Changing Your Mind – Thoughts on TMS

Changing Your Mind – Thoughts on TMS

Over the past year, and especially since the publication of Switched On by John Elder Robison, there has been a lot of attention around a therapy called TMS (or rTMS–Repetitive Transcranial Stimulation).

It’s something I have deep reservations about but others have written passionately and eloquently on the subject. What I want to consider is why somebody would choose to undergo such a therapy that literally changes their mind.

I’m no stranger to the negative feelings that arise when considering the gap between how I perceive myself and what I see when I look in the mirror: that’s a big factor in my gender dysphoria.

I also know first-hand how it feels to be teased and ridiculed for hand flapping, physical clumsiness, social awkwardness, unusual speech patterns and eclectic interests. I’ve had life-long difficulty making and maintaining interpersonal relationships, and I have times where I feel keenly the lack of people with whom I feel comfortable opening up about my problems and feelings.

I understand the drive to make physical changes to one’s body. After all, I’m in the process of seeking treatment to modify my own body, bringing it into closer alignment with what I see in my mind by erasing or concealing male characteristics and developing female ones.

There are two parts to my gender dysphoria. First there is my need to have other people respond to me as a woman, reinforcing my gender identity. Second there is my need to see my own body physically match the mental image I hold.

So as a trans woman I am actively seeking treatment to make changes to my body. This is in contrast to my feelings about my autism. Both my gender identity and my autistic identity go to the very heart of who I am.

The thing is, although I will happily modify the physical characteristics of my body I wouldn’t consider altering my mind. My neurology is inextricably tied to my identity: I feel that changing my mind would make me into a different person.

There’s a line there. I’ve put a foot over that line a few times, testing the water so to speak. I’ve experienced the effects of drugs that affect the workings of the brain: alcohol, marijuana, amphetamines, SSRIs (anti-depressant).

Some of them have positive aspects. For example, alcohol reduces my social anxiety. But there are negatives too: I make poor decisions under the influence of alcohol because it inhibits my self-control and risk-aversion: I’ve gotten myself into some dangerous situations as a result.

Speed (amphetamine) left me unable to concentrate, marijuana was relaxing but caused mild hallucinations and a degree of paranoia. The SSRIs reduced the intensity of my emotions, leaving me feeling numb: in the end I had trouble focusing and engaging with things in my life.

These were all temporary effects: my mind returned to its usual functioning state in time for which I was grateful. You see, I wasn’t myself when under the influence of any of these drugs.

I guess my point is that given the complexity of the human brain and the way its many regions interact it is not possible to adjust one aspect without affecting others. Just as a particular drug affects a small number of electro-chemical interactions in the brain with wider-reaching side-effects, so a therapy like rTMS that alters a small region must cause knock-on changes across the entire organ.

My opinion is that it is not like tuning an engine, a relatively simple system with a limited degree of interconnection and feedback between its components. It’s more like introducing a foreign species into an existing ecosystem. The effects can be slow to manifest, and predictions are error-prone due to the complexity and chaotic nature of the system.

There is no way to know what other effects rTMS would have. It might reduce my social anxiety, but even if that was all it did it would make me respond differently to people I interact with (like alcohol). And if my thoughts and behavior are changed then I’m no longer the same person.

I don’t want to change who I am: I’m comfortable with my identity as an autistic trans woman with all that entails. Changing my body doesn’t affect my personality, my thoughts: I remain me. Changing my mind makes me into somebody else. I would lose the essence of what makes me this particular unique individual, and the thought of that fills me with dread.

This leads me to suppose that for somebody to even contemplate such a thing they must not like who they are. Internalized self-hatred, blaming their neurology for what they see as their failings. It’s like body dysmorphia projected onto the ego, the sense of self. The antithesis of neurodiversity’s principles; an inability or refusal to accept one’s differences.

I see this as a result of thinking colored by the medical model of autism that sees it in terms of pathological deficits, as opposed to the social model which instead looks to society’s failures to provide suitable accommodations and acceptance as the causes of disability.

There’s nothing wrong with my mind: I have no reason to change it. I can’t say the same for the society I live in.

One Step Closer

One Step Closer

One week ago today I was in London attending my first appointment at the Charing Cross Gender Identity Clinic with one of their resident psychiatrists.

Although I was excited by the prospect of getting one step closer to accessing medical treatments for my Gender Dysphoria, I’d not been looking forward to traveling up there by train. I find using public transportation particularly stressful even when I’ve planned the journey meticulously: being confined in a small space with a group of strangers for a length of time causes me anxiety.

I worked until 11 am and then drove home via a store to pick up something quick and simple for my lunch during a brief stop at home before freshening up my makeup and heading out again to Farnborough, leaving myself plenty of time to park, walk to the station and buy my ticket. So far so good! The train arrived 15 minutes after I had taken a seat on the platform to wait, and I boarded along with several other people.

