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Approximately 25 million people living today face an unusual problem: their sense of self does not match the gender they were born with.
To achieve harmony with themselves and the world, many of these people undergo a transgender transition.
In this article, we use words that are understandable to most readers, avoiding medical terms and slang used in the LGBTQ+ community as much as possible. However, new words are used occasionally and their meanings are explained in the text and in the margins.
Why people may be uncomfortable in their own bodies.
Most people in childhood realize that they are boys or girls. This is determined not only by the things that their parents dress them in, but also by their inner sense of self. The realization of belonging to a certain gender is called gender identity.
Some people feel that their “inborn” gender does not match the gender they feel like. Genetically, hormonally, and in terms of reproductive organs, a person may be a man, but still firmly know that they are a woman. And vice versa. There are also non-binary people, who in general do not feel a belonging to either of these genders.
The state in which a person suffers from a mismatch of gender identity and biological characteristics of their body is called gender dysphoria. This has nothing to do with sexual orientation. Scientists and doctors do not fully understand why some people develop gender dysphoria.
International medical community representatives do not consider gender dysphoria as a mental illness. In other words, they recognize that the problem is not in a person’s mind, but in their body. People with gender dysphoria do suffer: approximately half live with depression and anxiety, and 30% have attempted suicide at least once in their life.
It is incorrect to refer to people with gender dysphoria as transgender, as gender identity is not directly related to sexual orientation and behavior. In the International Classification of Diseases, 10th Revision, which is still followed in the world, the diagnosis of F64.0 “transsexualism” is classified under the section of mental illnesses and disorders. In the International Classification of Diseases, 11th Revision from 2019, transgenderism was placed in a separate section not related to psychiatry.
How to correctly name transgender people
People whose gender identity does not match the gender assigned at birth are referred to as transgender people or trans people. A transgender person with a feminine identity (feels like a woman) should be correctly referred to as a transgender woman or trans woman. A transgender person with a masculine identity (feels like a man) should be correctly referred to as a transgender man or trans man.
What is “gender transition” and how does it occur?
There are two main types of transitions: transmasculine, which aims to acquire masculine traits, and transfeminine, which aims to acquire feminine traits.
There is no one correct scenario for such a transition. Each transgender person has their own. It is important to understand that not all transgender people have the ability and desire to make a gender transition. Some cannot afford it or have safety concerns. Some are afraid of rejection from loved ones and discrimination.
Some transgender people only make a social transition: they explain to friends, family, and colleagues in what gender and by what name they prefer to be addressed, wear appropriate clothing, or use decorative cosmetics.
The same applies to identity-confirming documents: some people change them, while others do not. Some people take hormone medication but do not undergo surgeries, while others resort to surgical manipulations. This allows for not only social, but also maximum external conformity to the preferred gender.
That’s why using the phrase “gender change” in the context of treating gender dysphoria is incorrect. It only describes one part of the process—the change of gender marker in the passport. But this is far from everything that may be included in an individual’s transition history. It is correct to use the term “transgender transition” or T-transition.
In this article, we will consider the situation when a person plans a maximum T-transition program: to replace all documents and transform their appearance through hormone therapy and surgical operations.
Several stages of transgender transition can be distinguished:
- Psychiatrist consultation.
- Medical commission.
- Hormonal therapy.
- Preservation of sex cells.
- Surgical operations.
- Changing of documents.
There is no mandatory sequence for these stages. Some stages can be carried out simultaneously with each other. For example, a transgender person can simultaneously take hormonal drugs under the supervision of an endocrinologist and undergo a medical commission.
Why is hormone therapy needed?
At this stage in a transgender person’s life, an endocrinologist who conducts hormone therapy appears. The drugs help achieve desired physical characteristics.
Many transgender people prefer to start therapy on their own, relying on schemes from thematic forums and chats. However, this is not the best solution. Taking hormones without the supervision of an endocrinologist is dangerous to your health. For example, combined oral contraceptives, which are often taken to quickly change their appearance to a “typical female” appearance, are not suitable for long-term therapy due to the high risk of fatal venous thromboembolism.
It is more reasonable to undergo an examination by an endocrinologist before starting therapy. It is important that this endocrinologist understands how to help trans people: not all doctors, both from state and private clinics, have such experience. The doctor will direct you to tests to evaluate liver and kidney function, blood composition. The results of the diagnosis will help the doctor determine which of the drugs will be the safest.
