And then a Plank in Reason, broke,
And I dropped down, and down –
And hit a World, at every plunge,
And Finished knowing – then –– Emily Dickinson
(I felt a Funeral, in my Brain, 1896)
Depression
Testosterone (Part 1): Drugs and Doses
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~ Part 1 in the Testosterone Series ~
Part 2: Assumptions and Questions
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When I initially reviewed the literature on hormone therapy for FTMs over a year ago, I hoped to find quick and easy answers about testosterone. At that time, I had a simplistic and optimistic belief that gender dysphoria was the main issue contributing to depression and other life issues, so I felt a desperate urgency to start medical transition as soon as possible. But because I was still so unsure about my own transition goals, my research felt disorganized and overwhelming and served only to magnify the intensity of my uncertainty.
But after resolving my chronic confusion with the concept of “gender identity,” deconstructing many of my own illusions about my appearance, creating a more concrete mental image of my “ideal” body, and gaining a greater measure of acceptance of my current body, I was finally able to consider hormone therapy with more clarity. As I described previously, my “ideal” body does not align with that of typical cisgender men. Rather, my “ideal” body would have somewhat more masculine facial features and a slightly more masculine silhouette than my current female frame (broader shoulders, more upper body muscle mass, wider waist, narrower hips), but would otherwise be more androgynous than masculine. So I revisited my old research with this new lens, and I was able to create what seemed to be an optimal hormone therapy plan to accomplish my desired physical changes.
It is beyond the scope of this post to summarize all of the published information regarding hormone therapy for FTMs. I present here my own tentative prescription plan with reference to information most relevant to my situation. I hope this may be valuable to others seeking to achieve slight and gradual physical masculinization outside standard FTM hormone therapy protocols. Recent publications have acknowledged increasing diversity in transition goals among gender dysphoric individuals. (Fabris 2006)
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Testosterone (T): 1-2g/day transdermal
Transdermal T is available as a gel or as a patch. I planned to consult with my prescribing physician about the availability and cost of those options in my area. Injectable (intramuscular) T formulations are most commonly preferred and prescribed for FTMs. (Simpson 2006, Meriggiola 2015) However, compared to the various injectable T formulations, transdermal T has several advantages with respect to my own transition goals.
First, transdermal formulations are associated with more stable serum T concentrations over time that mimic the physiologic secretion of T in cisgender men. (Simpson 2006, Meriggiola 2015) Intramuscular injections of T every 1-4 weeks cause supraphysiologic serum concentrations in the first few days after the injection, followed by a rapid decrease in T concentration. (Meriggiola 2015) Some studies report changes in energy and more pronounced mood swings associated with these rapid fluctuations in T concentration. (Simpson 2006, Meriggiola 2015) Mood changes include more frequent irritability, frustration/anger, and aggression as well as decreased positive and negative affect intensity. (Slabbekorn 2001, Simpson 2006) Maintaining a more consistent T concentration may help reduce mood changes, which is an important consideration for me given repeated episodes of severe depression.
Second, transdermal T may be associated with more gradual physical changes compared to injectable T. (Simpson 2006) “Transdermal formulations are recommended if slower progress is desired or for ongoing maintenance after desired virilization has been accomplished.” (TransHealth UCSF 2016). However, at comparable doses, transdermal and injectable T are associated with a similar overall degree of physical masculinization despite the slower progression of changes occurring with transdermal preparations. (Merrigiola 2015) Many FTMs hope to achieve pronounced physical masculinization as quickly as possible, but given my more conservative transition goals, I would prefer more gradual changes so that I have a longer period of time to evaluate whether the physical changes are truly desirable.
Third, transdermal T eliminates the requirement of giving myself intramuscular injections. I have an embarrassingly low pain tolerance, so I will admit that the prospect of injecting several millilitres of viscous oil into myself every few weeks is very unappealing.
Disadvantages of transdermal T in my situation include increased cost (my current health coverage is limited and does not include the off-label prescription of T for gender transition) as well as possibility for delayed cessation of menstruation (menstruation has always been a core source of body dysphoria for me and is one of the primary motivations to seek hormone therapy). (Simpson 2006) However, other studies have found that transdermal T induces amenorrhea on a similar timeline as injectable T. (Pelusi 2014)
The recommended maintenance dose range of transdermal T for FTMs who want to achieve considerable masculinization as quickly as possible is 2.5-10g per day. (Simpson 2006, Fabris 2015, Meriggiola 2015) A dose of 1-2g per day would likely allow even more gradual progress. Lower starting doses, such as 2.5g per day, are also recommended if there are concurrent psychiatric problems.(Simpson 2006)
Finasteride: 1mg/day oral
I previously discussed my desire to avoid hair loss by using finasteride concurrently with T. In addition to reducing male-pattern baldness in FTMs, finasteride can also be associated with slowed or decreased facial and body hair growth and slowed or decreased clitoromegaly. (TransHealth UCSF 2016) These effects are usually listed as disadvantages in articles about hormone therapy in FTMs. However, given my desire for only slight physical masculinization, these side effects are actually advantages because they align closely with my transition goals. The recommended dose of oral finasteride is 1mg/day. (Mella 2010)
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In the process of more seriously considering hormone therapy and trying to develop my own prescription plan, I returned to an important question from a previous post:
In an XX person, would long-term administration of low dose T ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of T? Or would long-term administration of low dose T lead to partial masculinization that would be sustainable and non-progressive past a certain point? I am hoping very strongly for the latter. I have started looked for published data to answer this question, but so far I have only found articles describing the effects of long-term administration of high dose T in FTMs or describing the effects of short-term administration of low dose T in women (including the effects of exogenous T administered to treat various medical conditions as well as the effects of endogenous T in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose T in female-bodied people without concurrent medical issues.
