Why The Trans-community Hates HRC

Why The Transgender Community Hates HRC

Written By: Monica Roberts

Why does the transgender community hate HRC? It’s a question I get frequently asked in GLBT settings. Considering the recent GLBT family feud erupting over ENDA, it's an appropriate one to ask as well.

Before I get started trying to shed light on it, I need to point out in the name of journalistic integrity that I was the Lobby Chair for the National Transgender Advocacy Coalition (NTAC) from 1999-2002.

The roots of the animosity start after Stonewall. In an effort to appear more 'mainstream' to the straight community, Jim Fouratt and friends bounced Sylvia Rivera and other transpeople out of New York’s GLF (Gay Liberation Front). Jim Fouratt’s anti-transgender comments culminating in a 2000 one at a Stonewall observance in which he called transpeople 'misguided gay men who'd undergone surgical mutilations' also added insult to the injury.

In a pattern that persists to the present day, The GLF had protections for transpeople removed from a proposed 1971 New York GLBT rights anti-discrimination bill under the pretext that it wouldn’t pass with such 'extreme' language.

Ironically the bill failed anyway and the New York City GLB-only rights bill wouldn't pass until 1986. Transgender inclusion was fought at that tome by Tom Stoddard, who would later head Lambda Legal. Transgender people didn't get added in the New York City bill until after Sylvia Rivera's death in 2002.

In 1979 Janice Raymond poured more gasoline on the fire with her virulently anti-transgender book The Transsexual Empire. Raymond also took it a step further in 1981 and penned a quasi-scientific looking report that was responsible for not only ending federal and state aid for indigent transpeople, but led to the insurance company prohibitions on gender reassignment related claims. Germaine Greer’s anti-transgender writing combined with Raymond’s led to involuntary outing and harassment of transwomen in lesbian community settings. It also sowed the seeds for the anti-transgender attitudes in the lesbian community that persisted through the late 90’s.

So what does this have to do with HRC since it didn’t get founded until 1980?

The problem is that the senior gay leadership is still influenced by the Fouratt-Raymond-Greer negative attitudes towards transpeople. That sentiment is concentrated disproportionately in California and the Northeast Corridor. The early gay and lesbian leadership also sprang up from those areas as well.

The transgender community around the late 80’s renewed its organizing efforts to fight for its rights. The early leadership was also concentrated in the Northeast Corridor and California as well and regarded the gay community as natural allies.

One thing they didn’t take into account was how deeply entrenched the anti-transgender attitudes and doctrines were amongst gay and lesbian leaders. Barney Frank (D-MA) is a prominent example of it. They still persisted in holding the view that transgender people were ‘crazy queens’ who would cost them their rights. Gay leaders were still trying to use the 70’s assimilationist strategy to counter the Religious Right campaign against gay civil rights fueled by fear of the HIV/AIDS pandemic.

In the 90’s the transgender leadership became more national in scope and more diverse by the end of the decade. In addition to the founding core leadership from California and the Northeast corridor, transleaders emerged in Arizona, Colorado, Texas, Louisiana, Florida, Georgia, Tennessee, North Carolina, Kentucky, Ohio, and Illinois. The emergence of leaders from what was derisively called ‘flyover country’ by the peeps from Cali and the Northeast Corridor changed the dynamics of the transgender rights movement.

The addition of leaders from these states brought people into the movement who not only believed in the principles of Kingian inclusion and non-violence, they practiced those values. The rise of the Internet gave them efficient communications links to exchange information and tactics, coordinate strategy and inexpensively talk to each other.

They were also people of faith who had ringside seats to the Religious Right takeovers of theRepublican parties in these regions. The Texans watched their state be used as a laboratory for the tactics that would be used in the South and later the rest of the country.

As people of faith who were mostly Southerners, the new transleaders correctly perceived that the Religious Right was the same coalition of 60’s racist anti-progressive forces masquerading in ‘family values’ drag and urged coordinated efforts to defeat them.

Unfortunately, while the Religious Right was using the 80’s and 90’s to organize for culture war and develop their Machiavellian playbook to power, transpeople were fighting a pitched battle with the gay and lesbian community just to be included. This civil war against the GLB transphobes sucked time, energy and money from the transgender community that could have been better spent combating the Religious Right.

The predominately white and bicoastal-based gay and lesbian leadership didn't see the Religious Right as a threat because they not only didn't have fundies in their backyards, they let their anti-transgender biases color their perceptions. They dismissed the threat because it was transpeople who were sounding the warning bells about it. At the same thime they were cavalierly dismissing their concerns about GLBT unity and the Religious Right threat, they arrogantly demanded that transpeople work to pass gay-only rights bills.

According to legal scholar Kat Rose, such laws have the effect of creating a regime in which the same gays and lesbians who fought to prevent trans-inclusion have the de facto right under the resultant non-inclusive law to discriminate against trans people. It also allowed them to keep their leadership ranks and employee populations in these organizations transgender-free without fear of facing discrimination lawsuits.

When transgender leaders would balk at those demands or point out the hypocrisy of leaving us behind, they would state they would ‘come back for us’.

So far the only states in which the gay and lesbian community has ‘come back’ for transgender people are Rhode Island (2001), California (2003), New Jersey (2006) and Vermont (2007). In New York they are still having a difficult time passing GENDA after transgender people were cut out of SONDA by gay rights advocating the same 'we'll come back for you' incremental rights spin.

The first gay only rights bill, passed in Wisconsin in 1982 has been that way for 25 years now. There's no indication by the GLB leadership in that state if they'll move to rectify the omission of their transgender brothers and sisters or if they'll assign it a priority as high as the one they place on marriage equality.

We also heard the excuses during the 90’s to justify the gay and lesbian strategy that ranged from ‘the country needs more education on transgender issues’, we need 'incremental progress' to the mean-spirited ‘it’s not your turn to get rights yet’. Ironically there are now more transgender inclusive laws on the books than gay-only ones, and those numbers are increasing.

And where does HRC fit into this equation?

One of the people most responsible for excluding transpeople from an attempt to pass a gay rights law in Minnesota in 1975 was a gentleman by the name of Steve Endean, who in 1980 would leave Minnesota to help found the Human Rights Campaign Fund, the proto organization that later became HRC. Some Minnesotans assert that it's not a conicidence that the same year HRCF was born in DC, Minnesota's gay rights proposals became T-inclusive and eventually lead to the first T-inclusive law in 1993.

