Surgery

Many surgical procedures have been adapted to meet the transitioning needs of the transsexual community.  Transitioning individuals may undergo any of the following, depending on the situation, personal needs and resources (eg, financial issues):

Breast Alteration

Since breasts are such a prominent part of sexual anatomy, both males and females require correction.  For transmen, that means a mastectomy, even during adolescence.  Appropriate hormonal management of a trans female will provide natural breast growth (to a size C or D cup).  However, many trans women undergo surgical breast augmentation to achieve an adequate breast size.


FEMALE -- Genital Correction

Removal of the testicles is necessary for adequate hormonal control in a trans female (known as orchiectomy  or castration).   Oral anti-testosterone medications can be used as an interim fix, but inadequate outcome & medication side effects preclude long-term use.  ...Which makes orchiectiomy a priority, even if further genital correction can't be done at the same time. 

Surgical correction of female genitals is known as vaginoplasty.  Basically the skin of the penis is buried in the groin area to create a vagina.  The penis' sensitive neural network is used for a clitoris.  Scrotal skin is used to fashion labia.  The final outcome is fully functional for penetrative intercourse.  It's sensitive enough to achieve orgasm in most cases.

Depending on the situation, some women may opt for a shallow vagina.  The resulting genitals are responsive to stimulation, but don't allow penetration.  The benefits of the smaller surgery are:

     -- Good appearance

     -- Less time in the operating room

     -- Less risk and fewer complications

     -- Lower expense


MALE -- Genital Correction

Metoidioplasty:  A relatively simple procedure which frees the clitoris from surrounding tissue, making it more prominent.  Usually, the resulting "penis" is fully sensitive and is capable of achieving a certain level of "erection".   The procedure is inexpensive and low-risk.  Subsequent testosterone therapy may even cause a limited amount of growth.

Metoidioplasty is particularly useful for Transmen born with Congenital Adrenal Hyperplasia (CAH).   (About half of XX-people born with CAH ultimately transition.)   CAH causes variable amounts of clitoral enlargement at birth.  Especially if enhanced using testosterone from an early age, the individual can have a small penis capable of erection by adulthood.  (However, it's incapable for ejaculation.  The person is also infertile.)


Phalloplasty:  Creation of a penis.  A very expensive, high risk set of procedures that require about a year for completion.  Fat and skin are removed from one part of the body (often the inner thighs) and grafted into the groin.  Subsequent operations fashion the graft to look like a (flaccid) penis.  More skin is stretched out or grafted around implants to provide cosmetic testicles.

With a skilled surgeon, it's possible to create convincing male genitals, but they're non-functional (no sensitivity, no erections or ejaculation).  With practice, it's possible to use a stand-up urinal.  A manual pump system can be added on the inside or outside of the penis to allow penetration.


Other Common Procedures

      --  Electrolysis or Laser Hair Removal

     --  Various degrees of Facial Feminization (Lips, eyebrows, jaw reduction, etc.)

     --  Tracheal Shave (To remove prominent Adam's apple)

     --  Feminization Laryngoplasty (Tightening of vocal cords to produce high-pitched voice)

      --  Rib Removal (Results in waist narrowing)

It Depends

Medical treatment isn't a one-size-fits-all situation.  Each of the following situations require a unique, tailor-made treatment protocol:

1.  Pre-Pubertal Youth:  Prior to puberty, youth have very low levels of sex hormones.  Hormonal therapy during this period requires meticulous monitoring.  A baseline level should be maintained to allow the usual physical & mental development that takes place during this period, but estrogen overdose may trigger precocious puberty.  Anti-testosterone agents are contra-indicated.

2:  Adolescence (ie, puberty management for teens):  During puberty, sex hormone levels start low and only at night.  They gradually increase to all-day, adult levels by age 18.  In spite of the low levels, significant changes in physical appearance take place.  This suggests that the target  organs (eg breast tissue) are more sensitive during adolescence than during adulthood.

Both sexes need both estrogen AND testosterone (in different doses).  Progesterone plays an important role in breast development.  Testosterone-blocking medications are contra-indicated.

Non-sex hormones such as Growth Hormone, IGF1 and Leptin also play important roles in puberty management.  They have complex, partially-understood interactions with the estrogen & testosterone pathways. 

3:  Puberty Induction for Adults:   Hormonal transitioning in an adult begins with inducing the same physical changes that occur during adolescence -- primarily, breast development and changes in skin & hair.  However, adult target tissues aren't "primed" to respond -- ie, they're less sensitive; they require higher hormone doses to achieve the same effect.

Progesterone is essential for breast growth.

Sex-specific skeletal changes have already taken place in an adult, so monitoring non-sex hormones isn't as important as during adolescent puberty.

4:  Maintenance Regimen for Adults:   After 3-4 years of "adult puberty", physical changes have reached their maximum.  Hormone doses can be reduced (usually by about one-half).  Progesterone is probably no longer required.

