Trans Masculine: What Does it Mean for You? Guide to Help with Medical and Surgical Transition.
Gender transition for trans masculine 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 whether you should go with a drain-free mastectomy or which penile implant is best for you 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. Masculinizing Hormones - How to Get Started
There is much misinformation on the internet about starting masculinizing hormones, and in the post The 3 Biggest Lies of Starting Masculinizing 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 HRT 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 masculinizing hormones, here are my top tips:
Hormone replacement therapy is an excellent option for adults who know their gender identity.
It’s an essential step for trans adults who want medical transition as part of their plan.
Masculinizing hormone therapy is not a substitute for those still unsure and wondering if they are transgender! This is where therapy can be beneficial. And note that masculizing hormones can produce immediate, irreversible changes.
Informed consent clinics are a fantastic resource for trans masculine adults ready to step into medical transition. The primary 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 Masculinizing Hormones
Medical transition comprises hormone replacement therapy to aid you with modifying the secondary sex characteristics to the extent possible. Testosterone or T is an essential part of the HRT regimen for those seeking to masculinize.
Testosterone, while great, is not a miracle, as it has its limitations regarding what it can and cannot do. For example, it cannot change your current chest. While your chest size may become smaller due to the redistribution of body fat and muscle, testosterone will not remove your chest, which leaves many suffering from increased chest dysphoria.
There are many positive, permanent changes many can’t wait to experience, such as hair growth on the face and deepening of the voice, along with numerous other changes I described in What are Reversible and Irreversible Changes when Masculinizing with Testosterone?.
You need to be aware that masculinizing hormones produce different changes at different times and that the results you want to get may drastically vary from someone else’s results.
The reason why changes on testosterone vary drastically among individuals is that numerous factors affect your ability to masculinize; common ones include:
It is very common for someone to desire facial hair only to wait a whole year or even two until you start seeing the results, even when your T levels are in the normal range.
Likewise, it is common for someone to experience a deepening of their voice a few months into treatment, while someone else may wait several years for the same effect.
Hopefully, you won’t have to wait for desired changes to occur, but if they do, please be mentally prepared and know that’s a natural part of the process.
3. Is There a Link Between Testosterone and Aggression?
The idea that you will become very aggressive on hormones is a lie that comes from gender stereotypes of men as aggressive and violent.
Yes, starting T will change how your emotions will fire and there will be a natural period for you to adjust to how you feel. But to say that you will become a raging lunatic is simply false!
In the blog post The 3 Biggest Lies of Starting Masculinizing HRT! I outline a 2018 study, “Does Testosterone Treatment Increase Anger Expression in a Population of Transgender Men?” that assessed the effects of testosterone treatment on anger expression in trans men.
The study concluded that in the observed subjects, the expression of anger increased, BUT the increase was due to:
Persistence of menstrual bleeding
AND…
Due to the already presence of anxiety disorders, such as panic disorder, social anxiety disorder, etc.,
Now if you think about it, I’d be pretty pissed off too, if I was still getting menstrual cycles while on T! Talk about experiencing severe dysphoria.
Note that feeling angry is not the same as acting aggressively or violently.
Your angry feelings will likely increase on T, but that's because you will now experience the changes you want. The contrast to the feminine features you already do possess will also increase, thus increasing your gender dysphoria.
TOP SURGERY - MASTECTOMY
4. How to Decide When to Have Top Surgery
Most trans men I encountered experienced mild to severe gender dysphoria regarding their chest. The bigger your chest is, the more severe your physical dysphoria may feel, leading to increased discomfort with how you experience yourself.
If you have started testosterone and have begun to experience the masculizing effects you desire, your chest dysphoria will most likely increase. This is because you are starting to present more and more as your true gender, and any signs of feminine attributes will make you feel profoundly uncomfortable and may lead to being misgendered.
Top surgery, or mastectomy, is a surgical procedure that removes breast tissue to masculinize the chest.
Most individuals decide to have top surgery at the start of their gender transition. Others wait for numerous personal reasons: finances, insurance approval, lack of health insurance, etc.,
PRO TIP:
Remember that one year on hormones is NOT required according to the WPATH guidelines. Many inaccurately assume they need to be on testosterone for at least a year, prolonging their suffering from gender dysphoria.
You will require to have one or two (depending on your insurance requirements) letters of approval from a mental health provider certifying the presence of Gender Dysphoria diagnosis. If you do need a letter, you can obtain gender-affirming letters from the below list of providers:
If you are planning on getting top surgery and need help finding a doctor, I highly recommend checking out my gender resource page in the states I am licensed in to find a gender-affirming surgeon in California, Texas, New York, or Florida.
5. The 6 Main Mastectomy Options to Choose From & How to Determine Best Option for You?
There are a number of surgical techniques available, and most surgical techniques depend on the size of your chest and its level of elasticity or firmness. The location of the incision is also critical. As well as your desire for the preservation of nipple sensitivity.
