Samantha Newman, National Center for Health Research
The focus of this article is medical transitioning from female to male, the process by which transgender individuals change the way they look so that their physical characteristics match the gender they feel. [2] Transgender is defined as individuals whose social or psychological gender identity is different than their sex assigned at birth. [2]
Transitioning isn’t necessarily medical. It can involve changing one’s name or one’s pronouns (such as changing she/her/hers to he/him/his and vice versa). It can involve changing the way one dresses. Medical transitioning can involve medical treatments, such as taking hormones or getting surgery. Experts agree that there is not one “right” way to transition. Transitioning can involve any combination of these changes or it can be any change that allows someone to more comfortably present to the world. [2] What is most important is that someone’s transition process reflects their needs and what works best for them and their body. [1] While there are many social ways to transition, such as coming out to friends, using different pronouns, or using a different name, this article will specifically examine the medical treatment options in the female to male transition process. (Our article on medical transitioning from male to female is available here.)
For someone considering medical transitioning, it is important to know the risks that are associated with specific medical treatments and to decide if the likely benefits outweigh those risks. It is essential to realize that many aspects of this medical transition can be very expensive, so make sure to find out what will or will not be covered by insurance. The goal of this article is to provide information to help individuals make an informed choice, choosing the safest options that will provide the most benefit.
Before beginning transgender transitional medical treatment, the World Professional Association for Transgender Health (WPATH) recommends meeting with a mental health professional for a gender dysphoria diagnosis and psychotherapy. [1] According to the American Psychiatric Association, a gender dysphoria diagnosis is when a person’s physical or assigned gender (such as someone born female or born male) does not match the gender they feel (for example, feeling they are male or female). [23] Most doctors will not offer most medical transitioning options unless the individual has this diagnosis. Some medical procedures do not require meeting with a mental health professional beforehand, but having a supportive mental health professional can be helpful in this process.
After receiving a gender dysphoria diagnosis, deciding whether or not to choose hormone therapy is often the first step. If a person chooses hormone therapy, it is usually followed by a period of living publicly as a trans man (biologically female who identifies as male) or trans woman (biologically male who identifies as female) before major surgeries are performed. This is called the Real-Life Test and it will be discussed later in the article. [3] Hormone therapy is usually recommended prior to most types of trans surgery. [1]
Each medical intervention has its own unique benefits and risks.
For trans men, medical transitioning may include any of the following:
- Hormone therapy (to create masculine characteristics such as a deeper voice, facial hair growth, redistribution of body fat away from hips and breasts, and not getting a period.
- Male chest reconstruction, or “top surgery” (to remove the breasts and breast tissue)
- Hysterectomy and salpingo-oophorectomy (to remove female reproductive organs such as the uterus and ovaries/fallopian tubes)
- Phalloplasty or “bottom surgery” (construction of a penis using skin from other parts of the body). [2] Metoidioplasty is a type of “bottom surgery” that causes the clitoris to work more like a penis, which is accompanied by hormone treatment to make the clitoris grow larger [2]
Hormone Therapy
There are many types of hormones in our bodies, but estrogen, testosterone, and progestogen are considered sex hormones because they affect characteristics that influence aspects of the body as well as sexual desire. All males and females have estrogen, testosterone, and progestogen, but the relative amounts of these hormones in the body give us our specific physical characteristics. [20] In female to male trans patients, testosterone is taken to help develop male characteristics. [1] The characteristics that could develop include a deeper voice, growth of the clitoris, growth in facial and body hair, the stopping of one’s menstrual cycle, decrease in breast tissue, increase in sex drive, and more muscle mass than body fat. [1]
According to WPATH, the criteria for hormone therapy are as follows:
1. Persistent, well-documented gender dysphoria diagnosis by a qualified mental health professional;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority (which varies in different countries and states). If a person wanting to transition is younger, there are different rules that can be found in Section VI of the WPATH’s Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People);
