Physical Transition Options for the Transgender Individual*

In conjunction with my last blog, “What’s in YOUR Pants?”, this blog is about physical transition options for the transgender individual. As stated in the aforementioned blog, many people ask about surgery the first time they hear about a transgender individual’s plans to transition. It may surprise many people to find out the transgender individual has no plans to pursue surgery, specifically genital surgery.

I recently watched a documentary called “Diagnosing Difference” by Annalise Ophelian (excellent; I highly recommend it!).  This quote from that documentary summarizes perfectly what I was trying to say in my last blog, and leads nicely into what I’m going to explain in this blog. “There’s this huge stereotype that trans people all have genital surgery, that we know that someone’s really the new gender because they’ve had genital surgery, and that’s one of the biggest misconceptions about trans people. In reality, the vast majority of trans people will never have any surgery, and many trans people have surgeries that aren’t genital surgeries. [Italics added.]  And some people don’t have surgeries and don’t undergo medical care related to their gender because they don’t want it, it’s not appropriate to them, there’s other ways that they’re expressing their gender, and some people don’t have it because it’s not available to them, it’s not covered by their insurance…and so for both of those reasons, rules that govern are you really trans or have you really transitioned based on genital status or surgical status are very damaging to trans people’s well-being.” –Dean Spade

Hormone Therapy

OK, so before I get to surgery, let me talk a little bit about hormone therapy, or hormone treatment. Hormones are often a huge part of the physical transition process. Transmasculine individuals can opt take Testosterone or “T” (by patch, cream, or injection, most commonly injection). Doses vary depending on the individual and his desire for physical outcomes. Often the first changes that occur from taking Testosterone are the deepening of the voice and facial hair. These are also two irreversible changes that occur from taking T. Other changes include changes in facial features, head shape, clitoral enlargement, and fat redistribution (less on hips/butt/thighs, more to stomach). For more information regarding this type of hormone therapy, visit http://transhealth.vch.ca/resources/library/tcpdocs/consumer/hormones-FTM.pdf or http://www.ohio.edu/lgbt/resources/transoptions.cfm.

Transfeminine individuals may opt to take Estrogen, which can be administered orally or by injection, most commonly in a pill form taken orally. This regimen often includes an anti-androgen such as Spironolactone, which blocks the effects of testosterone.  Results from taking Estrogen include but are not limited to: breast growth, softening of the skin and facial features, lessening of body hair, and changes in fat distribution (less on abdomen, more to hips and bottom). For more information about this type of hormone therapy, visit http://transhealth.vch.ca/resources/library/tcpdocs/consumer/hormones-MTF.pdf, http://www.transgendercare.com/medical/resources/tmf_program/tmf_program_6.asp, or http://www.ohio.edu/lgbt/resources/transoptions.cfm.

Female-to-Male Surgical Options

FTM individuals have the option of two types of surgery, commonly referred to as “top surgery” and “bottom surgery”. Top surgery refers to the removal of breasts, the shaping of a male chest, and re-sizing the nipples. In my experience, this is the most commonly pursued and desired surgery for the FTM individual. A main reason for this is that the removal of breasts eliminates the need to bind (http://www.ftmguide.org/binding.html) and also helps the individual “pass” as male. Many (if not most) FTM individuals pursue this surgery, and those who don’t often cite the obstacle of not having the finances for it. Top surgery commonly costs between $6-10k, out of pocket.  For more information re: FTM “top surgery”, please visit: http://www.ftmguide.org/chest.html.

As for “bottom surgery” (surgery to construct a penis), most FTM individuals do not pursue any genital reconstruction surgery (GRS). You read that right, most DON’T.  Finances are often a major obstacle; GRS costs anywhere from $20k to $70k, depending on the procedure.  Additionally, many FTM individuals are not happy with the options/projected results; techniques have not been perfected enough to deliver optimal results. Additionally, some FTM individuals don’t have a problem with their genitalia or see the need to have it changed. (Remember, one’s genitalia has more to do with one’s anatomy than gender. For a refresher on the difference between Gender and Sex, visit my blog Gender Vs. Sex.)

For those who do pursue “bottom surgery”, there are a few options. These include but are not limited to: a metoidioplasty, which involves cutting the ligament connecting the (now enlarged, thanks to T) clitoris and removing extra skin, resulting in a small phallus. The urinary tract can also be lengthened if the individual wants to be able to urinate while standing. Another surgery called a “phalloplasty” is basically the creation of a penis using skin from a donor site on the individual’s body, most commonly the forearm.  If the trans man desires testicles, the skin from the labia can be used to create a scrotum. At least six months after a phalloplasty, testicular and penile implants can be inserted.  To quote Hudson’s FTM Resource Guide, “Phalloplasty usually involves a urethral lengthening procedure so that the patient can urinate through the penis. Erections are usually achieved with either a malleable rod implanted permanently or inserted temporarily in the penis, or with an implanted pump device.”   For more information regarding GRS for FTM individuals, please visit http://www.ftmguide.org/grs.html or http://www.savaperovic.com/ftm-srs-metoidioplasty-total-phalloplasty.htm.