The carriage was about half-filled and I managed to find a seat next to a window. I much prefer to spend the journey staring out the window rather than risk making inadvertent eye contact with some person as I glance around inside the carriage.

It was about 45 minutes later that the train arrived at London Waterloo where I had to head to the Tube station to continue my journey. I don’t enjoy using the Tube, but it’s preferable to either the expense of a taxi or the uncertainty of trying to navigate bus routes. The only thing I do enjoy about the Tube is thoughts of Neil Gaiman’s Neverwhere that are evoked by the names of the stations as I pass through them or see them on the maps: Knightsbridge, Earl’s Court, Blackfriars.

One change at Piccadilly Circus and I arrived at Barons Court, the closest Tube station to the clinic. A short walk (0.7 miles according to Google maps) brought me to the clinic and I pressed the door buzzer to be let in. Through the door, up the stairs, through another door and there I was at the reception desk.

I handed my appointment letter to the receptionist and confirmed my details (name, home address, doctor) before being asked to take a seat in the waiting area. I had a little trouble picking up what the receptionist said because she wasn’t facing me as she spoke, instead looking down at the paperwork on her desk, and had to ask her to repeat herself a couple of times. I rely on lip reading to a degree when somebody is speaking so that I can better make out the words.

I sat down. I had arrived half an hour before my appointed time, which allowed me to sit and relax after the journey. I let my mind wander, daydreaming, and it seemed that very little time had passed when I heard my name called by the psychiatrist I was due to see. I followed her to her room and she began my assessment.

I was a little nervous at the start, but the opening question, “Why are you here today?” was easy enough to answer since it is something I have been thinking about since before I came out last year. The questions were quite comprehensive and covered my medical history, family, home and work situations, and my experience of gender non-conformity up to and including transitioning.

We established my priorities for treatment (facial hair removal, hormones, genital surgery, voice feminization) and I was pleasantly surprised when she said that they could apply for funding to cover electrolysis or laser hair removal. I guess it’s because it’s such a major issue for me: I had no hesitation in identifying it as number one on my list because it’s the thing I focus on every time I look in a mirror.

Hormone treatment came second because I need the changes they bring to body shape (breast development and redistribution of body fat) to reduce the gap between my self-image and my physical reality. Genital surgery was a definite yes, although it was only when she asked directly about the mechanics of sex between me and Anne that I actually realized how much of an obstacle the wrong genitalia has become.

Voice coaching was not something I had thought much about. I had largely resigned myself to getting called “sir” on the phone. It got added to the list after I talked about how I used to enjoy singing karaoke now and again, but haven’t felt able to do so since I transitioned because my voice has too low a pitch. I joked that I’d never be singing soprano whatever happened, to which she responded that I might be surprised how much a voice can change. I decided then that it was definitely worth a try.

That completed my first assessment. I was asked to make an appointment for my second assessment (with a different clinician) which will be in 6 months time, and sent for blood tests at the neighboring Charing Cross Hospital. Once they had drawn the blood samples it was all over, time to head home.

It all seemed to go very smoothly. There was no hint of judgement in relation to my expression of my gender identity, my age at transition, my sexual orientation, my depression, anxiety or poorly-developed social skills. I simply responded to the questioning and put across how I felt about the mismatch between my physical body and my gender identity. In other words, the reasons why I need medical treatment.

The journey home was difficult. It was the middle of rush hour (5:30 pm) with thousands of people crowding the trains and station concourse. It was only my determination and desire to get back home that stopped me from finding some cafe to sit and wait for everywhere to become less crowded. It was standing room only on the train out of Waterloo, passengers filling the aisles with barely six inches between me and the people around me. Luckily the majority of passengers left the train at the first stop, the commuter town of Surbiton, and I could sit for the rest of my journey.

It was with relief that I stepped from the train on arriving at Farnborough, and despite the light rain I enjoyed the walk to where I had parked my car. Getting into my car felt so good. I was finally back in my own space, able to relax and feel safe. The roads were not busy and it didn’t take long to drive home where I could put my feet up, relax with a glass of cider and spend the remainder of the evening with Anne: that was when I realized just how tired I was.

It took a couple of days before I completely got over the exhaustion from the traveling, but it was well worth it to progress past another milestone on my path to fully realizing my identity.

We Care A Lot

We Care A Lot

Being a carer is hard work at times. Don’t get me wrong: I’m not complaining. I do it through choice. But lately caring for Anne has become a whole lot harder. Her illnesses have gotten worse and she has become very depressed, frequently experiencing suicidal thoughts.

