Transition: Medical if Trans Female or Nonbinary

In the previous episode, I described social and legal transition, and in this episode I will explore medical transition, however the percentage that will medically transition to some degree, is somewhat lower.

Obviously there are differences between trans female, trans male and nonbinary medical transition, although there will be some overlap with either trans female or trans male medical transition, if nonbinary, depending on the assigned sex when born.

However my initial research would suggest that I would need a whole episode to fully explore trans male, medical transition, therefore this episode will focus on trans female and nonbinary medical transition, which means that the title I mentioned at the end of the last episode, is a little bit different.

Welcome to “Trans Wise Trans Strong”, I am Carolyne O’Reilly.

Episode twenty-three, “Transition: Medical if Trans Female or Nonbinary”

Although WPATH lead with the understanding of transgender health care, followed by the W.H.O. and the American Psychiatric Association, all three organisations were slow to encompass nonbinary health care.

And for my part, as a trans woman, I have a personal understanding of trans female medical transition, but I hope I am able to do justice to the nonbinary community.

And when describing nonbinary medical transitions, I hope you will understand that for brevity I will used the acronyms, AMAB, Assigned Male At Birth, and AFAB, Assigned Female At Birth.

When considering medical transition, it can be split into surgical and non-surgical, and I will explore each in turn, starting with the non-surgical.

In the previous episode, Transition: Social and Legal, I realised I did not say with whom I had voice feminisation speech therapy, it was with Christella Antoni’s Voice and Speech Therapy.

The decision to modifying how one’s voice sounds is very personal matter and although someone who is trans female may wish to alter it to sound more feminine, there is no rule that says you must.

And likewise if nonbinary, whether or not to alter ones voice is again a personal choice, and as well as speech therapy to modify the voice, there is also a surgical option, that I will discuss this later.

The next concern may be hair removal, facial and body, and getting rid of it is a pain, and I don’t just mean figuratively, and there are two main methods; laser and electrolysis.

However each method has pros and cons, laser can quickly remove large areas, but requires the hair to be pigmented, whereas electrolysis is the only permanent method of hair removal, but it is literally one hair at a time, so takes very much longer for full clearance.

I discussed in detail both methods and their origin in, A Journey of Transition - Carolyne’s Story - Part Three, at around 6 and 10 minutes respectively.

Next we come to Gender Affirming Hormone Therapy (GAHT), which performs two functions, adjusting the estrogen and testosterone levels, and to promote secondary sex characteristics.

If trans female or AMAB nonbinary this will be achieved by raising the estrogen and supressing the testosterone levels, and will result in; breast development, and body fat redistribution to the; hips, backside, and face.

Also body hair will become finer and less dense, as for the degree of breast development, cisgender female family members may give an indication.

Whereas if AFAB nonbinary, it may be to raise the testosterone level.

It is estradiol that is prescribed, to raise the estrogen level, which is one of a group of sex hormones that fall under the umbrella of estrogen, and can be prescribed in a number of different forms, as for testosterone suppression, I will describe three different drug therapies.

There are though some aspects to GAHT that a person must consider before they embark on this form of therapy, it will need to be maintained for the rest of their life and requires annual blood tests to measure hormone levels and to check liver function.

And if AFAB nonbinary the pitch of the voice may permanently drop, and there also some health risks, although there is one health benefit if trans female or AMAB nonbinary.

The formation of blood clots and gallstones are two of the most common risks as detailed on the NHS Treatment for Gender dysphoria page, and then there is the breast cancer risk due to raising the estrogen level.

There is an article by the bmj, a nationwide cohort study in the Netherlands, that did find an increased risk of breast cancer in trans women compared with cisgender men, however the risk was still lower than in Dutch cisgender women.

Estradiol is plant derived, and if over 40, either transdermal patches, gel or spray are recommended, however if under 40, the tablet form is safe, well relatively as mentioned.

Another female hormone you may have heard of is progestogen, however in the UK it is not prescribed as part of GAHT, as no objective benefit has been found, however for cisgender women on HRT who have not had a hysterectomy, it's important to protect their womb.

But back to testosterone suppression, and according to WPATH’s Standards of Care Version 8, in the U.S.A. spironolactone is most commonly prescribed, whilst in the UK it is Gonadotropin-Releasing Hormone analogue (GnRH-a) and in the rest of Europe it is cyproterone acetate.

