How to Shop for Service Providers (1991)
©1991, 2013 by Dallas Denny
Source: Dallas Denny. (1991, Summer). How to shop for service providers. Chrysalis Quarterly, 1(2), pp. 9-12, 16.
In 1991 professional help for transsexuals was so hard to find we tended to be grateful for anything offered—whether good or bad.
How To Shop For Service Providers
By Dallas Denny
In the course of your transsexual career, you will likely consult a variety of persons who offer services you will need. You will pay money to these men and women; in exchange, they will give you something you need. You will be interested in getting the most service for the least amount of money, and they will be interested in giving the least service for the largest amount of money. It’s called capitalism.
For financial reasons alone, it will behoove you to choose service providers with care. But there are other reasons to be choosy. It’s your body you’re playing with, the only one you’ve got. If it gets messed up, it stays messed up. The calculated risks of changing sex are bad enough, without needlessly adding to them.
You must be certain you’re getting what you’re paying for. If you find out two or three years down the road that your electrologist hasn’t been killing your beard or that your endocrinologist hasn’t been giving you enough hormones to cause significant physical changes, you may find that your transition is delayed.
You must also be certain that the services are not actually harming you. An incompetent electrologist can make deep pits in your skin, and an incompetent plastic surgeon can leave you with a ruined chest or face. A beautician who doesn’t know what she’s doing can fry your hair, and a psychologist who tries to “cure” your gender dysphoria can lead you down the primrose path to suicidal depression.
You have the same rights as any other consumer. You should shop for services for your gender dysphoria just as you would shop for a good mechanic or for a family doctor. You must not be hesitant or let yourself be embarrassed by your condition. If you are timid, others will pick up on it, and do with you what they will. You should make your desires known on the front end, and ask the service provider if he or she can deliver. You should keep in mind that you have the right to a second, or even a third opinion, and that you can change doctors or psychologists or electrologists as early and as often as you wish. You have the right to ask reasonable questions, and to expect reasonable answers. You should screen your service providers in the same way that you would screen a prospective employee, auto mechanic, or fiancee. Ask for credentials and references. Most providers won’t be offended. If they are, or if they refuse to give you the information you have requested, there may be a reason. Avoid them.
You also have the same responsibilities as any other consumer. You should be polite at all times, and otherwise act in a proper manner. You should dress and behave as becomes a lady or a gentleman. You should pay promptly, and when you cannot, you should make arrangements before the service is provided, and stick to your agreement. You should show up for appointments promptly. If you are going to be late, or cannot make an appointment, you should phone as early as possible. Time is money for service providers. When you stand them up, you are opening their wallet and taking out their money.
The above paragraphs could have been written about any sort of health-related consumerism. However, there are some special considerations caused by transgenderism. You will probably want to present for services in the gender of choice. That’s fine, so long as it doesn’t cause difficulties. But you should remember that your service provider has other customers, and that they must be kept happy. Although you have the right to dress as you see fit, you must realize that early in transition your crossdressed status may be very obvious to others, and embarrassing to, say, a hairdresser with a shop full of women or a physician with a waiting room full of patients. And you’ll certainly look strange bopping into your electrologist’s office in a miniskirt and three days of Don Johnson stubble. Keep in mind the needs of your service provider, as well as your own. Compromise is sometimes called for. Perhaps an androgynous presentation would be acceptable to all parties.
Although your service provider probably won’t mind seeing you change over time, you should avoid seesawing back and forth, presenting as a female on one visit, and a male the next. It will confuse the receptionist (“What name do I bill him under?”) and make other clients uncomfortable. If crossdressing is physically or psychically difficult, or if you have less than complete freedom to come and go, you may be wise to present in your everyday mode. Your doctor will not be impressed with punctuality problems caused by the “I can’t possibly go in there; I just realized that my outfit doesn’t match my Lee nails” and “I couldn’t leave the house until my neighbor finished mowing his yard” syndromes. How you look is clearly secondary to being there on time. Your service provider realizes it, and you should too.
Things You Should Know About Service Providers
Things You Should Know About Service Providers
Therapists
Psychiatrists are medical doctors who have additional training in psychology or psychoanalysis. As physicians, they can prescribe medications, and often do.
Some psychiatrists rely heavily on psychotropic (behavior-modifying) medication to control the symptoms of their patients. Others use psychotherapeutic or psychoanalytic techniques, and rarely rely on medication. Psychotherapy is an exploration and working-out of problems in a therapy setting. Psychoanalysis is an in-depth exploration of subconscious motives for behavior.
Psychologists are trained in human behavior. It is the whole of their study. They are not physicians, and cannot prescribe medication. There are many different types of psychologists, but transgendered people usually deal with those with clinical or counseling specialties.
Other persons who do therapy are social workers, marital and family therapists, psychiatric social workers, and clergymen.
You should be sure to select a therapist who meets the Harry Benjamin criteria for Clinical Behavioral Scientist, and who follows the Standards of Care.
