Trans 101 for Trans People

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. Such centers may have trans support groups, or at least 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 results of some kind. Still no luck? Try the search query “transgender support”. 

Provide by http://openmindedhealth.com/transgender-101-trans-people/

The links on this page are to sites outside of New Zealand, but the Information is still relevant.

This is not your average transgender 101. I will not go over the basics of what transgender is. If you want that, This is a transgender 101 for trans people!

Transition can be complicated and confusing. Information is not necessarily all there or 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. So… this is my attempt to pull together some answers to many of the common questions. I hope they’re helpful.

Table of Contents

General Questions

General Medical Questions

General Hormone Questions

Hormones for Adult Trans Women/Assigned Male at Birth

Hormones for Adult Trans Men/Assigned Female at Birth

Hormones for Trans Youth, focus on GnRH analogs

General Surgery Questions

Orchiectomy

Chest Reconstruction, aka “Top Surgery”

Vaginoplasty

Hysterectomy, Oophorectomy, Vaginectomy

Facial Feminization Surgeries

General Questions

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

You very well might be trans. At this time there is no test that will give you a definite “Yes” or “No.” You might find it helpful, though, to seek out a psychotherapist well versed in gender issues. Talking to trans people, or attending a trans support group, might also be helpful. Ultimately, though, only you can say whether you are trans or not. No one else can figure it out for you. Definitely do take your time – there is no age limit to transition.

Some people also use thought experiments to help them figure out if they’re trans or not. Some examples can be found here.

Some do go through a period of thinking that they may be trans and ultimately decide that they are not. That’s OK too! Exploring whether one is trans or not does not automatically ruin one’s life.

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

If you are truly trans, no. 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. That is, it didn’t work. 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?

So, there are some interesting brain data. I covered it previously. It does appear that trans brains may be different from cis brains. I would not take those data as absolute proof until we have more data though. Currently transgender is not included as an intersex condition by any intersex organization. Transgender is not considered a Disorder of Sex Development.

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 dichotomy. 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! 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 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. Do you choose to do something about it or not? You can continue to live your life the way you have been. You do not have to transition. You can postpone any changes.

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.

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 (e.g., surgeons may require gender-congruent presentation for 12 months before surgery), but other times they don’t. It’s up to you to decide what and where 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 — but many times there isn’t. A search engine can help you find physicians and lawyers who can assist.

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? Now’s the time to find out!

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

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. I’ve also heard that it’s 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 reflects a component of changing social norms.

Am I too old to transition?

No.

General Medical Questions

Some doctors are pretty cool.

 Where do I find a health care provider?

First, know that you don’t necessarily need to see an endocrinologist. An internal medicine or family practice physician can deliver high-quality care too!

If you have a trans-knowledgeable therapist, I’d start by asking them. Many times professionals know each other and network heavily. Likewise, if there’s a provider you know about who is somewhat nearby but not near enough to see regularly, you can call and ask their office if they know of anyone close 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, but 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 the hormone therapy protocols (i.e., the medicine and the science), 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. 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.

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 (e.g., an accidental misgendering – yes that does sometimes happen), or there may be corrective actions they want to take as a result of a complaint (e.g., additional staff training). 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 related board for mental health) 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 though it’s highly recommended. Still, many physicians feel more comfortable prescribing if there is a letter. In some instances, for example if you’re close to age 18, have comorbid psychiatric conditions, or are at university, it may be required. For safety, call your physician before making the appointment to find out their policy. A letter from a 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 actually mean that you can’t have hormone therapy, but may need to be controlled. Some conditions (e.g., previous thromboembolism, estrogen-sensitive cancers) 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 not out of the closet so they can be confidential in communications (and tell staff if confidential messages can be left on phone numbers). Also let them know 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 (e.g., transition slowly), 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, 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 right away. 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 (red blood cell concentration) 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 those 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 (and I’ve often called it that too). It’s important to note that trans hormone therapy may be 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 classic hormone regime includes an estrogen and an anti-androgen. Why the anti-androgen? Well testosterone is powerful stuff. To overcome the effects of testosterone you’d need a very large dose of estrogen. We don’t want to do large doses of estrogen because of negative side effects and associated health risks. 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 for hormone replacement therapy for cis women.

One type of estrogen pill (drugs.com)

·         Orally/Sublingually: The current estrogen of choice is 17β-estradiol. 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.

·         Intramuscular (e.g., estradiol valerate): Delivered as an injection that goes deep into muscle tissue (usually the thigh). 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 don’t know that they’re in use for trans care.