In 1995 Elizabeth Birch took over as Executive Director of HRC at a time when there was an epidemic of gays and lesbians cutting transpeople out of civil rights legislation.

In many cases gay people who sat on various HRC boards either nationally or regionally led the efforts. In 1999 Dianne Hardy-Garcia, who was the executive director of the Lesbian Gay Rights Lobby (now Equality Texas) at the time and an HRC board member, led the successful effort to cut transpeople out of the James Byrd Hate Crime Bill (to mine and TGAIN"s vehement opposition). That bill was eventually killed in the GOP-controlled Texas Senate but passed in 2001 as a GLB only bill and was signed into law by Gov. Rick Perry.

Elizabeth Birch for a while eclipsed Janice Raymond as Transgender Public Enemy Number One when she was quoted at a Chicago GLBT event as stating that transinclusion in ENDA (the Employment and Non Discrimination Act) a top legislative priority of transgender leaders would happen ‘over her dead body’.

That sowed the seeds to the growing perception amongst transpeople that HRC was ‘The Enemy’. It got worse when transgender lobbyists were told by sitting senators, congressmembers and various staffers that HRC Capitol Hill lobbyists Nancy Buermeyer and Winnie Stachelberg showed up on the Hill accompanied by GenderPac’s Riki Wilchins before transgender lobby events in 1997, 1998, and 1999. They asked those members and staffers to tell the transpeople coming to Washington that inclusion in ENDA wasn’t possible, but hate crimes was. That revelation so enraged the transgender community that a group of activists that included yours truly founded NTAC in 1999.

After doing an investigative report during the summer of 1999 that determined the extent of HRC co-option of GenderPac leaders, NTAC decided to pursue a multi-pronged strategy to deal with it. They decided to explore partnerships with other GLBT organizations, made it clear that transinclusion in federal ENDA and Hate Crimes was non-negotiable and during my time there I helped author a legislative strategy designed to go around the congressional barriers set up to block transgender inclusion in ENDA

In 2000 NTAC also began the ‘Embarrass HRC’ campaign to call attention to the hypocritical nature of the relationship between HRC and the transgender community. Activists across the country began protesting HRC dinners and calling them out at GLBT community events about their resistance to adding transpeople to ENDA. The campaign got the attention of people to the point where they started asking HRC leadership tough questions and their contributions started taking hits.

Despite this success, the transgender community didn’t embrace NTAC. It was a multicultural organization whose early leadership was predominately Southern. NTAC was relentlessly savaged by people for fostering what they called ‘horizontal hostility’. A group of white northeastern activists that wanted to push accomodation with HRC formed the National Center for Transgender Equality in 2003 and named Mara Keisling as its executive director.

But NCTE to some transpeople had uncomfortably close HRC links that caused people to question not only NCTE's effectiveness in lobbying for transpeople but its independence. Transgender historian and legal scholar Kat Rose bluntly said that "I simply do not trust NCTE or Mara Keisling".

The interesting thing was the timing. NCTE came into existence after HRC loudly proclaimed that they didn't want to talk to NTAC. There were unconfirmed rumors that some of NCTE's startup money was provided by HRC supporters.

Not long after NCTE’s startup, the shift of the gay and lesbian rights priority from successfully passing inclusive rights laws on a state by state basis to marriage equality started. Transgender leaders such as NTAC’s Vanessa Edwards Foster warned that this was a mistake to push the issue a year before the 2004 elections, but once again transgender concerns were brushed aside.

When the Religious Right backlash resulted in gay marriage constitutional bans overwhelmingly passed in 18 states during that election year, the transgender community was proven correct once again.

This irritated the transgender community on multiple levels. The marriage-as-a-priority gays refused to acknowledge that not only did their actions cause the backlash to gay marriage and possibly generated enough conservative voters at the polls to help propel George W. Bush to a second term, despite the evidence of dozens of state DOMAs and anti-marriage constitutional amendments, they are in severe denial about it.

Transpeople are also miffed at the lack of HRC concern as to how this backlash specifically affects our lives. Transpeople were never consulted and had no input whatsoever regarding the push for gay marriage, but the Religious Right anti-gay marriage laws get interpreted by the courts in such a way that they had the negative affect in some cases of wiping out existing pro-trans marriage and even identity rights.

We're also pissed that the same people who demanded (and still demand) that we accept 'incremental progress' when it comes to trans rights hypocritically have no intention of accepting 'incremental progress' when it comes to legal recognition of same-sex relationships.

In conclusion, the drama between the transgender community and HRC (which sadly flared up last week after Rep. Frank introduced a non-inclusive ENDA) is a forty-year-old stew flavored with historical hatred, arrogance, political miscalculations, communication failures, misunderstandings, mistrust, and Machiavellian duplicity.

HRC also has a pathetic history of refusing to deal with trans people as equals not only in terms of civil rights legislation but even in hiring talented transgender people for their organization. This historical negativity keeps transpeople from working with HRC in any capacity. (Don't even get me started about the African-American community beefs with HRC, that's another post.)

The sad part is that this animosity is preventing HRC and the transgender community from effectively working together to defeat their common enemy despite the desires of people on both sides to do precisely that.

The flare up this time may have not only burned the bridge that people like recently resigned HRC board member Donna Rose and others were trying to build towards a working partnership with HRC, but made any talk of doing that in the transgender community moot for years to come.