There are MANY different options for FTM individuals who don’t choose to or who can’t afford bottom surgery. There are all sorts of accoutrements available for purchase that allow the trans man to stand to urinate, wear a penis, and/or to have intercourse. In order to stand to urinate, there are “stand to pee” (STP) devices. (http://www.ftmguide.org/packing.html#stp)  If the trans man prefers to wear a penis, full-time if desired, this is called “packing”. (http://www.ftmguide.org/packing.html) There are a variety of different packers available for purchase.  (http://www.tranzwear.net/store.php?seller=TranZwear&navt1=101317&navt2=101323. For a 15% discount on purchases from tranzwear.com, use discount code “TRANZ” when checking out.)  For sexual intercourse, there are also a variety of options to choose from (http://www.ftmguide.org/packinghard.html).  I should add here that not all trans men choose to pack or wear any kind of prosthesis. As with any group of individuals, there is a spectrum of preferences about this!

Male-to-Female Surgical Options

Facial feminization is a common surgery pursued by MTF individuals. This can include changing the hairline, frontal bone contouring, mandible contouring, chin augmentation or reduction, rhinoplasty, lip augmentation, etc. I don’t know the exact numbers on this, but the cost of this surgery can be upwards of $30k. For more information on facial feminization, visit: http://en.wikipedia.org/wiki/Facial_feminization_surgery. Some trans women opt to undergo breast augmentation surgery. (Estrogen often does not enlarge one’s breasts to more than a “B” cup.) http://marcibowers.com/grs/breastaug.html

As for MTF “bottom surgery”, often referred to as Sexual Reassignment Surgery (SRS) or Genital Reconstruction Surgery (GRS), many transgender women opt to undergo a vaginoplasty, using skin and tissue from the penis to create a vagina, clitoris, clitoral hood and labia.  This is another expensive surgery not covered by insurance; I don’t know the exact figures but what I could find implied a ballpark figure of $20k. Sue Boyd, LCSW, a trusted colleague of mine who works with more MTF individuals than I do, estimates that about half of her MTF clients opt to pursue this surgery “expense and all”. My guess is because the results are more satisfactory to the consumer than the current results of FTM bottom surgery. For more information on MTF GRS, please visit: http://www.thetransgendercenter.com/transgendersurgerymaletofemaleMTF.html or http://en.wikipedia.org/wiki/Sex_reassignment_surgery_(male-to-female)#Genital_surgery.

I should say again that all of the above depends on personal preference. Some individuals believe opting to get any or all of the above surgeries is a way of buying into the gender stereotypes prescribed by society, particularly about how a man or woman “should” look. To quote the film “Diagnosing Difference” again, “I think ‘passing’ is a word to discriminate us immensely. Not everybody can pass. And passing is something that the doctors will tell you to do, you try to pass. Well, no matter how much I pass, I will never be a biological woman. How about empowering me as the transgender woman that I am?” -Adela Vazquez

A moment on my soap box:

After reading all these extensive options a transgender individual confronts, don’t you wish things could be a little bit easier? They can be. By intervening EARLY with a child or pre-adolescent who has yet to start puberty, their future does not have to hold as many medical interventions! For the MTF individual, staring on hormone blockers pre-puberty would prevent facial hair from growing in, thereby preventing HOURS of painful and expensive electrolysis. Hormone blockers would also prevent one’s Adam’s apple from growing and the voice from deepening, which would eliminate the need for a “trach shave”… ouch! Similarly, staring hormone blockers pre-puberty for the FTM individual would prevent breast growth and ultimately prevent an expensive and painful “top surgery”. Additionally, for the transgender individual who desires to “pass” as their true gender, intervening early gives them the best chance at doing exactly that. For more information about hormone blockers and intervening early for transgender children, please visit http://transhealth.ucsf.edu/trans?page=protocol-youth.

*Disclaimer(s):

  • I am a Licensed Clinical Social Worker, not a medical doctor. The information contained in this blog should not be considered a replacement for medical advice or consultation.
  • The websites used in this blog should not be considered as endorsements but rather sources of information.
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What’s In YOUR Pants?? (They’re called “privates” for a reason)

When a person reveals their transgender identity and plans to transition, one of the first questions they are often faced with has to do with their anatomy, or genitalia. If you have been one of those people asking such a question, don’t feel bad. It’s normal to be curious about this, and it’s something concrete I think people tend to ask about as a way of understanding the transition process. However, I’d like to take this opportunity to explain why questions about a transgender person’s genitalia might be a little off the mark.

When you ask about anatomy/private parts/genitalia, you are referring to one’s sex, not gender. When a person reveals their gender identity to you and it is different than how you have always thought, they are explaining how they would like to be seen by friends, family, and society at large. They are talking about which pronouns they would like you to use (“he/him/his”, “they/them/theirs” “she/her/hers”, etc.), which name they would like you to use, and whether they would like to be seen as a man, woman, both, or neither. If you think about it, our genitalia do very little for us in explaining our gender identification! Simply put, no one sees these parts of us except perhaps medical professionals or those with whom we plan to be sexually intimate. If the one of first questions you ask is about one’s genitalia, I would say you’re concerned with the “wrong end”. Bring your attention up… way up. One’s gender identity exists in one’s brain. If you really want to know about how a transgender person feels, identifies, or wants to be seen, ask about what goes on for them in their brain.