I want to achieve a sustainable, non-progressive, partial physical masculinization. But I am not sure to what extent this goal is possible, even with conservative use of low dose hormones.
The scientific literature regarding long-term outcomes of low dose T administration in healthy XX individuals is almost non-existent. The literature regarding the extent and timeline of physical and psychological changes on low dose T is also extremely limited. Virtually everything currently published in scientific journals about T-induced changes in FTMs describes study participants on doses of T that are 2-10 times higher than the doses I’m considering. (Fabris 2015, Meriggiola 2015, Slabbekorn 2001, Pelusi 2014) There are some anecdotal reports of the effects of low dose T on blogs and YouTube videos by transmasculine people, but their comments tend to be sporadic, unstructured, and inconsistent.
This scarcity of published information about the short-term and long-term effects of low dose T contributes to my chronic difficulty imagining a future version of myself. For those of us with atypical transition goals, most of the existing medical knowledge and established hormone protocols are simply not applicable. This creates a painful sense of isolation and confusion, as though I’m peering out at the rest of the world from behind a foggy looking-glass.
“It’s dreadfully confusing!”
– Alice (Lewis Carroll, Through the Looking-Glass and What Alice Found There, 1871)
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References
Fabris B, Bernardi S, Trombetta C. Cross‐sex hormone therapy for gender dysphoria. 2015. Journal of Endocrinological Investigation 38(3): 269-282. Note: see Table 3 for an extensive summary chart regarding testosterone doses and formulations.
Mella JM, Perret MC, Manicotti M, et al. Efficacy and safety of finasteride therapy for androgenetic alopecia: a systematic review. 2010. Archives of Dermatology 146(10):1141-1150.
Meriggiola MC, Gava G. Endocrine care of transpeople part I: a review of cross-sex hormonal treatments, outcomes and adverse effects in transmen. 2015. Clinical Endocrinology 83(5):597-606.
Pelusi C, Costantino A, Martelli V, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. 2014. Journal of Sexual Medicine 11(12): 3002-3011.
Simpson AJ, Goldberg J. Trans Care: Hormones – A Guide for FTMs. 2006. Trans Care Project.Vancouver, BC, Canada. Accessed through Rainbow Health Ontario. Note: see page 5 for a brief summary chart regarding testosterone doses and formulations.
Slabbekorn D, van Goozen SHM, Gooren LJG, et al. Effects of cross-sex hormone treatment on emotionality in transsexuals. 2001. International Journal of Transgenderism 5(3):2.
TransHealth UCSF. Primary care protocol for transgender patient care: hormone administration. Accessed online 26-04-2016.
He Who Fights With Monsters
I have not been posting much writing lately.
I was hospitalized (for the second time) on a psychiatric unit from May 9 to August 12, 2016. As I alluded to in previous posts, my time on the psychiatric unit was incredibly valuable with so many radical improvements physically and psychologically. I was allowed to use my laptop during off-unit privileges and I wrote extensively – in notes to myself and messages to friends – about the changes and insights that developed during my hospitalization. I occasionally posted on this blog during that time, but most of my writing remained unposted because there was simply too much to process so quickly. I had expected to maintain my positive trajectory following discharge so I had planned to revise and post my writing here shortly after leaving the hospital.
But now, trying to retrospectively capture the enthusiasm and excitement in my old writing feels forced and hollow. Over the past few months, most of the major improvements have deteriorated as rapidly and radically as they arose, and I have been left to watch my mind disintegrate once again. As this decline has progressed, my despair has been considerably amplified by the knife-sharp awareness of just how much I had gained in hospital and how much I am in the process of losing.
So I have avoided writing altogether, instead posting my drawings and my poems and my photos which have taken on much darker undertones in recent weeks. It would, perhaps, be something of a delusion to think that anyone has noticed the change in the nature of my posts. Very few people visit this blog, and of those that do, I doubt that most of them have the patience or interest to read my writing in its entirety. My closest friends have often criticized my writing in my correspondence to them as being too lengthy, too distressing, or too rigorously academic. I have no reason to believe that my writing here would be perceived any differently by an online audience.
Is sharing these thoughts a desperate self-pitying bid for attention? No. Because any attention granted in response to such a plea would be quite superficial and quite meaningless, so it would be illogical to seek that kind of attention. No. This is simply an honest account of my current experience. I value authenticity above most other personal attributes. To me, authenticity – and her sister trait, vulnerability – represent extraordinary courage: the courage to “endure the sharp pains of self-discovery” in the process of understanding one’s own experience, and the courage to share this experience with others despite the risk of invalidation and rejection that plague every potential human interaction.