4. If an individual who wants to transition already has significant medical or mental health issues, those mental health issues must be reasonably well controlled. [1]
Most physical changes occur gradually over the course of two years. The amount of physical change and the exact timeline of those changes vary. For more details, see Table 1, which outlines the effects and expected time these effects will take place once hormones are taken as presented in WPATH’s Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. [1]
Table 1 taken from WPATH’s Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People
Testosterone can be administered in various forms, but the most popular are hormone injections. Some choose to begin on a lower dose and increase slowly, while others chose to begin at a standard dose. It’s important to discuss these options with your doctor. [3]
Risks of Hormone Therapy
All medical treatments have risks. According to WPATH, masculinizing hormone therapy can cause a likely increased risk of higher red blood cell count in the body (polycythemia), weight gain, acne, balding, and sleep apnea. [1] Other possible risks include elevated liver enzymes, an increase in fats or lipids in the blood (hyperlipidemia), worsening of an underlying psychotic condition, cardiovascular disease and heart attacks, abnormally high blood pressure (hypertension), and Type 2 diabetes. [1] It has not been proven whether or not masculinizing hormone therapy increases the risk of breast cancer, cervical cancer, ovarian cancer, or uterine cancer if those organs are not removed. [1]
The effects of hormone therapy are seen gradually over a period of about two years. It is important to understand that taking higher than prescribed doses of hormones DOES NOT increase the speed of the transition process. [1] It can, however, cause dangerous side effects. [4] For example, excess testosterone can be converted to estrogen, which may increase the risks of uterine imbalance or cancer. However, as mentioned above, taking a prescribed amount of testosterone by a physician has not proven to increase the risk of cancer. [3]
Most importantly, never take hormones from overseas mail-order companies, street sellers, neighbors, or friends. Always go to a licensed physician because they will be able to administer the best dosage of these hormones as well as properly monitor their effects. [4]
Oral testosterone or synthetic male sex hormone (androgen) medication shouldn’t be used because of potential adverse effects on your liver and lipids. [5] Read more about hormone therapy at Masculinizing Hormone Therapy.
Because masculinizing hormone therapy might reduce the fertility a trans individual had as a woman, it’s important to make decisions about freezing one’s eggs or other options before starting hormone therapy. [5] However, a trans man can still be at risk of pregnancy if the uterus and ovaries have not been removed. If one wants to avoid becoming pregnant, use a barrier form of contraception or an intrauterine device (IUD). [5]
Top Surgery
Male chest reconstruction, also called “top surgery,” removes the breasts and breast tissue. Top surgery involves more than just breast removal. [1] Special techniques are used to design the chest wall, position the nipples and areolas, and minimize scarring. [1]
The criteria for a mastectomy and the creation of a male chest in female-to-male patients is as follows:
1. Persistent, well-documented gender dysphoria by a qualified mental health professional;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country;
4. If significant medical or mental health concerns are present, they must be reasonably well
controlled.
Hormone therapy is not a prerequisite for top surgery. [1]
Risks of Top Surgery
Similar to any other type of major surgery, top surgery for transgender men poses a risk of bleeding, infection, and an adverse reaction to anesthesia.
Other complications might include:
- Poor wound healing
- Fluid accumulation beneath the skin (seroma)
- A solid swelling of clotted blood within your tissues (hematoma)
- Damaged or dead body tissue (tissue necrosis), such as in the nipple
- Scarring
- Dissatisfaction with appearance after surgery
- Asymmetry [6]
After surgery, the chest should remain in a compression wrap for several weeks. There will likely be one or two small plastic tubes placed in the chest to drain any fluids that accumulate after surgery. [6] The surgeon will also recommend sleeping with the torso elevated for the first week after surgery. Avoid lifting more than 10 to 15 pounds for several weeks. [6]
Removal of the Uterus (hysterectomy) and Fallopian Tubes/Ovaries (salpingo-oophorectomy)
A hysterectomy is when a surgeon removes the uterus. A hysterectomy for transgender male patients is usually accompanied by a salpingectomy (removal of fallopian tubes) and a oophorectomy (removal of the ovaries). [1] Hysterectomy often includes removal of the cervix as well as the uterus. When the surgeon also removes the ovaries and fallopian tubes, it’s called a total hysterectomy with salpingo-oophorectomy. [11] However, a patient may make the choice to not remove the fallopian tubes and ovaries during a hysterectomy procedure.
