Samantha Newman, National Center for Health Research
The focus of this article is medical transitioning from male to female, the process by which transgender individuals change the way they look so that their physical characteristics match the gender they feel.  Transgender is defined as individuals whose social or psychological gender identity is different than their sex assigned at birth. 
Transitioning isn’t necessarily medical. It can involve changing one’s name or one’s pronouns. It can involve changing the way one dresses. Medical transitioning can involve medical treatments (hormones) and can involve 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.  What is most important is that someone’s transition process reflects their needs and what works best for them and their body.  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 male to female transition process.
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.  According to the American Psychiatric Association, a gender dysphoria diagnosis is when a person’s physical or assigned gender does not match the gender they feel.  Most doctors will not offer most medical transitioning options unless the individual has this diagnosis. However, some medical procedures, such as facial feminization surgery or laser hair removal, do not require meeting with a mental health professional beforehand.
After receiving a gender dysphoria diagnosis, one can consider whether or not to choose hormone therapy. If a person chooses hormone therapy, it is usually followed by a period of living publicly as a trans man or woman before major surgeries are performed (this is called the Real-Life Test and it will be discussed later in the article).  Hormone therapy is usually recommended prior to most types of surgery. 
Each medical intervention has its own unique recommendations and risks.
For trans women, medical transitioning may include any of the following :
· hormone therapy (to create feminine characteristics, such as less body hair, softer skin, and breast growth)
· laser hair removal (to remove hair from face and body)
· tracheal shave (to make the Adam’s apple smaller)
· facial feminization surgery (to create feminine facial features)
· breast augmentation (breast implants)
· orchiectomy (to remove the testes)
· penile inversion vaginoplasty (to create a vagina by inverting penile skin)
There are many types of hormones in our bodies, but estrogen, testosterone, and progestogen are considered sex hormones because they affect sexual characteristics. All males and females have both male and female hormones, but the relative amounts of these hormones in the body give us our specific physical characteristics.  For male to female hormone therapy, there are patches, pills, and injections containing estrogen and/or anti-androgens that can help change the arrangement of muscles, skin, and fat distribution, to make the individual appear more feminine. 
According to WPATH, the criteria for hormone therapy are as follows:
1. Persistent, well-documented gender dysphoria diagnosis from a 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. 
Estrogen and anti-androgens help block some of the masculinizing effects of testosterone, including facial and body hair and male pattern baldness.  As a result, the physical effects of hormone therapy also include “breast growth, decreased erectile function, decreased testicular size,” and an increase in the percentage of body fat compared to muscle mass.  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. 
Risks of Hormone Therapy
All medical interventions have risks. According to WPATH, feminizing hormones have an increased risk of a blood clot in a deep vein, usually in the leg, that is called venous thromboembolic disease (VTD) and can be fatal. Other risks include gallstones, elevated liver enzymes, weight gain, cardiovascular disease, and a high level of a certain type of fat (triglycerides) in the blood).  There is a possible increased risk of high blood pressure, higher levels of the hormone prolactin, and Type 2 diabetes. It has not been proven whether or not it increases the risk of breast cancer. 
Estrogen taken in pill form has more VTD risks than estrogen administered with a transdermal patch on the skin) estrogen administration. Ethinyl estradiol is the type of oral estrogen with a well-documented higher risk for VTD. For that reason, this specific type of oral estrogen should be avoided for feminizing hormone therapy. 
Using progestins in feminizing hormone therapy is controversial. Some experts believe it is necessary for full breast development, while others report that progestin hormones do not enhance breast growth. In addition, progestins may increase the risk of breast cancer and cardiovascular disease, and also have risks such as depression and weight gain.[1,5]
As noted above, 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. It can, however, cause dangerous side effects. 
Most importantly, never take hormones from oversea mail-order companies, street sellers, 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. 
Laser Hair Removal and Electrolysis
Laser hair removal (LHR) is the use of lasers to selectively target dark, coarse hairs. It is considered a medical procedure and uses light to target the pigment in dark hairs. The hairs absorb the light and create heat that destroys the hair follicle. 
LHR is FDA-approved for permanent hair reduction. Patients must be evaluated by a medical provider prior to being treated.  Electrolysis uses electric currents from a fine needle shaped probe to destroy the root of individual hair follicles. Electrolysis is FDA-approved for permanent hair removal, and can be used on all hair and skin types.  This procedure is effective for targeting hairs that do not respond to LHR. Neither procedure is covered by health insurance.
