When do people know they are transgender?

Every person is different. Some trans people may know their gender identity even as a very young child. They may have always felt a little different. They may have known at a young age that they didn’t fit into the gender role that was given to them. Other people may start to question their gender identity as a teen. And some people may not start to question it until they’re an adult.

Hormone therapy

Hormone treatment can change certain things about a person’s appearance so that they look more masculine or feminine. This treatment is done by a doctor who specializes in conditions related to hormones (an endocrinologist). This therapy can be done on its own. Or it can be done with any of the gender-affirming surgeries listed below. Hormone treatment is often advised before having any of these surgeries.

For transgender females

Hormones are given to create more feminine physical traits such as:

• Increased breast growth

• Less body hair

• Reduced muscle mass

• Softer skin

This treatment can also reduce the ability to have an erection and reduce testicle size. Body fat will start to shift more to the hips and breasts. Treatment may combine a female hormone (estrogen) with one that blocks the male hormone (called a testosterone blocker or anti-androgen).

For transgender males

The main male hormone (testosterone) is given to create more masculine physical traits such as:

• More facial and body hair

• More muscle growth

• Increased sex drive

• A deeper voice

There may also be a decrease in breast tissue. You may stop having your period.

Gender-affirming surgery

Below are the types of procedures that can be done. Always talk with your healthcare provider about the procedures that may be right for you.

Male-to-female surgeries

Procedures may include:

• Facial feminization surgery. Parts of the face and neck are softened and reshaped to create a more feminine look. Surgery can include some or all of these:

  • Forehead reduction and hairline lowering

  • Brow lift (browplasty)

  • Eyelid modification (blepharoplasty)

  • Cheek augmentation

  • Nose reshaping (nose job or rhinoplasty)

  • Lip lift and reshaping

  • Jaw shaping or reduction

  • Chin width reduction (genioplasty)

  • Adam’s apple reduction (thyroid cartilage reduction)

• Female chest (top) surgery. Breast implants are inserted into the chest (breast augmentation).

• Female genital (bottom) surgery. This surgery creates a functional vagina by inverting penile skin (penile inversion vaginoplasty). The testicles are also removed (orchiectomy) and a clitoris is created (clitoroplasty).

• Voice feminization. This surgery changes the voice to a higher pitch.

Female-to-male surgeries

Procedures may include:

• Facial masculinization surgery. Parts of the face and neck are reshaped to create a more masculine or nonbinary look. Surgery may include some or all of these procedures:

  • Forehead lengthening

  • Cheek augmentation

  • Nose reshaping (rhinoplasty)

  • Jaw reshaping

  • Chin contouring

  • Adam’s apple enhancement

• Male chest (top) surgery. The breasts and breast tissue are removed (mastectomy). The look and placement of the nipples is also changed.

• Surgery to remove internal female reproductive organs. The uterus may be removed (hysterectomy). Also 1 or both of the ovaries and the fallopian tubes may be removed (salpingo-oophorectomy).

• Male genital (bottom) surgery. This is surgery to construct a penis. A scrotum is also made (scrotoplasty). And the vagina is removed (vaginectomy). The new penis may be made using the clitoris (phalloplasty). In this case, hormones are given to enlarge the clitoris. Or the penis may be made using skin grafts from other parts of the body (phalloplasty).

• Voice masculinization surgery. This surgery gives the voice a lower pitch.

Requirements for medical transition treatments

The following guidelines are from the World Professional Association for Transgender Health (WPATH) Standards of Care. Most insurance companies require people to meet these standards before starting any treatment. Talk with your healthcare provider, plastic surgeon, and insurance company to find out what’s required. Requirements may vary depending on the state where you live. Before starting any hormone therapy or having gender-affirming surgery, you may need to have:

• A letter of support from a mental health or other healthcare provider

• A diagnosis of gender dysphoria from a mental health provider

For most gender-affirming procedures, you may also need to:

• Be age 18 or older

• Have hormone therapy for at least 1 year before surgery

• Live for at least 1 year before surgery as your self-identified gender (called the Real-Life Test)

• Have regular visits with a mental health provider

Transitioning and gender dysphoria

Having a person’s outside appearance align with their gender identity has many positive emotional and psychological effects. It changes the way that others see them. It changes how other people interact with them.

Studies also show that medical transitioning can greatly reduce the anxiety and distress (called gender dysphoria) that occurs when someone’s gender identity doesn’t match the sex they were assigned at birth.

Do all transgender people transition medically?

Deciding how and when to transition is a very personal decision. Not all transgender people want or are able to transition medically. Some people may only have hormone therapy. Others may choose 1 type of surgery, or no surgery at all.

Cost can be a major issue. These treatments and procedures are expensive. And they may not all be covered by your health insurance. Talk with your healthcare provider about your own personal situation and needs.

Next steps

Gender transition hormone treatment and surgery is complex. It’s important to have all of your questions answered beforehand. And it’s important to feel comfortable with the plastic surgeon, endocrinologist, and healthcare team that you choose to work with.

To get started on your transition journey, ask your primary healthcare provider for referrals. Be sure to choose board-certified providers who specialize in transgender healthcare and are experienced in these types of procedures. Together you can decide on the best approach for you.