zeebster (imported) wrote: Mon Aug 20, 2018 8:58 am As I said, if Medicare would cover the procedure, then it's fine. If you do have a valid condition or situation which Medicare would approve the procedure, then there is not a problem. As for getting the letters? I've checked with several local shrinks and the cost per hour of seeing those folks is what I would call prohibitive.

As for the Physicians involved, they are part of one of the best known SRS offices in the country, so I find no reason to doubt their word regarding the self pay issue.

No letters? That's a different story. In my case, self pay only lowered the required letters from two to one.

Your wording is very confusing, but apparently you were originally implying that the clinic you are speaking of would perform a self-pay penectomy with no letters if you were not on Medicare? If so, good on them. I have been pessimistic about US surgeons offering penectomy and SRS without letters, but perhaps more providers are adopting the informed consent model.

As far as shrinks go, I have noticed that their fees vary wildly. I have seen many that charge $250 per hour and do not take insurance, and many that charge $80 per hour and slide down even further for low-income patients. I am especially fortunate, and live within an hour of a doctorate-level psychologist who specializes in gender issues and is in network with Medicare.

Dekeldoh (imported) wrote: Mon Aug 20, 2018 9:40 am Your wording is very confusing, but apparently you were originally implying that the clinic you are speaking of would perform a self-pay penectomy with no letters if you were not on Medicare? If so, good on them. I have been pessimistic about US surgeons offering penectomy and SRS without letters, but perhaps more providers are adopting the informed consent model.

That is precisely the situation, sorry for the confusion.

Informed consent isn't a business model, it's the formal permission you're giving your doctor to perform surgery on you after informing you about the possible outcomes, possible complications, etc. Doctors, at least reputable ones, are going to demand a therapist letter (and possibly two) to perform this kind of surgery. First - The surgery is life altering, but not necessary for your body to continue to function. Second - They are not going to do something which will put their medical license at risk. The letter in my view has always been their doing CYA, and not about you. But it is necessary in our litigious society.

The above means all procedures require informed consent regardless of if you have a letter or not. This consent is given either by you, or if you're unable, a person you've pre-designated to make decisions on your behalf.

The question is then will the doctor amputate your genitals in whole or part with only informed consent, or will they require a support letter from a therapist or two before agreeing to perform the surgery for you?

I will also caution at this point. At the time of this writing, there is only one doctor I know of who will perform castration with only informed consent - Dr. Arnkoff. He will not perform penectomy with only that (at one point he did, but he now requires a letter). All other surgeons require a letter of support from a therapist. That said, you all need to stop freaking out about getting that letter (or letters), it's not as hard as you think it is.

Yes, letters are just CYA formalities. I also think people overreact too much.

Just schedule an appointment with someone, and tell them you need X surgery done and you want a fucking letter. If they don't respect you or they waste your time for no good reason, tell them they suck and find someone better. They can't throw you in the loony bin.

In fact, many therapists who write surgery referrals offer a one-session evaluation with its own rate. The counselor who wrote my second letter made it sound like those evaluations last for two hours, but I was out of there in 15 minutes and had the letter ready to fax to the surgeon that same afternoon. Nearly half of the appointment was just me listening to her rant about how she doesn't like gatekeeping.

Even if you still aren't comfortable, you can probably email a bunch of local psychologists anonymously and for free. Briefly outline your case and tell them your concerns. "I need a referral for surgery but I'm wondering it will take too long or be too expensive. How quickly can you write a letter? Do you do a bunch of gatekeeping?" Or: "I'm not M<->F and the term 'gender dysphoria' makes me uncomfortable. Can you just help me get surgery without talking about all that gender identity bullshit?" Etc. That's what I did. The first person I emailed referred me to someone they thought would be more suitable, who then ended up meeting my needs perfectly.

Of course, this conversation may not apply to Dionysus, who started this thread, unless they fly to the US.

This issue Dionysus will face is getting the process to conform to a standards of care. Most medical establishments and doctors in the western world will follow the DSM, which is where gender dysphoria is defined. People need to SERIOUSLY get over the label gender dysphoria. Sheesh, I would have let them call me a green purple spotted dinosaur if it got me to the goal. Keep the outcome in mind, not the label.

At present there is a standards of care being formulated for men like us who fall into the middle - not wanting to be intact, as born with a complete set of male genitals, but not female either. The powers that be are finally starting to recognize we exist, and the more of us who complete surgery before this is done, the more willing these folks seem to helping us along. We provide them with firm examples that yes, it is possible to live a complete and happy life as a man, sans penis and/or testicles.

The world is changing. Even today, it's one hell of a lot better than it was when I was castrated in 2005. It's even improved since I finished my nullification in 2015. The folks coming up today and lamenting how difficult this is have no clue just how difficult it was not that long ago. It's comparatively simple for them, at least in the USA.