One of the most confusing patterns that I’ve noticed as my depression has worsened during recent months has been the withdrawal of many of my closest friends. Formerly close relationships have become strained, distant, and detached. I have been trying very hard to understand what has contributed to this widespread withdrawal. At first I believed that I was the common denominator, and I spent many sleepless nights trying to figure out what is so wrong with me that my friends are no longer willing to engage with me in ways that feel genuine. But now I wonder if it is less a problem with me, and more a problem with them. Perhaps the common denominator is their inability or unwillingness to tolerate the excruciating intensity of the sadness, loneliness, hopelessness, and meaninglessness that dominate my psychological landscape.
Unlike previous episodes of depression, my current experience is also dominated by anger, a towering and terrifying RAGE. Often this rage is directed at myself, rage like drops of blood attracting a predatory frenzy of depressive sharks. Sometimes this rage is directed at the world, rage like hand grenades exploding in the face of societal adherence to oppressive conventions that marginalize so many broken people. And sometimes this rage has no target, rage like a forest fire burning at the whim of wind and weather, the crackling searing heat omnivorous and destructive. But fires are essential for regeneration of forest vegetation. Maybe my rage is the first step towards some kind of psychological reintegration.
Direct feedback from my friends and my own observations during interactions with them suggests that humans are fundamentally distressed by intense emotions, especially anger, in themselves or in others. I am not sure why emotional intensity is so uncomfortable for them, and they have all been unable to coherently articulate the reasons behind their discomfort. But I wonder about several possible contributing factors.
1. I think many people retain a false and judgmental belief that intense emotion is necessarily the result of some kind of distortion or magnification on the part of the person expressing it. This belief may be the internalized result of an affect-phobic culture. This belief may also reflect the fragility of human egos finding comfort in a comparative notion that the absence of such painful intensity in themselves represents their own superior emotional regulation.
2. I think many people also believe that the expression of intense emotion necessarily implies a desire or expectation to reduce that intensity. Almost without exception, people automatically respond to someone else’s pain with advice and suggestions intended to help fix the problem or suppress the emotional intensity. I think this tendency reflects an unwillingness to accept their own powerlesssness. People seem largely unable to understand how their aggressive attempts to be helpful actually eclipse their capacity to empathize.
3. And I think that most people are afraid of truly empathizing with intense pain because doing so would require acknowledging their own innate potential to experience pain beyond their control. Such an acknowledgment would shatter illusions of personal agency. When somebody like me calmly and rationally outlines the meaninglessness and futility of life when all sense of purpose, satisfaction, and self-worth have been stripped away, people are forced to re-evaluate the framework they use to justify their own worth and purpose – they must then confront the threatening truth that these ideas are often built around tenuous and artificial self-delusions.
I have always tried very hard to avoid overwhelming my friends with the negative aspects of my experience. I have shared the fact of my depression with them, but I have intentionally minimized the severity of it, I have openly and deliberately invalidated myself in conversation with them, and I have often completely avoided mentioning my most distressing experiences. These behaviors represent my conflicted and evidently unsuccessful attempts to be authentic yet avoid provoking their discomfort. But as my depression becomes more debilitating and more painful, it becomes increasingly difficult for me to hide it. And as the intensity of my pain becomes more evident to them, the more uncomfortable they become and the more they withdraw from me. I have seen their faces fall, I have felt the cooling of the air between us, I have heard their static silence oozing through the speaker on my phone whenever I allow them to see a fraction of my truth. They cannot face my reality, so they retreat and withdraw. Their silence becomes deafening, and their absence suffocating.
“Wer mit Ungeheuern kämpft, mag zusehn, dass er nicht dabei zum Ungeheuer wird. Und wenn du lange in einen Abgrund blickst, blickt der Abgrund auch in dich hinein.”
– Friedrich Nietzsche (Aphorism 146, Beyond Good and Evil, 1886)[Translation: He who fights with monsters should look to it that he himself does not become a monster.
And if you gaze long into an abyss, the abyss also gazes into you].
Depression is a monster. And I feel like an abyss. My existence is intensely painful. This pain is all-consuming, inescapable, and terrifyingly rational. I move from day to day accompanied by more distress than most people have ever known or even have the capacity to imagine. When I stop protecting them from me and allow them to glimpse the true extent of my hopelessness, they are horrified to find themselves gazing into the abyss. And they are even more horrified to find the abyss gazing back at them with a familiar face.
I never knew
I never knew that everything was falling through
That everyone I knew was waiting on a cue
To turn and run when all I needed was the truth
But that’s how it’s got to be
It’s coming down to nothing more than apathy
I’d rather run the other way than stay and see
The smoke and who’s still standing when it clears
Everyone knows I’m in
Over my head
Over my head
– Over My Head (Cable Car) (The Fray, 2005)
Reflection on Reflection #6
I have been one acquainted with the night,
I have walked out in rain – and back in rain.
I have outwalked the furthest city light.I have looked down the saddest city lane.
I have passed by the watchman on his beat
And dropped my eyes, unwilling to explain.One luminary clock against the sky
Proclaimed the time was neither wrong nor right.
I have been one acquainted with the night.– Robert Frost
(Acquainted with the Night, 1928)
Ambiguous Androgyny (Part 3): What You See
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Part 1: Recognizing an Optical Illusion
Part 2: Deconstructing an Optical Illusion
~ Part 3 in the Ambiguous Androgyny series ~
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Following the radical shifts in perspective after the mirror experiment, I have been working through several new considerations.
