Transitioning: Tips, Stories, and Information

Learn about social, medical, and legal transition, bottom surgery, working out, common emotions during transition, and much more.

Introduction

Transitioning is a beautiful, complicated, scary, empowering, doubt-filled, organic, slow, rushed evolution. In many ways, it’s an entire life, compressed. It is simultaneously the process of standing in line at the court house to petition for a legal name change or staring at a needle, willing yourself to stick it in your leg, and it is the moment when you lather your face to shave it for the first time, it is the moment when a stranger calls you sir, when you put on a crisp white tee and feel like a 1950’s dreamboat.

Historically, the process of transitioning has been kept in the dark for most trans people. I remember in one of the first memoirs of a trans man I read, him talking about desperately trying to find a singular picture of what he would look like after top surgery, and the medical establishment keeping it from him. (This was back in the eighties). With the rise of social media, this has totally changed. We are now able to see thousands of different expressions of trans identity online, as well as bits of piecemeal advice and insight across the board. While I applaud social media for the amount of visibility it has brought to the process, it is still scattered insight, and most of the articles I’ve found online are too sterile and info-graphic-y to resonate. Instead, I wanted to write the guide I would have wanted to read when I was beginning my transition. Something that is not medical advice, but is simply the gathered insight of myself and others who have gone through the process, felt all of the emotions, tackled all of the obstacles, and have had time to reflect on the journey.

The goal of this guide is to be–like transitioning itself–ever evolving. I have asked community members to contribute by answering certain questions or sections. Beneath each section there will be a name, attributing who is responding to it. Over time, we expect (and welcome) for you to ask us more questions, and for this to continue growing.

Without further ado, welcome to our first iteration. We hope you will find it useful.

What does transitioning mean?

Finnegan Shepard

In its root sense, the word ‘transition’ comes from Latin, and means ‘to go across.’ We all experience transition in our lifetimes: we transition between styles, between jobs, between hobbies, lovers, places. Transition is a poignant word: it captures how we as humans are finite and always changing, and how there is power in that and also loss. (Grief is a natural part of transition–more on that later). Before I get too philosophical about the term, let’s talk about how it is used in relation to gender.

There are three forms of transitioning gender: social, legal, and medical. Socially transitioning can mean any or all of the following: having friends/family/coworkers call you by a different name or pronouns, changing how you dress, or potentially what bathroom you use. To transition socially is probably the most open-ended definition of the three categories, because it’s really about the relationship between how you present and inhabit gender and how that interfaces with the social world. Gender is multifaceted, and the social world is too: hence, it’s pretty open to interpretation. To anchor us, probably the most common and simple example of someone socially transitioning is someone who asks loved ones to start using a different name and pronouns.

It is important to note that ‘to transition’ does not require you to transition socially, legally, and medically. Some people do all three, some people do two of the three, some people do just one. If someone is to only do one, it is most common for it to be socially transitioning–this is not a necessity, but it is simply a trend, because socially transitioning is the form of transitioning with the least external or bureaucratic friction. Because of this, it is often the first form of transitioning that folks do. It enables people to see how it feels to be called by a new name and pronouns, and whether that resonates in the way they suspected it would. If that is the case, then people often (but not always) then move on to legal and/or medical transition.

Legal transition is where you change your name on official documents. The process varies state to state, but it usually involves a lot of bureaucracy, forms, and a specific hierarchy you need to move through. For me, I had to start with a court order to change my name (which required a psychologist’s letter), then I could change my driver’s licence, then social security, then passport. I didn’t go to the bother of then changing my birth certificate, but some people do. (We will have a section with more of a deep dive on resources for legal transition written by Luke Lennon below).

Medical transition is the process by which you use HRT (hormone replacement therapy) and/or surgery to bring your gender identity into greater alignment with your body. This is a deeply personal experience for everyone, with different goals, timelines, fears, and excitements. Again, some people do both surgery and hormones, some people only do hormones or only surgery. For trans men, the most common combination is top surgery and HRT. Below, we will have a section with a bunch of questions about testosterone and surgery answered by Dr. Sidhbh Gallagher).

Before we go too deep on the nitty gritties of these processes, we want to answer what feels like a more fundamental question:

Why do people transition?

Finnegan Shepard

Right now, we are living through a cacophony of conflicting narratives and opinions about transness and why people transition. On the one hand, there is more visibility around trans people than ever before, but on the other hand, there has been a powerful political attack on the legitimacy of transition launched, which essentially frames transness as a kind of ‘trend’ that is afflicting the young and vulnerable. The reality–as is pretty much always the case–is much more nuanced.

First off, it is important to delineate transitioning from the broader movement, which is to deconstruct the gender binary/identify as nonbinary or gender queer. One of the political sleight of hands that has been used is to conveniently conflate the two. While there is of course enormous overlap between people who are transitioning and people who feel no need to transition but identify as nonbinary, they are not the same thing. Both are totally valid, and both groups are much larger than historically was thought, but as of the time we are writing this article, the rough estimate is that somewhere around 1% of the population is trans, whereas (depending on what numbers you look at), somewhere between 5-25% of younger generations identify as nonbinary or gender queer, with even larger percentages (upwards of 60%) rejecting the gender binary. These numbers are constantly being updated, but the important throughline is that while a majority of Gen Z and Gen Alpha reject a gender binary, the percentage of people who actively identify as trans and go through transition is around 1-2% of the population.

We are not offering or suggesting an interpretation of this data to mean anything in particular, other than the fact that there is an incredibly wide and diverse experience of gender, that everyone’s gender journey is personal, and that therefore there isn’t a set of ‘boxes’ one needs to ‘check’ in order to be trans or nonbinary. That’s the good news: this is a space of freedom and individuality, where you get to decide for yourself what feels right in terms of gender identity and presentation. The bad news is that with all that freedom, it can be hard to orient yourself. How do you know if you are trans or nonbinary? Which one are you? How would you know? These are common questions, and unfortunately there aren’t set answers. The best we can do is to share stories from other folks who have navigated the same questions, in the hopes that by hearing as many honest, transparent narratives as you can, you will find some kernels of wisdom.

Am I actually trans if I feel sad or scared or anxious about the process?

Finnegan Shepard

An extremely unfortunate by-product of the way the medical system is set up is the fact that the ‘narrative’ around being trans has been forced into a tight and unrealistic box. Again, I am no medical or legal expert, but based on my experience and the experience of many trans people I have spoken to, the process looks roughly like this: in order to receive gender affirming care, people need to be diagnosed with gender dysphoria by a psychologist. To receive that diagnosis, they need to ‘check’ specific boxes. Many of these boxes have language or assumptions around certainty and of ‘knowing’ since you were a young child. The result is that the ‘picture’ of a trans person becomes someone who has always had complete conviction that they ‘are in the wrong body’, are now experiencing extreme dysphoria and negative mental health outcomes, and are certain that the solution is to transition.

But what if that is partly true, but not completely true? What if, for instance, you felt fine in your body as a young child, but then began to feel extremely uncomfortable around puberty? What if you’ve always identified as a boy but you don’t experience extreme dysphoria, and the idea of transitioning is both exciting and terrifying? What if, in essence, you have doubts? Does having doubts invalidate your experience? No. Having doubts about any major decision is healthy. Doubt is useful: it orients us and requires us to dig deeper.

I was extremely lucky to have a therapist in my life who nipped this whole process in the bud. When I first spoke with her about my gender transition, she said something along the lines of, “I will write whatever note you need, but for now, let’s get down to work.” I had to process a lot of fear and insecurity and doubt and sadness with her. None of that meant that I wasn’t trans, or I wasn’t making the right choice. It simply meant that I was acknowledging the spectrum of emotions that go into the process, and dealing with them in a healthy way. For me, there was a lot of grief in transitioning. Becca (my name, and to an extent, identity prior to transition) was someone I really loved and who I had lived quite a joyful life with. My story was not one of acute depression or dysphoria before transitioning. The best way I could put it in those early therapy sessions were that I knew that looking back on my life, I could have lived a good life as Becca, but that the more true version, the version with higher resonance, was to live it as Finn, and the only reason not to was based in fear. I didn’t want to live through fear-based decisions. But it takes time to get there, and I had plenty of doubts along the way that I needed to really sit with and look at.

