An information resource for and about
trans* people in the Province of Alberta
The following assumes that you are interested in or considering medically and/or socially transitioning. Transition is in fact not the only choice available to you. No choice is an invalid choice, and each step (presentation, identity, medications, surgery) is its own decision. The only rule is that you do what you personally need to do in order to be at peace with yourself.
If you need to transition, the process in Alberta is long, and you will have to be certain and committed. Once you begin, you make serious changes to your body that often cannot be reversed. Also, the waiting lists for the doctors who oversee this process are extremely long, so be prepared (acting sooner is better).
That's the bad news. There is good as well. But it is not a decision to be made lightly.
It is an extremely good idea to get out into the trans community, meet like-minded folks, and get a good feel for whether this is for you. Chances are, you'll meet some great, supportive people, and get a chance to get a balance of information, and some idea of where you will be on the other side of this journey. It is invaluable to have people to turn to with experience.
1) Gender Specialists
In Alberta, transition is currently addressed as a mental health issue, and Gender Dysphoria is not something that many psychiatrists deal with. At the moment, the doctors who can act as signatures for surgical referrals and / or assist a transition process are Drs. L. Warneke, J. Petryk, J. Raiche, and J.H. Brooks. Dr. Raiche is based in Calgary, and the others are based in Edmonton.
To see them, you will need a referral from your family doctor / general practitioner (i.e. walk-in clinic doctor), or a psychologist or psychiatrist. Once the referral is sent, you may still have to wait a long time for your appointment. Do not harass the clinic -- it will not get you seen faster. However, you can call the clinic a week after your referral request to make sure that they received it. You can also request at that time to be put on a cancellation list, meaning that if there is a cancellation sooner, you might be able to get in at that time. It can shorten your wait considerably.
One way to cope with the waiting period is to proceed as best you can with transition with your family doctor's assistance and / or peer support. Coming out to family and friends, name changes, facial hair removal, and changing outward presentation are all things that can be done before starting a medical process, and they can take a considerable amount of time.
Some trans* people opt out of the mental health path and prefer to take an approach called "informed consent." There is nothing wrong with this path, and in fact as trans-related medical classification changes toward a destigmatized form of care, it may eventually become the norm. However, for now, it is a more difficult path in Alberta, particularly in terms of finding doctors who will help.
After a referral from a gender specialist, it is often an endocrinologist who prescribes the hormones. Family doctors certainly can, but many are reluctant to, sometimes because of training limitations. For general practitioners who are willing to assist but unsure how, there are some resources for medical professionals listed on this site. If a person has another medical condition (i.e. diabetes) to be cautious of, it might also be recommended to see an endocrinologist. Whatever the case may be, it is important to monitor endocrine levels, especially within the first year, and it is important to have the relevant blood tests done and follow up with your doctor.
It is not recommended to take "black market" (non-prescribed) hormones. However, if you do start doing so, please discuss this with your doctor, so that your health can be monitored.
Please note that hormones are not to be played with. There are sometimes cis* (non-trans*) individuals who wonder about taking hormones for one reason or another, but with no intention of changing their physical sex. Hormones will do much more than this -- for example, estrogen will soften facial features, round out hips, bring on mood swings (it is very difficult for cis males to cope with the severity of the change), shrink the penis, reduce sex drive, and quite often they will cause sterility. This is only for those who are serious about transition.
Breast Development for trans* women is always a long process, taking years. The amount of growth is determined largely by genetics. Growth will not increase or occur faster by increasing hormone dosage. During the development, breast tissue will become very sensitive, and occasionally itchy or sore.
Trans* men will experience facial hair growth and may also experience hair loss. Facial hair growth will increase over several months, but the amount and quality can be variable. It is possible that after full transition, a person's facial and body hair might still be fine and sparse -- genetics once again play a big part
3) Standards of Care and the Real Life Experience.