Therapy is not a horse race. It can and often does take months or years. Most therapists will not give you minimal times to achieve certain goals, but will let you work things out at your own pace. You shouldn’t expect miracles overnight, but over a period of six months or so, you should be able to see some progress. If you suspect your therapist of dawdling or stringing you along, bring the matter up. If you continue to be dissatisfied, ask for a referral to another therapist.
Endocrinologists
Endocrinologists are physicians with special knowledge of the internal secretions of the body. Some general practitioners will prescribe hormones, but it is best to consult an endocrinologist. Be sure she does blood work regularly, and that you are on a sufficient dosage to allow successful masculinization or feminization.
If you are moving in the female direction, your endocrinologist will put you on any of a number of brands of estrogen. She may also give you progesterone. She may prescribe the medication in either pill or injectable form, or, in a few cases, as transdermal patches or surgical implants. She may place you on an antiandrogen.
Female-to-male transsexual people should be wary of taking oral androgens, for they have been shown to cause liver abnormalities.
If you have questions about your dosage of hormones, you should seek a second opinion from another endocrinologist.
Electrologists
Electrolysis is the killing of hair by the application of electricity. A probe is inserted into the hair follicle, and current is applied. The hair is then removed with a pair of tweezers.
Some states license electrologists. But some states, including Georgia, unfortunately don’t. In states without licensure, anyone with enough money to buy a machine and enough energy to mash the foot pedal can legally do electrolysis.
Electrolysis, incompetently done, can seriously damage the skin. Or it may have no effect at all. The hair will appear to be gone, for it is tweezed, but it will eventually return. Continual treatment and tweezing may lead one to believe that beard growth is rapidly diminishing, when this is not the case at all.
Be wary of “needleless” electrolysis, which does not work, and of home electrolysis machines, which probably do not, either.
You should be very careful in selecting electrologists. Ask for referrals from customers (preferably transsexual customers) who have been cleared of facial hair.
Electrolysis is addressed more fully in an article by Debbie LaBarber, which appears elsewhere in this issue of CQ.
Plastic Surgery
Plastic surgeons should be certified by the American Board of Plastic Surgery. Be careful of credentials. Some “boards” require little or no formal training. The American Society of Plastic and Reconstructive Surgeons, and the American Academy of Facial Plastic and Reconstructive Surgery are two reputable associations of plastic surgeons, but there are others. You can call the American Society of Plastic and Reconstructive Surgeons toll-free at 1-800-635-0635 for referral to a reputable plastic surgeon near you. The board will also send you a brochure about selecting plastic surgeons.
Sex Reassignment Surgery
The number of surgeons who do genital sex reassignment frequently, reliably, and with great technical expertise is extremely limited. While many surgeons do reassignment surgery, only a few have sufficient skills to leave you with a state-of-the-art vagina, or with a penis which will pass muster in the locker room. You should search out surgeons who do sex reassignment for a living, and not as a sideline. And remember that quality is not always directly related to cost. Excellent male-to-female reassignment surgery is available for as little as four thousand dollars.
Your support group can provide you with the name of a reputable sex-reassignment surgeon. So will AEGIS, if you provide us with documentation showing you have been in real-life test for more than one year.
Medical Insurance
Medical insurance will often pay a percentage of the costs of therapy. You will need to check your policy closely. Some companies cover therapy at the same rate as other services, but some pay only fifty percent of costs. A few will not pay at all. Most have yearly or lifetime limits for psychological and psychiatric treatment. Some require that you see a doctoral level person, or even a medical doctor.
If you ask, most therapists will bill you in such a way that your gender dysphoria is not apparent. For example, you may be diagnosed as mildly depressive for insurance reasons, and as transsexual for your private purposes.
Hormonal treatment is sometimes covered by medical insurance.
Electrolysis is rarely, if ever, covered by medical insurance. In addition, beginning in 1991, the Internal Revenue Service considers electrolysis to be cosmetic in nature, and hence disallows it as a medical expense.
Cosmetic surgery is specifically excluded from coverage by medical insurance. Sex reassignment surgery (which is in fact not cosmetic) is occasionally allowable, but some companies have a history of erratic coverage of this procedure. The Internal Revenue Service considers sex reassignment surgery to be cosmetic in nature, and so excludes it as a medical deduction.
There are Service Providers, and There are Service Providers
Most psychologists, psychiatrists, endocrinologists, surgeons, and electrologists don’t treat transgendered persons. They are not aware of the Standards of Care, and would be uncomfortable with you and with trying to treat you. If possible (and it is not always possible) you should make the extra effort to find someone with specific training or expertise in dealing with transsexualism. They will know about the Standards of Care, be aware of the issues you need to deal with, and will have the wisdom of years of experience with people with gender problems.
