Transition takes time. Everyone wishes it weren’t so. Trans people wish it were over in the time it takes you to say “knife”. So do all the people made uncomfortable by transitioning people (which is almost everyone — we do love our tidy boxes). But, there it is: it takes time. Time for hormones to work. Time for hair to grow out so that you seem cis enough to get by (head hair, for most trans women; facial hair, for most trans men). Time to learn speech patterns and social interactions so that you become apparently cis enough to be able to get a job, and/or keep a job, and/or go to the bathroom, and/or not to be a choice target for anti-trans violence.

It takes time. Pretty much a year, minimum.

In my case, it took several years. I started taking hormones, and my body started to change. One of the most visible changes was that my breasts grew. Since I was still changing in the men’s locker room, and still wearing a ballistic vest designed for a male torso for 8 to 20 hours a day, my breasts were inconvenient.

I could hide them, at work. The strategies are numerous. Wear a tight sports bra. Change in the toilet stall. Arrive at work with tight sports bra under opaque undershirt and shuck out of the floppy fleece outerwear and into the ballistic vest while facing away from the men in the locker room. It helps to roll your shoulders forward a little, so that the fabric doesn’t outline the breasts. If you’ve sweated into the vest during the shift, use the toilet stall strategy so that the sweat patterns in the undershirt don’t show the outline of the sports bra. The diciest moment, for me, was doing the bench press during my fitness test. In the bench press, you’re flat on your back, and the down position has your elbows way down past your back. TWO layered compression shirts did the trick, though.

So I could hide my breasts, at work, and I did.

But I couldn’t hide them at the doctor’s office. A nurse would check me in. A doctor would expect me to remove my shirt. I’d have to come out to staff and put the fact that I’m trans in my chart, and all of the medical providers in my region are members of the community, so that might lead to me being outed at work before anyone was ready, which could lead to loss of job, inability to pay mortgage, loss of house, and devastating consequences for my family.

My society’s attitude toward trans people makes it meaningfully dangerous to come out, or even to risk the possibility of having to come out. So I weighed my options and chose my gamble. And I didn’t have a standard physical for over four years. I just saw my endocrinologist, who treats a lot of the trans people in my region, and who was safe to trust. But he was supervising my hormone therapy, not giving me standard screening physicals. I decided that was good enough, and rolled my dice.

When I came out at work it was finally safe to talk to a general practitioner and get basic care, it felt like such a relief. I could finally speak plainly to my doctor, I thought, and be myself. My old doctor, who was great, had moved on to another practice, so I had to come out to a brand new doctor, which I did. My wife, Lioness, came with me. She is wise: she wanted to communicate without saying a word that I had family support, and be a witness in the event that things did not go well.

I say that it felt like a relief, to be able to speak openly about myself, but it was also potentially very stressful. Looking in the mirror, I did not seem very cis, which can be key to being treated like a human being. I had heard horror stories in person from other trans people, and in news stories: medical professionals refusing care, even in life-threatening circumstances; medical staff telling trans people presenting with serious non-trans-related medical problems that “we don’t treat people like you.“.

So I was nervous. I tried to put a good face on it.

The nurse who did the intake wanted nothing but good medical care for me. She was firmly of the opinion that I and my brand-new breasts should get a mammogram. After all, I’ve been an adult for decades! I, on the other hand, did not believe that I should, since my breasts were new and possibly still actually developing, though at the tail-end of that process. I do not think that developing breasts should be irradiated without a very compelling reason to do so.

As I say, the nurse wanted nothing but good medical care for me. So, she made a smiling and enthusiastic pitch for standard medical screening, and started her smiling, enthusiastic pitch thus:

“So, you’re basically a guy, right?”

No. No, I am not. I am absolutely not “basically a guy”. “Basically a guy” is exactly and precisely what I am not. At base, I am a gal. I tried to be a guy, and it turned out I was a gal no matter how much we all tried to make me a guy. I cannot think of a single circumstance when that would ever be an acceptable question to ask any woman, cis or trans.

However, I knew what she was getting at, and when it comes to taking offense, I’m a slow burner. There was about a two-second pause as I struggled to find some response, any response, which would not be counterproductive.

I allowed, “…I have about forty years of life experience in a male-shaped body…”

She grinned happily, a merry ear-splitter of a grin. “Right! So you should…” and she made her pitch. I told her I would think about it. She left.

Dr. B came in. She had reviewed my chart. She led with, “So, I assume you’ve had both surgeries.”

Both surgeries? My mind raced. Surgery #1, in her mind, must surely be genital surgery, because people seem to be congenitally incapable of conceiving of trans people without thinking genitally. Was surgery #2 breasts? Most people don’t know about facial feminization surgery, so although FFS was factually likely, perhaps, it (a) probably wasn’t what she was thinking, and (b) was obvious on its (my) face that I hadn’t. Well, when in doubt, speak plainly with your medical provider:

“Which surgeries do you mean?”