Current medical practices follow the Harry Benjamin Standards of Care. The practice is that a person undergoes roughly a year living and working full-time as one's identified gender. Alberta Health requires that the RLE be fulfilled before SRS surgery is funded, and typically RLE is started before prescribing hormones or lesser surgeries. There are cases, including patients who are older or with certain medical conditions, in which this period might be shortened. The transition process is different for youth. But the intent of the RLE is to make sure that the person transitioning will be able to function, live and work as their identified gender and that they are fully committed to doing so.
4) Lesser Surgeries and Concerns.
These can differ from person to person. Many of them fall under cosmetic, though, and the costs are the responsibility of the person transitioning. These include breast augmentation, facial feminization surgery, laser hair removal / electrolysis, hair extensions / transplants / rejuvanation. Some of these procedures, such as breast augmentation, mastectomy or hysterectomy, are invasive, carry risks and will have a recovery period. Discuss these things carefully with your doctor.
Top surgery and / or hysterectomy for trans* men are both covered by Alberta Health Care, but the referral needs to come from a gender specialist. Few surgeons in the province will do these procedures for trans-specific reasons, and the ones who will tend to insist on a referral.
For many trans* men, mastectomy is the first and most life-changing surgery, ending the need to chest-bind or layer up. There are two main types of top surgery. One is double incision and is better suited for bigger chested guys. Two incisions are made under the pecs and these are used to remove excess tissue and excess skin. The nipples and aeriolas are taken right off, re-sized and grafted back on in the proper location. The downside is that there will always be scars. Depending on how well or badly the person scars and how hairy they are, the scars may or may not be noticable. They do fade eventually. The scars may be two straight or curved lines under the pecs and they may also meet in the middle. Some surgeons are not very good at re-sizing nipples and their patients may end up with 2 circles of aeriola and no actual nipple in the middle but that can be fixed later or just pierce the middle and voila, you have a nipple. Better yet, if your nipples are small enough to pass, just ask the surgeon to leave the nipple attached to the aeriola and just resize that. (note: although double-incision is a procedure of choice among doctors in Alberta, there is a high rate of failure when it comes to the nipple part of the surgery. The majority of trans* men who had nipples removed during surgery have ultimately lost them and much of the feeling in that region. If you're particularily attached to yours, you might want to see if other procedures are an option.) The other option is keyhole or peri-aeriolar and it varies between surgeons and the size of the chest if skin is removed and how much. Some surgeons do this as a two stage surgery, first removing excess tissue by going in at the side or bottom of the aeriola and a few months later after seeing how much the skin contracts they may cut around the aeriola and remove excess skin. If this is done on bigger chested guys, there is too much skin to remove to be able to close it nicely around the aeriola which may result in pleats in the skin and a not so good result. The only scar is around the aeriola so this can be a very nice result if it goes well. Some have tried liposuction in lieu of mastectomy, but be aware that liposuction only takes care of fatty deposits and does not do anything at all about other tissue and ducts. The most serious drawbacks to liposuction are that one lipo is usually not enough, and a person is usually left with loose "bag-like" skin that may not look right when shirtless, depending on original bust size.
After starting testosterone, periods stop and the ovaries atrophy and stop producing estrogen, but sometimes cramps and other problems develop. Some believe that a hysterectomy is not necessary for trans* men, and it's uncertain whether trans* guys have a higher rate of problems with these parts than cis* women but many prefer not to take the chance. There is some belief that trans* men masculinize faster after hysto, and it is also a necessary procedure to have done prior to having GRS.
There are two main types of hysto available. Abdominal incision requires making a 6" cut on the belly. The scar may be vertical from the belly button down to the pubic bone, possibly in the middle or off a bit to one side. It also could be a bikini-line cut, sitting horizontally in the crease between the belly and pubic area. The laprascopically-assisted hysto requires making 3-4 small incisions on the belly to stick in cameras and surgical tools and then the parts are broken up and passed out through the vagina. In both cases, the uterus, cervix and ovaries are removed.
Breast augmentation for trans* women is not funded by the province, and a referral is not needed. Again, however, there are very few surgeons (at times, none) who will perform them for trans* people in Alberta. Some travel to Vancouver for the procedure, or pay for it to be performed at the Montreal clinic at the same time as their GRS (though this lengthens recovery time and makes it more difficult).
