Trans Feminine: The Ultimate Guide to Gender Transition!
"Photo by Dainis Graveris on SexualAlpha" with a clickable link to https://sexualalpha.com
Gender transition for trans feminine adults is not as straightforward as you think. Especially if you decide to pursue a medical or surgical transition, knowing what to watch out for is key.
For example, understanding how progesterone can enhance physical transition or why having your facial surgeon be certified in craniofacial surgery becomes crucial in navigating transition waters.
Since social gender transition can often be self-explanatory or easier to learn about, my aim with this comprehensive guide is to offer all the ins and outs regarding medical and surgical transition.
As a gender specialist with 15+ years of experience, I have written extensively on gender-affirming care and the latest surgical advancements. To aid you in the decision-making process, I bring ALL of that together in this post to give you the essential guide for deciding which medical and surgical interventions are suitable for you.
HORMONE THERAPY
1. Feminizing Hormones - How to Get Started
There is much misinformation on the internet about starting feminizing hormones, and in the post The 4 Biggest Lies of Starting Feminizing HRT! I shared the most damaging lie: you must be in therapy for a long time before you can begin.
While it is true that some states in the US still require a letter from a mental health provider certifying the presence of Gender Dysphoria before starting hormones, you certainly don’t need to spend months and years in therapy to obtain one.
And if you do need a letter, you can obtain gender-affirming letters from the below list of providers:
Additionally, many States have switched to the informed consent model of treatment. What is the informed consent model? An Informed Consent Model allows medical providers to assess for capacity to provide informed consent (able to understand risks, benefits, alternatives, unknowns, limitations, and risks of no treatment).
If you are an adult and plan on starting feminizing hormones, here are my top tips:
Hormone replacement therapy is a great option for adults who know their gender identity.
It’s an important step for trans adults who want medical transition as part of their plan. Remember, being a trans woman does not mean that you must go through all stages of transition.
Feminizing hormone therapy is not a substitute for those still unsure and wondering if they are transgender! This is where therapy can be very helpful.
Informed consent clinics are a fantastic resource for trans feminine adults ready to step into medical transition. The main function is to provide you with access to medical care, NOT help you figure out what your gender identity is.
If you are planning on starting HRT, and want a local provider, visit my resources page in the states I am licensed to find a gender-affirming prescriber in California, Texas, New York, or Florida.
And if you are in the states not listed, no worries; any of the links below offer online consent-informed gender-affirming hormone care.
If you would like a more personalized plan tailored to your specific goals and circumstances and would like to work with me one-on-one, book your free phone consult with me below.
2. What You Need to Know About Feminizing Hormones
Medical transition comprises hormone replacement therapy to aid you with modifying the secondary sex characteristics to the extent possible. Feminizing hormones, while great, is not a miracle, as it has their limitations regarding what they can and cannot do. For example, it cannot change your bone structure, and that sucks because many trans women suffer from what I call “testosterone poisoning.”
However, many things feminizing hormones do change outlined in detail in this blog post: What are Reversible and Irreversible Changes on Feminizing Hormones?
The reason why changes on feminizing hormones vary drastically among individuals, is because numerous factors affect your ability to feminize.
Feminizing hormone therapy often involves a combo of estrogen and androgen blockers, with estrogen as the main hormone responsible for promoting female physical traits.
To maximize the effects of estrogen, lowering testosterone levels becomes essential, with the help of androgen blockers.
For most trans women, lowering testosterone feels incredibly freeing. Additionally, the decrease in sexual arousal and lack of morning erections is a heaven-send to many trans women who struggle with genital dysphoria.
Trans feminine folks who don’t struggle with genital dysphoria or want to preserve their sexual function for numerous personal reasons can often opt out of androgen blockers.
If you would rather remain on blockers but want to enhance your sexual drive, discuss options with your provider, such as topical T-cream or sexual enhancement drugs such as Viagra. I discuss ways feminine hormones affect your sexual function along with what you can do about it in the video: The Effects of Feminizing Hormones on Sexual Function & How to Deal With it.
