Editor’s note: This article is meant to provide information about gender transition and why a transgender person may choose to transition. It does not attempt to speak for trans people. We recognize everyone has a different experience, and we welcome you to share yours in the comment section below.
“So, when are you getting surgery?”
“Are you taking hormones yet?”
“Why would you want to go to all that trouble?”
These are just a few of the questions people in the process of coming out as transgender might face. Friends and family members who may have little to no understanding of gender transition or of what it means to be trans may ask invasive questions, make inappropriate inquiries, or say things that are invalidating or hurtful, regardless of intention.
Transition—the process by which an individual begins to live as a member of another gender—can be complex. It may involve many steps for some and fewer for others. These steps might include changes to legal documents, gender confirmation surgery, alterations to physical appearance, name and pronoun changes, and hormone replacement therapy, among others.
A person’s reason for choosing to transition, and the goals they have regarding transition, are personal and unique. Some individuals may not pursue certain aspects of transition, whether through personal choice, lack of resources, or lack of access. There is no single “right” way to transition. A person’s gender identity does not depend on whether they have had surgery or if they are taking hormones.
Why Do People Transition?
A person might realize they are trans (that their gender identity does not align with their birth sex designation) at any point in life. Some people may first experience an internal sense of identity that does not match their external characteristics in early childhood. Others report realizing this in puberty or later. Societal gender norms and expectations may contribute to a person’s realization of their true gender identity. These assumptions can also contribute to dysphoria, as a person might first attempt to conform to societal expectations by expressing a gender identity they do not have.
Gender dysphoria, which is believed to result from a mismatch between the brain’s internal map of the body and the actual physical body, is experienced by many trans people. The feelings of distress frequently associated with this condition may have a negative impact on a person’s quality of life.
Transition, whether social, through hormone therapy, through surgery, or through some combination, often improves feelings of dysphoria, though it may not relieve them completely. The goal of many is for their gender to be perceived correctly by others, which is often referred to as “passing.” Typically, people transition to align their physical appearance and characteristics with their gender identity. Many people begin the process after years of dysphoria and distress, and transitioning may help them feel as if they are finally able to be their true selves.
Family members and friends may find a person’s true gender difficult to accept. “You’ll always be ____ to me,” a mother might say, without the intention of harm. But this type of remark may be invalidating and cause distress in individuals who no more chose their gender identity than they chose to be born with blue eyes or brown hair. Participating in therapy or counseling sessions can help family members accept a person’s gender identity. In counseling, they may be able to ask questions, come to a better understanding of what it means to be transgender, and learn more about what transition entails.
According to Kimber Shelton, PhD, a licensed psychologist in Duncanville, Texas, transitioning can have significant psychological, social, and physical benefits: “In my experience, individuals who transition express that the desired effects of hormones and surgery outweigh the potential risks (such as increased acne or balding from hormone replacement therapy).”
Anxiety and depression caused by gender dysphoria may diminish as dysphoria improves. Individuals who no longer have to make uncomfortable adjustments—such as hiding unwanted physical characteristics—may not only feel better physically but may have greater confidence and self-esteem, Shelton also said.
People generally begin the transition process on their own before seeing a therapist or doctor. Even if a person has decided on medical transition, it may not be possible to begin immediately. Social transition is the first step for many, and some people may transition only socially.
Socially transitioning means a person makes changes in appearance and social situations to reflect their gender. This may include changes to hairstyle and clothing, name and pronoun changes, and use of different bathrooms/gendered facilities. When a trans person first comes out as trans, they often share their correct pronouns and their chosen name. They might share this widely—at home, school, or work—or they might disclose these changes only to family and close friends. Using the correct pronouns and the name a person has chosen shows support and acceptance of that person’s identity, but using an incorrect name and pronouns, beyond invalidating that person, could place them in danger or subject them to discrimination, harassment, or abuse in some situations.
The legal process of gender transition typically requires several steps, and in America, the process varies widely between states. All states allow name changes, but birth certificates issued in the states of Idaho, Kansas, Ohio, and Tennessee cannot currently be changed. This restriction can prevent trans people who desire to change their gender marker from being able to fully transition. Many trans people do not wish to disclose the fact they are trans, but being unable to change their gender marker may force them to do so and can prevent them from changing other documents.
Seeking education about the issues and concerns trans people face and offering acceptance and support can be of great benefit not only to a trans friend or family member but to the trans community.
Some states or individual treatment agencies require the completion of certain aspects of transition before providing others. For example, several states require gender confirmation surgery before issuing a birth certificate bearing the correct gender marker. Because this surgery is expensive and often not covered by insurance, it may be out of reach for some who desire it. Individuals who choose to transition without surgery but want their legal documents to reflect the correct gender may also be prevented from achieving this goal.
Steps for legal transition might include:
- Changing name (may require a court order)
- Updating Social Security card (often necessary for an updated driver’s license)
- Updating license/other identification (may require an amended birth certificate). A U.S. passport or passport card reflecting a person’s correct gender can be obtained with a letter from a physician, regardless of the requirements in that person’s state of residence.
- Changing gender marker on birth certificate
- Updating other documents such as wills, transcripts, or diplomas
Some people choose to take hormones as part of their transition process. Hormone therapy, which helps people develop secondary physical characteristics that reflect their true gender, can greatly impact those who are transitioning. People who choose to take hormones may see changes right away, but it can take years before the changes are complete. Some changes are not reversible, but others are, and hormone therapy will typically continue for the rest of a person’s life, unless that person chooses to stop taking hormones. The effects of hormones may vary, and changes cannot be predicted or controlled. They may take effect more quickly in some individuals than in others.
