Ask Me Anything: What is gender transition?

Photo: Kayla Emmert

This question has been asked and answered so many times that I usually demur. But someone caught me in a moment of weakness and, looking at other answers, I decided I might have something to add to the discussion, so here goes…

I’ll be speaking from the transfeminine perspective, naturally. Furthermore, I’m going to be speaking as a femme, cis-normative, cis-passing woman — in other words, a bit of a stereotype (I don’t really see myself that way, but others may; and by the way, cis just means ‘not trans’).

Some of the following will not apply to women who present differently to me, for example non-femme women — tom-boys, butch women, &c, as well as some nonbinary transfeminine folks. Much of this will also not apply to women who are not interested in passing; i.e., blending-in as cisgender women.

There is a lot of effort involved in transition, but it’s not necessarily where you’d think. The stuff you see on television — makeup, wardrobe, hormones, and of course ‘the surgery’ — these are not the hard things, they’re the easy ones. Most people think ‘sex change’ then assume it’s all about ‘the surgery’. As you’ll see, it’s really about everything but.

(I am amused, in a horrified kind of way, by those who imagine that being trans is a choice, a kind of ‘lifestyle’. Nothing could be further from the truth. For most of us, transition is a desperate, agonising, last-ditch effort to get away from being trans, to fix it once and for all and move on to a place where trans is not part of our lifestyle. Trans is how we’re born and how society treats us, not what we choose.)

There are two sides to transition: medical and social. Medical is the easy (but expensive) part, social is the hard one. But before any of that there’s the hardest thing of all: coming to terms with being transgender.

1. The Realisation and The Decision

Most of us spend years struggling with the internal, secret need to be recognised as a gender other than that to which we were assigned at birth. We may not even be sure (or aware) that we’re trans. We think we’re sick, we think we’re alone, we think there is no way forward for us. A chaotic, unmanageable life, often with substance abuse, destructive relationships, comorbid mental problems, and suicidality — life can be unliveable and all this is common.

If we survive all that we get to a point where we can’t take it anymore. Often the underlying gender starts to leak out. Private or public cross-dressing happens, behaviours shift, we become preoccupied with our gender. The pressure builds. Eventually we’ve had enough, we get enough good information, and we finally make that first appointment with a gender therapist.

2. Transitional Beginnings

We have sessions with the therapist. Depending on local rules and practices this could be weeks or months (or even years, god forbid). We get a referral to an endocrinologist or other doctor who prescribes cross-sex hormones and, usually, androgen blockers. We’re on our way.

3. Social Transition

Now comes that effort we talked about. There is usually a period of living in our proper gender ‘part-time’ — typically (for women) pseudo-male presentation continues at work and other environments where transition is especially hard (or impossible), female presentation begins in other parts of life.

This is the oh-so-awkward in-between phase when you’re getting ‘clocked’ constantly (i.e., you’re not passing and people are reading you as male rather than female — man-in-a-dress syndrome — the absolute most hideous part of being a trans woman), you’re struggling with your voice (ugh!) and appearance (dreadful makeup and fashion gaffes) and behaviours (What the hell do I do with my hands? What do they mean ‘female conversation style’?!), all whilst you wait for the hormones to ever-so-glacially carry your androgen-poisoned physique across to womanliness.

The really hard parts for most women are—

1. Voice and conversation style. This is not only pitch, cadence and inflection, but also vocabulary, listening style, back-and-forth signalling, eye contact, touching — there is a lot more complexity and lot more difference in speech, male-vs-female, than we imagine.
2. Body language. There are 1001 ways we signal gender without even knowing it, everything from the obvious stuff like walk and leg-crossing to details like head tilt, eyebrow expression, smile frequency, wrist angle, hip position when standing, finger position, foot placement — the unbelievable thousands of micro-signals all of us put out constantly without ever realising it. It’s nearly impossible to learn all these item-by-item, they are instead kind of ‘absorbed’ over time, as you settle-in and imprint on the women around you. Good observational skills are a plus.
   
   The thousand old pseudo-male ‘cover’ behaviours must be unlearnt and be replaced with a thousand gender-appropriate behaviours. This usually takes a couple years (just as it does with young cisgender girls), and results are quite variable, depending on inclination, effort and aptitude (as it is with cis girls).
3. Just simply mustering enough drive and confidence to carry on into the next day. The internal and external pressures are beyond belief.
   
