On Monday morning, I went to a consult with a surgeon to see about having what is often called in the trans community "top surgery." For those not in the trans community, it's a subcutaneous double mastectomy.
The consult went great. I liked the staff in the office and the surgeon was attentive and kind and clearly aware that interactions with health care for trans folks are not always positive.
During the consult, they asked me if I had brought a letter from a mental health professional endorsing my decision to undergo this procedure.
I had not.
I didn't know that would be necessary, but I also had not seen a mental health professional about anything related to gender identity since, I don't know, 2006? I didn't press the issue. I have a great doctor who is aware of my gender expression and fully supportive of whatever I need to be fully myself. I scheduled the surgery and headed home to ask my doctor for said letter.
God love 'er. When I asked if she'd write the letter, she declined. She said, and she was absolutely correct, that while she is aware of and sensitive to my needs regarding my gender expression, she didn't feel competent to pen such a letter.
I was filled with rage. Not at my doctor, whose refusal actually made me love her that much more, but at a system that requires me to have a mental health professional sign off on a decision to have a procedure that I'm fully capable to decide to have. As I thought about all of the women who had likely come in that day for breast augmentation, my rage grew. It felt crystal clear that people are free to alter their bodies without a mental health consult as long as it's in the right direction. You wanna be more feminine? Sold. Oh, you want to go away from what *everyone* is telling you about how to look? You must be crazy.
So, ya know , I pushed back. I wrote to the doctor and explained that it seemed ludicrous that I should contact a mental health professional who would meet with me one time so they could write a letter endorsing a decision I'd been contemplating for 24 years.
To my surprise, the surgeon agreed. She said, "You can write your own letter."
So I did.
Here it is, my friends.
To give you a little background, the form they gave me said that the letter from the mental health provider needed to address:
The duration of physician/therapist relationship with the patient, including the types of therapy/counseling provided
A summary of the patient's general identifying characteristics
legal age of consent in the country in question
Indication of a history of depression related to gender identity
Indication that the patient is mentally capable of making an informed decision consenting to treatment
Medical or mental health concerns. If present, letter should indicate that these are controllable.
Full assessment of the patient's psychosocial behavior, with results and diagnoses (if any)
A brief description indicating the basis for supporting the patient's request for transgender surgery
A statement asserting that informed consent has been given by the patient
A statement affirming that the physician/therapist will be available by phone to coordinate any details pertaining to pre-/post-op care
Dear and Gorgeous Humans of The Advanced Center for Plastic Surgery,
Cal Cates is a healthy, 44-year-old person who was assigned female at birth. They have lived as a person of non-binary gender expression for no less than 10 years. Probably longer than that, but there wasn’t a name for it. They are of average height and build. They consume alcohol moderately and deny smoking. They have never used recreational drugs. They exercise 3-4/wk at a moderate level. They are of the legal age of consent for the medical procedure in question: subcutaneous double mastectomy.
They have lived with depression and anxiety for most of their life, but the origin of those diagnoses cannot be solely attributed to issues of gender identity. In the opinion of this professional, Cal suffers from “humaning.” Humaning is a complex undertaking fraught with nuance and ripe for misunderstanding and just plain meanness. While Cal does sometimes display questionable choices, for instance, clipping their fingernails while sitting on the toilet, I believe them to be mentally capable of making an informed decision about the procedure in question.
I have no concerns about Cal’s medical or mental health. I do wish they would re-think their recent transition to veganism, but that’s not for me to say. I also find Cal’s love of puns borderline pathological, but that should not bear on their ability to make rational decisions about their health. Cal is irrepressible, but their issues, medical or otherwise are absolutely controllable. Cal is also aware that the surgery in question is of an irreversible nature. Cal shares their partner and female traveling companion’s take on this truth: “Thanks for the mammaries.”
Cal is a kind and engaged member of their community. They successfully co-parent a 10-year-old boy who prefers to call them “Dad.” They have no additional diagnosable mental health conditions of which I am aware beyond the aforementioned.