Transgender health care provider protocol

transgender health care provider protocol

Transgender Health Initiative of New York (THINY)

Policy & Protocol for Serving Transgendered Patients

In  its  broadest  sense,  the  transgender  community  encompasses  anyone  whose  identity  or behavior  falls  outside  of  stereotypical  gender  norms.  Transgender  has  become  an “umbrella”  term  that  is  used  to  describe  a  wide  range  of  identities  and  experiences, including  pre operative,  post operative,  and  non­operative  transsexual  people,  male  and female  cross dressers  and  those  referred  to  as  “transvestites,”  “drag  queens,”  or  “drag kings”.  The  term  transgender  can  also  refer  to  intersex  individuals,  and  men and women whose appearance or characteristics are perceived to be gender- atypical. In  order  to  meet  the  needs  of  this  diverse  patient  population,  the Transgender Health Initiative of New York (THINY) recommends the following:

1.  Hospitals  and  other  health  care  providers  should  adopt  and  implement  a transgender non-discrimination policy. An effective transgender nondiscrimination policy.  An effective and well understood non -discrimination policy  is  essential  to  ensuring  that  transgender  patients  are  treated  respectfully  and appropriately.  THINY  recommends  that  health  care  providers  adopt  and  implement  the following policy:

Health  care  providers  may  not  provide  inferior  care,  refuse  to  provide  care,  or  treat  a  patient  differently  because  of  that  patient’s  gender  identity  or expression.

Gender  identity  refers  to  a  person’s  internal,  deeply  felt  sense  of  being  either  male  or  female,  man  or  woman,  or  something  other  or  in between. Because  gender  identity  is  internal  and  personally  defined,  it  is  not always visible to others.  Gender  expression  refers to all of the external characteristics and  behaviors that are socially defined as  either masculine or  feminine,  such  as  dress,  mannerisms,  speech  patterns,  social roles and social interactions.

2.  In  order  to  ensure  that  transgender  patients  are  treated  appropriately  and respectfully,  THINY  recommends  that  the  following  protocol  for  serving  transgender patients in a non­discriminatory manner be adopted:

a.  Forms.  Forms  that  require  a  patient  to  designate  a  gender  may  create discomfort  for  transgender  patients,  especially  where  a  patient’s  legal  sex differs  from  his  or  her  gender  identity  and  expression.  Additionally,  many transgendered patients  will  have  concerns  about  medical  privacy  and disclosure  of  personal  information  about  gender  identity  on  forms  that  may be  accessible  at  a  future  time.  Accordingly,  THINY  recommends  that a system be developed by  which every  transgendered  patient may  designate his or  her  gender  identity  and  preferred  name,  as  opposed  to  necessarily  being designated  a  legal  name.  This  system  should  address  patient privacy concerns  while  allowing  a  patient  to  express  his  or  her  preferences regarding  preferred  names  and  pronouns.  This  system  should  further ensure  that  such  information  is  communicated  to  staff  having  contact  with the patient.

b. Preferred names and pronouns.  Referring to a transgender patient by his or her legal rather than preferred name

can be upsetting and even offensive to a patient. Similarly, it is important that a transgender  patient be referred to by  pronouns  appropriate  to  his/her  designated  gender.  Some  transgender people  have  more  than  one  gender  presentation  and/or  wish  to  use  more than  one  set  of  gendered  pronouns.  Health  care  staff  should  make  every effort  to  respect  the  gender  identities  of  those  individuals  even  if  their gender  presentation  may  seem  inconsistent  or  confusing  to  staff  members.  For such individuals, the insistence on a consistent gender presentation may itself  be  as  offensive  as  the  use  of  the  wrong  name  or  pronoun.  THINY recommends  that  health  care  providers  refer  to  patients  by  their  preferred names  and  in  accordance  with  their  designated  genders.  If  a  patient  has  not  designated  a  gender,  the  provider  may  politely  point  out  to  the  patient that  he  or  she  has  not  designated  a  gender  and  ask  whether  the  patient prefers to be referred to as “he,” “she” or something else.  Personnel should continue  to  use  the  patient’s  chosen  names  and  pronouns  associated  with the  patient’s  gender  identity  during  procedures  or  examinations of sex organs that the patient was born with (e.g., gynecological and breast exams for  female -to- male  patients  and  prostate  and  testicular  exams  for  male -to -female patients).

c.  Privacy.  Many  transgender  patients  have  concerns  about medical privacy. Transsexuals in particular who have completely transitioned from one sex to the  other  may  be  concerned  about  the  consequences  of  disclosing  their status,  including  the  threat  of  discrimination  in  employment  and  insurance coverage.  THINY  recommends  that  intake  forms  explain  the  provider’s privacy policy, including who  has access to  a patient’s  medical records.   The forms  should  make  clear  which  information  is  required  and  what  can  be discussed  with  health  care  providers  directly.  During  patient  examinations,  health  care  providers  should  be  prepared  to  explain  who  has  access  to  the information that is discussed with the patient.

d.  Restroom  access.  Unimpeded  access  to  restrooms  is  essential  to  all patients.  THINY  recommends  that  patients  be  permitted  to  use  facilities consistent with their gender identity.

e.  Room  assignments.  THINY  recommends  that  transgender  patients  be assigned  rooms  appropriate  to  their  gender  identity.  THINY  further recommends  that  a  transgender  patient  not  be  removed  from  a  room because  of  complaints  by  another  patient  related  to  the  transgender patient’s gender identity or expression.

f.  Avoid  focusing  on  gender  identity  or  expression  unless  necessary  for treatment.  Some  of  a  transgender  patient’s  health  care  needs  will  not  be directly  related  to  that  patient’s  gender  identity  or  expression.  THINY recommends  that  providers  avoid  focusing  on  a  patient’s  gender  identity  or expression  unless  it  is  directly  relevant  to  medical treatment. Disrobing should only be required if directly relevant to the examination.

g.  Items  that  assist  gender  presentation.  THINY  recommends  that transgendered  patients  have  access  to  items  that  facilitate  gender  expression (e.g., clothing, makeup)  to  the same extent that  other  patients have access to  these  items,  regardless  of  gender.  Transgendered  patients  may  also  have access to  items that only transgendered persons would ordinarily use to  effect their  gender  presentation,  including  items  used  in  binding,  padding  and  tucking,  unless  use  of  those  items  hinders  treatment  or  recovery,  as determined by an attending physician.

h.  Posting  the  non discrimination  policy.  It  is  important  that the provider communicate to members of the transgender community that it understands their  needs  and  will  treat  them  respectfully.  Accordingly,  THINY recommends  that  its  recommended  transgender  non discrimination  policy, set  forth  above,  be  posted  in  conspicuous  locations  near  all  points  of  entry to  the  facility,  the  patient  information  desk,  the  patient relations office, all patient registration and admission areas, all waiting areas in the facility, and any other appropriate areas, as applicable.

