In the first installment of this series, I mentioned my basic approach to and motivations for writing these posts. Just as a reminder, though, this series is intended for general, non-trans* readers, although I absolutely welcome readers who know more than I do on the topic, and hope that you will feel free to give me feedback, corrections and suggestions! I am not trans*. My child is. I try to stay informed, and Offspring does his best to keep me educated and up-to-date, but everything about the post-writing process is influenced by my own experiences, so don’t be afraid to weigh in on anything I write that you find to be incorrect, incomplete or narrow in perspective!
Also, I build the posts from questions that people have asked me, so I’d like to repeat my Content Note from last time. Some (by no means all) of the questions I have gotten are troubling, but I believe that they are honest questions, so I will answer them here. My goal is to clear up misconceptions rather than to leave them lingering in people’s minds by avoiding or only criticizing problematic questions. This is a luxury that I have in this space. It is not something that should be expected of trans* people unless they are explicitly willing.
In the first post in this series we looked at the basics of gender, binary thinking, and gender vs sex. Some of the most critical take-aways from that post include:
- Gender and sex are different, albeit intertwined, categories.
- Gender is not a strict binary, but is better visualized as a spectrum (or even a three dimensional web).
- A person who is transgender or trans* identifies as not being the sex they were assigned at birth.
- Transgender is an umbrella term that covers many different identities relating to sex and gender in which a person’s sense of self, sexual identity, or expression of gender do not conform to social expectations based on the sex they were assigned at birth
- A transgender person has not ‘changed’ their sex. They have simply affirmed the sex that they know themselves to be (which may not fall within the artificial male <—> female binary.)
- Medical intervention, including hormone regimens and gender-affirming surgery, are not what legitimizes a trans* person’s identity, and only a subset of trans* people decide to pursue any sort of medical treatment.
It’s important to keep those last few points in mind, particularly in this second post in the series, because I’m going to focus on medical interventions here and I don’t want that to cause you to lose sight of the bigger picture. I’m doing this right away in the series because medical transition tends to be what most people think about and want to ask about, while simultaneously being what is the least appropriate aspect to bring up. Many, many people are understandably misinformed, or uninformed or both. Additionally, this is a parenting blog, and, like it or not, the idea of medical intervention is one of the things that initially strikes terror into the hearts of parents of trans* people. We know that surgery is risky and painful, and our knee-jerk reaction is to want to protect our children from danger or pain.
This brings me to another point. You may feel ‘squicked out’ by some of the details below, at first. If you do, don’t beat yourself up; it’s ok and natural. That said, nothing is a better cure for fear and ‘squickiness’ than information and familiarity, so I encourage you to read through and process the information given, especially if it makes you uneasy.
Finally, remember to check out the segments after the main post. There’s a vocabulary section at the end of this post (and the last, I’m not repeating definitions in the interest of space) that you can use if you encounter unfamiliar terms, or want to double-check how I am using a word or phrase. There’s also a set of helpful links since this post only provides a brief introduction to what can be quite involved treatment options.
And now to the questions!
- I see terms like transman, transwoman, FtM, MtF. What do these mean?
Generally, a transman (or sometimes transguy) is a person who was labeled female at birth, but identifies as male, or a man. Similarly, a transwoman was assigned a natal sex of male, but is female, or a woman. The ‘trans’ part of the designation is not the critical part for most purposes ( i.e. unless you are close enough to the individual to be supporting them through or after their transition, or are involved in their medical care). Socially, professionally, and personally a transman is a man, full stop. Likewise, a transwoman is a woman.
When trans* people do discuss their experiences, you may encounter the abbreviations FtM (also written variously as FTM, ftm or F2M) and MtF (or MTF, mtf, M2F). FtM is the initialism for female-to-male, MtF for male-to-female. As with the designations transman and transwoman, an FtM person is a man (or boy), and an MtF person is a woman (or girl).
- How do I know what to call someone?
For MtF and FtM people, this is actually easiest if you meet someone for the first time once they have transitioned (physically or not). Many transmen and transwomen take great pains to not be mis-gendered, meaning that transmen will usually dress and groom in ways that are socially recognizable as male, and transwomen in ways that are conventionally understood to be female. You may also take cues from your introduction to a person, just as you would in any other circumstance. e.g. if someone is introduced to you as, “this is my friend Aidan, he’s an artist” there is no reason to second-guess Aidan’s preferred mode of address unless he asks you to.