3. Injections vs. Pill Rumors - True or False?
You most likely heard from many trans women that injections trump all when it comes to HRT administration, and while that is true, at least in my clinical experience, there are certain exceptions.
Some include being pre-disposed to a medical condition such as blood clots, which may require your medical doctor to offer you patches instead.
If you are in great health and your provider is OK with prescribing injections, I’d say that's your best option based on the thousands of trans women I worked with. But hey, don’t take my word for it, especially since I am not a medical doctor but carry a doctorate in Clinical Psychology.
Instead, it would be worthwhile to check out Beverly Cosgrove, a trans woman leading one of the top hormone groups on Facebook. I have covered her group and all the benefits of taking E via injections in Top 12 Myths About Injections for MtF Trans People!
And while we are on this topic, let me cover one more important factor! Oftentimes, I have observed my trans-feminine clients hitting the hormone plateau. A period when you feel there are absolutely no physical changes taking place.
What I have observed has worked, as per their medical doctor's suggestion, is to switch up the route of administration. Hence if you have been taking E via injections for a while and hit a plateau, discuss switching to pills with your doctor. Switching the way E is administered has been observed to spike physical changes.
4. Testosterone Fighter Spironolactone aka Spiro - What You Need to Know!
Since the infamous Dr. Will Powers YouTube presentation Healthcare of a Transgender Patient is a must-see, I have been advising all my clients to discuss getting off the Spiro with their providers. For starters, injectable E is often enough to lower T levels. Additionally, there are other options for androgen out there.
Apart from slowing feminizing changes, my main beef with Spiro is how foggy it makes my clients feel. Patients often describe feeling “out of it” when on Spiro and express more mental clarity when they stop taking it.
If you are still on the fence regarding Spiro, the amazing above-mentioned Beverly Cosgrove has extensively covered the effects on Spiro, which I have written about in Trans Women | The Ugly Truth Behind Spiro. Remember! Don’t stop taking any prescribed medications yourself without consulting your doctor, as many require tapering off.
5. The Magic of Progesterone.
Progesterone has received a mixed review from providers and, in my experience, is often due to a lack of scientific research and comparing trans women's needs to those of cis women.
Yet I have witnessed that adding progesterone to the feminizing hormone regimen has consistently shown numerous benefits! One of the greatest benefits I witness my clients experience is enhanced breast growth. Another is a better mood followed by better sleep, which I covered in The 6 Benefits of Progesterone as Part of HRT Treatment for Trans Women.
PRO TIP:
The endocrinologist, Dr Kristen Vierregger, a gender-affirming endocrinologist, who works with all of my clients, by the way, an amazing human whom I interviewed about various options of hormone treatments, and highly recommend working with, recommends introducing progesterone to your regimen six months into your hormone treatment.
There is something about this six months mark that makes things magically work better.
6. The Truth Behind Stopping HRT Before Surgery
Suppose you are further into your gender transition and are planning to have gender-affirming surgery. In that case, your doctor, depending on their level of knowledge, may suggest lowering or being off feminizing hormones before surgery. The main reason is to prevent venous thromboembolism.
Lowering or stopping your regimen results in an increase in gender dysphoria since your body is no longer receiving the hormone it needs. Additionally, it adds to mood fluctuations and may lead to an increase in post-surgical depression.
Recent research shows that you don’t have to stop your regimen before surgery. In the article I published, Yes! Study Shows You Can Remain on Estrogen for Gender-Affirming Surgery! the study concluded that preoperative venous thromboembolism was not a significant risk for individuals on feminizing hormone therapy.
FERTILITY PRESERVATION
7. Simplest Way to Preserve for Your Future
Many trans women I work with are above 40 and, as a result, either already has kids or oftentimes don’t want to have kids in the future. If you fall into this group, you can skip this section.
But what if you are a young adult or desire to have a family in the future? This is where planning for plan B, fertility preservation, becomes important.