5.  Senior Care:  For almost twenty years, a hot debate has been raging about hormonal treatment for seniors.  The original hope was that Hormone Replacement Therapy (HRT) would (A) stop hot flashes & other post-menopausal symptoms, (B) Prevent calcium depletion from the bones (osteoporosis), (C) Prevent heart attacks in senior women, and (D) improve sexual intercourse. 

...Until actual research showed an increase in heart attacks, stroke & cancer.  And then further research showed a benefit during the first ten years post-menopause, while after age 60 the risk appeared to increase.

So how does this apply to transsexuals?  Should they continue HRT after age 60?

No one knows.  Currently, all treatment protocols simply avoid the issue.  However, it seems certain that progesterone increases risk, as do oral forms of estrogen.

6:  Androgynous Treatment:   The general rule is that androgynous people don't benefit from medical transitioning -- EXCEPT, they may want to make their anatomy "sexless".  That usually means a flat chest and smooth hairless skin. 

Estrogen triggers irreversible breast growth, while testosterone causes permanent growth of coarse dark hair (including facial hair).  Androgynous anatomy through hormones would require removal of both estrogen & testosterone,  which is incapatable with a healthy life. 

The best approach would be to surgically remove the testicles (if present) to prevent hair growth, surgically remove breast tissue to prevent breast growth, and use estrogen to maintain health (ie, using estrogen patches or intact ovaries.)  However, WPATH doesn't recognize the validity of this approach. 

Usually androgynous XY-people are given placebo doses of estrogen (causing negligable breast growth).  They undergo electrolysis to remove all hair.   The testicles remain intact, so testosterone is available for maintaining health.  The outcome is primarily imaginary.

XX-androgynous people will need to do something about their chest development.

Dosage, Risks & Side Effects

The practical aspects of treatment aren't included here -- info such as dosage, frequency, possible complications, monitoring requirements, etc  Detailed recommendations can be found  in the New Paradigm Treatment Protocols.

A summary of the major possible complications can be found HERE.

See also the Treatment Protocols page for a comparison of the major alternative regimens that are currently available.

At some point, all transsexuals face decisions about medical treatment -- that is, hormones & surgery.  Every trans individual is unique, with different needs, different medical risks, and different access to resources (eg money & social support).  Therefore, each person's medical care goals will also be unique.  The guiding rule is:

          Seek the best possible outcome with the lowest possible risks.


Overall Goals

The first step in treatment is to determine the ultimate goals -- then plot a path to efficiently reach them:

(1)  Minimize Distress

Transsexuality brings three possible types of distress.  Each individual must assess their level of overall distress from each of the three possible sources.  Alleviating Wrong-gender Distress (Type 1) is usually the first treatment priority.  Social Hostility Distress (Type 2) may be overwhelming, but usually it's better to reduce harassment by moving to an accepting society rather than by allowing it to affect medical treatment.  However, Social Hostility may dictate the timing of medical intervention.


(2)  Fulfill Basic Needs

Every person has a unique set of needs & priorities.  Treatment success depends on being aware of those needs, and then plotting a path to achieve them.  For example:

      --  What features determine femininity and masculinity?  (Transitioning means dropping one set and adopting another.)

      --  What medical conditions are present?  (For example, breast cancer genes preclude the use of estrogen.)

      --  How important is sexual intercourse?

      --  What resources are available?  (Resources shouldn't affect ultimate goals, but they do change the path to reach those goals.)


(3)  Avoid Hostile Society's Traps

Most treatment protocols are specifically designed to prevent transitioning by erecting insurmountable obstacles.  For example:

       --  Psychiatric care  (Transsexuality is NOT a mental illness.  Why have a psychiatrist gatekeeper?) 

       --  Ineffective treatment  (Ineffective hormones prevent a trans person from reaching their goals.)

       --  Insurance driven  (Unconcerned about bad outcomes, ineffective treatment is less expensive than more effective alternatives.)

       --  Puberty Denial  (Results in at least a 10-point drop in IQ for the adolescent.)


(4)  Minimize Complication Risks

Medical transitioning carries risk.  It's essential for a patient to be aware of the risks, avoid them whenever possible, and carefully monitor progress to detect complications at the earliest possible moment.  Ineffective treatment and Puberty Denial both increase risk without offering any benefits.

Treatment Approaches

Every physician has a different approach to trans care.  Here are three possible treatment philosophies (choose your physician with care): 

Approach 1 - PLACEBO:  Disapproving physicians may wish to placate a patient without providing any actual benefits.  They prescribe hormones in doses too small to make any real biologic changes -- or they may use ineffective medication forms.  (Eg the half-life of ORAL Estradiol [Estrace] is 2-3 hours -- making it ineffective if given less often than three-times per day.  It also has a high risk of complications.  On the other hand, estrogen transdermal patches offer a constant blood level with fewer risks.)