Also, the letter is more than a gatekeeping or CYA. While it is also those things it is also a legitimate thing expressing doctors concerns about the mental health of the patient, both in terms of whether they are fully of sound mind in the first place but also making sure they are truly ready for what comes afterwards.

I know people are often embarrassed about the idea of seeing a psychologist, but my experience has always been really good. The main thing is to find one that specializes in either gender issues, or if you're like me then one that specializes in sexual addiction.

The truth is, and this is not a judgement in any way, that having your mind so misaligned to your body is by definition a "mental illness". But get over it, there is plenty of modern, knowledgeable help.

And honestly, although I fully support the idea that everyone has the right to modify their bodies, I think it is fair to recognize that it isn't always a good idea. Some people are truly crazy. Some people are cycling through different things and would regret acting on their impulses. Some people really don't think things through properly. Some people are not really properly accepting of the risks involved. And so on.

A good psychologist or therapist will HELP you. And that help will include a letter. It's really not too much for a Dr to ask for, it makes a lot of sense and is quite reasonable.

No person is "truly crazy." Labeling them as such is just being mean, judgmental, and lazy. The real question is whether it's practical for society to accommodate them.

Dekeldoh (imported) wrote: Thu Aug 23, 2018 4:36 pm In fact, many therapists who write surgery referrals offer a one-session evaluation with its own rate. The counselor who wrote my second letter made it sound like those evaluations last for two hours, but I was out of there in 15 minutes and had the letter ready to fax to the surgeon that same afternoon. Nearly half of the appointment was just me listening to her rant about how she doesn't like gatekeeping.

I did a bunch of searching in the local area for shrinks who dealt with gender issues and there was only one in the area. Bit more research and was told I need to fill out the intake forms so I downloaded the .pdf files. There were 20 some odd pages of questions most of which I did care to divulge to someone I'd never even met. In general, I was told that getting such a letter would probably take a year and her fee is $175 an hour.

I've given up chasing it for awhile as I'm in the process of selling my house and moving so I'll take it up again once I get things straightened out. As I mentioned, the folks in California asked me to check back with them sometime in October about the Medicare issue. They also have some shrinks they work with and offer a referral service, but none of those folks are in my State.

As far as Dr. Arnkoff requiring a letter for a Penectomy, it's the hospital he works with that wants the letter. While he did okay with my Orchiectomy, I've seen pics of some of his Penectomy patients and I do not think that is a way to go as LT mentioned.

Dekeldoh (imported) wrote: Fri Aug 24, 2018 6:42 am No person is "truly crazy." Labeling them as such is just being mean, judgmental, and lazy. The real question is whether it's practical for society to accommodate them.

Actually, that is a very bad way to think. You're the one adding judgment to the term, I'm the one who says they need help.

There are absolutely people who are truly crazy, and by that I mean that their brains are not functioning well or healthily. In some cases brains are malformed due to congenital conditions, or disease or injury. In other cases brains are chemically imbalanced either temporarily (due to drugs, addictions or other issues with their health such as fluctuating serotonin levels) or chronically (such as causing depression).

All of these categories of people need help, probably medical help, not just "accommodation by society". If you saw one of those homeless people who stands on a corner waving their hands in the air and yelling at imaginary things starting to cut off their genitals while sitting on the sidewalk do you really think the right thing to do is just go "oh well I guess we should accommodate him?".

In particular there are people whose thoughts vary a lot and things that seem like a really good idea to them at one point leads to huge regrets sometimes even moments later, and this is common with people who have paraphilias which happen to be closely related to obsessive-compulsive disorder. These people often talk about having episodes where they are watching them do something they don't really want to do, and then being filled with self-loathing and regret afterwards. These people need help.

Addictions are another example. I know from personal experience that my sexual addictions have caused immense conflict within me. I have risked my life, my health, my marriage, my job, prison time, etc. all in the search of orgasms. While I'm doing these things part of me is going "no not again!". When I used to cruise for hookers, I'd literally be shaking to the point my teeth were chattering completely afraid of what I was about to do, praying for the ability to stop.

So seriously brains can be broken. People can act contrary to their own self-interest. Those people need help.

My point then is that is entirely reasonable for doctors to question a person's motives in wanting to do a permanent thing like castrating themselves. There are some people on this very forum whose interest in castration seems to be tied up with things that send off warning signs as to the healthiness of their motive. For example, there are a number of people who have fetishized the act of being castrated (often forceably) but have not expressed any serious, sustained confirmation that they are really prepared or desiring the life afterwards. There are also a number of people that want to get castrated out of shame of some other aspect of themselves such as being ashamed of being gay, or like me for being ashamed of being a sex addict. There are others who seem to fit the "truly crazy" where they can't even form complete sentences so the healthy functioning of the brain is in question.

Anyway, I think it is super important to sort out people for whom castration is a healthy, sustained, reasoned step towards something that will improve a person's life versus people who are focusing on it for the wrong reasons. I think a good doctor will take some care in making that assessment, with compassion in both cases.

Well said SplitDik, well said.