One step at a time

In the trans community, ‘transition’ means changing so that you live in a way which is appropriate to your gender identity. This can have several phases, which can be completed independently of each other.

The point of transitioning is to help you live without dysphoria (an intense feeling of sadness, low mood and uncertainty - the opposite of euphoria). So what you will need to do will vary depending upon your feelings. The three aspects of transition can be termed ‘social’, ‘legal’ and ‘medical’ transition.

Social transition

This is the process of adjusting how you exist in society to match your gender identity - in this case to living and being known as male or non-binary. Part of this is ‘coming out’ to those who knew you as female and presenting in a way that you are comfortable with, and which signals your identity to others.

This transition can be incredibly difficult and can expose you to harassment and prejudice. It can also be a great relief when you no longer need to present as male. In order to undergo medical transition, it may be necessary to learn to live in society full time as you wish, under a requirement known as ‘Real Life Experience’.

Legal transition

This is the formal process of changing your documents and legal records of identity. This can take a long time to accomplish although most records can be changed with a record of name change (such as a deed poll or statutory declaration) plus a doctor’s note saying you are transitioning and intending the transition to be permanent.

An exception is your birth certificate, which requires a Gender Recognition Certificate.

Non-binary individuals may not have the legal option of an appropriate title (eg, Mx, Misc) although this is increasingly changing.

Medical transition

This is the process of changing your body physically, through hormone therapy and/or surgery, and other procedures such as permanent hair removal. This can be done privately or via the NHS, with different processes and requirements. Certain medical procedures are never or rarely covered by the NHS.

The decision to transition is rarely taken lightly, given the impact it has upon your entire life. Although it is a very stressful period, it can bring immense relief to lifelong dysphoria and bring a happiness that is otherwise impossible to achieve.

Whether you decide to medically transition and, if so, how far is a very individual choice.

If you decide you want to consider medical treatment then the first step is to go to your GP. From there you will most likely be referred to a local psychiatrist and then to the nearest Gender Identity Clinic (GIC). This will probably take several months. There are also some private consultants you can see.

Real Life Experience (RLE)

Before you are put forward for surgery you will have to go through the RLE (Real Life Experience). This gives both you and your consultants time to be sure that this is the right process for you. In some cases it will have to be done before any other treatment, in others you will be able to start hormones during the RLE.

Hormones

Once the diagnosis of Gender Identity Disorder (GID) has been made you will be put onto testosterone. This will override the ovaries and stop your periods, while also causing you to go through male puberty. Your voice will drop, body and facial hair will develop and your body will change shape slightly as muscle increases and fat moves about. You will need to have blood tests before and during this process to ensure that you are not having any adverse effects.

Surgery

Whether you choose to have surgery or not is very personal. Some men don’t want to have any surgery at all and find that hormones are all they need to pass and feel more comfortable in themselves. Others want all traces of female parts removed and changed to the male form.

Chest surgery comes in several different variations, and which one is right for you will depend upon your size and shape, and personal preference for how the scars are placed and whether nipple sensation is important to you. You are likely to have to be on hormones for a year before you get chest surgery on the NHS. If you choose to go privately you will still need a referral from a gender specialist.

Hysterectomy involves the removal of the uterus, cervix and often the ovaries too. There is some debate about when and if transmen should have this done. You are likely to be required to have it if you do want lower surgery, particularly if you want the urethra extended so that you can pee standing. Lower or genital surgery comes in two main options, either phalloplasty or metoidioplasty.

There is only one UK team doing genital surgery for transmen, so if you don’t want what they offer then your choices are to go abroad. It is possible to get NHS funding to go to a team in Belgium, although it isn’t automatically granted and you will have to make a case for why you should go there rather than the London team. Anywhere else will mean paying privately, which can be very costly.

Whether you go privately or through the NHS, you will almost certainly need to have been on hormones for two years before you will be considered.

We often speak of ‘coming out’ as trans - the same phrase used for lesbian, gay or bisexual (LGB) identification – but in some ways it is very different.

The key differences are in people’s prior understanding and consequences of coming out. The people you come out to may not have an accurate idea of what being trans means, especially if they have been misinformed by popular representations of trans people. For example, if you are non-binary identified (ie, you do not identify with being male or female) it can be particularly difficult for people who do not understand what that means.

People’s lives can change if they come out as lesbian, gay or bisexual – but, unlike trans people, they are unlikely to need to change the name and pronouns they use for themselves, or to present themselves in a very different way.

You may choose to come out as trans after you have transitioned - to partners, for instance, or to your GP in order to access medical tests that you would otherwise not be prompted to get (such as prostate checks). If you are medically transitioning, you may also want to ask for extra support from people or for time off work.

To make coming out easier, you could work on explaining your identity to people and making your feelings clear. While you may have a strong innate understanding of your gender and feelings, verbalising them clearly can be difficult and it may need practice. It can also help to explain how people can help to support you. They may not feel ready to use your chosen name straight away, for example, or they may take time to adjust. Coming out well can reduce this adjustment period.

