This is not your average transgender 101. I will not go over the basics of what gender and sex are. I will not define the word “transgender” here. There will be no gender unicorns here. If you’re looking for that, check out my Gender and Sexual Minorities 101 slides. This is a transgender 101 for trans people!

Transition can be complicated and confusing. Accurate and understandable information is rarely all in one place. There are a lot of “trans 101” articles out there for cis people, but not so many to help trans people through transition. This is my attempt to remedy that. It’s my attempt to pull together as many answers to as many questions as I can. I hope they’re helpful.

Just a friendly reminder — I am not your physician and cannot give medical advice on the internet. If you have questions or concerns about your health in particular, please do give your doctor a call. If you’re in the market for a doctor, please either contact your local trans organization or take a look through the lists that WPATH and GLMA maintain of trans-friendly providers.

This is a living document. I will continue to update it as I publish more parts and as I receive feedback from the community. Content will change over time.

This document was last updated on October 13, 2017.

Table of Contents

General Questions

General Medical Questions

General Hormone Questions

General Surgery Questions





General Questions

Help! I think I’m trans. How do I know for certain?

Only you can truly answer that question. At this time there is no test that will give you a definite “Yes” or “No.” There are, however, things you can do that might help you figure it out. These include…

Talking with a knowledgeable psychotherapist.

Talking with trans people

Attending a trans support group

Using thought experiments. Some examples can be found here.

Socially transitioning in safe spaces (e.g., if you’re male-assigned, wearing “women’s” clothing while at home).

Some people go through a period of thinking that they may be trans and ultimately decide that they are not. That’s OK too! Take your time and explore. There is no age limit to transition. If you ultimately decide to transition at age 80, you can. If you know right now that you need to transition, you can. If you decide that you are not trans or that you do not want to transition, you can.

How do I stop having gender dysphoria? Is there a therapy that can cure me?

There is no psychotherapy or drug that will make you stop having gender dysphoria. For years mental health professionals tried to “cure” transgender people by making them cisgender… and it worked about as well as reparative therapy for gay people. In other words, it didn’t work. Psychotherapy that tries to make trans people not trans only makes depression, anxiety, and suicidal thoughts worse.

Medical, social, and legal transition is the only recognized treatment that helps.

Is it a brain condition? I heard someone say being transgender is an intersex condition. Is that true?

Maybe. There have been some studies of trans brains that seem to suggest that trans brains may be different from cis brains. An area of particular interest is the bed nucleus of the stria terminalis. That brain area seems to be associated with gender, not chromosomes or hormones. But those studies have not been repeated, so we don’t know for sure if the findings were real. I would not take this evidence as absolute proof.

Transgender is not currently considered an intersex condition. Intersex refers to people who were born with ambiguous genitals or were diagnosed with a disorder of sex development (DSD). DSDs are medical conditions that affect the biological sex development of an individual. They can be chromosomal, hormonal, or gonadal. Examples include Accord Alliance has excellent information on DSDs. While some individuals with DSDs may transition later in life, they’re not considered transgender. According to the DSM, to be diagnosed as transgender a person cannot have a DSD.

Wait, diagnosis? DSM? What’s that?

Transgender is a medical and psychological diagnosis. It’s listed in both the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). The ICD is used by physicians. The DSM is used by psychologists. Transgender is listed either as “Gender Dysphoria” or “Gender Identity Disorder”, depending on the source.

The fact that transgender is considered a medical/psychological disorder is controversial. Some feel it is a natural human variation that shouldn’t be treated as a disease. Others prefer to keep the diagnosis as a diagnosis. They consider being trans as something to fix with transition. And transgender’s existence as a medical/mental diagnosis means that health insurances can be billed for medical care relating to being trans. That means hormone therapy and surgery can be covered by insurance.

Debate continues within the academic and medical communities, with trans and cis voices on both sides.

Can I be trans if I don’t identify as a man or a woman? What about being genderqueer?

Yes, and yes. There is increasing awareness that not everybody fits into the man/woman boxes. For a good blog on being trans but not gender binary, check out Neutrois Nonsense.

Am I trans if I didn’t feel trans as a child? or I only thought about this as a teenager or young adult, so I can’t really be trans, right?

Yes, you can be trans even if you didn’t think about it as a child. Some people strongly feel, and strongly argue, their gender identity as children. Others only begin to realize it when they begin to enter puberty. Still others don’t realize that they’re trans for decades — until they’re in their 30s, 40s, 50s, or beyond.

Whenever you being to suspect you’re trans, or whenever you decide to explore gender, it’s OK. It doesn’t make you any more or less trans. Everyone has their own road to walk.

I think I might be trans, but I don’t like the things I’m supposed to…

That’s ok! Not all women like to wear dresses and not all men like (American) football. It doesn’t make you any less a person nor any less trans. If a health care provider or therapist says you should like and do stereotypical things, that’s a red flag. You may want to seek a second opinion.

Okay, I’m definitely trans. Now what?

Now you have a decision to make. You can do something about it, or you can not do something about it. You can continue to live your life the way you have been. You do not have to transition. You can postpone any changes. Or you can choose to transition.

Some wait until they turn 18. Some wait for their kids to turn 18. Others wait for partners or parents to pass away. You can wait. Or you can do something right now.

Whatever you decide, you may want to consider getting support to help with any associated stress. That support can be a group, a therapist, a good friend, whatever is meaningful for you.

I want to come out and transition now. Where do I start?

In research studies, trans people tend to say that getting a support team in place is the best first step. And that’s a lot of what I’ve heard too.

Your road may get a bit bumpy. You may lose your job, house, friends or family. Many do. Take a look through the National Transgender Discrimination Survey to get a sense for what may happen for you. The time to prepare is now, before you’ve come out or started to transition.

Support can be from a trans-specific group, a more general LGBT group, a therapist, friends, family, people on the ‘net…. whatever works for you in your situation.

The other thing that I’ve heard is to start saving pennies, so to speak. If you choose to medically or legally transition, that process can be expensive.

Transition can be broken down into three categories: Medical, social and legal.

Medical transition: hormones and/or surgery to physically change your body

Social transition: changing pronouns, presentation, and social behavior

Legal: changing legal name and legal gender (M/F) on all your paperwork. In the US, usually involves a court order

Sometimes these areas intersect, but other times they don’t. It’s up to you to decide what, where, and how you want to transition.

Now it’s time for research. What are the laws in your state or country? Do you have access locally to hormones or surgery? A local organization can sometimes help, if they exist. They may not exist though. A search engine can help you find physicians and lawyers.

Do you want to do hormones? Surgery? A legal name change? Does your state prohibit workplace discrimination? Does your state require surgery before you can change your name or sex marker? How would you even pay for surgery or hormones — does your health insurance cover them? Now’s the time to find out!

Reading through the World Professional Association for Transgender Health‘s Standards of Care is probably a good place to start when it comes to medical transition. It’s a big wordy document, but it summarizes how providers should be approaching your trans-related health care.

If you are a minor, things get complicated even with parental support. That’s another question though.

How do I find support?

Try your local diversity/LGBT center first. It may be affiliated with your local university, so try there if there aren’t any independent ones. Diversity centers may have trans support groups or be able to recommend a therapist or physician in your area. Even if the closest center is on the other side of the state, it’s worth asking if they know of anything in your area.

No luck? Time to try your preferred search engine. Search terms like “transgender support group near…” usually bring up some kind of results. Still no luck? Try the search query “transgender support”. It pulled up a lot of things for me. You can ask around in the reddit’s /r/asktransgender too.

PFLAG has a massive list of resources as well, including support groups. Take a look and see if any work for you!

Is it transgender or transsexual?

The difference between transgender and transsexual differs depending on who you’re talking to. Some consider transsexual offensive, others prefer it. Transsexual is an older term and much more common in the medical community. It’s also used more in countries other than the US.

Some object to the term transsexual because of the way trans people have been treated by medicine. Others feel it hypersexualizes trans folk or conflates sexual orientation with gender identity. Yet others strongly prefer the term transsexual, as they feel their gender dysphoria is strictly a medical issue. Others object to the term transgender because of its use as an “umbrella” term, lumping transsexuality in with genderqueer, crossdressing, and drag.

All this argument is generally why I say trans. Some people say “trans*” instead, to make the dual meaning clear. I say/write “trans”, with the implication that I could be using either.

My working distinction between transsexual and transgender, when a distinction is needed? Transsexual is specifically an individual who is cross-sex identified, typically fits within the gender binary, and wants to go through full transition including genital surgery. Transgender includes non-binary identified people and people who do not want to do a full transition. Transsexual is much more a medical term, where transgender includes a component of changing social norms.

Am I too old to transition?

No.

General Medical Questions

Where do I find a health care provider?

First, know that you don’t necessarily need to see an endocrinologist. A family doctor or internist can deliver all the same care!

If you have a trans-knowledgeable therapist, I’d start by asking them. Many times professionals know each other and network heavily. If there’s a provider who isn’t quite close enough to you, you can still call and ask their office if they know of anyone closer to you. Local LGBT organizations, as always, are another good place to start. There’s an informed consent clinic list here which may also be helpful for you, though it’s not complete. WPATH has a provider list, as does GLMA. Some Planned Parenthood clinics provide transgender care as well. If you’re near one, your best chances are likely in big cities.

There may also be a website that’s compiled your local resources. For example, I stumbled onto Trans Ohio the other day and they appear to have a nice big list! So Google is definitely your friend here. Try a query like “transgender health care near….”

Help! I can’t find any providers! What are my options?

Sometimes there truly isn’t a knowledgeable health care provider near you. In that case, your best option may be to find a provider who’s willing to learn. This will likely take a lot of trial and error. You can save a few bucks by calling the office and asking instead of going in to meet face to face. Be patient. I generally have found that there are two different learning curves: learning how to give hormones, and learning how to treat trans people with respect. The latter seems to be harder than the former. Keep giving your provider feedback! Remember that you may be very different from trans people your provider has seen before, or will see later. And don’t lose hope. Remember that you’re also helping other folks who meet this physician in the future.

