Between the smirk and the smear

A woman with trans experience, accessing healthcare abroad, during a pandemic

I’m prompted to have conversations everyday that aren’t the conversations I choose. That’s become more true living abroad. Last year, I watched the Boston harbor slide underneath the wings of an Airbus destined for Berlin and a new life, one hard won after my expeditious and costly gender transition. I landed at Schönefeld Airport, where the customs agent scanned my Passport, which has an F marker indicating finally that I am (according to my therapist, endocrinologist, gender confirming surgeon, the State of California where I was born and the Department of State) female.

Since landing that day, my agency has been hemmed by mastery of a foreign language, culture, and law. I’ve found myself navigating systems where I don’t feel I’m in my personal power, where it’s constantly demanded of me to negotiate, balance, and make space for seeming contradictions in my outer and inner worlds — making space for the multitudes I contain.

A question always at the forefront of my mind when confronting these multitudes is, how will I adequately attend to my wellness and meet my medical needs while I’m abroad? My wellness as a trans woman hinges on my ability to access competent care and have agency within the care that I access. But we currently have systems that demand a conversation I never chose. The work-around within the system is that I need letters from experts mentioned above, written on my behalf, to say who and what I am so that I can pass through customs undetected as the anomaly that I am.

Generally, I marvel at how far behind the United States is in many regards. I’m learning. And yet, American feminism, anti-racism, and trans rights outstrips most European activism by at least a decade. I’m teaching. I’m patiently both at the same time. That said, the German health care system is quite an impressive accomplishment of its country’s bureaucracy. Organized, algorithmic, streamlined, specific. So long as you know how to work the complex system, almost any medical need can be satisfied by that system. The problem with a hyper-organized system is that it relies on categorization. This or that. Diagnosable or not. Male or female. German or non-German. If you fall into the range of the system, great. If not, you are an anomaly and the system is blinded by its own bureaucracy.

So, I went to the Frauenarzt for the first time, the catch-all term here for “women’s health practitioner.” Sitting in the waiting room, I chose ahead of time not to inform my doctor of my transsexual status. Though I was impressed with her inclusion of Trans on the demographics section of the intake form, I checked the box of my new patient questionnaire: Female. While we are in the waiting room, I want to quickly backtrack a little, and explain this choice.

I’m at a point in my gender confirmation journey, where I’m largely self-medicating with hormones and checking in with an endocrinologist once a year to appease the gods of bureaucracy. My injectable estrogen prescription had run out slightly ahead of schedule because, in my calculation of the year’s dosing rations, I failed to calculate shrinkage in the chamber of the needle. I had intended to visit my trans-affirming endocrinologist on a visit to the States for a wedding in May but then Corona regulations were put in place suddenly and indefinitely. I’d heard mixed stories about the German system for trans people. I knew the American system had problems but trans girls joke about how the States are still the wild West of trans affirming care and doctors are quite cavalier with throwing a prescription at trans women to make us go away. A cowboy “don’t tread on me” mentality, combined with transphobia is a nice recipe for quietly sneaking in through the unmarked sliding door of the medical system and then quietly ushered out the backdoor without much fuss or question. That is of course, if you are educated, employed, and therefore privately insured.

Back in the waiting room, the receptionist butchered my French Canadian name and my English surname, “Or-all-ee-ah… ähm… Ree-sh-arts?” I was taciturn, so as not to give away my slightly less than fluent German (let alone medical/technical German) but also not to let my androgynous, testosterone influenced voice give away my male past. I went through my exam, which included being asked about my last period. I lied: “Well that’s actually what brings me in. I haven’t bled. I know that I’m not pregnant. I’m wondering if you’d test my hormone levels.” I rehearsed this in the mirror, in German before leaving the house. The doctor challenged me but I guffawed back, smirking, “Trust me. I’m definitely not pregnant.” She ordered an estradiol test. I smirked when my levels came up low and she prescribed me estrogen gel. I lied so that I’d be free to choose the conversation. I lied so I could tell the truth.

Later that day, I attended a party, where I was called a self-loathing Jew by a non-Jew. My views on a subject in German politics were complicated by my immigrant status and not having grown up in a shame-culture. I listened intently, as long as I could endure the brutality of the German communication style, as she demanded that I not hold multitudes, even seemingly opposing views at the same time. Demanded I have the conversation I wasn’t choosing. But I’m a creature of in-betweenness. As a diasporic Jew learning to claim that identity for myself in adulthood, in Germany; as a woman with transsexual experience; as a white-appearing person with a Native grandmother, I contain multitudes and contradictions. I constantly reconcile various aspects of my life. Constellations, composed of the various and intersecting points of my identity, are pulled taut by the tension of my lived experience. They reveal a self that defies linear, hierarchical, binary categories. I fall outside the range of this and other systems in so many capacities. But am I not a constellation worthy of noting? Are we so unimaginative with our systems that we can not make new connections or trace new constellations?

Because I’m an anomaly, continually my in-betweenness, my transness, is reduced in hopes of making me fit into a range that the system can comprehend. In the case of my transness it is reduced to the conversations that people who do not have my lived experience demand that I have, namely in the form of referral letters and paperwork. A letter from my therapist: “Yep, turns out after 12 sessions, she is trans after all.” A referral from my endocrinologist: “Well what do you know, give a person the right hormones and her symptoms of gender dysphoria are manageable. I think she might be a girl, even though she’s been telling us this since she was 6 years old.” A notarized affidavit from my gender affirming surgeon: “This one has a vagina now. Is she a real woman to you, yet?” These are all paper trails that serve as bridges from my lived experience into the clinical and legal systems I need and also loathe. Systems that try to serve me but at the same time find my body and mind suspect.

Early in my transition, while still living in the States, some stitches came loose from my newly-reconstructed genitals. I was driven an hour to meet a gynecologist who said she had experience with trans patients. When I got to the appointment, legs up in the stirrups for the first time, she disclosed from behind her Speculum, “Not to make you the poster child of trans care, but our clinic has never had a neo-vagina come through and I’d like to invite our head nurse to observe your exam.” I let my head drift up off the paper-covered pillow. The room was spinning a bit from the quantities of painkillers I needed steadily dosed to get through the day and I slurred, “Yeah sure. Okay, I guess?” Notice, I wasn’t a female patient to them, not even a trans patient, but a neo-vagina with legs. They spoke to each other cheek-to-cheek. I remember their breath on my still hypersensitive labia. Two cisgender medical practitioners hunched over my transness, marveling at medical science.

After that day, I decided I was only going to have the conversations about me that I chose. I don’t have to abandon myself because someone (or an entire system) deems my body or mind anomalous, suspicious, or threatening. Living abroad, I’m learning to feel comfortable being misunderstood all the time. Living my womanhood, I’m learning to accept my experience will always be doubted and demand explanation. Living my transness, I’m learning that I am the only person who can take responsibility for my health and well-being. So while containing multitudes puts me at risk of not being entirely in control of my own wellbeing, it is also the source of my capacity for authenticity, resilience, and vibrant health.

Sometimes that means I’m out and proud. Other times, I’m the quiet expert of my own experience, holding my secret between the Mona Lisa smirk and the Frauenarzt smear.

I get to do and be both. I get to choose. And that’s freedom.

This is the unedited edition of the piece, originally published here: https://www.healthywomen.org/content/article/accessing-competent-health-care-trans-woman