The “best practice” for these surgical procedures in transgender patients has not been established. Hysterectomy may be performed abdominally, laparoscopically, or vaginally. An abdominal hysterectomy removes the uterus through an incision in the lower abdomen. [10] A vaginal hysterectomy removes the uterus through the vagina. [11] A laparoscopic hysterectomy is a minimally invasive surgery; the surgeon makes a small incision in the belly button or in the vagina and inserts a tiny camera. [12]
For all types of patients, not just for transgender men, the vaginal approach has the fewest complications and blood loss, quickest recovery, and is considered the most cost-effective. [11] For transgender men, vaginal hysterectomy has the added benefit of leaving no abdominal scars. Studies also show that laparoscopic hysterectomy can successfully be accomplished without additional complications. [9]
The salpingo-oophorectomy surgery is located in the same region as a hysterectomy surgery, therefore making a total hysterectomy with salpingo-oophorectomy procedure a popular option for transgender patients. [14] There are three different types of salpingo-oophorectomy procedures. You can read about them here: https://www.healthline.com/
Retaining or removing the ovaries and fallopian tubes at the time of a hysterectomy surgery is a personal decision based on the patient’s desires and future fertility plans. [9]
According to WPATH, the criteria for hysterectomy and salpingo-oophorectomy in trangender male patients is as follows:
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country;
4. If significant medical or mental health concerns are present, they must be well controlled.
5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless
hormones are not clinically indicated for the individual). The aim of hormone therapy prior to genital surgery is primarily to introduce a period of reversible testosterone suppression, before the patient undergoes surgery that can’t be reversed. [1]
WPATH advises that “Two referrals—from qualified mental health professionals who have independently assessed the patient—are needed for genital surgery (i.e., hysterectomy/salpingo-
Before genital surgery (hysterectomy, salpingo-oophorectomy, phalloplasty, or metoidioplasty surgery), surgeons who follow the WPATH standards of care usually require candidates for surgery to live for at least a year in their preferred gender role before the procedure. [1] This is called the Real-Life Experience or the Real-Life Test, and the goal is to expose the individual to social issues that could arise if they were to continue to medically transition. By gradually changing their physical appearance, individuals will be able to observe how this change affects various aspects of their life. Through the Real-Life Test, individuals may realize that they only want to socially transition or they may realize they want to continue down the medical transition path. [7,8] By actively experiencing their new reality they are able to overcome social challenges and make a more informed decision going forward. In addition, the Real-Life Test shows the surgeon that the individual is committed to this irreversible procedure. [7, 8]
Risks of Hysterectomy
The risk of a hysterectomy depends on the type of procedure performed. A hysterectomy is generally very safe. However, there are risks with any major surgery, as noted earlier in this article. Risks associated specifically with a hysterectomy include blood clots; infection; excessive bleeding; damage to the urinary tract, bladder, rectum or other pelvic structures during surgery; or earlier onset of menopause even if the ovaries aren’t removed. [10] Rarely, complications can be fatal [10]
There also might be scarring, but it depends on the type of incision made during the abdominal hysterectomy. [10] As a whole this type of procedure has generally been shown to be less desirable to transgender patients due to visible scarring, longer hospital time, and longer recovery time.
