I find this topic fascinating for many reasons. I have training in gender and sex therapy. Intrinsically, identity work comes into play with most of the lovely humans I help. At least in the west, it appears most identities are heavily steeped in gender as an origin. Often other parts of the world in this timeline certainly share this feature culturally to varying shades.

When helping someone who is DMAB *Designated Male at Birth, things like skeletal structure are fascinating. From an anthropological lens, this is an inherent fact due to going through testosterone dominate puberty. Having trained and worked with multidisciplinary teams to help trans folx, it’s a lot of fun and something I geek out about. If they desire a binary transition:

Facial Feminization Surgery

  • Brow Bossing (calcium mounds over the eye sockets that give the appearance of deep-set eyes – Solution-Cranioplasty with forehead lift (Brow lift)
  • Tracheal protrusion (Adam’s apple)-Solution- Surgical shave and hide scar in chin fold.
  • Larger nose-Solution-Rhinoplasty full or minor and at times not needed.
  • Square jaw-Solution- Jaw Reduction Surgery “V line” with possible need for a lower third lift. And at times not needed.
  • Longer upper lip- Solution- Lip lift i.e. small incisions under the nostrils removing small amounts of skin and then suturing. Thus shortening the lip in the female range.
  • Hairline set back-Solution- Taking the hairline and moving it lower into the typical female pattern.

Top Surgery (Breast Augmentation)

  • Rarely will HRT be enough to have breast tissue growth that will be satisfactory. This is due to Testosterone dominant puberty. If this is something you’ve gone through, the circumference of your ribcage will be wider than a cisgender females. Due to this fact, the breast tissue growth, even if quite large, will appear about one-two sizes smaller, possibly more than cisgender females with a smaller circumference in ribcage.

It will be important to engage a surgeon that likely will do Intramuscular (IM) breast augmentation (Most common anyways). You will require a larger implant than your cisgender female counterpart. This means that under-the-skin implants are inappropriate, as you will not be able to do larger sizes without IM placement i.e. the implant will be too heavy and thin the skin under the breast fold/bottom of the breast. Think Structure and Symmetry. Symmetry is usually more important than size.

It’s not uncommon for someone who’s gone through testosterone-dominant puberty to need 1.5-2 times the size of implant as their cisgender female counterpart.

Voice– Voice Training or (VFS) Voice Feminization Surgery. Increasing the pitch of the voice. Often this isn’t needed, but some do opt for this, due to the effort associated with what I call, “teaching someone to “tuck” for life.”

Hormone Replacement Therapy– Once in the cisgender female range, new fat will go into the female structure. Follow the women in your family to have a sense of how that will be presented. However, think bottom heavy versus top heavy. Your new fat will migrate to typical female patterns around the belly button, upper arms, chest, thighs, buttocks, and cheeks.

  • “Muscle Shedding”- Despite what some sports ball folx say, your strength will decrease dramatically. If you are in the cisgender female range you can expect that level of strength reduction/muscle shedding certainly by the 3 year mark. By 1 year will be quite noticeable.

Shoulder Narrowing– Removal of one inch from either side of the clavicle. Held together with Titanium. The  bones will fuse together and the titanium will not be needed, but often is never removed unless there is a reason to. Will put the width of your shoulders hopefully in the cisgender female range of about 16 inches in width.

Rib Removal– Removal of the floating ribs. 12, 11, and sometimes 10. These ribs do not do much, in fact they typically can be removed safely by a board certified plastic surgeon. This is a hot topic at the time of this writing. Most folx who engage this are cisgender women or transwomen, due to wanting more of that classical hourglass shape. Note, only about 8% of cisgender women have an hourglass shape.

Bottom Surgery

Vaginoplasty (More than two types, but most common)

Penile Inversion Technique (“Gold Standard”). This involves a 4-6 hour surgery and a lengthy recovery period.

  • Bilateral Orchiectomy (Removal Of testes and associated connective tissues.
  • Creation of Labia Majora
  • Creation of Labia Minora
  • Creation of sensate Clitoris
  • Creation of Clitoral Hood
  • Creation of Vaginal Canal. Will require a lifetime of dilation to keep the vaginal canal to desired size.

