Female to Male Transitioning
With societal attention commonly strongly focussed on trans women, or people undergoing male-to-female (MtF) transitions, trans men (undergoing female-to-male or FtM transitions) are often overlooked. While this is beneficial in that we are subject to far fewer media attacks (true for adult trans men at least; young trans guys are often painted as being vulnerable, misled girls), a side effect is that people have even less awareness of what FtM transitions actually look like.
As with in MtF transitions, there are a variety of different paths that FtM transitions can take. These include superficial, temporary measures that are often broadly referred to as social transitioning, going on hormones (HRT), and a range of possible surgeries. Trans men and trans masculine people may choose to do any selection of these things, or none; they are transgender regardless of the steps that they might feel are appropriate for them to take.
Social transition and other superficial measures
Social transition is generally held to mean altering the way that you interact with the world in order to better fit your gender. This often involves a range of relatively generic measures such as changing your name (easy and free to do via Deed Poll in the UK), the way you dress, and asking people to use different pronouns when referring to you. Trans men and trans masculine people may also work on pitching their voices lower, as voice is often something which gives people away, or spend time in the gym to build a more masculine physique. Building obliques and lats can box out your waist, while building shoulders and traps gives you a broader upper back, and this can make a huge difference to how people ‘read’ your gender at a glance. There are also a couple of specific tools in the FtM armoury that can help to relieve gender dysphoria or to nudge other people into recognising your gender.
Chest binders are a form of compression garment that is designed to flatten and shape the breasts enough to produce a more masculine chest appearance. There are a few reliable brands of these that are available as either full- or half-tank tops, so there are lots of options for people to try in order to find something that gives them the desired appearance. While much safer than older methods of using k-tape or ace bandages to try to manually bind down the breasts, these are not without risk. Ignoring recommendations about how long or how often to bind can cause damage to the skin, ribs and back, especially if you are wearing a binder that is too small – often a temptation as they tend to stretch over time and give a less effective bind. There are also risks of overheating or breathing issues, so it is very strongly recommended not to exercise in a binder – a warning which is often either ignored, or contributes to the low level of trans people who participate in any kind of exercise or sport.
Another tool in the trans masculine play book for people who have not had bottom surgery is the packer. This is effectively a form of prosthetic penis, with a wide range of choices available depending on how you want it to attach or what functionality you want from it. Cheaper models generally just sit in your boxers to produce an appropriate bulge, and which give rise to a range of comical anecdotes about people’s dicks falling out and rolling under dividers when in public toilets. More expensive models can also be used as ‘stand-to-pee’ devices, allowing a careful individual to use a urinal, or for sex.
HRT
When you get down to DNA, there is very little in the way of sex differentiation in humans. The human genome consists of 23 pairs of chromosomes; only one pair are of these are ‘sex chromosomes’, and half of that pair, the X-chromosome, is present in both men and women. The Y chromosome is a relatively tiny thing, accounting for about 1% of the total DNA in a male cell, and is known for being particularly gene poor; it contains only about 72 protein-coding genes of a total of about 20,000 in humans. Only one of these genes has been directly linked to sexual differentiation, because it acts as a switch to trigger testicular development in the foetus. The genome in any given human contains the full set of instructions to build a masculine or a feminine body; everything from there is down to whether the body is operating primarily on oestrogen or primarily on testosterone. If you change the hormones feeding the system, the system will switch trajectory. And that is where HRT comes in.
For FTM transitions, HRT primarily consists of testosterone. In the UK, there are three main ways of taking testosterone; it is available as a gel that is applied daily, and as two different injectable formulations that are taken every few months. People react differently to these different forms, and going on testosterone tends to require regular blood tests to monitor what is happening with your hormone levels and potentially switching different testosterone types if they are not reacting as expected or stabilising within target ranges. Testosterone is incredibly powerful and is often all the HRT that FTM people will need to transistion. In cases where T levels can’t be stabilised within a target range, some people might also get put on estrogen hormone blockers – particularly if menstruation doesn’t cease automatically. However, it is not a standard part of hormone therapy in the same way that testosterone blockers are in MTF transitions.