For people who do not identify within the ‘he’ or ‘she’ ranges of the spectrum, it may seem trickier. It’s worth keeping in mind, however, that if a person presents in a way that is gender-ambiguous, they are probably doing so consciously. If you are uncertain, consider asking which pronouns (e.g. he / she / they / xe / and so on) they would prefer that you use. In some cases you may give offense, but if you are asking from a place of wishing to respect their identity, and not crudely critiquing them, many people will appreciate the effort.
Speaking from experience, I will say that learning to use a new pronoun and / or name for someone that you have known for many years (as a parent, generally, their entire life) takes practice on your part and patience on the part of your trans* loved one. It is a rare person who doesn’t slip up, and, frustratingly, you may find the wrong pronoun or name coming out after you think you have fully adjusted. (I’ve noticed, for myself, that exhaustion, or going back to old places or friends can trigger pronoun regression. I’ve also been known to run through a series of names when addressing Offspring, including Spouse’s and the rabbit’s, before getting to the correct one.) Don’t give up. There is a world of difference between occasionally making a mistake, and deliberately refusing to even try to use the correct name and pronouns. After enough practice, you may find, as I have, that applying the old name or incorrect pronoun to your trans* loved one actually begins to sound odd and genuinely feel wrong (which makes messing up all the more aggravating, but there you are)
- What medical interventions are involved in physical transitions?
There are two basic classes of treatment that are available, (1) hormonal transition and (2) gender-affirming surgery.
- What sorts of hormone treatments do people undergo?
This depends on whether the person is transitioning Male-to-Female or Female-to-Male, as well as whether they have already gone through puberty. I’m going to confine my answer to this and the following question to individuals who are transitioning after puberty.
Male-to-Female Hormone Replacement Therapy (MtF HRT)
The first step in hormone therapy for transwomen is blocking the production or action of male hormones, or androgens. The second step is the administration of estrogen, the principal feminizing hormone. Different caregivers may prescribe varying combinations of androgen suppressants or testosterone blocking agents. Estrogen is often taken in pill form, but may be administered by a skin patch or via injection. Transwomen generally continue to take estrogen throughout their life.
Female-to-Male Hormone Replacement Therapy (FtM HRT)
Transmen do not need to take anything to suppress estrogen. Hormone treatment for FtM transition generally means administering the male hormone testosterone, often just referred to as T. Unlike estrogen, testosterone is not usually taken orally because it has adverse effects on the liver. While transdermal patches and subcutaneous (inserted under the skin) pellets are a possibility, it is most common for testosterone to be given via intramuscular injection into the thigh or hip. Testosterone is not stored in the body, so injections must be done every one to three weeks. Testosterone treatment for transmen is a long-term (often life-long) commitment.
- What effects do these hormone treatments have on a person?
Again, this is different for MtF and FtM transitions. In both cases, however, a person’s body is being exposed to a surge in a hormone (estrogen or testosterone) that it has not experienced before, so the transition has some similarities to puberty. As with puberty, full change does not occur overnight, and the effects noted below will usually take several years of treatment to develop fully. Also as with puberty, there is a great deal of individual variability in the timing and degree of any change. I’ve only listed physical results, as emotional effects differ widely from person to person, and it is extremely difficult to tease out what is due to hormones directly, and what is due to life changes.
Effects of Male-to-Female Hormone Replacement Therapy
Breasts – Breast tissue will grow over a period of two or three years. The amount of increase is variable, but is rarely a B cup or more.
Hair – Hair growth on most of the body (arms, legs, abdomen, chest and shoulders) usually lessens noticeably over several years of estrogen treatment. The exceptions to this are the pubic area, armpits, and areola where hair growth tends not to abate much. Whatever hair growth is present on the face at the start of hormone therapy will not change. Many transwomen must go through the often expensive and painful process of electrolysis to permanently rid themselves of facial hair. Likewise, when it comes to hair on the head, hormone treatment does not regrow hair in bald spots which are already present, although it can help to prevent baldness from beginning.
Fat Distribution – Estrogen treatment tends to shift fat deposits from the abdomen to thighs, hips and rear end. This usually takes around one or two years of treatment.
