Ask Me Anything: Transfeminine Medical Transition — Costs & Considerations

Procedure-by-procedure considerations follow the discussion.
My advice is at the end…

What are the costs and considerations for transfeminine medical transition?

I cannot speak directly to costs, but I shall offer considerations which will strongly affect not only cost, but how much you put yourself through and your ultimate satisfaction with your results.

Review the lists below, make conservative estimates of your needs, then get on Google for rough estimates, then consult directly with providers for real budget numbers. In some places medical transition is now covered, all or in part, by public health / insurance.

If you suffer from gender dysphoria please don’t use long lists and large ‘package costs’ to discourage yourself from starting transition. The initial consults and hormones are a relatively small cost and can provide a lot of relief. †

Disclaimer: I am not a doctor. The following does not constitute medical advice. This is a compendium of my personal experience, the collective experience of other women with whom I’ve corresponded, and my readings of the medical literature and personal anecdotes. I am not a doctor — see yours for medical advice.

HRT effect timeline, WPATH Standards of Care, Version 7 (2011).

A note on hormone therapy (HRT): Below I say 1–3 years for development. This is based on general consensus amongst both transitioned transfeminine people and experienced medical doctors. But — that said, you should see rewarding changes in 3–6 months (again, based on consensus). If you do not, consider getting a second opinion on your regimen. In fact, if at all possible, you should seek a second opinion at the outset. (There is a specific HRT effect timeline on page 38 of the WPATH Standards of Care, Version 7.)

The three big variables in what you end up paying are, of course,

• how much you have done,
• where you have it done, and
• how much (if any) will be covered by public health / insurance.

The shopping list of things you can have done these days is very long. But most transfeminine people actually end up ‘needing’ far fewer procedures than they imagined at the start. For many, probably most, by far the greatest changes are accomplished through learning/unlearning, and hormones.

The major categories of procedures you may or may not need / choose to have done are —

• psychotherapy (initial screening & referral, support maintenance) * †
• primary care (initial screening & referral, support maintenance) *
• endocrinology (hormones, androgen blockers, blood levels monitoring)
• hair removal (face/body; laser, electrolysis)
• head hair transplantation
• facial feminisation surgeries (brow bossing, hairline lowering, mandible reduction, rhinoplasty, implants, fat grafting, fillers, &c)
• facial beautifying procedures (various face-lifting and skin tightening procedures, skin resurfacing, Botox, rhinoplasty, implants, fillers, &c)
• tracheal shave (chondrolaryngoplasty)
• vocal surgery (various types)
• top surgery (breast augmentation)
• bottom surgery (orchiectomy, labia, clitoris, vaginoplasty, skin grafting) *
• body sculpting (liposuction, fat grafting, tucking, various implants, &c)

Procedures you may at first assume you need, but may not need (as much of) —

Hair removal (face/body; laser, electrolysis) —

• Note that, for some, facial hair can diminish with HRT over time, potentially reducing the amount of laser/electrolysis needed. This effect is not universal. ‡
• For many transfeminine folks body hair is greatly reduced and becomes finer with HRT; especially arm and chest hair. This may take 1–3 years. If you can bear to wait you may save a lot of money and pain here. ‡

Head hair transplantation, hairline lowering —

• Many people (including many surgeons) think female hairlines are further forward than is true in fact. Look carefully at cis models. I recommend reading through the extensive hairline analysis available at Virtual FFS.

Facial feminisation surgeries (brow bossing, hairline lowering, mandible reduction, rhinoplasty, implants, fillers, &c) —

• This is an area where you likely ‘need’ far less than you think. If any at all. Many, many transfeminine folks think their faces look far more masculine than they actually do. As a case study, I perceive my own face as being dreadfully masculine; but I’ve been passing stealth for 27 years and was once considered a beauty. Again, look carefully at cis models: you will see plenty of high hairlines, visible brow ridges, square jaw lines.
• HRT has surprising effects on the face, and it takes time: 1–5 years. Most surgeons will ask you to wait at least a year. The longer you can bear to wait, the more likely you are to save yourself money and pain. And the more likely you are to become satisfied with your ‘natural’ appearance.
• Again, I recommend reading through the extensive documentation available at Virtual FFS. Many prominent FFS surgeons recommend that you have Virtual FFS done prior to consultation. The cost is trivial compared to the cost of having even one unnecessary procedure.

