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Physically Transitioning 

Physical Transition

Hormone Replacement Therapy | Changes | Surgical Options

Ohio Medical and Counseling Services:

A list of service providers is available at TransOhio.org

 

 

Hormone Replacement Therapy

Some trans* people, but not all, seek to undergo Hormone Replacement Therapy (HRT). HRT options for female assigned at birth (FAAB) trans* people include testosterone therapy, and HRT options for male assigned at birth (MAAB) trans* people include estrogen therapy. The degree of effects, as well as how quickly they take place, varies between individuals, and some body characteristics are unaffected regardless. In addition to having realistic expectations for HRT, it is important to understand potential risks. This introduction does not constitute medical advice, and anyone considering HRT should consult their physician.

 

Changes from HRT:
Shortly after beginning HRT, MAAB trans* people may start becoming more emotionally sensitive, especially to stress, though this is not a universal experience. Six to eight weeks after beginning hormone therapy, the first physical effects in MAAB trans* people begin to appear. The first noticeable change is the beginnings of chest growth. Sometimes, this can be very painful. Acne usually begins to clear up, and skin becomes softer and less coarse. Balding ceases and some hair might even begin to grow back, though it is usually very fine. Body hair lessens and becomes finer. In some places (such as the stomach), it may disappear entirely. Gradually, body fat begins to redistribute from around the waist to the hips. Muscle mass starts to disappear, and it causes a noticeable loss in strength. The loss of muscle, though, gives the body a softer look and feel. Another thing to be expected with HRT is loss of sexual functioning. The external gonads generally shrink, it becomes harder to maintain an erection, and there is a loss of the ability to ejaculate.

The most immediate effects of testosterone on FAAB trans* people can be a heightened libido (reaching its highest point three days after the injection). Shortly after beginning HRT, menstruation stops. Physical changes, though, also take about six to eight weeks to be noticeable. The first change is a drop in the pitch of voice as the testosterone causes the vocal chords to thicken. Body fat redistributes from the chest, hips, and thighs to the waist. Muscle mass increases, making the body much harder and stronger. Facial hair begins to grow, but a full beard may take up to four years to grow in. Other body hair begins to grow in thicker, except on top of the head where MAAB balding patterns set in. The genital erectile tissue begins to grow, but it rarely will grow to a length long enough to penetrate, though size varies greatly from person to person. Menstruation can stops shortly after beginning HRT (though this can take longer for some people), and the uterus and ovaries begin to atrophy.

 

Limits of HRT:
While HRT can alter many physical traits, it has its limits. HRT can do nothing for the height, size and shape of hands, shape of the jaw, and the width of the pelvis after puberty has taken place. In MAAB trans* people, hormones can do nothing for the pitch of voice. Voice coaching can be utilized to learn to inflect words and to speak in a higher pitch. Second, chest growth due to HRT rarely exceeds a B cup. Chest growth usually stops after 18-24 months of hormone therapy. Some MAAB trans* people are unsatisfied with the results and opt to have chest implants once their chests have reached their maximum growth. Also, HRT has very little effect on facial hair. The only way to get rid of facial hair is to have electrolysis performed on every hair follicle, which is a very time consuming and expensive process.

For FAAB trans* people, testosterone can't undo chest development. Binding after a long period of time can cause the chest to start to atrophy. Removal of chest growth is only possible with chest reconstruction surgery, although this can be quite costly. Since growth of the genital erectile tissue typically doesn't reach a penetrating size, some FAAB trans* people also choose to pursue genital surgery.

 

Side Effects and Risks Associated with HRT:
One of the riskiest aspects of HRT is that such little research has been performed to find out what health risks are involved. One serious health risk that is definitely correlated with HRT is thromboemolic disease, which occurs in 2.1% of patients under 40 and 12% of patients over 40. Trans* people undergoing estrogen therapy can experience extreme mood swings on estrogen, and severe depression and loss of energy can result. Mortality in MAAB trans* people is six times higher than the general population, and this is primarily due to suicide and unknown causes. Estrogen can also cause MAAB trans* people to be at a higher risk for benign pituitary tumors, gallbladder disease, and hypertension.

 

FAAB trans* people undergoing testosterone therapy can develop serious acne problems, and it may require prescriptions. Weight gain of greater than 10% is also a major side effect. FAAB trans* people undergoing testosterone therapy also face risks of breast cancer, diabetes, high cholesterol, hypertension, and liver disease. Smoking tobacco makes these risks even greater, so the person should seriously consider quitting. The obvious risk with HRT is that, once changes begin to occur, many of them are irreversible. Sterility results in MAAB and FAAB trans* people after prolonged treatment. If a MAAB or FAAB trans* person thinks that they would like to eventually have a biological child, they should consider having their eggs stored, or storing sperm in a sperm bank.