Spironolactone is an antihypertensive and a potassium-sparing diuretic, and may cause hyperkalemia, abnormally high levels of potassium in the blood, although this is uncommon, and increases the frequency of urination, and reduces blood pressure, that’s a pass.

Cyproterone acetate has been linked to meningiomas, a primary brain tumour of the meninges, the protective layers of tissue covering the brain and the spinal cord, and hyperprolactinemia, abnormally high levels of the hormone prolactin in the blood, a definite hard pass.

Which leaves GnRH-a, which although it can result in osteoporosis, the loss of bone density, this can be prevented by a sufficient raising of the estrogen level, sign me up.

And yes GnRH-a was the method of testosterone suppression that I had in the form of an injection every 12 weeks, until my gender affirming surgery consigned two troublesome glands, that without these injections, would insist in producing testosterone, to a bin marked, medical waste!

As mentioned, GAHT will alter the hormone levels, and if trans female the aim would be to match the cisgender female range, and if under 60 this would mean raising the estradiol level to between 400 and 600 pmol/L and supressing the testosterone level.

However post 60, the estradiol level is lowered to between 200 and 400pmol/L, as post 60, there is an increased risk of cardiovascular events, blood clots, and stroke, and this lower dosage reduces this risk.

The Nottingham Centre for Transgender Health Network has an up to date guide to prescribing feminising hormone treatment.

But as mentioned there is a health benefit in suppressing the testosterone level, if trans female or AMAB nonbinary, GnRH-a reduces the risk of prostrate cancer, and post Gender Affirming Surgery, this risk is further reduced to very low, although not completely zero, what is that phrase, “never say never”.

And speaking of prostrate cancer, GnRH-a is one of the forms of treatment for prostrate cancer in cisgender men.

And another positive of suppressing the testosterone level, is that potential hair loss from the head will be halted.

Finally there are some negative side effects with GAHT, if trans female or AMAB nonbinary, there will be a substantial loss of libido, as testosterone is the primary hormone responsible for the sex drive, and there will also be a loss of the ability to have or maintain an erection.

Whereas if assigned female at birth, testosterone is naturally produced in smaller amounts by the ovaries and adrenal glands, and is vital for maintaining sexual responsiveness, desire, and the intensity of orgasms.

Which is why even post gender affirming surgery, a trans woman will still produce a small amount of testosterone by their, adrenal glands.

Before I could start GAHT, I had a consultation with an endocrinologist who explained the physical changes to expect, as well as the risks and the negative side effects, however from my perspective the side effects where a positive.

However for transwomen and a person who is AMAB nonbinary, who are currently not intending to have Gender Affirming Surgery, or are in a relationship, this libido loss may not be acceptable.

Another issue they raised was the suppression of sperm production that often leads to infertility, although this was not an issue for me.

However if a trans woman or a nonbinary person who is AMAB, wants to have biological children in the future, then cryopreservation of sperm is essential, whereas for a nonbinary person who was AFAB, then egg preservation will need to be considered.

Whilst I was aware of the physical changes to expect with GAHT, I wasn’t expecting such a profound psychological change, one of which is that I feel emotions very much stronger than in the past.

And in describing GAHT, I have been focusing on adults, and I would love to describe how trans and nonbinary children and young adults are able to halt the damaging effect that the wrong puberty causes them both physiologically and psychologically.

However as a result of “The Cass Review”, conducted by Dr Hilary Cass, which produced an Interim Report in March 2022 and a Final Report in April 2024, the option of puberty blockers for trans and nonbinary children and young adults, has been banned.

However there is a caveat, for those children and young adults who have been prescribed GnRH-a for puberty suppression in the 6-month period prior to the 26th of June 2024, as detailed on the General Medical Councils webpage, they can continue, which I would suggest makes a nonsense of the ban in the first place.

I have previously mentioned in the Portrait of…Dr Magnus Hirschfeld episode, “The Yale Law School’s” An Evidence-Based Critique of the Cass Review, whose conclusion is troubling, given that “The Cass Review” influenced government policy.

Puberty can be a confusing and worrying time if cisgender, let alone if trans female or nonbinary, as hormone levels are changing, as is body shape, and possibly the voice.

These changes for trans girls or nonbinary children, can be for some, very distressing, it’s as if their body is embarking on an act of betrayal, and of course now the option of halting puberty to give them time to determine their gender identity has been removed.