It’s also worth stating that just because having doubts absolutely can coexist with transitioning as a positive decision, it also doesn’t inherently indicate that transitioning is something you should do. Transitioning is a big decision, a deeply personal one, and something none of us should take lightly. The point here is that having feelings of fear or doubt in the process is natural, and not something that invalidates the process. We need to build a culture where it is normalized to share the full spectrum of our experiences with transitioning, not just the experiences that have been deemed ‘acceptable’ by the gatekeepers.

Socially transitioning: inner circle, mid circle, everyone

Finnegan Shepard

For me (and for many trans people I know), socially transitioning happened in waves. The first person I discussed it with was my partner at the time–she played a fundamental role in opening me up to the possibility and feeling comfortable talking about it. After her, I began selectively telling people in my innermost circle: my sister and some very close friends, and then a few months later, my parents.

At the beginning, saying the words felt like leaping off a cliff. I would be nauseous beforehand, running over and over the script in my head. Each time it got easier, more natural. I remember a turning point in my social transition journey, when I was hosting a party that was primarily attended by other grad students in the same department as me, and I witnessed the compression of my ‘coming out’ in real time. I had started a conversation with a grad student and his wife, who I had taken a few classes with. I began to tell them about transitioning, and it was a long story–I went all the way back to childhood as a way to justify or explain my current position. As we talked, someone else wandered over to join our group, and so to get them up to speed, I truncated what I had already said into a sentence or two and then continued the tale. People kept joining the circle, and I kept shortening the story, to the point where my final ‘coming out’ was to Darren, a fellow writer in the MFA program, to whom I said something like, “Darren, I’m a dude.” His response was completely accepting and nonplussed. I think he said, “word” and raised his beer in a cheers.

That night was a wonderfully cathartic and healing experience, in which I felt affirmed in my ability to simply present the truth rather than justify it. Of course, I am incredibly lucky with the kinds of people I am surrounded by and the fact that there was a uniformly positive response, but I do believe that these things feed into each other, and the more we present ourselves with self confidence, the more people accept it at face value.

After that night, despite being affirmed by the community, I still wasn’t ready to be trans to the general public, or in our classroom settings. For a few months, my friends did an extraordinary thing (the longer time goes on and I think about it, the more impressed I am). They would call me ‘Becca’ and use she/her pronouns in class, and then as soon as we left, they would effortlessly switch to Finn and he/him. They didn’t complain, and they rarely slipped up. It was truly incredible.

In retrospect, I’m not sure why I wasn’t ready to transition at school, or what the final hurdle was for me. I think it was partially to do with my physical appearance, and the fact that I hadn’t begun to medically transition yet, and partially just a time lag, as my emotional and mental state caught up. I had begun the journey and it intuitively felt right, but I wanted to give myself time to live in that identity and make sure it was the right path for me.

Over the next six months I would “come out” generally, though I didn’t begin to be read as male until 6 months or so into medically transitioning. I don’t remember that clearly, but I believe in that interim time I didn’t correct strangers when they read me as female. It was important to me that my community and loved ones use the correct name and pronoun, but it felt like more work than it was worth it to correct strangers.

Everyone’s process of transition is different. Some folks come out to everyone all at once, some do it gradually, and some keep certain areas of their life cloistered off from the transition indefinitely. There’s no right or wrong way to do it–I would simply urge you to be patient with yourself, and rest assured that there is absolutely nothing wrong with taking your time.

Socially Transitioning: Working Out As a Trans Man

Emmett Preciado

Working out has been a huge part of my transition. I always envied my dad and brothers proudly showing off their muscles whereas I wasn’t “meant” to build muscle. But once I started transitioning, I hit the gym so hard.

I had no idea what I was doing. I didn’t know how to properly lift weights without hurting myself or how many sets and reps to do. And I really didn’t know how to nourish my body for muscle growth. So I didn’t really make all that much progress in the first few years. About 4 years in, I finally really did some research behind the science of muscle building.

I didn’t just want muscle, I wanted functional muscle. Since I was socialized as a woman, I wasn’t really ever expected to lift heavy things. But now that I was passing, I wanted to have more strength so I could actually do the things that were asked of me. I also wanted to build muscle in order to make me feel more safe. I will never forget what it felt like to walk on the sidewalk as a woman. I never felt safe or like I could really take care of myself in a dangerous situation.

I’ve learned how to build functional muscle and I feel so much safer out in public, on the street, in public restrooms, and in locker rooms. And I hope to help the trans community with the tips I’ve learned over the years so that more people can feel SAFE. And hey, it also feels good to look good. ;) The muscle has boosted my confidence as well as my gender euphoria.

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Finnegan Shepard

I grew up in Boulder, CO, where exercise is a kind of religion (for better and for worse). What that has meant in my life is that exercise has always been a way that I have felt more agency and embodiment, both prior to transition and through my transition. I started lifting in high school, with the explicit goal of being able to lift more than my male best friend. While I don’t think I ever accomplished that goal, I did develop a comfort with weight lifting, the gym, and the process of working out as an iterative, productive habit. Throughout my twenties, I have vacillated between different forms of working out: for awhile I was really into Freeletics, which is a bodyweight high intensity interval training program I could access through an app. I did this mostly in grad school in England, and then during COVID lockdown, when myself and four friends would meet every day at five, when work ended, and do a zoom workout together. Once lockdown ended but the idea of going to a gym was still a strange thought, my partner and I joined my best friend and his brother at his brother’s house, where he had a squat rack in the garage and bunch of free weights. For about a year, we had a nice route going, where we would lift consistently together. This was also my second year on testosterone, and the consistency plus the hormone contributed to what is probably the phase of my life when I was the strongest.

Nowadays, I’ve caught the crossfit bug. It’s partly to do with the intensity, but a lot to do with the community and the feeling of shared energy. After years of being cloistered away from groups, it feels really good to be in a space with a bunch of other people, vibing off each other’s energy and struggling through a workout together. The gym I go to is a wonderful, inclusive space, with people of all ages, backgrounds, and skill levels. I proudly lift less than the recommended weight for women, and get absolutely no hassle, only encouragement.

Working out has been key for my gender journey in four ways. First, the simple neurochemistry of it. It produces endorphins, which makes me a happier, more level person. It also helps me get out of my head, so at times when I’ve felt less embodied and consequently more stuck in my head, working out regrounds me. Second, I love the feeling of soreness. It is a literal reconnection to the body, a little humming reminder of my muscles healing themselves. Third, feeling strong has always been an access point to masculinity for me. I love the process of lifting more and more weight. I love seeing that reflected in my body and in my capabilities. Finally, I like the community that is always built around working out for me. In college I lifted with one of my best friends at the time. Now my partner and I and her sister go to crossfit together, and we’ve become good friends with many of the people at the gym. Simply put, working out has been a throughline in my life that is gender affirming and also reaches beyond gender, to be something that is holistically positive in my life.

Social Dysphoria vs Physical Dysphoria

Yuri Lagnese

Growing up, I used to see gender— and by extension, transitioning in general— as a very binary thing. I thought only trans men and trans women were able to medically transition, that you only went on HRT or got surgeries if you were “fully” trans (whatever that means). Obviously, as a genderfluid individual who is now two years into TRT and over a year post op, my worldview has changed quite a bit. However, it was a long and tumultuous journey unpacking my feelings about gender and realizing that, in stark contrast to almost every trans person I’ve met, almost all my dysphoria is physical with very little manifesting in the form of social dysphoria.

You see, most trans people I’ve met began their journey by discovering and addressing social dysphoria first, which is to say they realized they didn’t like the gendered social role they were assigned at birth and wished to be addressed differently (new pronouns, name, terms, etc). My journey, however, was quite the opposite. As someone assigned female at birth, I always felt (and still feel) most at home in women’s spaces. I didn’t have any issues being addressed as a woman. I love makeup, fashion, and cute things, so it never occurred to me that I could be trans growing up since those were all reinforced as “girl” things (spoiler alert: all genders can enjoy those things). Ironically, I only started to realize when I felt my first taste of gender euphoria, which leads me to my next point.

At the age of 17, as an experiment I decided to do masculinization makeup and put on pretty much every sports bra I owned in an attempt to compress my chest (disclaimer: do not attempt to bind with anything but an actual binder for more than an hour!). As someone that was so incredibly hyper-femme, I still to this day don’t know what compelled me to do that, but it both awakened and shattered something inside me. On the one hand, seeing myself in the mirror wearing boxer briefs I stole from my brother and my flattened chest felt so right, but at the same time I felt a deep depression realizing how close and yet how far this improvised persona was from how I wished I looked. Looking back, this was the first time I really looked my physical dysphoria in the eye, even though I still chalked it up mostly to the usual teenage girl insecurities at the time.