For these reasons, selecting a surgeon specializing in gender-affirming care is crucial! Trust me. I have sadly written numerous revision letters of approval for trans guys with botched results. Please do not make this mistake.
Today, there are many skilled gender-affirming doctors available to choose from. My top three are Dr. Mosser, Dr. Gallagher, or Dr. Garramone.
The 6 main mastectomy options available to you are:
Keyhole procedure
Periareolar procedure
Double Incision procedure
Inverted-T (Anchor) procedure
Buttonhole Procedure
Fishmouth Procedure
As you can see, each of the above procedures comes with benefits and costs and I have outlined a clear PROS and CONS list of each procedure in The 6 Main Mastectomy Options for Trans Chest Surgery, Including Pros & Cons!
Curious to determine which procedure may be right for you? I highly recommend checking out The Mosser Method by Dr. Mosser to determine which option may be best for you.
If you are planning on getting top surgery and need help finding a doctor, I check out my gender resource page in the states I am licensed in to find a gender-affirming surgeon in California, Texas, New York, or Florida.
6. Pros and Cons of Drain-Free Top Surgery!
Most common mastectomy procedures, such as a double incision or peri-areolar top surgery, often require drains. Anyone who had top surgery with drains can vouch for what pain in the ass they can be. Not only do you leave the hospital with drains, but you will need to empty your drains periodically throughout the day for up to a week.
Additionally, many trans guys experience a lot of pain at the time the drains are being removed. For these reasons, many covet finding a surgeon who doesn’t use the drains, a specialty on its own with only a select few performing this procedure.
There have been a number of research studies on the benefits of drain-free surgery. Some of which I outlined in Benefits of Drain-Free Top Surgery for Trans Man & Non Binary! include:
Gender confirmation surgery using drain-free techniques with progressive tension sutures decreases the incidence of hematoma (Gallagher, S., Rahmani, F., and Duquette, S., 2018)
Decreases the need for acute re-operation (Gallagher et al., 2018)
May also shorten the hospital stay (Gallagher et al., 2018)
And decreases the need for revision surgeries (Gallagher et al., 2018)
While this may be the desired procedure, it is important to remember that not all surgeons recommend it. Dr. Garramone, a prominent gender-affirming surgeon, for example, doesn’t recommend this procedure due to the risks to not having drains placed after surgery including:
Excessive swelling
Increased pain
Serum (fluid pocket) formation
Contour irregularities from a serum
Delayed healing from a seroma, etc.
As with any procedure, there will be pros and cons to consider and I highly encourage an in-depth discussion with your surgeon.
If you are looking for a skilled surgeon, I recommend following 11 Tips on How to Choose a Gender Affirming Surgeon.
And if you are interested in undergoing drain-free top surgery, there is Dr. Gallagher in Florida and, as far as I am aware, Dr. Dulin and Dr. Harris in Texas.
FACIAL MASCULINIZATION SURGERY (FMS)
7. Main Facial Masculinization Options to Consider and How to Decide if You Should Have Surgery?
Many trans men struggle with facial gender dysphoria and experience dissatisfaction with how their face appears. It is common to desire a defined jawline, broader face, or the appearance of Adam’s apple.
The tricky part is knowing when you gave testosterone enough time to offer you these benefits without the surgery. Yes, testosterone does help masculinize the face and not only via the growth of facial hair but by thickening some of the facial bone structure.
To figure out whether you need facial masculinization surgery, consider how long you have been on testosterone and what changes you have experienced. One to five years is often sufficient depending on how your body metabolizes the hormone. Remember, deciding on when to have facial masculizing surgery is a personal quest.
Facial Masculinization Surgery is a surgery aimed at modifying facial features and underlying structures to make a face appear more masculine.
It involves a set of surgical procedures that include specialized reconstructive and plastic surgeries.
How many procedures you go through depends on your existing facial structure and desired aesthetic outcomes. The most common facial masculizing procedures are:
Forehead lengthening and augmentation
Jaw augmentation
Rhinoplasty
Chin surgery
Adam’s apple implant
Each one of these procedures offers its own benefits to help you achieve masculinizing facial features you are looking for and each has been described in detail in What are the 5 Main Procedures in Facial Masculinization Surgery?
If you find yourself desiring to masculinize your face without undergoing major surgery, various options are available. Some of the most common ones discussed in The 3 Main Masculinization Options Without Undergoing a Major Surgery! include:
Chin liposuction
Chin implants
Dermal fillers
PRO TIP:
Remember, as with any gender-affirming surgery, having a doctor who specializes in FMS is a must.
If you are looking for a gender-affirming surgeon offering these procedures, you may want to consider Dr. Scott Mosser.
Other gender-affirming surgeons specializing in Facial Masculinization Surgery, such as Dr. Josef Hadeed or Dr. Jordan Deschamps-Braly, are offering these services.
METOIDIOPLASTY, PHALLOPLASTY, & HYSTERECTOMY
8. Metoidioplasty Surgery - How to Decide?
Metoidioplasty and phalloplasty are two main options for trans men seeking gender-affirming surgery.
