Transitioning 101: MtF

*Note: This article was originally published on Pride Pocket prior to merging with MyUmbrella*

This is the first piece in a series of articles aimed at trans women, transfemmes, or assigned male at birth (AMAB) non-binary people who wish to present themselves in a more feminine way. Together with other articles on this site, it will cover the non –medical aspects of transition, which will help reduce day to day dysphoria and help bring your presentation more in line with your identity, as well as the medical and legal aspects of transition. It aims to give a rundown of costs, practicalities, safety, and other considerations.

Please note that not everything will be relevant to everyone, as each person’s journey is different. The short overview given here will be supported by longer articles on each aspect, as well as our crowdfunding community.

All prices given are approximate and relative to the United States.

Non-medical Transition: 

Non-medical transition refers to procedures you can do without a diagnosis of dysphoria or interacting with medical or legal bodies. These solutions tend to be cheaper, more immediate, and less permanent than medical options. Generally, they are where people begin their transition and constitute the social aspect of transition, which many medical professionals require evidence of before they will prescribe other treatments.

For some trans people, such non-medical things will be the main focus of their transition and can be broadly divided into changes that can be made without formal medical intervention and devices/clothing that help with dysphoria. The former covers things like tucking, hair removal, and voice training. The latter includes items like breast forms and gaffs.

Tucking and gaffs are two ways to conceal the penis and scrotum, in order to present a more feminine shaped pelvis and decrease dysphoria.

A Gaff is a wearable device that holds the penis back and up. There are various DIY methods of making a functional gaff, but there are many websites where it is possible to buy ones that look like regular panties for about $15.

Tucking is where the penis and scrotum are tucked back between the legs and taped into place using skin-safe tapes, such as sports or surgical tape. Tape that is not skin safe should never be used to tuck. To prevent skin damage and pain, it is important to wrap the penis in tissue paper and remove all hair from the area.¹

Tucking for long periods of time is not advised, as it means you will be unable to urinate. Also, while there is insufficient medical research on tucking, it is also possible that prolonged and frequent tucking may impact upon fertility and sperm count².

Hair Removal can be done by waxing, shaving, depilatory creams, electrolysis, or laser hair removal. The most suitable method depends on the area from which the hair is to be removed, and each person’s individual needs.

Depilatory creams and shaving are the least expensive options and can be done painlessly and easily at home. Of the two, depilatory creams have slower regrowth, as they weaken the follicle. However, neither is a permanent solution. Also, depilatory creams cannot be used on sensitive areas, or by those with sensitive skin, whilst frequent shaving can lead to irritation.

Waxing is slightly longer term (about 3-6 weeks) and is usually done at a salon. Wax is applied to and removed from the skin in order to pull out hair from the roots. It can cost anything from $35 to $80³, depending on the area you want to be waxed, and the rates at your local salon. One major drawback of waxing is that not all salons are trans-inclusive, so it is worth looking for reviews and recommendations from local trans people, and possibly calling in advance if you are comfortable doing so.

Laser hair removal is a long term hair reduction. It will remove much hair, and that which remains will be finer and paler, but it will not stop new follicles forming. More appropriate for larger areas, the most common type – Intense Pulsed Light (IPL) – works by targeting the melanin in hair in order to destroy the follicle⁴. As such, it is not suitable for those with dark skin, or whose hair is paler than their skin. However, a method known as Nd:YAG ⁵ laser removal is suitable for darker skin, and there are clinics that specialize in this. The cost of treating an area depends on size, but will probably be in the region of $250-$1000⁶.

Electrolysis is permanent hair removal which treats each follicle individually, and is therefore recommended for smaller areas, such as facial hair and eyebrows rather than chest or back. It costs around $30-100 for a 30 minute session, and more than one session will be needed for the result to be permanent. Full facial electrolysis can take anything from 100-400 hours⁷.