Now let’s look at surgical transition, which now is referred to as Gender Affirming Surgery, previously it was inaccurately phrased as, gender reassignment surgery, and even worse before that as sex-change surgery.

Gender Affirming Surgery’s aim is to align a person’s physiology to their gender identity, therefore it is nothing to do with sex, nor is it a reassignment, as that implies some validity to the sex assigned at birth, I think not.

Often when Gender Affirming Surgery is discussed it is in regards to vaginoplasty, which is genital reconstruction surgery, also known as bottom surgery, however there are a number of surgeries that can fall under the umbrella of Gender Affirming Surgery.

I will consider three areas, starting literally at the top with facial feminization surgery, then breast augmentation and finally vaginoplasty.

So starting with facial feminization surgery, what is involved?

It consists of a number of procedures whose aim is to reshape the face to achieve a more feminine appearance if trans female or AMAB nonbinary, if GAHT has not achieved sufficient femininization, however if AFAB nonbinary the aim may be to some degree to masculinise the face.

And again starting at the top, the shape of the forehead can be altered to give a more rounded appearance, and if the bony ridge above the eyes is prominent this can be reduced, and the hairline can be reshaped.

And to give the eyes a feminine appearance the brow may be elevated, and rhinoplasty will reduce the width and modify the shape of the nose, and finally the jaw and chin can be reshaped.

Whereas if AFAB nonbinary, perhaps flattening the forehead and slightly increasing the prominence of the area above the eyes, as well as slightly widening the nose, and making the jaw and chin more squarer, may be desired.

Lastly there is trachea shaving if the Adams Apple is too noticeable, and the reason is that during puberty if assigned male at birth, the thyroid cartilage covering the larynx, grows larger, thicker, and tilts to a sharper angle in the neck, making it noticeable, and another effect is a drop of voice pitch.

And speaking of the larynx, there is a surgical technique that permanently shortens, thins or tightens the vocal cords, to give a higher pitch.

As well as facial surgical procedures there are also some injectable ones, such as Botox that reduces thin wrinkle lines, although I would suggest less is more, and Sculptra®.

Sculptra® is a gel-like substance made of poly-L-lactic acid, and is a dermal filler that functions as a collagen stimulator to reduce deep wrinkles.

One of the earliest uses of Sculptra® was for the treatment of facial lipoatrophy, the loss of subcutaneous fat in the face, which was a side effect of the initial antiretroviral therapy for HIV/AIDS patients.

Moving down we come to the breasts, and whilst GAHT if a trans woman or AMAB nonbinary will result in breast development, to what degree can vary and also there can be an issue due to a possibly broader chest than a cisgender woman, and perhaps a wider gap between the breasts.

This can be countered by breast augmentation, which is also known as top surgery or chest feminisation, however the surgery should not take place until at least a year after starting GAHT, otherwise the breast size could become greater than desired!

The implants will be placed either behind the breast tissue or maybe under the pectoral muscle, and following the operation there may be some pain for a few days, however if AFAB nonbinary, a mastectomy may be desired.

Finally we come to the most major gender affirming surgery a trans woman or a person AMAB nonbinary may have, vaginoplasty which is the reconstruction of the genitals to create a neo-vagina.

However there is a technique that does not create a neo-vagina, it is vulvoplasty and with this surgery, a clitoris with hood is created, as are labia majora and labia minora, and the urethra is shortened and positioned were it would be on a cisgender woman, and that is it.

Whereas if AFAB nonbinary, having a hysterectomy may be desired.

And if you have listened to the already mentioned, Portrait of…Dr Magnus Hirschfeld episode, you will know that the first vaginoplasty took place, as long ago as 1931.

The patient was Dörchen Richter, and the surgery was at the “Institut für Sexualwissenschaft”, the “Institute for Sexual Science”, founded by Dr Magnus Hirschfeld, however the 2015 film “The Danish Girl”, gave the impression that Lili Elbe, was the first.

Following on from Dr Hirschfeld was Dr Stanley Biber an American surgeon in Trinidad, Colorado, who refined early vaginoplasty, and coming up to date, is Dr Marci Bowers, a leading expert on advanced vaginoplasties.

Dr Bowers has perhaps a unique perspective on vaginoplasty, given as a trans woman she herself has had vaginoplasty.

Before my surgery I saw my surgeon, who explained the procedure, and the possible complications, and I came away a little bit shell shocked, but not deterred, I still most definitely wanted my surgery.