There is support out there for physicians willing to learn about trans care. Refer physicians to them! I recommend:

I was treated badly by a provider or their staff. What do I do?

If you can, please let them know. It may have been unintentional. Accidental misgendering does happen, even by the best of providers. There may be corrective actions the provider may want to take as a result of a complaint. If you can, meet in person with the physician responsible. Stay calm, use lots of “I” statements. Writing a letter is another option. If things go south, find another provider. But you may be pleasantly surprised!

Also consider notifying your state medical board or investigating if the physician broke an anti-discrimination law. If the misbehavior was serious or negatively affected your health, consider consulting an attorney. The Transgender Law Center, the NCTE, and others can probably help.

Wait… don’t I need a letter from a therapist or something?

Maybe. It depends on your situation and the physician you see. WPATH’s Standards of Care (version 6) used to require 3 months of therapy and a letter from a therapist before hormones could be started. Version 7 no longer requires therapy. Therapy continues to be highly recommended.

Version 7 does recommend a letter from a mental health provider before getting hormones. Many physicians do feel more comfortable prescribing if they have that letter. Others work under an “informed consent” model. They don’t require a letter, but do ask that you sign paperwork saying that you understand the risks involved.

In some instances a letter or therapy may be required. For example, if you’re close to age 18, have comorbid psychiatric conditions, or are at university, Call your physician before making the appointment to find out their policy. A letter from therapist/psychologist is definitely required for bottom/genital surgeries.

Anything I should definitely tell or not tell my physician?

Tell your physician about all your health history. Better yet, have your records sent beforehand! Few conditions mean that you can’t have hormone therapy at all. There are some medical conditions that may need to be controlled before you can start hormones. Some conditions may require a different approach to hormones. Tell your physician about any “risky” behaviors (e.g., sex work) – they need to know these so that they can screen appropriately. If you have a trauma history and cannot tolerate some physical examinations or need extra help with them, let them know that too.

It will likely be helpful for your physician if you’re clear about preferred name and pronouns. Some physicians have intake sheets specifically for trans patients which ask about gender history, and pronouns may be included there. If you have a name/pronoun change, please let them know so they can continue to be accurate and respectful. Let them know if you’re closeted or stealth so they can be confidential in communications. Tell them if their staff should, or should not, leave confidential messages on your phone. Also tell them if you need a specific name or gender marker on prescriptions and/or lab work for insurance or legal reasons. If you have preferred names for body parts or are very dysphoric, tell them!

If you’re genderqueer, neutrois, or just want to individualize your transition, tell your physician. There are different paths available to you.

Don’t lie to your physician. Don’t feel you have to spout the “standard narrative” if it’s not you. Don’t feel you have to wear makeup or hugely baggy manly pants. Be yourself.

Can I start hormones on the first visit?

Maybe. Depends on the physician, your age, your health, and your readiness. If your hormones are delivered by injection (testosterone, some estrogens) then you’ll need training. Some physicians use a mail-order compounding pharmacy like Strohecker’s so you may not get your hormones immediately. Don’t be disappointed if you don’t get your prescription right away, but also don’t be afraid to ask why!

Wait a minute… my labs have the wrong gender marker!

This may not be a case of misgendering. For some tests there are “male” and “female” ranges – and not just for hormones. Hematocrit is testosterone-sensitive, for example. So the marker used will determine the “normal” ranges shown on the lab work, and those should be the most appropriate ranges for your physiology. Sadly physiology doesn’t always match up with gender. So if you’re pre-hormones your lab work may initially say your sex instead of your gender.

Do make sure you ask your physician though. They should be able to explain why a certain marker was used. Sometimes it really was an error.

It should also be noted that for cervical cancer screenings the gender marker often needs to be F for insurance purposes. Those silly insurance companies haven’t gotten the heads-up yet that men need cancer screenings too.

Hormone Therapy

Hormone therapy is a corner stone for medical transition. For many (but not all) trans people, hormone therapy is all they choose to do.

Terminology notes: In the medical literature, hormone therapy is often referred to as “cross-sex hormone therapy”. In the community I’ve seen it more often called HRT for short. I prefer to call it HRT myself. It’s important to note that trans hormone therapy is different from the “hormone replacement therapy” used in cis men and cis women.

Which specific hormones get used depend on one’s health, age, location, and money. Some physicians choose to do a slow ramp up on dosage. Others do not. Your mileage will vary.

Hormones for adult trans women/people assigned male at birth

The modern hormone regime includes an estrogen and an anti-androgen. Why the anti-androgen? It lets us use lower doses of estrogen. We don’t want to do large doses of estrogen because of negative side effects and associated health risks. Anti-androgens have also been used for a long time for other medical reasons, so their risks are well known. So both an estrogen and an anti-androgen are used.

Which Estrogen? There are three common choices: orally/sublingually, intramuscular, and transdermal. Oral/sublingual is the most common and cheapest. These forms are also used as part of hormone replacement therapy for cis women.

Orally/Sublingually: The current estrogen of choice is 17β-estradiol (brand name Estrace). It comes as a pill which can be either swallowed or dissolved under the tongue. Common wisdom says under the tongue (sublingual) may be safer for the liver, but there hasn’t been research published on that yet. This is often the cheapest form. Generic forms of Esterase are often available on $4/month plans at various pharmacies.

Intramuscular (e.g., estradiol valerate): Delivered as an injection that goes deep into muscle tissue. Requires injection training, and you probably should carry paperwork if you’re traveling with injection supplies. Some people say they transition faster on injection, but there’s little evidence in the medical literature. Dosing can be done weekly or biweekly. Women sometimes report that they start to feel moody or irritable towards the end of their injection cycle.

Transdermal (through the skin): Estrogen patches. Generally considered lowest risk, and provide the most consistent blood estrogen level. Patches are applied twice a week. Different brands of patch are different sizes and ability to stick to skin. Expensive if you don’t have insurance coverage for it.

Other options may be available. I’ve seen estrogen sprays and creams advertised, but have not seen them be used forr trans care. I’ve also heard reports of estrogen pellets being placed under the skin, but I’ve not seen them in use in the US.

There are forms of estrogen which aren’t recommended for transition. Premarin was used 10+ years ago, but is currently not recommended because it’s higher risk. Ethinyl estradiol is also higher risk than the estrogens listed above and is generally used in the United States for trans women. Birth control pills also should not be used because they often contain ethinyl estradiol.

What health conditions may affect whether I can take estrogen or not?

The big ones are previous history of deep vein thrombosis (DVT), estrogen-sensitive cancers, and allergy to estrogen-related products. They can all be fatal. If you have had them, you may not be prescribed estrogen at all. If this is the case for you, don’t despair. Anti-androgens can also provide some feminization.

A physician may be reluctant to prescribe estrogen if you have the following conditions…

Thrombophilia disorders or tobacco use, which make you prone to blood clots.

BRCA mutation, which raises your risk for breast and other reproductive cancers.

A personal history (not family history) of stroke, heart attack, or blood clots

Liver disease, including alcoholic cirrhosis, or untreated hepatitis.

High triglycerides or a history of pancreatitis (inflammation of the pancreas)

Meningioma

These conditions do not necessarily mean that you can’t receive estrogen. But estrogen is riskier for you. Talk with your physician about your risks. There may be medications, medical procedures, or lifestyle choices that reduce your risk.

Estrogen can also change how some disorders need to be managed. For example, estrogen can make asthma worse or increase the frequency of migraines. Make sure your doctor knows if you have any of the following conditions so adjustments can be made if necessary: asthma, insulin resistance, diabetes, cardiovascular disease, heart failure, kidney disease or failure, epilepsy (seizures), gallbladder disease, jaundice, obesity, parathyroid disease, migraines, porphyria, lupus, and thyroid disease.

And as always, estrogen and other medications can conflict. So make sure you tell your doctor everything you’re taking, including herbs, supplements, and alternative medicine!

Which anti-androgen?

The three anti-androgens of choice are spironolactone, cyproterone acetate, and the GnRH agonists. Other drugs, like those used for prostate cancer, do have anti-androgen effects but aren’t in common use for medical transition.

In the United States the anti-androgen of choice is spironolactone. This drug was used for many many years for people in heart failure. It’s generally safe. It is a diuretic, meaning it makes you pee. We’re lucky that it happens to act as an anti-androgen too. Spironolactone can feminize some on its own because of its anti-androgen effect. Doses can be as high as 200-300mg per day. We prefer doses around 100-200mg per day, since high doses tend to have more side effects without more benefits. Spironolactone both blocks testosterone receptors and directly reduces the amount of testosterone being made. Spironolactone is cheap and easy to take. It’s often on “four dollar” or discount medication plans at US pharmacies. That’s why it’s so popular!

Outside of the United States the anti-androgen of choice is cyproterone acetate. Cyproterone acetate was never approved by the FDA, so it’s not available in the United States. It blocks androgen receptors, preventing testosterone and other androgens from having their effects. By blocking those receptors, it reduces the amount of testosterone in the body through a mechanism called negative feedback. Cyproterone is chemically similar to progesterone and has some progesterone-like effects as well. It’s available both as a pill and intramuscular injection. The pill form should be taken every day at the same time after a meal. The dose often used for transition in the literature is 100mg/day. Anecdotally I’ve been told that lower doses, such as 25-50mg/day, have been used. The injection is given once every 1-2 weeks.

Information on GnRH agonists is covered in the trans youth section.

What health conditions may affect whether I can take spironolactone or not?

Spironolactone is a potassium-sparing diuretic. So it’ll make you pee a lot, but you won’t pee out your potassium.

The most worrisome side effect is hyperkalemia, or too much potassium in the blood. It can lead to heart rhythm disturbances and can be fatal. When you first start on spironolactone it’s important to get regular blood tests are important to screen for hyperkalemia. If your potassium levels start to go up you may need to avoid potassium in your diet. Here’s a list to get you started on potassium-rich foods. Most people don’t get hyperkalemia. Your physician should test your potassium levels regularly to help you stay safe.