Coming out can give you a profound sense of relief, removing the burden of hiding who you are. When planning how to come out, you may prefer the intimacy and immediacy of telling someone in person, in a safe, comfortable space. Alternatively, you may prefer telling someone via letter or email, allowing you to phrase things as you like without interruption or the risk of putting someone under pressure to respond quickly. However you do it, make sure you’re safe and have someone to talk to afterwards.

If you have recently started questioning your gender identity, you may be feeling like you need someone to talk to. A good starting point is Mermaids or the Trans Youth Network, which provides support and has an online forum.

You can also get help from Gendered Intelligence, which runs projects where young trans people can meet, give each other support and take part in a range of activities.

Puberty

If you are at the start of puberty, it may be possible to take ‘hormone blockers’ to suppress some of the biological changes puberty brings. The official names for these drugs are GnRH inhibitors or GnRH analogues. These can be given to someone of either sex. Puberty can be a very distressing time if you feel you are in the ‘wrong’ body, but being able to stop the changes while you think through your options can be a great help. In the UK you used to have to wait until you were 16 to take the hormone blockers, but this has now been lowered to 12 in some cases.

This means that if you haven’t gone through puberty yet and you think you might want to take this option, you will need to get medical help and advice much sooner. This will probably mean telling your parents, as they will be able to help you take the next steps.

The hormone blockers are fully reversible. They effectively put the physiological changes of puberty on hold - such as growth spurts, voice lowering and the development of an ‘Adam’s apple’, testicular growth, facial hair growth, breast and hip development, and periods (menstruation) starting. If the hormone blockers are stopped, your development will continue as normal, even if you have been on the blockers for several years.

If you haven’t gone through puberty yet and think you might want to take this option, you will need to get medical advice straight away. This will probably mean telling your parents so they will be able to help you take the next steps.  

NHS - A guide for young trans people in the UK
This booklet has been written by other young trans people will be able to give you more details and insights. 

Looking after your sexual health

It might be that you're starting to explore your sex life - as a Transman there are some things to consider about staying safe.

Next steps?

You might be wondering what your next steps are. If you want to explore options such as hormone treatment and surgery, you would need to talk to your GP who would refer you to your local Child and Adolescent Mental Health Service (CAMHS). They would be able to talk to you and, if appropriate, refer you on to a gender identity service such as the Tavistock and Portman NHS foundation trust.

We all produce the sex hormones oestrogen and testosterone but people who were labelled female at birth usually have more oestrogen and people who were labelled male at birth usually have more testosterone.

In an adult female the sex hormones, which are mainly produced by the ovaries, are oestrogen, progesterone and small amounts of testosterone. Throughout the menstrual cycle the hormone levels vary from day to day, causing changes in mood, skin quality, appetite and sex drive. In men, the hormone pattern is much simpler - they have about 10 times more testosterone than women, with lower levels of oestrogen and progesterone. The male hormone cycle takes 24 hours rather than a month, with the peak in the morning, although testosterone production is affected by activity such as playing (or even watching) sport.

You will need to have medical assessments before you can start hormone treatment. You will have blood tests to check your base levels of sex hormones as well as tests for liver function and cholesterol, as they can be affected by hormone treatment.

Testosterone isn't as easy to get into the body as oestrogen, so although there are testosterone patches, they have to be much bigger to get the right dose. The most common way to take testosterone is by injection, which will vary from being taken once per week to once every three months. An alcohol-based testosterone gel, which you rub on every day, is another option. There are also implants, which have to be replaced every six months, and gel tabs to stick on your gums. If you find that you don't get on well with the method you start with, you can always talk to your endocrinologist to find a different form of testosterone to suit you.

Some people take hormone blockers until they are ready to start testosterone. These will dull down the female hormones and stop your periods without the effects that testosterone has.

Monitoring

It is vital to have your hormones monitored regularly so that your doctor can make sure your body is absorbing them. It also means they can keep track of any side-effects and make sure you are taking the correct amount.

What will the hormone treatment do?

High doses of testosterone override the ovaries and cause them to shut down, which means your body essentially goes through male puberty and the menopause at the same time. Like both puberty and the menopause, the changes are gradual and are different for everyone.

Puberty-related effects:

Genital growth - the clitoris usually grows to an inch or two in length and will get thicker and have more noticeable erections.

• Voice changes - this usually takes a few weeks to start.
• Body and facial hair growth - this takes years to complete.
• Spots.
• Mood swings.
• Increase in appetite.
• Increase in libido.
• You can also expect an increase in muscle bulk but you are unlikely to get taller unless you are very young.
• Hair loss - this doesn't usually happen immediately but that will depend on your age and genetics.

Menopause-related effects:

• Your periods will stop - this may take months and you may have the occasional period for a while.
• Hot flushes.
• Mood changes.
• Headaches.
• Skin changes.
• Reduced libido.
• Vaginal dryness.
• Itching and soreness may make sex uncomfortable and many people also get cystitis or thrush.

Some of these symptoms are on both lists and some can counteract each other, so it is impossible to predict exactly which changes you will get and when. Some people seem to sail through the process with none of the negatives while other people will be spotty, stroppy and moody.