   (You know that dream where you’re in class and realise you’ve no clothes on? Yeah, that, times a thousand. For a year. Maybe two.)
   
   It’s incredibly intense and exposed. Nobody does this for fun.

Eventually you’ve got things sorted enough, and you go ‘full-time’; you finally get to live as yourself all day every day.

1. You get your documents changed — driver’s licence, passport, bank and credit, school transcripts, insurance, vehicle registration, employment records, medical records, credit reports, all your bills, government programmes, birth record (if they even let you) — name and gender marker. You just wouldn’t believe how many things have an M or an F attached, relevant or not. A huge bureaucratic hell involving huge amounts of time, stacks of forms, court dates, endless certified copies, embarrassment at every turn, and a lot of money. This can take months to years.
2. You come out to your family, if you haven’t already. Maybe they’re with you, maybe they’re not. Probably some of each. Probably some of them stop speaking to you. Maybe some of them never speak to you again. Maybe all of them.
   
   Maybe you get a divorce. Maybe your jurisdiction requires you to get a divorce. Maybe your spouse was on-board in the beginning, but now…not so much. Maybe you lose your children. Maybe you never see them again either. Maybe this is after you’ve spent all your money on attorneys and court costs. Nobody does this for fun.
3. You come out at work; now you live in a fish bowl, with every client and co-worker inspecting your every garment and gesture, commenting behind your back or criticising to your face. People misgender you constantly, some out of ignorance, some out of carelessness, some out of spite; whichever it is, you’re constantly being ‘outed’ to every new person you meet. And then there are the same (often incredibly personal) questions, over and over and over again, until you could scream but you paste on that smile and answer politely. Again.
   
   Maybe they let you use the ladies’ room, maybe not. Maybe they don’t let you pee at all and you have to choose between getting in trouble for leaving work and getting kidney damage. Eventually you can’t take the pressure any longer and you change jobs. Or maybe you change jobs up-front to avoid the pressure. Maybe you get fired. If you’re not passing or you have a paper trail that ‘outs’ you, then maybe you’re unemployed for a very, very long time. Nobody does this for…well, you get the idea.

Eventually all this sorts out to the point that you (finally!) get to just live your life as an ordinary woman. Just another woman. Hallelujah. (This can take years.)

So, yeah, putting on lipstick and walking in heels is nothing; enduring years of really hard challenges whilst keeping a job and chatting about the weather in the ladies’ room without getting clocked, that’s hard.

4. Medical Transition

1. Hormones.

• Oestrogen — tablets, patches, creams — injections are considered best by many (including me) and require a big needle jabbed into large muscle. Every week. It hurts.
• Progesterone — some take it, many don’t. To the best of my knowledge research hasn’t demonstrated a benefit, but opinions vary. I take it.
• Androgen blockers (a.k.a. T-blockers) — amongst those who’ve not had genital surgery, it’s a good idea to knock that nasty testosterone down. Poisonous stuff, that.

2. Hair. Some really great, other not so much…

• Head hair. Yes, please. If you had it short, now you spend years growing it out. Many women who don’t transition young end up with male-pattern balding, which is pretty dreadful. Many of us will get hair transplants, and may opt for more extreme procedures such as flap rotation or hairline advancement (see FFS, below). Wigs suck.
• Body hair. No, thanks. Fortunately oestrogen thins and lightens body hair sufficiently for most of us. When that’s not enough there’s laser and electrolytic hair removal, possibly a lot. Ouch. Hope for good oestrogen response.
• Facial hair. Oh my god, no. Oestrogen doesn’t really help much here — it’s all about the laser and electrolysis — ouch! Laser doesn’t work for some kinds of hair, so electrolysis becomes the only option: Picture a needle inserted into the pore and a hot electric zap for each and every hair, and sometimes a second pass later, for each hair. Yikes. Many, many hours costing many, many shekels. (Trans men take testosterone and love it when their beards grow in. We trans women understand…no, actually we don’t; that’s just crazy… ;-)

3. Surgeries. There is no ‘the surgery’, there are many possible surgeries. Some women get none, a few get the lot, many of us have one or two. Myself, I had only GRS and a tracheal shave.