There are various ways to preserve your future baby's potential, from pre- and post-hormone treatment. The simplest method I have written about in The Most Effective & Simplest Method of Fertility Preservation for Trans Women! and the cheapest is to do sperm banking.
Now I know that sperm banking costs plenty of money, and in addition to transition costs, maybe an impossible option for many. For those with the financial luxury to afford it, I highly recommend considering sperm banking at the outset of hormone therapy. Some of the fertile preservation banks I recommend:
HAIR REMOVAL
8. Electrolysis vs. Laser? How to Decide?
When trans women begin their gender transition, I often outline the three main pillars they must work on if, and only if, “passing” is important to them. The three main pillars are hormones (see above chapters), hair removal, and voice therapy (see below).
The reason why these are the top 3 pillars is that they take the longest to accomplish! Read that again! If “passing” is important, starting on these three pillars is vital.
There is much misinformation about which is better, electrolysis or laser, with no conclusive answers. Worse, when it comes to genital hair removal in preparation for bottom surgery (that is, if that's something you plan on), doctors have zero consensuses on what works best.
Let's start with facial hair. I have seen many clients obtaining great permanent results with laser alone and many who used a combo.
PRO TIP: My electrologist Lisa Rullie, one who works with all of my clients, shares this:
The laser may work fine if you have dark hair follicles. Try it, and if any hair comes back, take care of them with electrolysis.
The laser may work fine if you have very dark brown hair (almost black) or black hair. Try it, and if any hair comes back, take care of them with electrolysis.
If you have dark hair and a full dense beard, you may try laser sessions first. I would not keep trying several rounds of laser because it just might not be working, it may only be putting the hair into a dormant stage for a couple of months, and then it all grows back. If the laser does help at all, it sometimes can work on the cheeks and neck area, but the upper lip, lower lip, and chin areas can be more stubborn. With any remaining fine or thicker hair that the laser is not killing, finish it with electrolysis which will kill the rest.
*** Note: laser hair removal is not permanent hair removal and may come back at any time through the years. Electrolysis is permanent hair removal.
If you have light hair follicles, red hair, light brown, blond, or white hair, the laser will not work. Please stick to electrolysis, as the laser will waste your money.
Now let's address genital hair removal in preparation for vaginoplasty. For starters, you want clear guidelines from your surgeon on which area to work on for hair removal because not all skin is utilized to create a vaginal canal.
The main complication you want to avoid for vaginoplasty is hair regrowth in your vaginal canal, leading to infections. I have done a detailed write-up on laser vs. electrolysis in Hair Removal For Vaginoplasty Surgery | What Works? and highly recommend electrolysis for the genital region.
If you are in Los Angeles, my go-to electrologist is Lisa Rullie. If you want to work with gender-affirmed electrologists or laser hair providers and are in the locations I am licensed in, visit my gender resource page to find a provider in California, Texas, New York, or Florida.
VOICE THERAPY
9. Voice Therapy with Provider vs. DIY vs. Voice Surgery?
If your voice causes you to struggle with gender dysphoria or “passing” is your goal, starting voice therapy as soon as possible is a must.
And not necessary because therapy training takes a long time; it doesn’t, not if you work with my top voice therapists Eryn Giteles, MS, CCC-SLP, Nicole Gress MS, CCC-SLP, or Jordan ROSS M.S, CCC-SLP.
But because, as I mention in The #1 Reason Why Starting Voice Therapy is a Must! mastering your feminine voice to the point of not thinking about it when you speak takes time to form a habitual pattern.
When you start with voice therapy, which one of the options, provider, vocal surgery, or DIY, works best? I prefer voice therapy training because it has proven effective. As covered in The 5 Myths on Transgender Voice Therapy Debunked by a Voice Specialist! the DIY approach can harm your vocal cords. Surgery can either deliver no results or lead to complications.