Vaginal hysterectomy involves a shorter time in the hospital, lower cost and faster recovery than an abdominal hysterectomy. [11]
In addition to the risks above, there are specific risks associated with a laparoscopic hysterectomy:
- It can take longer to perform compared with abdominal or vaginal surgery
- There is an increased risk of injury to the urinary tract and other organs
Following surgery, one can expect to have some pain for the first few days. Pain medication is usually prescribed. There will be bleeding and discharge from the genital area for several weeks. Sanitary pads can be used after the surgery. [13]
Risks of Fallopian Tubes/Ovaries (salpingo-oophorectomy) Removal Surgery
Salpingo-oophorectomy is considered a relatively safe procedure, but as with any surgery, it has risks. These mostly include bleeding, blood clots, infection, or a bad reaction to anesthesia.
Other risks of the removal of the Fallopian Tubes/Ovaries could include:
- Nerve damage
- Hernia
- Formation of scar tissue
- Bowel obstruction [14]
It is essential to call a doctor if there is redness or swelling at the incision site, fever, drainage or opening of the wound, increasing abdominal pain, excessive bleeding, foul-smelling discharge, difficulty urinating, nausea or vomiting, shortness of breath, chest pain, or fainting. [14]
A hysterectomy/salpingo-
Phalloplasty or Metoidioplasty Surgery aka “Bottom Surgery”
A phalloplasty constructs a penis. The goal is to build a cosmetically appealing penis that is capable of feeling sensations and releasing urine from a standing position. [15, 16]
According to WPATH, criteria for phalloplasty in transgender male patients:
1. Persistent, well-documented gender dysphoria by a qualified mental health professional;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country;
4. If significant medical or mental health concerns are present, they must be well controlled;
5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals;
Although not required, it is recommended that these patients also have regular visits with a mental health or other medical professional. [1]
The current gold standard of phalloplasty surgery is known as a radial forearm free-flap (RFFF) phalloplasty. For this procedure, surgeons use a flap of skin from the forearm to build the shaft of the penis. [15] The clitoris is usually left in place near the base of the penis, where it can still be stimulated. [15]
The RFFF procedure provides penile skin sensitivity as well as good aesthetic results. The urethra can also easily be constructed in a tube-within-a-tube fashion. This is important to allow for standing urination. [15]
Metoidioplasty, also known as a meta, is a surgical procedure that uses the patient’s existing genital tissues to form a new penis. [19] It can be performed by growing the clitorius with testosterone. Doctors tend to recommend being on testosterone therapy at least one to two years before this procedure. [19]
Pros and Cons of Metoidioplasty compared to a Phalloplasty procedure
Pros
- Fully functioning penis (can become erect on its own)
- Minimal visible scarring
- Fewer surgical procedures than phalloplasty
- Can also have a phalloplasty later if one chooses
- Shorter recovery time
- Significantly less expensive than phalloplasty, if not covered by insurance: ranges from $2,000 to $20,000 versus $50,000 to $150,000 for phalloplasty [19]
Cons
- New penis relatively small in length and girth (measuring anywhere from 3 to 8 cm in length)
- Penetration during sex may not be possible
- Requires use of hormone replacement therapy and substantial clitoral growth
- May not be able to urinate while standing [19]
Risks of Metoidioplasty Surgery
As mentioned about, with any surgery there is a risk of infection, bleeding, blood clots, damage to surrounding tissues, pain, negative reactions to anesthesia or other medications. However, metoidioplasty has some unique risks as well. [18]
Risks associated with metoidioplasty surgery include:
- Urethral complications, the most common one is a urinary fistula, which is an opening in the urethra that causes urine leakage
- Wound breakdown (ruptures along the incision lines)
- Bladder or rectal injury
- Dissatisfaction with the size or shape of the penis
- Inability to stand-to-pee [18]
Some long term complications can include scarring or urethral issues that cause difficulty or prevent urine from going through. [18]
You can learn about different types of metoidioplasty procedures by visiting this website: https://www.healthline.com/
Bottom Line
Throughout the transgender transition process, each person should consider what is best for their social and medical needs. Since this is a serious medical and psychological process, it is essential that patients consult with a doctor that they trust. NEVER accept medical treatment from a non-licensed physician, and always choose a physician who is board certified in the relevant medical field. Patients should pay close attention to the laws and policies of their state and work with their insurance company to see what treatments will be covered.