In most states, individuals seeking hormone therapy need a letter from a mental health professional confirming the presence of gender dysphoria and recommending hormone therapy to treat it.
Male to Female (MtF) Hormone Therapy
People assigned male at birth who choose to take hormones will generally take estrogen and anti-androgens, also known as androgen blockers. Estrogen both feminizes features and helps to suppress testosterone, while anti-androgens block the effects of testosterone. Effects may include:
- Breast development
- Redistribution of body fat and loss of muscle mass
- Changes in thickness to body hair
- Increased skin sensitivity and softness
- Changes in feelings and mood
- Decreased libido and fertility, as well as other sexual side effects. The testes will shrink, as may the penis.
MtF hormone therapy does not have an effect on beard hair or voice. Voice therapy can help women reach the desired pitch and modulation, while laser hair removal and other treatments may be necessary for lasting facial hair removal.
Female to Male (FtM) Hormone Therapy
Testosterone is taken people who were assigned female at birth. Effects of testosterone may include:
- Development of acne due to thicker, oilier skin
- Increased libido
- Clitoral growth
- Stopped periods
- Redistribution of body fat and increased muscle mass
- Deepening voice
- Possible hair loss, change in hair growth pattern
- Body hair growth
- Changes in feelings and mood
Testosterone does not cause breast size to decrease, though the redistribution of body fat may make them less firm, and it cannot change the size of a person’s hands or feet. Anecdotal evidence suggests some men may experience a small growth spurt, but a slight increase in height might also be attributed to change in posture.
Nonbinary Hormone Therapy
Society has traditionally adhered to a gender binary that recognizes male and female identities. Many trans people do transition from female to male or male to female, but those who have a nonbinary, genderqueer, or other identity may also transition (though some nonbinary people do not identify as transgender). Though in the past the Standards of Care for the Health of Transexual, Transgender, and Gender-Nonconforming People reflected a gender binary rather than a wider spectrum of gender, the current edition uses language reflecting the acceptance of nonbinary and genderqueer people.
Though society is beginning to recognize and accept the existence of nonbinary identities, some people may find it difficult to accept other genders or understand why nonbinary individuals want to transition. It may be helpful to remember nonbinary individuals are no less transgender than those who have a gender that may be more familiar. They can still experience dysphoria, be misgendered, and desire to pass in society as a member of their gender, and hormone therapy can benefit them in the same way it benefits other trans people.
Hormone Therapy for Adolescents
Some youth may know they are transgender and want to begin transition, but their parents or doctors may want them to wait until they are more “certain” of their gender identity. However, waiting can be harmful, as changes that occur in puberty may induce dysphoria, which can have an effect on mental health. Trans teens often experience high levels of depression and substance abuse and have a high risk of suicide. Those who are able to transition typically report significant improvements in mental health and emotional well-being.
Health care professionals often prescribe puberty blockers, which delay the development of physical characteristics associated with sex assigned at birth, to trans youth until they are considered old enough to begin hormones. Some researchers suggest waiting until age 16, as the effects of hormone therapy on developing bodies are not entirely known.
Gender Confirmation Surgery (GCS)
Previously known as gender reassignment surgery or sex reassignment surgery, GCS alters a person’s genitalia and/or chest in order to reflect their gender. Calling these procedures “gender confirmation surgery” may help reinforce the fact gender identity is not a choice.
In the past, GCS was typically considered cosmetic, and trans people could expect little to no help from insurance companies. Today, many of these surgeries are known to be medically necessary for trans people, as aligning the physical body with internal identity can greatly relieve distress, mental health symptoms, and suicidality. All major psychological, psychiatric, and medical organizations in the U.S. have made statements to this effect, and many insurance companies now cover some GCS procedures, including mastectomy, gonadectomy, and genital reconstructive surgery.
Surgery to alter facial features, contour the body, modify the voice, increase breast size, or change nose shape or size may assist in the masculinization or feminization of physical characteristics. However, most insurance companies still consider these procedures cosmetic.
To receive gender confirmation surgery, individuals typically need to provide one or two letters of referral from a qualified mental health professional. Some providers require the individual to have had hormone therapy and lived as their gender for a period of time before receiving surgery (though this requirement may be waived in some cases).
Adults who do not have sufficient insurance may have to pay for medical procedures out-of-pocket, which may not be feasible for some. Shelton points out the ability to transition through surgery or hormone therapy is a privilege not everyone has. Some trans people do not have access to any health care resources at all and are unable to pursue any type of medical transition.
How to Offer Support
Some people believe trans people are confused, that they want to transition to be “different,” or that the surgery and hormones they need are nonessential. However, research has shown transgender people are not confused; hormone therapy and GCS can greatly increase quality of life; and the potential risks of hormone therapy and surgery are often far outweighed by the positive effects of transition. Seeking education about the issues and concerns trans people face and offering acceptance and support can be of great benefit not only to a trans friend or family member but to the trans community as a whole.
Immediately referring to a person by the correct pronouns and their chosen name, when that person has shared that information, is one way to show support. If a mistake is made with a person’s name or pronouns, apologizing, correcting the mistake, and moving on is often the best way to handle it.
Avoiding questions that could be considered invasive is also a way to show support. Being expected to provide information about “all things trans” can place the burden of being an educator on people who may not want or be able to take on this role and may lead to them experiencing emotional distress. This expectation may also be colored with the assumption that every trans person will take the same approach toward transition.
Some people may willingly discuss their transition, but it is important to respect their boundaries by allowing them to begin the conversation, direct it, and end it when they no longer feel comfortable.
Simply offering acceptance can be a significant mark of support, and doing so is likely to help an individual transition with greater ease.
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