Muscle Mass – Many transwomen taking estrogen experience a decrease in muscle mass and the ability to build muscle, especially in the upper body. This often takes longer than the redistribution of fat, commonly on the order of three years or more.
Skin – Skin texture generally becomes softer.
Genitals – Hormone treatment in transwomen will reduce the production of testosterone and sperm, resulting in a decrease in the size of the testes. Penis size also tends to diminish, and erections may become less frequent. Taking estrogen long-term often results in infertility.
Prostate Gland – The prostate diminishes in size.
Adam’s apple / voice – The thyroid cartilage which forms the Adam’s apple will not change in size, meaning that the vocal folds also will not change. Hormone treatments cannot change the depth in pitch or the resonance of voice. However, it is possible to develop feminine inflection and intonation by taking voice lessons or working with a speech coach.
Effects of Female-to-Male Hormone Replacement Therapy
Breasts – Hormone therapy will not decrease breast size in transmen. Many transmen will use binders and / or other clothing to minimize the appearance of breasts.
Hair – Testosterone will increase hair growth on the body and face. Depending on genetic predisposition, it may also result in hair loss at the temples, a receding hair line, or male-pattern baldness.
Fat Distribution – Body fat will shift from thighs, hips and rear end to the abdomen.
Muscle Mass – Lean muscle mass generally increases, and it is easier to build muscle.
Skin – Skin may become more rough. Initially, as during male puberty, testosterone may lead to increased activity in the oil glands of the skin, and to acne.
Genitals – The clitoris usually enlarges. Menstruation will cease, usually within about six months. In some cases treatment with testosterone will result in infertility.
Red Blood Cells – There is usually an increase in red blood cells. Additionally, T may result in a change in cholesterol levels. (Sometimes HDL levels go down, and LDL levels rise.)
Voice – In most (although not all) transmen testosterone will lower the pitch of the voice. The initial change may be accompanied by voice cracking or breaking as in teen boys.
- What sorts of surgery do people have?
Many transgender individuals do not get any type of gender-affirming surgery. Remember that not all trans* individuals are interested in appearing as conventionally male or female. For those who are and who consider surgical intervention, in addition to the hurdles of time, discomfort and recovery that any surgery entails, most health insurance will not cover gender-affirming surgery, and straight-up costs can be prohibitive. Furthermore, not all regions have surgeons who possess the skills or willingness to work with trans* individuals. This can compound time away from a job by adding in travel, as well as increasing expenses stratospherically. With all of that said, the following is a (non-comprehensive) list of some of the most common gender-affirming surgeries.
Breast Enhancement Surgery – As noted above, hormones may increase breast size a bit in MtF individuals, but often not to the point that is socially read as ‘woman’. Because of this some transwomen have breast enhancement or breast augmentation surgery (mammoplasty). This is pretty much like breast augmentation surgery for any other adult woman.
Genital Surgery – Although there are variations, the general pattern involves the creation of a vagina, clitoris and labia from existing tissue by a rather ingenious process. The penis is not (as you may hear in popular movies or conversation) ‘amputated’. Instead, most (but not all, this is important!) of the internal tissue of the penis is removed through a small slit. The skin of the penis is inverted and inserted into the body to form the vagina (vaginoplasty). The erectile tissue which was left in the original penis is repositioned to form a functional clitoris and the urethra is moved. The testes are removed (orchiectomy), and the skin of the scrotal sac is used to form the new labia.
Facial Feminization Surgery – The changes which occur in the structure of the male face at puberty (think square chin and jaw, sloping forehead, and heavier brow) are bony, and thus do not respond to hormone treatment, so some transwomen may have surgeries to make their face appear more feminine. These can include re-contouring the forehead, reshaping the nose, chin, or jawline, and getting cheek implants. Whether any or all of these are desired will depend on how ‘masculine’ a transwoman’s face appeared before transition. Because, like bone, the cartilage of the Adam’s apple cannot be reduced by hormones, surgical reduction, called a trachea shave or chondrolaryngoplasty, is also popular.