i.  Ombudsperson  for  Transgender  Concerns.  THINY  recommends  that hospitals  and  other  large  facilities  appoint  an  Ombudsperson  for Transgender  Concerns  or  similar  official  who  should  be  responsible  for implementing,  coordinating,  and  monitoring  the  facility’s  services  for transgender  patients  and  addressing  complaints  regarding  services  for transgender  patients.  THINY  recommends  that  this  official  report  to the Director of Patient Relations or similar senior management official.

j.  Complaint procedure.  THINY recommends that providers inform patients of their  right  to  file  a  complaint  and  that  all  complaints  be  handled  in accordance with a defined complaint resolution protocol.

k.  Training.  THINY  recommends  that  providers  conduct  training  sessions  on an  annual  basis  for  all  staff  regarding  the  provider’s  transgender  non -discrimination policy and service protocol.

l.  Continuing  Obligations.  THINY  recommends  that  providers continue to improve services to the transgender community and engage in the following ongoing activities:

(a)  conduct  annual  patient  and  provider  satisfaction  surveys  to  determine compliance  and  satisfaction  with  the  transgender  non -discrimination policy and service protocol;

(b)  communicate  on  a  regular  basis  with  transgender  community  groups and  associations  on  issues  relating  to  the  transgender  non -discrimination policy and service protocol; and

(c)  communicate  with  department  heads  and  the  Director  of  Patient Relations  on  a  regular  basis  to  assist  them  in  meeting  the  obligations set  forth  in  the  transgender  non discrimination  policy  and  service protocol, as applicable.

Erika Keels

Hit-or-Run Over

Why isn't anybody seeking answers about a transgendered prostitute's death anymore?

by Matt Stroud

Published: Nov 20, 2007

CRIME

Michael T. Regan THE SCENE OF THE INCIDENT: At Broad and Thompson, Erika Keels was either killed by an angry John or accidentally struck by an elderly driver. (CLICK IMAGE FOR LARGER VERSION)

his much is clear: Erika Keels, a 21-year-old transgendered prostitute, was killed on North Broad Street early in the morning on March 21. But, depending upon which account of her death one believes, she was either accidentally struck by an elderly driver who wasn't wearing his prescription glasses, or repeatedly run over by a crazed John.

Police report that Keels was standing in the street, close to the curb near the Thompson Street intersection and that she was struck at 5:04 a.m. by a late-model Lincoln Town Car driven by Roland Bottom, 70, of Germantown, who was on his way to work. Keels traveled 65 feet through the air, smashed through the rear windshield of another car and then finally landed unconscious next to a fire hydrant in front of McJay's Food Market.

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The Medical Examiner's Office initially classified the incident as a hit-and-run, but police said that wasn't true; their report stated Bottom's vehicle came to a halt about 100 feet past Keels' injured body. Finding no brake marks on the roadway, police stated Bottom "simply didn't see Keels." After admitting to speeding and not wearing his prescription glasses, he was released after brief questioning; he'd later be issued a traffic citation.
Keels died two days later, on March 23, from multiple injuries, according to her death certificate. But the incident left local trans activists lobbing accusations on blogs and in fliers; the phrase "hate crime" was bandied about since some found Keels' death representative of the underlying ills of an anti-trans society in Philadelphia.
By May, activists were rallying support and the Philadelphia Gay Newsrepeatedly questioned officials about why serious charges hadn't been filed. Led by Savannah Hornback, who said she's one of Keels' close friends, the "Justice 4 Erika" campaign accumulated more than 3,000 online signatures to "demand a thorough investigation of the circumstances surrounding Ms. Keels' death."
The petition read, "Her case must be re-opened. Now and in the future, the police must follow their mandate to protect and serve all Philadelphians, including those targeted for hate because of their gender expression and identity."
The words are justifiable when considering that the petition stated, "witnesses saw an assailant intentionally run over Ms. Keels four times after ejecting her from his car." After a June 14 rally outside the Roundhouse, Mary Kalyna of the Global Women's Strike, a worldwide network promoting the remuneration of war funding for peaceful purposes, said, "It seemed like something could be done — like justice could actually be served. We were excited people were listening, that maybe we could stop this kind of treatment of people who the police dub unworthy of fair treatment."
But by late July, PGN stopped writing about Keels. The allegations and blog posts ceased. Even the "Justice 4 Erika" MySpace page went stagnant. It hasn't been logged onto since Aug. 17; the most recent "friend comments" were spam advertisements for Macy's and sexiluv.com.
So, why did the interest fade? Police Capt. Michael Murphy offers a simple explanation.
"There's nothing more going on here than two people who weren't paying attention to what they were doing," he says. "This is a case of negligence. It's sad, but only one witness came forward, and that individual corroborated the details of our investigation." Murphy says he waited for more witnesses, information and testimony from Hornback, but has yet to receive anything that rises to the level of reopening the case. In fact, he's seen very little about the case in recent months. Not much recorded testimony exists to counter the official conclusions.
Poet CAConrad, who worked with Hornback to organize the June protests, says he hasn't seen Hornback since June. Sabina Neem, an activist at Attic Youth Center's Safe Outside the System program, declined to answer whether she had been in contact with Hornback. A receptionist at the William Way Center said she saw Hornback passing out fliers before the June protest, but hasn't seen her since. City Paper repeatedly called multiple phone numbers and messaged multiple e-mail addresses supposedly connected to Hornback but received no reply.
Murphy insists that Hornback — their only contact to supply witnesses corroborating murder implications — simply never pursued the case. But Neem implies that Hornback and her witnesses were intimidated by police.
"I have witnessed the ways in which trans people of color are constantly scrutinized, harassed, physically harmed, arrested or asked to exchange sexual favors to be left alone by law enforcement," she says. "Police use gender non-conformity — often conflated with age, race and socioeconomic status — as grounds for suspicion and discriminate enforcement of the law."
Meanwhile, Conrad maintains, "I spoke to several witnesses who all say they were really aggressively intimidated by the police, and told that they need to give their given names, which of course none of them want to do." He implies that, because the witnesses are prostitutes shunned often not only by society, but also by their families, they would rather sit silent than go public with their identities and their statements.
"If you hit someone with a car, that's a crime in itself," Conrad continues. "When you have witnesses who say that it was a murder, witnesses who say Erika was pushed out of the car and run over, how can you say nothing happened? It's like [the police] don't even fucking care."
But with nobody having come forward with fresh information about the case since the protests, all Murphy can do is say that there's no evidence to suggest any of Conrad's accusations ring true.

