The Song of Transition











As a physician of twenty-five years duration, the last five of which has been caring for over 360 transgendered patients, I felt it was time to try and put the accumulated knowledge to work to help others transition through the most difficult journey that a human being makes.  It is a journey not from one city to another or from one planet to another but rather a sojourn from one existence to another.  I have talked to hundreds of others, some who have been very successful, many who wish they were and a few who completely gave up and paid the ultimate price.  I do not claim to have all the answers.  I did have to talk and work with nine male  partners, twenty two doctors, 160 employees, two hospitals, 400 nurses, 200 medical staff physicians, the Drug Enforcement Agency,  the Oregon Board of Medical Examiners, the Washington State Board of Medical Quality Assurance, the Federal Aviation Administration, the Civil Aeromedical Institute, the American Academy of Family Physicians, the American Board of Family Practice, 24,000 families, and the cities of Milwaukie, Oregon, and Portland, Oregon.  There was also my spouse, my teenage daughter and son, and my siblings and other relatives. 


I have tried to divide it into what I consider to be four phases of transition.  I have cared for both MTF and FTM.   Their circumstances differ but their desires and hopes are the same.  I will tend to use the Male to Female circumstance because that is what I am most familiar with.  I have named these phases after the seasons because I think it reflects the basic feelings of these four periods of transition.  How long does it take to transition?   The true answer is a lifetime.   I think that a reasonable answer is about five years.    I would like to describe what in general I have seen works.

All transgendered people remember their earliest feelings of being different.  It usually is about age 6.   Most remember wanting to be of the other gender but being wise enough not to speak of it.  They live their lives, choose professions or jobs, and often marry and raise children in an attempt to fit the mold. Always in the background is the desire to be something they cannot possibly be.  They dream of it and fall asleep praying they will wake up different.    They go through puberty anguished over the changes in the body that take them away from their secret ideal.  They grow older and try to fit in.  They pursue their dreams to bury the innermost thoughts to a deep grave in the hope their desire will never emerge.  There may be secret moments where consumed by guilt and humiliation they try to assume the countenance that matches their soul.   However, they live in fear they will be caught in this brief moment of being that to others will be shocking, and utterly devastating to their lives as they have shaped them.  

At some point in time, all the material things of life do not keep the thoughts from leaking out.   The pain of not being and the self-deceit that has been practiced erodes the fragile but false shell, which is the contrived construct of their life.   Eventually, the transgendered person is faced with the ultimate dilemma.  They have to choose between a life that contains the sum of all their achievements and family or admitting to them that it is a lie.  However, this lie contains their occupation, family, home, children, and friends.   Sometimes this realization takes months to years to happen.  On occasion, as  happened with me, it occurred in a single day. I found that it produced a pain not unlike what I experience when my son died.

Eventually, the transsexual has to address their feelings.   As Mildred Brown states in her book, True Selves, the transsexual feels as if their life has no meaning and they are in a vast spiral downward.  At last, they have to address their feelings or perish spiritually or even physically.  I have found that virtually all transgendered individuals consider suicide at one point in their transition.



It is this point that, I would call Fall.  It is the time when the symptoms of Gender Identity Dysphoria start to manifest.    I do not think it is necessary to recount these symptoms but they are classified as a situational depression.   It may be a time when the individual may start to use drugs or alcohol to suppress the feelings that are emerging.  Commonly, many start to research on the Internet websites dealing with transitioning.  Transitioning is the commonly accepted term for going mentally and physically from one gender to another.   Many  view Sex Reassignment Surgery as the Cure.  In reality, it is an afterthought to all that must come before.

The greatest mistake in this segment of transition is failing to get expert counseling from a skilled and knowledgeable therapist.    Even though I was a trained Family Physician, I realized that websites such as Ann Lawrence’s Magnificent website and others could not answer the basic question that I had.   Was I transgendered or was I something else?   Having the diagnosis confirmed by an expert is critical in this instance.   Why?  Because if one is a transsexual, and has the symptoms of Gender Identity Dysphoria, there is only one cure.   Even the Federal Aviation Administration  (FAA) realizes this.   If you are a pilot and diagnosed with this condition, there   is only one way you will ever be able to fly again with a valid medical certificate (medical clearance from the FAA).   You have to have Sex Reassignment Surgery and be fully transitioned.  