The first consideration is an important caveat: all of these recent realizations – a more positive and more realistic body image, a concrete image of my ideal body to help guide transition choices, and increased gratitude and acceptance for my body – all of these realizations apply very specifically to my body as it currently exists. Had I attempted that mirror experiment at any other time over the past 10 years, I think I would have aborted the attempt within a few minutes because the disgust, self-loathing, and confusion generated by seeing my mirror reflection would have been intolerable.
But now, I am fitter, stronger, and physically healthier than I have ever been before. This is not to suggest that accepting your body is only possible if you meet externally imposed standards of fitness or conform to conventional expectations of attractiveness. Absolutely not. I am only saying that the increased muscularity and decreased body fat associated with a rigorous exercise routine are changes that have allowed me to finally feel comfortable in my own body.
This also is the first time that I have achieved a degree of androgyny sufficient to alleviate most of my physical dysphoria while also maintaining a healthy body weight. This is not to suggest that expression of androgyny excludes bodies that are thinner or heavier than mine. Absolutely not. I am only saying that finding a way to create a comfortably androgynous appearance for myself, without resorting to a dangerously low body weight, is a much healthier and more sustainable approach than my teenage anorexia.
I think it is also important to acknowledge that much of my gratitude for my current body comes from realizing that I have won the genetic lottery. As an XX individual, I consider myself incredibly lucky to have a body that is capable of looking this androgynous without medical or surgical intervention so far. I have made considerable effort, through my workouts and my diet and my clothing choice and my haircut, to create this appearance. But that effort is only one small part of the story. I am lucky that I have the metabolism to lose weight relatively easily and maintain low body fat. I am lucky that I have the anabolic capacity to build muscle mass fairly easily in response to the effort I put in at the gym. I am lucky that my facial features are naturally androgynous. I am lucky that my chest has always been flat and has become even flatter after thousands of pushups and thousands of bench press reps. I cannot take credit for those factors. I can only be grateful for them.
The second consideration is that maintaining my body in a way that feels comfortable for me will require consistent ongoing effort. I have several options about what kind of effort this might be. I could continue my current diet and exercise routine. I could proceed with medical options including testosterone and mastectomy. I could work towards greater internal acceptance of the aspects of my body that I cannot control. All of these possibilities represent ongoing effort. All of these options come with advantages and disadvantages.
My daily workouts require a considerable investment of time and energy. Having started a new combination of medications to manage the debilitating fatigue of depression and having adjusted my lifestyle to incorporate an early morning exercise routine, the time and energy costs are no longer prohibitive barriers.
My diet requires constant awareness of calories, grams of protein, grams of fat. My diet also requires active tolerance of the often intrusive nature of this awareness. Many of my food-related thoughts and behaviors are habits deeply ingrained from a decade of disordered eating, and I do not recommend these strategies to anyone else. But I have accepted that these thoughts and behaviors are unlikely to disappear entirely. And while I don’t think the improvements in body image will lead to any immediate changes in my approach to food, these thoughts and behaviors become much more tolerable in the context of acceptance and gratitude instead of disgust and self-loathing.
Now that my ideal body is more clearly defined in my mind, I feel better able to evaluate the many different options for testosterone moving forward. Because I have realized that my goal is not complete physical masculinization but rather minor masculinizing adjustments to my current body, I think I would prefer to start on a low dose of testosterone so that physical changes occur very gradually. At this point, I have one particularly prominent question: In an XX person, would long-term administration of low dose testosterone ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of testosterone? Or would long-term administration of low dose testosterone lead to partial masculinization that would be sustainable and non-progressive past a certain point? I am hoping very strongly for the latter. I have started looked for published data to answer this question, but so far I have only found articles describing the effects of chronic administration of high doses of testosterone in FTMs or describing the effects of short-term administration of low doses of testosterone in women (including the effects of exogenous testosterone administered to treat various medical conditions as well as the effects of endogenous testosterone in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose testosterone in female-bodied people without concurrent medical issues. I have only found a handful of anecdotal descriptions on personal blogs from trans people taking low doses of testosterone. But this is an important question for me, so I will continue my investigation.
The third new insight is that greater acceptance and comfort with my how my body LOOKS has been followed by much greater awareness of how my body FEELS. Prior to the mirror experiment, I was so detached from my body that I had very little awareness for how it felt. When prompted by my psychiatrist to identify physical sensations associated with certain emotions, I was completely unable to do so. The only time I ever felt any meaningful physical awareness was during exercise, as I have described with respect to running and boxing.
But since that mirror experiment, I seem to have developed an intensely heightened awareness of so many daily physical sensations. A shower used to be just a shower. Now a shower is a thousand individual drops of water, each one hitting my skin and trickling down my body. Applying hand lotion used to be just a necessary task. Now I am aware of how the knuckles and metacarpals and tendons of one hand feel inside the palm of my other hand. Clothing used to be just a set of pants and shirts and underwear. Now I am aware of how different types of fabric feel against my skin, aware of the pressure as a shirt stretches across my shoulder, aware of the gentle tension of cuffs around my wrists. Going outside used to be a retinal adjustment from dark hallway to sunny doorway. Now this transition is not just a visual adjustment but also a physical awareness of the change in temperature from hallway to door, an awareness of how the shadows feel when they dance across my skin as the sunshine chases them away. Waking up in the morning used to be an abrupt termination of a dream replaced by real-life thoughts. Now waking up is an immediate awareness of my whole body stretched out on the mattress, an awareness of the light weight of sheets and blankets surrounding me.
