The following piece is the fifth installment in “Dressing the Part,” a series exploring cultural issues and the effects of social transition from the perspective of a femme-presenting trans guy.
This essay contains graphic descriptions of body mutilation.
For me, physical gender dysphoria is not hatred but dissociation.
I’m not ashamed of my body. I don’t think that it’s ugly, nor do I want to completely hide it away. I just have an idea of what I look like in my head, and I get this nauseating sense of denial at moments when I realize that this inner vision doesn’t line up with my tangible reality.
I’m dysphoric about my height, voice, hip-to-waist ratio, and internal reproductive organs, but these feelings are fairly manageable. I can be taller in heels, wear loose-fitting dresses, or go the whole day without talking. I probably can’t change these aspects of myself without hormonal intervention, and I’m okay for the most part about living with them for the rest of my life.
Breast dysphoria is a whole other story. It’s intense and almost always present. In my mind, my breasts are attached to my body rather than being a part of it. The incongruence I experience when I see them is so strong that I sometimes think I’m looking at a stranger when I catch my unclothed reflection in the mirror.
This specific type of dysphoria is harder to regulate as a femme-presenting person. “Nice boobs” are considered “assets,” so it’s hard to find feminine clothing that doesn’t emphasize them. Every top is always a bit too low-cut, a bit too form-fitting. People with breast dysphoria often use binders to flatten their chests, but it’s hard to rock a binder with a spaghetti-strap dress. I taught myself to alter my dresses to hide as much of my chest as possible, and learned how to Photoshop away offending cleavage in my self-portraits. Even then, I’m reminded far too often that these things are dragged along with me wherever I go.
I may be uncertain about many aspects of physical transition, but I have always, always, always been on board with top surgery. As a child, I regularly fantasized about somehow convincing medical professionals that I needed a double mastectomy. In more extreme moments, I imagined slicing the growths off of my body with a big knife, or slowly sucking all the fat out with a big tube. When I got a bit older and found out that top surgery, which didn’t just remove fat but also resized the nipples and contoured the chest for a more masculine appearance, I knew without a doubt that I would one day undergo this procedure. I was certain of this even before I realized that I was trans.
Even though I wanted my breasts off of my body as soon as possible, I hesitated to actually book an initial surgery consultation. The world of medical transition was notoriously gatekeepy; going into it made me feel like I was venturing into a haunted forest where outdated notions and thinly veiled transphobia laid in wait. Whenever I even so much as thought about looking for surgeons, my mind conjured up images of me getting laughed out of offices, or being told that I had to “live as a member of the opposite gender” for a certain amount of time before any care would be granted to me. “If you think that you’re trans, then you’ve got issues all right,” I imagined sinister doctors cackling.
Official guides also contributed to this fear. “Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment,” stated the newest version of the International Gender Clinician’s Bible. What if I wasn’t masc-presenting enough to get medical and mental health professionals to take me seriously? I wanted top surgery, but I wasn’t sure which one was worse: continuing to live with breast dysphoria every day, or getting told by authorities that I didn’t “look trans enough” for gender-affirming care.
My outlook changed after I read Unbound: Transgender Men and the Remaking of Identity, a book that followed four individuals getting top surgery with Dr. Charles Garramone, a highly regarded chest-masculinization specialist in the trans community. One person was a cis woman who “identifies as female and has no interest in taking testosterone, but … sees her breasts as an impediment, a part of her body that does not reflect how she sees herself.”
I was stunned. Here was a cis person who just wanted top surgery to feel better about her body. That was a thing? Top surgeons did that? I couldn’t look Dr. Garramone up fast enough. His site stated that he performed top surgery on any person with breasts, regardless of their gender identity or presentation. He operated under the informed consent model, where a patient discussed the benefits and risks of medical transition with a professional, ultimately making the final decision for themselves. This model placed an emphasis on bodily autonomy, trusting that patients knew what was best for themselves.
Maybe my dress-wearing transmasculine self had a chance after all.
A fair amount of top surgeons operated under the informed consent model, I would come to find. Some required a letter from a mental health professional stating that a patient had indeed discussed all the pros and cons of top surgery; some didn’t require even that. If a patient wanted to use insurance, however, they’d have to follow their insurance company’s requirements, many of which still required a “well documented diagnosis of gender dysphoria.”
My research eventually led me right back to Dr. Garramone. Even though he didn’t take insurance or reportedly have much of a bedside manner, he had a spotless track record and only required a letter from a therapist or a physician stating that top surgery was the next step in the transition process. I didn’t want to take any chances with a procedure that was so important for me, so I decided that he was the one.
Relieved that this somewhat daunting step was over, I set out to get that letter from my therapist.
Top Surgery Pros and Cons, I typed into a Google doc. Potential positives of getting it. Potential downsides of getting it. Potential upsides of not getting it. Potential downsides of getting it. Neutral / other considerations.