A skilled Therapist will not solve any problems for you.  Rather,  they will allow you to examine the options for dealing with all the facets of your life that will be affected.  Sometimes one can get by living part-time in the gender of ones mind and soul and that will be sufficient to get by for a while.   Most realize that once the Dysphoria manifests, going back and forth between genders simply produces more and more psychic pain.   I have never met anyone who was cured of being a transsexual.  The Therapist is skilled at bringing out the best solutions for your particular circumstances for all the aspects of your life that will be affected.   Changing ones gender does not happen overnight.   Many individuals in your life will be affected.   Often I have found that most transsexuals do not realize that even though they have wanted to be the other gender, accepting himself  or herself  as this without guilt or shame is a difficult accomplishment.   When one changes gender, there is a death.  There is a potential loss of family, friends, income, jobs, and home.    However, even more important, there is a loss of ones  self.  The person you grew up with and came to know is going to go away forever.  Things will never be the same.   Some behaviors that you have learned will become unacceptable or impossible.   The familiar if superficial skills learned in being what your genitals said you were will need to be replaced by totally new skills which most people going through puberty have years and friends to learn with.   Transsexuals grieve and go through the stages of grief described by Elizabeth Keble-Ross in her works on death and dying.  They are shock, disbelief, bargaining, anger, depression and resolution.  It is unfair to be a transsexual and often have no one to talk to about it.   Sometimes, the hardest person to convince that they are a transsexual is the transsexual himself or herself.

As one begins to deal with being transgendered, the magnitude of the task begins to loom as well   as the timing of transitioning and the means.   I believe all transsexuals begin planning their transition from the moment they find out such a transition is possible.  My research has shown that the active planning of transitioning seems to start on an average in the late 30s to 40s in MTFs and early teens and twenties in FTMs.   There is an ever-accelerating desire to push forward…to get there as fast as possible.   It is however a slow and expensive process.    Hormones only work so fast and can do so much.   There are multiple facets of life to arrange, change, and modify.    Insurance companies are loath to pay for any part of transitioning.  Planning the financial aspects realistically can prevent disappointment and false steps.

To actively transition requires skilled counseling, emotional support, and intense planning.    This is an illness that does not favor the illiterate, the impoverished, or the ignorant.   It does favor the mind that can plan and write.

With the intent to transition comes Winter.




It is critical to find a therapist that will work with you and provide the feedback and the support needed to succeed.  How do you find the best therapist?  Talking to others, interviewing, and sometimes-just luck may all play a factor.  Once one has a good therapist, being honest and being realistic are vital to successful transition.    The first issues to address are the timing of transitioning, job preservation, hormone therapy and informing family, friends,  and relatives. 

I cannot stress how important it is to plan your transition.  It is the most important project that a transsexual will ever do.   You are dealing with dozens of people who are going to harbor feelings and opinions of their own formulated from their life experiences.  Some will be accepting.  Some will not.  As a general rule, it is not usually a beneficial to out yourself to large groups of people at a time. The loudest mouths do not always belong to the keenest minds.   It is better to build consensus and understanding with a few individuals who can act as your advocates.  Often individuals have to be educated as to what being a transsexual means and more important what it does not mean.  Being a transsexual means you wish to change how you relate to others in society as a member of the other gender.  It does not mean one is gay or trying to deceive others.  It is critical to help others to understand that it is not a choice to become.  Rather, it is the way one has always been.  An extremely valuable book is the work by Mildred Brown called True Selves.  I have found this to be the best-written book to give others an understanding of Transsexualism.

One of the first people that the transsexual will tell is a close friend that they can trust.  Usually it is more a sense that the friend will be accepting then anything tangible.  Having a close friend who is not the therapist gives one a mirror that is available and vested to bounce ideas and images off of.  They are someone they can trust. The friend is more readily available.