So, what happens when a trans guy (or other trans masculine person) is put on testosterone? In short, they go through male puberty – though with the caveat that if they are already adults when they start HRT and the growth plates in their skeleton are already fused, they’re not going to grow any further (resulting in a lot of trans guys being relatively short compared to cis guys, which is often a sore point). The exact results of going on T are a bit of a lottery, depending on one’s own personal genetic makeup and how receptive each part of your body is to testosterone. Looking at cisgender male relatives is a good way to get an idea of what to expect.
Common physical effects include:
-Growth of facial and other body hair. Stubble or facial hair is often a big deal for trans guys, as it makes a dramatic difference to ‘passing’; as with cis male puberty, however, it can take many years of testosterone to be able to grow more than some fuzzy or wispy patches. It’s common to use an over-the-counter treatment, minoxidil, to try to speed up this process.
-Loss of head hair – both in terms of the hairline receding and becoming more masculine, and for some people in the form of male-pattern hair loss. This is not often a welcomed effect.
-Voice dropping
-Change in body odour
-Changes in where body fat gets deposited. Body fat already laid down doesn’t move, but new fat will start to get laid down on the stomach rather than on the hips and behind. Exercising to burn existing fat can combine with this to quickly give a much more masculine physique, especially considering that your metabolic rate increases on testosterone anyway (often leading to guys on T getting very hungry).
-Increased muscle growth and improved cardiovascular performance. Trans men can be internationally competitive against cis men in sporting performance, the best-known example being American duathlete/triathlete Chris Mosier.
-Cessation of menstruation, though this tends to depend on how well controlled hormone levels are, and an important caveat is that being on testosterone is not to be relied upon as a form of contraception.
-‘Lower growth’: testosterone causes the clitoris to lengthen.
There are also a range of less obvious effects. There are emotional changes, generally a ‘flattening’ or ‘levelling out’ – a lot of trans men report that they stop crying, for example. For a lot of trans guys, this is a relief. Generally, testosterone gives you more energy, though paradoxically when testosterone levels are not well controlled it can make you more irritable and more tired – people on testosterone injections in particular report their mood turning very sour close to their injection date if their jabs are too far apart. Testosterone also causes your body to run hotter, and so between all this a lot of trans men will lose some weight, particularly some fat, when they go on HRT. This can also be outweighed by the ‘second puberty’ effect making people hungrier, of course. And again in line with cis male puberty, testosterone often dramatically increases libido.
Top Surgery
One big thing that testosterone does not do: it does not get rid of breasts, though it may change their appearance as a result of changes in where fat deposits and in skin elasticity. As such, ‘top surgery’ – a bilateral mastectomy with chest reconstruction – is the most common trans surgery performed. This is a specialised procedure carried out by a very limited number of surgeons, who are often either also involved in breast cancer mastectomies or who are plastic surgeons. There are a number of different surgical approaches that can be taken depending on breast and chest shape and size, and desired outcome or priorities. Unlike a mastectomy for breast cancer, top surgery doesn’t have a goal of removing all breast tissue, crucially not impacting lymph nodes, often leaving the nipple in place (or regrafting it after resizing and repositioning it), and potentially leaving some other breast tissue to result in a masculine-looking chest.
In the UK, the two most common techniques are known as ‘peri-alveolar’ or ‘double incision’. Peri-alveolar can only be performed on very small chests, and involves incisions being made around the alveolae and liposuction to remove tissue. This method produces relatively minimal scarring and leaves the nipple stalk intact, meaning that nipple sensation is often maintained. However, while the alveolae can be trimmed down, the nipple can’t be repositioned, so sometimes the results can look a little odd on people with chests that are borderline for the procedure. Due to the size restrictions with peri-alveolar surgery, most people require double-incision, which is a technique that leaves the distinctive straight or slightly curved scars along the bottom of the pectoral muscles. This method removes the nipples to resize the areolae and ‘core them out’, making them less protruding, before re-grafting them into an appropriate position. This gives the surgeon a lot more control over the final results, but post-surgical sensation in the nipples is a lot more hit and miss - and there is a chance of losing the graft, so some people will choose not to have the nipples grafted back on and may instead get them tattooed on later.
