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Living with an outward persona that doesn’t match your inner identity is a heart-wrenching daily experience for many transgender people. Many transgender individuals decide to align their bodies with their true gender identity, a process called transitioning. The transition process has many dimensions and is a very personal journey, but we’ll explore some common aspects of the male-to-female transition process in this article.
What is male to female transition?
A transgender woman is someone who was born with a male body but whose true gender identity is female. The discomfort and distress that come with this mismatch between a person’s body and identity are often called “gender dysphoria” (Garg, 2021). Thankfully, there are many options now for male to female (MTF) transition—the process by which these individuals can change their appearance and social role to match their female gender identity.
MTF transition can involve wearing traditionally feminine clothing and hairstyles, changing their name and pronoun use to “she/her/hers,” and coming out to family, friends, and colleagues as female. It can also mean seeking medical treatment to acquire a more feminine body through hormones or surgery (Hembree, 2017).
Timeline and process for MTF transition
The transition process can take anywhere from months to years to complete, depending on the person’s age and which, if any, medical procedure options for transition they choose. Transition is usually a longer-term process if the person is a child when they recognize their true gender does not match their body (Garg, 2021).
The MTF transition process is different for every individual. For someone who recognizes they are transgender during childhood, a first medical step could be hormonal treatment for puberty suppression. This begins once a transgender girl has entered puberty, limiting her development of masculine characteristics throughout adolescence. Once the girl reaches adulthood, she can receive gender-affirming hormone treatment, which continues to promote a more feminine physical appearance. Finally, gender-affirming surgery may be an option, usually done after or simultaneously with hormone treatment (Hembree, 2017).
But many transgender women do not come to this realization—or don’t feel ready to begin the transition process, for any number of reasons—until they’re well into adulthood. The timeline is a bit shorter in those cases since hormone suppression won’t be part of the process.
Hormone treatment can have an effect as early as one month after starting treatment (for example, the person may notice a decrease in libido and spontaneous erections pretty quickly). Most effects tend to be seen after about three months, though (including breast growth, body fat redistribution, softened skin, and decreased testicle size). Reduced growth of body and facial hair starts at around six months. The full benefits of feminizing hormone treatment tend to be seen after 1–3 years (WPATH, 2012).
What is dysphoria? How is it related to gender dysphoria?
Hormones for male to female transition
There are two main types of hormone therapies for MTF gender transition: puberty suppression and gender affirmation.
Hormone treatment for puberty suppression
Children usually begin to identify their gender between ages 3–5, but recognition of transgender identity can happen at any point throughout life; this can be influenced by social norms, stigma, and family culture (Garg, 2021).
If a child identifies as transgender, it may be appropriate for them to receive hormonal treatment for puberty suppression. Still, they must meet certain criteria before going down that road (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.
- Their caregivers consent to and support this treatment.
The puberty suppression treatment used is known as a gonadotrophin-releasing hormone agonist (GnRHa). When used for MTF transition, it shuts down testosterone production in the testicles, softening the developing features of the face and body and minimizing penis and testicle growth (Hembree, 2017; Heneghan, 2019). If a transgender girl still undergoing puberty decides to stop taking GnRHa therapy, puberty will revert to her male biological sex; in other words, the effects of puberty suppression are reversible before a certain point (Hembree, 2017).
This treatment is approved for adolescents 12 years or older but commonly starts around age 14. This treatment may only be started after puberty because many children who experience gender dysphoria at a young age will no longer want to change their gender after they experience puberty (Heneghan, 2019).
However, many still will, so it’s valuable to use individual, family, and group therapy to help gender-questioning children explore gender preference. Anticipating puberty can be upsetting for some trans adolescents, so psychotherapy and hormone suppression are often done simultaneously (Garg, 2021).
Side effects of puberty-suppressing hormone treatment include changes to bone development and strength, reduced fertility (as development of the testes will be suppressed), mood changes, and fatigue (Hembree, 2017). Fertility changes are important to discuss; receiving estrogen and suppressing male sex hormones will reduce a transgender girl’s testes development and ability to create sperm. Fertility preservation techniques, like sperm freezing, are an option for people who may want the option to have biological children later in life (WPATH, 2012).
Testosterone: what is it, what does it do, levels, treatment
Hormone treatment for gender affirmation
When a transgender girl has reached adulthood, additional hormone therapy may be beneficial for cultivating a more feminine appearance. This option is also available to transgender women who did not undergo puberty suppression. It can reduce facial and body hair, reduce testicle size, decrease libido and erection frequency, increase body fat, promote female body contours, and form breasts (WPATH, 2012).
The specific combination of hormones can vary but usually includes estrogen, combined with progestin, antiandrogens, GnRH agonists, or other hormones. Treatment is tailored to each individual to reduce the risks and side effects of treatment with estrogen, such as blood clots (Garg, 2021).
As with puberty suppression hormone treatment, adult hormone treatment with estrogen can reduce a transgender woman’s fertility and ability to have biological children. Sperm freezing should be discussed before starting hormone treatment if a person wants the option of having biological children later in life (WPATH, 2012).