Now, you’re probably thinking from that experience alone I must’ve known I was trans, but I actually didn’t fully come out and start transitioning until much later. As was the typical case for me, it followed a similar pattern: I had been binding on and off for years, but it was only when I started experimenting with binding daily and starting to pack (and yes, I was doing this while using she/her and still wearing dresses) that it dawned on me I may be trans, and that I wanted to start transitioning. However, I never viewed transitioning as a, “I’m doing this so other people see me the way I see myself” kind of thing, because again, I was fine being seen as a woman. For me, it was simply, “I want to make a home in my body and I want to feel free to dress how I want in a body I feel comfortable in”. I was quite adamant starting T that I did not want to be a man, I just wanted more fluidity and ambiguity in my gender presentation. Ironically, it was only once I was well into HRT and started getting gendered as a man by others that I realized, huh…maybe this isn’t that bad! I could write a whole other essay on my gender crisis throughout transitioning…but now, I finally am at peace knowing that I am just an extremely gender-fluid individual, and HRT as well as top surgery have finally gotten me to a place where I no longer base my wardrobe around lessening dysphoria, but rather increasing euphoria.

Looking back on all the twists and turns and challenges I experienced sorting out my gender, I am so grateful to be able to share this story now since I still to this day have never met anyone that has fully medically transitioned and yet still likes to be a girl sometimes as I do. I mean, I have a full beard and am covered in dark, coarse body hair—and I love it! I also love being able to shave and put on makeup and get “she/her”-d by strangers for a day, or a week, or however long until I get tired of it. You see, I’ve learned my dysphoria isn’t about “being born in the wrong body”, but rather, it came from an internal dissonance regarding the lack of control I felt over how me and my body were perceived. However, I will add that it is none of your business what other people think of you—that information is only “useful” for them, and isn’t necessary for you to know! Honestly, I find that as I have begun to feel more and more comfortable and at home in my body, any naysaying voices take a backseat to the effervescent song that is gender joy taking its place anyway, and what makes all gender affirming care so important.

Luke Lennon

First off, let’s be clear – legal recognition does not make you any more or less trans. You know who you are!

Meanwhile, government classifications of sex and gender have been used historically to gatekeep resources and distribute power. Because of this, changing your legal name and/or gender marker looks very different depending on where you live, with various hoops and hurdles.

In many states, for example, I can’t change my gender marker on my license without a physician’s letter (and even then I can only choose between M or F), while I can simultaneously select an X gender marker on my US passport, no questions asked. And the two gender markers don’t even have to match. So then why even bother updating my identity documents?

It’s a fair question, and one I think about often at Namesake Collaborative. Even though Namesake helps folks navigate the legal name change process, I should say that I’m definitely not a lawyer – this process just perplexed and frustrated me that much. For me, legally changing my name and updating my IDs came down to feeling safer navigating my day-to-day life, especially the already anxiety-inducing administrative burdens like managing finances and healthcare. I mean, from a high school diploma to a Nintendo Switch account, think about all of the places your name appears…the list is seemingly endless!

I didn’t want to constantly worry about where my old name appeared and who would see it (and what it could mean if they did). Whether trying to pay a bill or get into a bar, I’d find myself arguing with strangers about the fact that I was who I said I was. And I know I’m not alone – and that often, the situations can be even more dire. Nearly half of all respondents of the 2022 US Trans Survey, for instance, reported being verbally harassed, assaulted, asked to leave a location, or denied services when showing someone an ID with a name or gender that did not match their presentation.

When I finally got my new ID in the mail, the euphoria was real. It felt good to be carded and not be scared. I could apply for jobs knowing I wouldn’t have to explain myself to HR. I felt empowered to travel more. And as I slowly worked my way through updating my laundry list of accounts, it felt almost surprisingly good to not see my dead name everywhere. It wasn’t about the government’s “official” recognition of my fluid identity – I didn’t need that (and honestly, its definition of gender via a M, F, or X didn’t personally resonate at all). It was about feeling like I didn’t need to hide or pretend to be someone else just to access basic resources and do everyday things.

Now, I also recognize that not everyone is in a place where they can update their legal name and/or gender marker (or want to), and that identity is much more multidimensional than this – which means that even with accurate IDs, everyone’s experiences are different (read: racism, sexism, homophobia, transphobia, xenophobia…they’re all very real). It can also feel tough to do something as seemingly “permanent” as changing your legal name or gender marker when your identity is fluid or evolving.

In light of all of this, the decision to update your legal name and/or gender marker is definitely personal. If you’re looking for support through the process, you’re not alone! It’s confusing and complex (in many ways, by design). NCTE’s website is a good place to start your research, and my goal is to expand Namesake beyond Massachusetts to help more folks navigate the process (feel free to reach out if you want to get involved or talk more!).

When I felt like it was time to update my legal name to Luke a few years back, I started by filing a court petition in Massachusetts (and completing related requirements such as a background check). Once I finally got my court ordered name change certificate in the mail, I updated my social security card, driver’s license, and passport (in that order). Then I started tackling really important accounts, like with my health insurance, bank account, credit bureaus, loans, and apartment lease, to name a few. Since then it’s been a slow and steady process, and that’s okay.

It’s been years, but sometimes my old name still pops up here and there, and sometimes computer systems find ridiculous (and hilarious) ways to combine my old and current names to spam me with sales promotions (break the algo!). But overall, I’m glad I did it – I now spend way less mental energy thinking about how to navigate bureaucracy or being outed without my knowledge or consent, especially by strangers.

Ultimately, I feel like I have autonomy over my name and identity in ways I didn’t before. And even as I continue to change and grow, the foundation of “Luke Babin Lennon” feels much more mine than my old name ever did.

Top surgery: different forms, public vs. private, recovery time

Dr. Sidhbh Gallagher

Top Surgery

A patient can have top surgery without ever having been on testosterone. Hormones are not right for everybody. For many non-binary identifying patients, hormones are not necessarily part of the transition. However, I am often asked by patients if they should try testosterone for a while, would it possibly shrink things down, and maybe help with the result. The answer to this is dependent on whether you have a small chest or not. If you have a very small chest to begin with, it could possibly make the difference between whether you are a candidate for keyhole versus double incision. This is very rare, usually if you have any extra skin at all there, testosterone is going to do absolutely nothing to shrink this down. Indeed, very often testosterone does not really shrink breast tissue much at all. The answer therefore is that it doesn’t make that much of a difference, so I don’t usually have patients wait.

“Will binding effect the outcomes of my top surgery?”

In my opinion as a top surgeon binding doesn’t really impact top surgery results negatively. However, in patients who wear a tight garment for a long time, grooving or indentations can appear, typically at the shoulders or underneath the arm just above the breast. These are often permanent; however, they are usually much improved with top surgery.

In rare cases if the breasts are small to begin with, binding the chest downwards could potentially turn a candidate for keyhole surgery into somebody who must get a double incision. Patients shouldn’t be too concerned about this though, because if there is that much skin there in the first-place, double incision was likely always going to be the best option.

We can therefore conclude that binding in moderation is a safe practice provided the following care strategies are adhered to:

1. The patient needs a break from the binder.
2. It needs to fit correctly and not be too tight.
3. In hot months, be vigilant for rashes that may appear underneath the breasts.

Binding is usually required for just a short time after the surgery between a couple of days and two months depending on the technique used.

It is critical to remember that a flat “masculinized” chest may not be the goal for everyone. It is very important that the patient and surgeon decide what would be most affirming for the individual. As such there are certainly other options. An example of this would be a dramatic reduction in the breast size but not removing as much breast tissue as in a typical masculinizing procedure so that the patient still has some breast mound. The same thing goes for the size and shape of the nipples – we do not have to stick to the typical “male” nipple dimensions. Photos can be helpful for the patient and surgeon to agree on what exactly the goal is.

Types of Top Surgery

Trying to understand the different top surgery techniques and which one will work for you can be very confusing. The good news is it really just comes down to 2 main techniques a patient must decide between.

01  DOUBLE INCISION

Around the world the most common procedure is simply removing the breast and the skin on each side- the double incision- and most commonly the nipples come off completely and are grafted into their new position.

02  KEYHOLE TECHNIQUE

This is a technique most useful in patients with very small breasts to begin with. A small incision is made disguised in the lower half of the nipple and the breast tissue is removed through this. With this procedure we are hoping that the skin will shrink down over the next few months as no extra skin is removed (the only way to remove extra skin is by placing scars). Often the surgeon may reduce the size of the nipples as part of this procedure or possibly wait till later to do this. This technique is more likely to require a second procedure for a revision than double incision.

