To Be Seen: A Nonbinary Struggle for Validity by Dr. Natalia P Zhikhareva

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Our society, despite an ongoing gender revolution and largely due to our own ignorance, tends to recognize just two genders, male and female.  This stems, in my view, from the social construction of gender - a notion that society and culture create gender roles and these roles are prescribed as the ideal and appropriate behavior for people of each specific sex.  This notion driven by political, social, religious and economic institutions tends to narrow and marginalize the truth of gender variance.

The reality is that we truly know very little about gender expression, gender identity, and the inner Self relationship to gender.  For a gender binary society, the reality of gender variant spectrum can be threatening.

Most people, including some transgender people, identify as either male or female. However, many others, such a nonbinary, dont fit into the binary categories of a “man” or a “woman.”  A person is nonbinary if their gender identity is not exclusively a man or a woman.  Someone who is nonbinary might feel like a mix of genders or like they have no gender at all.

While nonbinary gender identity is nothing new, being a nonbinary in a gender binary society can be an invisible handicap.  Consider passibility.  Something cis-gendered people take for granted on a daily basis.  For a nonbinary individual, it is almost impossible to pass as their gender identity because there is no slot in the public conscious for a “nonbinary person.”  As a result, a nonbinary person gets filed into a binary category and that can and does trigger dysphoria (yes, not only transgender individuals feel dysphoric).

Each time a nonbinary person gets gendered as a “man” or a “woman,” their inner Self identity takes a blow again and again.  To validate and reaffirm their identity, a nonbinary person has to clarify their gender identity practically to everyone they meet!  This struggle for validation as a nonbinary person takes a huge toll on one’s mental health and can lead to depression.  

“I feel pretty socially anxious in situations where people use gendered terms to describe me without asking my pronouns,” Mel says in the referenced article, “and I battle with dysphoria and frustration with myself for being so sensitive when people are completely unaware and don’t know how hurtful that kind of language can be.  I can’t expect people to mind-read and know how I identify, but being called ‘miss’ or ‘ma’am’ can shake me up depending on what kind of day I’m having.” (We Need to Talk About How Non-Binary Invisibility Affects Mental Health https://www.ravishly.com/non-binary-invisibility-affects-mental-health)

Ironically, we as human beings, while smart enough to land robots on Mars, seem to be incapable of genderless dialogue.  Imagine a society where gender terms such as “sir” and “ma’am” or “her” and “him” didn’t exist, a society where we could simply call each other by our names.

Until the day comes where society recognizes the inherent gender diversity within humanity, let’s support one another.  

Let’s not assume everyone identifies as male or female, because the truth is they don’t.  

Let’s thrive for genderless dialogues by calling people by their names.

Let’s eliminate gender binary by proactively asking how people identify.

Let’s challenge our own ideas of gender binary by educating ourselves on the social constructs of gender.

And above all, let’s be human, loving beings and respect how each one of us identifies regardless of our own inner beliefs or convictions.

The Ultimate Guide to Penile Implants for Trans Men. by Dr. Natalia P Zhikhareva

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Trans men interested in undergoing gender confirming surgery, specifically phalloplasty, often find themselves wondering which penile implant is right for them.  Penile implants, also known as penile prosthetics, are devices placed inside the penis to allow trans men to get an erection.  The FtM phalloplasty procedure offers three kind of penile implants to consider from: the non-inflatable or semi-rigid implant, the 2-piece inflatable implant, and the 3-piece inflatable implant.  Before we get into pros and cons of each penile device, lets consider some medical research.  

A long-term study documented the outcome in 129 FtM transgender individuals with a neophallus after the implantation of an erectile inflatable prosthesis from March 1996 until October 2007 (Hoebeke et al. 2010).  Of 129 patients, 76 patients (58.9%) still have their original implant in place as of the date of the study’s publication in February 2010.  Fifty-three patients (41.1%) needed to undergo either removal or revision of the prosthesis due to infection, erosion, dysfunction, or leakage.  Despite high complication rates, the study authors concluded, implantation of an inflatable erectile prosthesis remains the best option for achieving the possibility of sexual intercourse in FtM transgender (Hoebeke et al. 2010). 