The Biochemistry of Sex Hormones

The Biochemistry of
Sex Hormones
All steroids in the body are formed from acetate, which is a 2-carbon compound. Steroids display a characteristic four-ring system. This steroid carbon skeleton, often referred to as the steroid nucleus, is found in all the steroids described here.

The first step in its conversion to a variety of steroids is the formation of cholesterol, which is a 27-carbon steroid. The formation of cholesterol occurs through a complex, eleven step series of reactions. Cholesterol is by far the most common steroid.  It is found in most animal tissue, with the greatest amount in the tissues of the central nervous system, that being the brain and spinal cord.
With any introduction to the essential nature and importance of cholesterol, it should be noted that the common concern with cholesterol is derived from its excess, whereby it contributes to vascular and heart disease. Cholesterol, in of itself, is absolutely not unhealthy, but essential to life.

The Degradation of Cholesterol
In the next phase, the cholesterol degrades, and in the ensuing process, creates all sex steroids (sex hormones) and corticosteroids.
The variety of steroids created occur from a stepwise degradation of cholesterol: Pregnenolone, progesterone, 17-hydroxypregnenolone, 17-hydroxyprogesterone, and corticosteroids, having 21 carbon atoms, followed by androgens (testosterone and androstenedione), having 19 carbon atoms, and natural estrogens having 18 carbon atoms.

Pregnenolone plays a vital role in the production of all other human sex hormones. It is converted to androgens (male sex hormones), progestins (hormones involved in pregnancy), and estrogens (female sex hormones).
All three of these hormones are in the bloodstream of males and females at all times; the differing concentrations of testosterone, progesterone, and estrogen contribute to the gender characteristics specific to males and females. These hormones are largely produced by the ovaries or the testes, as well as the adrenal glands of both sexes.  As mentioned earlier, the pituitary controls the production of these hormones.
Progesterone is the most important pregnancy hormone. It is produced in the ovaries by the enzymatic oxidation of cholesterol and is responsible for both the successful initiation of a pregnancy and the successful completion of pregnancy. Its initial role is to prepare the uterine mucosa (lining) for reception of a fertilized ovum. When the fertilized ovum is successfully attached to the uterine wall, the progesterone continues to be produced, aiding in the successful development of the fetus and at the same time suppressing further ovulation. The role of steroids in pregnancy had led to research into the uses of these compounds as birth control agents. Initially progesterone itself was studied in this regard, but it was found that the dose required to prevent ovulation is much too large.
Progesterone in turn can be biochemically converted to testosterone, which is found in the testes, and finally to estrone (an estrogen), which incidentally was first isolated from the urine of pregnant women. Both of these steroids play a major role in the development of male and female characteristics. Progesterone can also be converted to cortisone (a corticosteroid found in the adrenal gland), which is responsible for regulating a variety of metabolic processes.
Hormonal Breakdown
The liver plays an important role in hormonal modification and inactivation through its metabolism of both estrogen and testosterone, the latter being largely broken down at its target cells.
Nearly all drugs are modified or degraded in some way in the liver. Oral medications are first absorbed by the gut and transported via portal circulation (a certain amount of blood from the intestine is collected into the portal vein and carried to the liver). At that point, drugs are modified, activated, or inactivated before they enter systemic circulation (the normal blood nourishment that is the major part of the circulatory system). The body's circuitous path to the administration of oral medication lends this process to be described as "requiring a first pass" through the liver versus the rapid access to systemic circulation when drugs are administered parenterally (into the muscle, into a vein, under the skin).
These hormones are effectively handled by the various cells of the body, of particular importance, the cells of the liver, without harm to the individual.  But long term, as well as short term, administration of hormone therapies require careful administration and periodic monitoring to assure good health is maintained. The healthy liver will manage these processes very well.  However, a damaged liver, whether related to substance abuse or infection, does not easily facilitate the necessary breakdown process.

The overall process of hormonal biosynthesis.

Measuring Your Transition

Measuring Your Transition
While undergoing a regimen of hormonal feminization, keeping a diary or log of physical progress and medication/hormone usage can be very helpful in making the most of your physical transition.
Taking Body Measurements
Over the years, we have tailored a variety of record keeping strategies for our patients. A basic strategy for recording measurements follows.
Body size measurements should be taken on approximately a monthly basis. For best results, use a cloth (tailor's) tape measure. Keep tape level and take measurements using the same areas depicted by the model shown below. Measurements should be taken standing straight with your body remaining relaxed, and drawing the tape until it is barely snug. Take measurements nude, or wearing a slip or nightwear made of a thin material. Keep in mind that maintaining consistency in the way that you take these measurements will assure your changing body is accurately represented in your measurements.

Measure under the armpits, above the area of the breasts. Measure around the widest part of the back, straight across the fullest part of the bust. (See below for important details on our breast measurement technique) Measure under the area of the breast. Measure your waist approximately one inch above the navel.  This is the female natural waistline, the smallest part of her waist. During successful hormonal feminization, this will become your natural waistline. Measure around the fullest part of your hips. Put your thumbs at your natural waist and rest your hands on your hips. The tips of your fingers should be the area at which to take the hip measurement. Measure at a point just above the pubic area and over the area of your buttocks. Measure the fullest area of your left upper thigh.

Use a cloth tape to measure the areas shown.

Recording Body Measurements with
the TransLog Database Application
One should have a place to record these body measurements along with weight and brief notations (optional) over the months and years of your transition. You may also wish to include a record of your hormone and anti-androgen usage together with these measurements in order to provide an even greater understanding of your progress during transition.
Based on the clinical information we normally collect, we have developed a freeware database application calledTransLog that records all of these necessary details of your physical transition.  You can learn more about TransLog as well as download it free from the TransLog Home.
Recording Body Measurements on Paper
The other choice for storing information still works remarkably well—taking notes on paper. Keep your information in a format that can be read at a glance, such as tabular format.  Creating a table (i.e., rows and columns) is a good way to keep your entries organized.