There are forms of estrogen which are less favored for transition. Premarin was originally used, but is currently not recommended because it’s higher risk. Ethinyl estradiol, commonly found in birth control pills, is also higher risk than the estrogens listed above and is generally not in use in the United States. 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 (a kind of blood clot) and estrogen-sensitive cancers because they can be fatal. If you have a history of either, you may not be prescribed estrogen at all. Anti-androgens can provide some feminization, though, as can progesterones so some amount of medical transition is possible. A physician may also be very reluctant to prescribe estrogen if you test as high risk for breast cancer (BRCA genes). Tobacco smoking is a big No-No since it increases your risk for deep vein thrombosis. A physician may insist you quit tobacco before s/he is willing to prescribe estrogen. Weight loss may also be required or recommended if you’re overweight.

Other conditions which could be factors include high cholesterol or hypertriglyceridemia (high triglycerides), migraines and diabetes type 2. These other conditions may need to be controlled with medications or lifestyle changes before estrogen can be safely prescribed.

Estradiol Molecule

Which anti-androgen?

In the United States the anti-androgen of choice is spironolactone. This drug was used for many many years as a diuretic/antihypertensive for people in heart failure so it’s safety is very well established. It also happens to act as an anti-androgen and can feminize some on its own. Doses can be as high as 200-300mg per day, but high doses tend to have more side effects without more benefits.

The big side effect that people note about spironolactone is that it… well… it’s a diuretic. So lots of trips to the bathroom, lots of peeing. But as always, your mileage will vary.

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. I can’t speak to it since I’ve never seen it myself. Let me know if you can!

One type of spironolactone pill (drugs.com)

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

A history of hyperkalemia is the big thing. Hyperkalemia means too much potassium in the blood, and can be life-threatening. Spironolactone likes to “hold on” to potassium, so blood tests are important to screen for hyperkalemia. You may need to avoid high-potassium foods, or you may not. It depends on how your body handles it all. Here’s a list to get you started on potassium-rich foods. Your physician will likely screen you for potassium levels to help you stay safe.

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.

Progesterone is another drug which is sometimes used. Progesterone is another sex hormone found in high levels in female bodies. 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.

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 a little while ago. You can see my review of it here. A few case reports also exists. 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.

UCSF recommends the same level of screening as for cis women: yearly clinical breast exams and mammograms starting at age 50 unless you’re at high risk.

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 and there are no studies, but it is a fair place to start. Like all women, it’s 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 the deepness of 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. Voice surgery is also an option.

All this sounds awesome. I just started taking HRT. When can I expect results?

From the WPATH Standards of Care version 7

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, will revert. 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 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 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. Vision changes, sudden headaches and sharp persistent leg pains should be called in and you may need to go to urgent care or the emergency department. If you develop a rash or swelling after injecting estrogen, you should also tell your physician because that may be a sign you’re allergic to the oil the estrogen is suspended in.

For safety, read through the prescribing information packets that come with all your medications and familiarize yourself with the complete list of side effects to call your doctor about that’s included. If you lose the packet, the information is available from drugs.com.

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
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, though there are some physicians experimenting with anti-estrogens. 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 carries the risk of liver damage.

Testosterone should never be given above what your health care provider recommends because the body converts some of its testosterone to estrogen. This can be counterproductive for transition and raises health risks.

Testosterone molecule

·         Intramuscular injection (e.g., Depo-Testosterone): The primary form of testosterone given for trans men, especially early in hormone therapy. 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 new way of giving testosterone. It’s 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. 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. Typical treatment for polycythemia involves removing “excess” blood (some polycythemic people donate blood regularly, for example), but your testosterone dosage may need to be lowered. A history of estrogen-sensitive cancers may require an alteration in care. 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.

Depo-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.

·         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 men recommend working to keep that emotional connection. 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, 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. It can’t change bones or height significantly.

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.

All this sounds awesome. I just started taking HRT. When can I expect results?

Thanks to the WPATH team. From their Standards of Care version 7

What if I choose to go off hormones?

You can totally 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.

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 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 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 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 because that may be a sign you’re allergic to the oil the testosterone is suspended in.

For safety, read through the prescribing information packets that come with all your medications and familiarize yourself with the complete list of side effects to call your doctor about that’s included. If you lose the packet, the information is available from drugs.com.

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 and 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

One type of GnRH analog implant (image courtesy of medgadget.com)

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 one disagrees with allowing the child to transition, there can be a very messy legal battle. Providers are generally more hesitant to treat trans youth as a result and this 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 practice 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 way 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 way before the puberty growth spurt and voice drop. They may also have breast buds for a short period.