In regards to the quality of sexual life, an observational study (De Cuypere et al. 2005) observed more than 80% of patients reported improvement in sexuality.  Patients with penile prosthesis were more able to attain their sexual expectations than those without prosthesis, although the group with prosthesis more often reported pain during intercourse (De Cuypere et al. 2005).  In addition, the study concluded that trans men reported masturbating significantly more often than trans women and experiencing greater sexual satisfaction, more sexual excitement, and greater ease in reaching orgasm. 

NON-INFLATABLE or SEMI-RIGID PENILE IMPLANT 

This type of penile implant consists of one or two bendable rods inserted into the penis made of an outer coating of silicon and an inner stainless steel core of interlocking plastic joints.  The semi-rigid implant can be bent into different positions for erect and flaccid states.  It works simply by bending the penis into the erect position to achieve the look of an erection and by bending penis down to end an erection.  Because non inflatable implants are always firm, one should note that the look of a flaccid penis may appear as a semi-erection.  

Pros

-Can be conveniently used by individuals with manual dexterity issues

-Simplest procedure to perform and is least expansive

-Less vulnerable to mechanical failure than inflatable implants and can last more than 20 years

Cons

-The rigidity of erection is less

-Downside of having a permanent semi-erection, which can feel and look awkward

-Can be difficult to conceal even when beneath several layers of clothing

The two popular brands of semi-riding penile implants are Coloplast Genesis and AMS Spectra.

2-PIECE INFLATABLE PENILE IMPANT

This type of penile implant has a reservoir that holds salt water at the beginning of the cylinders (base of the penis) with the pump and release valve located in the scrotum.  It works by gently squeezing the concealed pump iseveral times to move the saline solution from the reservoir into the cylinders.  As the cylinders fill, the penis becomes erect and firm.  To transfer fluid back into the reservoir to end the erection, one has to gently bend the penis down for 6 to 12 seconds.

Pros

-Easy to use

-Totally concealed in the body

-More easily concealed under clothing

Cons

-Likelihood of malfunctioning or developing leaks

-The penis is not as rigid as with a three-piece penile implant due to smaller amount of fluid being transferred into the cylinders

-The pump can be felt more in the scrotum to sexual partners compared to the softer pump of the 3-piece penile implant

AMS Ambicor is a popular brand for a 2-piece inflatable penile implant. 

3-PIECE INFLATABLE PENILE IMPLANT

This type of penile implant has the cylinders in the penis, the reservoir in the belly, and the pump and release valve in the scrotum.  To use, gently squeeze the concealed pump in the scrotum several times to move the saline solution form the reservoir into the cylinders.  To end the erection, press a “deflation site” on the pump, transferring the fluid back to the reservoir resulting in a flaccid penis.

Pros

-Easy to use

-Easier to inflate than a 2-piece device due to larger, softer pump

-Offers best rigidity

-Offers best flaccidity when not in use

-Totally concealed in the body

-More easily concealed under the clothing

Cons

-Highly vulnerable to leakage and dysfunction

-Requires the user to have good skills for operating it

-Most involved implant surgery and most expensive out of the three options

-Can last as little as 3 years before needing replacement

-Highest complication rate

Popular brands of a 3-piece penile implant are AMS 700 Series and Coloplast Titan OTR and Titan.

Given the limited research on the post-op individuals, it may be a challenge to contemplate phalloplasty as part of one’s transition, not to mention deciding which penile implant, if at all, to consider.  The combination of a neo-urethra and penile prosthesis in a single neo-phallus remains a challenge for medical professionals.  Of course there is always the future.  Animal studies have shown the potential implantation of tissue engineering for penile reconstruction with bioengineered tissue being used for penile reconstruction in rabbits (Chen et al. 2010; Yoo et al. 1999).  Other options are future use of tissue-engineered human cartilage rods as penile prostheses (Kim et al. 2002).  