Vulvoplasty

  • Bilateral Orchiectomy (Removal Of testes and associated connective tissues.
  • Creation of Labia Majora
  • Creation of Labia Minora
  • Creation of sensate Clitoris
  • Creation of Clitoral Hood
  • Creation of Illusion of the Vaginal Canal (Zero Depth, about one half-one inches typically) 

Facial Hair Removal

  • Laser-If your hair is pigmented, it is a quick and efficient way to suppress hair growth. The laser will seek pigment only, so clear, red, blonde, white type hairs are not good candidates. Will take 8-12 sessions spaced 4-6 weeks apart to be effective.
  • Electrolysis– using electricity or a chemical process to destroy the hair follicle itself. This is often a longer process and a full beard will typically take no less than 200 hours. Cost is a prohibitive factor for most. With dedication you can expect weekly visits for 18 months to 2 years minimum, unless you did not have a very pronounced beard.
    • Large Volume Electrolysis– If you can afford this option. Usually being put to sleep or lidocaine injections by Nurses. 2-3 electrologists will work on your face and chosen areas for up to 8 hours at a time. You will return every 6-8 weeks for the same process until finished. This is a very fast option, but costly. You will see this option in larger metropolitan areas only.

Transmasculine

When helping someone who is DFAB *Designated Female at Birth. Very similar, though the antithesis applies. HRT Hormone Replacement Therapy is often enough to quickly transition in an outwardly secondary sex characteristics sorta way.

Voice- HRT is often enough to lower resonance of the voice very quickly. In most cases 6-12 months, but I’ve even seen 3 months. It can often be remarkably fast!

  • Voice Masculinization Surgery– This is rarely done, due to HRT being so effective. However for some the resonance is not satisfactory. Thyroplasty type III. This surgery lowers the fundamental frequency of the voice by decreasing the vocal fold tension.

Facial Hair– HRT. Variable, but will typically follow the cisgender males in your family tree. Think about expectations.

Muscle Mass- HRT. As much as 50% increase in muscle mass from the waist above. Typically 1-3 years.

Fat Redistribution– Think bottom heavy versus top heavy. Once your hormone structure is in the cisgender male range, new fat and muscle gains will migrate to the typical male pattern. Buttocks, flanks, front of the stomach, chest at times.

Body Hair– HRT. Variable, but will typically follow the cisgender males in your family tree. Think about expectations.

Top Surgery-Double Mastectomy. “Chest Masculinization.” Ensuring that nipple placement is anatomically correct to the typically cisgender male range.

Bottom Surgery– Usually not before 3 years. With testosterone dominating hormone structure, the clitoris grows substantially. In utero we all start as female. Exposing the clitoris to T, automatically does what DMAB’s do in utero. The clit turns into the glands (The head) of the penis, a shaft is created, Labia majora and minora turn into the perineum and fuse together (quite literally an organic surgical scar” i.e. Perineum.

  • Metoidioplasty
  • Phalloplasty

Shoulder Widening– Due to estrogen dominant puberty the rib cage circumference and subsequent clavicle will not be in the cisgender male range (18 inches) (typically). This involves a brief surgery where the surgeon cuts the clavicle on each side and holds them together with Titanium Spacers. These spacers are only needed structurally until the bones fuse together to ultimately create a wider chest.

Facial Implants/Body Implants

Facial Implants- These are custom and typically are focused on widening the jawline.

  • “Brow Bossing” the calcium deposits over the brows. This gives cisgender males the illusion of deeper set eyes, but is a market of visual binary gender.
  • Jawline– Custom Jawline implant to square the front of the chin and define the side of the jawline.
  • Pectoral Implants– If muscle mass or structure of the chest is not desirable to the individual, pectoral implants can be done. Provides a more pronounced masculinized chest.

Something to note, those that aren’t in a binary structure for gender goals. Many of the aforementioned surgeries if desired can be considered a la carte. Often even those with binary goals do not engage in all of these surgeries. Sometimes for various reasons other than cost.

There is no “right way” to transition. In fact, one does not need to engage in gender-affirming medical interventions at all to be on the gender spectrum.It is just so fun to see someone go from hating how they look and feel, to being who they’ve always been inside. I love my work!

-Autistic FruitCake

Note: This is not medical advice and should not be considered so. If you feel you are on the gender spectrum (not cisgender) and need support, please seek a licensed mental health practitioner for an assessment and licensed board-certified medical doctors, that are familiar with transgender care. 

This article is no substitute for trained and licensed professional gender-affirming care. There are risks associated with all care and this must be guided by professionals to ensure safety.