The biggest day-to-day side effect that people note about spironolactone is that it… well… it’s a diuretic. It makes you pee. A lot. You may want to avoid taking it right before bedtime so it doesn’t disturb your sleep. But as always, your mileage will vary. Make sure you drink plenty of water.

You may not be able to take spironolactone if you have a history of kidney disease, hyperkalemia, or Addison’s disease. Spironolactone should not be taken if you’re also taking eplenerone, a drug in the same class without anti-androgen effects. Some people have an allergic reaction to spironolactone — if you have, then you should definitely not take spironolactone.

Other disorders that should be discussed with your doctor before starting spironolactone include: heart failure, liver disease, and kidney disease of any kind.

What health conditions may affect whether I can take cyproterone or not?

Most seriously, cyproterone is associated with liver damage. That damage can be severe. It can lead to liver failure even after the drug is stopped. Damage has been reported with doses over 100mg/day. Because of this, people on cyproterone should have their livers regularly monitored with blood tests. The drug should not be combined with other drugs that can cause liver damage. That includes alcohol and many prescription drugs. Individuals with known liver damage/disease should not take cyproterone.

There is also some question of whether the drug is associated with some cancers. Specifically, hepatocellular carcinoma (liver cancer) and meningioma are the cancers of concern. Researchers are still exploring this connection. Other side effects of cyproterone include allergic reactions and worsening of depression.

People with these disorders should avoid taking cyproterone: allergy to cyproterone, liver disease, liver tumors, meningioma, blood clots.

People with these disorders should use extra caution and talk with their doctor before taking cyproterone: Depression, cardiovascular disease, diabetes.

Other drugs that are used?

Finasteride is an anti-androgen used to slow/stop a receding hair line. Specifically, it blocks the conversion of testosterone to its more active form, dihydrotestosterone. Some trans women and trans men use it for receding hair line. Other trans women use it when other anti-androgens can’t be used for health reasons. Dutasteride is a similar drug that is also used.

Progesterone is another drug which is sometimes used. Progesterone is another sex hormone created by ovaries. Its use in medical transition is currently debated. Some people use it for mood, libido, or breast development. Research supporting these claims is scarce, and progesterone comes with its own health risks, particularly heart disease and blood clot risks.

Viagra is sometimes prescribed when there are significant erectile problems.

What are the major physical/emotional effects of HRT?

Breast growth, fat redistribution, decreased libido, decreased ability to have an erection, testicular shrinkage, skin softening. Facial hair may grow more slowly. HRT also has psychological effects but these are highly variable. Some report greater moodiness and ability to cry, others feel more calm. Spatial abilities may change. Sexuality may also shift – not just who you’re attracted to, but how you’re attracted and what you want to do in the bedroom. HRT can cause infertility, so if you want biological children you should bank sperm or conceive them before starting HRT.

There is no way to pick and choose effects. Your body will do with HRT whatever it is going to do. Wiki has a great, detailed, cited list.

What kind of blood test monitoring am I looking at here?

Your physician will likely want to do regular blood tests every couple of months in the beginning to make sure you’re staying healthy. The big things they’ll likely check include potassium levels (via a “complete metabolic panel” or CMP), lipids including cholesterol and triglycerides, and estrogen/testosterone levels (varies by physician). They’ll also want to check your prolactin level at least once, since HRT carries a risk of a type of growth called a prolactinoma. Other tests may also be done, depending on your health history. Other common tests include a complete blood count (CBC) which can detect anemia, and thyroid tests. Your physician may do other screening depending on your own risk factors.

What about breast cancer?!

There’s a lot of fear about breast cancer. There are no large studies of breast cancer in trans women. However a small study was published in 2013. You can see my review of it here. A few case reports also exist. So far it doesn’t appear that trans women are at high risk for breast cancer.

Ask your physician what level of screening is appropriate for you.

How big are my breasts going to get?

The “rule of thumb” is that you’ll likely be one cup size smaller than your closest women (genetic) relatives. This is by no means accurate. There are no studies. It is a fair place to start, however. Like for all women, your breast size will be a roll of the genetic dice.

What won’t HRT do?

HRT cannot change your bones. Your height will remain the same. Though the fat on top may redistribute, your hip bones and facial bones will stay the same. It cannot change your voice, though you can change the way you use that voice. It cannot reverse a receding hair line or remove facial hair. There are surgeries which can help with some of these. Hair can be removed by electrolysis or laser. Facial feminization surgery is an option for women who can afford it. Vocal training and vocal surgery are also options.

I just started taking HRT. When can I expect results?

WPATH’s SOC7 has a really nice breakdown…

This is taking way too long. I want changes now!

Hormone therapy like a second puberty – it will take years. There is no way to speed up hormonal transition. Increasing your hormone dose will not speed things up.

What if I choose to go off hormones?

You can do that. Some hormone changes, like breast growth, are permanent. Others, like the redistribution of fat, are not permanent. Going off hormones can cause many of the symptoms of menopause: hot flashes, night sweats, and irritability.

If you no longer have your testes then going off hormone therapy means you have very low hormone levels. This can increase your risk for osteoporosis and later bone fractures. Your physician will advise you on your own risks, and recommend staying on hormones or not.

How will my hormones change after surgery?

Once your testes are removed, you will lose your major source of sex hormones. Anti-androgens are no longer needed, though some women choose to stay on spironolactone at a very low dose. You will likely need to stay on estrogen supplements for the rest of your life. Having no sex hormones at all is not good for bone health.

What can I do to minimize my risk factors?

Take care of yourself. Don’t use tobacco. Drink alcohol in moderation or not at all. Eat a healthy diet — not a lot of red meat, processed food or fast food but lots of fruits, vegetables and whole grains. Maintain a healthy weight – right in the Goldilocks zone, as it were. Avoid crash diets. Exercise!! Find something that works for you and do it. If that means walking on the treadmill while you play your favorite video game (like me when I started), then do it and have fun. If you have any disease that run in the family, be sure to tell your physician. Ask them if they have any recommendations. Take care of your mental health. See a therapist if you need to. And don’t forget to practice safe sex.

What side effects should I call my doctor about?

In addition to the “usual” stuff, like high fever, chest pains, faintness, or any significant changes, there are certain symptoms you should definitely tell your doctor about. Vision changes, sudden headaches and sharp persistent leg pains should be called in. You may need to go to urgent care or the emergency department for more testing. If you develop a rash or swelling after injecting estrogen, you should also tell your physician. That may be a sign you’re allergic to the oil the estrogen is suspended in.

Will masturbating limit the effectiveness of my hormones?

No. You will not be “flushing” hormones out of your body when you masturbate. You can continue to masturbate. On hormones you may have difficulty getting aroused. This is normal. A little creativity and patience can usually help, but if that’s not working there are medical options for you. Talk with your physician.

Anything else?

Communicate with your physician! Let them know what effects you’re experiencing – the information is useful not just in your care but for anyone else they prescribe hormones for in the future. Make sure you read all your prescribing information and ask your physician or pharmacist if you have questions.

Hormones for adult trans men/people assigned female at birth

Testosterone is the primary hormone therapy medication for trans men. No anti-estrogen medication is required. Be aware that testosterone is a controlled medication, so be sure to carry paperwork when you travel with it!

Which Testosterone? Testosterone can be given either as an injection or transdermally. Oral testosterone should not be used because it can cause liver damage.

Testosterone should never be given above what your health care provider. The body converts some of its testosterone to estrogen. So the higher the dose of testosterone, the higher the estrogen in the end. This can be counterproductive for transition and can be risky.

Intramuscular injection (e.g., Depo-Testosterone): The primary form of testosterone given for trans men, especially early in hormone therapy. It’s an injection given deep into muscle tissue, like the flu shot. As with all injections, it requires injection training. Injections can be given weekly or biweekly. Some European countries have formulations that are given monthly.

Subcutaenous injection: This is a newer way of giving testosterone. It an injection given under the skin, rather than deep into muscle (intramuscular). Studies are currently underway to determine efficacy. However, it may be an option offered by your health care provider.

Transdermal gels, creams, sprays, and under-arm applications (e.g., Androgel, Axiron): More expensive than injections, but no needles involved. They are a cream or gel product that is smeared on the skin and absorbed through the skin. Common wisdom says transition is slower with transdermal applications but I haven’t seen data published yet. Gels and creams can be messy and must be kept away from other people especially pregnant people (it can cause harm to the fetus). Gels and creams can also be used on the clitoris, in addition to testosterone injections, to help increase growth.

What health conditions affect whether I can take testosterone or not?

High red blood cell concentrations (polycythemia) is a really big one. Testosterone can worsen or cause polycythemia by stimulating bone marrow to produce more red blood cells. If this happens, your testosterone dose will likely need to be lowered.

Other serious health concerns that may mean you should not take testosterone include: allergy to testosterone products, breast cancer, pregnancy.

Conditions that should be discussed with your doctor before starting testosterone include: cardiovascular disease, migraine, liver disease, high calcium blood levels (hypercalcemia), sleep apnea.

High cholesterol, high blood pressure, and diabetes will likely need to be assessed and controlled before testosterone. Other conditions may also need to be controlled. As always, you should not drink alcohol heavily or smoke while on testosterone.

What other drugs are used?

Depo-Provera can be used to stop menstruation when testosterone can’t be given. It appears not to increase gender dysphoria because it doesn’t feminize.

Other forms of hormonal birth control, like the Nexplanon, can also be used to stop menstruation.

Aromatase inhibitors may be used for some people. These drugs prevent testosterone from converting to estrogen.

Finasteride and related anti-androgens can be used in trans men to prevent hair loss.

Special formulation testosterone and dihydrotestosterone creams can be used on the clitoris to increase growth if desired.