References & Sources

Chen, K.L., Eberli, D., Yoo, J.J., & Atala, A. (2010).  Bioengineered Corporal Tissue for Structural and Functional Restoration of the Penis.  Proc. Natlk Acad. Sci. U.S.A. 107(8): 3346-3350.

De Cuypere, G., T’Sjoen, G. Beerten, R., Selvaggi, G., De Sutter P., Hoebeke, P., Monstrey, S., Vansteenwegen, A., & Rubens, R.  (2005).  Sexual and Physical Health after Sex Reassignment Surgery.  Arch. Sex. Behav. 36(6): 679-690.

Hoebeke, P., Decaestecker, K., Beysens, M., Opdenakker, Y., Lumen, N., Monstrey, S. (2010).  Erectile Implant in Female-to-Male Transsexuals: Our Experience in 129 Patients.  European Urology. Volume 57, Issue 2, 334-341.

Kim, B.S., Yoo, J.J., & Atala, A.  (2002).  Engineering of Human Cartilage Rods: Potential Application for Penile Prosthesis. Journal of Urology. 168(4 Pt 2): 1794-1797.

http://www.trans-health.com/2013/penile-implants-guide/

http://www.aarp.org/home-family/sex-intimacy/info-12-2013/sex-erectoin-viagra-castleman.html

Can We All Fit Under One Transgender Umbrella? by Dr. Natalia P Zhikhareva

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Lately, I have been hearing a controversy from the trans community about the use of terminology to describe the trans experience.  The word up for debate is transgender, an umbrella term that describes people whose gender identity or expression does not match the sex they were assigned at birth.

Under such a broad description, individuals who identify as gender non-conforming, gender non-binary, genderqueer, or agender to name a few, are clustered together.  For those considering or in the process of gender transition from one binary to another, having to share an umbrella with others who have no interest in transition, is confusing. 

Those individuals who strongly identify with the sex opposite of the one assigned at birth, place great emphasis on the desire to modify one’s body.  Viewing transition as some form of physical body modification via hormones and surgery, these people undergo transition in order to fully live as a different gender, the gender on the extreme opposite end of the binary.  These individuals are not interested landing somewhere in between of the gender spectrum, nor are they interested in partial transition (HRT but no surgery or partial surgery). 

To clarify, this discussion is strictly aimed at those individuals who strongly do not identity with the sex assigned at birth, strongly feel the opposite of that sex within the dual binary of our society, and go through medical and surgical transition to achieve the desired result.  The end goal is not only to pass but fully live their lives on the opposite spectrum of gender.

Of course not all people who refer to themselves as transgender, choose to make surgical body modification, and here is where the problem lies.  Perhaps the term transgender is being used too broadly to describe individuals anywhere on the spectrum, including those who have transitioned and now living within a binary of their choice.

Historically, the term transsexual, introduced in 1923 by a German physician Magnus Hirschfeld, referred to individuals wishing to become members of the sex to which they do not belong.  David Oliver Coldwell, was the first author to use the term in reference to individuals desiring physical sex change.  The term was then disseminate by Harry Benjamin and by 1980 entered the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a psychological disorder.  Today, the term transsexual has been clustered under the umbrella designation transgender as a concept of describing a sense of incongruence between one’s gender expression and assigned gender at birth.  The problem is, the term transgender also includes individuals who do not wish to undergo physical transition.

Is it surprising that the term transgender has been rejected by some individuals who have undergone physical transitioning and view their transition as a process of aligning their bodies with their sense of gender identity?  If anything, the controversies around the terminology reveal the shifting ways of understanding the relations between gender identity, gender expression, and gender diversity

Thus I ponder, can and should, the term transsexual be rescued from its earliest history?  