Keyhole- vs Double Incision- How to Decide.

Is Keyhole even an option for you?

First, not many patients are candidates for keyhole surgery at all. Patients must be pretty small in order to undergo it, this means an A cup or less. This can be very confusing because obviously not many transgender men wear bras! So, what is an A cup? Basically, my rule is you want to have no droopiness in the breast whatsoever. That means the nipple sits above where the fold is. If you have that situation, you may be a candidate for keyhole surgery. In keyhole surgery we are making a small incision in the underside of the nipple and through that removing the breast tissue. We are doing nothing to reposition the nipple and hoping that any extra skin will shrink down. How do we know whether the skin will co-operate and shrink down? Unfortunately, we don’t know. This depends on your genetics and “quality” of your skin. Much like when a woman has a baby some bellies will shrink down like nothing happened and some will always have loose skin. The younger the patient the more likely they will probably shrink the skin (but this isn’t always reliable). About 1 - 2 out of every 10 top surgery patients I see will do very well with either keyhole surgery or a double incision. This often comes down to a matter of personal choice. How important is it to you to avoid that scar?

What if you have both options?

Firstly, you are in a good place – you don’t have much tissue to remove so will likely have a great result either way.
One trick I find that is useful to help patients predict what their result will look like, is to stand in front of a mirror, and just imagine that we have “sucked all the air” out of your breasts and they are completely deflated, now in your mind’s eye, where those nipples are, is exactly where they are going to end up. There is not much we can do in keyhole surgery that will move them. A problem is that often in a “female” chest nipple are more closely spaced and sit a few inches lower than in a “male” chest. If we just deflate everything, sometimes the eye can catch that, and it may look a bit unnatural. Also, often if you need a nipple reduction, that may have to happen at a second surgery.

Keyhole is NOT necessarily the easier option.

There can be a misconception that just because we avoid the scarring in keyhole it’s an easier recovery. We have found that surprisingly the opposite is often true.

1. Studies have shown that patients are much more likely to want or need revisions after keyhole as opposed to double incision or Masculoplasty.
2. A binder is needed for much longer after keyhole (usually 2 months vs. a week). Fluid collections are a real problem with keyhole as we are not able to put in the special quilting stitches, we use in Masculoplasty and instead must rely on the outside compression to keep the fluid down.
3. It takes longer to see results. With Masculoplasty we are beginning to see a nice flat chest immediately after surgery. With keyhole it can take months especially if the patient develops fluid collections. Waiting for the skin to shrink down requires a lot of patience.
   
   

What’s the deal with drains?

Drains can cause a lot of confusion. Most surgeons still place them for double incision type top surgery. Are they really needed?

Why are drains placed anyway?

Drains are placed to get rid of fluid (serum) that your body produces whenever a space is made (in this case where the breast tissue has been removed). If that fluid is allowed to collect in there it will cause swelling that can take a long time to go away and may get infected.

What are the downsides of placing drains?

Patients hate drains with many patients complaining that they are the most uncomfortable part of the process.

• If drains are placed, they must stay in until they stop draining which is usually about a week (or longer!). It can be annoying having them hanging out of the chest till then and make showering difficult or impossible.
• Getting the drains out can be uncomfortable and requires an extra trip to the office.
• Drains aren’t foolproof – if they accidentally come out too early or fall out the space is still left behind which can lead to seromas anyway.
• If drains are left in for a long time, it is thought that bacteria can “crawl” up there and cause infections. For this reason, most surgeons will keep patients on antibiotics while the drains are in. Antibiotics can cause their own problems such as diarrhea and fungal infections.
  
  

How does Masculoplasty / drainfree surgery work?

If there is no space left behind there is no need to place a drain. To simplify we get rid of the space by using a technique of placing multiple internal stitches to “tack down” the tissue and eradicate dead space. This technique has been shown to essentially eliminate the risk of significant seromas and also decrease the risk of hematoma. If your top surgeon however is not comfortable leaving out the drains it is best to listen to them as you want to get the best possible result in their hands.

Nipples or Not?

Most patients coming for top surgery will know exactly how they feel about having nipples or not. About 15% of my patients have dysphoria surrounding their nipples and the more affirming procedure for them is just to create a nipple free chest.
As long as this is a well thought out choice this is of course very reasonable.

I do like patients to know however that if they DO want nipples in the future they usually look best if made in the OR from the patient’s own tissue. I have had some folks wonder if they would be better off just getting tattoos instead of nipple grafts. In those cases, we look through before and after pictures so the patient can decide for themselves. If a patient does however decide to go nipple free – this is a simpler procedure usually lasting 1.5 hrs. instead of 2 hrs. The recovery is also easier as the patient does not have to come back so soon for bolster removal and doesn’t have to do nipple care in the first 2 weeks.

How to get an idea of what your result will be

One way to figure out how things may turn out is to look through your surgeons before and after pictures. Find somebody who has a before closest to you and this will likely be your result or similar. If you are planning to go with keyhole, you can get a rough idea of the final result by imagining the breasts were just emptied out and there is a little shrinkage of the skin. The shrinkage varies a lot from person to person.

For double incision we always try to land the scars in the most natural place possible. For lower BMI patients we can often get these in the fold underneath the pec muscle. In larger folks or patients who have lost a lot of weight this can be trickier. We need to remove the tissue, so we have to have the scars follow where that is. In larger folks this can often be in the shape of an upside- down V across the chest.

Take a look at where the tissue to be removed on the chest is and this will give an idea as to what shape the scars will have. In general, I also prefer straighter lines for the chest incisions rather than curved “u-shaped” scars.

• If the breasts are spaced close together or in patients with larger BMIs, the scar likely will have to meet in the middle.
• If the breast tissue extends a lot to the sides or wraps around the back likely some of this tissue will still remain after surgery. Patients who have chests like this are at higher risk of “dog ears” and are more likely to want a revision surgery later.

What is a dog ear?

A dog ear is tissue that sticks out like a pyramid at the end of a scar. Patients do not like these because they look un-natural and can even poke and rub with clothes. With top surgery it’s possible to get them either out at the sides (more common) or in the center or the chest. Some amount of dog ear is very common in the first few weeks and months after surgery as swelling goes down. If the dog-ear doesn’t go away by itself an additional surgery is needed to get rid of it usually. The good news is compared to the first surgery it is quick and easy.

Preparing for Top Surgery

Hormones

Thankfully surgeons are now beginning to understand that many folks who need top surgery may never want or need to be on testosterone. Therefore, this is not a WPATH requirement and rarely an insurance requirement.

We do however know that testosterone shrinks breast tissue so patients often ask if they should wait to see what it does for them before proceeding with surgery.
The full effects of testosterone on breasts takes probably a couple of years to kick in and unfortunately patients may find the effects disappointing. Testosterone will do nothing to reduce skin, so patients don’t have to wait usually before having top surgery. The only exception may be for a very small chested patient who is on the fence between keyhole and double incision. These patients could potentially be swayed one way or the other after testosterone use.

In our practice we typically don’t stop testosterone around the time of surgery and believe it’s safe to continue as usual.

Screening

It is recommended that patients undergo a screening mammogram after the age of 40 or sometimes earlier depending on family history of breast cancer. Patients may be reluctant to do this as it’s often dysphoric and “doc if they are coming off anyway”.. Unfortunately, however 1 in 8 women get breast cancer so this is a very important step. If something shows up on the mammogram, we need to know about it before surgery as there are very specific steps, we must first follow to ensure the safest course. All breast tissue removed is usually sent off at the time of surgery to be on the safe side. There currently are no guidelines as to how transgender men should be screened after top surgery. I recommend that patients should follow the recommendations for non-transgender men. Screening mammograms are not needed but any lump found must be investigated. Top surgery will never remove 100% of breast tissue.

Losing weight Before Surgery

Ideally if a patient plans to undergo significant weight loss this should be done before surgery. In this way your surgeon will be able to remove more unwanted skin and probably get you a better result. However smaller amounts of weight such as 10-20lbs won’t have much effect really. It is important however that the patient’s weight is stable before surgery. Meaning we do not want the patient to be actively trying to lose weight as they will not heal properly. Patients who have lost a significant amount (such as those undergoing bariatric surgery) should wait 6 months after losing weight for this reason.

