In this article we will briefly talk about transitioning from male to female (MtF) and from female to male (FtM). We will not talk about the bureaucracy of gender transitioning nor about the legal aspects of the transition for which we advise you to read other specialized websites on the matter. Hence, we will talk about:
- Diagnosis of gender dysphoria
- Hormonal therapy for transgender patients
- Surgical therapy for gender dysphoria which includes several surgical treatments defined as
- Primary surgery (Sex/Gender Reassignment Surgery or SRS)
- Secondary Surgery (Chest wall reconstruction)
- Accessory Surgeries (all the other feminization or masculinization surgeries)
We start by saying that this path is not mandatory for everyone; none of these steps is required to validate your gender identity. We’re just trying to provide information to those interested in the medical and surgical aspects of transitioning.
The World Professional Association for Transgender Health (WPATH) published the guidelines (Standards of Care) for the medical facilities and professionals involved in the transitioning process, from psychologists, to speech therapists, to doctors and surgeons, all those involved in assisting the transgender, transsexual and gender nonconforming population.
This protocol sets also the requirements to access medical and surgical therapies. The criteria are based on the best available science and expert professional consensus and are set to avoid premature choices; the criteria provide ample opportunity for patients to experience and socially adjust in their desired gender role and to minimize the cases in which a patient might undergo invasive medical and surgical procedures, sometimes irreversible ones, and then regretting them.
Cisgender and gender nonconforming individuals: understanding the terminology
Cisgender refers to all the people that recognize themselves with their biological gender. Cisgenders behave, conform to the social role and feel their gender identity as the one that was assigned to them at birth.
Gender nonconforming refers to all the individuals who are not cisgender because of one or more aspects of their identity. It refers to all the people who display psychological, behavioral or socio-cultural traits which don’t conform to the stereotypical ones of their gender assigned at birth. This broad category includes several different heterogeneous groups which do not fall into the classic male and female categories. One of the many subcategories recognized in this group is the one of the transgender population.
Transgender refers to all the people whose gender identity, meaning the gender they feel to be part of or their perceived gender, is not their biological one or the one that was assigned at them at birth; they identify in the opposite one. Sexual orientation has nothing to do with gender identity and is not relevant for this classification.
F2M or FtM refers to all the transgenders whose gender assigned at birth is the female one, while they feel to be part of the male gender, and that have begun transitioning from one gender to the other. It stands for “female to male”.
M2F or MtF refers to all the transgenders whose gender assigned at birth is the male one, while they feel to be part of the female gender, and that have begun the transitioning from one gender to the other. It stands for “male to female”.
Belonging to a category other than cisgender is not considered a mental disorder as established by both the WHO in its ICD-11 (International Classification of Diseases 11th edition) and by the DSM-V (The Diagnostic and Statistical Manual of Mental Disorders 5th edition).
Gender Dysphoria is a pathological state of distress and discomfort which could cause many symptoms such as depression, irritability, anxiety, compulsive behavior and others. Gender dysphoria is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Not all the transgender or gender non-conforming individuals suffer from this which could manifest both as a permanent and as a temporary illness.
Therapy and treatment for gender dysphoria
For some of the cases, the help of psychotherapy is sufficient to allow the transgender patient to integrate their gender identity into the gender they were assigned at birth. These individuals will hence solve the dysphoria (distress) without the need to turn to medical and surgical therapies.
Other individuals are able to overcome the dysphoria by simply express their gender identity socially and with their behavior, with or without psychotherapy, and again without any medical or surgical treatment needed.
Gender dysphoria though, is often, but not always, associated with the desire to get rid of the primary and secondary sexual characteristics that belong to the sex assigned at birth and with the strong desire to develop and have the primary and secondary sexual characteristics of the perceived gender.
In these cases, from the diagnosis of gender dysphoria and from the initial psychotherapeutic approach needed to avoid premature treatments which are partially or totally irreversible and that carry risks, the patient can move on to one or more medical and surgical treatments. None of these treatments is compulsory, it’s up to each individual to decide what they need and what is best to achieve peace of mind. Hence, each therapeutic approach is different and tailored to the patient’s needs and their own characteristics.
In almost all of the cases the first step is the hormone therapy.
- In the case of FtM patients it is called masculinizing hormone therapy and it is based on the administration of testosterone
- In the case of MtF patients it is called feminizing hormone therapy and it is based on the administration of estrogen and other medications.
Hormonal therapy can have variable results based on the starting characteristics of the patient, but also based on their own goals and expectations. Moreover, hormonal therapy is a prerequisite for some of the surgical therapies.
For what concerns the various available surgeries we refer you to the links below, which will take you to thorough posts on each topic.
For the FtM transgender patient:
- Hysterectomy and bilateral salpingo-oophorectomy, which is the surgical removal of the uterus, fallopian tubes and ovaries
- Vaginectomy, which is the removal of the vaginal lining and the closure of the vaginal opening.
- Bilateral mastectomy, or “top surgery” which is the removal of breast tissue.
- Scrotoplasty, which is the surgical construction of the scrotum
- Metoidioplasty, one of the alternatives for the surgical construction of the penis
- Phalloplasty, the other alternative for the surgical construction of the penis
- Facial masculinization, a series of cranio-maxillo-facial surgeries to reshape facial features giving them a masculine appearance.
- Voice masculinization therapies and surgery.
For the MtF transgender patient:
- Vaginoplasty, which is the construction of the vagina
- Mammaplasty, or top surgery or breast augmentation which is the surgical reshaping and or augmentation of the breast
- Facial feminization, a series of cranio-maxillo-facial surgeries to reshape facial features giving them a feminine appearance
- Voice feminization surgery
In all of these cases the proper definition is reconstructive procedures, not aesthetic procedures, since they are carried out to make the physical appearance of the patient congruent with their gender identity. It is to all intents and purposes a medical and surgical therapy, since it is aimed and capable of effectively treating gender dysphoria.
- Standards of Care – 7th edition – World Professional Association for Transgender Health (WPATH)
- DSM-V – Diagnostic and Statistic Manual of Mental Disorders – Fifth Edition