Post-Top Surgery

I had top surgery in mid-July. For those not in the know, that’s breast augmentation surgery (BAS) or breast implants. As in starting hormones and getting bottom surgery, I underestimated the effect it would have on my life. I guess if there’s one theme that has run through the last six years of transitioning, it’s that I have been repeatedly skeptical of the impact that a step would have on my life.

I attribute this tendency both to my natural skepticism and to the general feeling of disconnection to my body that I have had since I was a kid. After almost forty years of gender dysphoria, in which my own mental perception of my gender remained deeply rooted in my core sense of self in spite of puberty, masculine conditioning, and constant contrarian societal affirmation (oof, sorry for that sentence), I suppose it’s hard for me to believe that anything happening to my body, which feels outside of myself, will impact how I feel on the inside. Perhaps there should be a book written about the stubbornness of the trans woman. Of course, I’m jesting, but like all jests, it’s a mode of exploring truth, because if being trans is a choice, then trans people are the most stubborn, mule-minded group of folks on the planet, absolutely refusing to change their opinions of their gender, regardless of the entire planet telling them that it’s not true. In terms of the performativity theory of gender, trans folks, and trans women in particular, refuse to willingly participate in the role that society has created for them, and when they do perform they grit their teeth and only do it because there is the sense of the guillotine behind the curtain waiting for those who don’t perform their assigned role.

So where is their sense of gender coming from? It’s not coming from society, or the words that society uses to interact with them, or the entire stage that has been set for their appearance. It’s as if their sense of gender developed so early, and took such root, during their cognitive development, that something was whispering to them inside of themselves. Perhaps it was the cognitive dissonance produced from having a brain shaped one way and a body shaped in another. As of right now, it’s all murky? And what does this have to do with a post about top surgery anyways? It’s just a rambling distraction from the fact that I now have breasts, and that it took a damn long time to get them, and that it has been life changing in a way that I did not predict. In terms of my ability to predict my own reactions to transitioning, it turns out that I am completely blind.

But it has been transformative. For the first time in my life I am gendered correctly most of the time. It turns out that breasts, especially when proportional to one’s frame, are key to gendering. And it’s much more of a relief than I thought it would be because after the bottom surgery misgendering affected me much more than before.  Being misgendered after having had bottom surgery felt like a blow against the fresh feeling of authenticity that I had acquired. Whereas before bottom surgery I was able to shrug off misgendering for the most part, afterwards it hurt quite a bit, and I braced myself in almost every social situation in order to protect that feeling. It turns out I just had to acquire a pair of breasts.

I don’t doubt that I will always be misgendered some of the time, but that’s ok. Life isn’t perfect, and I never expected it to be. But being gendered correctly even 51% of the time feels like stepping through a door and into the sunshine, and that’s something to celebrate.

Waking Up

After many years of wondering if it would happen, I had gender affirmation surgery (vaginoplasty) in February of 2020. The road to full recovery took a full three months, and it was much more painful and difficult than I expected. From speaking with women who have given birth, the experience seems to overlap in many respects with recovery from having an episiotomy or significant tearing during birth. Recover aside, the experience was fascinating from a psychological perspective, at least to me.

I had expected to feel at least somewhat physically disoriented after the surgery. It’s such an alteration in physical, and to an extent neural, anatomy that I expected to have at least some feelings of unease or discomfort. Even if one doesn’t particularly like one’s house, it’s not unreasonable to expect that moving will cause some distress after having lived in it for 44 years. But the  strangest thing to me is that when I woke up, with Jo by my side, the first feeling I had was one of deep body contentment and rightness. Even as the anesthetic wore off, and my mind began to clear, the feeling persisted. I felt whole and natural in a way that I had never experienced, except perhaps when I was very young.  

The suddenness of this feeling astonished me even in the moment of waking. With a vacuum cup over the surgical area pumping away blood, bruises the size of plates on my thighs, and two stitch lines running up my abdomen, I felt great! Well, maybe not great, but whole. It has been six months since the surgery, and the feeling has only grown deeper and stronger, like a parched and inhospitable lakebed filling with fresh cool water. I wish that I had an answer for this feeling. The idea that I was always a woman, so of course it feels right, isn’t really an explanation at all. What about my neurochemistry and psychology would make such a dramatic surgical alteration “feel right”?

As of now, we are only scratching at the surface of gender identity, but I have hope that the coming decades will bring new discoveries. In a way, the trans experience might help all of us understand our relationship with gender better, and providing care for trans folks may in the end be a form of self-care for everyone.