“You used to be much more… muchier. You’ve lost your muchness.”
– The Mad Hatter (Alice’s Adventures in Wonderland, 1865)
I really can’t describe this feeling any better than The Hatter. Being inside my body now is much more muchier. There’s so just much muchness.
I had been living with my parents before I was admitted to hospital but was unable to move back in with them after discharge, so one of the priorities was finding a place to live after discharge. Up until the mirror session, I had been thinking only in terms of apartments and rent and location. But now, I finally understand that I can live HERE, in my own body. It feels like authentic inhabitation of a home I didn’t even realize that I had.
The last new realization is also the most powerful. I previously described watching how women shift their interpretation of my appearance from male to female when they see me in public washrooms. I recently had the opportunity to observe this perceptual reversal in a dentist’s waiting room instead of a womens’ washroom.
I sat down in the waiting room to fill out a general history form, which required that I list my current medications. An elderly man sitting nearby saw me writing and said, “Whattaya doin’? Writin’ down the names of all your girlfriends?” His tone and posture seemed to suggest that he was making a conspiratorial joke, but I did not find his questions humorous at all. I was annoyed by the interruption, astonished by his presumption, and curious about his assumptions.
I was wearing jeans and a loose-fitting blue sweater, with my backpack on the floor beside me. I thought it most likely that his attempted joke hinged on the string of assumptions that I am male, straight, teenage, and obsessed with girls. I also considered the possibility that he perceived me as female and assumed that I am lesbian because I have short hair. I won’t list all the problematic stereotypes associated with those assumptions, but I will say that I have encountered all of them on multiple occasions before.
I continued writing without looking up from the page, and said, “No, I’m writing down my medications.” And then, because I was both intensely curious and intensely irritated, I looked up and asked him, “Do you think I’m male or female?” He frowned, and I watched his eyes roam up and down my body, eventually returning to my face. He finally said, uncertainly, “Ooooh… I guess… you’re actually female?” So it seems that he had indeed made that first series of assumptions: male + straight + young = girl-crazy. And while his assumption that I was a boy provided some validation of my physical androgyny, his comments also demonstrated incredible ignorance. So I shrugged, unwilling to definitively confirm either maleness or femaleness. But because he now saw me as female, I said, “Doesn’t mean I don’t have girlfriends.” He let out a short uncomfortable chuckle, and then stood up and moved to the chair as far away from me as possible.
And you know what? I did not feel the slightest hint of guilt about being the source of his discomfort. Nagging guilt about the discomfort that my appearance causes other people has plagued me in the past. But not anymore. Because I have achieved not only an authentic inhabitation of my body, I have also achieved an authentic acceptance of my ambiguous androgyny.
This here? What you see when you look at me?
This is not a deliberate deception.
This is not an intentional illusion.
It is authentic ambiguity.
It is not a palmed card.
It is not a crafty shuffle.
It is not a false cut.
It is an ace worn proudly on my sleeve.
“So come close. Get all over me. Because the closer you think you are, the less you’ll actually see.”
– J Daniel Atlas (Now You See Me, 2013)
The Boy with the Crooked Smile
My fellow patients on the psychiatric unit are certainly an interesting cast of characters. Of course I wonder about their stories, I wonder what combinations of pain and circumstance and bad luck (and maybe good luck too?) have brought them here. And for all of them, I harbor a detached empathy, an impersonal hope that they can find their way back to their lives. Even so, I try as much as possible to avoid interacting with the other patients. Most of the time I lack the energy for superficial conversations. And I lack the imagination required to use small talk as a shield from the reality of our situation, the fact that we’re all here on the psych ward, that the locked unit doors are under video surveillance, that we’re all under the influence of the many multicolored pills we swallow every morning. My personal rainbow is red, white, and yellow.
I avoid the other patients too because many of them seem to have lost appropriate social inhibitions along the way, often spewing rude and abusive comments that I get so tired of deflecting and increasingly less willing to tolerate. I also get so tired of other patients asking my name, mispronouncing it, mispronouncing it again when I correct them, and eventually just inventing their own bastardized version of my three easy syllables because my name is too much effort for them. And finally, I avoid the other patients out of a desperate instinct of self-preservation – it takes all my strength to remain focused on my own therapeutic goals, and I just can’t afford to be distracted by caring too much about anyone else on the unit. They are here for their problems, I am here for mine – I can’t forget that.