Often, hormone therapy alone is not enough to fully produce the feminizing effects that many people desire (Heneghan, 2017). In these cases, several MTF surgical options are available.
Male to female transition surgery
Many surgical procedures (collectively referred to as gender-affirming surgery) can help change a transgender woman’s body to become more feminine. These can include cosmetic surgery, breast augmentation, removal of male sex organs, and surgical construction of a vagina (van de Grift, 2017). Depending on individual preference and comfort, a person can choose to undergo some or all of these procedures.
Genital surgery (vaginoplasty)
Genital surgery—often called “bottom surgery”—involves removing the penis and testicles and creating a vagina (and possibly a clitoris and labia). The surgery to create a vagina is called a vaginoplasty, and a trans woman will need to be on hormonal treatment for some time before undergoing surgery.
The specific plan and technique for vaginoplasty completely depend on a person’s goals, priorities, and body. For example, a woman may want a vagina that allows her to have fully penetrative sex, or she may be content with one that allows for shallow penetration. In some cases, she may not want an “internal” vagina at all. She may wish for a clitoris or labia with as much erogenous sensation as possible, or that may not be her priority. The woman’s surgical team will work with her to ensure she’s getting the outcome she’s hoping for (Pariser, 2019).
The most common method of vaginoplasty is called penile inversion, in which the skin of the penis is used to create a vagina (Chen, 2019). Usually, the vaginoplasty will involve reconstructing the urethra to allow for seated urination from the vaginal opening (Pariser, 2019). Vaginoplasty has very high rates of patient satisfaction regarding vaginal appearance and function; patients widely report improvements to their quality of life and sense of happiness with their identity (Moisés da Silva, 2021).
Body dysmorphia: what is it, symptoms, causes, and treatments
Chest surgery (breast augmentation)
A transgender woman can also undergo chest surgery (often called “top surgery”) to alter the shape of her chest and increase breast size. While not required, it’s encouraged for a person to receive hormone therapy for a year before the surgery. Hormone therapy can promote fat redistribution that often helps maximize breast tissue growth and improve the eventual appearance of breast implants (WPATH 2012).
Chest surgery is generally more available than gender-affirming genital surgery, as it has been available for a longer time in modern medicine, and there are many surgeons with the skills and experience to perform it (Chen, 2019). With some differences, the surgical process is largely the same as commonly performed breast augmentation or reconstruction in cis-gendered individuals (Fardo, 2021).
Many transgender women want to look in the mirror and see the woman they feel and identify with, and their genitals and breasts are only one part of the equation. Hormone therapy can only do so much, but thankfully, cosmetic surgery has come a long way, and many feminizing surgeries are available for transgender women. These procedures include brow lifting, reducing the angle of the jaw, altering eye shape, reducing the size of the Adam’s apple (tracheal shave), and rhinoplasty (nose job).
These types of surgery tend to be more widely available than genital surgery (as the procedures are less complex and less specialized knowledge is required). In addition, unlike bottom surgery, cosmetic surgery does not require that the patient meet certain medical or personal criteria (Hohman, 2021).
5 MTF transition tips
Transitioning can be a long and complicated process but is ultimately rewarding and a big emotional relief for many transgender women. Increased visibility of transgender issues, as well as recent advances in medicine and surgery, are making MTF transition options better and more accessible than ever before. However, there is still a long way to go. In light of this, there are many things you can do to help minimize difficulties and stress so that you can have as successful a transition as possible.
1. Be patient with the process
It can take anywhere from months to years for you to fully complete the particular MTF transition process that you desire. This long timespan can be incredibly challenging to deal with, but it can take time for certain therapies to work (like hormone treatment). It can also take time to fulfill surgical criteria, recover after surgery, wait a sufficient amount of time between surgeries, and find the funds or healthcare providers who can help you.
While all of these factors can be frustrating, and of course, you want to align your body with your identity as quickly as possible, knowing in advance that the process will take time can help mitigate frustration along the way.
2. Manage expectations
Every transgender person’s transition journey is personal and unique, and it’s important that you receive the support and information to make the right choices for you. People considering surgery should have honest conversations with their surgeon about their tolerance for risk and their goals and expectations.
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Considering the many decisions surrounding transition—when to get hormone therapy, whether to get surgery, what kind of surgery to get, and more—a series of guidelines exist for healthcare providers to use when caring for transgender patients. The World Professional Association for Transgender Health (WPATH) lists the following criteria for adult patients hoping to receive surgery or hormonal therapy (depending on treatment type) (WPATH, 2012):
- Persistent, well-documented gender dysmorphia
- Letter(s) of reference from qualified mental health professionals
- Capacity for informed decision making and consent
- Age of majority (the age at which the law in your location recognizes you as an adult)
- Good physical and mental health
- 12 continuous months of living in the desired gender role
Your healthcare provider, surgeon, and counselor should all help with this. Still, it’s important to reiterate that managing expectations early on can help ensure that the MTF transition process winds up feeling satisfying and successful. Before undergoing any procedure, it’s important to clarify the possible outcomes of treatment, the risks, and possible side effects. It’s a worthwhile step; good insight and realistic expectations are associated with good surgical outcomes and satisfaction (Garg, 2021).