Top Surgery / Chest Surgery / Chest Reconstruction Surgery – Top surgery is the most common surgical procedure for transmen. It involves both removal of breast tissue, and positioning (as well as sometimes reshaping) the nipples. Depending on breast size prior to transition, there are two basic classes of surgery. FtM individuals with larger breasts are usually advised to get Double incision / Bilateral mastectomy. Incisions are made across each breast, usually below the nipple, so that mammary glands and fatty tissue can be removed. Excess skin is trimmed away. The double incision method leaves two scars below the level of the pectoral muscles (which are not changed). Other methods in this class of surgery, such as “inverted T” or “pie wedge” leave differently shaped scars. Nipples are repositioned higher on the chest, sometimes after being trimmed to make them smaller. Transmen with smaller breasts (A cup or below) have the option of getting Keyhole or Peri-areolar incision surgery. In the keyhole method an incision is made along the bottom of the areola of the nipple, and breast tissue is removed with a liposuction needle. In the Peri-areolar technique the incision is made around the circumference of the areola, and breast tissue is removed with a scalpel. Scarring in these latter methods is minimal
Bottom Surgery / Lower Surgery / FTM Genital Reconstruction Surgery (GRS) – Far, far fewer transmen get genital surgery than top surgery. This is partly due to cost and the low number of skilled, practiced surgeons, but also largely because, so far, the methodology has not progressed as far as other gender-affirming surgeries. Results are often unsatisfactory, and complications are common. With that in mind, there are currently two basic classes of genital surgery for transmen, metoidioplasty and phalloplasty. In metoidioplasty, the connective tissue between the clitoris (which has increased a bit in size with testosterone) and the pubic bone is cut, “freeing” or “releasing” the clitoris. This may be accompanied by moving and lengthening the urethra, and constructing a scrotum. In phalloplasty a penis is constructed using skin taken from another area of the body such as the abdomen, groin, leg, forearm, or side of the torso. Usually the urethra is extended, the vagina is closed, and a scrotum is created. Erectile prosthesis may be added after the new penis develops sensation, which generally takes at least a year (and as of the state of the art now, may never develop). Many surgeons in the US will not currently perform phalloplasty because of the risk of complications, including fistulas.
Hysterectomy or oophorectomy – Some transmen opt have the female reproductive organs removed. If the uterus is removed it is a hysterectomy. If only the ovaries are removed it is an oophorectomy. Because the population of transmen who undergo hormone treatment and gender-affirming surgeries is relatively small, there is much debate, but little data, on the differential health effects of long-term testosterone treatment on FtM individuals who do vs do not have uterus or ovaries removed.
- Why are you calling it “gender-affirming surgery” instead of “sex change” or “gender reassignment” surgery?
From the time that the US general public was first introduced to the idea of surgery for transgender people by Christine Jorgensen’s transition in the 1950s, the phrase “sex change” has been in use. The term now carries all the historical baggage of prejudice and bigotry directed at trans* people, but, just as importantly, it is a misnomer. As noted above, trans* people are not ‘changing’ their sex. They are merely recognizing and clarifying the sex that they are. While the terms “sex reassignment surgery” (SRS), “genital reassignment surgery”, and “gender reassignment surgery” (both GRS) are less burdened by decades of popular hatred than “sex change operation”, they still have the shortcoming of implying that a person’s sex is being changed like a shirt. Because of this, many people (including me!) prefer the terms “gender-affirming surgery” or “gender confirmation surgery” (GCS).
- Is medical transition the same for children and adults?
No, there are some significant differences. Some individuals realize that their identity and their sex assigned at birth do not coordinate before they go through puberty, although many do not. For those who do know before the secondary sex characteristics (e.g. breast growth, facial hair, voice change) develop it is easier to start to live as their actual sex, providing they have the support of family and institutions. Additionally, trans* children can take puberty-inhibiting medication, or blockers, which will, as the name implies, put the development of secondary sex characteristics on hold. Although this is considered elective by most insurance, and can be incredibly expensive, it is also vitally important. Many people feel alienated from their bodies during puberty under the best of circumstances, and for children who are trans* and aware of their sex incongruence, being forced to undergo puberty and have their bodies change into the wrong sex is devastating. It also means that they will need more invasive and risky intervention in adulthood.
Puberty-inhibiting medication can be continued for several years while the young trans* person, their family, and their medical team plot a workable course of future treatment. Once the child is ready to go through puberty, they can be given the appropriate hormone for their sex (i.e. transmen will receive T, and transwomen estrogen). They will then develop the secondary sex characteristics of their identified sex, although genitalia and internal organs will remain those of their natal sex. Decisions about genital surgery are not usually made until the trans* person is at least eighteen years of age.