Though I intentionally maintain this safe detachment from the other patients, I cannot help but watch them all with involuntary interest. There’s The Watchman, always lurking at the end of the hall where the lights are dimmest, his dark restless eyes seeming always to be fixed on me, the hood of his black sweater drawn up around his face like the cowl of a vigilant monk. And old Abraham Lincoln – the resemblance really is uncanny – who never seems to leave the spindly chair by the courtyard windows, his lanky body folded up like an oversized praying mantis. Sleeping Beauty, who emerges from her room only rarely and wears her hospital gown like an elegant cascading dress, floating through the hallways with a radiant self-absorption and a distended pregnant belly preceding her quiet footsteps. Eyebrows, whose bushy black brows dominate his placid face and create an expression of perpetual confusion, his eyebrows dancing up and down to punctuate each spoken word, each sideways glance, each bite of food. Santa Claws, with his leering eyes and scraggly food-littered beard, his leather Harley Davidson jacket and fingers decked out with silver skulls, hands so grotesquely swollen that the rings are nearly buried by the bulging flesh, his long and fungally discolored toenails scraping the floor like ugly claws. Serene, with coiffed gray hair and deep grooves running down from the corners of her mouth like a ventriloquist’s dummy, who complains endlessly about the smell of dust, who marches back and forth across the same few feet of floor holding her diaper in place with both hands, often shouting at nobody in particular, “I just want peace of mind! You have peace of mind! Why can’t I have peace of mind? I used to be a spiritualist, you know. I used to be able to enter the spirt world but I can’t anymore. I just want peace of mind!” (We all ignore her outbursts, no-one here has peace of mind). And there’s The Howler, heard but never seen beyond one brief glimpse of a bare torso twisted across a mattress on the floor of the high-obs room, his chillingly inhuman screams filtering through the corridors at all hours of the day and night.
All of these patients I regard with a carefully cultivated detachment. Except for Cody.* I am drawn to him with a startling and shattering compassion that slices through my cautious distance and makes my heart ache. I don’t know why. Perhaps it is his physical resemblance to my brother – same endearingly disheveled hair, same ice-blue eyes, same roguish youthful handsomeness, same lingering hint of unwashed masculine musk. Perhaps it is my own selfish desire to inhabit such an effortlessly narrow-hipped, broad-chested body, the masculine alignment of his bones and muscles so achingly appealing to my girl-trapped brain.
Or perhaps it is that Cody’s demons are more outwardly obvious than most other patients on the ward. He cannot hide his battles with monsters I can’t even imagine. His blue eyes rarely register the real world around him, focused instead on high invisible shelves that he stretches up to reach, invisible barriers on the floor that he probes carefully with dirty bare feet, invisible companions sitting in the empty chairs beside him. All of his movements are slow and tense and deliberate, coherent only in a separate world the rest of us can’t see. And all these movements are narrated by his ceaseless whispering, too quiet to hear the words themselves, just a soft susurration like butterfly wingbeats. Occasionally he is interrupted from these explorations of his invisible world – quite suddenly his entire body stiffens, his head snaps to the side, his mouth stretches in a soundless scream, and a series of tremors rattle through his rigid slender body until – just as suddenly – his body stills, he blinks, looks around dazedly, and resumes whispering.
Perhaps I am drawn to Cody by a powerful but unfamiliar protective instinct – a parental sort of protectiveness, perhaps, although in my case neither maternal nor paternal – an irrational hope that if I could just fold him in my arms and shield him from the world (real and invisible) then I could somehow absorb his pain and leave him whole. Even if it killed me. I wonder if this is how my parents feel when they watch my struggle with depression. I wonder if I underestimate how hard this might be for them, how strong the instinct to protect and shelter, if this boy I barely know can draw such fierce protectiveness from my cautious heart.
But I think, more than anything, I am drawn by Cody’s smile. I have seen it only once, walking past him in the hallway. He was engaged in a repetitive pulling motion, as though he were dragging something heavy up towards his chest, his whispers seemingly directed at the evidently irksome object. As I walked closer, his hands stilled and his whispers faded and his bright blue eyes met mine – and I could see the crystal clarity suddenly alive behind the blue. The ghost of a smile tugged at the corner of his mouth – a tiny crooked smile climbing up and crinkling the corners of his eyes as his head dipped in a respectful nod of recognition. A thready filament of connection hovered between us for a moment – the flash of recognition in his eyes heartbreaking and unmistakable – until suddenly the thread snapped, his eyes dropped downwards, his whispering resumed, and just like that – with all the finality of a guillotine blade – his moment of awareness was abruptly severed.
So now whenever his path crosses mine, I find myself searching his face for that crooked smile, that awareness, that flash of recognition, searching with a desperate selfish reckless caring that takes my breath away. I see you, Cody. I’m here. I know you’re there too. But he remains lost in his world of whispered things.
But he left me one more smile. After breakfast one morning, he shuffled into the dining room two hours late but I’d asked the nurse to save his tray. He attempted to eat at first but quickly lost track of his fork, his gaze drifting off, his whispering more fervent, and began lifting invisible items up off the floor. As he leaned down, the bunching of the muscles in his back was visible through the gap of his hospital gown – hard knobs of vertebrae protruding between the trailing strings he didn’t finish tying – that gap in his gown a green-rimmed sliver of heart-wrenching vulnerability. Then his attention shifted to his paper menu and, slowing picking up a nearby pencil, he began writing. Eventually he abandoned his writing and drifted away – whispering and shuffling – and I could see the scrap of paper he’d left behind. It was a list of names, I’m not sure who they are, scrawled in the overlarge and messy handwriting of a child. Near the bottom, the “r” in Tyler – with unexpected whimsy – was drawn as a stick figure with arms outstretched. Below the names, he wrote two statements: “walking sucks run” and “40 like steves as you say” – not quite nonsense, not quite sense – followed by a pencilled crooked smile. I see you, Cody. I know you’re there too.
