Female to male transition: what is it, process, hormone therapy vs. surgery

It’s estimated that there are roughly 1.5 million transgender individuals in the US today. But despite increasing support for transgender issues, many people whose bodies don’t match their true gender identities experience profound emotional turmoil and stigma. Many transgender people choose to make changes to better align their bodies and social roles, a process called transitioning. There are many aspects of this process, which are different for each person. This article will explore some aspects of the female to male (FTM) transition process.

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A transgender man is someone who is born with a female body but whose truly-felt gender identity is male. This experience can be emotionally and socially tumultuous. Transgender men who do not live in a way that expresses their true identities frequently experience relationship problems, feelings of anxiety and depression, and deep self-esteem issues. A person's distress in this situation is a condition called “gender dysphoria” (Garg, 2021). 

Thankfully, there are many ways a transgender man can harmonize his emotional, physical, and social identities—a process called “FTM transitioning”—that can help him live a fuller and more authentic life. 

FTM transitioning can involve many kinds of changes, including legal name changes, using the personal pronouns “he/him/his,” wearing traditionally masculine hairstyles and clothing, chest binding, and coming out as male to family, friends, and colleagues. FTM transitioning can also include medical steps such as masculinizing hormonal therapy and surgery to create a more masculine body (Hembree, 2017).

Depending on multiple factors, the transition process can take anywhere from months to years to complete. These include the age when a person recognizes that their true gender identity doesn’t match their bodies, whether they choose to start medical treatment, and which treatments they choose. 

Every individual will have a different process for transitioning from female to male. For someone who identifies as transgender in childhood, a first step could be hormonal treatment for puberty suppression, preventing female characteristics from developing throughout adolescence. 

Many transgender men don’t decide to transition until adulthood for any number of reasons. In this case, the transition can be a shorter process because he won’t need treatment for puberty suppression; he can go straight to gender-affirming hormone treatment to promote a more masculine physical appearance. If he wishes to remove female anatomy and create male genitalia, gender-affirming surgery may be an option and is usually done after hormone treatment (Hembree, 2017).

The effects of hormone therapy are apparent at different points (WPATH, 2012): 

• After one month of treatment, a person might notice increased acne and oily skin. 

• After three months, other effects become more obvious, like increased facial and body hair, changes in body fat distribution, an enlarged clitoris, decreased vagina size, a deeper voice, and an end to menstruation. 

• At six months, muscle strength should increase. 

• The full effects of masculinizing hormones are usually seen between one and five years after starting treatment.

There are two main kinds of hormone treatments for FTM transition: puberty suppression hormones (for adolescents) and gender affirmation hormones (for adults).

Hormone treatment for puberty suppression

Children usually begin to identify their gender between ages 3–5, but recognizing a transgender identity can happen at any point throughout life. Social norms, stigma, and family culture can influence when a person recognizes a difference between their body and their true gender (Garg, 2021).

If a child identifies as transgender, it may be appropriate for him to receive hormonal treatment for puberty suppression. He and his parents will need to meet some criteria before he can start the process (WPATH, 2012):

• The child experiences persistent, well-documented gender dysphoria.

• Gender dysphoria has worsened with puberty.

• Any other underlying medical or mental health issues have been addressed.

• The child has the mental capacity to consent to this treatment.

• The caregivers consent to and support this treatment.

The puberty suppression treatment used is a gonadotrophin-releasing hormone agonist (GnRHa). When used for FTM transition, GnRHa treatment reduces two sex hormones (LH and FSH) that play key roles in the development of the female reproductive system in biological females. So, the treatment prevents menstruation and reduces the development of breasts and female genitals (Hembree, 2017; Heneghan, 2019). 

If a transgender boy still undergoing puberty decides to stop taking GnRHa therapy, puberty will revert based on his female biological sex; in other words, the effects of puberty suppression are reversible before a certain point (Hembree, 2017).

Puberty suppression is approved for children 12 years or older, but it’s usually started around age 14. Treatment isn’t generally started before puberty is underway because many children who experience gender dysphoria at a young age will no longer want to change their gender once puberty begins (Heneghan, 2019). However, many still will; individual, family, and group therapy can help gender-questioning children explore gender preference, even before puberty starts. For transgender adolescents, oncoming puberty can be upsetting, so psychotherapy and hormone treatment are often done simultaneously (Garg, 2021). 

Some side effects are possible with GnRHa therapy, including changes to bone development and strength, changes to fertility (since the hormones will suppress the development of the ovaries), mood changes, and fatigue (Hembree, 2017). 