- Shouldn’t trans* people have to prove that they’ve thought seriously about it before they can get medical treatment?
The answer here is that they do, and I mean this both in the sense that trans* people are forced to jump through an incredible number of social, legal, financial and medical hoops before they can get treatment, and in the sense that trans* people do not decide to get medical treatment on a whim.
Here’s an embarrassing confession, but I’m sharing it because it illustrates how knee-jerk the reaction illustrated in this question is. When Offspring gently guided me through what was going on with him, and explained his treatment options, the words “I think you should think about it” crossed my lips. In fairness, I recognized how stupid they were pretty much immediately, but it didn’t change the fact that I said them. He’d been struggling with coming to terms with what was wrong for years. He’d exhaustively researched treatment options, including possible doctors and insurance, as well as the pros and cons of different interventions, even to the point of watching video of surgeries. Clearly what I was really saying was “help! I need time to think about this!”
As a parent the thought of surgery terrifies me, and the realization that my child has had a difficult time and needs treatment saddens me. It takes time to adjust. It takes time to come to terms with the medical needs and vulnerability of any loved one in any circumstance. Taking time to process and adapt is ok. We just have to remember that we are the ones who need to do the thinking and learning now. Our trans* child has already done the toughest part by coming to terms with what is going on.
When it comes to social and legal responses to medical treatment for trans* people, I cannot help but think of the similarity to the incredible number of hurdles and barriers that are placed before women seeking reproductive care like abortion or birth control. Our culture infantilizes individuals who do not belong to the dominant group, questioning their ability to understand themselves or to make informed decisions. This needs to stop. There is no class of people, not women, not transmen, not transwomen, not genderqueer individuals, no one, who does not deserve the right to make their own informed medical choices, and the support in seeing them through safely and with respect.
- My trans* child wants to have hormone treatment and / or surgery. Is it really worth the risk if they don’t have to undergo medical treatment in order to be considered the correct sex?
I’ll direct you first to the answer to the question above, if you haven’t already read it. I’d also like to add that the sense of relief, the growing happiness, and the recovered ability to enjoy and participate in life that I have seen in trans* people, and most especially in Offspring, are an answer in themselves. Of course, you want to make sure that your child has a qualified medical team, and the best, safest care possible. But with that said, unequivocally, yes, it is worth it.
- Is there anything involved in transitioning aside from physical changes?
Absolutely. Physical transition is only one possible aspect (and remember that not all trans* people desire, choose, or obtain any sort of medical intervention) of the much broader process of transitioning. We’ll take a look at the social and legal aspects of transitioning next.
androgen suppressants / testosterone blockers – chemicals which block the production and / or action of male hormones
binding – using clothing or other methods to flatten breasts. Used by some FtM individuals.
bilateral mastectomy – a chest surgery procedure used by female-to-male individuals to give a masculine look to the chest (see double incision)
blockers / puberty blockers – agents which block the production of testosterone or estrogen, inhibiting the onset of puberty, and the development of secondary sex characteristics
bottom surgery / lower surgery / female to male genital reconstruction surgery (GRS) – surgical methods used to make the genitals of transmen align more closely with their male identity. These can be broken into roughly two classes of surgery: Metoidioplasty and phalloplasty.
bottom surgery / lower surgery / male to female sex reassignment/reconstruction surgery (SRS) – surgical methods to create a vagina, clitoris and labia for transwomen using the tissue of the penis and scrotum
breast augmentation / mammoplasty – surgery in which breasts are constructed or enlarged, usually with implants. May be sought by some transwomen to give the chest a more feminine appearance
double incision – a type of chest surgery recommended for FtM individuals with larger breasts. Incisions are made horizontally across each breast below the nipple so that breast tissue can be removed. Nipples are trimmed and placed higher on the chest to give a more masculine appearance.