Tanner Stage 2 is the ideal time to start drugs called puberty blockers, aka GnRH analogs (analogues if you use British spelling). It’s also the ideal time to go ahead and start cross-sex 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 Tanner Stage 2 means that a trans youth will not be fertile.

What are puberty blockers?

Puberty blockers are GnRH analogs. The way they work is kinda weird. 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 a pulse-like manner. These surges 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 past puberty.

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 continual high levels, feedback mechanisms in the body cause LH/FSH levels to drop and thus sex hormone levels to drop. 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 whose 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 potential loss of bone density.

GnRH’s molecular structure

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 used in adults. When used with hormone therapy, puberty blockers can reduce the hormone dose and/or make certain drugs (e.g., spironolactone) unnecessary.

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. The biggest concern is over 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. However studies have shown that there is no long term reduction in bone density from being on a puberty blocker. Long-term administration of a puberty blocker to a person who went through natal puberty may result in loss of bone density because of the low levels of sex hormones.

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. Leuprorelin/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 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 discontinue 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

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

·         Discontinue 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?

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.

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?!

That depends on the laws in your particular state. I recommend you find some 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.

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

And 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.

Surgeries

Surgery waiting room

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 may be willing to cover an orchie, hysterectomy/oophorectomy or top surgery but is unlikely to cover any other surgeries. Genital surgeries are often 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.

Holy crap 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. 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 post-operative instructions. If they say “no ibuprofen 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 10+ 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

Not the orchie you’re looking for…

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 the shrinking of the scrotum after orchiectomy would make later vaginoplasty difficult. 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 methods of orchiectomy, with different incision points (places that they cut). I  heard one surgeon 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, but 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 discontinued 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….

·         WebMD’s article on orchiectomy for testicular cancer in cis men

·         TS Road Map

·         Wikipedia

·         Dr. McGinn’s website (18+ only)

·         Dr. Meltzer’s website (18+ only)

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 reduce the visibility of feminine breasts. With top surgery, the binder is no longer needed, which has a myriad of effects. Binders can be uncomfortable and reduce one’s ability to breathe fully. Being without a binder may mean you’re better able to exercise and improve your health overall.

·         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.

·         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.

·         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 help form the pectoral mounds. There is breast tissue even up into the armpits. Please continue screenings as your physician suggests, especially if you are in a high risk category.

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:

·         Hudson’s FTM Guide

·         For images, I highly recommend joining transbucket.

·         Dr. Garramone’s website

·         Dr. Crane’s website 

·         Dr. Steinwald’s website

·         TopSurgery.net

Vaginoplasty

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

Suggestive flower is suggestive

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. I used both terms in the title because they can be different surgeries. It’s also important to note that the terms are sometimes used for surgeries for cis women – 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 involves taking skin from the penis and using 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 preserved and used to form a clitoris. Some variations on these basic principles 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 present issues of 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 (besides, would you really want to be conscious?!). 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, and able to return to more strenuous activity in eight. 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. Dilation I’m covering in a separation question.

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!

A set of dilators from Soul Source

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 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 colours! 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 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, though surgeons do their best to prevent it.

·         Scarring. Scars are usually minor in the end and/or hidden by hair, but scars do occasionally retain 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 penetrative 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.

It’s the wrong lube, Gromit!

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 liable to tearing for a trans woman than a cis woman. But I’ve heard reports of OB/GYNs unable to tell the difference. So relax!

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.

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 FAQ on orchiectomy.

Trans women after vaginoplasty do NOT need a pap smear. A pap smear is a specific test that looks at the cell shapes and types of cervical cells. A vaginoplasty will not give you a cervix, so you are at no risk for cervical cancer and do not need to be screened. 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 TLC that vaginas tend to need. Vaginas are dynamic systems. Your smell, taste and sense of touch will change depending on a myriad of variables. You are still susceptible to sexually transmitted infections. Get to know your vagina so that you can alert a physician if something changes.

Be aware that the vagina is made of skin. Like other vaginas, it can develop cancers. Another good reason to get to know your body!

Your vagina will grow its own set of flora (yes – all vaginas have their own micro-organisms living in them!). While after surgery your surgeon will tell you to douche, after that period douching is typically considered bad. It destroys the delicate balance of flora in the vagina and can lead to yeast infections.

If you have it, ask your doctor if it needs checked!

Will the prostate be removed?

No. Depending on what your physician says, you may still need prostate screenings. 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.

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

I do not know of any absolute contraindicators. 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, depending 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?