I can’t switch off from it. I’m receptive to her state of mind, and — believe me — when you’re prone to depression yourself it’s extremely stressful to feel the echoes of somebody else’s. It negatively affects my own emotional state and after a while, day after day, it builds up to the point at which I have to do my best to shut off. To lock myself away and wait for the overwhelming feelings to recede.

It is exhausting. I have found myself needing to take a break more and more often. And that is a cause of stress in itself because I feel guilty for failing to be there constantly. She relies on me, she needs my help, and I’m not always able to respond.

I’m aware that I’m not looking after myself as well as I would normally. I’m mostly subsisting on take-out food and candy. Things like washing are falling to a bare minimum. I’m becoming snappy far too often, my motivation is poor and I’m feeling low. Oh, and aspects of my gender dysphoria are increasingly intruding on my thoughts.

There is a feeling that I’m losing control, adrift and at the mercy of life’s currents. I know from past experience that this is a dangerous situation for me because it is a powerful trigger for self harm: cutting in my case. The thoughts and impulses are there, even as I write this. I sat for about an hour over the weekend holding a blade, just thinking about using it.

I haven’t yet because I do consider it something of a last resort. I’m just concerned that the time when I yield to my impulses is getting closer by the day: the time when I will regain the illusion of control over my life, at least for a while. The temptation is strong but so far my fear of falling into the cycle of dependency has stayed my hand.

My Experience of Gender Transition

My Experience of Gender Transition

It’s over seven months now since I transitioned to living full-time as a woman and I think it’s a good time to review what has happened in that time and what I’ve learned.

My Work Transition

At work
Hard at work (soundtrack by Green Day)

The time has certainly flown. It doesn’t seem so long since I first turned up at work as Alex. Perhaps preparation was the key — I discussed it with HR beforehand — but it went without a hitch. I visited a local solicitor on a Friday evening to have my Statutory Declaration — my legal change of name — witnessed. I had printed several copies of my own document based on a template on the Citizens’ Advice Bureau web site. The solicitor checked the wording and I had four of them witnessed at £5 each. Quite a bargain! and I ended up with four original documents from which I made a number of photocopies. (Some organisations require an original when changing one’s name; most do not.)

The following Monday morning I arrived at work as a woman for the first time and sent a company-wide email in which I simply stated that I am a trans woman and I had changed my name. I included a brief description and links to information on the web as well as two of my own blog posts.

The reactions ranged from total indifference to active support, and sitting here months later I can say that I have not had a single negative experience at work. Understandably, since I had been in the job for seven years as a male, some people have slipped up occasionally with pronouns but they correct themselves and I just let it go as an honest mistake.

Changing my name on my employment records was straightforward with a copy of the declaration for my personnel file, and I had already contacted the Inland Revenue and my bank to inform them so that all my details would be in step. I was issued a pass in my new name with an updated photo, and my company login and email address were altered that same day.

What Happened Since

When I transitioned at work I was taking medication for depression that was caused by my gender dysphoria. I’ve written about that before, but I’ll just summarise: the SSRI pills (Citalopram) helped a lot initially with the low mood, loss of appetite and poor concentration, but I did suffer moderate side-effects including nausea and disturbed sleep. After I transitioned I increasingly felt that the negatives of the medication were outweighing the benefits, especially since transitioning improved the circumstances that were the main cause of my depression.

Now that I’ve been off the pills for several weeks I feel more myself. I’m better motivated, I’m sleeping well, my appetite is normal and I’m able to concentrate fully. I do still feel very low at times — the depression hasn’t been magically cured — but it’s manageable.

My relationship with my wife, Anne, continues to be strong even though her illness means we have not been out socially at all since New Year. Her support is another factor helping me cope with my depression.

What I’ve Learned

I went into my transition with an open mind and only the minimum of planning — not one of my strengths. All I have — all I need — to guide me is my self-image. I know who I am and the steps I take along the way are to bring me closer to that.

That’s not to say I didn’t learn all I could about transitioning, about the various options for medical treatment and about other trans people’s experiences through their writings. There are a number of things I’ve learned; some practical, some important and some trivial.