The next group to enlighten will be relatives and family.  If one is married, the spouse is the next logical choice.  Very often the spouse or significant other will be aware that there is something wrong.  Most human beings are not skilled at deceiving others for long periods of time.  Eventually, the life of dishonesty catches up with the transsexual.  A good way to tell them is to find a quiet place where the person you are telling is comfortable, to tell them or give them a well-written letter outlining what is happening.  Make the therapist who has been working with you available to answer questions.   Reactions may range from relief to shock.  Give the spouse space and time to comprehend.  Spouses may often feel betrayed and bewildered.   Be ready for all kinds of reactions and remember that the spouse has had minutes to hours to comprehend what you have endured for a lifetime. One commonly repeated error is forgetting that it takes time for others to get where you have been thinking on for years.   Be prepared to arrange separate living situations and housing.  Be prepared for the children, if any, to be involved acutely.  Be prepared to lose everything.   If divorce is a possibility, be familiar with state laws on divorce and child custody.  Try to have access to an attorney who is familiar with transgendered individuals and divorce.  Do not reveal yourself until you have arranged contingencies for what may occur.  As you can see, planning is key to survival and transition.  I have seen transsexuals go from a job, a home, and a family to homeless in the space of a week.

Children are usually the next people to discover their parent is not what they seem.  How they react is a function of how well the other spouse is handling the revelation and their age and gender.   I have found that if the spouse is at least tolerant and not too judgmental the children can be very accepting.  Age and gender of the children is also a factor.  Girls tend to be more accepting then boys.  Children younger than puberty age tend to be more accepting then teenagers.   The best way of telling them parallels the method of telling the spouse.   Arrange to tell them on a Friday preferably at the start of a vacation so they are not exploding at school.  Make your therapist available to talk to them and explain exactly what is happening.   Allow them to see you, if they wish,  as you hope to be in the future in your new gender.  Plan then to disappear for a day or two to allow them to ventilate and grieve for the parent they used to have.  Try to be patient and realize for children they have not only the loss of a parent but also the possibility of losing their friends over your transition.   As you can see, the more people that know you are transgendered, the larger the circle becomes.

Eventually, you will want relatives to know what is happening in your life.  Approach the ones who are likely to be supportive or sympathetic first.  If they live a long ways away from you,  a good method is to write a letter describing what is happening in your life.   This is an area when devoting several hours to writing a good letter describing your circumstances will pay off dividends.   In this letter try to educate your family why you are transitioning.   Try to be succinct and accurate.  Feelings are important.  Again, educating them that this is not a choice, that you have always been “this way” , and that you are not trying to deceive them.  It is important to point out that what your gender identity is and whom you love are different things.  Include in your letter, if possible a copy of the book, True Selves  and the best possible profession picture of you dressed  PROFESSIONALLY AND CONSERVATIVELY

I  cannot stress enough that this is not the time to appear sexy, pretty,  or risqué.   You will gain or lose whole battles based on appearance.


Of all the factors in transition, probably the most important aspect is employment.  As my friend Ashley Hall says,  “Cash is King”.   Without income, transition comes to a screeching halt.  Insurance pays very little for medical needs.   Unemployed transsexuals who have partially transitioned are only slightly more employable then recently released from prison bank robbers.  You might think that starting a new job while transitioning will be nice but employers are not going to be so motivated.   If you have a decent job it is worthwhile to try to transition at the job you already have proved yourself on.   Many companies have human resources personnel who can work with you.  The first step is to identify someone at place your work that  you can confide in and get feedback on what will be acceptable and what will not.   These friends can function as educated “moles” that  will be able to speak for you and related what the facts are.  Often,   once  a person is found to be a transsexual, they will initially lose much if not all validity.  Someone needs to be able to speak on your behalf.  A fellow employee who is respected and can say “Yes, I know about him or her and this is what it is all about” is invaluable.

