Living in Colorado, I have heard of Trinidad the small town on the southern border of the state that had

d become a major center for sex reassignment surgery. Ive been through Trinidad several times and I have always thought of it as a rather sleepy little historic town, hardly somewhere that was known as the sex change capital of the world. In fact, when I visited there for a short time I had no idea that much of the small towns economy was built around this medical procedure. A 2010 article in The Denver Post gave the history of the town and explained that Dr. Stanley Biber came to Trinidad after serving in the Korean War. He came as a general surgeon, but was asked by a transexual to perform sex reassignment surgery. Dr. Biber contacted a surgeon form Johns Hopkins University for more information, received drawings of the procedure, and agreed to perform the surgery. It was a success and soon others were seeking him out. Marci Bowers, another surgeon, who had undergone the surgery herself, joined the practice. She soon made it famous and took over the practice entirely when Dr. Biber died in 2006. However, in 2010 due to conflict with the hospital in Trinidad, Dr. Bowers moved her practice to California. Stevens explains that, when it was open, the clinic in Trinidad was one of about fifty in the world that perform sex reassignment surgeries. This surgery has been being performed for about fifty years now and it is possible that there must be about one million post-operative transexual men or women in the world, as there are about 22,000 gender reassignment surgeries performed each year. I used to work for a doctor who performed facial plastic surgeries. Those who wanted to have a face lift simply came in and asked for the surgery, proved they could pay cash for the procedure, since it was not covered by insurance, and in only a few short days were scheduled to have the work done. I wondered if gender reassignment was this easy. However, I learned in Stevens book, Everything You Wanted to Know About Sex Changes . . . but Were Afraid to Ask:

A Primer for Male-to-Female Transexuals, that before someone can have the male-to-female surgery performed, there are five basic requirements that they must meet: 1. See a transgender-knowledgeable therapist and get a written recommendation from them. 2. Be given female hormones prescribed by a physician for at least six months. 3. Undergo electrolysis or laser hair removal for facial and possibly body hair. 4. Live full-time as a woman for at least six months; frequently a year is required. 5. Provide proof of the above steps to the clinic performing the surgery. While most sex reassignment clinics require that you have a letter of recommendation from at least one therapist, many require two letters with at least one from a psychiatrist. The World Professional Association for Transgender Health (WPATH), Teich reports, has written standards for treating trans patients. Therapy will allow the professional to decide surgery eligibility based on whether or not the trans patient displays persistent and well-documented gender dysphoria, has the capacity to make a well informed decision, is the age of majority in the country they live in, and whether or not there are medical or mental health concerns present. Stevens agrees that therapy can also be helpful to trans patients as it can aid them in determining if they are, indeed, a transexual; assist them in coming out to family, friends, and coworkers; work with them on any internal transphobias they may have; and guide them through the emotional changes they will experience. Hormones are a two-step process for transwomen as testosterone is so powerful that they must take androgen suppressants along with female hormones, Teich tells us. As the hormones begin to take effect breast tissue increases, body hair growth decreases, body fat is redistributed to a more female and curvier shape, sexual libido will decrease, and skin texture will soften.

Estrogen does not alter the voice so transwomen usually take voice lessons to learn how to speak with a feminine inflection to the voice. Stevens points out that living for up to a year as a woman full-time can be a real life test for trans patients. They often learn just how much people will treat them differently. A good example is that an auto mechanic will often talk to a man as an equal, but talk down to a woman. Just dressing as a woman can be stressful for a transwoman, Teich concurs. Transmen are allowed, of course, to wear jeans and ball caps. In fact, many may have already been dressing this way as it is more accepted in Western society for females to dress as males than vice versa. Transwomen, however, must begin to wear womens undergarments, and may want to wear dresses and high heeled shoes at times. Transwomen require more body enhancements than do transmen. Stevens tells us that facial and body hair removal can be a long and expensive procedure, but must be done. While hormones will encourage breast growth they usually dont make them as large as a patient might want, so breast enhancement surgery may be needed. Furthermore, often those labeled as males at birth, tend to have more masculine features causing the transwomen to undergo cosmetic surgery. Finally, Stevens writes, sex reassignment surgery is the next step. It is not as expensive as one might think, but normally health insurance does not pay for it. It is less expensive overseas, such as in Thailand, but can still cost in the tens of thousands. A hospital stay of a few days to a week can be expected. Patients can expect to return to their normal life within about two weeks, but full recovery takes up to six months. Transmen can choose to have top or bottom surgery, or both, Teich reports. Top surgery reconstructs the chest to be more masculine. Bottom surgery is not as common and is available in

two types: metoidioplasty or phalloplasty. In metoidioplasty the clitoris is released, having been enlarged by testosterone, until it resembles a small penis. The urethra can be extended and rerouted so that urination while standing is possible. Furthermore, the vagina can be closed and a scrotum formed from existing tissue and implants. Phalloplasty, on the other hand, is when a penis is constructed from a donor skin site and is attached along with closure of the vagina and a scrotum formed. This procedure takes multiple surgeries, as well as an erectile prosthesis. Full sensation requires about a year in these surgeries. Transmen can opt whether or not to have a hysterectomy along with the other surgical procedures. I was happy to learn that the American Psychiatric Association voted on December 3rd of this year to remove the term Gender Identity Disorder (GID) from The Diagnostic and Statistial Manual of Mental Disorders (DSM-V). GLAAD reports that is being replaced by the term Gender Dysphoria. I asked a friend who is a social worker exactly what this meant. He told me that Gender Dysphoria will be used to describe the emotional distress that a transgender goes through when their physical body does not match their expressed gender. GLADD sees this as a 21st century step in removing the stigma associated with the term disorder. In the fall of 2010, Wired Magazine reported that Cytori Therapeutics, a San Diego biotech company, has discovered a way to use stem cells mixed with fat cells to grow breast tissue. The company states that this is a way for women who have undergone breast surgery, even a radical mastectomy, or who simply want breast augmentation to grow their own natural breast tissue. This leads me to wonder if this same procedure could be used for a transwoman combined with the hormones the physician has prescribed. If so, this could save them from needing a more artificial breast augmentation.

Although we have a long ways to go in eliminating discrimination toward transgenders, we are seeing some positive changes during the 21st century. A quick search of the internet finds that many campuses, in particular, are at least exploring the idea of gender-neutral restrooms. States, cities, and counties are passing anti-discrimination laws and tightening up hate crime laws. The medical field, always searching for advancements, may be able to apply new techniques to sex reassignment surgeries in the future and the APA is removing part of the stigma by no longer calling transgenderism an identity disorder. Indeed, the 21st century is bringing a brighter future to our friends and family whose biological body does not match their gender expression. A few months ago a woman I guessed to be in her mid-fifties came to my office and told me she would like to do a name change. She instantly reminded me of my mother-in-law. She was a large-boned, tall woman who I would not describe as traditionally beautiful. However, it was immediately obvious that she knew how to care for herself. Her blonde hair was attractively styled, her cosmetics expertly applied, and her nails professionally manicured. Her clothes were feminine, yet professional and she moved with a grace that only a confident woman portrays. I immediately told her that she reminded me a lot of my mother-in-law. She beamed at me and instantly became very warm and friendly. She then handed me her shiny new drivers license along with an official court document showing a name change from a traditionally masculine name to a traditionally feminine name. I took them and scanned the documents, entered the new name in the computer and then, after glancing once again at the license, said Would you like me to change your gender as well? She replied, Yes, dear, please do.