Our Breast Measurement Technique
We have tailored our measurement techniques based on the results of our hormone therapies—we have prescribed to literally hundreds of transgender women.  And while most measurements are taken no differently than for a genetic female, we have noticed that a crucial body measurement needs to be taken differently for the transgender woman.
The measurement area of concern is the breast.  Often the medical literature as well as physicians not familiar with transgender practice will suggest measuring the breast itself.  This technique calls for measuring each breast—taking a measurement of the breast along the horizontal and vertical axes.  While treating the breast as a hemisphere and taking measurements accordingly works well for the genetic female, it offers little for the transitioning female. Let's take a look at why:
For the genetic female, no de-virulizing takes place.  The muscles in the upper body do not diminish as they do in the transgender woman and breast growth is normally significant. So for the genetic female, taking a measurement of the breast, itself, is the most telling.  But, this traditional technique is not very useful for the transgendered woman.
For the transgender woman, breast growth occurs along with the diminishment of upper body muscle mass.  So the traditional technique which measures only the breast area does not take into account the competing forces of breast growth and decreasing upper body mass, and provides little in the way of useful information. 
For the most accurate and reliable means of measuring the breast area for the transgender woman, we recommend measuring the breasts and the surrounding upper body area as a single measurement, as shown above.  Our TransLog database application supports this method.
Look for the Differences
Often during transition, the breast area values (numbers) do not show much change.  At first glance, one may feel that not much change is happening.  Usually, more changes are occurring than you realize.  Keep in mind that your muscles are diminishing as fat is redistributing itself towards a normal female form. The change in breast size is seen by looking at the numeric differences between the chest, bust and rib cage measurements.  Additionally, the overall decrease in one's frame size (size decrease due to overall loss of muscle mass) is seen in these measurements.
The true degree of breast growth in the transgendered woman is often hidden by the fact that the chest wall diminishes as quickly as the breasts enlarge. Therefore, the overall breast measurement may stay the same even though it has enlarged by an inch or more because the chest wall has diminished by that amount.