·         Transsexual Road Map – general overview

·         Toby Meltzer, MD – one surgeon who performs vaginoplasty

·         Marci Bowers, MD – another surgeon who performs vaginoplasty

·         Christine McGinn, MD – and another surgeon who performs vaginoplasty

Hysterectomy, oophorectomy, vaginectomy

One of the many patent medicines, for the “treatment” of hysteria, which was once thought to be the uterus wandering about the body.

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 similar to orchiectomy for trans women: hysterectomies, oophorectomies, and vaginectomies.

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

Let’s go through a bunch of the options one by one…

·         A hysterectomy is the removal of the uterus, and only the uterus. There’s a common misperception that a hysterectomy is the same thing as removing all the bits. It’s not. 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 (aka oviducts).

·         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.

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 your primary care physician or 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 so far because of that. 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 cut in the abdomen.

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 (not too unlike a cesarean section) 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 by means of long…uh… sticks basically, 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, it may alter 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 community/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. Remember, too, that testosterone is not a contraceptive and also that some trans men can become pregnant and successfully deliver happy healthy babies after being on T for years.

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. 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

Comparison of male and female skull foreheads

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 without resorting to genetic analysis. 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 prominent 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 strategically cutting the jawbone and removing or repositioning segments of it.

·         Jaw tapering/angle reductions: Changing the angle of the point of the jaw. Male jaws are more rectangular, female more pointy. There are three basic ways to accomplish this: grinding away bone in strategic spots, removing sections of bone, and/or reducing the size of the masseter muscle.

·         Thyroid cartilage reduction: The “Adam’s apple” is shaved down to a more feminine size.

Which procedures might be added on, which aren’t necessarily “feminizing”?

·         Temporal fossa augmentation: Filling in the temple with material so it doesn’t look “hollow”

·         Blepharoplasty: An “eyelid lift” – tissue is removed to stop tissue around the eyes from sagging. May not be necessary if you’re having forehead surgeries or scalp-related surgeries.

·         Rhytidectomy: A face-lift. Like blepharoplasty, tissue is removed to “tighten” it up and keep the face from sagging.

·         Otoplasty: Reshaping of the ear

·         Cheek implants: Adding implants to the cheeks to enhance their appearance

Other procedures may be included, depending on what you want and what your surgeon advises.

Will it all be under general anesthesia? How long might my hospital stay be? Recovery time?

Generally speaking, most of these procedures are done under general anesthesia. Some can be done in an outpatient setting (e.g., scalp advance), but most of the time surgeries like these are clustered. That means you typically have more than one procedure done at a time. That clustering helps produce better results and is less risky because you only go under anesthesia once.

The length of your recovery and hospital stay depend on which procedures you have. But generally speaking, if you require a hospital stay at all, it likely won’t be for more than 1-2 days at the most. Most can return to work within a few days, but it may be up to two weeks depending on your procedure. If your procedures involve jaw work, you’ll be on a soft food diet for a period of time.

What risks are involved? Any long-term health risks?

Compared with genital surgeries, the risks in FFS are much less. The work is generally less extensive, and doesn’t enter the abdominal or chest cavity. Still, keep in mind that all surgeries carry risk. Because FFS affects the face, I’d say the biggest risk is of an unsatisfactory result. Do your research and choose your surgeon wisely.

Another risk is that of numbness or sensory problems. Temporary numbness is common after surgery, even a year afterward in the case of scalp advancement. Permanent numbness is a very rare event.

I don’t know of any long-term health risks for facial feminization surgery. Make sure your primary care provider knows what surgeries you had, just to be on the safe side.

Scars? This is my face after all!

Surgeons who do FFS are usually very good at hiding scars. It’s their job after all – to show no evidence that there was surgery done. One of the most common scars is a small scar along the hairline from a scalp advance – that can be covered by hair transplants at the time of surgery, and it will fade over time. Do talk with your surgeon about the possibility of scars and ask his/her recommendations for scar prevention, but don’t stress over it.

So what’s the downside here? There has to be one!

FFS can be expensive. And it’s even less likely to be covered by insurance than genital surgery – so you’ll need to save up your pennies. There are also very few FFS surgeons in the world, so your options are limited.

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

Just the usual prohibitions for surgery. Some surgeons may also have their own requirements, like non-smoking status or low BMI.

Anything else I should know? Resources?

Listen to your surgeon, but be willing to get a second opinion. Also check out…

·         Lynn Conway has a wonderful page up including her FFS details.

·         TS Road Map also has a good guide.