Those who are gender-naive may be well meaning, but can waste a considerable amount of time and money—and it is not their time and money that will be wasted, but yours. You should ask yourself whether you can afford to educate a psychologist or electrologist, or whether your bucks would be better spent elsewhere. Knowledgeable electrologists, for instance, will tell you that treating the beard hair of males requires different insertions and machine settings than treating the facial hair of women. An electrologist who has several years of experience in treating transsexual people will probably have a higher kill rate than someone who has treated only genetic women. Likewise, an experienced psychologist will not be needlessly cautious in writing the magic letter which will give you access to hormones or sex reassignment surgery. An experienced endocrinologist will know that males will need about 5 to 10 times the hormonal dosage of women who have had hysterectomies.
It is always possible that you will get a psychiatrist or psychologist who will try to cure your gender dysphoria, or an internist or endocrinologist who will try to talk you into taking same-sex hormones. If this happens, don’t walk—run—to the nearest exit, and don’t go back.
Whoever you decide to see, don’t trust blindly in them. Constantly monitor their progress. Compare notes with your transgendered friends. Stay on the lookout for someone who is cheaper, closer to home, or has more expertise.
Here’s something else to remember: cheapest is not always best, but neither is most expensive. Look at the quality of service offered. How much value are you getting for your dollars? Would you be better off seeing Nyla, an electrologist who charges $45 an hour, or Lyla, who charges only $30.00, but removes only half as many hairs? No, this is not an algebra problem.
Differences in Technique
In addition to questions of competence and expense, you should consider the procedures favored by your service provider. For example, there are three types of electrolysis: galvanic, blend, and thermolysis. Which type does your electrologist use? If you are considering breast augmentation, how will your plastic surgeon insert the prosthesis—under the arm, under the breast, or by removing the nipple? If you are having sex reassignment surgery, what method will your surgeon use—penile inversion, or penile inversion combined with transplantation of a section of large intestine? If you are having a hysterectomy, will your surgeon make a cut which will make phalloplasty more difficult?
A little research can help you to determine the advantages and disadvantages—and the relative risks—of the various procedures.
Locating Service Providers
Services are generally easier to obtain in urban than in rural locations, but even large metropolitan areas can be surprisingly dry. Some cities tend to attract transgendered people—San Francisco, New York, and Atlanta, for example—and consequently have more service providers than other areas. But in any urban area, service providers are probably there. The trick is finding them.
Perhaps the worst way to find services is to finger-walk through the Yellow Pages—but it works at times. If you have no leads, you can always go through the listings. It is best, when doing so, to be straightforward, explaining who you are and what you want. You will probably get a lot of negative responses. Don’t fret. Keep a record of them. Don’t stop at the first yes, either. Continue until you have several choices, and then call them back again and do a telephone screening. Chances are, it’ll save you time and money.
Gay Hotlines and Physician Referral Services may be of some help, but in general, they know as little about gender problems as anyone else. Still, it won’t hurt to try. You might visit a gay bar and pick up some of the free literature. It’s free because of the advertisements. All sorts of service providers have ads. Those who routinely treat gay men and women will be less likely to have a problem with you than those who don’t. You’ll find psychologists, attorneys, and cosmetologists aplenty.
The easiest and best way to find services is through the gender community. The gender community is an unofficial network of support groups, clubs, publishers, service providers, and transgendered persons. It can be extremely invisible, but it is there, active in every state (except perhaps North Dakota). Once you are plugged in, it is amazing how many magazines, newsletters, and meetings there are. And those magazines, newsletters, and meetings are great sources for referrals. Support groups, in particular, tend to know who provides quality services, and who does not. You’ll find that not only those who run the group, but the members, will be happy to supply you with names. If you get even one lead that pans out, the small price of admission to the support group will have been worth it.
OK, so how do you break into the gender community? The easiest way is to send $10 to the International Foundation for Gender Education (IFGE), at P.O. Box 367, Wayland, MA01778—or call them on the telephone at (617) 899-2212. Request the latest copy of Tapestry, their house journal. In it, you will find a comprehensive listing of support groups, social organizations, and gender clinics, as well as advertisements and notices of upcoming events. You’ll also find personal advertisements from transgendered people, some of whom may live surprisingly close to you. It’s well worth the money.
Just because you’re transgendered, you don’t have to accept second best. If you shop wisely, you’ll find quality services. If you don’t, you’ll waste money. It’s up to you. But I know you. You’ll do the right thing.
Won’t you?
Why Do Service Providers Treat Transsexual People?
Transsexualism is a controversial condition, and providing services for transsexual people can result in criticism from peers, opposition from rightist groups, and unwanted publicity. Having obviously crossdressed people in the waiting room can offend other clients.
In most instances, a service provider’s transsexual clientele will be but a small fraction of their caseload. There may be much more to lose than to gain by treating a small number of transgendered persons. And yet, many professionals go out of their way to provide quality services to their transsexual clients. Why? Because they care.
Despite my remarks about capitalism in the accompanying article, the prime motivation of most persons in the human service delivery field is not money. Most physicians, psychologists, electrologists, and social workers enjoy helping people. It is a part of the definition of their professions, and hence, of themselves. Those who see transgendered persons usually do so because they know there is a need for their services, and not because it profits them in any way.