did boy things, I wore boy clothes, played with boy toys, played boy sports, and was a Boy Scout. At the time I didn’t know any different. I didn’t mind these things, and some of them I enjoyed, but I was never happy, never satisfied, never content. I was not able to form deep meaningful relationships with friends. I knew there was something wrong with me and I was afraid of opening myself up to anyone. At the time I told myself I was boring and overweight, and no one would be interested in spending time with me.

I realize now that I didn’t know who I was. I wasn’t me, the all American boy. I was a confused kid. I spent my life feeling that; Insecure, unsure of myself and my place in the world. When finally, in my 50s, the truth broke through. I finally realized who and what I was. I was a woman, I should have grown up as a girl, and suddenly it all made sense. All those puzzle pieces fell into place. I now knew why I was so out of it as a kid and through the rest of my life.

Here’s where we get to the mourning. I began to realize all the experiences I missed growing up. I didn’t get to do the girl stuff. I didn’t make friends with other girls, have the sleep overs, learn the behaviors and mannerisms of being a girl. I didn’t get to learn all that fun girl stuff, like fashion and makeup along with the not so fun stuff, like heartbreak and periods and so on. Of course, I am not reducing girlhood to these few things, I am trying to give some examples.

I realized that I will never get those experiences. I will never know what it is like to be a young girl, a teenage girl, a young adult woman and an adult woman. I now hopefully get the chance to experience being a mature woman. I particularly think about my high school and college years. That is the time for lots of confusion and problems, but also joy and freedom. I had a ’79 Jeep CJ-7 that I loved and always had the image of driving with the top down and my long hair blowing in the wind, looking good, feeling good. Doing that as a boy was great, but not the same in any way.

One TV show that appealed to me back then was the Mary Tyler Moore Show. That is who I wanted to be. That was the life I wanted; a young, single, confident, capable, and intelligent woman. Needless to say, I missed out on that fantasy. My daughter is living that now and I am envious of her and I support her as much as possible.

The feeling of missing out on a childhood, lost experiences never to be found, is real and painful. It really is mourning a lost life. Parents, friends and others should be aware of this and be supportive.

The joy a trans person experiences when they accept themselves is profound. They may appear almost giddy and full of life. But underneath, next to the fear of coming out and the reactions of the outside world, is also the disappointment of realizing all they missed out on in their life. While they are celebrating the birth of their new self, they are mourning the lost childhood they never got to know.

Every human who has ever lived, that had a secret, had to decide whether to share that secret with the outside. This conundrum is not exclusive to LGBT+ people, but that is what I want to discuss. My personal experience is with the T part of that initialism. Coming out is a deeply personal decision and one that everyone must make for themselves. Add in the issue of transitioning and it becomes even more difficult. First a disclaimer, I would never make light of the struggle of the L, G, and B. Perhaps I am being naïve in this blog post. I have not had any of the experiences of a gay person coming out and living their authentic life. I do not know their struggle and I cannot know their actual journey and compare it to mine. There are many similarities, but I want to draw attention to one big difference. They can choose who they come out to, and they can generally walk in the world without drawing attention. They come out once to each person they choose to tell.

A Trans person has the same issues with regard to who to tell, but deciding to transition will mean coming out every time they step out the door. A gay person can come out to their family and still go into work the next day without worrying that everyone else will know. A trans person will come in to work looking very different from the day before, and they will be noticed. You can’t choose to tell just your family and close friends if you plan to transition.

So, that is what I am struggling with now. I’m sliding out of my mid-50s. I’ve spent my entire life playing the part of a man in society. It is all I know. I’ve been pretty convincing. I’ve nurtured relationships, and built a business in that guise. Coming out to family is doable, but transitioning and living as my authentic self has some serious potential pitfalls. I have no experience being a woman. I’ve known that I wasn’t right my whole life, but I didn’t get the opportunity to socialize and interact with the world as a girl. How am I supposed to do this?

The first is the fear of looking absurd. Some AMABs can appear very convincing when presenting as a woman. Not so much for me. First, I am 6’ 2”. While not impossible, that is way out of the norm. Second, I weigh too much, way too much. Even if I lost the weight, I am not a slight person. I will stand out. To put the cherry on top, I wear a size 15 men’s shoe. That is a hard enough size to find for men, women’s shoes in that size are rarer than hen’s teeth. Surprisingly women’s stores seem to do well for “extended sizes” and I can find stuff to wear.

So, assuming I got the clothes right. The hair, makeup, whatever. I’m still a giant presence and will never be able to blend into the background the way I have wanted my whole life.