 

Treatments Options:

MAAB trans* people have several different options for hormone therapy, but there has been no research as to which ones are superior to the others or as to which dosage amounts provide the best results. Mostly, the drug used depends on what is available, how much it costs, and personal preference. More than just estrogen is required in hormone therapy, though; anti-androgens are required to block the effects of testosterone on the system. If the external gonads are removed, though, anti-androgens are no longer necessary. Oral estrogens can cause problems with the liver, but they are generally cheaper. "Natural" estrogens (metabolized estrogen from other species) have fewer side effects than other estrogens, but they also cause an increased risk of thrombosis. Estrogen can also be administered in shots or transdermally (with patches). The patches have very few estrogen-induced side effects, but they can cause skin problems where they stick to the skin. People that perspire a lot also have problems keeping them stuck to the skin. The patches are also the most expensive form of treatment. Even if a MAAB trans* person undergoes genital surgery, it is necessary to continue taking estrogen to prevent osteoporosis.

FAAB trans* people, though, typically don't require any additional treatments to block the effects of estrogen; the testosterone treatment is usually strong enough to make it unnecessary. When testosterone isn't enough to stop menstruation on its own, progestagens are necessary to stop menstruation. Testosterone can be administered intramuscularly (with shots), in a topical gel (ex. Androgel), or via patches. Some countries also offer oral androgens, but the United States does not. These, however, don't sufficiently suppress menstruation in half of the patients, so progestagens would also have to be taken if a patient wished to stop menstruation. If a FAAB trans* person chooses to undergo testosterone therapy and genital surgery, it does not mean a person can quit taking hormones. Testosterone therapy eventually atrophies the ovaries, and the body will no longer produce testosterone or estrogen. In this case, the person must take either testosterone or estrogen to prevent osteoporosis. If the ovaries have not atrophied, they can end testosterone therapy with a physician’s supervision and they will become estrogen-dominant again.

 

Conclusion:
Hormone Replacement Therapy does have its risks, but it can bring about many desired physical changes for trans* people who wish to medically transition this way. In the end, it is up to the individual to decide whether or not to pursue HRT and which method to use.

 

Sources:
www.transgendercare.com/
www.gayhealthchannel.com/transgender/ht.shtml

Compiled by Elliot Long and revised by Mika Herman

 

Changes

Physical transition for trans* people has many different possibilities. Not everyone chooses to pursue hormone replacement therapy (HRT), and those who do take different doses of hormones for varying lengths of time. There are also several different forms of hormones to choose from. This is only a brief overview of HRT. For more information, see the sources below or talk to your physician. 


Testosterone Therapy

Potential changes

Traits that won't change

·         Growth of facial hair (slow process) 

·         A lower voice

·         Distribution of body fat from chest, hips, and thighs to stomach

·         Increased strength and muscle development

·         Enlargement of genital erectile tissue

·         Increased body hair

·         More angular facial features, less facial fat

·         MAAB-pattern hairline and baldness

·         Increased aggression

·         Heightened libido

·         Cessation of menstruation

·         Enlargement of Adam’s apple (before age 21)

 

·         Height (unless starting treatment at a young age)

·         Size of hands (though feet may grow a few sizes)

·         Chest growth (though they may shrink a little)

 

 

Estrogen Therapy

 Potential changes

Traits that won't change 

·         Softer skin and body appearance

·         Chest growth

·         Lessening of body hair

·         Loss of muscle mass

·         Increased emotional sensitivity, especially to stress – depression not uncommon

·         Diminished ability to achieve erections and to ejaculate

·         Redistribution of body fat from stomach to chest, hips, and thighs

·         Voice

·         Height

·         Size of hands and feet

·         Presence of facial hair (may grow more fine)

·         Hair loss stops, but what has been lost won't grow back

·         Adam's apple


Possible Health Risks

Some health risks are involved and should be fully researched and considered before beginning HRT. Pre-existing health problems could also disqualify a person for HRT. One of the most troublesome aspects of HRT is that such little research has been performed to find out what health risks are involved.  There could possibly be serious long-term health risks involved that still have not been uncovered. One serious risk that is definitely correlated with HRT is thromboembolic disease, which is a disease that causes blood clots. The risk for this can be decreased by regular exercise.