During hormone therapy, negative outcomes for health are possible. These are the main risks for trans individuals:
- For transfeminine transition – thromboembolic disease, macroprolactinoma, breast cancer, ischemic heart disease, gallstone disease and cholesterol metabolism disorder.
- For transmasculine transition – erythrocytosis, severe liver dysfunction, ischemic heart disease, arterial hypertension and breast and uterine cancer.
If there are increased health risks, the question of hormone therapy is decided individually. Sometimes it has to be postponed until a health problem is resolved.
An endocrinologist helps a patient choose a hormonal therapy regimen based on their health status, existing risks, and individual sensitivity to hormones. The doctor takes into account the patient’s preferences. For example, someone wants to look as masculine or feminine as possible, while someone else wants to look androgynous, without pronounced male or female traits in appearance.
During the first year of hormone therapy, endocrinologist consultations and blood analysis monitoring should be at least every three months. Afterwards, at least once every six months. Therapy regimens may change with age.
Hormonal preparations are prescribed for life. Otherwise, changes will not be preserved, and appearance will mostly return to its original state. This property of hormone therapy is important for people who have decided to undergo detransition.
Why hormonal therapy is not prescribed for transgender children
If hormone therapy is given to a child, it will cause premature puberty. When a teenager with gender dysphoria reaches puberty, they need to undergo a medical examination to assess the risks of further treatment. Then, they can either start hormone therapy or suppress puberty with non-hormonal drugs to delay the decision-making process. Before reaching the age of majority, both options are only possible with the consent of the guardians.
For two types of T-transition hormone therapy is conducted with different drugs.
Transfeminine transition — with estradiol and progestins with anti-androgenic effect, which are essentially female sex hormones. The use of gonadotropin-releasing hormone receptor agonists is possible, they are used to slow down sexual maturity.
Female sex hormones lead to feminization of appearance: fat tissue on the body is redistributed, mammary glands grow, areolas of nipples increase, body hair changes to female type, while facial hair growth usually continues, although slower. The voice usually does not change.
What Happens to the Body During Feminizing Hormone Therapy
| Changes | Onset | Maximum | Reversibility |
|---|---|---|---|
| Slowing of hair growth on face and body | 6-12 months | 3 years | Yes |
| Redistribution of fat tissue | 3-6 months | 2-5 years | Yes |
| Decrease in muscle mass | 3-6 months | 1-2 years | Yes |
| Decrease in libido | 1-3 months | 1-2 years | Yes |
| Growth of mammary glands | 3-6 months | 2-3 years | No |
Transmasculine transition – using testosterone preparations for masculinization. With regular testosterone administration, muscle mass increases, the voice becomes lower, body hair changes to a male pattern (for example, a beard begins to grow), the clitoris enlarges forming a so-called micro-penis.
What happens to the body during masculinizing hormone therapy?
| Changes | Onset | Maximum | Reversibility |
|---|---|---|---|
| Growth of facial and body hair in a male pattern | 6-12 months | 4-5 years | No |
| Redistribution of fat tissue | 1-6 months | 2-5 years | Yes |
| Increase in muscle mass | 6-12 months | 2-5 years | Yes |
| Increase in libido | 1-3 months | Individual | Yes |
| Change in voice | 3-6 months | 1-2 years | No |
| Increase in clitoris | 3-6 months | 1-2 years | No |
| Ceasing of menstruation/ | 2-6 months | Individual | Individual |
Why are surgical interventions necessary?
Surgeries to change external sex characteristics are not mandatory, like any other stage. But for someone, they may become a necessary step towards a quality life in the desired gender role.
There are usually two arguments for surgical intervention during gender transition:
- The desire to align one’s body with their internal sense of self. For some trans people, the external sexual characteristics of their “birth” gender are a source of discomfort in and of themselves.
- The desire to avoid discrimination, transphobia, or even threats to life in gender-segregated spaces, such as changing rooms, showers, and public toilets in sports facilities, swimming pools.
It is important for the surgeon to discuss the risks of the surgery for sexual life and fertility with the patient before the intervention. Although surgical technologies have improved in the last ten years, the problem still persists. Because of this, many transgender people are dissatisfied with the results of the surgery.
Interventions in transfemininity transition
Breast augmentation. For transgender women, plastic surgery to increase the breast is recommended to be performed no earlier than two years after the start of estrogen therapy: during this time the mammary glands continue to develop.
Orchiectomy. The removal of the testicles may be discussed even if the presence of the gonads itself does not disturb the patient, but they continue to produce testosterone, and this process cannot be suppressed due to contraindications to drugs, individual peculiarities, or the high cost of treatment.
