Medical Treatment
View information about hormonal and surgical interventions available to those who are gender diverse.
All medical treatment recommendations included below are from the World Professional Association for Transgender Health (WPATH).
- Medical intervention is not the goal of treatment. It exists as a way for TGNC people to transition their external body to represent who they are in their mind. It is by no means a requirement, even for surgical procedures.
- No mental health evaluation is necessary to receive medical treatment. A primary care provider (PCP) may ask for an evaluation if they are concerned the patient is unclear about the risks and benefits of treatment.
- Hormones can be provided using an informed-consent model. Once a patient has established care with a PCP, completed baseline laboratory work and reviewed the risks and benefits of care, they can receive treatment.
- Medical treatment can be split into feminizing and masculinizing effects. Knowing the timeline as well as the risks and benefits of treatment are essential. (See tables below)
- It is very important that anyone taking hormones have access to a primary care physician and appropriate follow-up, including laboratory testing and monitoring.
Feminizing Hormones (See Table 1)
- The feminizing hormone prescribed is estrogen and is available in multiple forms.
- Spironolactone is an androgen receptor antagonist that is typically prescribed until higher levels of estrogen are reached.
- Progesterone may or may not be prescribed. The somatic effects are unclear, but many patients request to take it as well.
- Potential side effects of feminizing hormones include:
- Changes in cholesterol that can affect cardiovascular health
- Increased serum potassium levels with the potential to affect cardiac conduction
- Potential hypercoagulability (For spironolactone)
- Anemia
- Changes in sex drive or sexual functioning
- Changes in mood or anxiety level
Table 1. Effects and expected time course of feminizing hormones (WPATH, 2011)
| Effect | Expected Onset2 | Expected Max. Effect2 |
|---|---|---|
| Body fat redistribution | 3-6 months | 2-5 years |
| Decreased muscle mass/ strength | 3-6 months | 1-2 years3 |
| Softening of sking/ decreased oiliness | 3-6 months | unknown |
| Decreased libido | 1-3 months | 1-2 years |
| Decreased spontaneous erections | 1-3 months | 3-6 months |
| Male sexual dysfunction | variable | variable |
| Breast growth | 3-6 months | 2-3 years |
| Decreased testicular volume | 3-6 months | 2-3 years |
| Decreased sperm production | variable | variable |
| Thinning and slowed growth of body fat and facial hair | 6-12 months | > 3 years4 |
| Male pattern baldness | No regrowth, loss stops 1-3 months | 1-2 years |
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Masculinizing Hormones (See Table 2)
- Testosterone is available in multiple forms and can be given in a variety of doses and frequencies.
- Potential side effects of masculinizing hormones include:
- Changes in cholesterol
- Increased red blood cells which can cause or exacerbate cardiovascular conditions
- Changes in sex drive
- Changes in mood or anxiety levels
Table 2. Effects and expected time course of masculinizing hormones (WPATH, 2011)
| Effect | Expected Onset2 | Expected Max. Effect2 |
|---|---|---|
| Skin oiliness/ acne | 1-6 months | 1-2 years |
| Facial/ body hair growth | 3-6 months | 3-5 years |
| Scalp hair loss | >12 months3 | variable |
| Increased muscle mass/ strength | 6-12 months | 2-5 years3 |
| Body fat redistribution | 3-6 months | 2-5 years |
| Cessation of menses | 2-6 months | n/a |
| Clitoral enlargement | 3-6 months | 1-2 years |
| Vaginal atrophy | 3-6 months | 1-2 years |
| Deepened voice | 3-12 months | 1-2 years |
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Surgical Interventions
An overview of gender-affirming procedures that are available.
- Surgical interventions can be divided into those which are feminizing or masculinizing.
- Depending on the insurance, different requirements exist for different surgical procedures.
- It is likely that while Gender Dysphoria is in the DSM some sort of mental health evaluation will be needed prior to surgical procedures.
- Mental health professionals are placed in fortunate but challenging role of being both patient advocate and gatekeeper to these procedures.
- Mental health clinicians are in an ideal position be collaborate and advocate for our patients with our general medical and surgical colleagues.
- Surgical interventions are not the ultimate goal in treatment. They are available, like hormones, to aid a patient in transitioning their external body to represent who they are in their mind.
- Like hormones, it is important that the patient understand the risks, benefits, and follow-up plan for these procedures.
Feminizing Surgical Interventions
Top surgery involves breast augmentation. Some insurance plans will not cover the procedure unless hormones have resulted in absolutely no breast tissue growth. Patients are generally very happy after the procedure. The recovery time is short with a need to follow-up for wound care.
Vaginoplasty is an invasive surgical procedure that requires staying in the hospital for up to three days with dilation of the neo-vagina for 20 minutes at least three times a day for several weeks after the procedure.
Facial feminization is a multi-step procedure, consisting of multiple surgeries, and only recently have insurance companies begun to cover it. The results can vary widely depending on the surgeon. It is important for the patient to be aware of the expected outcomes of the procedures. The most commonly available facial feminization procedures include:
- Changing the hairline and contouring the forehead
- Rhinoplasty
- Reshaping the jaw line
- Shaving down the thyroid cartilage (Adam’s apple)
- Changing the shape of the orbits
- Cheek implants
- Lip reshaping
- Lip lift
Masculinizing Surgical Interventions
- Oophorectomy, hysterectomy, and vaginectomy involve removal of the ovaries, uterus, and vagina respectively.
- Metoidioplasty involves cutting ligaments around a clitoris enlarged by hormones that creates a microphallus.
- Phalloplasty is the creating of a neo-phallus from donor site tissue, typically the patient’s forearm. There can be many complications. Healing and follow-up time are often quite extensive.