• ‘The’ Surgery (GRS). Some (by no means all) women have GRS a.k.a. SRS (genital reconstruction/gender reassignment/sex reassignment surgery, also called GCS — gender confirmation surgery — there are many name variations), where they take the ‘wrong’ naughty bits and fix them into the ‘right’ ones. Today this is usually a single, very major procedure, sometimes with revisions, costing $£€ 15K-30K. In my day it was two major procedures costing $£€ 30K-50K in today’s money. There are relatively few surgeons across the world, current demand has pushed waiting lists out to years, and people have a very hard time coming up with that kind of money, so that most transitioning trans women have not had access to GRS.
  And by the way, yes the results are quite good; no, you probably can’t ‘tell’; and yes, the plumbing works and so does the electricity. Satisfaction rates for GRS are very high.
• Orchiectomy. Castration, to you lay-folk. If the dangly bits are still present at GRS this gets taken care of then. Some women who have not yet had or will not have GRS have them removed, because testosterone (ick). T-blockers can be hard on the body, and you don’t really want to be on them for years. This is a simple and relatively inexpensive procedure, often used to at least solve the T problem when GRS is out of reach.
• Breast Augmentation (BA). Some trans girls aren’t satisfied with the endowment nature gave them, so they have that fixed, just like some cis girls do. Rates of complication and reoperation are high for BA, but satisfaction rates also seem to be high. (Trans men have anti-BA, which is pretty weird…jk, love you guys!)
• Facial Feminisation Surgery (FFS). Testosterone can make a lot of changes to the face, most of them subtle (but they add up), often including a more prominent brow ridge, larger nose, squarer jaw, more protruding larynx, and receding hairline. Some of us are facially lucky, and some of us feel a need for some help.
  
  Available FFS procedures include brow bossing (reduction), rhinoplasty (nose job), mandible (jaw) contouring, cheek implants, hairline advancement, larynx reduction (tracheal shave), as well as more common cosmetic procedures such as various kinds of face-lifts, blepharoplasty (eyelids), fillers, fat transplants, chemical peels and dermabrasion, and on and on and on.
  
  Many women opt for FFS, but most end up ‘needing’ less than they might have thought, if any. We tend to be pretty hard on ourselves in the mirror. Oestrogen works wonders with the subcutaneous fat layer, but it takes time.
  
  (BTW, with increased general awareness of trans women, some cis women are now getting clocked as trans, and I know of a cisgender woman who got so sick of this that she had FFS so she could ‘pass as cis’. Yes, really. I don’t know if it worked or not.)
• Body Sculpting. Yes, this is a thing. Fat transplantation, liposuction, implants, skin tucks, you-name-it, they do it.
• Vocal Surgery (various procedures). Most women don’t have this; surgical techniques are highly variable and so are the results, with a high degree of dissatisfaction. Vocal retraining, though difficult, does it for most of us.

And by the way, imagine trying to get through medical transition if you don’t happen to be wealthy. Imagine trying to get through this if you lost your job because trans. Imagine trying to get through social transition if you can’t get hormones or pay for facial hair removal. Very many trans women have it very, very hard.

5. Done and Done

Actually, there is no ‘done’ to transition, per se. At some point we just kind of stop making changes and get on with life. The main part of transition usually takes a year or three, but sometimes longer, and pretty much never less than a year. I was just over one year from first therapy appointment to GRS, but that is unusual.

Social transition is more vaguely defined, but it usually takes a couple years to blend in (if that’s the goal), and some aspects require on-going effort for quite some time.

It is not uncommon to come back and make changes years later. A close friend who transitioned ages ago recently had BA; I am small-breasted myself, and I still think about it sometimes. Now decades post-transition, I am still self-conscious about my voice, but a lot of women are. I still work on it, sometimes.

We age and things change and we make adjustments. Transition takes a year and a lifetime. But it is so worth it, every bit.

And by the way, should you encounter a trans woman who has been through transition, you are looking at one of the toughest human beings you’ll ever meet. Count on it.

This story was adapted from my answer on Quora.

Related articles:

‘How do I know if I’m trans?’
Transfeminine Medical Transition — Costs & Considerations
How does HRT work after GRS?
What’s it like to be a trans woman?
My experience during the Trans Dark Ages

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

Major monthly financial support is provided by Jayne Tucek, Beth Adele Long, Maya Stroshane, Stevie Lantalia Metke, and J. Morefield.

I make a spare living doing this. You can support my work and get draft previews and my frequent ‘Letters Home’ for less than the cost of a coffee.