Regarding voice feminization surgery, it is important to know that transgender voice surgery is focused on pitch change. For voice feminization, surgery focuses on raising the habitual speaking pitch and reducing the ability to produce a low-pitched voice. Surgery will only change your pitch, and you may still need to work on other vocal behaviors with a voice therapist! There are also risks of surgery, such as:
surgery could raise your voice to become too high
your voice may end up rough or hoarse
It may feel strained or breathy, making communication difficult
PRO TIP:
If you do not have the financial means to work with a voice therapist or have a voice feminization surgery, DIY training such as TransVoiceLessons on YouTube is a solid option.
Working with a voice therapist can help you achieve desired results if you have the financial means. Visit my gender resource page to find a gender-affirming voice therapist in California, Texas, New York, or Florida.
If you have financial means and would rather have vocal surgery, ensure the surgeon has voice feminization surgery experience. Visit my gender resource page to find a gender-affirming voice therapist in California, Texas, New York, or Florida.
BREAST AUGMENTATION SURGERY
10. What do You Need to Know About Breast Surgery?
Some trans women are fortunate to obtain the desired breast size on feminizing hormones alone. The anecdotal rule of thumb is to look at females in your family to assess your potential for feminizing hormones.
When the desired breast size is not achieved, breast augmentation surgery becomes the next step in the transition.
If you are getting ready for breast surgery, the first thing you need to realize is that transgender breast surgery does differ from cisgender breast surgery.
This becomes an important distinction because you want to work with a surgeon who has experience working on transgender bodies and understands key anatomical differences, such as differences in the width of the rib cage. You can read a summary of all five key differences in The 5 Main Reasons Why Transgender Breast Surgery Differs From Cisgender.
When choosing the breast size, you may have heard me discuss the “rice method” in my video 4 Essential Tips For Breast Surgery You Don't Want to Miss! The rice test is credited to Dr. Scot Mosser, a prominent gender-affirming surgeon in San Francisco, CA. It is one of the best ways to figure out which breast size you feel most comfortable with, and you can learn more about rice test here.
Once you decide on the breast size, the next decision is between saline vs. silicone implants. While you may think there are no differences between them, there is a difference.
As I described in How to Choose Between Saline vs. Silicone | Transgender Surgery?, generally speaking, silicone implants are softer. They feel more natural, making them ideal for transfeminine patients with little breast tissue covering the implants.
When deciding which implant to go with, I recommend hearing what your doctor offers based on your current breast tissue, the size you want to achieve, and your overall feel and look.
11. How Long Should You be on HRT Before Breast Surgery?
People often assume a year on hormones is a requirement before getting surgery. The truth is that World Professional Association for Transgender Health guidelines does not require a year of feminizing hormones before the surgery. Still, it may be to your benefit to wait a year or two for these reasons:
Firstly, you may achieve the desired breast size naturally via hormones.
As you go through gender transition and your body becomes more aligned with your gender, your perception of what is aesthetically beautiful, small breasts vs. large breasts, shifts.
Additionally, having breast tissue, even in small amounts due to feminine hormones, can help wrap around the implant, making for a more natural appearance.
FACIAL FEMINIZATION SURGERY
12. Why is Craniofacial Plastic Surgeon a Must?
Facial feminization surgery is often the first surgery in the sequence of surgeries a transfeminine patient goes through. That’s because your face is visible to everyone and often causes the most gender dysphoria, especially if “passing” is a goal and misgendering happens often.
In my experience, facial surgery is a game changer for many trans women and can drastically help reduce gender dysphoria. But are all plastic surgeons work alike? Far from it, and here is where the main difference lies.
Most plastic surgeons can only perform the sum of the soft tissue procedures, leaving bone work untouched. Unfortunately, many trans women who desire to “pass” struggle with masculine facial features because of their bone structure due to exposure to testosterone. These trans women often need bone surgery, such as forehead contouring, involving reshaping skull bones to a more feminine shape.
Now that’s a skill, even a specialty, and not everyone can perform. Enter the plastic surgeons certified in craniofacial and maxillofacial training. The training aimed at working with the bone structure on the face, not just the soft tissue covering it.
