8. What is Transitioning?
I have heard that a common thing people who are close to a newly-out trans person wonder about is “what kinds of things is this person going to do to transition?” This sometimes might be rather benign — for example, wondering about new names, pronouns, aesthetics, etc — or potentially invasive — “what surgeries are they going to get? How is their body going to change? How do they have sex? How will they have sex?”
For some trans people, invasive questions are very offensive. Many cis people would be taken aback by such questions (“what do your genitals look like?”), and there can be an added layer since many trans people have major insecurities and/or dysphoria related to their physical bodies — especially early during transition.
Fortunately (or maybe unfortunately) for people who know me, I don’t have those same reservations: I imagine folks are going to be discrete (for example, not starting an online blog where anyone in the world could read the sordid details of my transition…), and are only going to ask questions they have genuine curiosity about while, at the same time, avoiding asking questions about things they would be uncomfortable hearing about (believe it or not, not everyone is super excited about hearing about genitals, injections, surgeries, or other potentially gruesome topics).
So, steel yourselves, because I’m going to take a moment to go through many of the things transgender people (at least trans-feminine, or assigned-male-at-birth-but-now-identifying-as-women) are looking to change, whether through personal actions or through the assistance of well-trained professionals with very sharp tools. Content Warning; I’ll try to offer enough information at the top of each section to help those who want to skip things to skip stuff they don’t want to hear about, repurposing the MPA’s film ratings system. I will be talking about details of my own experience, so if you don’t want to know that stuff (mom), that’s on you.
A primer
(G, I’m just explaining what to expect)
I’ll provide some general information in regular paragraphs, like this. Gross stuff will be clearly marked as follows:
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I have a little experience writing HTML, so I’m going to use this amusing book-end — along with the block-quote formatting — to denote things that the squeamish among us might find disturbing.
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I will provide some details into my personal experience at the end of each section, leaving out gorey details. Howeve,r if the topics in question are gorey-in-nature, it would be difficult to internalize this information without connecting it with any gorey details outline in a blocked-off section that preceeds it.
On to the content:
Style Changes
(PG)
Many trans women will, at some point, change the way they perform their gender through wardrobe or affectation changes. The classic trope includes painting nails, wearing dresses, growing out hair (or wearing wigs), putting on (sometimes lots of) makeup, shaving, adopting different mannerisms, speaking in a different voice, etc. Not everyone wants to do all of these things, or wants to do these things to the same degree. For example, I am not at all interested in painting nails or wearing makeup; I am already wearing slightly different clothes (and later in my transition may occasionally wear more feminine things for special occasions, although I don’t plan on making a daily habit of it); I do shave; I am growing out my hair (after doing a lot of research on hair care for curls); I am doing voice training, and will likely implement a new voice at least part-time in certain contexts (voice training is hard, and is probably the things that will take me the longest to get any good at).
Identity Changes
(PG)
Many trans women will request new names, pronouns, or other ways for other people to interact with them. To be clear, “requesting” this of other people is not suggesting that this is what trans people would “prefer,” but rather articulating the expected decorum exhibited towards them as a base level of respect. For example, saying “my name is Percival,” is not the same thing as saying “my preference is that you call me Percival, but that’s not me real name and/or you can call me something else if you like,” nor is saying “I am a man, but if you call me a lady it doesn’t really matter to me.” A cis person would be frustrated (at the very least) if they were constantly referred to in the wrong language; many people are very particular about whether it is even okay to use nicknames: trans people should be afforded the same respect by having their identity acknowledged.
I’m on the fence about my name. It’s my name, it’s in my email address (twice!), it doesn’t make me feel badly at all. It isn’t very feminine (at all), but it does have a kind of butch flavor to it. I also have another much more androgynous nickname I used when I was very young (still occasionally used by my mother, and still used consistently by one of my childhood friends — if you’re in-the-know and are wondering who, he brings cookies to hangouts), so maybe I’ll use that in some places. I really REALLY don’t want to have to deal with all of the insanity that is involved in legally changing a name.