For trans* women, it is highly recommended to start facial hair removal as early as possible. Laser hair removal can be particularly effective with a qualified, trained doctor on staff (very few have one -- be choosy, and be wary)... but laser hair removal is mostly effective on darker-colored facial hair against light skin. Electrolysis is less expensive but requires more treatments over a long period of time. Do your homework before choosing a laser centre, or electrologist, as these industries are unregulated.
Trans* men will usually experience significant change in their voice from taking testosterone. Estrogen, however, does not feminize one's voice. Trans* women will have to retrain their voices, and this sometimes requires professional voice training, which is available in many venues. In Edmonton, though, there are voice clinics at the Glenrose Care Facility and Grey Nuns Hospital. Calgary trans women can go to the Rockyview Voice Clinic. These clinics do require a referral though and have a wait period. An alternative to clinical voice training would be dramatic voice training, which is a different approach and can be found in some drama communities.
The tracheal shave to reduce the appearance of the Adam's Apple is not covered by Health Care. Voice surgery is also not covered -- again, research your options, but vocal chord surgery is not recommended.
Orchidectomy (a.k.a. orchiectomy, "orchie," or castration) is usually done for trans* women at the time of GRS. GRS surgeons discourage the practice of having orchidectomy prior to surgery (some even refuse to perform GRS if this is the case), as current methods tend to destroy valuable tissue that they use in their procedure. If one must have an orchidectomy prior to GRS, it is recommended that the surgeon do so by a midline scrotal incision, and save as much of the external tissue as possible (discuss with your surgeon, first).
5) GRS / SRS.
Alternately referred to as Sex Reassignment Surgery or Gender Reassignment Surgery (sometimes as "genital reassignment") obviously varies depending on the sex one identifies as.
For trans* women, vaginaplasty is a single procedure, and it has been well-perfected. Success rates are high, although with any surgery there can be risks. Extensive aftercare is required.
For trans* men, there are anywhere between one and three bottom surgeries, depending on the mode preferred.
Phalloplasty is the only surgery that results in a full-size penis, and is performed in three stages. The appearance isn't bad, but is also not exact, and a manually-operated valve is required for the penis to function. The first surgery constructs the penis using skin grafts taken from forearm or thigh, with the nerves attached to the clitoral nerve, and an extension to the urethra artificially constructed. If the donor tissue is taken from the arm (which usually results in better sensation), it is a good idea to have laser hair removal done on the donor area and helps to build up muscle tone to ensure there is adequate tissue. The second takes place usually a year afterward to install an erectile implant for functionality, and a third surgery is required to construct the testicles. Phalloplasty is not as perfected as vaginaplasty, results tend to be mixed, and satisfaction varies.
Alternately, testosterone causes the clitoris to grow, sometimes it ends up being 2-3" long. The surgeon can release the clitoris from the body to make it feel more like a small penis. When this is done and nothing else, that is called a clitoral release. The vagina and urethra are not touched for this operation.
Metoidioplasty goes a step further than clitoral release to reconfigure the genitals to a traditionally male configuration. The vagina is closed off by scraping the lining out of it and letting it collapse and heal shut. The outer labia is used to make a scrotum. The clitoris is released and lifted up and the labia minora used to form the bottom of the new penis. The urethra is extended to the tip of the new penis using the vaginal lining for the inside of it. This is a fairly small surgery, requiring three weeks in Montreal and back to work anywhere from 3 to 6 weeks after surgery. Testicle implants can be done 6 months later and require another 3 weeks off work but only 3 days in Montreal.
The surgery results in a small penis but normally with excellent sensation. It only utilizes what the person has so if they did not get a lot of growth, it will be very small. Many guys with meta's can not pee standing up through their fly because it's too small to reach. It has some erectile function, but it is often considered not enough for intercourse.
If a surgery is being funded, then Alberta Health usually refers to the GRS clinic in Montreal, which has an excellent website which has a Flash-based function that details the procedures that they perform.