Ohio University

Transitioning 

Physical Transition

Hormone Replacement Therapy | Changes | Surgical Options

Ohio Medical and Counseling Services:

A list of service providers is available at TransOhio.org

When it comes to physical characteristics that define gender, hormones play a huge role. Thus, hormone replacement therapy (HRT) is a very important part of some transsexuals' lives. By taking testosterone, Female-to-Males (FTMs) are able to eliminate many of their feminine attributes and replace them with more masculine features. Similarly, Male-to-Females (MTFs) use estrogen to achieve more feminine features. While HRT can bring about many changes, it has its limits . . . and its risks.

Changes from HRT:
Shortly after beginning HRT, MTFs start becoming more emotionally sensitive, especially to stress. Six to eight weeks after beginning hormone therapy, the first physical effects in MTFs begin to appear. The first noticeable change is the beginnings of breast 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 testicles 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 FTMs are a heightened libido (reaching its highest point three days after the injection) and more aggression. 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 breasts, 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 male balding patterns set in. The clitoris begins to grow, but it rarely will grow to a length long enough to penetrate, though size varies greatly from person to person. Menstruation stops shortly after beginning HRT, and the uterus and ovaries begin to atrophy.

Limits of HRT:
While HRT can alter many physical traits and make a person more "passable," 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 MTFs, hormones can do nothing for the pitch of voice. Voice coaching is usually utilized to learn to inflect words and to speak in a higher pitch. Second, breast growth due to HRT rarely exceeds a B cup. Growth of breasts usually stops after 18-24 months of hormone therapy. About half of MTFs are unsatisfied with the results and opt to have breast implants once their breasts 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 FTMs, testosterone can't undo breast development. Binding after a long period of time can cause the chest to start to atrophy. Chest surgery is the ultimate solution, although this can be quite costly. Since growth of the clitoris typically doesn't reach a penetrating size, some FTMs also choose to pursue surgical procedures to create a penis.

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. MTFs can experience extreme mood swings on estrogen, and severe depression and loss of energy can result. Mortality in MTFs is six times higher than the general population, and this is primarily due to suicide and unknown causes. Estrogen can also cause MTFs to be at a higher risk for benign pituitary tumors, gallbladder disease, and hypertension.

FTMs can develop serious acne problems, and it may require prescriptions. Weight gain of greater than 10% is also a major side effect. FTMs 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 both MTFs and FTMs after prolonged treatment. If an MTF thinks that she would like to eventually father a child, she should seriously consider storing sperm in a sperm bank.

Treatments Options:
MTFs 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. After removal of the testes, 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 after sex reassignment surgery, it is necessary to continue taking estrogen to prevent osteoporosis.

FTMs, 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 become necessary. Testosterone is administered intramuscularly (with shots). Some countries also offer oral androgens instead of shots, 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. After achieving the physical changes desired and following through with sex reassignment surgery, though, it does not mean a person can quit taking hormones. In order to prevent osteoporosis, hormone therapy must be continued for the rest of that person's lifespan, though the dosage can be reduced once all competing hormones are eliminated.

Conclusion:
Hormone Replacement Therapy does have its risks, but it can bring about many desired physical changes for transsexuals. 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

Changes

Physical transition for transgender 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.
Female-to-Male (FTM)

 Male-to-Female (MTF)

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.

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

FTMs can develop serious acne problems, and weight gain of greater than 10% is fairly common. FTMs face higher risks of breast 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 MTFs and FTMs after prolonged treatment. If an MTF thinks she would eventually like to father a child, she should seriously consider storing sperm in a sperm bank prior to starting HRT. If an FTM would like to have a 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:
MTFs 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.

For MTFs, estrogen alone is not enough to block the effects of testosterone; anti-androgens are also a very important part of hormone therapy. After removal of the testes, though, anti-androgens are no longer necessary. Oral estrogens can cause more 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 increase the 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. The patches are the most expensive form of treatment.

FTMs typically do not require any additional treatments to block the effects of estrogen; the testosterone treatment is usually strong enough to make it unnecessary. However, when that is not enough to stop menstruation on its own, progestagens can be used in conjunction with testosterone to stop it. Testosterone comes in several forms:  patches, gels, pills (not available in the US), and intramuscular shots. Shots are the most common and cheapest method.

It is possible to take hormones for a short period of time to achieve some physical changes, but the health effects of that have little if any research about them. However, if a person completes sex reassignment surgery, a person must stay on hormone treatment for the rest of their life in order to prevent osteoporosis, though the dosage can be reduced once all competing hormones are eliminated.

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 Harry Benjamin Standards of Care regarding eligibility for surgery for transgender people. In recent years there has been some movement away from these standards, 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 transgender 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 doctor.

To Have Surgery or Not
Choosing whether or not to pursue various surgical procedures is a very personal thing. Not all transgender people desire to have surgery, and having surgery or not having surgery does not make a person more or less transgender. Surgery is also a very costly endeavor. The results are not always entirely satisfactory for transgender people in functionality, sensation, or in appearance, and good 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 seen by some as being necessary to be comfortable in their bodies, and completing some kind of gender reassignment surgery allows people in many states to officially change their sex with driver's licenses and birth certificates. 

Covering the Cost of Surgery
The biggest obstacle for many to overcome in pursuing gender reassignment surgery is covering the cost. A majority of health insurance companies consider transgender-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 FTMs 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 and speaking with other transgender people.

MTF:
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– Breast growth for MTFs on hormones rarely exceeds a B cup. Once a person's breasts reach their full size (after about two years of hormones), some transwomen 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 FTM patients and breast implants for MTF patients.

Facial Surgery– For some transwomen, the feminizing 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 more feminine appearance.

Feminization of the Transsexual: This page includes a list and description of many of the facial surgeries transwomen sometimes opt to pursue.

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.
http://www.geocities.com/sherrylanina/OrchiectomyTrans.html
http://www.tsroadmap.com/physical/orchiectomy/index.html

Vaginoplasty –A Vaginoplasty involves inverting the penis to create a vagina.
Transsexual Sex Reassignment Surgery (MTF): An in-depth description of SRS for MTF individuals, including the history of the procedure and stories of some of the most famous transsexual women. This site contains many images of completed vaginoplasty surgeries and some graphic illustrations.

Vocal Surgery– Since hormone therapy leaves the MTF's voice unchanged and voice therapy has its limits, some transwomen may choose to pursue surgery to alter their voices. However, results are not always satisfactory.

FTM:
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 FTM patients and breast implants for MTF 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 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 FTMs 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 transmen opt to not have surgery due to dissatisfaction with the results of any of the available surgeries. 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 FTM gender reassignment surgeries. This eBook is only available online and has not been published in hard copy.

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 archives are a great resource for commentary about surgeons and other issues relating to surgery.

Other Transgender Surgery Resources
Gay Health Channel: Transgender Health: Basic overview of surgical options.

Trans-health.com: This site has a few informative articles about surgeries for transgender people, among other transgender topics.