Metoidioplasty, a lesser complicated of the two, is a surgery where the existing genital tissue of the testosterone-enlarged clitoris is used to create a phallus. This gender-affirming procedure can be done with or without lengthening the urethra, including creating the scrotum.
Numerous factors affect your decision-making, and to help you narrow it down, in the blog Metoidioplasty vs. Phalloplasty? Here Are 4 Tips to Help You Decide! I encourage you to consider the importance of:
Sensation
Aesthetic results
Ability to have penetrative sex
Standing to pee
Out of the two surgeries, metoidioplasty carries less risk and fewer complications. As far as the benefits go, well, that’s a very subjective category determined by what you consider essential concerning your gender and your lifestyle.
I recommend first considering the benefits of metoidioplasty, outlined in detail in The 7 Benefits of Metoidioplasty in Trans Men! Which includes important benefits such as sensation, lower complication rates, and less scarring.
9. Phalloplasty Surgery - What You Need to Know!
Phalloplasty is a more complex multi-staged procedure where a penis is created using a donor site, often radial forearm free flap RFFF or anterolateral thigh flap ALT. Phalloplasty may include a variety of different procedures, including lengthening the urethra, creating the tip (glans) of the penis, creating the scrotum, removal of the vagina, and placing erectile and testicles.
If you are planning on undergoing phalloplasty, you most likely have heard that it is one of the most complicated gender-affirming procedures on the menu, and that’s true.
That’s because it’s easier to resect tissue than to add to it. And since in phalloplasty, a neophallus is constructed, it is considered a much more complex surgical procedure.
Even with the higher complication rates, phalloplasty remains one of the more desired procedures by trans men compared to metoidioplasty. Mainly as discussed in Metoidioplasty vs. Phalloplasty? Here Are 4 Tips to Help You Decide! if the size and length are a priority and to increase the ability to have penetrative sex.
Considering phalloplasty is a serious undertaking and as mentioned in Thinking About Phalloplasty? Here is One of the Major Complications to Consider! two of the most common complications are infection and the inflatable device's failure.
For this reason, knowing your various options regarding penile implants, including the pros and cons, is vital.
As outlined in detail in The Ultimate Guide to Penile Implants for Trans Men, the most common implant option offered by a gender-affirming surgeon is a 3-piece inflatable implant primarily due to its various benefits:
Easy to use
Easier to inflate than a 2-piece device due to the larger, softer pump
Offers the best rigidity
Offers the best flaccidity when not in use
Totally concealed in the body
More easily concealed under the clothing
While this is the most common implant used, it is also the one offering the most cons as well. Hence it is crucial to have a detailed discussion with your surgeon before considering which implant is best for you.
10. Should You Consider Hysterectomy?
Hysterectomy is a surgical procedure to remove the uterus. There are various personal reasons why a transmasculine person may desire a hysterectomy and you may be wondering if it is worth considering.
While I can’t tell you whether a hysterectomy will benefit you, I can share the two most common reasons I see trans men get this surgery.
The #1 reason trans men decide on hysterectomy is because they feel incongruence with their gender identity. To the general public, the desire to remove part of the body organs that one cannot see may seem bizarre. To the transgender men struggling with Gender Dysphoria, knowing they have internal organs socially viewed as feminine feels deeply incongruent with who they are.
A study surveying 134 trans male individuals discovered that 58% of individuals underwent surgery to remove organs that were incongruent with their individual identity (Rachlin et al., 2010).
The #2 main reason trans men decide on hysterectomy is to eliminate experiencing menstrual cycles, including cramping and aches accompanying them. Those who choose masculizing hormone therapy as part of their gender transition may experience stopping menstruation.
However, it is essential to note that not all have a similar experience, often leading to an increased feeling of dysphoria. Imagine a trans masculine person on testosterone who experiences the desired changes, such as deepening their voice and facial hair, finally starting to feel aligned with who they are, only to find themselves suffering with periodic menstrual cycles requiring a visit to the drugstore for hygiene products.
The #3 reason trans men seek hysterectomy is fear of associated ovarian and uterine cancer risk when using testosterone for a prolonged time. Is there a cancer risk associated with testosterone use? To find out, I looked at the research in my article Is There a Cancer Risk Associated with Testosterone Therapy for Trans Men? Which concluded that there is limited research and dubious evidence on this topic. The literature review demonstrated a low cancer risk in transgender men. Thus if you are considering a hysterectomy to reduce cancer risk, you want to take into consideration the lack of medical research.
11. What You Need to Know Pre and Post-Bottom Surgery!
Whether you go with metoidioplasty or phalloplasty, bottom surgery is often the last step in the transition process for trans men. 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 hair removal on the donor site right away! Make sure you ask your doctor which area they would like cleared. Suggest reading Hair Removal For Phalloplasty 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 the surgery. Do not underestimate this part of the process.
Above all, BREATHE! I promise you got this!