What are the major physical and emotional effects of HRT?

Cessation of menstruation, deepening of voice, facial and body hair growth, masculinization of face, increase in muscle mass, enlargement of the clitoris, increase in acne and possible male-pattern baldness. Please note that testosterone is not birth control and it is possible to become pregnant on testosterone. Testosterone can also cause vaginal atrophy (drying out of the vagina, loss of elasticity).

Emotionally many men report that they have increased energy and confidence. Some trans men report that they have a harder time accessing their emotions. Some have expressed concern that testosterone may increase rage (“Roid rage”) or worsen mental health. Anecdotally this does not appear to be the case for trans men. Sexuality may also shift – not just who you’re attracted to, but how you’re attracted and what you want to do in the bedroom.

There is no way to pick and choose effects. Your body will do with HRT whatever it is going to do. Wiki has a great, detailed, cited list.

What kind of blood testing will I need?

Your physician will likely want to do regular blood tests every couple of months in the beginning to make sure you’re staying healthy. Likely tests include a CMP (complete metabolic panel) to check the health of your liver and kidneys, CBC (complete blood count) to check for polycythemia, lipids (cholesterol/triglycerides), and estrogen/testosterone levels. Other tests may be ordered depending on your health history. Thyroid tests are also common.

What won’t HRT do?

It can’t remove breast tissue, though some trans men anecdotally report slight shrinkage. Removal can only be done surgically. Testosterone can’t change bones or height.

Will I be really fuzzy? Really smooth?

Frankly, nobody knows. Your best bet for a prediction is to look at your closest male relatives. You will likely have similar levels of hair and hair loss.

I just started taking HRT. When can I expect results?

WPATH’s SOC7 has a really nice breakdown…

What if I choose to go off hormones?

You can do that. Keep in mind that many of testosterone’s effects are permanent (voice deepening, hair growth). Some of its permanent effects can be reversed by surgery or other procedures (e.g., body hair removal). If you still have your ovaries and uterus then menstruation will resume, fat will distribute, etc. Going off testosterone when you do not have ovaries can lead to loss of bone density and increased risk of a bone break. You should talk with your doctor before stopping testosterone.

My doctor says I have high testosterone levels before I even started T! What gives?

You may have polycystic ovarian syndrome (PCOS). No one knows why, but trans men are more likely to have PCOS than cis women. In PCOS, cysts form on the ovaries, resulting in a high level of testosterone, irregular periods, and sometimes masculinization (e.g., body hair). PCOS is often associated with obesity, metabolic syndrome and diabetes, which carry health risks. PCOS itself is not a danger, though it does affect fertility.

How will my hormones change after surgery?

Once your ovaries are removed, you will lose your major source of sex hormones. Your testosterone level may need to changed. Check in with your health care provider. However you will need to stay on testosterone for the rest of your life in order to preserve bone density. Some men also report needing a change in dosage after top surgery.

What can I do to minimize my risks?

Take care of yourself. Don’t use tobacco. Drink alcohol in moderation or not at all. Eat a healthy diet — not a lot of red meat, processed food or fast food but lots of fruits, vegetables and whole grains. Maintain a healthy weight – right in the Goldilocks zone, as it were. Avoid crash diets. Exercise!! Find something that works for you and do it. If that means walking on the treadmill while you play your favorite video game (like me when I started), then do it and have fun. If you have any family risk factors, be sure to tell your physician and ask them if they have any recommendations. Take care of your mental health. See a therapist if you need to. And don’t forget to practice safe sex.

What side effects should I call my doctor about?

In addition to the “usual” stuff, like high fever, chest pains, faintness, or any significant changes, there are certain symptoms you should definitely tell your doctor about. Symptoms of polycythemia include shortness of breath, headaches, dizziness, numbness or itchiness in hands and feet, and fatigue. If you develop a rash or swelling after injecting testosterone, you should also tell your physician. That may be a sign you’re allergic to the oil the testosterone is in.

Anything else?

If you do weight lifting, be careful when you start testosterone! Ramp up very slowly in the first few months at least. Testosterone causes an increase in muscle mass, but it takes longer for your tendons to strengthen as well. You may snap a tendon if you try to lift too much too soon.

Communicate with your physician! Let them know what effects you’re experiencing – the information is useful not just in your care but for everyone who may see that physician in the future.

Hormones for Trans Youth

Care for trans minors is more complex because minors do not have the same legal rights as adults. Parents may deny medically necessary hormones or surgeries. In many cases, that means the youth will have to wait until age 18. If two parents have legal custody and they disagree about transition, there can be a very messy legal battle. Providers are generally more hesitant to treat trans youth. This reluctance can extend to trans people just barely over age 18.

There is also a lot of fear about whether a trans youth’s gender is stable because of their age. Gender identity and expression can be fluid in young people, which can be confusing for adult caregivers. There is a lot of debate about the “proper” way to treat, or not treat, gender non-conforming and transgender youth. It’s not settled by any means, even among health care providers who do adult transgender care.

If care is needed for a transgender (or gender non-conforming) youth, seek a pediatric endocrinologist, pediatrician, or family physician with experience with transgender youth specifically.

When do I start thinking about hormones?

Hormone therapy generally does not come into play until natal puberty begins. Puberty is split into 5 stages, called Tanner Stages (link NSFW). Stage 1 is pre-puberty, Stage 5 is full adult (physical) sexual development. Stage 2 is the stage you want to be looking for, and it often happens around ages 9-11 (younger in people whose bodies have ovaries, later in people whose bodies have testes).

For people whose bodies have ovaries, Tanner Stage 2 is when breast buds begin to form. There begins to be a little development of breast tissue behind the nipple. It can feel like a little lump. The areola, the colored area around the nipple, may also begin to get larger. This usually happens long before the puberty growth spurt and menstruation.

For people whose bodies have testes, Tanner Stage 2 is when the testicles begin to grow and the skin of the scrotum begins to darken. This usually happens long before the puberty growth spurt and voice drop. They may also have breast buds for a short period.

Tanner Stage 2 is the best time to start drugs called puberty blockers, aka GnRH analogs. It’s also the ideal time to start hormone therapy if puberty blockers aren’t going to be used. Starting at Tanner Stage 2 means that none of the permanent physical effects of natal puberty will happen. However, not going through all the Tanner stages means that a trans youth will not be fertile.

What are puberty blockers?

Puberty blockers are GnRH analogs. The way they work is unusual. GnRH is gonadotropin releasing hormone, and there’s very little of it in our bodies through childhood. When puberty begins, it starts to be released in pulses. These pulses of GnRH cause luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to be released. LH and FSH then trigger the release of sex hormones (estrogens, progesterone and androgens), causing the changes we see in puberty. The pulsing nature of GnRH also maintains the release of sex hormones in adulthood.

An analog is something that increases the activity of a hormone or neurotransmitter. So a GnRH analog increases the effect of GnRH. How does that delay puberty? It turns out that if GnRH is at steady high levels, there is a feedback loop that causes LH/FSH levels to drop. Low LH/FSH means low sex hormone levels. Ultimately, that means no pubertal changes for as long as the GnRH levels are that high.

Once a person goes off the GnRH analogs, they resume puberty (or resume production of sex hormones) wherever they left off. If a person who has gone through natal puberty goes on a GnRH analog, the drug will drop their estrogen/progesterone/testosterone levels. Side effects of that include hot flashes, headaches, and long-term potential loss of bone density.

Why would I want to go on puberty blockers?

That’ll depend on your circumstances. Blockers are commonly used to buy time. Time for parents to become more accepting, time to find and work with a therapist, time for the school to arrange accommodations, etc.

They’re also used in conjunction with hormone therapy, and that’s where they’re also used in adults. Puberty blockers can be used to suppress natal hormones, so lower doses of hormone replacement therapy need to be used.

They can be used in place of spironolactone. They can also be used in trans men to stop menstruation prior to, or during the start of, testosterone therapy.

Are there any problems with puberty blockers?

Not particularly. They have a fairly long history of use for children with precocious puberty. GnRH agonists should not be used if a person is allergic to it or is pregnant or breast feeding.

The biggest concern is over their potential long-term effects on bone density. A sex hormone, either estrogen or testosterone, is required for maintaining and developing bone density. So there were some concerns that being deprived of a sex hormone for longer than “usual” would result in low bone density levels. To be safe while on puberty blockers it’s best to participate in weight bearing exercise and make sure there’s enough calcium and vitamin d in your diet.

Other health conditions which may affect your ability to take puberty blockers includes: cardiovascular disease, long QT syndrome, diabetes, pituitary adenoma, epilepsy, and prostate cancer.

Puberty blockers are, unfortunately, quite expensive. I’ve heard parents comment that it was “either buy a car or get puberty blockers for a few years”. Insurance companies are not likely to cover the cost of treatment either…. though there are some financial assistance programs from some manufacturers.

How are puberty blockers given? Are there different types?

Puberty blockers are given primarily as an injection or an implant, though nasal sprays exist. Injections can range from once a day to once every three months. In theory implants can last up to a year but there is anecdotal evidence that they can last longer. Leuprolide/Lupron and histrelin/Vantas are two examples of puberty blockers used in trans care.

Anything I should know when starting a puberty blocker?

It should be noted that when a puberty blocker is started there may be a spurt of puberty. Please, don’t panic. GnRH analogs do increase the effect of GnRH so it’s like it’s pulsing. The effects will go away – just hang in there for a bit.

Will I need to have blood tests or monitoring?

Depends on your physician and your financial resources. They may want to do a one-time check of LH/FSH levels (to check that you’re being suppressed enough), or they may want to do a check of LH, FSH, GnRH, a bone density scan, and more every few months. There is very little standardization so far.

Okay… I’m on a puberty blocker. Now what?