When choosing between LHR and electrolysis, it depends what a person wants from the procedure. LHR may be done just about anywhere on the face and body, except around the eyes. There is little-to-no recovery time involved. While new hair may still grow, they generally grow finer and lighter in color than before. As a whole, this procedure tends to work best with fair skin and dark hair.  Electrolysis is also versatile and produces more permanent results. It can help prevent new hair growth for all skin and hair types. Electrolysis may also be used anywhere on the body, including the eyebrows. However, there are usually more sessions of electrolysis than LHR, which may result in a higher cost for electrolysis procedures. 
When choosing a hair removal option, one may also choose to use both types of hair removal processes for different areas of the body. It is important to consult with a physician about skin sensitivities.
Risks of Laser Hair Removal and Electrolysis
Overheating from the lasers can result in redness, blisters, burns, scab formation, and changes in skin color. The procedure itself is also painful and may require the use of topical anesthetics. 
Electrolysis has many of the same risks as LHR, including pain, swelling, tiny blisters, scabs, dryness, and ingrown hairs. To reduce the chances of bad side effects, it’s important to choose an experienced and licensed practitioner. 
It is also important to note that NEITHER home laser NOR home electrolysis devices have demonstrated effectiveness. Both home devices may actually cause harm. 
Tracheal shave involves making one’s Adam’s apple smaller by shaving down the thyroid cartilage.  This procedure involves creating an incision on one’s neck, where the trachea is shaved as much as possible without damaging the vocal cords. The surgery usually takes less than an hour. 
Risk of a Tracheal Shave
Mild discomfort is expected in the days after this procedure. Other side effects may last a few days and could include bruising, swelling, lumpiness around the neck area, sore throat, mild voice weakness, and some tightness around the neck area. 
The incision area may be red and thick for the first few weeks. This is a delicate area and the voice can be affected if too much cartilage is removed.  A tracheal shave should only be performed by an experienced and qualified surgeon.
Facial Feminization Surgery
Facial Feminization Surgeries are surgeries meant to create feminine facial features. They usually include or are a combination of procedures such as botox, lip augmentation, chin contouring, chin width reduction (genioplasty) face-lift, eye and lid modification, jaw contouring, forehead contouring, molar/cheek contouring, and nose reshaping (rhinoplasty).  Like all surgeries, there are risks. As a patient, it is important to assess personal needs and the risks of the procedure. To read about more various procedure options, visit the Mayo Clinic’s Facial Feminization Surgery page. 
According to WPATH, letters of readiness from mental health providers are not necessary for facial feminization surgery. However, mental health professionals can play an integral role in helping one make fully informed decisions about the timing and role of these procedures in the transition process. 
However, facial feminization surgery isn’t the best option for every transgender woman. A doctor might recommend against these surgeries if the patient has:
Unmanaged mental health conditions
Significant health conditions, such as heart or kidney disease, a bleeding disorder, or a history of blood clots in a deep vein (deep vein thrombosis) or in a lung (venous thromboembolism)
Any condition that limits the ability to give informed consent 
Facial Feminization Surgery Risks
As previously noted, any surgery has risks. The decision to have facial feminization surgery is extremely personal and one must decide if the benefits are worth the risks and potential complications of the surgery. The risks of facial feminization surgeries include (but are not limited to), infection, bleeding, poor healing of incisions, failure of the bone to heal, hematoma (localized bleeding outside of blood vessels), prolonged swelling, implant migraine (where an implanted structure moves away from its original location), hair loss, as well as surgical risks involving anesthesia. 
Other short-term complications might include:
· Suture rupture along an incision line
· Fluid accumulation beneath the skin (seroma)
Long-term complications might include:
· Visible scarring
· Dissatisfaction with appearance after surgery
· A facial nerve injury 
Breast Augmentation (Breast Implants)
According to WPATH, the criteria for breast augmentation in male to female patients are the same as those for hormone therapy (see above).
In order to achieve the best aesthetic results, it is recommended that male to female transitioning patients undergo feminizing hormone therapy for at least 12 months prior to breast augmentation surgery.  Although prior hormone therapy is not always required, think carefully before speeding up the process, and discuss options with a qualified surgeon.
Breast implants can either be filled with saline (salt water) or silicone gel. All breast implants have an outer envelope made of silicone. This envelope can be “smooth” or “textured.” All breast implants have risks, but some types of implants have more risks than others.  In general, saline implants with a smooth texture are less dangerous, but may not provide the best aesthetic results. Read here to learn about the different types of breast implants and the risks and benefits of each type of implant. 
Risks of Breast Implants
Breast implants have many risks, including rupture, capsular contracture (hardening of scar tissue around the implant which causes pain and hardness), autoimmune symptoms, breast pain or swelling, and infection. The following Patient Informed Consent Checklist includes most of the risks of breast implants: http://breastimplantinfo.org/
Although breast implants have numerous risks, silicone injections are much more dangerous. As stated by the Food and Drug Administration (FDA), silicone from injections can travel to other parts of the body and block blood vessels in the lungs, heart, or brain. This can result in permanent damage to those tissues and lead to stroke or death. 