As I have mentioned before, I am allowing the people around me to use language that reflects their perception of my gender. Selfishly, I’m using that as a barometer into where I am at in my transition, as I know my ability to self-evaluate will likely be distorted and unreliable. Thanks, everyone, for the assist!
Hormone Changes
(PG13, drugs and injections)
Many trans people seek to effect some physical changes through the use of hormone replacement therapy. For trans women, this is typically a two-part treatment that involves one type of drug to reduce testosterone (and similar) hormones, and another type of drug to increase estrogen. There are several different drugs that can be used to reduce testosterone, all of which were developed for cis people who require treatment for various issues (for example, the drug I am on is listed to treat fluid build-up due to heart failure, liver scarring, kidney disease, high blood pressure, low blood potassium that does not improve with supplementation, early puberty in boys, acne and excessive hair growth in women… or as part of hormone replacement therapy for trans women). Not only are there several different drugs for increasing estrogen, but there are several different delivery methods, including pills, patches, gels, and injections.
I am on Spironolactone for testosterone reduction, and am not experiencing any concerning health-related side-effects. It involves one pill twice a day.
I am on injectable Estradiol Valerate, and am experiencing the intended consequences of that drug without any concerning health-related side-effects. It involves one injection once a week (It’s not my favorite, but it’s worth it).
Typically, the desired and achieved outcomes of feminizing hormone replacement therapy include, in varying degrees:
Body fat redistribution — less fat in the shoulders and stomach, more fat in the legs, hips, and butt, as well as slight fat redistribution in the face
Decreased muscle/mass strength
Softening of skin/decreased oiliness
Decreased libido — in varying degrees, sometimes described as a reduction or elimination in a sexual drive, or the loss of the sexual desire feeling like a sort of hunger
Decreased spontaneous erections (side note: this would have been beneficial during puberty, especially during the middle of random school days)
Male sexual dysfunction — i.e., inability to gain or maintain erections
Breast growth
Decreased testicular volume
Decreased sperm production
Thinning and slowed growth of body and facial hair (note: HRT will not result in loss of facial hair)
Cessation, or, for the lucky few, reversal of Male pattern baldness
These effects take between months and years to become fully realized. Many are reversible (body fat redistribution, for example), whereas some are permanent (breast growth, for example).
I am still in the early stages, so I expect the effects to increase over time for at least the next few months, but so far I have been experiencing the beginnings of fat redistribution (especially in my face); reduced sex drive (although the “hunger” style drive is being supplanted by a more sentimental longing, which I actually find rather endearing and lovely); cessation of spontaneous erections; breast growth; slowed growth of body hair.
Hair Removal
(PG13, needles and lasers)
Many trans women want to remove some body hair and, more commonly, facial hair. For anyone who either has or knows someone with a beard, you are probably aware that even after a close against-the-grain shave, there is still a shadow visible were the beard will grow back. This is not the same as a five-o-clock shadow, where the hairs have started to grow back out above the surface of the skin, but rather is the effect of the part of the hair that is still present below the surface of the skin (skin is semi-transparent, which is fun to explore if you have a really powerful optical microscope, some very fine-tipped tweezers, and a willingness to come to understand that you can’t ever wash your hands enough for them to actually be clean clean).
There are two methods to achieve permanent cessation of hair growth: laser and electrolysis.
Laser involves using a laser (surprise) to very briefly super-heat an area of hair such that the heated hairs damage the hair follicles, preventing future growth. Large areas of the body are treated in relatively short sessions (15–30 minutes), although only hairs that are currently in a growth phase are potentially affected (at best, 85% are in an active growth phase at any one time). Each session beyond the first has diminished returns, but laser tends to be the best cost/time-to-removal ratio, however laser is only effective on people with darker hair and lighter skin (light hair won’t get hot enough; dark skin may get burned before the hairs get hot enough). Of note: IPL (a laser-like treatment) is not the same as alexandrite laser systems often employed by reputable laser treatment centers, and are not as effective — sometimes, reportedly, not effective at all in permanent hair removal).