*Not his real name.
A perfect smile is more appealing but it’s funny how
My shit is crooked, look at how far I done got without it
I keep my twisted grill, just to show them kids it’s real
We ain’t picture perfect but we worth the picture still
– J Cole (Crooked Smile, 2013)
Magnetic Resonance
This is my brain. You’ll have to take my word for that though – it looks so ordinary, doesn’t it? Just an ordinary brain – a vast and beautiful ecosystem of interconnectivity. The extraordinary complexity of it is somehow diminished by the flatness of the image, the deceptive simplicity of the gently undulating sulci and gyri.
A nurse leads me from the psychiatric unit down through the guts of the hospital to the MRI room. Scrub-clad staff shuffle softly past us, diligent and busy, unnoticed aboveground but vital to the round-the-clock function of this teeming facility. We pass the steamy laundry room, the fragrant kitchen, several silent storage vaults. The hallways are cast in pale fluorescent light with an occasional dull orange flash from the elevator displays. A stripe of faded blue tape splits the corridor in half, faint dusty footprints crisscrossing back and forth across the dividing line. We have entered an entirely different world down here – a dim basement fairy-tale world of medical equipment and quiet footsteps.
MRI stands for magnetic resonance imaging, a technique developed in the 1970s that uses magnetic fields and radio-frequency waves to create cross-sectional images of organs and tissues. I am getting an MRI of my brain as part of the work-up for chronic depression, to rule out possible organic causes such as inflammatory disorders, cerebrovascular anomalies, or brain tumors. All of these are very unlikely, but because my depression has been unusually severe, prolonged, and resistant to conventional treatments, my in-patient psychiatrist wants to explore the possibility of rare underlying causes.
So the nurse rolls my body into the machine and I lay as still as death – movement artifact can interfere with image quality – wth my head in a plastic cage, cranium cushioned by foam pads on either side. The loud mechanical clunking from the machine becomes a visceral thudding din that seems to penetrate right down to my bone marrow. I can force my body into stillness, but I cannot quell the restless activity in my mind as it dredges up fragments of conversations from what feels like a thousand lifetimes: who I was and who I am, things I’ve lost and things I’ve locked away, wise voices echoing in a chamber of despair.
“She is probably the best student I have worked with over the past 15 years I have been in academia.”
“People with great abilities naturally have great successes and great failures.”
“You expect people to behave in logical and predictable ways. But they don’t. Not everything is logical. And that expectation creates a lot of frustration and disappointment for you.”
“You wear your emotions on your sleeve, McMurray. You can’t hide your anger and frustration, even when it’s directed at yourself. That much emotional intensity is intimidating.”
“You are a solution that’s just waiting for a problem.”
“Remember we once talked about finding your way out of the darkness of a great forest?”
“That’s not how it works here, princess…”
Today my psychiatrist tells me that the MRI showed no abnormalities. I ask to see the images – not because I don’t believe him, but because I want to see this brain of mine. On the screen it looks so… grey and calm and normal. I had expected, at least, that the machine would have somehow captured the racing chaos of my thoughts, like headlight streaks in a long-exposure photo of a busy city during rush hour. Or I thought perhaps the image might show a rim of necrotic blackness devouring the grey matter, some kind of visible sign of the darkness in my mind. Or I even half-expected to see a nest of snarling demons ensconced in their cerebral lair, ghoulish grins like candid mugshots of the pain that grips my brain.
Staring at my brain on the screen, this restless mind once more starts sifting through the debris of recent conversations. The technician who said, “What’s a nice girl like you doing in a psychiatric unit?” The nurse who asked me about my suicidal intentions and then, after I described my list of lethal methods and the pros and cons ascribed to each, said, “You look really good right now. You seem calm and coherent.” The friends who have expressed their confusion and disbelief when I describe the severity of this depression, “But you sound so normal! You seem like your usual self!” Even my out-psychiatrist who admitted that I seem so composed and articulate during appointments that he initially questioned why we were considering readmission to hospital. My outward composure – sometimes the hard-won result of energy I can barely muster, sometimes simply the only way I know how to be – seems to mask the intensity of my internal pain. And this MRI image feels the same way: it looks perfectly ordinary, composed and coherent, while the agony remains entirely invisible.
“Forgetting pain is convenient, remembering it: agonizing. But recovering the truth is worth the suffering…”
– The Cheshire Cat (Alice: Madness Returns, 2011)
Present Tense
Depression has a curious way of disturbing the passage of time.
On depression’s terms, time s t r e t c h e s . . . o u t . . . s o . . . s l o w l y . . . with a maddening and mocking languidness.
Remembering and sequencing the events of today becomes an overwhelming challenge, my mind trudging grudgingly through the heavy fog that clouds those recent memories. The last few days and weeks and even years are stacked haphazardly, an inseparable scatter of all things past.
More cruelly, depression amputates the future. Tomorrow and next year are equally incomprehensible. This missing sense of future is deeply unsettling. It is like losing your peripheral vision – only when it’s gone do you realize, with horror! – how casually you took it for granted, how much it used to guide your behavior and perception, and how without out it you feel lost in a narrow and distorted world.
