MtF Transitions: The Guide

by Ela B

According to a study by the Williams Institute in 2016, there are roughly 1.4 million transgender people in America. Since then, hundreds of thousands of trans women and men have come out – each taking steps to transition and live out their gender identities. But how exactly does such a transition work?

Every gender transition is different – some transgender people prefer hormone treatment, many opt for a medical transition involving surgeries, while others may not want any kind of medication or surgery. The path to living out one’s gender identity isn’t linear or homogenous, so it’s no surprise that transitioning is confusing for many transgender women.

In this guide, we address some of the most common questions about going through an MtF transition. This includes basic information about hormone replacement therapy (HRT), social transitions, and gender confirmation surgeries.

Transitioning From Male To Female

Many transgender and gender non-conforming people are interested in transitioning their bodies to match their gender identities, but they don’t always know where to start. This section describes the first steps involved in making a complete medical transition as a trans person.

Mental Health Evaluation

Transitioning to one’s identified gender is a complicated process that may include a combination of hormones and surgeries. That’s why we recommend connecting with mental health providers specializing in gender-based health care as a first step.

This is crucial for two reasons. The first is that your physician or therapist needs to confirm your gender dysphoria, which is when a transgender person experiences distress about the discrepancy between their gender identity and the sex they were assigned at birth. The second is because transitioning is both physically and emotionally taxing. That means your doctor needs to gauge your understanding of the transition while assessing you for potential risk factors.

Risk Assessment

According to the World Professional Association of Transgender Health (WPATH), patients must fully understand their transition and its accompanying procedures before they can consent. This is done in tandem with a psychosocial evaluation that screens for potential risk factors.

Something most mental health practitioners consider is the presence of stable support groups, friends, families, or a wider community that the patient belongs to. Doctors will also note pre-existing conditions that may be exacerbated by the procedure.

Hormone Replacement Therapy

While each MtF transition is slightly different, hormone replacement therapy (HRT) remains an excellent option for many trans girls. Hormone therapy is designed to induce emotional, sexual, and physical changes in your body, which is similar to the development of secondary sex characteristics during puberty.

What To Expect

When starting hormone therapy, you’ll receive medications designed to block testosterone production and curtail androgen receptors. During this phase, most trans women are prescribed daily doses of 100 to 200 milligrams. Once the initial six-to-eight weeks of hormone blockers have passed, patients advance to the next part of the HRT process: estrogen.

Estrogen can be delivered to your body in a few ways. Some trans women may opt for less-invasive estrogen delivery methods like gels, patches, and creams, while others might prefer taking their hormones orally or through injections.

Physical Developments

Some people might feel their bodies changing within weeks of starting hormone therapy, but this isn’t the case for everyone. Many trans girls report treatment only fully taking effect months or even a full year after starting treatment. The journey is a little different for everyone!

Once the changes begin to manifest, you may experience any (or all) of the following developments:

Softer, less oily skin: One of the first changes a transgender woman might experience is drier, thinner skin. Because you’re likely to develop bumps or bruises quicker than before treatment, we recommend taking extra care when navigating your day-to-day life.
Breast tissue development: Over time, you may start to see bumps developing under your areolas – that’s a good sign! While these bumps may be painful to the touch, they’re part of the breast development process and discomfort will fade over time.
Body fat changes: Redistribution of body fat is the primary way your body changes during the early stages of hormone therapy. That means transgender women can expect plumper hips and thighs, resulting in a more feminine silhouette.
Decreased muscle mass: Following the migration of body fat, muscle definition and strength may diminish throughout the course of your transition. We recommend staying active to keep your physical strength up despite your changing body.
Less facial hair growth: In conjunction with smoother skin, many transgender women notice that their facial hair grows significantly slower than before transitioning. However, hormones alone won’t stop growth completely, and you may want to consider laser hair removal later on.

Emotional Changes

Like any hormone-related medical transition, you can expect a few changes in your emotional state. Many transgender adults describe their emotions during the MtF transition process to be like a “second puberty” – meaning that you may start feeling more emotional than usual. This may result in different approaches to relationships with your friends, family, partner, and community.

However, if the emotional changes interfere with your quality of life, you’ll need to inform your doctor to get your dose adjusted. Some transitioning folks may even need supportive psychotherapy to help them cope with their emotions. There is no shame in getting a new dose or going to therapy; it’s all part of the process of self-love through a major life change.

Sexual Changes

One of the things you need to know about your MtF transition is that sex and sexual behaviors will change during hormone therapy. For example, you may notice that you experience fewer erections overall. Even when you do, they may not be firm enough for you to penetrate. However, this isn’t to say that sex will suddenly become unpleasurable – you’ll still experience orgasms, although they may feel different from before.

Some people report that their orgasms impact their entire bodies rather than just their genitals. Post-HRT trans women may also find that ejaculation involves clear fluid or none at all, depending on how long they’ve been taking hormones. Finally, testicles can shrink to half their original size over time.