Identity and Growth

I sometimes feel like I spent ninety percent of my life with my "true" identity hidden, living in the closet, hoping that no one ever found out that I was trans and at the same time wishing that everyone knew. My identity for those long decades felt hidden away from the world, a thing that only I could see. Struggling to validate this part of myself, this piece of myself felt like it shrank every year until by the time I was at the end of graduate school I perceived it as an echo. 

And then one day I put on some make-up, and a door opened inside myself, and I saw that my internal world was an iceberg. I saw that what I thought of as my identity, the male presentation that I funneled myself through to engage the world, was just a small piece of a large, submerged identity that had never gone away. The space inside myself was immense, and I had been living in progressively smaller compartments, and the echoes were really ripples on the surface as the iceberg sank deeper. I was extraordinarily lucky to have put on make-up that night, combined with the years of love and support from my graduate community, because I'm not sure how long those ripples would have been noticeable. 

Naively, when I came out, I  thought it would be like pulling back a curtain to reveal this part of myself. Instead, it was like being born an awkward eight year old girl, about the age I started to suppress that part. It's easy to judge trans-women for their love of make-up and silly, girlish things, but we have to remember that it's a stage of identity growth through which many biologically born women have passed. Their identities as women were forged, birthed, and created through countless experiences with themselves and with the world. For myself, I gradually walled off these desires, and yet, surprisingly to me now, they never went away. For all the years I wore a beard, and joked with men, I felt like a prisoner and a fraud. 

Expressing my identity has been like walking on shaky new legs through a Montana high grass field, where there are dangers and difficulties inherent in each step, but always more space than you ever imagined to the horizon. It's the journey that we all take, an endless spiral of expression that becomes creation and then again expression, creating ourselves through every moment. 

Voice Training

My voice made me uncomfortable in the early part of my transition. After your nose and jaw, your voice is the cue that most people use to determine gender, and my voice was deep and not at all passable. Now passing doesn't seem like a big deal to many non trans-folk, but being able to pass successfully saves transgender people, especially trans-women, lots of harassment and discrimination. I anguished over my masculine voice in the first couple of years, and I thought it was a pipe dream to try changing it, something that scam artists sold to desperate trans-women. I was very wrong.

I have been working with a voice coach who specializes in transgender voice training for a little over two months. My voice is now starting to become passable. Of course, it's never going to be Julie Andrews, but it's starting to sound ambiguous enough that it's not going to cause someone to immediately misgender me. The training consists of projecting your voice up into the nasal mask area, thus preventing the lower tones to resonate in your throat, chest, and head.

It takes a lot of work, but the hardest part was dissociating myself from my older vocal patterns. After decades of living with my own voice in my head, my identity had become intertwined with it, and I stressed that my new voice was something fake or put on. But speech is a behavior, one that is learned as much as anything, and that tip from my coach helped me dissociate from the old voice and enjoy learning a new speech pattern. The change has been so gradual that most of my colleagues haven't noticed the change (the ones I asked were surprised that my voice was different). 

If our speech patterns are so pliable, how deeply ingrained is gender performance? How much of gender can possibly be genetic? I suppose like all things, it is a complex tapestry of the strands of agency, environment, and genetics. It is easy for those who have never struggled with their own gender identity to propose simple explanations, but for me, and I think anyone who is transgender or queer, each day is lived at the intersection of these three strands. 

Upping the Hormones

Three weeks ago, after a little of three months on a very low dosage of hormones, my doctor and I decided to double the dosage and switch over to injections. The results have been noticeable physically, although there hasn't been much of a mental difference that I can notice. The first week on the higher dose was an emotional roller coaster, but it quickly subsided. I would hazard a guess that low doses are enough to change neural firing patterns through receptor kinetics and eventual transcription processes, but that the low doses are not enough to affect things like fat deposition and breast growth. Since intestinal absorption isn't 100% by any stretch, what was getting into my system was even less than the swallowed dose.

Within days of the first injections, however, my chest felt tender, and buds have begun to form. Maybe too much information, but if you're reading this blog I doubt you mind. The process has continued at a fast pace. Also, new hair has sprouted on my head where it hasn't been before, which is odd and might be a product of the higher dose of spironolactone as much as the estradiol. The other effects are also noticeable: softer skin, more oil in the hair. A part of me feels that descriptions like this are a sort of navel gazing, something I've never been a fan of in the past. But I know I will forget how the process went at some point, and the trans experience is novel enough that a solid timeline of the transition might prove useful for myself and possibly someone else. 

In terms of subjective experience, I am still riding high. I have never felt more comfortable in my body. I've taken up running (no more weights), and it actually feels good! It's like I inhabit my legs, my back, my arms, in a way I never did before. Like there's room for me here inside.  