Try to ascertain whether it is truly feasible to transition at your present location or can you move laterally to a different site within the company where you are less known. When you have evaluated this item, approach your boss or human resources director with not only the fact that you are transitioning but also a preliminary plan as to how you are going to accomplish this.  A good general rule is that reasonable people will accept a complete  well thought out solution that is readily available rather then try to think of one for themselves.  Each occupation holds its own special dilemmas and circumstances.  If you know someone who has transitioned in your occupation, contact him or her and find out how they did it.  The International Foundation for Gender Education has started a program called professionals helping professionals.  Contact them.   Simple plans involve explaining to fellow employees what transitioning means and what you hope to expect from them.  Plan to make your therapist available to the group to explain in general terms what being a transsexual is.   Topics should include how you wish to be addressed, health insurance issues, bathroom use, and explaining to customers and other businesses. Have several copies of the book True Selves for employees to read.  It is absolutely critical that you learn how to educate others in an intelligent fashion.     Practice what you will say to them until it is fluid and natural.   If you do not believe it yourself you will not convince the other employees.   Do not be ashamed of what you are.    It is only our culture that makes it seem deviant.   Bathrooms are a big point of contention.  I would recommend using a unisex bathroom until Sex Reassignment Surgery.  Pressing to use the ladies room when you have testicles is not going to win friends.  This is often a big sticking point.    Once a plan has been made with the employer,  it is a good idea to have a break between your last day as one gender and the first day as your new gender.   This gives time for people to adjust and change nametags and email.  On the first day, dress professionally and conservatively.   Get expert help on clothing and if necessary make-up.   I believe all transsexuals who are transitioning go through an accelerated adolescent period.   This may be a time when short skirts, tattoos and body piercing are used.  I would suggest trying to avoid this phase at work.   Looking good and professional is absolutely essential.  People are going to look at you very closely.    If possible,  have a professional photo made that can be used in the business and sent to distant family members.

Remember on the first day of your new life that mistakes in pronouns will be made.  If the mistake were not malicious,  smile and ignore them.  If it gets to be a chronic problem, approach your human resources person to assist.  Review constantly what is happening, what has worked and what has not.  Time never reveals the best answers only the wrong ones.

Identification is important.   Each county and state vary in their requirements for name change.  Try to have your name change and gender change done on your driver’s   license at the same time.  In most states, your gender is what your  driver’s license says it is.  Always carry a letter from the therapist that states you have the diagnosis of Gender Dysphoria.   If the police stop you it may save you great embarrassment or trouble.

If you are not able to transition at your job,  then you must find work somewhere else.   Again circumstances will differ but, be sure to have your name and gender changed on your driver’s license before seeking employment.  This is one of the most common mistakes I have seen where an individual is dressing as one gender but their identification does not match their dress.  This is a setup for problems getting employment.

Have a well-done resume and if possible samples of your work. If your employer will not let you stay,  ask if they will give you at least a decent reference.   It will be hard to find work as a rule unless you are self employed or highly specialized.

Once you are working, try to refine your image and your skills.   Support groups, keeping a journal,  and accessing the Internet can provide support for the transitioning individual.


Hormones are a big topic and for some represent the full endpoint  of transition .   To obtain hormone therapy, one needs a letter from a knowledgeable therapist and a physician who is experienced in giving them.  Be patient.  Start electrolysis or laser therapy early as possible.

Eventually,  the individual is living and working in the desired gender fulltime in what is called the real life test (RLT).  This is the trial period for the individual to show that they can work and survive in the new gender.  This is generally accepted to be a one-year period that must be complete before Sex Reassignment Surgery can be recommended by a therapist.

Once the above problems are resolved in some stable fashion comes spring.


Spring is the period of time where the individual is comfortable in their new role most of the time.  Family problems have reached some degree of stability.   The person is working and supporting him or herself in the new gender.  Passing is not a full time occupation and the fear of being found out starts to fade.  I have found this takes one to two years from the decision to transition.   There is a certain peace in ones life that has been lacking and the daily struggle to deal with the dysphoria and the coincident items recedes.    By this time there will be some losses but hopefully, the transsexual is working through the grief of the losses.  For some this is the culmination of transition.   For others,   with the completion of the real life test comes the second letter from a PhD psychologist or an MD level psychiatrist certifying the individual is ready for Sex  Reassignment  Surgery.