Approach 2:  NORMAL LEVELS:  A slightly more positive approach is to maintain "normal hormonal levels".  In other words, keep blood estrogen or testosterone levels within the normal range.  For an adult woman, that would mean between 10 - 375 pg/ml of Estradiol.  For an adult man, it's 320 - 1000 ng/dL of Testosterone.  ...In other words, the "normal range" is quite wide. 

The experts at the Endocrine Society recommend maintaining an estrodiol level < 200 pg/ml for transsexual women (Guidelines p 20).  But no specific target is offered for transmen.


Since "normal levels" vary so much in the general population, it's impossible to predict how much is appropriate for any one individual.


FSH:  A more sophisticated approach is to monitor Follicular Stimulating Hormone (FSH) levels.  FSH is the body's natural way of regulating hormone levels.  A high FSH tells the gonads to make more hormone.  A very low level says, "slow down; there's too much!"   With this approach, at least the body has some input regarding how much hormone should be given.  (Note that every person's FSH system works just as well for regulating testosterone as it does for regulating estrogen. -- Human bodies are designed for sexual flexibility.)


Approach 3 - PHYSICAL CHANGES:  The best approach to hormonal treatment is to follow the body’s actual response.  The right hormone dose for a woman is whatever it takes to:

     -- Promote breast development:  An effective hormonal regimen stimulates the natural growth of C- or D-cup breasts over a 3-year period.  Tenderness during the growth phase can be controlled by adjusting the Progesterone regimen.


     -- Stop the growth of body hair:  Hormones should transform a heavy growth of coarse body hair into a light dusting of fine hair -- without a need for electrolysis.  (Facial hair growth usually isn’t affected.)

 

     -- Reduce muscular development:  Women don’t have prominent muscles, particularly in the shoulders, biceps & calves.


     -- Redistribute body fat:  In women, body fat is evenly distributed over the entire body.  Skeletal contours become smoothed in the process — most notable in the elbows, knees and ankles.


     -- Areas that don’t change:  deep voice, Adam’s apple, facial hair growth, skeletal structure (hips, waist & hands)


The physical changes approach requires a reassessment of key anatomic structures every 3 - 6 months.  If little change is observed, the regimen should be adjusted.

Medical Treatment

The New Gender Paradigm

WPATH Diagnosis

The WPATH treatment protocols take a very different approach to diagnosis.  The presenting symptom is "non-conformity" -- ranging from someone who knows he's a man (Gender Identity), loves football, pizza, beer and drives trucks (Gender), but he likes the color pink.  ...To a 7-year old with a penis who has maintained that she's a girl since birth, and tries to commit suicide after years of having her parents overrule her.

Supposedly, all "gender non-conformers" have an equal chance of (A) deciding to conform, (B) becoming a homosexual, or (C) becoming a transsexual.   There are no characteristics that make one outcome more likely than another.   The only diagnostic approach is to wait to see what happens. 

WPATH also considers transsexuality to be the worst possible outcome.  Psychiatrists should try every possible intervention to prevent it.

Diagnosis

Medical treatment begins with symptoms.  A specific group of symptoms and test findings leads to a diagnosis.  Every diagnosis has an associated treatment protocol.   In all areas of medicine, it's the physician's responsibility to make the diagnosis.  Unfortunately, in trans medicine the patient is tasked with making the diagnosis, then convincing the attending physician that they're right.   

Be that as it may, the basic presenting symptom is Wrong-gender Expression and the distress it causes.  (Sometimes described as "being born in the wrong body" -- an image that's not accurate technically, but conveys a feeling of gender conflict.)  

Wrong-gender expression distress occurs in three groups (ie, the differential diagnosis):

      (1)  Androgynous people 

      (2)  Crossdressers

      (3)  Transsexuals

All three of these conditions are defined by the individual's gender status -- in other words, by where the individual sits in the gender spectrum (see the graph above.)   Usually an individual is able to just look at the graph and point to where they are.  But gender tests can be done to determine how many core "male" and "female" gender traits are present.  However, transsexual women usually have the following characteristics:

       -- Female Gender Identity

       -- Predominantly female Gender Traits

       -- Present from birth

       -- Conflict with society over Gender Expression.

      -- Can be definitively detected by doing a fMRI.


Transman Diagnosis

Most of the issues discussed on this page apply to transsexual women.  On the other hand, the stages of Transman evolution make it difficult to differentiate between Transmen & butch females (the latter are actually androgynous.)  For that matter, individuals who are "really Transmen" may choose NOT to transition medically.  That is, they're willing to endure some Type 1 Distressin order to buy a large reduction in Type 2 Distress. 

The Treatment Portal

Disclaimer

This page is for educational purposes only.  Any treatment must take place under the guidance of a appropriately trained physician. Treatment regimens must be individualized to the patient's unique circumstances and physiology.  The medications discussed have risks, possible complications and drug interactions that are not mentioned here -- see the individual package inserts.