The next fear is rejection. My wife knows and is broadly supportive. She does not want me to tell our kids because she is afraid it will emotionally harm them. We have a 28 year old daughter living on her own in NYC and a 23 year old son pursuing a PhD in Albany. They are both well educated and very liberal. My son has a couple of friends who are non-binary, so he is well familiar with the concept. My daughter gets along well with his friends as well as having her own LGB friends. My wife is particularly worried about our son feeling betrayed and abandoned by his male role model. That he will feel he has been lied to his whole life. At first I didn’t think that would happen, but now doubts are creeping in and my wife’s worry is eating into my psyche.

Then there is my father. He is 93 years old now, still going strong, but won’t be around forever. He and I have built a business together over the past 28 years, so we see each other every weekday and get along well. One positive is that one of our clients confided in him that they have a grandchild who is trans. Then his, I guess you would say, girlfriend has disclosed that she too has a grandchild who is trans. So, he knows it is a thing and it does not repulse him. He is definitely confused by the phenomenon.

When he told me about these two kids, my reply was that they just needed love and support and they would do fine. I didn’t make a big deal about it, but inside I was screaming, We have a part time secretary/assistant who has worked with my dad for 40 years. I overheard the two of them talking over lunch and her saying that she was so glad they were past the stage where they have to worry about these things. I gave a little internal chuckle at that.

I have lots of thoughts about telling him and how it would play out. You see, when I was about 12 or 13, he walked in on me dressed in women’s clothes. I had snuck some of my mom’s stuff. He demanded to know what I was doing, and as a terrified kid, I said, I don’t know. He told me to take it off and then he came to my room and again asked and I again said I didn’t know. He said don’t do it again and don’t tell your mother. And that was it. Needless to say, it didn’t stop the feelings and the desire to dress. It continued on and I was just more careful.

But from that day on, I lived in fear of that coming back to bite me. Fear of him saying something. I knew it was wrong, weird, and perverted. I was terrified of messing up, making a mistake and him bringing the incident. I have likened it to the sword of Damocles, hanging over my head. It wasn’t until recently that I was able to work through the trauma associated with it. I can say that EMDR worked amazingly well for me.

So, what do I imagine would happen if I told him. I think he would believe me. I think I would break down. I worry that he would feel guilty about the incident, if he even remembers it. Since he is aware of the “condition”, I don’t think he would be hostile. I would like the chance to discuss it with him and explain what I was dealing with growing up, but I don’t want to blame him or make him feel guilty. I know he already regrets traveling for work so much and not being home all the time. I hold no ill will, my parents did the best they could and it was pretty good.

He is 93, still very healthy, but age is most certainly catching up. He is not the most steady on his feet and uses a walker sometimes. He has developed prostate cancer, but if you last until your 90s, a man will get prostate cancer. It won’t kill him. He’s also developed a basal cell carcinoma behind his ear. Also treatable. Pretty amazing since he spent a lot of time outside and never used sunscreen or wore a hat. So, a part of me wants to just wait it out and I won’t have to tell him. But, his mother lived to 103, and I am getting older every day.

Then there is my sister. She’s 2 ½ years younger than me. We had a younger sister who died at age 30 from epilepsy. Anyway, my sister had difficulties growing up. She’s been exposed to every lifestyle out there and would probably deal fine with it.

I don’t have much more in the family department. I have one sister in law, who I think would be fine. I have some cousins I haven’t seen in over 5 years. My mother in law and her sisters might be a problem.

The next huge issue would be work related. I am essentially a small business owner and my business requires a personal connection. There is no doubt some of the people we work with would not be receptive to a trans person. We would certainly lose business. I can’t inflict that on my father and I can’t afford that. So, that is another big hurdle. If I worked for some major company, they would likely have policies in place to protect employees and I could probably transition with minimal disruption. Not so when your business relies on personal connections. So, before I do anything I will have to cultivate some more business with LGBT+ friendly people.

I am fortunate enough to be physically large and strong enough and mature enough to not worry too much about bullying. I know that is a major obstacle to younger people coming out. I had a bit of verbal bullying about my weight as a kid, but I never really faced any physical bullying. Actually the only time a kid did try to bully me was in junior high school, I picked him up and held him against the school lockers and suggested he stop the behavior.

So, these are some of the obstacles to transitioning that trans people face. Were I just gay, I could still tell a small group of people and continue on my way. I wouldn’t have to tell the world. It wouldn’t be obvious just looking at me that I was gay. But, if I want to live as my real self, there is no hiding. Oh, there I go, the grass is always greener, right? I apologize if I am making light of anyone’s experience. However, that is the place my brain is right now.