This page would be the basis of my breast dysphoria and top surgery “consultation” with my therapist. Goodbye, top dysphoria! Will be able to look at myself naked in the mirror and not hate my top half, I typed under “Potential positives of getting it.” No more having to find outfits that minimize cleavage or visibility of chest. Can go topless whenever I want. Can go swimming again!!!
The “Potential negatives of getting it” held far less weight. Costly. Potential issues with new partners? This has not been a problem in the past, though. Will have to alter most of my dresses.
I smirked to myself as I filled out the “Potential positives of not getting it”: Maybe one day I’ll have a magic reawakening where I decide that I actually like my breasts. This has not happened yet, though.
Potential downsides of not getting it: Continued dysphoria. There were no neutral or other considerations.
It was obvious that I thought of top surgery as an overall positive. The hard part of the discussion, however, was yet to come. My therapist and I ended up taking several additional sessions to fully discuss the exact extent of my breast dysphoria as well as my history with it. During these sessions, I talked about how terrified I was of growing breasts as a child, how I’d had a “ritual” as a teenager in my magical-thinking, Are-You-There-God-It’s-Me-Marty phase, willing to try anything if it meant that my chest would stay flat. I told him about how strange it felt to grow up dysphoric in a society which told me over and over again that my chest was an asset, a good thing, something I should’ve desired.
During the weeks in which we had these sessions, I found myself constantly alternating between dysphoria and giddy excitement. Digging up these long-buried memories made me experience that lonely, confused anger all over again, but then I’d realize that I was remembering these things for a reason — that I was moving forward, that people finally understood.
That’s how I ended up sitting on my floor one weekday morning, blinking back tears as I read the recommendation letter from my therapist. Patient has a well documented diagnosis of Gender Dysphoria (ICD-10 F64.1). Chest surgery is the next step in the transition process. Hormone therapy is not a prerequisite. Just medical terms, of course, clinical sentences on an impersonal document. But in those words was an acknowledgement that I was a man who needed top surgery — proof that all the feelings I had were real, legitimate.
Being seen in this way is a rare luxury for me. Throughout my life, adults I’ve trusted have called me strange, freakish, a confused teenager going through a phase, a scared little girl looking for a way to opt out of misogyny. This letter was an assurance that, after all this time, I finally had medical professionals on my side.
It was really happening: after twenty-three years of waiting, I was going to get this shit off my chest.
I’m very fortunate to start my transition at a time when transgender acceptance is at an all-time high. The world is beginning to understand that there’s no “right” way to be trans. Had I come out even five years ago, could professionals have seen past my presentation to diagnose me with gender dysphoria? Would there even be surgeons operating under the informed consent model?
It also strikes me that my ultra-femme, cis-passing appearance may have enabled me to transition. I am able to afford surgery out of pocket because I work at a large tech company. This same company also fully covers my out-of-network therapy sessions. Perhaps I’d gotten this job in the first place because I’d applied before I’d come out, showing up to my on-site interviews as Mimi, she/her, in a floral dress and heels, polished and direct and prepared, the perfect prototype of a Woman in Tech. To what extent had this body, this set of aesthetic preferences helped me avoid unpleasant, gatekeepy interactions?
I’ll never know the answer to that, but I do know that I’ll use my financial and cis-passing privilege in any way I can to help others who want or need to undergo medical transition, especially if they’re gender nonconforming. To me, privilege isn’t something to be guilty or ashamed about — it’s an opportunity to pay it forward. I want to do my part in making informed consent-based, accessible transgender care available to anybody who needs it.
I am getting top surgery to treat my physical, not social, dysphoria. I know that getting rid of my breasts alone won’t change the way society treats me. Strangers currently misgender me even if I’m binding and wearing an androgynous outfit; after surgery, I’ll be perceived as a flat-chested girl, not as a guy. I’m prepared to deal with it, though. Different types of dysphoria can be treated in different ways.
Making this physical change isn’t about “passing” as cis; it’s about feeling more comfortable in my own body. Making this physical change isn’t about “passing” any better; the only judge is myself. “Prior to getting top surgery, my chest was a problem to ignore, but now my chest is mine … though the physical change to my chest may seem insignificant to others, the mental change I have undergone has been drastic … I feel a freedom that runs deeper than the scars, a freedom that comes from within me, a freedom to not think about my chest all the time,” writes transgender author Tao Gadd. This is exactly what I want — freedom from the incongruence, from the dysphoria that has plagued me since puberty.
The WPATH Standards of Care define “transition” as a “period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role.” I will, in a way, forever be in transition — thanks to my presentation, there’s always going to be a period of adjustment in every new environment I enter. I will never be able to take my “gender role” for granted. But that’s okay; it’s the choice I made when I came out as a dress-wearing trans man.
I’m so excited to put on a dress and not constantly worry about showing too much cleavage, to be able to go outside in just a skirt, to look in the damn mirror and have my outer image match my inner one. I’m excited to be free of this constant denial, to have my body feel like my own again.
I’m fortunate to have people in my life who can see me for who I am. Top surgery will allow me to truly see myself, too. I can’t fucking wait. ✦