Tracheal shave (chondrolaryngoplasty) —

• Cis women have Adam’s Apples too. They are, on average, less prominent than those which have been masculinised, but they are visibly there, and most of us perceive our own larynxes as being more obvious than they actually are. There is a myth that one can ‘clock’ a trans woman by her Adam’s Apple, but this is only true in a minority of cases. A large fraction of ‘male’ larynxes are within the cisfeminine norm.

Vocal surgery (various types) —

• There are a lot of before-and-after samples of voice surgeries available online. To my ear most sound no better, and often worse, than results achieved through training alone.
• Many vocal surgeries have turned out to be unstable over time. Newer techniques may be more stable, but it will be some time before we know for certain.
• As with our faces, our own perceptions of our (retrained) voices read more masculine than is objectively true. Again, as a case study, I perceive my own voice as being dreadfully masculine; but again, I’ve been passing stealth for 27 years, and I’ve had numerous cis women (including singers) tell me that they envied my ‘smoky contralto’.
• There are many excellent voice tutorials available on YouTube (along with many poor ones — take time to sort through them).
• For the extreme of vocal retraining, read my articles about what professional transfeminine singers have done with their voices, here and here. There is also a list of vocal resources here.

Top surgery (breast augmentation) —

• Many western women, cis and trans, wish they had larger breasts. This emphasis is cultural and has no relation to actual human variation; i.e., many women who ‘feel small’ are actually larger than the mean.
• Additionally, it may take up to 4 years for your breasts to fully develop. You may want to wait on BA whilst you finish developing and have time to consider how much you want to conform to western ideals of feminine beauty.
• Should you choose to have BA, consider finding a surgeon who specialises in working with trans women. It’s a somewhat different skillset to working with cis women, due to variation in hormone response and breast placement across the somewhat wider ribcages some of us have.

Bottom surgery (orchiectomy, labia, clitoris, vaginoplasty, skin grafting) —

• If you respond well to androgen blockers and intend to have genital revision (GRS) within a few years, you probably don’t need a separate orchiectomy. If you do not plan to have GRS you will want to consider orchiectomy against a lifetime on androgen blockers. This is not a decision that needs to be made early-on, unless for some reason you cannot take, or do not respond to, androgen blockers.
• Vaginoplasty/vulva construction generally divides into single-stage and two-stage procedures. You are likely to get as-good or better results with a modern single-stage procedure performed by a skilled surgeon, than you would with a two-stage procedure (vaginoplasty followed by vulva revision). With a single-stage procedure you will benefit from reduced trauma and recovery, and it may cost you less overall.

So much of this comes down to patience, awareness of the vagaries of body self-image, and doing your research.

My advice: Get started. Be determined. Be patient. HRT and training accomplish most of what’s needed in 1–3 years. Set money aside, but don’t waste a lot of worry on surgeries until you’re well on your way.* One step at a time, girl, one step at a time.

Best wishes for your journey,
❤ Allison

Related articles:

‘How do I know if I’m trans?’
What is gender transition?
How does HRT work after GRS?
What’s it like to be a trans woman?

Notes:

* But do be aware of waiting lists. Some are years long, and you can always cancel later.

† My friend Michelle Shaw, a psychotherapist specialising in trans care, and a trans woman herself, has the following to say about therapy’s place in transition:

My little plug for working with a psychologist: Hormones will change your body, the real work of transition goes on inside. Adapting to a new social context, navigating the world within a different framework of rules and constraints, and learning to feel comfortable with yourself takes time. By all means, take hormones, and enjoy their effects on your body and mind; but be conscious about the changes you are making as you adapt.

‡ There is some controversy as to whether oestrogen treatment does or does not significantly alter body hair, with many trans people claiming that it does, and some medical professionals claiming that it does not. When I have looked at the medical counterclaims in detail, I have found them to be every bit as anecdotal, dismissive, and meaningless in sample size as the claims pro. Furthermore, I have yet to see a counterclaim address the observed variation in individual response to oestrogen treatment. Add this to the long history of bias amongst those treating trans people, and I’m disinclined to take these opinions at face value.

On the other side, the sheer weight of anecdotal claims pro swamps the available crop of counterclaims; so until there is a controlled study with n=50+ (don’t hold your breath), I’m going with the greater weight of anecdotal reports. It is worth noting that the WPATH Standards of Care concur (Version 7, page 38).

This is part of my Ask Me Anything series. Ask me anything in the comments…

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