Considerations for overweight Patients

In an ideal world a patient should not be obese before surgery. This however is not always possible and it’s my philosophy that often times the benefits of surgery outweigh the risks. These benefits not only include relieving dysphoria but also the physical problems such as back pain and binding problems.

We recently published our Masculoplasty (drainfree top surgery) outcomes from my practice where 55% of our patients were obese. These obese patients didn’t have a statistically significant increase in complications (however the super morbidly obese folks did). Therefore, in my practice I like to assess each patient on an individual basis and don’t have a strict BMI cut off. Very overweight folks should know they are at slightly increased risk of complications like infection. If a patient is diabetic or has other medical problems its crucial to optimize these before surgery. In addition, “dog ears” are more likely and the chances of needing a revision are also more likely. Often it is best to make the incision meet in the middle to avoid a lump being left behind in the center of the chest. Overweight patients are also more likely to have sleep apnea which may require an overnight stay in hospital after surgery as these patients can be slower to wake up from anesthesia.

Smoking

Smoking anything before top surgery is a no-no. This is because we are removing the nipples and replanting them, so they are surviving off delicate little blood vessels over the next few weeks. Each time we smoke the blood supply can be “cut-off” so it’s one of the surest ways to “kill a nipple”. I always remind patients that their chest is for life so making sure they are off cigarettes completely 6 weeks before and at least 6 weeks after surgery is worth it to ensure the best results. It’s unclear what vaping does to healing but nicotine is known to be bad for healing (this unfortunately means that even patches are out). Smoking anything increases carbon monoxide in the blood stream, which is also bad.

Diabetics

Unfortunately, Diabetics have a tougher time healing and we see wound dehiscence (wound opening up) and infections way more commonly in these patients. It is critical to make sure blood sugar levels are as well controlled as possible around the time of surgery to ensure best results. Surgeons will want to see the patient’s A1C results which gives an idea of how blood sugar control has been over the proceeding few months this will give an idea of how safe it is to proceed.

Being Otherwise Prepared

Top surgery is such an important step, it's critical to make sure that now is the time. How is your mental health? Top surgery can be stressful and very anxiety provoking – are you in a good place to proceed? Are you going to be able to do your part to look after nips or should we wait till a better time?

You will need your three “P”s

1. Person – Not only are you going to need somebody for psychological support around surgery, but you will need someone to drive you home, drive you to follow-up appointments, fill your prescriptions and reach for that thing of the top shelf…
2. Place – More importantly for folks travelling in but usually a patient can leave about 2 hours after surgery, so you need a safe comfortable place to recover.
3. Pennies – Surgery is expensive business. Even if you have saved up for the price of surgery or insurance, don’t forget other unexpected costs may pop-up (deductibles, prescriptions, uber rides, hotels). Also, you won’t be working for at least 2 weeks after surgery (6 weeks for strenuous jobs) do you have a plan for this?
   
   

What to expect the Day of Surgery

Obviously different surgeons will have different practices but below is a rough guide of what to expect on the big day.

Most patients are asked to show up an hour or so before surgery. Typically, the nursing staff will have you change into a gown and put in an IV line. Next you will meet your anesthesiologist (remember to talk to them about any concerns from previous anesthesia). Your surgeon will typically do some marking on the chest and pretty soon its show-time.

Patients are completely asleep for this surgery and most agree it passes in an instant and before you know it you are sitting in recovery with a compression vest over a nice flat chest. Top surgery usually takes about 2 hours.

In my practice I place lots of numbing medicine while you are asleep as a “block” so usually the pain is not too bad after surgery. Most folks rate it less than a 4 out of 10. Your buddy will pick up prescriptions and once you are able you get dressed and go home. Patients who live a long drive are encouraged to stay nearby for the first 24hrs at least for 2 reasons – the drive can be very rough after anesthesia. Also if there were any problems after surgery it’s good to be close by.

Recovery from top surgery

As a rule, I tell patients that they won’t feel back to normal for about 6 weeks after top surgery. Even though there are less incisions, the keyhole technique requires longer binding and can, even though there are less incisions to heal, feel like a longer recovery. For both surgeries it can take a few months to start seeing the results as there will be a lot of swelling and nipples in particular can look very strange initially.

In the first few days after surgery patients typically won’t want to move their arms round much and will be acting like a “T-rex”.

Lifting and Mobility

Patients will be able to move around the house, feed themselves and go to the bathroom but any sort of heavy lifting is out. No more than 10lbs is recommended. Listen to your body, it has a great built in warning system, if it hurts, don’t do it.
Most patients feel exhausted and “gross” in the first couple of weeks after surgery.

Driving

To drive the patient must be completely off narcotic medication and able to make sudden movements. For most folks this is at least a week but more commonly 2.

Sleeping Position

If it’s comfortable the patient’s sleeping position doesn’t matter too much. Many patients will prefer sleeping on more pillows than usual or even in a recliner. Sleeping on the back for the first couple of weeks is typical and then slowly side sleeping can be re-introduced. Belly sleepers find this time of recovery toughest. The rule is just sleeping whatever way is comfortable.

Work

The soonest folks return to work would be one week after surgery but typically 2 weeks are needed. If heavy lifting or a lot of reaching / strenuous activity is part of the job up to 6 weeks may be needed off work.

Working Out

Gentle walks are a good idea in the first few days after surgery but remember you will get tired quickly. Lower body low impact workouts can usually begin about 2 weeks after surgery and patients are released to regular working out at 6 weeks. Patients who avoid overhead (shoulder) exercises for 6 months after surgery seem to have better appearing scars so if that’s an option, I encourage patients to do that.

Compression

Your surgeon will usually provide you with a compression vest in which you will typically wake up. After Masculoplasty patients require compression for just one week or less after surgery although many surgeons require longer. We prefer patients to wear it 24/7 to decrease swelling however breaks are of course allowed.

Showering

It’s up to the patient’s surgeon when showering is allowed. Sometimes patients must wait a week or more (for drains to come out). In our practice both keyhole and double incision patients have waterproof dressings underneath the compression vest so whenever they feel strong enough a shower is possible. For most this is 2 days after surgery.

The Months after Surgery

In the weeks and months after surgery patients will often have larger areas of numbness over the chest. As a rule these areas of numbness will shrink over the first year so that everything begins to feel normal again. Sensation will come back in the nipples typically also during this time. Some patients will notice weird sensations in the chest during this time such as “lightning bolts” of pain that vanish quickly. We attribute this to the nerves “waking up”.

All about Nipples. Choosing your nipples

You do have a say in your nipple size and shape after surgery. Many patients will choose to have their surgeon “masculinize” them. What exactly does this mean?
The “male” nipple is different than the female nipple in a few ways.”

• The areola is usually oval not round
• The areola is smaller usually around 22mm
• Nipples are spaced wider on the chest
• The nipple has less projection

Your surgeon will (based on your height and body type) decide during the surgery on the size and shape of the nipples and position them accordingly on the chest.
Masculinization is certainly not for every trans patient and the nipples can be sized and shaped according to what is most affirming for you. Nipple size is one thing you do get a say over!

Some patients prefer not to have nipples reconstructed at all. This option makes your recovery slightly easier and reduces your surgery time itself by about 30 minutes.

What to expect after surgery?

Nipples are the slowest part to heal after top surgery. They require the most care and freak patients out the most!

The First Week

Your nipples are (depending on your surgery) completely removed and grafted or “planted” back on. We sew the dressings onto the chest for the first few days to help everything heal. These are wrapped up then anywhere from 3 days to 9 days (depending on your schedule). These dressings or “bolsters” are removed with the patient awake in the office. This takes 5 minutes and is usually painless. The nipples can look frightening at this point!

They often look purple and flattened. There is often dried up “scabs” around the edges which may “lift up” and look like the whole nipple is falling off. It won’t.
Also, blood and other discharge may appear out from around the nipple in the first few weeks. In some patients the entire nipple can even turn black and the top layer of skin “dies off” in a process known as epidermolyis. This can cause a lot of anxiety, but rest assured there is a healthy pink nipple underneath. It is always fine to reach out to your surgeon during this time however if you are worried.

Nipple care

You will be shown how to take care of the nipple until it heals over which is usually about 2-3 weeks after surgery. Most surgeons recommend a topical antibiotic ointment – such as bacitracin, Neosporin or triple antibiotic. This is often placed on the nipple about twice a day as the nipple will do best in a moist environment. Then gauze or band aids are placed on top to protect the patient’s clothes. Typically, the binder isn’t needed after the first week but if the patient likes how it feels then they can wear it.