Penectomy. The removal of the penis with clitoroplasty and/or vaginoplasty (formation of a neovagina from their own tissues) is a surgery performed when a transgender person wants to drastically change the appearance of their external genitalia.
Surgeons can create a neovagina using the skin of the penis, fragments of the intestine, or oral mucosa epithelium. The glans transforms into large labia and the tissue of the penis head is used to form the clitoris. Recently, techniques for creating small labia and uterus transplantation surgeries have been developed.
Sometimes transgender people surgically reduce the testicles and perform surgery on the vocal cords: during hormone feminization, the voice does not change and surgical intervention helps to make it higher. Vocal exercises with a speech therapist or a phoniatrist also help to set the voice.
At the patient’s request, the plastic surgeon can perform a facial feminization surgery that smoothes male features of the appearance.
Interventions during transmasculinity transition
Surgeries to correct external genital features in transgender men are not performed until several years after starting hormone therapy.
Mastectomy is probably the most important intervention for transgender men. The size of the mammary glands decreases only slightly, if at all, as a result of hormone therapy. This operation is often a necessary condition for comfortable life in a new social role.
Salpingo-oophorectomy, vaginectomy, and hysterectomy are the removal of the ovaries and their appendages, the vagina, and the uterus, respectively. These surgeries are typically performed if the patient has a high risk of developing ovarian or endometrial cancer, there are gynecological diseases, or menstruation continues even with hormone therapy.
The creation of a neopenis – a sexual organ created from the patient’s soft tissue, clitoris and skin. The operation is often performed in several stages and is expensive, but the cosmetic results are usually good. Modern surgical techniques for forming a neopenis vary – the choice depends on the patient’s goals.
Phalloplasty. Recommended if the goal of the operation is a good appearance of the neopenis, urination standing, sexual sensitivity or the ability to have penetrative sex with penetration. This is a technically complex and expensive procedure that is performed in several stages. To use the neopenis for penetrative sex, a mechanical implant such as a rod or even a special hydraulic device is inserted into it.
Metoidioplasty. A simpler operation resulting in a micro-penis, often without the ability to urinate standing. With metoidioplasty, the erection of the micro-penis occurs on the same principle as the clitoral erection. Sometimes this is enough to engage in penetrative sex.
Scrotoplasty is the creation of a pouch from the labia majora in which testicular implants are placed. The procedure is often performed simultaneously with the creation of a neopenis.
Many transgender men do not undergo surgeries on external genitalia as it is difficult, expensive, and the risk of complications is high.
How to preserve sperm cells
In case a person wants to have biological children, it’s advisable to freeze sperm cells in advance. This gives a chance to become a parent even after surgical removal of reproductive organs or a long hormonal therapy.
Not all doctors are aware of this possibility. Moreover, some transgender people who want to start the transition as soon as possible refuse to see a reproductive specialist: they think that preserving sperm cells will take a lot of time.
In reality, cryopreservation of oocytes in transmen can be done even after many years of hormonal therapy by taking a break from the medication. The break is individual, but one should be prepared to stop hormonal therapy for up to six months. The main condition is the preservation of ovaries and absence of contraindications for stimulation.
Regarding cryopreservation of spermatozoa in trans men, it is best to perform it before starting hormonal therapy. Female hormones suppress the formation of reproductive cells in the testes. Therefore, there is a risk that even after discontinuing treatment, it will not be possible to obtain healthy spermatozoa.
How long does it take to preserve reproductive cells?
Trans men who have decided to cryopreserve their reproductive cells before starting their transition should allocate at least two months for this. During the first month, a thorough medical examination is required. During the second month, the procedure for obtaining and freezing the eggs should be carried out.
The procedure for freezing spermatozoa will take one visit to the cryobank provided that the results of blood tests for infections – HIV, syphilis, hepatitis B and C – are already ready.
Why Psychological Support is Important
Gender dysphoria is a stress in and of itself. Moreover, transgender people often face rejection, discrimination, and even persecution from those around them, including family members. So psychological support is important.
In addition to traditional forms of psychotherapy such as individual, couples, family and group therapy, there is also what is known as peer counseling, where one transgender person counsels another. This type of counseling emerged from support groups for people living with HIV. Because of stigma, they often fear seeking help from doctors, and it is often easier to first talk to people with similar experiences.
Transgender people often receive current information about their transition, access to medical and psychological services, and contacts of friendly doctors from each other. This has led to the development of peer counseling services.
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