 

MAAB trans* people undergoing estrogen therapy can experience extreme mood swings on estrogen and severe depression and loss of energy can result.  The mortality rate in MAAB trans* people is 6 times higher than the general population. This is primarily due to suicide and unknown causes.  Estrogen can also cause MAAB trans* people to be a higher risk for benign pituitary tumors, gallbladder disease, and hypertension.

 

FAAB trans* people undergoing testosterone therapy can develop serious acne problems, and weight gain of greater than 10% is fairly common. FAAB trans* people face higher risks of chest cancer, diabetes, high cholesterol, hypertension, heart attacks, and liver disease. Smoking tobacco makes these risks even greater, so a person pursuing HRT should be or become a non-smoker.

 

The most obvious risk with HRT is that once changes begin to occur, many of the changes are irreversible. Sterility results in both FAAB and MAAB trans* people after prolonged treatment. If a MAAB trans* person thinks they would eventually like to have biological children, they should seriously consider storing sperm in a sperm bank prior to starting HRT. If a FAAB trans* person would like to have a biological child, it is sometimes possible to become pregnant after being on testosterone for a period of time, though pregnancy would require cessation of hormone treatment. It is possible to freeze eggs, but the technology has not sufficiently developed yet for this to be a long-term feasible solution for most people.

 

Treatment Options:
MAAB trans* people have several different options for HRT, but there has been no research as to which treatments are superior to the others or as to which dosage amounts provide the best results. Mostly, the drug used depends on what is available, cost, and personal preference.

Sources:
http://www.transgendercare.com
http://www.gayhealthchannel.com/transgender/ht.shtml
"True Selves" by Mildred Brown and Chloe Ann Rounsley

 

Surgical Options

There are several guidelines dictated by the World Professional Association for Transgender Health Standards of Care regarding eligibility for surgery for trans* people. In recent years there has been some movement away from these standards towards consent-based access to care, however if you are considering surgery, it would be a good idea to read over these guidelines and speak to your therapist regarding their particular interpretation of these guidelines. The following information and links provide a brief overview of some of the surgical procedures used by some trans* people in physically transitioning. This list does not cover all of the possibilities, nor should it be considered official medical advice. For more information, one should consult with a licensed medical doctor.

 

To Have Surgery or Not
Choosing whether or not to pursue various surgical procedures is a very personal thing. Not all trans* people desire to have surgery, and having surgery or not having surgery does not make a person more or less trans*. Surgery is also a very costly endeavor. The results are not always entirely satisfactory for trans* people in functionality, sensation, or in appearance, and personally preferred results never can be guaranteed. There are also health risks involved with whether or not to pursue surgery. It is important to be aware of all of these factors and to have several conversations with one's doctor before going into surgery to get the best idea of exactly what to expect. However, surgical procedures are important for some trans* people, and often gender affirmation surgeries of some kind is required to change sex markers in various government agencies (though specific requirements vary widely).

 

Covering the Cost of Surgery
The biggest obstacle for many to overcome in pursuing gender affirmation surgeries is covering the cost. A majority of health insurance companies consider trans* related surgeries to be "elective" and thus refuse to cover the costs. However, some companies will cover particular procedures, especially if they can be deemed medically necessary (such as a hysterectomy for FAAB trans* people undergoing testosterone therapy due to an increased risk for ovarian cancer). Being aware of all this and your insurance companies policies, as well as finding a doctor willing to work with your insurance situation, you can save on the cost of surgery. Also, some people choose to travel to other countries where surgery is significantly cheaper and there are different guidelines regulating who can have surgery and who cannot. The best ways to investigate these options are through searching online (such as Trans Bucket), speaking with other trans* people, and connecting with local trans* organizations.

 

MAAB trans* people:
The LGBT Center does not endorse any doctor, authors or service providers. We list links below for information sharing purposes only. The lists do not reflect all providers and should not be viewed as comprehensive.

 

Breast Implants: Chest growth for MAAB trans* people on hormones rarely exceeds a B cup. Once a person's chest reach its full size (after about two years of hormones), some MAAB trans* people choose to increase their size with breast implants.

 

Dr. Daniel A. Medalie, University Plastic Surgery in Cleveland, OH: Photos of results and descriptions of his procedures are listed on his website. Medalie does chest reconstruction surgery for FAAB trans* patients and breast implants for MAAB trans* patients. This website may be triggering for some as it assigns gender to bodies and does not include non-binary trans* people.

 

Facial Surgery: For some MAAB trans* people, the softening effects of estrogen do not change their facial appearance enough to satisfy them. They may opt to pursue one or more facial surgeries in order to achieve a softer facial structure that is more comfortable for them.

Feminization of the Transsexual: This page includes a list and description of many of the facial surgeries trans women sometimes opt to pursue. This resource is aimed towards trans women, but has information relevant for any MAAB trans* person.