It is possible, but unlikely, that your insurer or national health service will cover the cost of electrolysis or laser hair removal. However, if you are having to cover the cost yourself, it is worth researching your local salons to see if there are any which are trans specialists, as these may offer a discount to transgender clients .

Breast forms and enhancers are prosthetic breasts or padding, worn to give a more feminine appearance to a chest. There is a lot of variety and what you choose will depend on your budget and your needs.

Breast forms can be sold as individual forms, or as a single piece – which, depending on design, can be worn like a breastplate, or a bra. Individual forms are either worn inside a bra, or attached using skin-safe adhesive tape.

The most expensive forms are medical grade silicone breast forms which are designed to look and feel most like biological breasts. They are sometimes weighted. These generally start from around $100 for a budget product but can be much more expensive.

Foam breast forms are lighter and generally have a more generic shape. They are slightly cheaper than silicone forms and start at around $50.

Breast enhancers can also be used to emphasize breast growth from hormone replacement therapy. Breast enhancers, sometimes called ‘chicken fillets’ are pads made of foam or silicone that fit inside a bra to produce a ‘fuller’ look. Paired with a padded bra, they can create the appearance of small breasts and provide a much cheaper option to more expensive forms. They can be bought for as little as $7.

Medical Transition:

For MtF people, medical transition tends to refer primarily to – Hormone Replacement Therapy (HRT) and Vaginoplasty, but may also include facial feminization surgery, voice feminization surgery, a tracheal shave, and augmentation of the buttocks, hips, and breasts.

HRT refers to the use of hormones to cause some of the body changes that, in a cis woman, occur during puberty. This generally refers to testosterone blockers and oestrogen, and sometimes progesterone⁸. The changes caused will affect muscle mass and fat distribution – which includes the growth of breasts. Other effects are a thinning of the skin and hair and a probable cessation of hair loss from male pattern baldness. It will also cause a reduction in the size of the external genitalia and may affect the ability of the penis to become erect.⁹

The size of breasts developed on HRT will probably be similar, but slightly smaller, than those of the cis women in your biological family.

Because these medicines can cause side effects – such as affected liver function, raised cholesterol, and a possible increased risk of breast cancer¹⁰ – doctors will perform a checkup, including blood tests, to check there are no contraindications before prescribing it. Doctors will also monitor users at regular intervals to make sure it is not causing any problems.

Oestrogen is usually taken by oral tablets or injection, progesterone as a tablet or cream. Testosterone blockers are usually taken as oral tablets. These are all prescription medicines and may be covered by your healthcare provider, or you may have to pay for them. In the US, this could be between $15 and $100 a month, depending on form, dosage, and concentration. In countries with a national health service, it should be covered by your usual prescription fee.

Vaginoplasty¹¹ refers to the creation of a neo-vagina. The standard way in which this is done is by penile-inversion to create the vaginal cavity, labia, and clitoris (labiaplasty and clitoroplasty, respectively.) This is usually done as one operation, along with an orchiectomy (removal of the testicles). Prices may vary significantly, but it may cost in the region of $20,000¹² inclusive of the anesthesia and hospital stay.

Far less common, and not available in the USA, is recto-sigmoid vaginoplasty, which uses a section of the colon to create a neo-vagina and is also usually performed with labiaplasty and clitoroplasty. It is a more complex and expensive surgery – costing in the region of $15,000 exclusive of anesthesia and hospital costs. If you live in the USA, travel costs must also be considered.

After penile-inversion vaginoplasty, the neo-vagina will need to be dilated regularly with vaginal stents to prevent the loss of width and depth¹³, whereas one created by recto-sigmoid vaginoplasty will not need this.

