A transmasculine non-binary person gesturing to their leg, which is tattooed and hairy.

What Does it Mean to Medically Transition?

Image credit: Gender Spectrum Collection.

 

Please note that some of the language used on this page may cause gender dysphoria, as anatomical terms are used.


Not every trans person can, or wishes to, transition medically. Everyone has different needs and experiences. Some trans men have top and bottom surgery, and transition with testosterone. Some trans men never have any gender-affirming surgeries, and never hormonally transition. Some trans women, similarly, have surgeries and transition using hormones, whereas others do not. Some non-binary people have surgeries to feel more comfortable, and may hormonally transition, but others do not.

Robert Eads, who identified as a transsexual man, discusses his transition in this documentary. He said that, once he had top surgery and started testosterone, that was all he had to do in order to feel affirmed. In his view, "Being a man, or being a woman, has nothing to do with your genitalia. It has to do with what's in your heart, and what's in your mind." Some trans people, conversely, do need surgery on their genitals in order to feel comfortable. There is no universal "complete" transition, because everybody's needs are different. Whatever your needs are, Trans Health Research recognises you as an authentic member of the trans community!

 
A person holding up their phone to display text messages where they're celebrating starting HRT.

Hormone Therapy

For many trans people, gender-affirming hormone therapy, is a very important step during their transition. Gender-affirming hormone therapy is different for everybody, so it is important to go through the right avenues to obtain and use hormone therapy.

 

Where to Find a Doctor

Traditional Pathway to Accessing Hormones

This pathway to hormones involves obtaining an approval letter to start hormones after a detailed assessment and support (usually 3–6 appointments) with a specialised mental health professional experienced in gender transition. Whilst there is criticism that this process is ‘gatekeeping’, many find this process beneficial and valuable to support them through gender transition, and prepare them for starting hormones.

Informed Consent Pathway

Under an ‘Informed consent’ model of care, General Practitioners perform the initial assessment, play a key role in mental health and risk assessments for trans clients, and organise referral for secondary consultation where required. This process was designed to reduce unnecessary barriers.

 

Treatments for Trans Women and AMAB Non-Binary People

Hormone therapy for trans people who were assigned male at birth typically increases the hormone estradiol, and lowers the hormone testosterone. Estradiol is the mainstay, but often testosterone blockers are needed too.

 

Estradiol

Estradiol in Australia is available on the PBS which comes in three different forms: oral tablets, patches and gels. Tablets are taken everyday and patches are changed twice weekly or weekly depending on the brand. Gels are applied to the skin daily. Medications covered by the PBS cost a maximum $40.30 per month or $6.50/month for health care card holders. There are no Therapeutic Goods Administration (TGA)-approved or PBS implants or injections available in Australia (speak to your doctor about compounded medications).

Testosterone Blockers (Anti-Androgens)

There are several types of anti-androgens (all are daily tablets) with the most common types being cyproterone acetate (not available in the US), spironolactone and micronized progesterone.

Effects of AMAB Hormone Therapy

Like puberty, physical changes occur gradually over 2-3 years and sometimes continue to occur thereafter. Early effects include skin softening, breast growth, loss of muscle mass, redistribution of body fat to hips, thighs and buttocks, a reduction of facial and body hair, reduced sex drive, reduced fertility, and shrinkage of the penis and testicles. Hormone therapy won’t change your voice pitch or bone structure. There is much more research needed to determine the best hormone regimen, so don’t be surprised to hear varying responses online and varying recommendations. Always discuss your individual needs and responses with your doctor.

Side Effects

There are side-effects of estradiol including reduced fertility, a raised risk of blood clots and probable increased risk of heart disease and stroke. Some others include mood swings (more with cyproterone), passing too much urine (spironolactone) and nausea. There are uncertain effects on breast cancer and other cancers. More research is needed, but potential risks include:

  • Thromboembolic disease

  • Hypertriglyceridaemia

  • Prolactin elevation

  • Gall bladder disease

  • Cardiovascular disease

  • Breast cancer

  • Safety

Health Behaviours

There are certain things to consider which help reduce the side effects of AMAB hormone therapy. Look after your mental health and get as much support as possible.

  • Exercise regularly

  • Minimise weight gain

  • Eat healthily

  • Reduce/stop smoking

  • During long flights to keep active and well hydrated to reduce

  • risk of blood clots

  • Have regular monitoring with your doctor, particularly as new information comes out all the time.