Ten Weeks of Hormones

I'm at the tail end of ten weeks drinking the transwoman cocktail - estradiol martini and testosterone blocker chaser. I have noticed changes in the way I think and feel, and they are different than what I expected. As an adult, I expected minimal physical changes and even fewer emotional and psychological changes. I know myself pretty well at this point in my life, and my interests and attitudes have been stable for a long time. I think I expected I deepening of some feelings, but not really any big changes. How I feel now was unpredicted, but it has been welcome. 

The biggest change physically is how I sit in my body. For most of my life I have lived in my head, only inhabiting my body in controlled ways, such as lifting weights. My body was something unenjoyable, and I resented it. Starting about three weeks ago, I felt space starting to open up inside my body. It felt like I was becoming hollow, and that I could  drop into my body and actually fill it out and occupy it. Being in my head was my normal life, and it's only retrospectively that I can see how scrunched up I was, and how little space I had to operate in myself. That has been liberating. 

My interests have also changed, which strikes me as very odd. I liked literature, but not writing. When I did write, I liked working on the grammar, but not the style. Musically I was attracted to structure melodies and disliked heavy emotion and riffing. These tastes have been stable for decades, but now I find myself relishing the sound and style of words. Words spoken or written have become a source of pleasure and interest in very different way than before. And musically I am discovering the blues and rock and roll in a way that I never could have appreciated before. 

My relationships, both to myself and others, has become focused on the particular. I liked philosophy, and I wanted to understand the structures and ideas underlying human experience. I was attracted to the general and the trend. I still like philosophy, but I am now interested in the particular and the concrete. The everyday world of our lives, its texture and the relationships embedded within this texture, are becoming more important to me than general ideas and principles. I guess I was focused on the trunks and big branches of life, but now I like looking at the leaves. 

I wish I could say there have been more physical changes, but these have been minimal. Ten weeks, however, is not that much time for hormones to change epithelial, fat, and muscle structure. Surprisingly, to me at least, it's enough time to have a dramatic affect on neural structures underlying interest and personality. 

Week 4 & 5 Nov 21 2016

I wish that I could better describe the changes that are starting to take effect since the last post, but my life has been a blur of work, scrambling whatever underlying physiological and emotional changes are taking place with a storm of paper grading, lecture prep, and grant writing. Underneath the winds, there are shifts in the foundation that I can feel. The body sits differently, the emotions sometimes spin out, and my being rolls around. I feel like I am waking up to a new person frequently, which is disorienting after having become accustomed to one way of walking through the world, even if that way was closeted. I have not had the time to process these feelings and sensations in any meaningful way, so they remain large swells and undercurrents in the background of my life, but I hope to sit with them more this week. 

Week 3 Nov 7 2016

As expected, there haven't been noticeable physical changes. I have been experiencing some emotional fluctuations, but I am loathe to attribute emotional differences to hormones. It not only sounds terribly cliche to me, I think it plasters over learned behaviors between men and women in processing emotions. Despite this, my partner has noticed that I've been more visibly emotional than she's ever seen me, and after reflecting back on the last two weeks I agree. I don't usually tear up, but it's happened a couple of times. I am very uncomfortable with the idea that a molecule having that much power, in a sense, over my state of mind. Many trans women describe an increase in their emotional presence, and I've often, unfairly, attributed this to their becoming more in touch with themselves and not to the plasma concentration of estradiol. I still don't think a person's emotional responses can be reduced in any simplistic fashion to a single molecule, and the intertwining of experience, attitude, cognitive processing, and social feedback makes any causal connection between estradiol and emotion tenuous at best. Still, I've been crying more. 

Gender versus Behavior

It's difficult to describe gender dysmorphia without pointing to behaviors, but this conflates two very different things. Certainly no behaviors are strictly female or male, and the use of behaviors like playing with dolls or enjoying makeup are problematic and set off red flags for anyone who is gender conscious. But if someone of cis-gender has to describe why they felt comfortable in their gender, what would they say? It would be easy to point to gender conforming behaviors. I've heard many people say something along the lines of, "I like being a girl/boy", which I think translates into "I like doing the behaviors that a girl/boy does". I don't think, and maybe I am completely wrong, that it usually means that the person has a deep sense of comfort with the physical space they inhabit. So identity and behavior are often conflated in our society. Judith Butler has taken this idea to its extreme in saying that behavior creates gender. 