Bottom surgeries
The two other main surgeries available for FTMs are hysterectomy and FTM Gender Confirmation surgery, also called ‘bottom surgery’. Hysterectomy in trans men is no different to anyone else who requires a hysterectomy for any reason, though it is still a serious operation with an extended recovery time. The ovaries can either be left in place or removed; if they are removed, the individual’s testosterone dose can often be reduced and their levels often become more stable and easier to control, but they will also need to remain on some form of HRT for the rest of their lives subsequently due to concerns about bone density and osteoporosis risks if you are not getting either major sex hormone. Hysterectomy is generally recommended after someone has been on testosterone for five or more years, as you can start to get painful side effects from an extended period on testosterone with a womb, and there is an increased cancer risk. Some people may choose to delay this surgery if they think that they might want to bear children at a later date, however; it is possible for FtM transitioners to come off HRT, conceive and have a normal pregnancy and birth even after a prolonged period on testosterone.
‘Bottom surgery’ itself is even more specialised than top surgery – in the UK, there is only one team that does it. The biggest decision here is between two different approaches, known as ‘meta’ and ‘phallo’.
Meta is the more minor surgery, often doable in a single operation; it involves freeing the testosterone-enlarged clitoris from the surrounding tissue, and optionally using a graft to extend the urethra up through it. This effectively produces a small penis that can become erect by itself and can be used for urination, but often is not useful for penetrative sex due to its size.
Phalloplasty is a more major procedure, often requiring multiple separate operations. This technique uses skin grafts, normally from the arm, abdomen, or thigh, to construct a fully-functional penis with tactile sensation. These phalluses typically require a penile implant to be able to become erect and be used in penetrative sex, which are exactly the same as those that can be used in cisgender men who have erectile difficulties for any number of reasons. Rarely these might take the form of malleable rods, allowing the penis to be bent up when an erection is desired. More commonly, inflatable implants are used, which feature a concealed pump in the scrotum that can be gently squeezed several times to move saline solution into cylinders within the penis to cause it to become erect.
In the UK, only a minority of FtM individuals seen by gender clinics seek a referral for bottom surgery. People are often put off by outdated popular wisdom on the topic, which says that results from phalloplasty are often unsatisfactory or that the resulting penis is non-functional or lacks sensation. However, where follow-up questionnaires have been done for men who have had these surgeries in the last few years, the satisfaction rates with the look, feel and functionality of the phallus have been generally high. If someone initially opts for meta, this can later be converted to phallo. There are other optional procedures that can take place alongside meta or phallo, such as a vaginectomy, or possibly the creation of a scrotum containing testicular implants.
The personal touch
So that’s all the theory, but what does this look like in practice? While I’m not a trans man, I do consider myself to be trans masculine, as that’s my rough direction of travel to find a presentation that is sufficiently androgynous to make me comfortable.
In terms of social transition or superficial measures: I’ve dressed and styled myself in a more typically masculine way since I was very young; the main thing that has changed here is that I stopped trying to make concessions to femininity to make other people comfortable (so, for example, I switched to wearing the far-superior men’s jeans). I’ve always had particularly noticeable dysphoria about my chest, and so I started wearing a binder a few years ago. While I haven’t changed my name, I have started to ask people to use they/them pronouns for me (though I’m fairly easy-going on this). I do a lot of exercise, especially weights and calisthenics, to try and build up my chest, back and shoulders to offset my hips. I’m also trying to control my voice better to pitch it a bit lower, but this requires a lot of focus!
On the medical side, I am not currently on HRT. While there are some effects that would definitely be positive for me, such as my voice dropping or body fat redistribution, there are others that I think that I would struggle with – all the men in my family noticeably went bald in their 20s, and I really like my hair! I’m keeping my options open on this, however, and am certainly entertaining the idea of requesting to go on a low dose of testosterone gel that is not intended to get your testosterone levels into the cisgender male range. Low-dose testosterone is an intervention that quite a few non-binary transmasculine people choose to pursue.
The biggest intervention that I have done: in January 2019, I had top surgery (using the double incision with free nipple graft method). And for me, this has been amazing. There has been no sense of dislocation, and in many ways no sense of anything having changed – whereas previously there was always something just nagging away that was wrong in the corner of my vision, and I was often caught off guard by seeing myself in the mirror, now everything just looks ‘right’ to me. I’ve struggled with anxiety for years, particularly in crowds and social situations; this is now massively reduced, and people have commented on how much more confident I seem. I just feel much more at ease in my body, and feel like I can appreciate it more because it’s no longer being masked by this pair of strange growths that I’ve never been able to internalise into my mental self-image as being a part of me. So now I just need to be good and look after those scars properly!