Experiences Throughout HRT

 

Treatments for Trans Men and AFAB Non-Binary People

Hormone therapy for trans people who were assigned female at birth consists of a testosterone formulation which increases a person’s blood testosterone concentrations, typically to the 'male' reference range. Some people, particularly non-binary people, may choose to use a lower dose of testosterone to achieve partial affects.

 

Types of Testosterone

  • 3 monthly injections (Reandron)​

  • 2 – 3 weekly injections (Primoteston)

  • Daily testosterone gel in a pump pack (Testogel). The pump pack makes it easy to provide low doses which often suits people wanting partial or slow masculinisation.

  • Daily testosterone cream (Androforte)

Changes

  • Voice lowering (irreversible)

  • Increase in muscle and decrease in fat

  • Redistribution of fat to masculine pattern

  • Facial hair and body hair growth.

  • Clitoral growth.

  • Change in libido

  • Change in appetite 

  • Stopping of menstruation. 

  • Testosterone doesn’t change bone structure, presence of chest tissue (many use chest binders), or reproductive organs.

Side-Effects

  • Acne.

  • Oily skin.

  • Mood changes.

  • Thick blood (polycythemia).

  • Increased risk of blood clots.

  • Potential increase in heart attack risk

  • Fertility is often affected, but typically menstruation returns when T is stopped, and pregnancy is possible even when on Testosterone.

  • There is thinning and dryness of the vagina, and sometimes pelvic pain can occur.

Possible Side-Effects

There are also uncertain long-term effects on cancer, bone health, immune function and cardiovascular risk. More research is needed, but possible risks include:

  • Polycythaemia.

  • Sleep apnoea.

  • Male pattern baldness.

  • Dyslipidaemia (increased triglyceride and LDL levels; decreased HDL levels).

Health Behaviours

There are certain things to consider which help reduce the side effects of AFAB hormone therapy:


  • Look after your mental health and get as much support as possible.

  • Exercise regularly.

  • Minimise weight gain.

  • Eat healthily.

  • Reduce/stop smoking.

  • Have regular monitoring with your doctor, particularly as new information comes out all the time.

Experiences Throughout HRT

 
A transmasculine person taking a mirror selfie after surgery, while their chest is still healing.

Surgery

For many trans people, surgery is an important step. Our research has found that many more desire surgery than have had surgery. Cost is the biggest barrier, as gender-affirming surgery in Australia is only performed in the private sector. There are many different types of surgeries available. You can find a list of Australian Professional Association of Trans Health member surgeons here.

 

Surgeries for Trans Women and AMAB Non-Binary People

 

Facial Feminisation Surgery

FFS is a combination of facial reconstructive procedures, performed with the aim of changing the effects testosterone has had on the person’s face, and to create a more typically 'feminine' face. However, a person may undergo such a surgery with aims of appearing androgynous, too. Facial feminisation is simply the more common term for this procedure.

Voice Feminisation Surgery

As with FFS, the term for vocal cord surgery is 'voice feminisation surgery', but Trans Health Research recognises the needs and experiences of AMAB trans people who are not necessarily feminine in identity. That said, so-called voice feminisation surgery changes the length, size, or tightness of your vocal cords, and may help reduce dysphoria. This is a surgery pursued by people who are not satisfied by voice training, and desire further changes.

Laryngeal Shave

This reduces the appearance of the Adam's apple in the neck.

Bottom Surgery/Gender Confirmation Surgery

Bottom surgery for AMAB trans people is when a doctor surgically constructs a vulva from the existing genitals they were born with at birth.

 

Surgeries for Trans Men and AFAB Non-Binary People

 

Chest Reconstructive Surgery

Chest reconstructive surgery (or top surgery) removes breast tissue to create a more flat, male-typical chest. There are many methods to do this, but some of the popular methods include keyhole surgery and the inverted “T” method.

Reproductive Surgery

Reproductive surgery involves removing the reproductive system, including the uterus and fallopian tube, with either a hysterectomy and or bilateral oophorectomy.

Bottom Surgery/Gender Confirmation Surgery

For AFAB trans people there are multiple options for having bottom surgery. The most common types include metoidioplasty and phalloplasty, and are usually done over multiple stages.