If behavior entirely creates gender, then it is difficult to see how a trans person could exist. If all I were given was male behaviors, then how did I form the idea that it was not for me. By saying that I'm trans, is this simply saying that I don't like to do typically male activities? For me,being trans cannot be explained or justified with behaviors. While many of the things I like would fall into the girl camp (makeup springs to mind), there are quite a few activities that I also enjoy (weightlifting, mechanics) that are over on the stereotypical male side. And I agree that associating any behavior with a gender is deeply problematic. 

I did not decide to come out as trans and begin transitioning because I wanted to do more female typical things like wear make-up. I could have done these activities within the context of a male presentation, and most of the people I know who cross-dress or engage in gender bending have no desire to change their biological sex. So what did I want? I can say that in my own experience being in a male body has been deeply unpleasant. Simply being present in it, especially since puberty, has been an unrelenting source of unhappiness. Every trans person has a different experience of their body, so I can't say what it is like for them, but body dysmorphia is a common aspect of the trans experience. I don't know what causes the dysmorphia, or the neurology behind it (no one does at this point), but I do know that when I say I am trans I am not talking about the behaviors. 

The behaviors, however, make more sense and are easier to explain than this deep existential feeling of being in the wrong body. It's easy to conflate the two in conversation, but by parsing out the internal feeling of identity from the behaviors we should seek clarity and not a way to devalue that internal experience. I admit that I don't understand this very well. The roots of a person's identity tap into the deepest recesses of their being, and how we construct these identities, their relationship to our language and behaviors, and the neural architecture underlying them is well beyond my ken. I'm a thermal biologist puzzling my way through fields well outside of convective cooling. I do know I like makeup, and I also know that's not what makes me a woman. The question is, what does? 

Week 2 Oct 30 2016

Softer skin? Probably just in my imagination. While the physical changes of the estradiol will take time, there have already been psychological changes that make me wonder how quickly changes in plasma steroid levels can affect neurochemistry. Certainly the blockers are having an affect, and the low level energy I now associate with testosterone is continuing to drop. It's an odd feeling to have that physical background noise continue to fade, and it still makes me sit in my body in a much more comfortable way.

 

Week 1 Oct 23 2016

I started a testosterone blocker (spironalactone) and estradiol on Wednesday. As expected, it didn't have much of an effect the first couple of days. Steroids generally take months to have an effect, although the blocker is faster. Oddly, at least to me, I woke up on the third day feeling very at peace in my body. It was like a background noise that you become so used to it escapes your attention until it is turned off. I woke up with a sense of presence in my body, in my muscles, that I don't remember ever having experienced in my life. My initial reaction is that it must be in my imagination, but it was a noticeable sensation. 

Some background

It was a surprise to most when I came out as trans. I was 36, bearded, muscular, and fairly butch (for a scientist). For many years I worked hard to present a masculine persona. The word overcompensation jumps to mind. I had been tearing myself up about gender identity for decades, and a masculine identity wasn't possible for me any longer. 

There were certainly indications in my childhood. I wore dresses and panties as much as possible, avoided any typically masculine activities, and vigorously pursued activities that I perceived as feminine. I understand the web of stereotypes that are inherent in a young person's perception of gender, but that's how it was. While other boys were playing sports, I took cooking and choir. I would have been the only boy in the choir class had not a very good friend of mine decided to join with me, I think to make sure that I wasn’t the only boy. He was a very good friend.

Throughout these early years I often questioned my sexuality, conflating sexuality and gender. I pursued cross-dressing (really same gender dressing) as much as I thought safe, purchasing articles of clothing as much as I felt comfortable in the pre-internet days. There were times when the only time I felt like myself was when I put make-up on in the privacy of my apartment. It was a source of friction in every youthful relationship, and at twenty-five I decided to seek help. 

I was referred by the college counselor to a psychiatrist who diagnosed me with gender dysphoria, the first time I had heard the term. It took her about ten minutes to make the diagnosis. She recommended that we worked on building a strong male identity structure to remove the delusion that I was female. This sounds barbaric now, but in 2004 the world was still very unfamiliar with trans. I spent over a year working with her, and at the end of our time together I felt more confident in my masculinity than ever before. By 2006 I had thrown away all of my female clothing and make-up, and I was ready to pursue graduate school with a solidly male presentation. 

Graduate school changed my life. I met wonderful, intelligent, warm people who supported me as a researcher and as a person. I know this is very different than many of peers experiences in grad school, but I had a truly fantastic experience. Towards the end of graduate school I tried on some make-up with a friend, and it felt as though I had re-connected with a giant piece of myself, the portion of the iceberg under the sea! The therapy hadn't worked at all; it had merely reduced my awareness of myself to the most superficial piece. It was the catalyst for coming out and begging the transition.