If you have been diagnosed (or self-diagnosed as I was in August 2001) with Gender Dysphoria - or even if you haven't, but have realised that you are trans* the obvious question is "What can I do about it?"
* Gender dysphoria isn't a prerequisite for being trans.
Sadly, there's no simple, single answer - what works for one person may be quite disastrous for another. It's your life - and your choice. You can socially transition and/or medically transition if that seems right for you - but there is no single "right" path, and only you can make that call...and the more information you have available, the more informed a choice you can make.
When I started out on this long road in summer 2001 I tried hard to learn everything I could so I knew exactly what I was getting into, particularly from a medical perspective.
I hope to share some of that here. I'll start with an overview of the medical treatments I know something about, followed by some of the tradeoffs (as I understand them) between the two available treatment regimes available in the UK - NHS and privately funded. Finally I'll talk a little about the treatment I've had myself.
Please bear that in mind while reading this that it was originally written over 15 years (!!!!) ago from my own perspective - i.e. that of a trans woman with a very straightforward binary identity. As such I'm not qualified to speak for trans masculine or non-binary folks and I won't attempt to.
The process of changing public gender role in society (in my case from male to female, but other routes are obviously also available) is known as "social transition".
The definition is a bit blurry, but this process effectively starts with start preparing to make such a change, and ends with making (hopefully permanent) changes to things like name and social gender presentation. Medical treatment may run in parallel with the transition process, precede or lag behind it.*
* Historically, the period between social transition and genital surgery was referred to a the "Real Life Experience" (RLE) or "Real Life Test" (RLT), but both terms are now obsolete.
If a patient has been on hormone therapy for several months and their appearance has changed significantly, social transition can become easier, but it's not a prerequisite - I know lots of trans women who've transitioned without medical treatment in the UK (indeed, the way the NHS works effectively mandates such an approach for most).
Equally, I also know others who've had access to HRT throughout but had a very rough time. It's different for all of us, and all each of us can do is what's best for us.
My transition effectively started in March 2002 when I started facial hair removal (more on that later), and ended on Christmas Day 2002 when I no longer had to pretend to be male. At that point my medical treatment was far from over, but my time pretending to be male was.
I won't kid you here - transitioning can be a very difficult thing to do, and anyone who does so can expect the possibility of a lot of heartache along the way. Although I've been lucky in that lots of things worked in my favour, I've had my fair share of pain and I know many others without the advantages and privileges I've benefited from who've also transitioned without problems.
Physically, the treatment process for a trans woman like me can involve any of the following types of medical treatment:
- Social transition and the period formerly known as "Real Life Experience"*
- Hormone Replacement Therapy (HRT)
- Facial and (if required) body hair removal
- Vocal training
- Surgical interventions, including perhaps Breast augmentation (BA), Genital Reconstruction/Sex Reassignment/Gender Confirmation Surgery (GRS/SRS/GCS) and Facial Feminisation Surgery (FFS)
* Although not a medical treatment per-se, I've included this because it is part of the process.
Although the fine details vary hugely from individual to individual, there is sufficient commonality that any one person can quickly gain a fairly good idea of their path through transition and treatment, and what they are likely to need. I'm sure I was no exception in that regard.
Social transition and the so-called "Real Life Experience"
Before being accepted for genital surgery (see below), clinicians typically require a trans patient to live "as themselves" in an identity-congruent gender role for a minimum period (12 months according to international Standards of Care, but two years according to the NHS). This used to be known as the "Real Life Experience" (RLE) or "Real Life Test" (RLT), but such terminology is now obsolete.
During this period the patient is expected to present as themselves. In theory clinicians monitor this, but in practice it's usually a box-ticking exercise based on whether the patient has changed their name on bills, bank accounts etc. Eventually referrals (the NHS requires two) referrals may be made to certify that the patient is a suitable candidate for genital surgery.
Note that social transition can take place either before or after Hormone Replacement Therapy (HRT) has started. In my own case I socially transitioned on Christmas Day 2002 - just under 7 months after starting HRT.
Hormone Replacement Therapy
Cross-sex hormones (e.g. oestrogen for trans women and testosterone for trans men) can have radical effects on the body. For example, female hormones can affect the body in numerous subtle ways:
- Growth of body hair reduces drastically (although facial hair is not significantly affected, unfortunately!)
- The skin softens and becomes more "feminine" in texture
- Breast tissue starts to grow
- Facial appearance becomes more feminine
- Fat distribution changes throughout the rest of the body, adopting a more apparently "feminine" pattern (for example the hips may widen, whilst abdominal fat deposits may reduce).
Unfortunately, oestrogen will not affect bone structure (although cartilage can shrink, so feet in particular may get noticably smaller!), or the size of the voicebox. Testosterone will however affect both, so in this regard trans men are a little more fortunate than trans women.
Trans women are often also prescribed an anti-androgen to suppress the effects of male sex hormones (which are likely to still be present in the body in appreciable concentrations prior to genital surgery, even if oestrogen is being taken). Progesterone is also beneficial and may also be prescribed, though most UK clinicians refuse to do so.
