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 female or non-binary. Part of this is ‘coming out’ to those who knew you as male 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 - such as facial feminisation surgeries or facial hair removal.

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.

Different trans women will be at different stages in their journeys – you may not be planning to transition or you may have done so a long time ago. The following information is for you if you are planning to take the route of physically changing your body so that your physical body matches your gender.

In order to go ahead with treatment on the NHS you will need to see your GP who will be able to refer you to a gender identity clinic. You will have to be diagnosed with gender dysphoria before you will be able to have treatment. Usually you will have an assessment with a psychiatrist who will make the diagnosis.

Hormones

If you are diagnosed with gender dysphoria, you will be prescribed hormones – this is called cross-sex hormone therapy and means that as a trans woman you will be able to take oestrogen and possibly hormone blockers to stop the production of testosterone.

Oestrogen will feminise you - it might reduce facial and bodily hair growth and increase the fat on your hips and breasts. It may slow down or stop male-pattern baldness and will often cause your penis and testicles to shrink and reduce your muscle strength.

If you are taking oestrogen you might also be taking a hormone blocker, (an anti-androgen) to stop your body producing testosterone. This is to make sure that your oestrogen treatment is as effective as possible.

Real Life Experience

Before you will be able to have gender confirmation surgery you will have to live full time as a woman for at least a year. This is called real life experience and it will help you to be sure you are making the right decision.

During this time you might explore ways to dress, make up, hair styles and other things that might be different for you as a woman. Some trans women find that their real life experience confirms that they want to go ahead with surgery. Others might find that they feel happy to be a woman without hormones and surgery. If you are having your surgery privately, you won’t need to go through Real Life Experience.

Gender confirmation surgery

If you decide, following your real life experience, to go ahead with surgery, the next stage will be to talk to your surgeon. Many trans women do not have surgery – in fact there are more trans women who haven’t had any surgery. Other trans women decide to take hormones but not have any surgery.

Surgery can involve upper and/or lower surgery. Trans women are advised to carry on taking hormone treatments for at least 18 months before having upper surgery. This is because the oestrogen you are taking will increase the breast tissue – but this can be a very slow process. If you choose to have breast implants, they will look more natural if they are implanted onto existing breast tissue rather than onto a flat chest.

Lower surgery will involve some preparations such as have the hair from your penis and testicles removed permanently. The surgery itself will take a few weeks to recover from and you may need help around the house or with shopping during this time.

After you have surgery, you may feel a range of emotions from relief to elation.

Your new genitals will also mean you need to know more about safer sex.

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.

Puberty can be very distressing if you feel you are in the ‘wrong’ body. As your body begins to change and mature, it can compound the feelings you are going through. If you are at the start of puberty, it may be possible to take hormones to suppress it. Being able to stop puberty 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 hormones that suppress puberty, but this age limit has now been lowered to 12. 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.

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 Trans woman there are some things to consider about staying safe.

Help and support

It might be that you’re looking for emotional support. If you have recently started questioning your gender identity, you may be feeling confused and lost and need someone to talk to.

A good starting point is the group Mermaids, which can provide support.

Trans Youth Network also 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.

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 talk to you and, if appropriate, refer you to a gender identity service, such as the one at 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.

Trans women often take oestrogen – in the form of a patch, a gel, an injection or a pill. Not all trans women take oestrogen – some trans women just take hormones and others take them as a precursor to surgery.

If you are taking oestrogen it will feminise you - it might reduce facial and bodily hair growth and increase the fat on your hips and breasts. It may slow down or stop male-pattern baldness and will often cause your penis and testicles to shrink and reduce your muscle strength.

If you are taking oestrogen you might also be taking a hormone blocker (an anti-androgen) to stop your body producing testosterone. This is to make sure that your oestrogen treatment is as effective as possible.

If you want to maintain the effects of oestrogen, you will have to take it for life; but if you go on to have lower surgery, you won’t need to take hormone blockers any more. This is because your body will produce less testosterone once your testicles have been removed. You will also take less oestrogen if you have lower surgery. However, after lower surgery it is important to take the right amount of oestrogen for you.

Knowing your hormone levels will help you maintain healthy bones and reduce the risk of osteoporosis.

Monitoring

It is vital to have your hormones monitored regularly, especially as you get older, 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. You will be taking enough oestrogen to try to protect your bones against osteoporosis.

Your doctor will need to know about any other health conditions you have, to ensure the hormones you are prescribed do not impact on these. There only seems to be a small risk of developing complications from hormone treatment – however, there is a risk of deep vein thrombosis or pulmonary embolism. Although these are rare, it is another reason why you need to be monitored regularly.

Hormones and fertility

If you have a penis and testes but take oestrogen, sperm production will eventually stop and you will become infertile after some time. However, there is still a chance of making someone pregnant, especially if you have only recently started taking hormones. To avoid a pregnancy, use condoms or Femidoms during sex. If you later have your testes removed you will be irreversibly infertile.

If you take hormones but want to have a child which is biologically yours, you can store sperm to use later. Ask your healthcare team for more information.