HRT-Part 1 Hormone Replacement Therapy Medications and Results

A Look at Medications

Forms of Feminizing Hormone Therapy

The general process of supplementing a woman's natural hormones is often called hormone replacement therapy or HRT. The oldest form of supplemental hormones is estrogen.  When estrogen is taken alone (that is, not mixed with a progestin), it is called unopposed estrogen (also, estrogen replacement therapy or ERT). When estrogen is taken in combination with progestins, the process is called combined hormone therapy.
For transgender women, the standard HRT regimen is inadequate. The latest and most effective therapies include more potent estrogens and anti-androgens.  This combination of medications not only offers greater feminization, but also provides a greater reduction of the masculinizing effects from past virilization.  Each regimen and form of administration not only has its own specific benefits, but also carries with it a variety of differing risks.
Over the years, we have used many different feminizing and de-masculinizing drugs with our patients in order to maximize the positive benefits while reducing any negative side effects. The feedback from these ongoing treatment methods coupled with consultations with other professionals, and discussions with patients who have experienced other regimens have allowed us to compile a sizeable amount of data concerning the administration of hormonal therapies. 
The following is a brief synopsis of medications that are used in feminizing hormone programs.
Estrogen
ESTROGENS - ORAL USE
Estradiol (Estrace)
17-Beta Estradiol provides the most potent estrogen available, and is most commonly taken by mouth. It may also be administered by way of a skin patch or injected into muscle, whereby the drug travels expeditiously through the bloodstream to the areas it affects or targets.
Oral estradiol provides a very effective means of feminization. Its dosing and subsequent adjustments, like other medications to follow, is dependant on measured testosterone levels, the degree of feminization achieved, side effects and other impediments to a healthy condition.
Oral estradiol is usually supplied in 0.5 mg (milligram), 1.0 mg, and 2.0 mg tablets.
Conjugated Estrogens-Naturally Occurring (e.g., Premarin)
The most common mixture of natural estrogens is called Premarin. Derived from the urine of pregnant mares, Premarin contains a number of different (conjugated) estrogens and is obtained through the extraction process.  Compounds derived from such a process not only subject animals to unduly harsh conditions, but may contain additional substances  that create a potential for unknown or adverse effects.  In our observation, there is a greater likelihood of mood swings and depression seen in patients using naturally derived estrogens as compared to synthesized preparations such as estradiol. 
Conjugated Estrogens-Synthesized (Cenestin)
Conjugated estrogens may be synthesized also. One such medication, Cenestin, is a slow-release conjugated estrogens product derived from plant sources.  Cenestin contains the same three primary and six minor estrogens found in Premarin.
Other Estrogens
Other plant-derived estrogens, called esterified estrogens, are usually made from modified soy (Estratab, Menest).
Estropipate (Ogen, Ortho-Est) is a version of estrone, a weaker form of estrogen.
ESTROGENS - FOR INJECTION
Estradiol Valerate
Estradiol Valerate is formulated as a longer-acting product that is usually contained in an oil preparation. Like oral medications, injectable preparations are manufactured in differing strengths. In the case of Estradiol Valerate, the drug is typically formulated in a concentration between 10mg to 40mg of active ingredient per milliliter (mL).
While some may be fearful of injection, the amount administered will usually be contained in one mL. To give an idea about that amount of liquid, a small spoon holds about 5 milliliters. Estradiol Valerate may be typically injected weekly to monthly, with the frequency/concentration based on the measured testosterone levels for the patient.
The more direct route of administration provided by injection may speed the physical change by creating a higher and more constant source of estrogen.  Ideally, injection should require less processing by the liver, but all to often improper administration (poor or no monitoring, self-medicating, etc.) instead creates undue health risks.
ESTROGENS - TOPICAL USE (Through the skin)
Interestingly, some of the most ineffective as well as some of the most beneficial preparations are available in topical form.
Creams
Estrogen creams (e.g., Premarin cream) are sometimes applied to areas of the skin, such as the breasts. The benefits from such an approach usually range from very minimal to unfelt.
Skin patches
Medication skin patches, also called transdermal or percutaneous patches, provide a very effective means of medicating.  In this approach, the estrogen (estradiol is used) is transferred into the body directly through the skin.  The transdermal approach offers ample delivery of medication for full feminization.  And its consistent and prolonged release make for a safe and sensible approach.
But the transdermal approach is pricey, being probably the most expensive means of administration.  Some individuals suffer skin irritation related to the adhesive. For others, the presence of a patch is awkward or tends to come loose from the skin, especially during sustained activity, such as sports or outdoor activities.  The adherence problem can be addressed with the use of a skin preparation that helps the patch stay in place even in the presence of moist conditions or heavy perspiration. See A Sticky Solution to Transdermal Adhesion Problems.
Transdermal patches uniformly contain estradiol as the active medication, produced in 0.05mg (50 micrograms, 50 mcg) and 0.1 mg (100 mcg) concentrations, and are branded under a variety of names such as Climara and Alora. The reader will notice that the dose amount contained in the patch is about one-tenth to one-twentieth as the same drug that is taken orally.  These concentrations are considered potent since transdermal entry of the drug is many factors more efficient than oral administration.
Progesterone
PROGESTINS (PROGESTERONE) - ORAL USE
As mentioned in Section 5, progestins have an arguable positive effect for the transgender individual. It is likely that if a progestin is chosen, a minimal dose of oral medroxyprogesterone acetate (Provera) may be given on a cyclic basis.  Such a typical regimen may provide for its use for about ten days of the month.  Less likely would be its use on an uninterrupted basis.
PROGESTINS (PROGESTERONE) - FOR INJECTION
A progestin may also be given by injection. The same medication, medroxyprogesterone acetate, is available in an aqueous suspension for injection. It is typically branded as Depo-Provera and its typical use is to provide long-term (about three months) contraception from a single injection. Another injectable medication sometimes chosen for transgender use is hydroprogesterone caproate (Proluton Depot). From our experience, we do not see a benefit from the use of injectable progestins. Patients have regularly expressed complaints and have suffered adverse side effects.
Anti-Androgens
The use of an anti-androgen has been used for many years by endocrinologists as a biochemical means of controlling unwanted hair growth in the genetic female. In recent years, this treatment approach had been introduced in treatment of transgendered women and is now being widely practiced.
It has been our experience that anti-androgens have a role second only to estrogen in the feminizing process.  Further, without the use of anti-androgens, adequate and desirable demasculinization will likely be greatly curtailed. And following genital surgery or castration, continued use of anti-androgens is strongly recommended if continued feminization is expected.
Spironolactone (Aldactone)
The drug most commonly used for the task of diminishing one's response to androgens is spironolactone (branded as Aldactone). Like many other drugs in the category of anti-androgen, spironolactone is used other than for its primary or generally intended purpose.  In the case of spironolactone, it is a diuretic and anti-hypertensive medication.
Spironolactone is a good choice for an anti-androgen.  It is generally well tolerated, even when administered over a period of years. And when by happenstance, a mildly hypertensive patient enters into transgender treatment, often spironolactone can be provided as a substitute; by doing so, the medication now serves a dual purpose.  While spironolactone is a potassium saving diuretic, the normal monitoring of blood chemistry during transgender treatment assures its safe administration.
Patients often report increased unpleasant side effects (such as a need for frequent urination) when doses over 300mg per day are taken. Typically doses of 200mg daily or less are well tolerated.
Finasteride (Proscar, Propecia)
Another good choice for an anti-androgen is finasteride (Proscar, Propecia), and is able to be used in concert with spironolactone. The primary use of Proscar (finasteride 5 mg) was in the treatment of benign prostatic enlargement, but with its reintroduction as Propecia (finasteride 1 mg), the drug is being largely marketed to promote scalp hair growth.  For transgendered women, finasteride when given in the larger dose promotes not only scalp hair growth but acts as an potent anti-androgen as it is highly effective in inhibiting the conversion of testosterone to DHT (dehydrotestosterone) responsible for male sexual characteristics.  Finasteride is usually physically well tolerated over long durations, but is expensive. 
Anti-Androgens whose potential risk may outweigh their benefit
Keep in mind that unlike estrogens, the drugs that are used as anti-androgens, when initially released, were typically intended for a variety of medical conditions, including some very serious conditions. In effect, through clinical use, these drugs have been re-purposed for a feminization regimen.
Typically, drugs that address more serious medical conditions (e.g., cancer) have effects that may be not only potent, but harmful and unexpected, as their potential hazards may far outweigh their benefits. Simply put, these drugs may be more harm than good.  Such drugs include:
Leuprolide acetate (Lupron)
Leuprolide acetate (Lupron) is used as an anti-androgen as it has the potential to reduce testosterone to castrate levels. It is an analog of naturally occurring gonadotropin releasing hormone (GnRH or LH-RH). The analog possesses greater potency than the natural hormone. Lupron is normally used in the treatment of advanced prostatic cancer when orchiectomy (removal of the testicles) or estrogen administration are either not indicated or unacceptable to the patient.
Lupron does carry a variety of risks that have been associated with its use including a variety of cardiovascular difficulties (congestive heart failure, ECG changes/ischemia, blood pressure changes, murmur), musculoskeletal pain and fluid retention.  While the non-transgender male suffering from prostatic cancer may consider these risks acceptable as compared to castration or estrogens, these same risks seem absurd in the parlance of a feminization regimen.
Flutamide (Eulexin)
Flutamide (Eulexin) is another drug used ordinarily in the treatment of prostatic cancer and has somehow been adopted as acceptable medication in transgender treatment.  Flutamide carries the risk of liver injury to the patient.
Ketoconazole (Nizoral)
Ketoconazole (Nizoral) similarly carries the potential of injury to the liver, however its normal use is as an anti-fungal agent.
Cyproterone acetate (Androcur)
Cyproterone acetate (Androcur) is an anti-androgen that has been used to treat hypersexuality and sexual deviation in men; it is also used in the treatment of cancer of the prostate. It is used, in part,  to treat severe acne in women.  Its high-dose treatment sufficient for a feminization regimen may cause liver damage, resulting in jaundice or hepatitis.
Overview
When one considers the advancements and availability of sound medical management in the area of transgender treatment, most often the feminization regimen required for the transgendered individual can be handled with little complication.  Today, there are well trained providers available worldwide.
Sadly, too few individuals have addressed their own internal conflicts and fears concerning their transgenderism. As a result, addressing one's transgender concerns may unsettle the individual wishing to pursue proper and sound medical treatment. The individual who may readily appreciate the risks associated with self-medication and less than acceptable therapies under other circumstances, may opt for such solutions in the transgender milieu.  And accordingly, the likelihood of serious health risks and poor outcomes is unacceptably high as a result. Sensibility and proper medical management are the cornerstones for a successful outcome. 