Electrolysis involved using a very thin (sub-hair thickness) needle to probe into individual hair follicles, which is then momentarily charged with a voltage sufficient to destroy the hair follicle and prevent future growth. Each hair is removed individually, which is time-consuming and expensive, but electrolysis removes every hair that is treated. Often electrolysis is used in tandem with laser to remove stubborn hairs, or, in my case, grey hairs.
I am currently in the process of having my beard removed through a combination of laser and electrolysis. I will likely have other body har — such as chest and back — removed sometime in the future.
Face-Feminizing Surgeries
(R, knives, blood, grinding bones)
Many people who have gone through male puberty develop secondary sexual characteristics in their face that, while not necessarily easily-identified by the typical person, do provide gender cues that can be difficult to overcome with clothing, style, makeup, or other unassisted changes. These secondary sex characteristics (excluding beards, which I talked about above), can include receding hairlines; “M-shaped” hairlines (where the hairline is more square, or is higher near the temples); a pronounced brown (especially between the eyebrows); a pronounced mandible (especially in the back of the jaw where it turns upwards below the ears); a wide chin; a pronounced larynx (Adam’s Apple).
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There are surgeons who specialize in addressing these issues for people, which may involve removing or reducing section of bone, transplanting hair (or removing sections of the scalp to “advance” the existing hairline), and/or removing cartilage from the larynx to reduce it’s prominence. These surgeries are often not covered by insurance (SPOILER ALERT), and can cost a reasonable-to-unreasonable amount of money (you get what you pay for…)
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It is likely I will seek treatment to address my fairly prominent M-shaped hairline, and will look to address my large Adam’s Apple. I am going to wait to see what fat redistribution on my face looks like before I make any decisions about what else I may do, but this will not be for several months or perhaps even longer than a year before I seek this care, depending on the course of the effects of HRT and on insurance coverage.
Vaginoplasty/Penectomy/Orchiectomy
(NC17, we’re literally talking about removing gonads)
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Sometimes referred to as “Bottom Surgery,” or, if you live in the 1970s or are an insurer operating in 2023, “Sex Reassignment Surgery,” Vaginoplasty and Penectomy are exactly as they sound: creating a vagina; removing a penis. Orchiectomy is the removal of the testicles. There are several different methods for creating a vagina, each with different benefits and drawbacks that I, frankly, do not have a firm understanding of. Different surgeons seems to prefer different methods, and different surgeons seems to have different aesthetics they seem to commonly strive for. For this reason, may trans women spend a lot of time looking at more pictures of vaginas than any reasonable human would ever expect to in service of making one of the more important transition-related decisions they make make. Most trans women — and most surgeons who operate in this line of work — simultaneously perform penectomy and orchiectomy at the same time as the vaginoplasty, and will use tissues from those procedures (notably the glans and scrotum) to create new structures (notably the clitoris and labia). However, some trans women will opt for surgery of lesser scope, such as limiting procedures to only include orchiectomy, or (still very uncommon, but no longer unheard of) penile-preserving vaginoplasty. Fortunately, most insurers (at least where I live) provide coverage for these operations — at least for the more traditional ones.
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I do not currently have any plans to pursue any of these surgeries, however it is entirely possible that my feelings will change as I get further into my transition. I am fortunate in that my genitalia is not a source of dysphoria for me, however I do not know if that will change as I get further along in my transition; for example, things that used to not bother me at all have started to bother me as my body has slowly started to feminize. I hold open the possibility that genitals may become a part of that in the future, although it it not something I am focused on right now.
Conclusion:
There are many aspects to transitioning, and some, all, or none may be on the table for any particular person. As I am sure most people would expect, I am making my own way in this process for myself. I have an idea of where I am going and what it will take to get there, but I also expect my desires may change (or, less ideally, my access may become limited in ways I might not predict). But for everyone — myself included — transitioning is ideally a time-limited process that has a beginning, middle, and end. Much like puberty, most people are hoping to just get through it and have it over with so they can go back to living their best lives. The fully-actualized trans person is not likely someone who is in a constant state of medical intervention or identity alteration, but rather someone who has gone through the process and come out the other side a more authentic version of themselves. And so, too, do I look forward to moving on from this process to a new equilibrium. But I do appreciate the company as I make my way.