There are two interlinked sets of double standards which privilege CAFAB trans people over CAMAB trans people with respect to the actual process of physical transition in the United States and most other Western nations:

First, there are the treatment protocols specified by the WPATH 6th Edition Standards of Care. Under these rules, CAFAB trans people are granted access to top surgery with no restrictions beyond “officially” transitioning under the supervision of a psychologist; the SoC explicitly states that “female-to-male patients may have surgery at the same time they begin hormones”. CAMAB trans people, on the other hand, are subject to an 18-month mandatory minimum for top surgery and must also have documented support from both their doctor and their surgeon agreeing that their existing breast size is inadequate.

Second, there are the legal gender change protocols specified by the laws of each state. These vary from state to state, but in most cases the law allows trans people to change the gender listed on their legal papers based on written documentation from a doctor certifying that they have had “appropriate medical treatment”. The exact definition of “appropriate medical treatment” is left to the courts, and the standard interpretation is that CAFAB trans people are granted legal recognition based on top surgery alone, but CAMAB trans people are only granted legal recognition if they have had bottom surgery.

Thus, the bottom line is that a CAFAB trans person can visit a psychologist just two times and get their authorization letter for top surgery, immediately obtain said top surgery from pretty much any surgeon in the country, and then immediately obtain legal ID in the proper gender. They can always count their surgery as a tax-deductible medical expense and/or use a tax-sheltered health savings account to pay for it, and in many cases they can also have it covered by medical insurance as a “preventative mastectomy”. They do have to wait twelve months for bottom surgery, but this is purely optional for them.

CAMAB trans people, on the other hand, cannot gain legal recognition until they have had bottom surgery, which is a minimum twelve months of regular visits to a psychologist before they get their primary authorization letter and then at least one visit to another psychologist for a confirming authorization letter. They can then seek one of a tiny number of specialists in the world who perform bottom surgery (most of whom are fully booked for months in advance), and only then can they gain legal recognition. They cannot count any of their surgery as a medical expense or use health savings account money for it, and it is specifically excluded from virtually all medical insurance. If CAMAB people want top surgery as well, they have a minimum of six more months before they can get authorization, and even then top surgery is only allowed if the “experts” agree that their breasts are too small.