Fertility changes are an important consideration for adolescents; receiving testosterone and suppressing female sex hormones may reduce the health and viability of a transgender boy’s ovarian egg reserve. Fertility preservation techniques, like egg freezing, are important options to discuss with transgender boys considering hormones for puberty suppression (WPATH, 2012).

Hormone treatment for gender affirmation

Once a transgender boy reaches adulthood, he may want further hormone therapy to cultivate a more masculine appearance in his FTM transition process. This treatment can also be used by transgender men who did not undergo puberty suppression, as it has similar effects. This therapy can increase facial and body hair, deepen the voice, stop the menstrual cycle, increase libido, enlarge the clitoris, change the proportion of muscle and body fat, and minimize breast tissue (Garg, 2021; WPATH, 2012). 

The hormone used for treatment is testosterone, which is injected once per week. Some side effects are possible, particularly if testosterone levels become too high, including sleep apnea, high blood pressure, excessive weight gain, weakened bones, and overly concentrated red blood cells. Your healthcare provider will monitor you closely to watch for these side effects (Garg, 2021).

As with puberty suppression hormone treatment, adult testosterone therapy can reduce a transgender man’s fertility and ability to have biological children. It’s important to discuss fertility plans and preservation options with a healthcare provider before starting hormone treatment (WPATH, 2012).

Often, hormone therapy alone is not enough to fully produce the masculinizing effects that many transgender men desire (Heneghan, 2017). In these cases, several FTM surgical options are available.

Several types of gender-affirming surgeries can help a transgender man make his body more masculine. These include breast removal (sometimes called “top surgery”), penis creation, and removal of female sex organs (sometimes called “bottom surgery”) (Garg, 2021). There is no right way for a person to transition, and each FTM transition process can be tailored to a person’s individual needs, goals, and preferences. 

Bottom surgery can be a very expensive procedure if paid for out of pocket, and there is only a small pool of surgeons who are skilled and experienced in performing it. Fortunately, the number of hospitals offering these services has increased, and more insurance companies are offering coverage for transition care (Baker, 2017).

Phalloplasty 

Phalloplasty is a surgery to create or reconstruct a penis. It can involve several steps, including removing the vagina and female sex organs (ovaries and uterus), reconstruction and lengthening of the urethra, and creating a penis and scrotum from a person’s own grafted skin (either from the forearm or the thigh). It’s often completed with a few separate surgeries.

It’s optional but not required to remove all female sex organs along with phalloplasty. For example, a transgender man can choose to have a phalloplasty, remove his vagina, but keep his uterus and ovaries. This may be important for people who want to maintain their ability to have a biological child. Another option is having a phalloplasty and keeping a small vaginal opening for urination. It all depends on what a person’s goals for transition are, along with their comfort level with the risks of surgery (WPATH, 2012).

Phalloplasty typically requires a 5-day stay in the hospital to allow close monitoring after surgery because of special FTM surgery recovery needs and risks of the surgery. Complications soon after surgery are common (including UTIs and skin infections) but are fortunately minor for the most part. It’s common for other complications to arise later, like problems with the urethra, and these often require corrective surgery (Chen, 2019).

Metoidioplasty

Metoidioplasty is an alternative to phalloplasty for creating a new penis. It involves the same steps and options for female sex organ removal and urethra reconstruction, but the technique and source of tissue for creating a penis are different. 

In metoidioplasty, a penis is created using tissue from the clitoris and labia rather than from a “donor site” elsewhere on a persons’ body. This can make it a good option for transgender men who want to avoid the scarring and possible side effects of having such a large piece of skin removed from their thigh or forearm. It’s also a simpler, shorter surgery and doesn’t require a hospital stay. Follow-up surgeries are sometimes, but not always, necessary (Chen, 2019). 

The penis created with metoidioplasty is much smaller than those created with phalloplasty, but these patients tend to report higher satisfaction with the cosmetic results, sexual sensation, and even the ability to have an erection (although results vary as to whether the phallus is big enough to have penetrative sex) (van de Grift, 2019). Hormone treatment with testosterone before the surgery is important to help the clitoris grow as large as possible so that surgeons have more tissue to work with (Jolly, 2021).

Chest surgery (subcutaneous mastectomy)

A transgender man can opt for a breast-removal process called a subcutaneous mastectomy—“top surgery”—to gain a more masculine chest appearance. In the surgery, breast tissue and extra skin are removed, nipple position and size can be altered, and the chest shape is contoured to a flatter, more ‘masculine’ appearance. Surgeons pay a lot of attention to minimizing scars and preserving nipple sensitivity (Bustos, 2021).