That will depend on many things, including cost. Options include (but are not limited to)…

Continue on puberty blockers until after age 16, then stop them and go on cross-sex hormones

Continue on puberty blockers until after age 16, then add cross-sex hormones on top

Continue on puberty blockers for a while, then do either of the above

Stop puberty blockers at any point and resume natal puberty, then transition at a later date with cross-sex hormones

Stop puberty blockers, resume natal puberty, choose not to transition

Why age 16?

It started in the Netherlands, where a lot of trans youth protocols were pioneered. That’s the standard from those protocols, and it’s carried over into the Endocrine Society guidelines. Many physicians and organizations do follow that age requirement, though there is a growing awareness that starting puberty at age 16 is unnecessarily stressful.

So I don’t have to go through natal puberty?

Not necessarily. A person could go from Tanner stage 2 directly to hormones. Or a person could go from Tanner stage 2 to puberty blockers to hormones.

What about biological kids and fertility?

This is a huge question for parents of trans youth. They sometimes worry that by allowing their young person to transition at a young age they’re depriving them of biological children.

In order to have your own biological children, you must go through all of natal puberty, all the way to Tanner stage 5. If you have not gone through natal puberty, then your testes/ovaries never got the capacity for reproducing. With today’s medical technology, genetic children would not be possible. Trans youth can (and likely do) choose to go through natal puberty solely for the purpose of biological children, but I have heard that it is immensely stressful. There is some recent movement in the area of harvesting undeveloped ovaries/testes for future fertility. This research, to my knowledge, is being done primarily with children with cancer. It’s very much in its infancy though and will not be commercially available for years.

If you have had orchiectomy (removal of testes), oophorectomy (removal of ovaries), or any other medical procedure/drug that would affect your ability to reproduce, then you would not be able to have genetic children (with today’s technology).

If you have gone through natal puberty, or have functioning gonads (testes/ovaries), it gets more complicated. The best way to ensure children is to either have them before hormone therapy or to store sperm/eggs/zygotes. If you have started hormone therapy then you may or may not be able to have children. Consult your physician. There are many, many factors your physician would consider, including: how long you’ve been on hormones, your hormone dosage, medical conditions affecting your ovaries or testes (e.g., polycystic ovarian syndrome), your other medical conditions. Long-term hormone therapy can cause sterility.

Having biological children while on hormones is not a good idea (e.g., testosterone causes birth defects) and may not even be possible (e.g., trans women sperm counts going very low). To become pregnant, or to cause a pregnancy, you would need to go off hormones for a significant period of time. The reversible effects of hormone therapy would begin to reverse and could aggravate gender dysphoria.

Please remember also that children do not have to be genetically related to their parents. A trans person could be parent to a cis partner who carries the child. A couple could employ a donor mother who carries the child. Adoption and fostering are hugely valuable. There are so, so many kids who need loving parents. A trans-friendly family could be a boon to a foster child who is a gender/sexual minority. There are so many more options than biology. Explore them!

What can I do if my parents won’t let me start hormones or puberty blockers?!

First: hang in there. Take care of yourself. Eat well and exercise. Develop good coping strategies and a network of friends and allies. If you have the option of therapy, use it. Know that, worst comes to worst, at 18 you will be a legal adult you can make your own medical decisions.

Keep talking with them. Direct them to resources like Gender Spectrum and PFLAG, or books like The Transgender Child and Transitions of the Heart.

If you fear for your physical or emotional safety, it’s time to get outside help. Start by talking with an adult you trust — a teacher, therapist, or physician. Consider reaching out to your local diversity center for help. If you need to, physically remove yourself from the unsafe situation.

Lastly, consider seeking legal advice. There may be grounds for becoming an emancipated minor. There may be grounds for calling child protective services if they are denying you medically-necessary care.

Surgeries

Ah, surgery. Certainly surgery is what the average cisgender person thinks of when they think of transition. It’s certainly important (and expensive), but not the be all and end all of transition.

What kinds of surgery are available for trans people?

That depends on your anatomy. For people who are feminizing (e.g., trans women), options include:

Vaginoplasty. Literally means “vagina molding”. This is the “sex reassignment surgery” commonly referred to by the media. A vagina is created, commonly using penile tissue. It can be done as 1 surgery or 2. Can include the creation of labia (labiaplasty). If testes are still present they are removed.

Orchiectomy/orchidectomy (“orchie”): removal of the testes only. A much smaller procedure than vaginoplasty. Vaginoplasty can be done after an orchie, but make sure you let your orchie surgeon know that’s your plan – the technique can differ. After an orchie, sex hormone supplementation may be necessary to maintain bone health.

Breast augmentation/implants. For feminine people who aren’t happy with the size of their breasts at full growth, this is an option.

Chondrolaryngoplasty: Shaving of the Adam’s apple.

Voice surgery: Vocal chords can be shaved to raise the voice. Unusual and typically considered risky.

Facial feminization surgery (FFS): A complex combination of facial modification, depending on need. It can involve shaving bone off the brow ridge, jaw line, and nose.

Other plastic surgeries: including liposuction

For people who are masculinizing (e.g., trans men), options include:

Top surgery: removal of most of the breast tissue and formation of a masculine chest. Not the same thing as mastectomy. Various techniques exist, all with the same aim.

Hysterectomy/oophorectomy: removal of the uterus, fallopian tubes, ovaries, and cervix. Permanently ends menstruation. Sex hormone supplementation may be necessary to maintain bone health. Can be a first step to genital surgery.

Facial masculinization surgery. Not common, but I’ve seen it around the ‘net. Implants can be added to the brow ridge, jaw and/or nose to masculinize the face.

Metoidioplasty (“meta”): One of the genital surgeries. Uses only existing genital tissue, “releasing” the clitoris/penis from surrounding tissue and adjusting its position so it hangs in the right place for a penis. Can, and often does, include creation of a scrotum (scrotoplasty), routing the urethra through the penis (urethroplasty), and testicular implants. A phalloplasty can be done at a later date. With a meta, the penis can become erect on its own.

Phalloplasty: The other genital surgery. Uses tissue from elsewhere in the body — tissue from the forearm is common, as is part of the latissimus dorsi muscle. Usually 3-4 surgeries. Can include creation of a scrotum (scrotoplasty), routing the urethra through the penis (urethroplasty), penile implants to allow erection, and testicular implants. Erogenous sensation is preserved by weaving the clitoris into the penis and/or scrotum.

Scrotoplasty: Creation of a scrotum. often a component of metoidioplasty or phalloplasty. The scrotum is usually made from the outer labia (labia majora). A vaginectomy is often involved here.

Vaginectomy: Removal of the vagina.

Urethroplasty: Routing the urethra through the penis. This involves using other tissue to extend the urethra. The labia majora (inner labia) are sometimes used.

Other plastic surgeries can be done to improve aesthetic appearance.

How can I get surgery? Pre-requisites?

Depends on the surgery, surgeon, and the laws where you live. Many, but not all, surgeons follow WPATH’s recommendations, which I paraphrase here:

For top/chest/breast surgeries, 1 letter from a mental health care provider. Hormone therapy generally not a pre-requisite for top surgery for trans men. For breast augmentation for trans women, 1-3 years on hormones is highly recommended if not required.

For bottom/genital surgeries, 2 letters from mental health care providers. 1 year of hormone therapy and being out of the closet, living as your gender not as your sex, is required.

Surgeries performed for a reason other than transgender (e.g., hysterectomy/oophorectomy for cancer) do not require any letters.

Many surgeries (especially bottom surgeries) require you to be the “age of majority” in your country. In the United States, that’s age 18. Some surgeons, however, do not follow that recommendation and do perform surgeries on younger people. More letters or visits with the surgeon may be needed for people under the age of majority in their country.

Some countries or clinics require you to work within their system. Others allow you to surgeon-shop, or even require you to do your own foot work. I’d generally start this whole process by asking your primary care physician and/or surgeons about local requirements.

A surgeon may also request letters from your primary care provider verifying your health history, current health status, and readiness. Make sure you consult with your surgeon early so you get all your paperwork in order!

Will my insurance cover it?

Insurance is more likely to cover an orchie, hysterectomy/oophorectomy or top surgery. They are less likely to cover any other surgeries. Genital surgeries can be deemed “cosmetic” or “optional” by insurance companies. Your best bet is to ask beforehand. One discreet way of asking might be to ask to see a list of covered procedures.

Your physician may also be able to advocate for you, arguing that the surgery is medically necessary and thus not cosmetic. Definitely keep your primary care provider in the loop and ask them for help if you run into trouble.

What kind of cost am I looking at?

Depends on the surgery and where you get it…but no matter what it’s going to be thousands of dollars. Cost may go up if you have complications, or down if you have a very simple case. For accurate numbers your best bet is to surgeon shop and ask!

Want some really rough estimates? Okay! The more “simple” surgeries like orchiectomies, hysterectomy/oophorecotmy, top surgeries, and the simple versions of metoidioplasty, can be anywhere from $2,000 to $10,000. Facial feminization, complex metoidioplasty, and vaginoplasties could be $10,000 to $20,000 or higher. Phalloplasty is generally the most expensive, and I’ve seen it quoted anywhere from $40,000 to $100,000.

How can I afford it? My insurance won’t cover surgery!

First: I am so sorry! Besides saving pennies, a private or medical loan may be possible. Some surgeons allow payment plans too. And some people are now fundraising for their surgeries through the internet. Any of those might be an option for you.

How can I get the best results possible?

Be as healthy as you can before surgery. Exercise is important – the more muscle tone you have, the faster you’ll be able to recover. Eating well can make sure that you have the nutrients your body needs to recover. Not using tobacco speeds up your healing time. Avoid other drugs too, as your physician advises. Having a stable weight can maintain your good results. If you’re able to lose extra weight in the years before surgery, that helps recovery. Control any health conditions you have (e.g., diabetes).

Choosing your surgeon carefully is also very important. Look at their results, ask to speak with people who have had the surgery. Think carefully about your own needs and make sure that your chosen surgery/surgeon can meet them.

Lastly, follow all pre- and post-operative instructions. If they say “no aspirin for 3 weeks” – do it!