Over the coarse of a long history, the term transsexual, has acquired a negative connotation in trans communities.  To some, the word transsexual is burdened with the history of medical pathologization of gender non-conformance since its introduction to the DSM in 1980.  Interestingly, the term is currently in widespread use among clinicians and medical professionals in Europe and also by some in US.  As I write this, among other books on my desk I spot “Transsexuality and the Art of Transitioning; A Lacanian approach,” and “Current Critical Debates in the Field of Transsexual Studies,” published 2015 and 2018 respectively.

If you are wondering why would any professional use a term deemed as being pathologizing by members of its community, let me clarify.  In Europe, psychoanalysis and psychoanalytic thought predominates other modalities.  As such, the notion of sexuality, as in transsexual, is conceived not in biological terms, sex assigned at birth, but rather is seen from psychoanalytic perspective as drives.  Therefore, along psychoanalytic thinking, sexuality does not equate with physical sex but rather conceived as a drive for life and death.  

While some trans members see the word transsexual as being pathologizing, others see it compromised by dichotomous gender thinking and argue the term stands in the way of deconstructive efforts to overcome the binary.  Does it really?   Is it possible that the term embraces the effort to overcome the binary, and that is precisely the point, for those individuals, and only those, seeking to transition from one binary to another!  Transsexual is not a term used to describe individuals who are comfortable dipping into each binary, who enjoy bypassing society’s rules and social constructs of gender expression, or those identifying as being without a gender. As such, this term does not compromise the wide range of gender spectrum, if anything, by removing itself from the clustering of genders under transgender umbrella, it enables clear advocacy for those who are comfortable along the gender spectrum and are not interested in going from one binary to another.

Perhaps the term transsexual can not be and should not be rescued from its earliest history given the negative perception it has acquired over the years.  Perhaps what we need is a new word to help identify those individuals who are interested in transitioning from one binary to another and are not comfortable to be clumped under the word transgender.  

Trans Women: Here are 3 Things to Jump-start Your Transition, Even if You are Not Out! by Dr. Natalia P Zhikhareva

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One of the patterns I see working with trans women over the course of my career as a gender specialist, is FEAR!  Fear of coming out and expressing who they are.  Given our societal ignorance with regards to gender identity, it is understandable why so many people would be terrified to express gender other than their assigned sex assignment at birth, not to mention their desire to transgress the binaries.  

“I am afraid I will lose my job if I come out,” is a common fear, or “my family may disown me if they know,” is another.  Even such fears as “I will be cut out of my inheritance,” or “my legacy will be jeopardized,” have been uttered in my office before. 

While these fears vary in concerns, they do share a common theme of preventing you from moving forward with transition.  Similar to a T-blocker, FEAR acts as a Courage-blocker, inhibiting our strength to move forward.  

Let’s be honest.  All of us experience fear on some level and confronting fear head on with reckless abandonment can be a stupid thing.  In fact, fear just may be communicating to you things you should be mindful of or attend to with caution.

If you are a trans woman struggling with FEAR, thinking you have no options on the table until your family members suddenly become trans friendly or your grandma that holds the key to your inheritance drops dead, I am here to tell you there are things you can do to start your transition while not being out!  Here at 3 things to jump start your transition with one foot in the closet without anyone even batting an eyelash!

1. What are you waiting for girl?  Unless you are hairless (lucky you), you better get started working on your facial hair and perhaps even body hair.  Start looking into electrolysis (my preference) or laser hair removal in your area.  Did you know LA Care covers electrolysis/laser and so does Kaiser! (For LA Care, you will need a letter from a therapist, contact me for a free eval letter).  Don’t have insurance?  There are many affordable trans friendly locations listed on my local resource list http://drzphd.com/resources/.  Or better yet, look into Groupon for a great deal!  You can start this process without anyone raising an eyebrow or questioning your new smooth face because many people today, especially in LA, go hairless!