Risks of the procedure are relatively low and similar to other major surgeries, including bleeding and infection. However, a 2018 systematic review found that only 6% of patients in the review experienced problematic bleeding (a hematoma) requiring follow-up surgery (Wilson, 2018).

There are a few different surgical techniques for reshaping chest contours and positioning nipples, but across the board, top surgery has been shown to improve self-esteem, body image, personal relationships and social interactions, and quality of life for transgender men. For many, it is the only gender-affirming surgery they feel the need to complete (Bustos, 2021).

Transitioning can be overwhelming but is ultimately rewarding and a big emotional relief for many transgender men (van de Grift, 2019). 

Increased visibility of transgender issues and recent advances in medicine and surgery make FTM transition options better and more accessible than ever before. However, there is still a long way to go. Maintaining good self-care practices can help minimize the stress and difficulties of transitioning. Some helpful points to remember are:

1. Be patient with the process

It can take anywhere from months to years to fully complete the particular FTM transition process that you choose, which can feel immensely challenging. Each step can take time, like waiting for hormone therapy to work, fulfilling surgical criteria, recovering after surgery, waiting a safe amount of time between surgeries, and finding the funds or healthcare providers who can help you. 

It’s understandable to want to transition as quickly as possible once you’ve made the decision, but knowing in advance that the process can take time can be a way of helping mitigate frustration during your journey.

2. Manage expectations

Every person’s journey through transition is unique, including their hopes for results from hormone therapy and surgery. A key way to help your transition process be as successful and satisfying as possible is to receive the right information and support to choose your next steps. Having honest and candid conversations with your healthcare provider about possible risks and outcomes of your treatment will help ensure realistic hopes and expectations for treatment. These kinds of conversations have been shown to help people be happier with their transitions (Garg, 2021). 

Considering the complexity of decisions surrounding transition, a series of guidelines exist for healthcare providers to use when caring for transgender patients. The organization that put these guidelines together, the World Professional Association for Transgender Health (WPATH), is an international professional body committed to promoting and freely sharing the highest standard of evidence-based care principles for healthcare providers taking care of transgender people. 

WPATH lists criteria for adult patients hoping to receive surgery or hormonal therapy, which can include (WPATH, 2012):

• Persistent, well-documented gender dysphoria

• Letter(s) of reference from qualified mental health professionals

• Capacity for informed decision making and consent

• Age of majority (the age at which a person is legally recognized as an adult)

• Good physical and mental health

• 12 continuous months of living in the desired gender role

3. Seek support

The many steps of the FTM transition process can be stressful, overwhelming, and costly. It is incredibly important to make sure you create a strong, supportive network of people in your life who know what you are going through and who support you emotionally. Transgender people often encounter social stigma, shaming, and family issues, so finding a supportive network is all the more important. 

Fortunately, there are many support groups and resources available, including online forums and local community groups you can connect with. Additionally, it is strongly recommended for transgender individuals—whether or not they are seeking to transition—to develop a relationship with a counselor to have a trusted professional support person (Garg, 2021).

4. Don’t worry about the “right age”

Some transgender men are concerned about FTM transition later in life. But there is no “best age” for transition; it can happen at any age. While it’s true that it’s possible to initiate transition during puberty, this doesn’t necessarily make it a “better” time to transition. There are pros and cons to transitioning at every stage of life; which is better depends on the individual. 

For example, a transgender boy who transitions at age 14 may not have to endure the years of personal struggle a man who transitions at 34 or 54 might deal with, but transitioning at a young age may also limit some options for him later in life. Suppose his ovary development is suppressed and he chooses not to take fertility preservation measures. In that case, he may remove his option of having a biological child later in life without fully appreciating that his feelings may later change. On the other hand, transitioning earlier may allow the boy to feel less distress and have more genuine-feeling relationships.

5. Get healthy

One of the requirements for receiving any FTM hormonal or surgical treatment is that your other health conditions are well-managed (including diabetes, obesity, depression, and anxiety). Ensuring you are taking good and responsible care of your health before starting transition is an important way to help make sure your surgery is as successful as possible. Another way of doing this is to quit smoking at least three months before surgery. This will help immensely with wound healing, reducing side effects, and promoting a successful outcome (Chen, 2019; WPATH, 2012).

The FTM transition process can be complicated, but many transgender men find that taking these steps can lead to feelings of great relief and help to lead fuller, more authentic lives. If you struggle with gender dysphoria and are thinking about transitioning, seek support from a sensitive, qualified counselor and healthcare provider to learn what steps might be right for you.

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Current version

February 04, 2022

Written by

Nancy LaChance, BSN, RN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.