Facial Plastic Surgeons: This page contains a listing of doctors that have been recommended by other transgender women for facial surgery.

 

Orchidectomy: The removal of the testes. This procedure is much more affordable than a vaginoplasty, and it has several benefits: decreased health risks from high levels of hormones and greater feminization by removing the source of testosterone from one's body. Some use this as an intermediate step between beginning transition and having a vaginoplasty.


Transexual Roadmap: Ochidectomy: Aimed towards trans women, but includes relevant information for MAAB trans* people.

 

Vaginoplasty: A Vaginoplasty involves inverting the penis to create a vagina.

 

Transexual Roadmap: Vaginoplasty

 

Vocal Surgery: Since hormone therapy leaves MAAB trans* people’s voices unchanged and voice therapy has its limits, some MAAB trans* people may choose to pursue surgery to alter their voices. However, results are not always satisfactory.

FAAB Trans* People:
The LGBT Center does not endorse any doctor, authors or service providers. We list links below for information sharing purposes only. The lists do not reflect all providers and should not be viewed as comprehensive.

 

Chest Surgery ('Top Surgery'): There are several procedures available for chest reconstruction, and different doctors have their own ways of performing these procedures. The type of surgery used depends greatly on personal preference and specific body type.

Dr. Daniel A. Medalie, 
University Plastic Surgery in Cleveland, OH: Photos of results and descriptions of his procedures are listed on his website. Medalie does chest reconstruction surgery for FAAB trans* patients and breast implants for MAAB trans* patients.

Yahoo group ftmsurgeryinfo: In order to access any of the group's files, one must be a member of Yahoo groups and be admitted into this group. There are tens of thousands of posts, and there is an extensive catalog of photos and information about different surgical procedures and photos of results. The group is intended for trans men but includes useful information for all FAAB trans* people. The archives  are a great resource for commentary about surgeons and other issues relating to surgery.

 

Genital Surgery ('Bottom Surgery'): The most common forms of genital surgery for FAAB trans* people are metoidioplasty (the freeing of the enlarged clitoris and typically testicular implants) and phalloplasty (the creation of a penis from a roll of skin from the forearm or abdomen). These surgeries are extremely expensive, and many FAAB trans* people opt to not have surgery due to dissatisfaction with the results of any of the available surgeries or because they are comfortable with their genitals. For some, however, having bottom surgery is a very important part of becoming happier with their bodies.

Loren Cameron's eBook Man Tool: includes photos and profiles about gender affirmation surgeries for FAAB trans* people. This eBook only includes trans men,  but surgical information can be relevant for on FAAB trans* person considering bottom surgery.

 

Other Transgender Surgery and Hormone Resources

Trans Health: This site has a few informative articles about surgeries for trans* people, among other transgender topics.

 

Trans Bucket : Collection of surgeons, self-submitted photos of surgical results and estimated costs. The website only includes binary trans men and women, but the information is still relevant to all trans* people.

 

Surgery: A guide for MTFs : This booklet was written in 2006 in a joint effort of Transcend Transgender Support & Education Society and Vancouver Coastal Health’s Transgender Health Program.

 

 

Hormones: A Guide for MTFs: This booklet was written in 2006 in a joint effort of Transcend Transgender Support & Education Society and Vancouver Coastal Health’s Transgender Health Program.

 

 

Hormones: A Guide for FTMs : This booklet was written in 2006 in a joint effort of Transcend Transgender Support & Education Society and Vancouver Coastal Health’s Transgender Health Program.

 

 

Surgery: A Guide for FTMs: This booklet was written in 2006 in a joint effort of Transcend Transgender Support & Education Society and Vancouver Coastal Health’s Transgender Health Program.

 

The Transitional Male : Includes photos of surgery results, descriptions of hormones and surgeries, lists of trans-friendly surgeons and therapists, and resource pages for books and videos for trans men. This resource excludes non-binary female assigned at birth (FAAB) trans* people, but much of the information is still relevant.

 

Hudson's FTM Resource Guide: Information on transition options, gender expression items and other issues. Aimed at trans men but contains relevant information for other FAAB trans* people

 

Susan's Place: Wiki : Wiki primarily covering physical transition options. It focuses on binary trans* people, but much of the information is relevant to all trans* people.

 

The Transgender Herb Garden: This is a guerilla gardening guide for male assigned at birth (MAAB) trans* people who don’t want to rely on corporate pharmaceuticals.

 

Trans Tribulus: Blog discussing non-pharmaceutical transition options for female assigned at birth (FAAB) trans* people.