If you or someone you know identifies as a transgender person, you likely have many questions. In a previous post, we discussed some important definitions, gender dysphoria, and coming out from a healthcare perspective.

In this post, we’ll discuss non-medical and medical body modifications, hormone therapy, and transgender counseling.

One of the first things that many transgender people do is start to change their appearance in ways that are more gender congruent with how they identify.

Many people start first with changing the clothing they wear, whether in public or private, wearing clothing that aligns with their gender identity. There are an increasing number of websites and stores that create clothing for the transgender market, e.g. shoes that are sized larger. Transgender people start to change their hair and makeup in ways that lessen gender dysphoria and allow them to feel more like themselves. 

Our Sioux Falls therapists provide support to all gender-variant individuals seeking professional care and support. The information provided below serves as a resource for you and our community. If you should need further support, please contact our office directly. 

Non-medical Body Modifications

There are a number of non-medical body modifications that can be done to relieve gender dysphoria:

• Packing is putting something in your pants for the look of a penis and testicles, e.g. folded-up socks, a condom with hair gel, or specialty products like packers made of silicone. There are both hard and soft packers; hard packers can be used for intercourse. There are also a number of dual-use packers.

• A stand-to-pee device is a tube with a upturned curve that can be placed against or underneath the urethra. This allows the wearer to use them while standing to urinate. This is important for some transmen who want to use the male bathroom for passing and to relieve gender dysphoria.

• Tucking is placing the penis between the legs towards the anus and pushing the testicles up. Some transwomen use medical tape to keep their genitals in place; it is useful to shave before doing this. There are special undergarments known as gaffs and dance belts, which can also be used to keep male genitals in place. These can be found in theater or dance shops.

• Nonsurgical breast enhancement is wearing a bra and stuffing the cups.

• Binding is a method of compressing the breast tissue to achieve a flatter chest profile for transmen. Sports bras or compression shirts, ACE bandages, and binders can be used. It is important to not bind to the point of cutting off circulation.

• Facial and body hair removal can be done with shaving, electrolysis, or laser hair reduction. Facial hair growth will slow or increase with hormone use, depending on which hormone being used. Most creams and other methods of hair removal designed for cisgender women will not work for transwomen. Most transwomen seek electrolysis, laser hair removal, or both:

  • Electrolysis involves inserting a needle-shaped probe into the hair follicle and using electricity or heat to permanently kill the hair root. This is slow and painful, but permanent.

  • Laser reduction is not permanent; it involves using a focused beam of high energy light whose frequency is tuned to the color of the pigments of the hair. This requires ongoing treatments.

With any procedure, it is important to find a provider who is experienced with transgender patients.

Medical Body Modifications: Hormone Therapy

Hormone therapy, cross-sex hormone therapy, or hormone replacement therapy involves taking medications (hormones) to allow secondary sex characteristics to develop. This will result in a second puberty, which will take several years for the full effects to be achieved.

It is important that transgender people are educated on this process and have realistic expectations for the changes over time.

Hormones that transgender people take are estrogen, testosterone, and progesterone. These are considered sex hormones because they affect our sexual and reproductive capacity and drives. 

Transmasculine Hormone Therapy

The primary aim of transmasculine hormone therapy is to add testosterone (T) for a female-born person to become masculine. Most transmen use injections, either intramuscular (IM) or subcutaneous (SQ). There are also transdermal forms of T, such as patches, gels, and creams. 

There are a number of physical changes that will occur when someone starts taking T. Some of these are reversible, and some are not; this is dependent on how long the person has been taking the hormones. Clitoral growth, facial hair growth, voice changes, and male-pattern baldness are not reversible. Below is a list of other physical changes that occur upon taking T:

• The skin becomes thicker and oilier, and pores become larger to produce more oil, so the person may develop acne.

• Odors of sweat and urine change, or the person may sweat more overall.

• Some people may perceive pain or temperature differently.

• Some breast pain or slight decrease in size may occur.

• Fat diminishes somewhat around hips and thighs, arms and legs get more muscle definition, more rough and fat beneath skin gets thinner, and some may gain fat around the abdomen.

• Eyes and the face can develop a more angular appearance as facial fat decreases and shifts. Younger people may have some subtle bone structural changes.

• Muscle mass and strength will increase, and the person may gain weight, depending on lifestyle factors.

• Thickening of vocal cords results in a deeper voice. This can start within the first few weeks of starting T.

• Hair on chest, back, and arms will increase in thickness, become darker, and grow at a faster rate. Body hair will be similar to other men in the family. These changes can take five years or more. Most trans men see some degree of frontal scalp balding. Beards can develop but depend on the person’s genetics and age of starting T.

There are many emotional changes that occur after starting T. There can be a roller coaster of emotions, a narrower range of emotions, more anger, or more calm. Many times, transmen who start hormone therapy will behave differently in relationships. It is important to talk openly about these changes as they occur. 

There are sexual and reproductive changes that occur after starting T. The clitoris enlarges; this can be called a micro-phallus. Transmen who start hormones at a younger age will have more growth. Increased vaginal lubrication can occur with increased libido, and decreased vaginal lubrication can occur from falling estrogen levels. Menstruation ceases within two to three cycles after starting T. Sexual preferences may broaden.