2. What does your voice sound like?  Concerned it is too masculine and feeling paranoid you may not pass once you transition?  While still remaining in the closet, it is a great idea to start voice therapy to practice your true feminine voice in private.  This may take anywhere from 6 months to a year or more, depending on your voice.  I highly recommend Eryn, who is fantastic and has tons of experience working with trans people  https://www.prydevoiceandspeechtherapy.com or Anna who herself is a trans woman and has hands on experience and knowledge Anna Lantry BM, GCPH.

3.  Feeling dysphoric?  Unable to concentrate at work?  Feeling more anxious or depressed as a result of not being able to start transition?  Consider HRT!  No, I am not kidding.  Do consider starting hormone therapy while you are still in the closet.  For starters, you can start on a low dose of hormones without having drastic results that may give you away.  I know many individuals who are on HRT and are still not out, nor do they present in their preferred gender.  Starting HRT will not only help you feel less dysphoric, help you focus, and relieve anxiety and depression, but it will also make you feel empowered to begin your journey!  A common concern is using work or parents insurance to start HRT out of fear of having gender dysphoria disclosed.  Here is a tip, if you are truly concerned, consider St. Jon’s Transgender Clinic http://www.wellchild.org/transgender-health-program/.  As of today, they have an amazing out of pocket package that costs $120 for 3 months of HRT, doctor visit, and lab works.  

Why Should Support Group Matter to You! by Dr. Natalia P Zhikhareva

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Let’s be honest.  Transition can be challenging.  Heck, oftentimes it is frustrating, leaving one feeling angry at the unfairness of being born in the wrong body.  And while friends and family can offer a supportive ear during difficult times, we have to be mindful of their personal boundaries.  

As a transgender specialist, I often recommend support groups to all of my clients, regardless of their current support system.  

You may be wondering why someone would consider adding a support group on top of individual therapy, especially considering the additional cost.  After all, individual therapy is an investment both financially and personally.  

But what would you do if I told you it doesn’t have to cost you a penny?  You heard me right.  Free.  The only investment you’ll be making is a personal one.  One that can aid you throughout your transition.

Do I have your attention?

Good.  Here are a few of the reasons why a support group should matter to you!

REALIZING YOU ARE NOT ALONE

Oftentimes in my Transition & Beyond Support Group, someone would describe their first group meeting.  They often say, “You know, until I went to the group, I didn’t realize there were other people dealing with the same gender stuff.”  

This realization brings a feeling of relief and connectedness to others.  A support group connects you with other trans people who are experiencing similar issues.  And while each person may be at a different point in their transition, joining a group offers a window into how individuals cope.  

EXPRESS WHO YOU TRULY ARE FOR THE FIRST TIME

Knowing you are attending a group full of trans identified folks can boost your confidence and encourage you to present in your preferred gender for the first time.  In fact, sometimes people in my group would arrive a bit early to change into preferred clothing in the bathroom so that they can embody who they are. 

SHARE YOUR FEELINGS AND FRUSTRATIONS 

Group is an excellent space to offer a supportive environment, especially during difficult times.  Sharing your personal feelings in a safe environment with people going through similar experiences can be incredibly therapeutic.  

LEARN WAYS TO COPE

Feeling overwhelmed and stressed about your situation? Not sure when to come out or how to start HRT?  In a group, you’re able to get advice from members who have been where you are and share what they found helpful throughout the process.

REALIZE POSSIBILITY OF TRANSITON

It is very powerful when you see others in the group who are further along in their transition or individuals who have transitioned many years ago.  These positive role models show you that transition, especially passibility, is possible, which brings hope and excitement for the future.  

This are just a few of the benefits of why you should consider attending a support group.  Now I did mention it won’t cost you a penny.  At least, not if you consider the following support groups in Los Angeles area:

ACTION PLAN

Browse the above listed support groups.  Pick one.  RSVP.  Attend.