Typical Results
While the individual's response to feminizing therapy will vary, we have observed several key changes that appear for the majority of transgendered women in addition to the general estrogenic effects related in Section 5.
Breasts
For the transgendered woman, breast development will vary greatly, as it does with the genetic female population.  However, breast development will typically be less than what is experienced in the genetic female population.
With the transgendered woman, breast tissue growth is basically promoted by estrogens and anti-androgens.  Under most circumstances, breast development exceeding a B cup is rare. Development will take at least 2 years to reach maximum size.
Changes in the nipple will likely be somewhat less than in the genetic female. The areola (the small ring of color around the nipple in the center portion of the breast) will change in appearance and size in relationship to the breast.
Soon after beginning hormone therapy (about 2 to 3 months), there will be a nodule-like formation behind the nipple and a feeling of tenderness or sensitivity in the area. This early stage of development is caused by an increase in the ductal system behind the nipple is part of the transition process and will usually normalize in a matter of months.
Body Hair
Depending on how hirsute (possessing hair) an individual's body may be, body hair will generally lessen noticeably to almost entirely over a period of several years.  Individuals will generally notice a diminishment of bodily hair occurring on the extremities, and most of the torso.  As example, arm and leg hair as well as hair on the abdomen, chest, and shoulders will greatly lessen and in some instances disappear completely.  Hair growth in specific regions including that around the areola, armpits and pubic area will not lessen to the same extent.
Skin
The general appearance of the skin, overall, will change greatly by becoming softer and less coarse.  With proper skin care, which includes protection against the damaging effects of the sun, the skin's general appearance will be noticeably enhanced by the influence of estrogen and anti-androgens.
Fat Distribution
Over a period of time (1 to 2 years time), a change in the subcutaneous fat (located just beneath the skin) will occur.  The hips, thighs and buttocks will collect the majority of this distribution, and the tendency to collect fat in the stomach will diminish somewhat. The resulting redistribution will result in a smaller waistline and larger hips.
Muscle Mass
A good deal of the size that is normally attributed to large or broad shoulders, arms and chest is actually contained in upper body muscle mass—not bones.  Through the process of feminization much of the upper body bulk will disappear.  Muscle mass will generally take longer to diminish (about 3 years) than the accompanying shift in fat distribution previously mentioned. As upper body mass is lost, a certain degree of looseness may be seen in the skin of the upper arms and shoulders. As is the case with normal weight loss in these areas, a period of one to two years may be necessary for the skin to adjust to the smaller frame.
Genitals
With regard to appearance, hormone therapy will produce its most marked change in lessening the size of the testes. Due to the influence of estrogen, the testes' production of testosterone and sperm will be greatly reduced.
Penile size will likely diminish somewhat.  While penile skin is used for lining the neo-vagina, the amount of donor skin available is more a matter of inherent size than that of the diminishing effects of testosterone. Sexual function will decrease, but the degree of which is unpredictable. Erections may still continue, but will probably be much less frequent and long lasting, or may not be possible. Ejaculate will lessen, probably to the point of only producing a very small, clear discharge as a result of the prostate and the associated structures responsible for semen production being impeded. (See Section 9, Male Genital Anatomy)
Prostate Gland
The prostate will diminish in size due to the effects of estrogen and finasteride (Proscar), the latter being administered as an anti-androgen. Beside from the feminizing effect of these medications, both drugs are helpful in the treatment of benign prostatic enlargement.  This condition is often responsible for the difficulty with urination experienced by many older individuals. Through the course of hormone therapy, this urinary complaint will likely be relieved.
Cardiovascular
Coronary heart disease is the leading cause of death in the United States. Due to various lifestyle and hereditary factors, cardiovascular conditions may pose additional risks to those undertaking elective medical therapies, such as the variety of drug treatments engaged in the feminization process.  However, the effects of hormonal therapy may be similarly beneficial to the male-to-female transgender patient with respect to arteriosclerotic plaque disease and cardiovascular conditions, as it demonstrates itself in the genetic female population.
Infertility/Impotence
Long term use of estrogens may likely result in infertility, with permanent infertility being a distinct possibility.  Sexual responsiveness will likely diminish over the course of hormonal therapy, potentially resulting in the inability to achieve or maintain an erection.  These effects are the basis for feminizing hormone therapy being termed chemical castration.
If the transgendered individual has any concern or desire to "father" children in the future, it is imperative that the male-to-female transgendered individual choose the option of sperm banking –  having samples of their sperm frozen and stored for later use – prior to beginning hormone therapy.  
Results Not to be Expected
Given a discussion of the physical changes that are typical as a result of feminizing hormone therapy, some misconceptions concerning the process arise. The following topics address those physical changes that one will see very little or no change specific to the hormonal regimen.
Beard Hair
Whatever active hair is present in the beard area upon onset of hormone therapy will remain.  Given years of hormone therapy and removal of the testicles, the beard will remain albeit somewhat slower growing and not quite as thick. Naturally, this status is far from acceptable.  A method of permanent hair removal, or combination of methods thereof, must be used to rid oneself of facial hair.
Permanent hair removal will show its greatest results by concentrating efforts on those areas least affected by hormone therapy, i.e., the beard area, and leaving treatment of chest hair and the like until last, if treatment is even required at all. See Electrology Guide.
Raised Voice
The depth in pitch and resonance of the voice are unaffected by hormone therapy.  However, inflection and manner of speech are very well suited to change.  Additionally, pitch can be raised through persistent vocal practice.  Given the importance of a gender congruent voice, surgical options have been explored in an attempt to alter pitch, but this most delicate of instruments is not likely to be properly retuned through surgery.