When looking for a facial surgeon, make sure to inquire about their training and ask them the questions Dr. Keojampa, a prominent facial feminization surgeon in California, shared with me during our interview in Trust Me! You Want Your FFS Surgeon to be Craniofacial/Maxillofacial Trained!
Keep in mind that the goal of facial surgery is to feminize your face. Not to completely make you look like someone else. That’s simply unrealistic, not to mention psychologically traumatizing. What you want to aim for are real results that I have discussed in my video Trans Women! Here is What Facial Feminization Can't Do! Think along the lines of: “If I had a twin female sister, what would she look like?” The more realistic your expectations are, the better off you’re going to be.
13. How Long Should You be on HRT Before Facial Feminization Surgery?
The WPATH guidelines do not require a year of hormone therapy before the surgery. There is, however, much misinformation on the internet suggesting one waits 2-4 years to obtain the best feminizing results on hormones alone.
Over the decade of my career, I have noticed that skilled facial feminization surgeons don’t need to wait until you obtain the ultimate results from HRT. That’s because they are primarily concerned with feminizing your facial bones, an aspect of your facial structure that does not change due to hormones. They also understand that the feminizing hormones will continue to soften your features even more once the surgery is performed.
PRO TIP:
If you desire facial feminization surgery and have the financial means to go with the top gender-affirming facial surgeon, book your consult today!
Yes, drop whatever you are doing right now and book your consult! The top surgeons are booked for a year, two, or even three for an actual surgical appointment.
Remember, my gender resources page has the best gender-affirming surgeons in the states I am licensed. Visit my gender resource page to find a gender-affirming surgeon in California, Texas, New York, or Florida.
VAGINOPLASTY SURGERY & ORCHIECTOMY
14. Types of Vaginoplasty Surgeries to Consider
In the US, the most common vaginoplasty technique is penile inversion. A technique where a vaginal vault is created between the rectum and the urethra and the vaginal lining is created from penile skin.
If a trans woman does not have enough penile tissue to create a vaginal canal, a sigmoid colon vaginoplasty may be an option. This technique utilizes a part of the colon for the inner lining of the vaginal canal.
A more recent and highly desired technique is a peritoneal pull-through vaginoplasty, known as PPT, performed by a few surgeons in the US, with my top referred to Dr. Wittenberg, Dr Ting, and Dr. Bluebond-Langer.
Another option is a zero-depth vaginoplasty or minimal-depth vaginoplasty, a procedure including orchiectomy, penectomy, and the creation of sensate neo-clitoris, labia minor, and major, all without the creation of neovagina or vaginal canal. A procedure gaining popularity among older individuals who are not interested in sexual intercourse, trans women who identify as asexual, and trans women who lack adequate tissue to qualify for other types of vaginoplasty techniques. This technique also reduces complication rates, as I discussed in Should You Consider Zero Depth Vaginoplasty? There is also no need for dilation.
Abroad, primarily in Thailand, non-penile inversion vaginoplasty, also known as the Suporn technique (after Dr. Suporn who invented it) uses perforated scrotal tissue to graft for vaginal lining and intact scrotal tissue for the labia majora.
15. The Myth of Self-Lubricating Vagina!
The number one desire I hear from trans women is a self-lubricating vagina! And please don’t forget that as women get older and experience menopause, lubricant becomes a must for all types of vaginas!
Since the addition of sigmoid colon and peritoneal pull-through vaginoplasty, there has been much talk about trans women being able to achieve self-lubrication. To evaluate the myth I reached out to gender-affirming surgeons and probed deeper, as I wrote in Trans Women! The Myth Behind the Self-Lubricating Vagina!
What I discovered was fascinating. For example, penile inversion does not produce lubrication, except small gland in the urethra. In the sigmoid colon, part of the colon is used for the inner lining secrets mucus, acting as a lubricant. In peritoneal pull-through, part of the peritoneal used for the inner lining of the vaginal canal produces lubricant. Read the above-mentioned blog post for a more juicy detail.