Alix Weasel 2019
As with in MtF transitions, there are a variety of different paths that FtM transitions can take. These include superficial, temporary measures that are often broadly referred to as social transitioning, going on hormones (HRT), and a range of possible surgeries. Trans men and trans masculine people may choose to do any selection of these things, or none; they are transgender regardless of the steps that they might feel are appropriate for them to take.
Social transition and other superficial measures
Social transition is generally held to mean altering the way that you interact with the world in order to better fit your gender. This often involves a range of relatively generic measures such as changing your name (easy and free to do via Deed Poll in the UK), the way you dress, and asking people to use different pronouns when referring to you. Trans men and trans masculine people may also work on pitching their voices lower, as voice is often something which gives people away, or spend time in the gym to build a more masculine physique. Building obliques and lats can box out your waist, while building shoulders and traps gives you a broader upper back, and this can make a huge difference to how people ‘read’ your gender at a glance. There are also a couple of specific tools in the FtM armoury that can help to relieve gender dysphoria or to nudge other people into recognising your gender.
Chest binders are a form of compression garment that is designed to flatten and shape the breasts enough to produce a more masculine chest appearance. There are a few reliable brands of these that are available as either full- or half-tank tops, so there are lots of options for people to try in order to find something that gives them the desired appearance. While much safer than older methods of using k-tape or ace bandages to try to manually bind down the breasts, these are not without risk. Ignoring recommendations about how long or how often to bind can cause damage to the skin, ribs and back, especially if you are wearing a binder that is too small – often a temptation as they tend to stretch over time and give a less effective bind. There are also risks of overheating or breathing issues, so it is very strongly recommended not to exercise in a binder – a warning which is often either ignored, or contributes to the low level of trans people who participate in any kind of exercise or sport.
Another tool in the trans masculine play book for people who have not had bottom surgery is the packer. This is effectively a form of prosthetic penis, with a wide range of choices available depending on how you want it to attach or what functionality you want from it. Cheaper models generally just sit in your boxers to produce an appropriate bulge, and which give rise to a range of comical anecdotes about people’s dicks falling out and rolling under dividers when in public toilets. More expensive models can also be used as ‘stand-to-pee’ devices, allowing a careful individual to use a urinal, or for sex.
HRT
When you get down to DNA, there is very little in the way of sex differentiation in humans. The human genome consists of 23 pairs of chromosomes; only one pair are of these are ‘sex chromosomes’, and half of that pair, the X-chromosome, is present in both men and women. The Y chromosome is a relatively tiny thing, accounting for about 1% of the total DNA in a male cell, and is known for being particularly gene poor; it contains only about 72 protein-coding genes of a total of about 20,000 in humans. Only one of these genes has been directly linked to sexual differentiation, because it acts as a switch to trigger testicular development in the foetus. The genome in any given human contains the full set of instructions to build a masculine or a feminine body; everything from there is down to whether the body is operating primarily on oestrogen or primarily on testosterone. If you change the hormones feeding the system, the system will switch trajectory. And that is where HRT comes in.
For FTM transitions, HRT primarily consists of testosterone. In the UK, there are three main ways of taking testosterone; it is available as a gel that is applied daily, and as two different injectable formulations that are taken every few months. People react differently to these different forms, and going on testosterone tends to require regular blood tests to monitor what is happening with your hormone levels and potentially switching different testosterone types if they are not reacting as expected or stabilising within target ranges. Testosterone is incredibly powerful and is often all the HRT that FTM people will need to transistion. In cases where T levels can’t be stabilised within a target range, some people might also get put on estrogen hormone blockers – particularly if menstruation doesn’t cease automatically. However, it is not a standard part of hormone therapy in the same way that testosterone blockers are in MTF transitions.
So, what happens when a trans guy (or other trans masculine person) is put on testosterone? In short, they go through male puberty – though with the caveat that if they are already adults when they start HRT and the growth plates in their skeleton are already fused, they’re not going to grow any further (resulting in a lot of trans guys being relatively short compared to cis guys, which is often a sore point). The exact results of going on T are a bit of a lottery, depending on one’s own personal genetic makeup and how receptive each part of your body is to testosterone. Looking at cisgender male relatives is a good way to get an idea of what to expect.