3. Seek support
The myriad steps of the MTF 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. This can be difficult for some transgender people, as social stigma, shaming, and family trouble often arise.
In these cases, finding a supportive network is all the more important, and fortunately, many support groups and resources are available. There are 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 in order to have a trusted professional support person (Garg, 2021).
4. Don’t worry about the “right age”
Some transgender women are concerned about MTF transition after age 40 or later in life. But there is no “best age” for male to female transition; it can happen at any age. While it’s true that it’s possible to initiate transition early in life through puberty suppression, this doesn’t necessarily make it a “better” time to transition than later in life. There are pros and cons to transitioning at every stage; which is “better” depends on the individual.
For example, a transgender girl who transitions at age 15 may avoid years of personal struggle that a person who transitions later in life may endure, but transitioning at a young age may also preclude some options for her later in life. She may not be able to have a biological child if she desires (if testicle production was too suppressed in puberty, or if steps weren’t taken to freeze her sperm), and she may also not develop enough genital tissue for some surgical options to be available if she decides to have a vaginoplasty later in life. However, she may avoid a great deal of personal turmoil by transitioning early. It is okay for transition to be different for each person.
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5. Get healthy
One criterion for undergoing any MTF hormonal or surgical treatment is to make sure any underlying health conditions are well-managed. This includes managing chronic conditions like diabetes, obesity, heart disease, and mental health conditions like depression and anxiety. It’s also best to quit smoking at least three months before surgery. This will help immensely with wound healing, reducing side effects, and promoting a successful outcome (WPATH, 2012; Chen, 2019).
The MTF transition process can be complicated, but it can be an immensely rewarding step for transgender women to lead fuller, more authentic lives. If you are struggling with gender dysphoria and are thinking about transitioning, seek support from a sensitive, qualified counselor and health care provider to learn what steps might be right for you.
- Bustos, V. P., Bustos, S. S., Mascaro, A., Del Corral, G., Forte, A. J., Ciudad, P., et al. (2021). Regret after gender-affirmation surgery: a systematic review and meta-analysis of prevalence. Plastic and Reconstructive Surgery. Global Open, 9(3), e3477. doi: 10.1097/GOX.0000000000003477. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099405/
- Chen, M. L., Reyblat, P., Poh, M. M., & Chi, A. C. (2019). Overview of surgical techniques in gender-affirming genital surgery. Translational Andrology and Urology, 8(3), 191–208. doi: 10.21037/tau.2019.06.19. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626317/
- Fardo, D., Sequeira, C. M., & Pensler, J. M. (2021). Breast augmentation. [Updated Oct 1, 2021]. In: StatPearls [Internet]. Retrieved on Jan. 24, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK482206/
- Garg, G., Elshimy, G., & Marwaha, R. (2021). Gender dysphoria. [Updated July 20, 2021]. In: StatPearls [Internet]. Retrieved on Jan. 24, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK532313/
- Hembree, W.C., Cohen-Kettenis, P.T., Gooren, L., Hannema, S.E., Meyer, W.J., Murad, M.H., et. al. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11):3869–3903. doi: 10.1210/jc.2017-01658. Retrieved from https://academic.oup.com/jcem/article/102/11/3869/4157558
- Heneghan, C. & Jefferson, T. (2019). Gender-affirming hormone in children and adolescents. BMJ EBM Spotlight. Retrieved from https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/
- Hohman, M. H. & Teixeira, J. (2021). Transgender surgery of the head and neck. [Updated Oct 18, 2021]. In: StatPearls [Internet]. Retrieved on Jan. 24, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK568729/
- Moisés da Silva, G. V., Lobato, M., Silva, D. C., Schwarz, K., Fontanari, A., Costa, A. B., et. al.. (2021). Male-to-female gender-affirming surgery: 20-year review of technique and surgical results. Frontiers in Surgery, 8, 639430. doi: 10.3389/fsurg.2021.639430. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131861/
- Pariser, J. J. & Kim, N. (2019). Transgender vaginoplasty: techniques and outcomes. Translational Andrology and Urology, 8(3), 241–247. doi: 10.21037/tau.2019.06.03. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626315/
- van de Grift, T.C., Elaut, E., Cerwenka, S.C., Cohen-Kettenis, P.T., & Kreukels, B.P.C. (2017). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: a follow-up study. Journal of Sex and Marital Therapy, 44(2):138-148. doi: 10.1080/0092623X.2017.1326190. Retrieved from https://www.tandfonline.com/doi/full/10.1080/0092623X.2017.1326190
- World Professional Association for Transgender Health. (2012). Standards of care for the health of transsexual, transgender, and gender nonconforming people [7th Version]. Retrieved from https://www.wpath.org/publications/soc
Dr. Steve Silvestro is a board-certified pediatrician and Manager, Medical Content & Education at Ro.