I have also seen these wrinkles in time described by people with terminal physical illnesses. Most eloquent of these descriptions was written by Paul Kalanithi in the days leading up to his death from lung cancer:
“Verb conjugation became muddled. What tense was I living in? The future tense seemed vacant and, on others’ lips, jarring. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.”
The relentless suicidal ideation that accompanies depression seems, in many ways, very similar to the last months of a fatal physical disease. To outsiders, the most salient difference between those two is the illusion of choice.
I think that a coherent sense of future can also be a casualty of gender dysphoria, especially for those of us with uncertain transition goals and unpredictable transition outcomes.
“I have had a hard time visualizing my future, as either female-perceived or male-perceived. Needless to say, this is a bit of a dilemma, as it can create the sense of moving into an enigmatic, inconceivable oblivion. Now, I don’t think it’s healthy to focus too much on the future, but I do think it’s normal to have some sort of future projection of yourself to hold onto – and I think that’s something that transgender people are plagued with – with not being able to visualize their future self during uncertain times, particularly when they are considering medical intervention.” – gendermagik
The point where depression and dysphoria intersect is a terrifying discontinuation of the mental and the physical, an inescapable Möbius strip of mind and body locked perpetually in the painful present tense.
The broken clock is a comfort, it helps me sleep tonight
Maybe it can stop tomorrow from stealing all my time
I am here still waiting, though I still have my doubts
I am damaged at best, like you’ve already figured out
– Lifehouse (Broken, 2007)
“You do not get the time back. Whatever time is eaten by a depression is gone forever. No matter how bad you feel, you have to do everything you can to keep living, even if all you can do for the moment is to breathe. Wait it out and occupy the time of waiting as fully as you possibly can. Hold on to time.”
– Andrew Solomon (The Noonday Demon, 2001)
Unrelenting Darkness
I recently spent three weeks hospitalized in a psychiatric unit for treatment of depression. In clinical terms, I have severe chronic treatment-resistant major depressive disorder, a mouthful of words to describe a debilitating disease that has affected the trajectory of my entire adult life. My pharmaceutical history reads like a drug compendium, A to Z by generic name: aripiprazole, bupropion, caffeine, citalopram, clonazepam, desvenlafaxine, dexamphetamine, lisdexamphetamine, lorazepam, mirtazapine, oxazepam, trazodone, tryptophan, venlafaxine, vortioxetine, zolpidem, zopiclone. Over the past year in therapy, I have turned my soul inside out looking for answers, finding only a buzzing hive of angry stinging questions. But effort means nothing in the face of this monster. My brain just keeps attacking itself over and over, with ever shorter reprieves between recurrent nightmare episodes.
My time in hospital was frustrating, necessary, and marginally helpful. I worked hard to create realistic expectations for myself after discharge and I was prepared to tolerate the distress arising during the initial readjustment to real life. But coming home from hospital has been unlike anything I have ever experienced before… I feel empty, hollow, completely gutted, broken beyond repair with a skull full of ugly scars, so far beyond hopeless that there are no words to describe this degree of detachment and despair. Since then I have been going through the motions of daily life, but that is truly all they are – mechanical motions performed perfunctorily to pass the time. I still adhere to the hospital schedule because it is the only structure I can cling to in the shattered remnants of my world: breakfast at 8:00, lunch at 12:00, dinner at 17:00, one pill at 19:30, another at 21:00. And when I’ve reached the end of each endless day, I have to fight through the night to snatch a few hours of disturbed and broken sleep.
I feel like I held on to my last shred of sanity while I was in the hospital, because I was focused on the short-term goal of getting discharged and because a smoldering filament of rage kept me connected, somehow, to the outside world. But now I have no goals, no anger, nothing, I’m just drifting in a completely meaningless void while the world keeps moving around me.
This depression feels like a brain tumor that has been growing for six years, slowly at first but ever faster as the malignancy multiples, gradually taking up more and more space inside my head and slowly choking off pieces of who I am. It has strangulated my motivation, eroded my energy, killed my capacity for hope. All I am left with now – and for how much longer I don’t know – is the capacity for gratitude, and a raw and feral intelligence caught in a leg-hold trap, thrashing ferociously and trying to chew off its leg to escape but unable to gnaw through the bone. And this toxic neoplasia continues growing faster than my acceptance of it, an escalating arms race, a Cold War in my brain. There are no surgical options for treatment, no chemotherapy, not even any palliative means to ease this excruciating pain.
My psychiatrist, my sister, my friends – friends! such an inadequate word to describe these people that I love so fiercely – they encourage me so often to find things to be hopeful for. I try – I do – I try so hard – with infinite gratitude for their kindness and support – but I cannot manufacture authentic hope. It’s like being naked in a winter wind, trying to imagine what warmth feels like – even if you can conjure up the most vivid memory of hot summer sun, it will not prevent you from freezing to death.
I think the most powerful emotions are gratitude and hopelessness. They both have the ability to eclipse all semblance of rational thought. They both leave me breathless in the wake of their intensity. And the two can coexist in a devious kind of harmony, like brilliant fireworks bursting in an unrelenting darkness.
Sometimes the curiosity
Can kill the soul but leave the pain
And every ounce of innocence
Is left inside her brain.
– Shinedown (Her Name is Alice, 2010)
Thomas in Genderland 