Trans people can be prescribed cross-sex hormones from early in the transition process, but it really depends upon what resources and clinicians they have access to. At the time of writing long waiting lists for UK gender clinics mean that many trans people self medicate rather than wait years for clinical support.
Finally, it's worth noting that post-operative trans people must continue to take sex hormones since their own bodies will not produce them in the correct amount or balance to maintain long term health.
Female hormones do not have any observable effect upon facial hair growth in trans women, so if facial hair is a concern it must be removed in some manner.
Although short term hair removal methods (through methods such as plucking, waxing etc.) may be practical in the short term, in most cases a long term solution is preferable. Two of the most common methods available at present are electrolysis and laser hair removal. Both techniques rely on causing damage to the root of hair cells, thus retarding or stopping hair growth.
Electrolysis achieves this by applying a measured electric charge via a needle inserted into each follicle in turn. Since each follicle must be treated individually, treatment can take a long period of time (it is not uncommon for facial hair removal by electrolysis to take several years in total).
Laser hair removal is a newer technique, in which a measured pulse of laser energy is applied to a small area, causing thermal shock to the hair follicles in that area.
In order to transmit the laser energy to the hair follicles rather than the skin (which would cause burns), the wavelength of the laser used is selected to match the absorption frequency of melanin present in the hair follicles. As a result, this technique is only suitable for individuals with dark hair and fair skin.
Although not the long term results are not yet proven, laser treatment is much faster than electrolysis.
Vocal Training and Speech Therapy
Like facial hair removal, voice training can be very useful or even essential for trans women. However, unlike hair removal a degree of voice training can be undertaken without outside assistance. Although formal speech therapy may be beneficial or required, it really depends upon the individual.
Vocal chord surgery can also be undertaken, but as the techniques involved are still very new and the results unpredictable, few patients risk this approach.
Genital, Sex Reassignment or Gender Confirmation surgery (often referred to as GRS, SRS or GCS) is an irreversible part of the physical treatment process.Whereas GRS and SRS specifically apply to genital surgery, the term GCS can apply to either that or include upper body surgery (Breast Augmentation (BA) or Mastectomy).
By the time a patient has been accepted for surgery, they are typically expected to have been living in a congruent role within the community for (according to the international Standards of Care) at least a year, and have demonstrated their suitability as a candidate for such a major step to their gatekeepers in the medical profession.
In practice the this period is usually significantly longer: patients undergoing NHS treatment have to contend with long waiting lists due to the high demand and the small number of NHS surgeons qualified to perform genital surgery, whilst private patients may have to save up or fundraise to pay for the costs of surgery.
In order to further soften facial appearance, and improve their ability to be accepted by society, some trans women may also undergo Facial Feminisation Surgery (FFS). FFS is a collection of possible procedures which can (for example) reduce of the size of the eyebrow ridges, chin/jawline and nose - and even possibly reconstruct the entire forehead. The results can be quite striking.
Depending on the techniques used, recovery after FFS is normally fairly quick, but GRS/SRS surgery can require a long recovery time (between 6 months and a year to heal full) and a significant time off work (8-12 weeks is commonplace).
NHS and Private Treatment
There are basically two paths through transition in the UK - NHS or private. From the perspective of the patient, the treatment regime followed in the two cases is not greatly different, although there are still some differences (most notably in the area of the waiting times involved).
Patients opting for NHS Treatment used to find that funding varied considerably between areas - which could make it very difficult or impossible to even get a referral. For example, some areas would provide funds for psychiatric counselling, but not for treatment. This is now illegal. All Clinical Commissioning Groups must provide treatment, although they may try to put roadblocks in the way - and as of 2020 the waiting lists are horrendous. It's a bit of a mess, quite frankly.
The long waiting lists of the NHS gender clinics can result in everything taking a greatly extended period of time. NHS Gender Clinics tend to require patients to socially transition before receiving hormone therapy, which obviously makes it much harder.
As a result of these problems, many patients self-medicate or attempt to fund at least part of their transition privately. Unlike the NHS regime (which tends to be rigidly structured), private treatment places more of the responsibility for their progress on the patient. Hormone therapy is usually started much more quickly for private patients.
If the patient copes well with social transitioning, referrals for privately funded surgery could theoretically follow a year or so afterwards. In practice, the fact that many patients seek an NHS referral for surgery or are subject to the waiting lists of the surgeons themselves can delay things significantly.
My Own Transition and Treatment
I was lucky in that my skin tone and natural hair colour was suitable for treatment by Laser Hair Removal, so I initially opted to use this technique in preference to electrolysis for facial hair removal. From March 2002, each month I visited Christianos Laser clinic in London, with each treatment taking up to 50 minutes including preparation, and costing £220.
Unfortunately I discovered that my facial hair was very resistant - I had 16 treatments before switching to electrolysis in October 2003 to deal with the remaining hairs. Since hair removal by electrolysis is much more commonly available than laser treatment, rather than travel into London I was able to have treatment locally (with Appointments with Vanessa in Farnborough), which of course made things easier. I really can't recommend her enough.