Facial feminization surgeries are plastic surgeries intended to give the face a more feminine appearance. This includes things like tracheal shave (removal of cartilage to reduce the appearance of the adam’s apple, also known as thyroid cartilage reduction) rhinoplasty, upper lip shortening, and augmentation of the cheeks and chin. This is a vast area and what is desired depends a lot on each person’s needs. However, costs for individual surgeries will be somewhere in the region of $2,000-$7,000.¹⁴

Voice feminization surgery, also known as feminization laryngoplasty, is sometimes recommended if non-surgical voice training has not produced a satisfactory effect. It works by shortening and stretching the vocal cords and reducing the size of the voice box. It simultaneously removes the Adam’s apple – so a tracheal shave would not be necessary¹⁵. It can cost between $5000 and $7000¹⁶.

Breast/ buttock augmentation, along with calf augmentation, are cosmetic procedures to create a more feminine shape, especially when breast growth/ fat redistribution from HRT has been unsatisfactory. All procedures can be done with either saline or silicone implants, and buttock augmentation can also be done with a fat transplant. Costs for individual procedures tend to be between $5,000 and $9,500¹⁷.

General: In order to access any of these services, one will need to approach a healthcare provider and receive a diagnosis of gender dysphoria, which may involve a psychological evaluation. The exact procedure will vary depending on the region. In the UK, diagnosis by a General Practitioner (GP) will lead to a referral to a Gender Identity Clinic (although it is possible to do this privately.)

In the US, a lot will depend on your healthcare provider and insurance -with many not covering surgeries seen as cosmetic rather than directly gender confirming. In addition, it is worth researching any trans-friendly doctors in your area.

The usual clinical model is that HRT is prescribed first, followed by any surgeries. Most providers will suggest a minimum time on HRT before they will approve a person for surgery of any kind – a period which is usually at least 6 months. However, if there are medical or personal contraindications to oestrogen use, it is possible to receive gender confirmation surgeries without HRT.

Legal Transition:

Legal transition falls into two categories: change of name and title and change of legal gender. Changing name and title usually can be done simply and inexpensively, while changing legal gender may involve changing the gender marker on a birth certificate or the granting of a Gender Recognition Certificate. This often requires that you have already transitioned socially and begun to pursue some medical aspects of transition.

The exact procedure for both these aspects varies depending on the region, and we hope to have more specific articles on this shortly.

1. Talusan, Meredith, https://www.buzzfeed.com/meredithtalusan/all-the-questions-you-had-about-tucking-but-were-afraid-to-a?utm_term=.lk253Lqbq#.jdjrPQ3J3, Buzzfeed, 2016.
2. Hall, Alexandra, cited in Talusan, Meredith, 2016 ibid.
3. Abbie, Jo, http://stylecaster.com/beauty/hair-removal-101/, Stylecaster, 2015, updated 2017
4. ibid
5. This stands for neodymium-doped yttrium aluminium garnet – the type of crystal used in the laser – https://en.wikipedia.org/wiki/Nd:YAG_laser
6. DocShop, https://www.docshop.com/education/dermatology/laser-hair-removal/cost, 2017
7. James, Andrea, http://www.tsroadmap.com/physical/hair/zapcost.html, 2015, and cost helper health http://health.costhelper.com/electrolysis.html, 2017.
8. Progesterone is prescribed less often as it has additional risks and limited benefits.
9. Deutsch, Maddie, UCSF Transgender Care, https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy, 2015.
10. ibid
11. MTF surgery, http://www.mtfsurgery.net/mtf-vaginoplasty.htm, 2017
12. The Philadelphia Centre for Transgender Surgery, http://www.thetransgendercenter.com/index.php/mtf-price-list.html, 2017
13. Susan’s Place, https://www.susans.org/wiki/index.php/Vaginal_dilation, 2013.
14. The Philadelphia Centre for Transgender Surgery, 2017, ibid.
15. TS Surgery Guide, http://www.tssurgeryguide.com/voice-feminization.html, 2017.
16. Centre for the Care of the Proffessional Voice, Haben Practice, http://professionalvoice.org/feminization.aspx, 2009.
17. The Philadelphia Centre for Transgender Surgery, 2017, ibid.

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