Common physical effects include:
-Growth of facial and other body hair. Stubble or facial hair is often a big deal for trans guys, as it makes a dramatic difference to ‘passing’; as with cis male puberty, however, it can take many years of testosterone to be able to grow more than some fuzzy or wispy patches. It’s common to use an over-the-counter treatment, minoxidil, to try to speed up this process.
-Loss of head hair – both in terms of the hairline receding and becoming more masculine, and for some people in the form of male-pattern hair loss. This is not often a welcomed effect.
-Voice dropping
-Change in body odour
-Changes in where body fat gets deposited. Body fat already laid down doesn’t move, but new fat will start to get laid down on the stomach rather than on the hips and behind. Exercising to burn existing fat can combine with this to quickly give a much more masculine physique, especially considering that your metabolic rate increases on testosterone anyway (often leading to guys on T getting very hungry).
-Increased muscle growth and improved cardiovascular performance. Trans men can be internationally competitive against cis men in sporting performance, the best-known example being American duathlete/triathlete Chris Mosier.
-Cessation of menstruation, though this tends to depend on how well controlled hormone levels are, and an important caveat is that being on testosterone is not to be relied upon as a form of contraception.
-‘Lower growth’: testosterone causes the clitoris to lengthen.
There are also a range of less obvious effects. There are emotional changes, generally a ‘flattening’ or ‘levelling out’ – a lot of trans men report that they stop crying, for example. For a lot of trans guys, this is a relief. Generally, testosterone gives you more energy, though paradoxically when testosterone levels are not well controlled it can make you more irritable and more tired – people on testosterone injections in particular report their mood turning very sour close to their injection date if their jabs are too far apart. Testosterone also causes your body to run hotter, and so between all this a lot of trans men will lose some weight, particularly some fat, when they go on HRT. This can also be outweighed by the ‘second puberty’ effect making people hungrier, of course. And again in line with cis male puberty, testosterone often dramatically increases libido.
Top Surgery
One big thing that testosterone does not do: it does not get rid of breasts, though it may change their appearance as a result of changes in where fat deposits and in skin elasticity. As such, ‘top surgery’ – a bilateral mastectomy with chest reconstruction – is the most common trans surgery performed. This is a specialised procedure carried out by a very limited number of surgeons, who are often either also involved in breast cancer mastectomies or who are plastic surgeons. There are a number of different surgical approaches that can be taken depending on breast and chest shape and size, and desired outcome or priorities. Unlike a mastectomy for breast cancer, top surgery doesn’t have a goal of removing all breast tissue, crucially not impacting lymph nodes, often leaving the nipple in place (or regrafting it after resizing and repositioning it), and potentially leaving some other breast tissue to result in a masculine-looking chest.
In the UK, the two most common techniques are known as ‘peri-alveolar’ or ‘double incision’. Peri-alveolar can only be performed on very small chests, and involves incisions being made around the alveolae and liposuction to remove tissue. This method produces relatively minimal scarring and leaves the nipple stalk intact, meaning that nipple sensation is often maintained. However, while the alveolae can be trimmed down, the nipple can’t be repositioned, so sometimes the results can look a little odd on people with chests that are borderline for the procedure. Due to the size restrictions with peri-alveolar surgery, most people require double-incision, which is a technique that leaves the distinctive straight or slightly curved scars along the bottom of the pectoral muscles. This method removes the nipples to resize the areolae and ‘core them out’, making them less protruding, before re-grafting them into an appropriate position. This gives the surgeon a lot more control over the final results, but post-surgical sensation in the nipples is a lot more hit and miss - and there is a chance of losing the graft, so some people will choose not to have the nipples grafted back on and may instead get them tattooed on later.