Be warned though: Fifteen (!!!) years later, I still see Vanessa for an hour or so a month. Facial hair removal can be a very long term process!
I also had some chest and abdominal hair removal by laser treatment, this time by Hairaway (subsequently rebranded as Lasercare and more recently sk:n Clinics) in Shaftesbury Avenue, London. A full treatment cost me £140, and needed to be done every 8 weeks or so. After six treatments of my chest and five on my abdomen, I was largely clear, and I've not had any subsequent issues with regrowth in that area.
In preparation for reassignment surgery I also had several sessions of hair removal on my bikini and genital area.
Hormone Replacement Therapy (HRT)
I started hormone therapy under the private care of Dr. Russell Reid (of the London Institute) at the end of May 2002. The hormone regimes I've been prescribed since then are given below.
Original regime (prescribed by Dr. Russell Reid):
- A now discontinued birth control pill (Ovran)
containing 50µg ethinylestradiol (a synthetic form of oestrogen) and 50µg levonorgestrel (a synthetic progesterone), taken twice daily
- An externally applied gel (Oestrogel) containing 0.75mg 17Β oestradiol, to assist in body hair reduction and breast development, applied twice daily.
Second privately prescribed regime (prescribed by Dr. Russell Reid after the withdrawl of Ovran):
- A combined birth control pill (Yasmin) containing 30µg ethinylestradiol (a synthetic form of oestrogen) and 3mg Drospirenone (a synthetic progestin with anti-androgenic properties), taken three times daily.
At this point my local GP was refusing to convert Dr. Reid's prescriptions, possibly as a result of a misguided policy (subsequently reversed after I challenged it) by the local Primary Care Trust (the forerunner of the current NHS Clinical Commissioning Groups). This was a particular issue because of the cost of Yasmin - then around £182.50 for a 3 month supply, or around £60.83 a month.
Eventually (with the aid of the Patient Advice Liaison Service or PALS) the PCT relented and agreed to fund it directly - though my GP would still not convert the prescription. The arrangement they came to was quite novel - they arranged for a particular local pharmacy to convert the prescriptions and invoice them directly for the cost of doing so.
Third, abortive regime (it seems I can't metabolise Estradiol valerate, and after 3 months on this regime I lost most of my breast development!):
Progynova (Estradiol valerate) 2mg three times daily
Duphaston (synthetic progesterone) 10mg twice daily.
Current regime (prescribed by my current GP, with my involvement):
- Zumenon or Elleste Solo (Estradiol Hemihydrate) 2mg three times daily
- Utrogestan (natural progesterone in a peanut oil suspension) 10mg twice daily.
I'm glad to say that throughout my time on HRT I've not noticed any side effects other than the expected changes in appetite and metabolism. Aside from the brief period on estradiol valerate the HRT has done its work well - I've ended up with a good figure and a natural 36B bust.
Social Transition and Beyond
When I moved out of the family home at the end of October 2002 I changed my gender presentation "part-time" - which effectively meant presenting as female at weekends and in the evening if I was going out. Over time, my confidence improved immensely - I no longer felt self-conscious or anxious by the time I fully transitioned.
For some time beforehand I'd been buying clothes and learning makeup skills, which gave me time to make and recover from the inevitable mistakes along the way, and increase my confidence in my ability to survive the experience and rebuild my life.
I formally transitioned on Christmas Day 2002, and I'm glad to say that I didn't encounter any major problems. The problems I did have were emotional in nature rather than to do with others perception of me...I seemed to "pass" fairly well and didn't face any real hostility. The fact that my appearance and manner softened significantly probably helped a great deal in that - although, in truth, you never stop unlearning the old and learning the new.
Vocal Training and Speech Therapy
Aside from a handful of Speech Therapy sessions at the local hospital, I've not undertaken any formal speech therapy. Instead, I researched the techniques involved, ordered a voice training CD and started practicing (by singing in the car while driving to and from work!), with OK-ish results.
Based upon what I learn, I came to the conclusion that I could achieve the results I needed to be accepted by society without any form of vocal surgery (which given how risky that is is probably a good thing). In practice, I have found that despite limited success in this area it hasn't been a problem; any fear I had of speaking in public has long since faded, and I've not had any problems from others. While I'm not really happy with my voice, it's not a major problem and I've come to accept that I can live with it.
I underwent reassignment surgery with Dr. Suporn in Aikchol Hospital, Chonburi, Thailand on 14th November 2003. I returned for Facial Feminisation Surgery (FFS) on 21st January 2004. I've not had Breast Augmentation or any other surgeries.
There are lots of treatment options avalable for trans folks these days, so if you think you need medical intervention please do your research, think carefully and choose wisely. Remember though that you are just as valid if you do not seek medical intervention!
Overall, the results of my own medical treatment have been far, far better than I ever dared dream possible, and have helped me to grow from someone who was really struggling after my self-denial collapsed to someone who is much more confident and just getting on with life.