Physical Transition


Hormone Replacement Therapy

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)


Changes to expect

Traits that won’t change

* Growth of facial hair (slow process)

* Height (unless starting treatment at a young age)

* A lower voice

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

* Distribution of body fat from breasts, hips, and thighs to stomach

* Breast growth (though they may shrink a little)

* Increased strength and muscle development

* Enlargement of the clitoris

* Increased body hair

* Masculinization of facial features

* Male-pattern hairline and baldness

* Increased aggression, heightened libido

* Cessation of menstruation


Male-to-Female (MTF)

Changes to expect

Traits that won’t change

* Softer skin and body appearance

* Voice

* Breast growth

* Height

* Lessening of body hair

* Size of hands and feet

* Loss of strength

* Presence of facial hair (may grow more fine)

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

* Hair loss stops, but what has been lost won’t grow back

* Diminished ability to achieve erections and to ejaculate

* Adam’s apple

* Redistribution of body fat from stomach to breasts, hips, and thighs



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. 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.



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. 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 to have surgery . . .
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.
The LGBT Programs Center does not endorse any doctor, authors or service providers. We list the contacts below for information sharing purposes only. These lists do not reflect all medical 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: 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.
Dr. Becky’s Website: 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.

Vaginoplasty – A Vaginoplasty involves inverting the penis to create a vagina.
Transsexual Sex Reassignment Surgery (Male to Female): 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 choose to pursue surgery to alter their voices.
International Journal on Transgenderism: Satisfaction of MTF Transsexuals with Operative Voice Therapy: This study compares the voice ranges of transwomen before and after surgery. It also contains basic information about the procedure and the satisfaction of people that have undergone vocal surgery.


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.
Transster: Transster is a great resource for photos of FTM chest and genital surgery results. Surgeries are indexed by type of surgery, surgeon, location of surgeon, and price.
Dr. Daniel A. Medalie: 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.
Yahoo group ftmsurgeryinfo
Loren Cameron’s eBook Man Tool
Loren Cameron’s eBook includes photos and profiles about FTM gender reassignment surgeries. This eBook is only available online and has not been published in hard copy.

Other transgender surgery resources
Gay Health Channel: Transgender Health:
Basic overview of surgical options.
International Journal of Transgenderism:
Collection of studies about transgenderism, including surgical and hormonal results and studies regarding therapy and education about transgender issues. Older journals with full-text articles can be found at http://www.symposion.com/ijt/index.htm.
Trans-health.com: This site has a few informative articles about surgeries for transgender people, among other transgender topics.

Ohio University
Athens, Ohio 45701
(740) 593-1000
All Rights Reserved