Books have been written on the topic of SRS and the Internet abounds with websites such as Ann Lawrences dealing with the surgeons and places and techniques. For me, I could not practice safely as a female physician without having  SRS.   However, by the time I got to this, it was an afterthought.  The solution for me was living full time as a woman and being able to be a lady physician.  The surgery was something I did to protect myself from lawsuits.  I will not minimize that it was a great comfort for me for my body, soul and mind to finally match.   There is a harmony that the mind expects the body to be a certain way and for Gender Dysphoric Individuals,  SRS for me did provide that harmony and I have no regrets about it.  But, it does not necessary follow for all transsexuals that SRS will solve all your problems.  



After one transcends all of the above what is left?  The answer is time and experience.  Even  five years out,  there are still times when the memories of what has gone before can be overwhelming.   I believe that transition induces a condition called Posttraumatic Stress Disorder in all who experience it.  I think they are left a little damaged, vulnerable, sensitive and introspective over what they have experienced.   There will be the losses of family, friends, opportunity, and the life that might have been.  There will be the scars made by those who made life a nightmare sometimes during the transition.  But there will also be the memories and reflections of moments when dreams,  feelings and thoughts that haunted one all their life become flesh.  It is a time when there is a joy of just being instead of having to do.   To gaze upon ones own countenance and instead of loathing, find peace and contentment is an experience known only by transsexuals who have transitioned.   It is a time to savor the milieu that the soul has thirsted for but never had before.  It is an eternity in time when the flesh, the spirit and the mind have a harmony that has been long denied.   It is a long hard journey that leaves no one completely unscathed.  I do not believe anyone would chose to be a transsexual if they could avoid it.  Early in my medical training, I met a transsexual male to female who had horrible psychological problems with multiple suicide attempts.  Because I had buried  my earlier cross gender  thoughts within my subconscious  and constrained my feelings with a large dose of denial,   I could not imagine why a human being would choose to try and become the other gender.   I deeply pitied this person and wondered what could drive someone to deliberately alienate her family to become something I thought was impossible.  Little did I realize that twenty years later, I would find that being a transsexual was not a choice, rather it is a primeval drive that twists and tortures the soul much as a butterfly twists in the chrysalis to free itself and spread its wings,   It is a force so strong that people shred the secure stolid shells  of their established lives.   They do so to rid themselves of a blinding pain that was so strong that for me it mirrored that of the death of my son.

I called the day of my SRS the day of the Butterfly.  I named it so because it would be the day I would never have to return to the dark tortured struggles to be what I wasn’t but thought I had no choice in.

I wrote in my journal the following:


Jeanne (my Mother-in-Law) asked me where I will I  go from here?  I do not know.  I have been in a battle the last five years. I have not had the luxury of planning a simple life.  Jeanne asked if I had regrets?  I regret that I did not have a choice.  I  regret I brought it home.  I regret certain material losses. I regret lost time with my family although I was not a very good Dad (I don’t think).  I hope to be a better parent and spouse in the time I have left.


What is really different after all I have gone through.  Thousands of dollars lost.  Lost friendships and lost patients.  I look out with the same eyes and the same mind.  I dress differently and I am different anatomically-yet,  inside,  I am the same person only happier.  I do not have the emptiness of trying to be a male when I wasn’t,  trying to fit in where I didn’t.  I think the reason I got as far as I did was I could be a girl as a doctor and no one knew.


The horrible agitation and the need to control others and to do is a distant but not forgotten memory.  Emotionally, I sense the fear of others but what of what difference is it to others what I want my gender to be.  If I had a clubfoot or a cleft palate would I have live that way because God made me that way.


I look forward to many years of living with my spouse, watching my family grow and just being instead of clawing for existence.  Unlike so many others, I did not accept my fate.   I survived it to become a better, happier more useful human being.  I have accomplished much and God willing, I will accomplish more before my eyes see no more.



                                                                  Sara Kristine Becker

                                                                  September 4, 1999
                                                                26 days, 11 hours, 15 minutes
After the Butterfly