What could lead a surgeon to decline operating on me?

Every surgeon has their own criteria. However, being overweight or obese, using tobacco, and the presence of certain health conditions may lead a surgeon to conclude that surgery is too risky for you. Health conditions may include uncontrolled diabetes, cardiovascular or respiratory problems.

No surgeon should refuse on the grounds that you’re “not masculine/feminine enough”.

I’ve heard that bottom surgery for trans men doesn’t give good results. Is that true?

NO! Bottom surgery, both metoidioplasty and phalloplasty, can give very very good results. For wonderful first-hand accounts of results, check out Hung Jury.

For bottom surgeries, what about erogenous (sex) sensation?

Surgeons do not simply cut out whole clusters of nerves. Bottom surgery is complex, and care is taken to preserve as much sexual tissue as possible. The vast majority of people who have had bottom surgery have as much of a sex life as they want, and are happy with their results. The old sexual tissue is often “woven” into the new structures, so orgasm is possible. Orgasm itself may feel different too, as some trans people have reported.

For vaginoplasties, extra lubrication may be needed but penetration is often possible. For metoidioplasties, erection is possible as is penetration (though some creativity in angles may be required). For phalloplasty, a penile implant allows for erection.

However, all surgeries do cause some nerve damage. That’s just going to happen when cuts are made in skin and tissue. Sometimes sensation returns — sometimes it doesn’t. Care is taken to try to avoid the worst, but it is possible that some sensation will be damaged. Your surgeon should go over all the risks of the surgery with you beforehand. Consider them carefully.

Can I have bottom surgery if I never went through natal puberty?

Very likely! There’s some concern that trans women who never went through puberty may not have enough tissue growth to allow for a deep vagina, but surgeons report success in doing such surgeries. Don’t be shy – call up a surgeon and see what they say.

How can I reduce scarring?

Scars are going to happen, and the degree of scars will depend on your surgeon, your body, and the complications you have. More complications will likely mean more scars. And everyone scars differently. Some scar very easily. Others do not.

The single more important thing you can do is to follow all post-operative instructions! Call your surgeon if you see signs of infection. And ask your surgeon or physician about over-the-counter scar-reduction products before you use them. Some very wide scars can be reduced surgically. But please, consult your primary care provider first.

What new surgical advances can I expect to see in the future?

The thing everyone is waiting for is bioengineered genitals and gonads. Sadly, that is many many years away – I’d guess 20+ years.

In the short-term, there is focus on improving the current techniques. Lubrication for vaginoplasties, a phalloplasty with fewer stages, and improvements in urethroplasty are all areas of interest.

What about surgery overseas?

It’s an option, and it may be cheaper than pursuing surgery in the United States. Thailand is popular for trans women, Serbia for trans men. However, keep in mind that there may be language issues… and if problems come up once you’re back in the States, it’s not exactly easy to hop on over to see your surgeon. Not all surgeons will even take patients from outside the country (e.g., some Canadian surgeons won’t treat non-Canadians).

Choose your surgeon even more carefully when looking outside your country. Listen to the community and former patients. Ask to hear experiences and see results. There are unscrupulous surgeons out there and undesired results do happen, Corrective surgery is expensive and doesn’t always fix the damage. Remember: it’s your body, and it the body you get to live with for the rest of your life. Choose carefully and well.

What if I don’t want surgery?

Then don’t have it. Don’t do anything you don’t want to do! It’s your life and your body – take control, choose what you want and do not want to do, and go enjoy yourself.

Orchiectomy

Orchiectomy/orchidectomy, also known as an “orchie”, is the surgical removal of the testicles. If both testicles are removed, it’s a bilateral orchiectomy.

Why would I want an orchiectomy?

With an orchiectomy, anti-androgens are usually no longer needed. Some may choose to stay on anti-androgens at a lower dose. Estrogen doses may also be lowered after an orchiectomy.

While everyone has their own, deeply personal reasons for choosing one surgery over another, there are some potential common threads, including:

Health concerns. For someone who cannot be on an anti-androgen, or has a bad reaction to an anti-androgen, or has health conditions that make HRT risky, an orchiectomy may make hormonal transition safer.

Money. While orchiectomy costs somewhere around $4,000, it may be more cost effective in the long run to get an orchie. In my area at the time of writing this (~2014), without insurance an orchiectomy is about the same cost as 10 years of spironolactone.

Permanent pregnancy prevention (try saying that 5 times fast!). While hormones do have the potential for permanent infertility, an orchiectomy is a much surer thing.

Dysphoria. Some may be distressed by having testes but have no desire for a vaginoplasty. An orchiectomy may be the only genital surgery they desire or need. Some may also have no desire for penetrative vaginal sex, and thus no desire for a vagina.

Aversion to higher-risk surgeries. An orchiectomy is generally safer and less painful than a vaginoplasty, which may be a factor in deciding to have an orchie.

Are orchiectomies done on cisgender people?

Yes. It’s a fairly unusual procedure, though. Most commonly an orchie is performed for testicular or prostate cancer.

Would an orchiectomy keep me from getting vaginoplasty?

Very likely not. It used to be thought that an orchiectomy could affect vaginoplasty results. The scrotum can shrink after an orchid, so there might be less tissue to use in surgery. However surgeons now say that’s not a problem.

What you do want to do, though, is talk with your various surgeons and physicians. There are different ways to do orchiectomy. I have heard surgeons comment that some methods are better for future vaginoplasty than others. If possible, tell your orchiectomy surgeon whether future vaginoplasty is a consideration and refer him/her to your potential surgeons for consultation. You may also choose a surgeon who does both orchiectomy and vaginoplasty to do your orchiectomy.

Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

All of those factors will vary depending on the surgeon. Here are some generalities to give you an idea. Orchiectomy can be done under full anesthesia, or only under a light sedation. You will likely be able to leave the hospital the same day. Some surgeons ask that you stay in the area for 3 days after. You may be able to return to work in 3-5 days. Pain is reported to be “minimal.”

As with all surgeries, there will be some preparation required. You’ll need to meet with your surgeon for a consultation beforehand. Many medications, including estrogen, aspirin, and other blood thinners will have to be stopped for a certain period before the surgery.

What are the possible risks of an orchiectomy?

Orchiectomies are relatively low-risk for surgery. The major risks are infection, excessive bleeding, and bad reactions to medications given in the hospital. Your surgeon should go over all possible risks of surgery with you before you give your consent to surgery.

How will an orchiectomy affect my long-term health?

Orchiectomy removes the majority of your body’s sex hormones. Sex hormones help to maintain bone density, among other things. Without testes, your sex hormone levels will be below that of a post-menopausal cis woman. To help prevent osteoporosis you may need to be on hormone replacement for the rest of your life. Different physicians have different philosophies about life-long HRT, though, so your mileage will vary.

Removal of the testes greatly reduces any chance of testicular cancer. The drop in testosterone may also help prevent prostate cancer. In any case, with that drop in testosterone your prostate will shrink. There may be sexual side effects, similar to the effects of anti-androgens. Sex drive may go down, and your sexuality may feel different. Erections may be more difficult. Also remember that removing the testicles makes you permanently sterile. Unless you have sperm stored or have children already, you will be unable to have genetic children.

More information?

I am not a surgeon. I pulled a lot of my information from various websites, including the websites of surgeons. Resources and references include….

Chest Reconstruction

Top surgery (chest reconstruction) may be the single most important surgery for trans men.

Why would I want top surgery?

Often simply called “top surgery”, chest reconstruction is a surgery where breast tissue is removed and a more masculine, flat chest is produced. There are functional benefits in addition to helping reduce dysphoria.

Binder no longer required. Before top surgery, a binder is usually needed to flatten breasts. Binders can make exercise difficult and cause health problems. With top surgery, the binder is no longer needed. That removes all the problems of a binder!

Increased ability to be recognized as male. With healed top surgery, one could walk around topless like any other guy. There is more mobility in male spaces (especially locker rooms). Top surgery, in other words, helps make you safer in a potentially hostile world.

Dysphoria. Having a masculine chest may be very important for psychological health.

Other benefits may include a reduction in back pain if you are large-chested.

Is top surgery different from a mastectomy or breast reduction?

Yes! A mastectomy just removes breast tissue. It does not create a masculine chest. A breast reduction removes some breast tissue, but leaves the feminine breast shape intact. Neither of these would produce a masculine chest. While they may be options for some trans people, they’re not usually chosen by trans men today.

Is chest reconstruction done on cisgender people?

Not exactly. Gynecomastia (development of breast tissue in cis men) may be treated similarly, but the techniques may differ. One technique for gynecomastia I’ve seen is liposuction only. Liposuction only would not be enough for many trans men, as it removes fat only but not breast tissue.

I’ve heard there are different techniques. What are they?

The most common techniques are the keyhole method and the double incision method.

Keyhole: Keyhole, or peri-areolar, can only be done on small breasts (somewhere around an A cup, where there is little to no “extra” tissue). In this technique, a small cut is make on the edge of the areola and the breast tissue is removed through that. Thus, a “keyhole”. The nipple is not moved and sensation likely remains intact.

Double Incision: The double-incision method is much more common. The nipples and areolae are temporarily removed, and a cut is made under the breast tissue. The breast tissue is removed through that lower cut. The nipples and areolae are grafted on once the chest is shaped. Sensation is affected in this technique.

A few surgeons perform an anchor technique. This is similar to the double incision, but the nipples are left connected. This results in better sensation and possibly better placement, with an inverted T scar pattern.

Generally speaking, the keyhole method helps to save nipple sensitivity and reduce scarring, but can only be done on a limited number of people and may not produce the most aesthetic result. In the keyhole, the nipple is not moved so it may be lower/higher than is typically seen on a masculine chest. The double incision method, on the other hand, can be done on many more people and allows customization of the nipple position.

For many, double incision or anchor are the only choice. However, it’s good to know your options. In addition, each surgeon has their own tweaks to each basic procedure – so do ask them detailed questions!

Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

Full anesthesia is definitely involved in top surgery. Most can return home the same day. You will probably go home (or to wherever you’re staying for initial recovery) with surgical drains. These are tubes that go into your tissue to help drain away excess liquid into a little container that gets emptied. Initial recovery time may be about a week.

It will take longer for the cuts to fully heal. They may be red for a few months after. You may also have areas that are numb after surgery. Sensation may or may not return over the next few years (nerves grow slowly!). You may need to continue to wear a binder for the first week to month to assist healing. While healing, your movement may be restricted. You will also need to refrain from lifting objects above a certain weight for a period of time. Your surgeon will advise you on the specifics, and you should follow their recommendations!

What are the possible risks of top surgery?

The usual risks with surgery apply here: adverse drug reactions, bleeding, infection and the like. Permanent loss/reduction in sensation may occur, as with many surgeries.

Your aesthetic result may also not please you – the nipples may not be placed quite right, or there may be puckering or sagginess in odd places. Wait until you’re fully healed before speaking with your surgeon about a revision.

With the double-incision method there is the risk that the nipple grafts will not hold. The tissue may die. That tissue can never be recovered, but other tissue can be used to make nipples and the skin surrounding them can be colored (medical tattooing) to look like areolae.

What about scars?

You will have scars from top surgery. Period. The keyhole method results in a much smaller scar, but it will still be there. A double-incision surgery results in scars under the chest/pecs and scars at the end of the areolae.

How much you scar will be unique to you. You can guess based on past scarring, but there is always the risk that these scars will be particularly noticeable. They may be raised or discolored. Be prepared for the possibility. Scar revision surgeries may be possible.

My recommended scar strategy? Spend some of your recovery/prep time making a really awesome story. Maybe involving a bear or a daring rescue!

How will top surgery affect my long-term health?

Because top surgery does not remove gonads, it has relatively few long-term health effects compared to other trans-related surgeries. As with all surgery, it can be immensely helpful for combating gender dysphoria and may improve your mental health.

I’ve had top surgery. Does this mean I’m no longer at risk for breast cancer?

No! Top surgery does not remove all the breast tissue. In fact, some surgeons use breast tissue to form a masculine shape. There is breast tissue even up into the armpits. Please continue screenings as your physician suggests, especially if you are at higher risk.

Would I be able to breast feed a child after top surgery?

Possibly. Definitely speak with your surgeon about it, but I know of at least one case where a trans man was able to breast feed after having a child.

More information?

I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:

Vaginoplasty

Often known as “the surgery” by the media, genital surgery for trans women has come a long way since 1930.

What exactly is vaginoplasty? Labiaplasty? Why different terms?

Vaginoplasty specifically refers to the creation or modification of a vagina. Labiaplasty is the creation or modification of the labia. They are sometimes done in the same surgery. Sometimes they are separate surgeries. The terms are sometimes used for surgeries for cis women too – often to reduce the size of the inner labia to “smooth out” the appearance. For simplicity’s sake, for the rest of this FAQ I’ll use the term “vaginoplasty” to refer to the whole of genital surgery for trans women.

What kinds of vaginoplasty are available?

There are two basic kinds: penile inversion and colon graft. Penile inversion takes skin from the penis and uses it to create the vagina. The skin of the scrotum is used to create outer labia. The nerves and part of the head of the penis are used to make the clitoris. Some variations include:

Using tissue from the urethra to create the lining on the inside of the labia. This may help to produce a pinkish color to the area and additional lubrication.

Performing a second surgery to refine the labia. This may improve the appearance of the labia.

Scrotal tissue may be used to line the vagina. Naturally, this tissue would need to have all hair removed by electrolysis or laser therapy beforehand.

Using tissue from the inside of the cheek to line some portion of the vagina. This may provide additional lubrication.

Colon graft is not as common, but still practiced today outside the United States. This uses tissue from the colon to line the vagina. Many of the other techniques involved are the same. Colon tissue provides copious lubrication, but may also have odor or unusual color. It’s also prone to certain kinds of narrowing.

Why would I want vaginoplasty?

Everyone is different, but these are factors I have heard…

Reduction of dysphoria, whether you desire simply not to have a penis or desire to have a vagina.

No more need to “tuck”, which can be uncomfortable and encourage yeast infections. No more bulge to hide!

Safety. No more fear of being accidentally “outed” by a straying hand or eye and assaulted because of it.

Better access to women-only spaces, such as changing rooms and bathrooms. Also, no staring in clothing-optional spaces such as hot springs!

Being better able to sit down to pee

Having vaginal penetration during sex

Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

Vaginoplasty is major surgery. It absolutely requires full anesthesia. Surgery length depends on the type of surgery and your surgeon. Expect to be in the hospital for several days, and staying in the area for at least a week.

Full recovery will take months. You may be able to return to a desk job in two weeks. You may be able to return to more strenuous activity in eight weeks. This depends on your surgeon of course. As I said, this is major surgery.

Your surgeon and their staff will instruct and assist you in specific aftercare: Drains, antibiotic ointments, cotton packing/padding, hygiene, and so on.

Naturally you’ll need to abstain from sex for a period of time. Your surgeon will give you thorough instructions. If s/he omits an activity you’re interested in, please ask before trying!

Tell me about dilation!

The “neo”-vagina needs to heal. The body’s natural response to “wounds” is to close them up. Your body responds to your new vagina as if it’s a wound and tries to close it up. A dilator is a plastic or glass rod that is inserted into the vagina to hold it open and stretch out the tissue, keeping it open. Some dilators even come in pretty colors! You can think of it like a new piercing – a new piercing will close up without something in it to keep it open. Unlike a piercing, a dilator is not used constantly.

Dilation needs to be done multiple times a day at first. Your surgeon will instruct you in their use and make sure you’re using them correctly. Over time you will be able to go down to once a day. Once you’ve fully healed, dilation can be once a week or even less often.

If by any chance you lose depth, dilation may be a possible way to regain it. It’s been used to increase depth in cis women who are born with short vaginas. But it takes time, and please do consult your physician. Surgery can also be performed to increase depth.

Penetrative sex can help keep the vagina open, but not as well as a dilator. Don’t replace dilation with penetrative sex unless your physician(s) tell you it’s okay!

What are the possible risks?

As with any major surgery, vaginoplasty carries risks that could affect your long-term health. In addition to the risks of anesthesia, vaginoplasty carries the following health risks:

Urinary problems, including urinary stricture (narrowing of the opening of the urethra)

Fistula, or a hole between the vagina and rectum. This requires follow-up procedures and may require the complete closure of the vagina to allow for healing.

Blood clots. The risk of blood clots is reduced by stopping hormones before surgery, but the risk is still there. A blood clot can, rarely, be fatal.

Infection and death of tissue

Blood loss leading to a transfusion

Among the more “minor” problems are…

Loss of sensation or a change in sensation. This is a major surgery in which nerves are cut, simply because that’s the nature of surgery. Nerves can and do regrow, but they don’t always regrow “right”. You may lose sensation or sensations may be permanently altered. Surgeons do their best to prevent nerve damage.

Scarring. Scars are usually minor and/or hidden by hair, but scars do occasionally keep their color or stay raised.

Be prepared to face these risks. They are generally rare, but they do happen.

How deep will my vagina be? How sensitive with the clitoris be? Will I be able to orgasm? Will I be able to have sex?

Vaginas made via vaginoplasty are generally about as deep as a cis vagina: anywhere from 5-6 inches. Some surgeons offer a revision surgery which can be used to deepen a vagina if you’re not happy. Modern vaginoplasty techniques are designed to keep sensitivity, so your clitoris will likely be sensitive if all goes well.

Orgasm and penetrative sex are usually achievable. Post-op women generally report that their sexual experiences feel different, but I can’t comment on “how”. Keep in mind that not all cis women can orgasm, so it makes sense that not all trans women can orgasm. Enjoy your experiences, whether they involve orgasm or penetration or not!

Will the fact that I’m circumcised/uncircumcised matter?

Generally speaking, no. Don’t stress about it.

Can I have vaginoplasty if I never went through natal puberty?

Yes! And surgeons are reporting satisfactory depth for people using the penile inversion technique. A skin graft from elsewhere in the body might be necessary for depth, but surgeons are reporting success without it.

How is a trans vagina different from a cis vagina? What about lubrication?

Again, it does depend on the surgeon and the technique. For women who had a penile inversion, in general the vagina is less stretchy and more likely to tear and/or bleed. Gentleness and avoidance of sharp objects is advised.

I highly recommend you check out resources like the Wall of Vagina if you’re concerned about final appearance looking “normal”. Cis women vary enormously. Chances are, you’ll fit right in. Because of that natural variation, I’ve heard reports of OB/GYNs unable to tell the difference.

Believe it or not, the vagina of a post-op women does lubricate. The fluid itself is thought to be a result of glands like the prostate which remain. Not all women find that it’s sufficient by itself for vigorous penetrative sex, though. Don’t be afraid to use lube – and do remember to have fun! If your lubrication is still too little for comfort, speak with your physician.

Will vaginoplasty affect my long-term health? Pap smears?

Aside from the risks of surgery, the biggest effect to long-term health is the removal of the testes. For those risks, check out the section on orchiectomy.

Trans women after vaginoplasty do NOT need a pap smear. A pap smear is a test where a sample of cervical cells are taken. Those cells are stained and looked at under the microscope to look for cancer. A vaginoplasty will not give you a cervix. You are not at risk for cervical cancer and do not need to be screened for it.

However, a “neo” vagina can get torn or for some other reason need to be medically examined. This is part of why it’s important to have a primary care physician you’re comfortable with!