estrogen – main feminizing hormone
facial feminization surgery – a class of surgeries in which parts of the face (e.g. brow, chin, jaw) are reshaped to give the face a more feminine appearance
female to male – individuals who were assigned female at birth, but who identify as somewhere within the male part of the gender web
FtM / FTM / ftm / F2M – see female to male
gender-affirming surgery / gender-confirmation surgery (GCS) – the various surgeries used to help bring the bodies of trans* individuals into closer accordance with their internal sense of their gender or sex
gender identity – a person’s internal awareness of where they belong within the webwork of male, female, masculine, feminine, a combination of, or none of the preceding
hormone replacement therapy / HRT – treatment with the appropriate hormone (testosterone for transmen and estrogen for transwomen) to bring physical appearance into closer alignment with gender identity
hysterectomy / hysto – the surgical removal of the uterus. Some transmen have hysterectomies as part of their medical transition, others do not. Some states in the US require a transman to undergo a hysterectomy in order to legally change their gender from female to male.
keyhole surgery – a type of top surgery for transmen somewhat similar to peri
male to female – individuals who were assigned male at birth, but who identify as somewhere within the female part of the gender web
metoidioplasty – a type of surgery used by some transmen in which the clitoris (which has enlarged somewhat in response to testosterone therapy) is ‘released’ or ‘freed up’ from surrounding commective tissue so that is presents more as a phallus
MtF / MTF / mtf / M2F – see male to female
oophorectomy – surgical removal of the ovaries. May be sought by transmen, often in combination with a hysterectomy
orchiectomy – surgical removal of the testicles; may be sought by transwomen alone or in combination with vaginoplasty
peri-areolar / peri – a type of chest surgery recommended for transmen with small amounts of breast tissue. An incision is made around the areola of the nipple so that breast tissue can be removed, and the surface of the chest reconstructed to look more masculine
phalloplasty / phallo – construction of a penis from donor tissue taken from another part of a transman’s body (e.g. torso, leg, forearm)
sex change operation – a term which is commonly used, but which is both incorrect and pejorative, to mean gender affirmation surgery
testosterone / T – the main male hormone responsible for producing masculine secondary sex characteristics such as increased muscle development, facial and body hair, and a low pitched voice
trachea shave / chondrolaryngoplasty – a type of surgery popular with transwomen in which the Adam’s apple is reduced to appear more feminine. This will not raise voice pitch
transman / transguy – see female to male
transwoman – see male to female
vaginoplasty – an MtF bottom surgery procedure in which a vagina is constructed from the skin of the penis
links and reading:
There are a number of excellent links in the post above. I’ll highlight a few for breadth of information here. You can find more useful links at these sites.
- Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, UCSF Center of Excellence for Transgender Health
- Hudson’s FTM Resource Guide
- Transgender Care
- Female to Male by Corbin
- UK FtM Information – Transitioning on the NHS
- The Scottish Trans Organization
- Trans* Resource Guide – FtM Essentials
- The Transgender Support Site by Melanie Anne Phillips
Some trans* people are incredibly generous and brave, and write about their transitions for people outside of the friend / family group. Sadly, not everyone else is eloquent and kind, so these sites frequently get ‘pornulated’ (my word, I think) or hijacked by porn sites. If you click on one of the links below and get a screen asking if you are 18 it is NOT the site I am recommending. I considered not linking these sites because of this risk. I decided that if I avoided the sites of trans* people here, I would be allowing the ‘pornulators’ to silence trans* voices and that is just unbelievably wrong.
- My transition story: an offering for the Transgender Day of Remembrance by Pace Smith
- ftm transition by Ethan Daniel
- The Hidden Woman Keira Daniels’ story
- True Stories of Transition at the Transgender Support Site
- Becoming Tamara: My story of gender transition … literally becoming Tamara by Tamara Jean Wallace
I’ll also (re)recommend the book Transgender 101: a simple guide to a complex issue by Nicholas M. Teich. Again, it is not the only guide out there, but I have found it both concise and helpful.
other posts in this series:
featured image: Clinic in Transition
transquote #17, Imagine quote, How to Be an Ally to the Transgender Community, transmute #23, Snapshots of transgender life, trans flag and symbol all from Trans. Proud
trans umbrella from the OutTake Blog
Trans Man / Trans Woman from The Safe Zone Project
Hello-Pronoun-Stickers available from Storenvy
Transgender Health caduceus by Eleanor Greene
I support the transgender community from ftm support Tumblr
Map of state health insurance rules from the National Center for Transgender Equality
Rainbow Sheep from Gallery for Lgbt Pride Quotes
Canadian Transgender Numbers