Removal of Testicles
An orchiectomy is a surgical procedure that removes the testicles, since they produce sperm and testosterone. There are several types of orchiectomy procedures and transgender patients are not the only ones undergoing these procedures. For example, a cancer patient may need a different type of orchiectomy procedure than a transgender patient. For transgender patients, either a radical inguinal orchiectomy or a bilateral orchiectomy is recommended. In a radical inguinal orchiectomy, the testicles are removed through a small cut in the lower part of your abdominal area instead of your scrotum. In a bilateral orchiectomy, both testicles are removed from the scrotum. Bilateral orchietomy is more common for male to female transgender patients, but both have shown to be effective surgeries. [11
Male to female patients can also consider sperm preservation options and should be encouraged to consider banking their sperm before hormone therapy. 
According to WPATH, “Two referrals—from qualified mental health professionals who have independently assessed the patient—are needed for genital surgery (i.e., hysterectomy/salpingo-
According to WPATH, the criteria for removal of the testes in male to female patients include the same four criteria as those for hormone therapy and breast implants, but also include a fifth criteria:
· 12 continuous months of hormone therapy as appropriate to the patient’s gender goals. (The aim of hormone therapy prior to genital surgery is primarily to introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes an irreversible surgical procedure.) 
The surgeon will remove the testicles from the scrotum. During a scrotectomy, the surgeon will remove the entire scrotum or a portion of it. If the patient thinks that their transition will eventually include a vaginoplasty, which constructs a vagina, a scrotectomy may not be recommended because the scrotal tissue could later be used to create the vaginal lining. 
Risks of Removing the Testicles
The risks of this surgery are typical of many surgical risks, which include bleeding or infection, injury to surrounding organs, scarring, or dissatisfaction with results. Other risks include nerve damage or loss of feeling, infertility, decreased libido (sex drive) and energy, and osteoporosis (a condition where bones become weak or brittle). 
However, the benefit of this procedure is that one’s body will produce less testosterone, which may may make it possible to reduce the dose of feminizing hormones. 
Penile Inversion Vaginoplasty
Before genital surgery (including removal of the testicles), surgeons who follow the WPATH standards of care usually require candidates for surgery to live at least for a year in their preferred gender role before the procedure (this is called the Real-Life Experience or the Real-Life Test). The goal of the Real-Life Test 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 impacts various aspects of their life. Through the Real-Life Test, individuals may realize that they only want to socially transition. In other cases they may realize they want to continue down the medical transition path. By actively experiencing their new reality they are able to establish new behavior patterns, overcome social challenges, and make a more informed decision going forward. Furthermore, the Real-Life Test shows the surgeon that the individual is invested in the surgery and is committed to this irreversible procedure. [3, 26]
Penile inversion vaginoplasty is the surgical procedure that male to female transgender patients undergo to change their penis into a vagina. The testicles and most of the penis are removed and the urethra is cut shorter. Some of the skin is used to create a functional vagina, which is made out from the space between the urethra and rectum.  Then a “neoclitoris” (new clitoris) is constructed from the sensitive skin at the top of the penis. This is so arousal sensations can eventually be felt in the genital area. 
Plastic surgeons consider penile inversion vaginoplasty to be the gold standard genital reconstruction technique.  It is also recommended by the Center of Excellence for Transgender Health. 
Penile Inversion Vaginoplasty Risks
Surgical risks include bleeding, infection, rupture of the surgical sutures, and complete or partial cell death (necrosis) of the vagina and labia. Other risks include an abnormal connection (fistulas) from the bladder or bowel into the vagina, narrowing (stenosis) of the urethra, and vaginas that are either too short or too small for sex. While the surgical techniques for creating a vagina that looks good and functions correctly are impressive, some patients are unable to achieve orgasm. Furthermore, a second labiaplasty (plastic surgery that alters the labia minora and labia majora) may be needed to make visual adjustments. 
Healthline, a website that provides health and wellness information, recommends the following after penile inversion vaginoplasty surgery: 
· Don’t take a bath or submerge the body in water for eight weeks
· Don’t do strenuous activity for six weeks
· Don’t swim or ride a bike for three months
· Showering is fine after the first postoperative visit
· Do sit on a donut ring for comfort
· Don’t have sexual intercourse for three months
· Do apply ice for 20 minutes every hour of the first week
· Don’t worry about swelling
· Do expect vaginal discharge and bleeding for the first four to eight weeks
· Do avoid tobacco products for at least one month
· Be careful of pain medication; take it only as long as absolutely necessary
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.
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