First few months

Nipples heal slowly. In the first few months they usually have a “stuck on” appearance. At about 6 weeks after surgery scar massage of the nipples and other incisions can help.

Patients with darker skin will often have pale or pink patches. These can take up to about 2 years to heal properly. If after, then the pigment hasn’t returned, tattooing is a good solution. Interestingly many top surgery patients report a return of sensation after several months. Many of our patients report getting hard nipples in the cold too. In some circumstances the nipples may be overly sensitive in cold weather, but this usually settles down with time.

Scar Care

Unfortunately, the chest is somewhat unforgiving when it comes to scarring. No matter how carefully the surgeon closes the wound some patients will develop raised bright pink scars. Some patients however will get barely detectable fine lines. Much of this is likely due to a patient’s genetics. The best predictor of scar healing is how the patient has healed in the past from other incisions.

The good news is with time (up to a few years) the scars will fade and look fine. In fact, scars that have an intense pink color at first often look best in the long run as they will fade to white.

Here are some tips though to help with scarring.

Typically, we will want to wait at least 2 weeks before starting scar care to allow the skin to heal. There are many products on the market promising better scar care but unfortunately there is not much science behind any of the products. Rather than wasting money on unproven creams here are my recommendations.

1. Scar massage. This typically is started at around 6 weeks. Using whatever lotion or moisturising cream the patient usually uses the scar is rubbed in a circular motion with a moderate amount of pressure. This can be done on both the chest incisions and the scars around the nipples. Most patients will do it in the morning when they get out of the shower and maybe at night while watching TV.
2. Limit stretching. There isn’t any science behind this recommendation but folks who limit putting their arms over their heads much in the first 6 months seem to have better scars. Typically, this means cutting out overhead workouts.
3. Silicone. The only topical treatment that seems to make a difference to scars (and we don’t even understand how, scientifically) is silicone. Both gels and tape seem to work but most patients will opt for the tape as it can be reusable. The more the patient can wear it the better scars seem to do. Your surgeon may be able to supply this, or it is also available online. Some patients may have an allergic reaction to these products so watch out for redness and swelling.

Risks of Top Surgery

Hematoma (bleeding on the inside after surgery)

This would be the most common serious risk after top surgery.
During your surgery the surgeon obviously stops all bleeding however it is possible that the patients may get some bleeding that stirs up after surgery. The most common time for this to happen would be in the recovery room. If the bleeding is significant enough the surgeon will usually take patients back to the operating room to stop it and clear out any blood clots that have formed. If the hematoma is small, it will usually just cause swelling and bruising that will go away over the next few weeks.

Seroma or Fluid Collections

Whenever we remove tissue in the body, it fills the space left behind with fluid. This fluid can be problematic as it causes swelling, can get infected and cause an abscess or it can try to drain out the incisions. This is the reason that drains are left in, to remove this fluid. With Masculoplasty we close down this space so a seroma cannot form. This technique essentially eliminates the risk of large seromas.
Smaller fluid collections may form but they usually disappear on their own in a few weeks.

With keyhole surgery we unfortunately can’t close down this dead space with stitches so oftentimes some fluid will accumulate. This can usually be easily and painlessly removed in the office with a needle.

Infections

Some patients may develop redness, pain and swelling round the incision in the first few weeks after surgery. This is only usually seen in overweight patients or diabetic patients. It typically resolves quickly with a course of antibiotics.

Wound Dehiscence

This means opening of the wound. Sometimes a small area of the wound may open up in the first few weeks after surgery. There are usually a few reasons for this -here are the most common.

1. If the patient has not been eating properly after surgery. Especially if they have not been getting enough protein.
2. Smoking
3. Diabetics with poor blood sugar control.

Once the wound opens up the surgeon will typically debride (clean up) any dead tissue and show the patient how to do wound care. This is usually painless. We do not try to close the wound as it will open right up again and possibly get infected.
Depending on the wound size and how well we can control the risk factors listed above it will heal over in a few weeks.

Nipple Loss

Complete loss of a nipple is almost unheard of. As scary as nipples look in the first few weeks, they usually do fine, so we encourage folks to wait. We do sometimes see however that one side may lose some projection as compared to the other.
Oftentimes this is an easy fix in the office to better match them.

Bottom Surgery

 Gender-affirming genital surgery for trans-masculine individuals offers various options tailored to individual preferences and anatomical considerations. Prior to undergoing procedures such as phalloplasty or metoidioplasty, it's essential to consider factors like hormonal therapy, mental health, and lifestyle. Surgery timing, typically after at least a year of testosterone therapy, should be discussed with a multidisciplinary team including surgeons, mental health professionals, and primary care providers.

Preparation for surgery involves optimizing physical health, including managing weight, controlling chronic medical conditions like high blood pressure and diabetes, and abstaining from tobacco and recreational substances. Mental health support is crucial for coping with the challenges of the postoperative period.

Metoidioplasty

Metoidioplasty, developed as an alternative to phalloplasty, offers a smaller, natural-looking phallus with the ability to stand to urinate. However, it may not meet all patients' goals, and candidacy depends on factors such as clitoral growth and body mass index. Patients must consider their surgical goals, including urination function, scrotum creation, vaginal retention for pleasure, and fertility.

Metoidioplasty offers options for trans-masculine individuals, but not everyone's anatomy allows for urethral lengthening. Ideal candidates have significant clitoral growth, ample inner labial skin, and a lower BMI. If the clitoris is visible in the standing position, urethral lengthening may be possible. However, there's a risk of fistula formation between the urethra and vagina, especially with vaginectomy.
For those prioritizing vaginal retention, a simple metoidioplasty is an option. This involves repositioning the clitoris for a more masculine appearance without urethral lengthening. It allows for a quicker recovery with fewer associated risks, typically enabling patients to go home on the day of surgery without requiring a bladder catheter.

Metoidioplasty with urethral lengthening involves repositioning the clitoris for a more masculine appearance and extending the urethra to enable standing urination. It may require a buccal graft and is associated with higher complication rates. Vaginectomy, typically required to reduce risks, involves closing the vaginal canal to prevent fistula formation. Monsplasty, which removes excess fat over the pubic bone, can further enhance the masculine appearance. These procedures may be performed together or separately, depending on individual needs and surgeon preferences.Scrotoplasty, an optional procedure during metoidioplasty, uses outer labia tissue to create a small scrotum, enhancing the masculine appearance. Testicular implants can be added later if desired.

Optional "2nd stage" surgeries, such as VY-advancement and testicular implants, focus on cosmetic improvements but are done separately to avoid compromising tissue blood supply.

Special preoperative considerations for metoidioplasty include avoiding clitoral pumping due to potential risks and uncertainties regarding its effectiveness. DHT gel, although potentially effective for clitoral enlargement, presents risks and challenges in availability.

Recovery from metoidioplasty varies based on the procedure's complexity and individual healing. Swelling is common initially, but typically resolves within 3 to 6 months. Patients are advised to avoid excessive activity during the healing process, especially after vaginectomy or scrotoplasty.

Patients considering phalloplasty after metoidioplasty should discuss their goals with a surgeon experienced in both procedures, as technical differences may affect outcomes.

Phalloplasty

Phalloplasty, a complex surgery, offers various options tailored to individual needs, including shaft construction, erectile implants, urethral lengthening, glans creation, scrotum formation, testicular implants, vaginectomy, and hysterectomy.

Patients should establish clear goals and consider fertility desires and sexual preferences before surgery. It's crucial to voice your needs during consultation and find a surgeon who listens and aligns with your goals.

One significant decision is whether standing urination is important, as it requires a neourethra and often entails vaginectomy and hysterectomy to reduce risks. Keeping one ovary for hormone backup is an option at some centers.
For a shaft-only phalloplasty, options include leaving the genital region untouched, performing hysterectomy and vaginectomy with scrotoplasty, or retaining the vaginal canal with scrotoplasty and clitoral tissue burial. A flap in phalloplasty refers to a piece of tissue with its own blood supply, typically comprising skin, fat, and nerves. It's crucial for tissue survival and function. Flaps can be sourced from areas like the forearm, thigh, lower belly, or back, with forearm and thigh flaps being most common.

The design of the phallus depends on factors like donor site, patient anatomy, and desired function:

• Rectangular flap: Used for shaft-only phalloplasty without urination capability, or for staged urethral creation.
• Tube Within Tube: Commonly used for forearm and thin thigh flaps, creating a urethra within the flap for urination.
• Composite Phalloplasty: Involves combining flaps from different body sites for shaft and urethra construction, suitable for complex cases.