Fertility decreases, but it is still possible to become pregnant on testosterone. It is important to use birth control. If a transman wishes to become pregnant, they may need reproductive technologies to assist them. It is important to discuss the risks and side effects of taking T with a medical provider prior to starting to take it. 

Transfeminine Hormone Therapy

The primary aim of transfeminine hormone therapy is to reduce testosterone levels into the cisgendered female range using a testosterone blocker, which provides a low dose of estrogen to bring estrogen levels into the cisgendered female range. It is important to understand that many of the effects of hormone therapy for a transwoman can be permanent, including the ability to have children. 

There are several different types of transfeminine hormone therapy regimens:

• Estrogen, progesterone, and testosterone blockers.

• Estrogen delivered as a pill, injection, skin cream, gel spray, or patch.

• Removal of the testicles (which can cause a decreased need for estrogen doses).

• Progesterone (which is believed to have a number of benefits, such as improved mood and libido, enhanced energy, better breast development, and body fat redistribution).

• Blockers or anti-androgens, such as spironolactone (spiro).

There are many physical changes that will occur as a result of taking hormone therapy. Many effects are reversible, but this depends on how long the hormones have been taken. Changes in breast growth and possible sterility are permanent changes. Other changes include:

• The skin becomes drier and thinner, pores are smaller and produce less oil, and the skin is more prone to bruising or cuts.

• Odors of sweat and urine change.

• Within a few weeks, breast buds develop beneath our nipples and may be painful to touch. Most breasts develop to an A or B cup. It is best to be on hormones for 12 to 24 months before having breast augmentation therapy.

• Fat will begin to collect around hips and thighs. Muscles in arms and legs will be less defined and have a smoother appearance. Muscle mass will decrease significantly.

• Eyes and face will begin to develop a more female appearance as the fat under the skin increases and shifts. It can take two to three years to complete this process, so it is important to wait to have facial surgery.

• Hair on body will decrease in thickness and grow at a slower rate. Many transwomen need laser or electrolysis.

There are sexual and reproductive changes as well. There is a decrease in the number of erections. When transwomen do have erections, many may lose the ability to penetrate because erections will not be as firm or last. Erotic sensations and orgasm can still be achieved. Orgasms may feel like a whole body experience and last longer but with a less intense peak. Transwomen may experience ejaculation of a small amount of clear or white fluid or perhaps no fluid. For some, testicles may shrink to less than half their original size, but this will not impact the amount of scrotal skin available for future genital surgery.

Within a few months of hormone therapy, most become permanently and irreversibly sterile. If patients desire to produce biological offspring, it would be important to preserve sperm in a sperm bank. 

Psychotherapy & Counseling for Transgender Health

The WPATH standards of care outline the protocol and guidelines for working with transgender patients in a mental healthcare setting. They focus on the role of mental health professionals in the care of adults seeking help for gender dysphoria and related concerns. There are several tasks of a mental health professional:

• To assess the degree of gender dysphoria via an assessment of gender identity, history, and development of gender dysphoric feelings, impact of stigma attached to gender nonconformity, and availability of support from family and friends. The evaluation may result in no diagnosis or multiple diagnoses.

• To provide information regarding options for gender identity and expression, including possible medical interventions. The important task is to educate clients regarding the diversity of gender identities and expression and the options possible to alleviate gender dysphoria. The professional should make referrals as appropriate and discuss long-term changes and implications for the person’s life.

• To diagnose and treat other disorders. Mental health concerns beyond gender dysphoria are common in this population, whether related or related to what is often a long history of gender dysphoria. Concerns include anxiety, depression, history of abuse or neglect, substance abuse, sexual concerns, personality disorder, and psychotic disorder. Disorders should be diagnosed and treated because they can facilitate the resolution of gender dysphoria.

• To use the criteria provided by WPATH SOC to guide decisions regarding hormone therapy. Clients should be both psychological and practically prepared and, if of childbearing age, should explore reproductive options.

• To educate, advocate, and assist clients with making changes in identity documents. The professional should educate members of the public on behalf of their clients.

Why Do We Treat Gender Dysphoria?

Having an oppressed identity is not healthy for anyone. There are a number of mental health issues known or suspected to affect transgender people more than cisgender people. There is limited research in this area, but in general, people who live in societies that stigmatize them are under more stress.

Many trans people face discrimination. They are at greater risk of experiencing family rejection, peer rejection, bullying, threats of violence, abuse, assault, homelessness, job prejudice, lower socioeconomic status, negative media attention, lack of governmental and legal protections, and religious bigotry.

This causes them to be at higher levels of emotional distress. Trans and gender nonconforming population have a self-injury rate twice as high as the general population. Suicidal thoughts for trans people in various studies have ranged from 48% to 79%. Between 21% and 41% of trans people report a history of suicide attempts. Many transgender people are at increased risk of developing a substance use disorder, a body image or eating disorder, or a personality disorder.

Treating gender dysphoria through the coming-out process utilizing non-medical or medical interventions is ethical and effective care.

Finding Support & Understanding

Our team of Sioux Falls therapists works closely with our LGBTQIA community. We specialize in supporting individuals with a host of specialties including evaluations for hormone therapy and gender confirmation surgeries, transition plans, advocacy, and support.