Since you would now have a vagina, there is some maintenance that vaginas tend to need. Vaginas are dynamic systems. Your smell, taste and sense of touch may change at different times. What you eat, the underwear you wear, and the products you use can all affect your vagina. Avoid heavily scented products. Plain cotton underwear is likely your best starting place. Do not douche. Get to know your vagina and labia so that you can alert a physician if something changes. Signs that you may need to consult a physician include: discharge that is foul smelling, discharge that is yellow or green in color, copious discharge, pain or burning with urination, bleeding, skin ulcers, skin infections, and skin discolorations.

Of note: Just like cis women, you will be at higher risk for urinary infections than when you had a penis. To prevent UTIs, drink plenty of water, wipe front to back when using the toilet, and consider urinating before/after penetrative sex. If you have frequent infections, talk with a physician about medications that can help prevent infections.

You will still be vulnerable to sexually transmitted infections. Because the post-op vagina is relatively easy to tear, make sure to use barriers when having sex to prevent infections like HIV.

Additionally, don’t forget that the vagina is made of skin. Like any skin, it can develop skin cancers. Alert your physician if you see a discoloration or bump that is growing, changing, or simply not going away.

Will the prostate be removed?

No. Depending on what your physician says, you may still need prostate screenings. Because the prostate remains, there is still a theoretical risk of prostate cancer.

Some women report that it’s easier to feel the prostate through the vagina than through the rectum. So if you enjoy prostate stimulation, try it that way!

Peeing…?

You will need to learn to pee all over again. Such fun. The shower is a great place to practice, but expect to have some… interesting urinary experiences. Also note that your urethra will be shorter after vaginoplasty, so you may be more prone to urinary tract infections. So hydrate well, and seek medical care if you develop burning during urination that doesn’t go away or foul-smelling urine.

Are there any health conditions that mean I can’t get it?

I do not know of any absolute contraindications. Even if you do not have a penis, tissue from other areas can be used to create a vagina.

However, some surgeons may have their own requirements like being a certain BMI. There are conditions, like diabetes, heart disease, or infection that need to be controlled before surgery can be attempted.

Anything else I should know?

Your mileage will vary. It depends on your body, how you take care of yourself pre and post-op, and your surgeon. Remember to do your own research – this is just a starting point! Your surgeon should have results photos s/he can share with you. Talk with other women about their experiences as you make your decision.

Resources I should check out?

Hysterectomy, oophorectomy, vaginectomy

For some trans men the very fact that he has ovaries, uretus, cervix and vagina is a source of dysphoria. For trans men who aren’t ready or able to have genital surgery (i.e., metoidioplasty or phalloplasty), there are options to remove the gonads: hysterectomies, oophorectomies, and vaginectomies.

That’s a lot of -ectomies. What exactly are you talking about?

Let’s go through the options one by one…

A hysterectomy is the removal of the uterus, and only the uterus. A hysterectomy may or may not involve the removal of the cervix.

An oophorectomy is the removal of an ovary. A bilateral oophorectomy is the removal of both ovaries. A bilateral salpingo-oophorectomy is the removal of both ovaries and both fallopian tubes.

A vaginectomy is the removal of the vagina. If a cervix was still present, it would also be removed.

So why get one of these surgeries?

Reasons are of course very personal. Reasons also vary depending on which surgery is involved, but some men have cited the following:

Reduction of dysphoria. For some men, just knowing that a uterus and ovaries are present is distressing. Removal can reduce that distress

Eliminating the need for pelvic examinations and pap smears (for paps, only if the cervix is removed)

Eliminating the risk for some reproductive cancers, including ovarian cancer, cancer of the fallopian tubes, endometrial cancer, and cervical cancer

No more menstruation. Ever. Woohoo!

Cis women get these surgeries too, right?

Yup. They can be done for conditions as benign as polycystic ovarian syndrome or fibroids, or for conditions as potentially deadly as cancer. Hysterectomies and oophorectomies are far more common than vaginectomies. However, vaginectomies can be done for cis women for vaginal cancer. Yes, vaginal cancer exists.

Because these aren’t trans-specific surgeries, finding a surgeon and getting insurance coverage isn’t as difficult as it is for a meta or phallo. It gets even easier if you have a condition (like fibroids) where surgery is recommended in cis women. Ask your primary care provider for ways you can get the surgery covered. Also note that while many surgeons do perform these, it might be difficult to find one who will treat you in a way that affirms your gender. Be ready to call in others to support you.

Can these surgeries all be done at once?

Some of them, definitely. So much so that there’s a medical acronym: TAHBSO. Yes, it totally looks like the word “tabasco”. It’s one of my favorite acronyms. TAHBSO stands for Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy. It’s the removal of the uterus, oviducts/fallopian tubes, and ovaries all at once through a bigcut in the abdomen. However, most hysterectomies/oophorectomies today are done laparoscopically — through several little cuts in the abdomen instead of one big one.

I don’t know for sure whether a vaginectomy could be performed at the same time. As your potential surgeon.

What variations in techniques are there?

The biggest variation is in where and how the cuts are made to remove the organs. Vaginectomy is simple – it’s done vaginally.

But hysterectomies and oophorectomies vary. The oldest technique for those is the abdominal incision – a horizontal or vertical cut is made on the abdomen. This technique is the most traumatic for the body, leaves a scar, and has a longer recovery time.

Two other techniques for hysterectomy and oophorectomy have emerged fairly recently. Laparoscopic surgery is where multiple small cuts are made, and the surgery is performed through those cuts with long tubes with cameras and grasping ends. Lastly, sometimes a hysterectomy can be performed through the vagina, leaving no outward scar at all.

You should discuss the pros/cons of each technique with your potential surgeon to determine which is best for you. A second opinion is important here too.

What should I do if my surgeon says s/he isn’t willing to do a specific technique for me?

Be aware that not all surgeons use all techniques. Some simply have more experience with one over the other. They may well say (or be thinking): “I don’t have a lot of experience doing vaginal hysterectomies, and I don’t want to risk harm. So if you have your hysterectomy with me I want to use the technique I’m best at to minimize your risks.”

Or there could easily be other reasons. Ask your surgeon why!

Can you tell me more about the surgeries? Do they require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

These surgeries are all “major” surgery, meaning the main body cavity is penetrated. They absolutely will be done under general anesthesia (would you really want to be conscious through that?).

Recovery time will vary depending on what you have done, and how it is performed. It can be as little as two weeks (vaginal hysterectomy) to 6-8 weeks (TAHBSO). Unless you have a complication, even for a TAHBSO you probably won’t spend more than a few days at the most in the hospital.

What are the possible risks?

Risks are mostly the ones associated with any major surgery, including infection, a bad reaction to anesthesia, and the risk of a blood clot. Remember: any surgery can end up resulting in death – the chances may be very small, but still present. There’s also the chance that some of the organs nearby may be accidentally nicked or damaged. Your surgeon will do their best to avoid such damage but it’s a possibility.

If you use your vagina for sex, surgery may change some of your sexual responses. Some cis women report pain with intercourse after a hysterectomy, for example.

Your surgeon will go through all the possible risks with you.

What are the possible long-term health effects?

Depends on what was removed.

If you had an oophorectomy, your own biggest source of sex hormones will be gone. You’ll still have a tiny amount from your adrenal glands but not much. This makes it super important to stay on a sex hormone to prevent osteoporosis. There may be other changes too, even if you’re regular with your testosterone. Check in with the trans male communities to see what else they’ve noticed.

Removal of your ovaries makes you permanently infertile. If having genetic children is important to you, either have them before an oophorectomy or store your eggs.

Would these surgeries affect my future ability to have a metoidoplasty or phalloplasty?

They shouldn’t. Some or all of these surgeries may even be the first step in a meta or phallo!

Any health conditions that mean I can’t get any of these surgeries?

As far as I know, only the health conditions which would prevent anyone from having any surgery. That includes obesity, heart disease, lung disease, and end stage liver disease. As always, to maximize your recovery you’ll want to quit tobacco use and get as fit as you can before your surgery.

Any other thoughts?

As always, communicate with your primary health care provider. He or she will be best able to help you figure out whether a hysterectomy, oophorectomy, or vaginectomy is right for you.

Facial Feminization Surgeries

Facial feminization surgery (FFS) is broad term used to refer to many plastic surgeries which modify the face, head and scalp with the aim of feminization. For this article, I’m referring heavily to the work of Dr. Douglas Ousterhout, who literally wrote the book on FFS. Many thanks to him and his staff for their great work. If you want to get into the nitty gritty on each of these surgeries, I highly recommend you pick up a copy of his book. I’ll be doing much more of a summary here.

Facial feminization? Huh? Why would I need that?

The difference between male and female humans is not just in our body fat distribution, pelvis shape and general fuzziness. The presence or absence of testosterone influences our skull shape too, so much so that many adult human skulls can be identified as male or female. Some of the more obvious features of a male skull include a brow ridge and wide jaw. Facial feminization surgeries correct some of these effects of testosterone. Other testosterone effects, such as hair loss or the presence of an “Adam’s apple”, can also be corrected surgically.

The #1 goal cited for FFS is the ability to be recognized as female. Alleviation of dysphoria is also a reason.

Because FFS corrects the masculinization by testosterone, those who did not go through natal puberty likely will not need or want FFS.

Which procedures are core to FFS?

Forehead contouring: Bone that makes up the brow ridge is removed and the forehead is re-shaped to a more feminine curve. In most people, the amount of bone that is removed would expose the sinuses in that area, so a bone graft or similar is used. Often combined with scalp advancement.

Scalp advancement: To compensate for a higher hair line and/or hair loss, the scalp is repositioned lower down. Often combined with forehead contouring.

Rhinoplasty: Reshaping the nose. Male noses tend to be larger than female noses and have different contours. A rhinoplasty can involve all part of the nose, including the tip, the ridge down the center, the size of the nostrils, and back into the nasal septum. Highly recommended to be done with forehead contouring.

Lip reshaping: Lips can be feminized by shortening the distance from nose to upper lip and/or adding material to the upper lip to “fill” it out,

Sliding genioplasty: Changing the shape and width of the jaw. This is typically done by 