Each option has specific considerations regarding tissue thickness, surgical staging, and potential complications.

Phallus Length/Girth:

• Aim for resemblance to average erect cis male penis.
• Ideal length generally < 5.5 inches to minimize complications and interference with activities.
• Phalloplasty not attached to pelvic bone, leading to potential stretching over time, necessitating secondary surgeries for adjustments.
  
  

Multiple vs Single Stage:

Surgeons differ in staging phalloplasty surgeries. Options include:

A. Single Stage: Both perineal and shaft urethra constructed in one surgery, reducing overall surgeries to 2-3.

B. Metoidioplasty First: Initial surgery involves metoidioplasty with urethral lengthening, providing option to stop surgery if satisfied but risk of additional stages for complications.

C. Big Ben Method: Shaft and shaft urethra created first, followed by connection to native urethra in second surgery, allowing separate management of complications and near reversibility.

D. Grafting Methods: Utilize graft material for shaft urethra, with options including prelaminated graft or graft placement after initial phalloplasty, offering thinner non-hair bearing skin but higher risk of complications.

Considerations:

Glansplasty, scrotoplasty, erectile devices, and testicular implants discussed in "other surgeries" section.

Postoperative Care:

• Phallus should remain upright during healing (4-6 weeks), with limitations on hip bending.
• Walking should be limited for 4-6 weeks to allow incisions to heal.
• Maintaining good hygiene helps prevent infections.
• Expect catheter for 4-6 weeks post urethral connection, often using a suprapubic catheter.
• Physical or occupational therapy aids in regaining strength and flexibility, particularly if donor tissue is from arm or leg.
  
  

Sensation:

• Nerves from clitoris or groin are connected to flap nerves, requiring time for regeneration.
• Sensation outcome may take over a year, with potential for partial sensation.
• Orgasm usually achievable post-surgery, though experiences may differ.
• Forearm donor site typically provides more sensation than thigh, while abdominal and back donor sites offer least sensation.

Other Surgeries:

• Glansplasty involves creating a circumcised appearance with a skin graft, sometimes resulting in a ridge for external devices.
• Scrotoplasty and testicular implants are covered in the metoidioplasty section.
• Secondary shaft revisions adjust girth, either by thinning or adding fat from other body parts.
• Erectile implants, only for phalloplasty patients, offer malleable or inflatable options, with external devices as alternatives. Cost and insurance coverage vary; implants may need replacement due to potential complications:
• Injury to blood supply or urethra
• Infection, despite antibiotic use
• Extrusion from chronic pressure
• Loosening, migration, angle or strength issues
• Visible hardware or chronic pain
• Implant failure requiring removal or replacement.
  
  

Risks & Complications of Bottom Surgery

The metoidioplasty and phalloplasty processes are long. They will likely include multiple stages, and several regions on the body are affected. While your surgeon will do their best to avoid complications, they can and do arise with varying severity.

Complications can change the course, so having a flexible mindset in the postoperative period is key to addressing issues healthfully, if they arise. Surgeons who offer these procedures routinely will be able to manage most complications successfully, but it may mean additional surgery and longer recovery.

Torso Masculinization

Dr. Sidhbh Gallagher

For some patients unwanted curves may lead to just as much dysphoria as other parts of the body such as the breasts.

Many patients dislike the “muffin top” area which can signal to some a more “feminine” silhouette. Patients usually request a more “straight up and down”, athletic look rather than the curves which make the waist appear narrow compared to the pelvis and hips.

Some patients may have larger thighs which can cause dysphoria. In some cases, patients may have lost a lot of weight and have a lot of loose skin or loose muscles from carrying children.

Testosterone may help give a more masculine shape – this usually happens slowly over the first 2 years but for many the curves persist despite years on testosterone.
Working out and exercise can certainly help, but many patients find it impossible to “spot reduce” or eliminate those curves and the shape stays the same.

The most effective way to permanently eliminate these curves is often surgery. A range of techniques can be used to help give a more masculine, muscular appearance to the patient’s torso. Depending on the patient’s problem areas and preferences a combination of liposuction, fat grafting and lifts or tummy tuck can be used as an individualised approach to help give a more affirming appearance.

The Advantage of Torso Masculinization

Most commonly we use liposuction to specifically target unwanted curves. The incisions are very small and usually they will disappear with time. Once the fat cells from those curves are removed, they should not come back in the same place in the future if the patient were to gain weight.

Some patients will choose to masculinize the entire torso with a tummy tuck. This can involve tightening of the six pack muscles if needed.

Other patients can remove extra abdominal skin and get a monslift or pubic lift at the same time. A monslift brings bottom growth more to the front and helps masculinize the pubic area. This can often be done as part of bottom surgery.

Who is a candidate?

Many patients who chose this surgery add it on as part of their top surgery. It can of course however be done at any time. Torso masculinization usually works best with a BMI of around 22-32 but we can usually offer it up to a BMI of 39.

What is involved?

Typically, if a patient adds this procedure to top surgery it adds about an hour to the procedure. Depending on what exactly is needed it may be between 1 and 3 hours if scheduled by itself.

Typically, more patients just experience some soreness with the procedure as well as swelling and bruising. In the first few days the patient will wear foam and after the first visit the patient will have a binder to wear for at least six weeks after surgery. The binder is just worn under clothes while folks get back to their daily activities. The binder helps decrease swelling and may help shrink the skin to the new anatomy.

There are at least three different approaches to torso masculinization depending on your body type and preferences. Dr Gallagher works with the patient to figure out which procedure will work best for their individual needs.
It can take up to 6 months to see the final result after this surgery as it causes a lot of swelling.

Most patients return to work in around 2 weeks and strenuous activity in 6 weeks when added to top surgery. This is the usual time frame for recovery from top surgery, so it doesn’t add much to recovery. When done alone recovery just depends on how extensive the surgery was.

Bottom surgery: a personal experience

Emmett Preciado

Even though I had bottom dysphoria throughout my transition, I didn’t plan to have bottom surgery. For me, the most important steps were “passing” and alleviating the dysphoria I had, as much as possible. So that meant starting hormones and getting top surgery. I had an emergency hysterectomy as well due to endometriosis. All those steps I had taken eliminated most of my gender dysphoria. But I noticed, as I became more comfortable in my body in those areas, the dysphoria between my legs grew more and more.

Around 5 years on T, I started pursuing my bottom surgery journey. I did A LOT of research. And I eventually found a surgeon that I really liked and I loved his work as well. A month after I hit 6 years on T, boom…I was waking up from Stage 1 of Radial Forearm Flap (RFF) Phalloplasty.

The journey from Stage 1 to Stage 3 was a long and stressful one, I’m not going to lie. I had some very common complications as well as some very rare ones. And it took my body a bit longer to heal than most. I was very frustrated with my body…for months. Why was it taking so long for me to do the things that most patients could do within weeks? I thought the process would never end and I was really scared that I would regret and resent my choice to have bottom surgery. I told myself that I could have just put up with the dysphoria for the rest of my life. That maybe I didn’t actually need surgery to make me feel “complete” or “whole” or at the very least more comfortable in my body. I realized that everyone in the Facebook forums was right about needing a lot of support to get through recovery. Because my mind was my greatest enemy.

But when I tell you the absolute joy and euphoria I felt when I FINALLY healed and fully recovered from issues I’d had from Stage 1…it was All. Completely. Worth It. I cried over my toilet as I stood to pee for the first time, with no pain. Seeing the bulge in my shorts… something that seems so simple and yet was so difficult for me, personally, to obtain.

I wasn’t born with a penis or testicles. But I am so grateful to be alive in a time when medical science has progressed, so much so that my gender dysphoria has been almost completely eradicated. And I experience far more gender EUPHORIA than I have ever felt in my entire life. And the best part of my new bulge is that it’s attached to my body, made from my own flesh. And it’s mine.

HRT: going on testosterone. Creams, Sub-Q, Intramuscular Injections

Finnegan Shepard

I started testosterone September of 2019. I still remember my first injection vividly: I had just returned from a canoe trip with my father and some of his friends, and one of them–a Swiss doctor–was still at the house. I asked him to oversee my first shot, and he did so with great kindness and encouragement. We were in the backyard of my parent’s house, and it was a warm afternoon. I wiped down the testosterone vial, as well as the patch on my leg I planned to inject into. I used the pull needle to get the viscous, slightly yellow looking liquid into the syringe, and then switched the tip to a smaller gauge needle for injection. To this day, I am still confused by where exactly the distinction between intramuscular needles and subcutaneous ones. As a diabetic, I am very used to using tiny needles to inject insulin. The needle I received when I started doing T was significantly larger than that–it looked enormous, in fact. Despite all of my years injecting insulin, this needle was a whole new thing, and I remember the nervousness, and the need to simply push that fear away and go for it, plunging it into my thigh. It hurt, but it wasn’t too bad.