The myth of a self-lubricating vagina is less of a myth, depending on how technical one gets.
16. Is it True You Need to Dilate Less with Peritoneal Pull-Through Vaginoplasty?
When I wrote Risks and Benefits of Peritoneal Pull Through Vaginoplasty one of the top 6 benefits listed was less need for dilation compared to the penile inversion technique. That article was written in 2019 when this technique was gaining popularity, and little was known of long-term follow-up studies. Back in 2019, even doctors assumed less need for dilation was needed.
Fast forward to 2022, where I sit down with Dr. Wittenberg and Dr Bonnington, top gender-affirming surgeons specializing in peritoneal pull-through, and explore whether the benefits I have written about prior, including dilation, are still true.
As mentioned in Doctors Share What They Have Learned After Performing 185 Peritoneal Pull-Through Vaginoplasties! I highly recommend reading this if you are considering this procedure, both doctors made it clear that dilation requirements are the same as penile inversion and that the long-term data of follow-up patients demonstrate loss of depth if they do not dilate.
If you are considering this procedure hoping to avoid dilation, please note that you may end up with vaginal stenosis. Vaginal stenosis is when the vagina becomes narrower and shorter, often described as “loss of depth.”
In the blog post The 3 Tips To Help Reduce Risk of Vaginal Stenosis for Providers and Patients! I have discussed how vaginal stenosis is one of the most common complications transfeminine patients face. This often happens sadly because many don’t set expectations of post-op care, are not psychologically prepared, and neglect to identify barriers to post-dilation.
17. What You Need to Know Pre and Post-Vaginal Surgery!
Vaginal surgery is often the last step in the transition process for trans women desiring bottom surgery. Still, it can also be the first, depending on your level of genital dysphoria. The most important things to know about are:
Even though WPATH issued the latest Eight Version of Standards of Care in 2022, outlining one letter requirement from a mental health provider before surgery, your doctor and insurance company will most likely require two evaluation letters. That’s because insurance takes a long time to conform to the new standards. Make sure you are prepared with two letters, one of which has to be obtained from a Ph.D.-level provider.
You can obtain gender-affirming surgical letters from the below list of providers:
Start genital hair removal right away! Make sure you ask your doctor which area they would like cleared. Suggest reading Hair Removal For Vaginoplasty Surgery, What Works.
Ensure your gender-affirming provider is experienced in genital reconstructive surgery! To help you with the process, I have put together 11 Tips on How to Choose a Gender Affirming Surgeon!
Get your support system in place or have one person who can be there for you during your first week after the surgery. Do not underestimate this part of the process.
As you prepare for surgery, ensure you have your must-have essentials recommended by gender-affirming surgeon Dr. Satterwhite in The 8 Must-Have Essentials for Your Postoperative Vaginoplasty Kit!
Expect these five most common post-operative issues: pain, nausea & constipation, wound separation, discharge, and swelling. To know how to handle each of these issues, make sure to read and have your support person read, The 5 Most Common Postoperative Issues You Wish You Knew About Following Vaginoplasty!
Above all, BREATHE! I promise you got this!
18. Should You Consider Orchiectomy Before Vaginoplasty?
Many transfeminine patients considering penile inversion vaginoplasty are afraid to go for orchiectomy because they fear losing testes tissue they will later need for vaginoplasty. The truth is, with the right surgeon, you won’t.
That’s because a gender-affirming surgeon specializing in vaginoplasty knows how to preserve testes tissue while removing testes. And if you are considering orchiectomy with a doctor, such as a urologist, who will not perform vaginoplasty, ensure they are aware of your plans or have them talk to your gender-affirming surgeon.
Especially since the wait time for genital surgery with a skilled surgeon can be up to 2-3 years, getting an orchiectomy earlier is a great option, not to mention it is an outpatient procedure. Some of the main benefits I outlined in The 3 Main Benefits of Getting Orchiectomy! Include no longer having to take androgen medication to reduce testosterone blockers and increased comfort with tucking.