Bottom surgeries
The two other main surgeries available for FTMs are hysterectomy and FTM Gender Confirmation surgery, also called ‘bottom surgery’. Hysterectomy in trans men is no different to anyone else who requires a hysterectomy for any reason, though it is still a serious operation with an extended recovery time. The ovaries can either be left in place or removed; if they are removed, the individual’s testosterone dose can often be reduced and their levels often become more stable and easier to control, but they will also need to remain on some form of HRT for the rest of their lives subsequently due to concerns about bone density and osteoporosis risks if you are not getting either major sex hormone. Hysterectomy is generally recommended after someone has been on testosterone for five or more years, as you can start to get painful side effects from an extended period on testosterone with a womb, and there is an increased cancer risk. Some people may choose to delay this surgery if they think that they might want to bear children at a later date, however; it is possible for FtM transitioners to come off HRT, conceive and have a normal pregnancy and birth even after a prolonged period on testosterone.
‘Bottom surgery’ itself is even more specialised than top surgery – in the UK, there is only one team that does it. The biggest decision here is between two different approaches, known as ‘meta’ and ‘phallo’.
Meta is the more minor surgery, often doable in a single operation; it involves freeing the testosterone-enlarged clitoris from the surrounding tissue, and optionally using a graft to extend the urethra up through it. This effectively produces a small penis that can become erect by itself and can be used for urination, but often is not useful for penetrative sex due to its size.
Phalloplasty is a more major procedure, often requiring multiple separate operations. This technique uses skin grafts, normally from the arm, abdomen, or thigh, to construct a fully-functional penis with tactile sensation. These phalluses typically require a penile implant to be able to become erect and be used in penetrative sex, which are exactly the same as those that can be used in cisgender men who have erectile difficulties for any number of reasons. Rarely these might take the form of malleable rods, allowing the penis to be bent up when an erection is desired. More commonly, inflatable implants are used, which feature a concealed pump in the scrotum that can be gently squeezed several times to move saline solution into cylinders within the penis to cause it to become erect.
In the UK, only a minority of FtM individuals seen by gender clinics seek a referral for bottom surgery. People are often put off by outdated popular wisdom on the topic, which says that results from phalloplasty are often unsatisfactory or that the resulting penis is non-functional or lacks sensation. However, where follow-up questionnaires have been done for men who have had these surgeries in the last few years, the satisfaction rates with the look, feel and functionality of the phallus have been generally high. If someone initially opts for meta, this can later be converted to phallo. There are other optional procedures that can take place alongside meta or phallo, such as a vaginectomy, or possibly the creation of a scrotum containing testicular implants.
The personal touch
So that’s all the theory, but what does this look like in practice? While I’m not a trans man, I do consider myself to be trans masculine, as that’s my rough direction of travel to find a presentation that is sufficiently androgynous to make me comfortable.
In terms of social transition or superficial measures: I’ve dressed and styled myself in a more typically masculine way since I was very young; the main thing that has changed here is that I stopped trying to make concessions to femininity to make other people comfortable (so, for example, I switched to wearing the far-superior men’s jeans). I’ve always had particularly noticeable dysphoria about my chest, and so I started wearing a binder a few years ago. While I haven’t changed my name, I have started to ask people to use they/them pronouns for me (though I’m fairly easy-going on this). I do a lot of exercise, especially weights and calisthenics, to try and build up my chest, back and shoulders to offset my hips. I’m also trying to control my voice better to pitch it a bit lower, but this requires a lot of focus!
On the medical side, I am not currently on HRT. While there are some effects that would definitely be positive for me, such as my voice dropping or body fat redistribution, there are others that I think that I would struggle with – all the men in my family noticeably went bald in their 20s, and I really like my hair! I’m keeping my options open on this, however, and am certainly entertaining the idea of requesting to go on a low dose of testosterone gel that is not intended to get your testosterone levels into the cisgender male range. Low-dose testosterone is an intervention that quite a few non-binary transmasculine people choose to pursue.
The biggest intervention that I have done: in January 2019, I had top surgery (using the double incision with free nipple graft method). And for me, this has been amazing. There has been no sense of dislocation, and in many ways no sense of anything having changed – whereas previously there was always something just nagging away that was wrong in the corner of my vision, and I was often caught off guard by seeing myself in the mirror, now everything just looks ‘right’ to me. I’ve struggled with anxiety for years, particularly in crowds and social situations; this is now massively reduced, and people have commented on how much more confident I seem. I just feel much more at ease in my body, and feel like I can appreciate it more because it’s no longer being masked by this pair of strange growths that I’ve never been able to internalise into my mental self-image as being a part of me. So now I just need to be good and look after those scars properly!
Alix Weasel 2019