If someone says they are “transsexual”, this translates to “changing sexes”. So the more outdated “sex change operation” applies here. (Now called Sexual Reassignment Surgery.)  However, your loved one will probably not refer to themselves as transsexual. You will likely hear the term “transgender” which yes, means “changing genders”. Stay with them in this revelation and focus on their gender, not their sex.  (For a more detailed explanation of these two concepts, please check out my Gender Vs. Sex blog.)

They’re called private parts for a reason.  A complaint I often hear from transgender individuals is that as soon as they reveal their plans to transition, others feel they have the right to know about what’s in their pants, or what’s going to be in their pants post transition. A good rule of thumb: if you wouldn’t normally ask this person about their genitalia, don’t do it after they’ve come out as transgender to you.

If the transgender individual is a VERY close friend or family member, and you think it’s ok to ask, ask eventually.  Don’t have it be one of your initial questions. Show you understand their gender FIRST. Do research on what options are out there for transgender individuals and then lovingly ask  your loved one what they are considering.

Be different. Because many transgender people have told me this is one of the first questions they get, it will be refreshing for them to come across someone who doesn’t ask about their anatomy. Ask about what you can expect with their upcoming changes and how you can support them during this major transition. More importantly, ask them how they are doing with such an important change.

Because changing genders is largely about how someone is seen and perceived, transgender individuals are often most interested in those changes that will help them “pass” as the gender which matches their brain gender identity. One’s genitalia is not proudly displayed while one is shopping at the grocery store. Therefore, genitalia is not one of the first considerations of a transgender individual when focusing their efforts on trying to pass. The main things that help individuals pass for a particular gender include but are not limited to: hair length and/or style, presence or absence of facial hair, pitch of voice, clothing, and presence or absence of breasts. When someone is trying to assess another’s gender, these factors are usually used the most when trying to make a decision. Hormone supplements (Testosterone or Estrogen) can assist with many of these changes.

Shay O’Reilly explained it well in the article “Shunning Medical Hoops, Transgender Patients Turn to ‘Informed Consent’ Model”: “While much media attention is paid to gender confirmation surgery, it’s hormone replacement therapy that often makes the largest difference in the lives of transpeople. Patients frequently report that hormone therapy makes their body feel more comfortable or more like home—more importantly to many, hormones masculinize or feminize the body, helping trans people be read correctly as their gender.”

Referencing one’s genitalia immediately following a revelation about their gender can enforce stereotypes and insecurities. When the questions and conversation goes immediately to one’s genitalia, you are reinforcing the misconception that one’s gender is based on and entirely connected to one’s anatomy. When one immediately “goes there”, the interpretation may be something like this, “You say you want to be a man, well, men have penises” or “So if you say you’re a woman, you’re going to have a vagina, right?”.  If the transperson cannot afford or does not wish to pursue “bottom surgery”, the implication could then be that they will not “really” be the gender they are saying they identify as.

Additionally, it is likely the trans person is acutely aware of how their anatomy (sex) does not match up with the gender identity of their brains. Calling attention to this and asking them to explain it (often over and over to many different people) can be exhausting. Not only because it’s private and could make the transperson uncomfortable, but because it may bring up feelings of inadequacy, sadness, or wishing their anatomy were different.

For the transperson reading this blog who does not like discussing this with others, here are a few tips to deal with “the” dreaded question.

  • Have a response ready, or an arsenal of responses ready. Be a broken record if you need to.  Examples:  “I’m not comfortable answering that”, “That’s a little too personal”, “I don’t feel comfortable telling you about me specifically, but I can tell you that some transgender people choose to … and some choose to….”. “That’s private”.
  • If the question brings up feelings of frustration or exasperation, take a deep breath. Give yourself space for a response. As I said before, I don’t believe others are trying to be invasive or inappropriate; they are merely curious and trying to understand.
  • Re-direct the person to a more appropriate means of getting their curiosity satisfied. “I appreciate your interest. Let me suggest some websites… books… blogs, etc.”
  • A great way to re-direct a question like this is to briefly clarify the difference between gender and sex. You could say, “Actually, that question is more about my sex, and I’m trying to tell you about my gender.”
  • Use humor. Laughing it off will make the other person more comfortable, and it will probably be good for you, too. Kim Pearson, co-founder of Trans Youth Family Allies and mother of a Female to Male transgender individual, uses a great response when fielding questions about her son. When asked if he’s had “the” surgery, she states, “No, he still has his appendix”. When the person then clarifies they were referring to genital surgery, she asks them to please go first and describe their child’s genitals in detail. 🙂

Stay tuned for my next blog which will include descriptions of bottom surgery and other options for transgender individuals. My hope is that this will help satisfy some curiosity so the questions don’t need to be asked as often, and for transpeople to use as a resource to give those who are curious.