It use to be that estrogen therapy had to stop a while before surgery, because of a perceived thrombosis risk, however now if levels are stable it can continue to just before the operation, and can be resumed a week after.

With vaginoplasty there are four techniques, and the choice depends on the available penal skin.

The first is penal inversion, that uses the penal skin to line the neo-vagina, and was the technique I had, it is a good technique for patients who have not been circumcised, and does not require hair removal.

Next there is penal inversion with graft, and this is used if there is insufficient penal skin, and uses graft tissue like tunica vaginalis, the tissue within the scrotal sack but outside the testes.

Then for those who have been circumcised and want a full depth vaginoplasty, there is the penoscrotal inlay technique, that uses the scrotal skin, but this does require hair removal.

Finally there is robotic-assisted peritoneal vaginoplasty, which uses the peritoneum to create the vaginal canal that is connected to the external vulva, the peritoneum is a membrane that sits outside the bowel within the abdominal cavity.

However irrespectively of which technique is used, there are some commonalities between them.

During the operation the neo-vagina is packed with a sterile dressing, to maintain the girth and depth, which stays in place for a short period after surgery.

The testes are removed, this is an orchidectomy, however this does not mean that the testosterone level will drop to zero as mentioned, as the adrenal glands will still produce a very small amount testosterone, but the level will be in the same range as a cisgender woman 0.5 to 2.4 nmol/L.

A neo-clitoris is created from a small part of the gland tissue, and this is a clitoroplasty, and is positioned where a cisgender woman’s clitoris would be, and along with the rest of the gland, the erectile tissue is also removed.

And here is a connection between female and male anatomy, the nerve connected to the clitoris is the same as to the penis, the dorsal nerve, and is responsible for conveying sensory information, essential for sexual arousal to the brain.

And this is why during surgery it is important to not damage the dorsal nerve, and yes trans women can experience orgasm, which has been described as less localised and more as a whole body experience.

The urethra is shortened and is also positioned where it would be found in a cisgender woman, and a catheter is also fitted, however the prostrate is not removed, but will invariably shrink in size, due to the testes no longer being there to provide nutrient.

Finally a vulva is created with labia majora and labia minora, this is called labiaplasty, and its aim is to create a more feminine aspect to the volva, and a pressure bandage is applied.

There can be complications as mentioned, one of the most common is some slight bleeding.

5 days after my surgery, the dressing was removed, along with the catheter and the packing, and I was taught had to dilate.

Dilation is a process by which the girth and depth of the neo-vagina is maintained, and I had to first insert a lubricated small diameter plastic dilator with a tapered end into my neo-vagina and hold it there for 5 minutes and then repeat with a larger diameter one for 15 minutes.

After dilation I had to douche with warm water to flushed out the lubricant, and initially dilation was three times a day for 10 weeks, which is why if working one would need to be signed off work for 10 weeks.

Then the frequency over the course of a year is reduced until after a year it is just once a week for 5 minutes, but this will have to be maintained, as the risk of girth and depth loss does not go away.

It can take up to 18 months for full sensation to return, and sex should be avoided until fully healed, and as mentioned having an orgasm is possible, although I would liken reaching it, to a surfer riding the crest of a wave, any distraction and you will fall off, so you definitely needed to focus.

And going to the toilet is another difference, such as the sensation that I want to have a pee, which at first, was how shall we say, was a bit hit and miss, and I was told to, “wipe front-to-back”, for the obvious reason of now having an opening at the front, and even now, if I need to pee, I really need to pee!

Another aspect of the surgery, you cannot lift anything heavy, for quite some time, a pint of milk was my limit for quite a while, and the first two weeks out of hospital I stayed with a relation.

I can’t remember exactly when I no longer worried, about the weight of any object I was lifting, but for sure I was OK at 15 months, maybe a bit earlier.

And that was medical transition if trans female or nonbinary.

And before you go, I would love to devote an episode to answering listeners questions, and you can submit questions totally anonymous on the Have Your Say page of my website supporting this podcast at www.twts.co.uk.

And given the recent roll back of trans and nonbinary rights, in the UK and the USA, perhaps dear listeners on both sides of the pond, you could use a Q and A episode to raise any concerns you may have, so over to you, wonderful dear listeners.

This episode was written and presented by me, Carolyne O’Reilly, thank you for listening.

Next time, “Transition: Medical if Trans Male”