  • There are no “right” or “wrong” ways to transition, no particular order in which steps must be completed. Indeed, there are no compulsory steps at all. It’s important to find what works for you because your situation and individual needs will be particular to you.
  • It takes longer to get ready in the morning. Showering, dressing, applying make-up and styling my hair means that my morning routine is longer and more time-consuming than it used to be. Rather than get up earlier I now start work later. (I’ve never been a morning person!)
  • I am very self-conscious about my facial hair. I have not yet had any form of hair removal treatment so I rely on shaving my face and reducing the shadow using make-up. I am reluctant to go out the door, even into our back garden, without at least a shave and some foundation.
  • I hate shaving my face! I have sensitive skin and after shaving it is always reddened, dry and sore in places. I also, despite all my years of experience, still manage to cut myself with the razor more often than not.
  • Pretty much everybody I interact with at work and outside just treats me normally. Maybe I shouldn’t be surprised, but I kind of expected to be regarded as a bit of a freak. This was one of my most pleasant surprises.
  • I feel more vulnerable when I’m out on my own than when I was presenting as male.
  • The NHS services for the treatment of gender dysphoria are seriously under funded and under resourced. It took over 6 months to even get a response from the Charing Cross clinic after my referral, and it is likely to take many more months before I get my first appointment for assessment. All this is required before any treatment such as HRT will be considered.
  • There is more variation in the sizing of women’s clothing than men’s. One item labelled size 20 (UK) could be equivalent to another labelled 16. Being able to judge a garment’s size by eye is a useful skill to develop.
  • Driving in heels doesn’t affect my control of the vehicle but can cause a lot of wear on the backs of the shoes. I now wear flat shoes for driving and change when I get where I’m going.
  • Having my ears pierced didn’t hurt much at all. I guess the earlobes are not very sensitive.
  • It’s not worth spending a lot on clothes when starting your wardrobe for your new gender role. It takes time to learn what colours and styles suit you, and what feels most comfortable.
  • It is worth having a reasonable budget for shoes, and taking your time when choosing them. Don’t forget that any shoes for work will be on your feet all day, so don’t sacrifice comfort for looks.
  • Sports bras that have built-in padding work great with breast enhancers (aka “chicken fillets”). They’re comfortable, keep things in place well, and the pads smooth out any “lumps” as well as adding a little extra size.
  • A lot of women’s clothes use softer fabrics than men’s, which is a bonus for someone like me who has above normal tactile sensitivity.
  • Fancy outfits are fun and great for going out (or to work), but don’t forget to include something casual for popping down to the shops, lounging around watching movies, and doing chores. As much as I love a dress and heels, I find a T-shirt and leggings or pyjamas are most comfortable and practical in and around the home.
  • Invest in a practical bag. Very few dresses or skirts have pockets, so you’ll need something to carry your wallet/purse, keys, phone, etc. while making sure you can actually find these items. It’s not good if retrieving your keys means emptying your bag every time you arrive at your front door!
I Have a Choice?

I Have a Choice?

A recent story shared by George Takei on Facebook about a 12 year old winning the right to have his birth certificate changed to reflect his correct gender attracted a lot of comments. This is not surprising, nor is the fact that so many were negative or transphobic. Not surprising, but very depressing.

Along with the usual equation of physical characteristics with gender (penis = male; vagina = female) there were many comments saying that 12 was too young to make this kind of choice.

Choice? Are they suggesting that somebody can choose their gender the same way they choose what to wear or eat?

Coming out, informing people around you that your gender is not the one you were assigned at birth, is not a lifestyle choice like being Vegan. It is a recognition of the true essence of one’s self.

If you asked a hundred random people of all ages what their gender is you would almost always get a hundred definite answers. Would you doubt that these people know what gender they really are? Would you insist on testing their chromosomes and genitalia? Would you even dare to ask a random stranger to confirm their gender?

So why is it that the element of doubt raises its head when the “transgender” label is present? Surely a transgender person has just as clear a view of their own gender identity as anybody else.

I didn’t choose to be a woman. I appeared to be male at birth and was raised as such. But from puberty onwards (about age 11) I knew that my body didn’t develop correctly. It didn’t (and still doesn’t) look like my internal self-image. I look in the mirror and if I’m lucky I will catch the occasional glimpse of myself, but more often I only see the out-of-place male characteristics. My brain developed as female, my body as male.

If you are not transgender yourself then imagine this: you are yourself, the same person you have been all your life, but every time you look at yourself you do not see what you expect to see. You see a face and body that is the opposite gender. Now also imagine that everybody else sees that too, and acts towards you as if that is your actual gender. But you know it’s wrong. Every day of your life you know, but you are stuck with it. Yes, it hurts to the point that it can be hard to carry on.

Unless you start to tell people that the way you look is not who you are. Unless you confront their disbelief, prejudice and mockery. Unless you fight to change your body so that it matches what you know inside to be your true self. The alternative is to try to pretend that you are somebody other than yourself, to live a lie. I tried to do that until it almost destroyed me. That is gender dysphoria.

So please try to be understanding when a transgender person comes out. Be accepting. It is hard enough living with the discomfort and distress of your body being of the wrong gender without also having to suffer prejudice and abuse.

Note: I have simplified things here for rhetorical purposes to mention only binary gender identities. These account for the majority of people but there is a significant minority for whom the categories of male/female do not fit. I’m not going to go into details here because there are many excellent articles about non-binary gender and I do not have the personal experience to add to what others have already written.