For the next two years, I would give myself these injections once every two weeks. At one point, someone suggested I try Sub-Q instead, that recent research had shown it was just as effective for HRT. I went online and did a brief survey, but was then further confused, because on a video listed as Sub-Q, the needle looked pretty similar in length to the one I had been using, which I had thought was intramuscular. Because of this confusion, I continued doing what I had been doing for probably another 6 months or so. Somewhere in this time period, my endocrinologist suggested I move to once a week injections, as a way of making my numbers more stable. I believe it was this shift that prompted me to then ask about Sub Q. My doctor didn’t really have much information to share. He basically said, “we can try it, and if it works, great, and if it doesn’t, then we go back to IM.” He put in a new script, and when I went to pick it up, the needle was significantly smaller. Not as small as my insulin needle tips, but probably a third of the length of the needle I had been using previously. I much preferred this from a pain/comfort stand point.

In terms of my experience on testosterone, and how it was impacted by these different forms of injecting I am either too unobservant to have noticed a shift, or there weren’t really any shifts. How your body responds to testosterone is unique for each person. My voice started changing quite quickly as well as the ability to develop more muscle. Body and facial hair took longer. My period stuck around for six months or so, stopped for a month or two, and then came back irregularly for years. I have had times where my T was super high and converted back into estrogen, which then contributed to a lot of lethargy, but for the most part, I have staid in the 400-600 range, and that has felt good for me. I’ve never really considered the cream, as it seems like a lot of hassle, but of course it would be nice if I didn’t need to have more needles in my life. The needle tip I use now, though, which is quite small, rarely hurts.

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Yuri Lagnese

I have a pretty unique story when it comes to HRT, and it’s one I speak about often with people who are against gender affirming care, actually. I started HRT on May 13th, 2022 (and it’s May 7th, 2024 today!). So, almost exactly two years ago I gave myself my first subcutaneous testosterone injection (and I remember it was in my tummy!).

For starters, if you told me even five years ago I’d go on HRT, I would not have believed you, and even when I started I was very adamant about wanting to microdose the entire time and stop after a year (clearly, that is not what happened). You’re probably thinking, what changed? Well, my initial goal of HRT was to be more fluid in my presentation, but I did not want to look like a man, and especially did not want body and facial hair. The funny thing about that is, when the body and facial hair actually started coming in and I started being gendered as a man in public…it felt amazing. So, the first big realization on HRT for me was that I actually didn’t mind looking more masculine at all, and my fear of looking more masculine was actually just my internalized transphobic expectations of what an AFAB non-binary person was “supposed” to look like, and not reflective of my true feelings at all. However, the main reason I stayed on HRT is much simpler: my body just…functions properly on testosterone, for the first time in my whole life.

For context, I dealt with a myriad of health issues prior to being on HRT: horrifically painful periods, mood swings that came with severe depression/anxiety, chronic exhaustion, POTS syndrome, and (slight TMI but necessary) a severe case of bacterial vaginosis that persisted for years, and no doctor could help me. I was on over 11 medications a day at the time. Imagine my surprise when every health issue I’ve had magically started disappearing as soon as I got on HRT! Today, I have been off of all medication for four months now, and I’m feeling the best I have ever felt as well as am the healthiest I’ve ever been. And get this: I have had zero negative effects on T, even the “normal” ones.

Now, we have to talk about my microdosing journey, because I think a lot of people have the wrong idea about what microdosing is. For starters, contrary to popular belief microdosing does not only give you “some” effects. What effects you get and don’t get depend entirely on your genetics, and nothing else. What microdosing does do is give you all the effects you’d get on a regular dose, but much slower and subtler so you can ease into the changes and have more time to figure out if you like it or not…in theory. What I found out firsthand, though, is that dosages are not a universal standard, and it’s all about how your body receives it, which means for some special people, microdosing isn’t possible (spoiler alert, I was one of those people). For context, most people start at 0.2ml or 0.25ml a week on testosterone. I started on 0.1ml a week, the lowest possible dose. Get this: after only six weeks on testosterone, my testosterone levels were at 650. For context, my friend who had been on 0.4ml a week for almost a year got their levels tested at the same time and tested at 410. Yeaaah. So, seeing as microdosing is less about taking the lowest dose and more about having your levels stay on the low end of the therapeutic range since your testosterone levels are what determine the speed of changes, not the dose, needless to say “microdosing” I was not, despite taking the lowest dose (and boy, did my body know it). Funny enough, I actually take 0.4ml now and my levels are sitting at a cool 950, which neither me or my doctors can comprehend how I somehow am at my most stable and healthy at that level, but this is what I mean when I say dosage isn’t standardized! It’s whatever works for you to feel your best (within a healthy range recommended and monitored by your doctor of course). I recommend keeping a diary and photo log of changes to reference when discussing your dosage with your doctors, especially early on!

Oh, and let’s talk about the elephant in the room: injection anxiety. I personally have terrible needle phobia, however, I have been doing my own shots for almost two years now and have had quite the journey. I actually do two shots a week because I find my levels stay more balanced that way, so overcoming injection anxiety was pretty crucial for me. To be honest, the first three months I didn’t have much anxiety at all because the adrenaline and excitement was so fresh I didn’t even think about it! However, month four is when the anxiety really took hold, so I decided to order an autoinjector— the Union Medico Autoinjector to be exact, which was a lifesaver! …That is, until my doctor stopped filling the specific syringes I needed for that particular model, and I was back to square one. Luckily, I discovered a long term, free, and accessible cure for my needle anxiety: Davie504’s “10 Levels of Spooky Scary Skeletons” video. No, I am not kidding. Every time that bass solo hits at the end, I can’t help but bop, but instead of bobbing my head I flick my wrist and do the injection, and I swear it works every time. (Please tell me if you use this trick, nothing would make me happier than to know if this works for someone other than me too)

The last thing I want to talk about (although I could go on, I have so many stories about my HRT journey), is allergic reactions to testosterone injections, which, yes, can happen. Similar to most trans masc folks I knew, I was originally prescribed testosterone cypionate. In the beginning, I did all my shots in my stomach because I had the most fat there, but one day it started burning horribly after I finished the injection. I started using other injection sites, which worked most of the time, but it was about a 40% chance those places would burn badly as well. I didn’t want to switch to gel because at the time my partner was on estrogen and we couldn’t risk any transfer, and besides, the gel sounded like a huge headache to me. Luckily, I found out that there is another injection solution called testosterone enanthate, which is made using a different oil that is much better suited for sensitive-skin-baddies like myself. I am extremely happy to report that after switching to testosterone enanthate, I have had zero burning, itching, or swelling since!

Bios

Luke Lennon (they/he/any pronouns) is the founder of Namesake Collaborative, a platform that streamlines the legal name and gender marker change process for trans, nonbinary, and gender expansive individuals. Say hi to Luke on LinkedIn and follow Namesake on Instagram at @joinnamesake.

Emmett Preciado is an American transgender actor and singer-songwriter and is known for his roles as Rowan on Freeform's Good Trouble and Rio Gutierrez on ABC’s The Good Doctor. Find him on TikTok and Instagram @emmettpreciado.

Finnegan Shepard (he/him) is the founder and CEO of Both&. When he isn’t both-anding, he is writing about etymology here, and giving talks at universities, start ups, and conferences.

Yuri Lagnese (any pronouns) is the founder and sole operator of Cool Hair Boi Studios, a luxury salon made specifically with trans and neurodivergent folk in mind. Outside of the salon, Yuri spends their time watching anime with their two cats, meditating in nature, and sometimes streaming niche video games that nobody knows in the Both& discord server. You can find them at the following links: Professional Instagram | Drag/Personal Instagram | TikTok | Youtube | Salon website

Dr. Sidhbh Gallagher is double board certified in both general and plastic surgery. Originally from Ireland, Dr. Gallagher opened her world renowned practice in Miami in 2020. She is a pioneer of innovative new techniques, such as Masculoplasty and works with every patient to personalize the best approach for them. You can learn more about her and her practice here.