There is not just one “right” way to transition. Each person should think about what is best for their mind and body. They should consider the risks and benefits of each option, and then decide which treatments are best for their transition process.
All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.
The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.
References
[1] World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2012. https://www.wpath.org/media/
[2] Planned Parenthood. What Are Appropriate Labels; Terms For Transgender People? PlannedParenthood.com. www.plannedparenthood.org/
[3]. Deutsch, Maddie. Transcare UCSF. Information on Testosterone Hormone Therapy. Transcare.ucsf. https://transcare.ucsf.edu/
[4] Trans bodies, trans selves: a resource for the transgender community /edited by Laura Erickson-Schroth.New York: Oxford University Press, USA, 2014. Ch. 12 – Medical Transition. Dr. Maddie Deutsch.
[5] Mayo Clinic, Mayo Foundation for Medical Education and Research. Masculinizing Hormone Therapy. Mayoclinic.org. April 14, 2020. https://www.mayoclinic.org/
[6] Mayo Clinic, Mayo Foundation for Medical Education and Research. Top Surgery for Transgender Men. Mayoclinic.org. September 27, 2019, https://www.mayoclinic.org/
[7] Bernstein, Lenny. Here’s How Sex Reassignment Surgery Works. The Washington Post, WP Company.www.washingtonpost.
[8] TransHealth. Origins of the Real-Life Test. Trans-health.com. http://www.trans-health.com/
[9] Obedin-Maliver, Juno. Transcare UCSF. Hysterectomy. Transcare.ucsf. June 17, 2016. https://transcare.ucsf.edu/
[10] Mayo Clinic, Mayo Foundation for Medical Education and Research. Abdominal Hysterectomy. Mayoclinic.org. July 25, 2019. https://www.mayoclinic.org/
[11] Mayo Clinic, Mayo Foundation for Medical Education and Research. Vaginal Hysterectomy. Mayoclinic.org. Feb. 8, 2020. https://www.mayoclinic.org/
[12] McMacken, Melissa. Johns Hopkins Medicine. Laparoscopic Hysterectomy. Hopkinsmedicine.org. Feb. 2, 2018. https://www.hopkinsmedicine.
[13] ACOG. Hysterectomy Frequently Asked Questions: Special Procedure. Acog.org. https://www.acog.org/Patients/
[14] Pietrangelo, Ann. What to Expect from Salpingo-Oophorectomy. Healthline. Healthline.com. Feb. 13, 2001. https://www.healthline.com/
[15] Osborn, Corinne O’Keefe. Phalloplasty: FTM Gender Confirmation Surgery Recovery, Complications. Healthline. Healthline.com. May 7, 1983. https://www.healthline.com/
[16] Ercolano, Alexa. FAQ: Phalloplasty: The Johns Hopkins Center for Transgender Health. The Johns Hopkins Center for Transgender Health. Hopkinsmedicine.org. Sept. 17, 2019. https://www.hopkinsmedicine.
[17] Boston Children’s Hospital. Metoidioplasty: Boston Children’s Hospital. Childrenshospital.org. http://www.childrenshospital.
[18] Trans Media Network. Metoidioplasty Risks and Complications: Is Metoidioplasty Really Worth It?. Metoidioplasty.net. https://www.metoidioplasty.
[19] Clements, KC. Metoidioplasty: Surgery, Results, and Recovery. Healthline. Healthline.com May 7, 1983. https://www.healthline.com/
[20] Trans Media Network. How Penile Implants Work. Phallo.net. Aug. 18, 2018.https://www.phallo.net/how-