I met Cal Cates when they were approximately 4 years old. They were playing flag football with the boys. They pulled up their shirt to cool off and were roundly reprimanded. This was the first of many incidents in Cal’s life when they knew that maybe there was more to this whole “being in a body” thing than they had previously understood. As they grew, they realized that it was less about being in a body and more about being in a culture, in a system, in a web of beliefs they had no part in creating.
Over the years, Cal experienced a variety of taunts. Cal -- whose loving parents named them Lauren Gayle because, honestly, how can you know when you’re looking at little pink ball of fingers and eyes and toes what this person’s name will really be -- was derided as “Laurence” by their brother and called dyke and bulldagger (which Cal looked up and discovered was not only hurtful, but just plain inaccurate) and a host of other insults by others over the years. Cal counts themselves lucky to have never experienced overt violence as a result of being who they are.
Cal has benefitted from a variety of types and styles of therapy ranging from good old CBT to narrative therapy to EMDR, a kind of whacky thing called “brainspotting” and also Internal Family Systems. In addition, Cal has engaged in deep personal work around shame, pleasure and guilt. Cal is clear that their career in caregiving is inspired largely by their sense of being unseen in essential ways throughout their life. They have always advocated for the underdog whether it be as a rape crisis counselor or as the Shelter Operations Director at a domestic violence shelter or as a meditation teacher at the county jail. Cal knows what it is to be inspired to care for others by a deep need to fill one’s own holes. And Cal has learned how to fill their own holes, as it were.
In their 20’s, Cal considered what was then called “sex reassignment surgery.” The cost and the “all or nothing” approach put Cal off and left them to spend the next 20+ years “figuring it out” for themselves. They have never hated their body. In fact, as a lifelong athlete, Cal has enjoyed their body more times than not and with an intensity not enjoyed by many. At the same time, Cal has not been much more than corporeal roommates with their breasts since they arrived. When they showed up, Cal had already surrendered to the reality that their body would do this. Then they started to menstruate, and then sexual urges began to emerge, but the incredibly nice and kind and smart boys who came around never quite scratched the itch. Cal knew they must be seriously broken.
There is so much more to this journey, but the adventure that has been Cal’s life since realizing they were different has been nothing short of fascinating and exhausting and yes, sometimes depressing. Now Cal finds it simply and deeply enlivening to be fully themselves. Each day, Cal feels it is their job and their downright privilege to step more and more into who they are, no matter where that leads.
In recent years, Cal has come to realize that is it the world and not Cal that is broken. They can now see that there is no option but dysphoria when a world you deeply understand as “yes, and…” is sold to you as “either/or.” The Body Shame Profit Complex works just as seriously on non-binary, queer bodies as it does on cis-gendered, heterosexual bodies. And it’s all a giant load of ladder-climbing bullshit.
Cal feels confident in the Truth they feel inside them. Nothing outside them can change that. Cal knows that they are beautiful, handsome, funny, smart, curious and a serious pain in the ass. They know that they need reminding about each of these aspects of themselves regularly. They are surrounded by a community of courageous and real humans who do just that.
I fully support Cal’s decision to undergo this procedure. They are the owner of their body. They are also the owner of any consequences related to the decision to alter it. Cal has given their informed consent and will be available throughout the process for consultation, as needed.
In closing, Cal has asked me to suggest that you consider creating a more empowering option for patients to move into a space of owning this choice when it is time to make it. Even as a self-possessed, solidly grounded person, Cal felt insulted, undermined and unseen by the request that a mental health professional be enlisted to attest to their ability to make this decision. Perhaps a preliminary questionnaire that could help you understand each patient’s motivations and the extent and strength of their support system might lead you to make a more discerning request that leaves the decision in the hands of the patient while, only when necessary, inviting additional support from a professional. The idea that another human should be empowered to grant (or refuse to grant) me the right to be fully who I am feels deeply out of step with the ethos of your practice. Cal thought you would want to know.
Cal’s most trusted resource