Suddenly Dr. B looked uncomfortable, and I realized that she had taken a shot at seeming knowledgeable, and missed her target. I told her what surgeries I had had, at that point. She became more flustered. We discussed my medical history, and talked about mammograms. She agreed that the standards were not developed with my situation in mind, and that perhaps we should wait a couple of years.

I had no specific complaints; I had just wanted an annual physical and to meet my new doctor when there was no particular urgency. She confirmed that I had no complaints, and then said, “I don’t think a physical exam is necessary, do you?”

Now, a physical exam was clearly the correct medical protocol. I had not had a physical exam in over four years.¹

I should have thought faster, at this point. Or taken more time. Yes, I certainly did want a physical exam from a capable professional, because I had not had one in over four years. Which she knew. But my mind, already whirling and trying to make a good thing out of a trying situation, came up with something like this: “No, I guess not, if you think it’s not necessary.”

She agreed, and fled the room. She did not actually run, but her pace was definitely on the spritely side of brisk.

Discussing it, afterward, Lioness and I agreed that I had not received good medical care. Unfortunately, unless we chose to make an actual stink about it, it would be a year before I could get a regular physical again, unless I wanted to pay out-of-pocket.

Now, unlike some trans people I have no difficulty interacting with my body, on a daily basis. That is not the nature of my dysphoria. So, I am able to pay routine attention to my own body and do the usual self-monitoring. I was fighting enough battles on enough fronts, being in the middle of social transition. I decided to wait a year. During that year, I called in and changed the designated Primary Care Physician for myself and my family. I don’t need a medical provider who pretends to knowledge she doesn’t have, and who flees the room to avoid touching me, and my wife and I did’t want such a doctor examining our children.

It was less than a year later when I found the lump.² I took it to the doctor the very next day (my new doctor had seen me once already for a pre-surgical screening). She referred me to a specialist (that same day). They ultrasounded it and scheduled me for surgery for removal (that same day) and biopsy.

What said the biopsy? It was cancer.

Fortunately, it was Stage 1 and there was no sign that it had gone anywhere. I had caught it early and they had probably removed all of it. There will be followup screening. But if everything follows statistical norms, then in a few years my chances of longterm survival will look just like everyone else’s. Or, at least, everyone else’s who is a trans, and a police officer.

Everybody loves a happy ending.

But consider Alternate Trans Gal (ATG), trying to get by in this world.

In my case, who caught it? I did. Who treated it? A team of medical professionals at a premiere medical complex in New England, a facility where I myself have assisted at staff trainings on how trans people are actually people, and how to treat us as such.

ATG might not be that lucky. It would be very easy not to be that lucky.

Suppose ATG’s dysphoria were such that she could not comfortably handle or examine her body? She would not have found the lump. Eventually systemic symptoms would drive her to the Emergency Department, where they would find Stage 4 cancer in multiple tissues.

Suppose that, being trans, ATG could not get anyone to hire her, so she had no medical insurance? There would be no casual medical visits to examine a small lump which might just go away by itself, and no doctor would see it until, at earliest, there were significant systemic symptoms. At that point, she would have a metastasized cancer and would probably be Dead Woman Walking.

Suppose ATG’s doctor refused to examine her because she was trans, because the doctor’s society had taught her explicitly and implicitly that people like ATG are disgusting, or disturbed, and because the doctor’s medical school training never contained a single mention of people like ATG and how to treat us like people? (See the previous links; for instance, what if ATG lived in Africa, or Idaho, or Illinois, or further down the Eastern seaboard?) Suppose, in other words, that ATG’s doctor had been like my Dr. B? The doctor might not refer ATG for followup care, and ATG would die of cancer.

Suppose any of the specialists said, “I don’t know how to treat people like you?” ATG would not receive an ultrasound, would not have prompt surgical removal of all of the cancerous tissue. And AG would die of cancer.

I’m probably not going to die of cancer. But I’m under no illusions: I got lucky, and also I was able to advocate for my own care in a way that many people can’t. My society teaches a lot of medical providers not to treat people like me properly, or at all, and a lot of them never learn differently. Having transitioned, I can no longer even travel within my own country with the level of safety I used to take for granted. Next time I might not be so lucky. I might not be able to advocate for my own medical care. I might not be conscious.

Next time it might be a femoral bleed after a drunk driver plows into my taxi while I’m visiting a friend in, oh, Oregon. The sort of accident that just happens to people sometimes. And then some paramedic may learn somehow that I’m trans and recoil in horror and fail to stop the bleeding.

And then I’ll be dead.

Grace

1. When I later got to this part of the story with an experienced nurse who works in the same facility and has seen everything, she nearly dropped her teeth, labelled it as malpractice, and demanded to know the doctor’s name. I gave it to her. [↩]
2. It would not have shown in a mammogram. [↩]