Potential Side Effects

Similar to any medical procedure, there is a range of side-effects associated with transitioning, but these vary with your specific treatment plan. For example, blood clots are less likely to happen when a patient chooses to take estrogen through pills or patches instead of injections. Regardless, all transgender people that are considering transitioning should be aware of the following risks and unintended outcomes of their decision:

Slightly increased risk of stroke, cancer, and blood clots
Marginally increased risk for breast cancer, but still much lower than cis women
Decreased risk of prostate cancer
Elevated liver enzymes
Heart disease
Blood clots
High blood pressure
Type 2 diabetes
Weight gain
Infertility

Gender Confirmation Surgeries

A transgender person that’s in the process of transitioning may consider going under the knife to achieve a look that matches their gender identity. These procedures are called gender confirmation surgeries (formerly known as sex reassignment surgery.)
Because these procedures are so complicated, they often need a whole team of multispeciality surgeons to ensure each transition is handled with care. Common procedures for trans women include top surgery or breast augmentation surgery and bottom surgery or vaginoplasty.

Top Surgery or Breast Augmentation

For transgender women and non-binary people, lacking breast tissue can be a source of discomfort or insecurity about one’s appearance. While undergoing HRT stimulates breast growth, it won’t deliver the same increase in breast augmentation or breast implants. But how does this surgery work?

Patients can choose to have their breast implants inserted over (sub-glandular placement) or under (sub-muscular placement) the chest wall muscles. Each surgery is different, and your surgeon may adjust their approach based on your unique anatomy. For example, a doctor may make a small incision near the breast area to create a pocket that holds the implant or create an opening near your areola, armpit, or the bottom of your chest muscle.
Like with any invasive procedure, your breast augmentation involves a bit of recovery time and pain. That said, the placement of your implant affects your overall downtime and final result. People that are seriously considering breast augmentation may want to note that implants inserted under the muscle result in a more natural-looking bust in exchange for a slightly more challenging recovery.

Bottom Surgery

Bottom surgery, or vaginoplasty, is a significant part of many trans women’s transition. The three most popular methods to achieve the desired change are penile inversion, rectosigmoid or colon graft, and the non-penile inversion vaginoplasty.

Penile Inversion

This surgery involves using the penile skin to form a sensate vagina. The labia majora and minora are constructed from scrotal tissue, while the clitoris is sculpted from the penile glans. Some surgeons may opt to use the remaining scrotal tissue to create additional vaginal depth. Keep in mind that self-lubrication can still be an issue.

Rectosigmoid Or Colon Graft

Like any medical procedure, there are a few options trans people can consider when getting a vaginoplasty. For example, if the patient lacks scrotal tissue or started HRT before puberty started, they may want to consider getting a rectosigmoid or colon graft to complete their transition.

This procedure involves using intestinal tissue to form a vaginal wall and can sometimes be used in conjunction with a penile inversion. Surgeons use intestinal tissue because it’s mucosal and therefore able to self-lubricate.

Non-Penile Inversion

Otherwise known as the Suporn technique (named after its proponent, Dr. Suporn), a non-penile inversion uses perforated scrotal tissue for the vaginal lining and intact scrotal tissue for the labia majora. Instead of inverting the penis, this type of medical transition uses penile tissue for the labia majora and clitoral hood. This can result in greater vaginal depth and a more sensitive inner labia.

Social Transitions

Medical transitions can be cost-prohibitive, meaning that a regular trans girl might start transitioning socially long before she considers any hormonal or surgical procedures. But what exactly is a social transition, and how do transgender people go about it?
Social transitions refer to the changes you make in your day-to-day life that allow you to live in congruence with your gender identity. For some, this may include changing their names to something more feminine and dressing differently. However, every person’s social transition timeline is different, and you should only make the changes you’re comfortable with.

Coming Out

Contrary to popular belief, coming out isn’t a one-time affair. Many people choose to come out to their close friends before family, or vice versa – it all depends on who you’re more comfortable with. There’s no right or wrong way to come out as a transgender person, but you must prioritize self-care and act only when you’re 100% ready to let people know your truth.

If you’re unsure about coming out, we recommend contacting your local support group. This is so you can surround yourself with people that understand what you’re going through and can maybe give you useful advice when navigating any potential complications of coming out.

Voice Training

Here’s an unfortunate fact: even if you’ve gone through HRT and feminization surgery, your voice will remain the same. That’s why some transgender people may attend voice training lessons or even use apps to achieve a higher, more feminine speaking voice. This helps with feelings of gender dysphoria and allows transgender women to conduct themselves with confidence in their day-to-day lives.

Body Hair Removal Options

As we mentioned earlier, HRT treatments can reduce hair growth, but it doesn’t stop it altogether. That’s why hair removal procedures are so common among transgender women.
These procedures can range from easily-accessible and temporary (like shaving one’s legs, using depilatory creams, or going to a waxing salon) to expensive and permanent. One popular approach is laser hair removal, which smooths hair follicles to inhibit unwanted hair growth in your underarms, pubic area, or even on your face. This results in soft, smooth skin – complementing a feminine physique or manner of dress.

Transitioning as a transgender or non-binary person is non-linear and varies from person to person. Some folks prefer to go all-in and start HRT before going under the knife for gender confirmation surgery, while others are content with non-surgical transitions. So if you’re interested in transitioning and you want to get started on your journey, head over to our product page and take a look at what we've got to offer!