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If you've been diagnosed with Gender Dysphoria (as I was in August
2001) the obvious question is "what can I do about it?"
Sadly, there's no simple answer. What works for one person may be
disastrous for another. One thing is for certain - the more
information you have available, the more informed a choice you can
When I started out on this long road in 2001 I tried hard to learn
everything I could so I knew
exactly what I was getting into, particularly from a medical
I hope to share some of that here. I'll start with an overview of
the process from a medical perspective, followed by some of the
impliccations (as I understand them) of the two different treatment
regimes available in the UK - NHS or Privately Funded.
Finally, I'll describe the specific details of my own transition
and the treatment process I underwent.
The process of changing role in society (in my case from male to
female, but the reverse also applies) is known as "Transition".
The definition is a bit blurry, but this process effectively starts
when you start preparing for the change (which could be well in
advance of starting treatment), and ends when you publicly change
your name and public gender role. My transition effectively started
in March 2002 when I started facial hair removal (more on that
later), and ended on Christmas Day 2002 when I no longer had to
pretend to be male.
I won't kid you here - it's a very difficult thing to do,
and anyone who attempts it can expect a lot of heartache along the
way. Although I've been lucky in that my build and appearance works
in my favour, I know others without these advantages who've also
transitioned without problems.
Equally, I also know others who've had a very rough time.
The physical treatment process for a trans woman can basically involve any of the following:
- Hormone Replacement Therapy (HRT)
- Facial and (if required) Body Hair Removal
- Voice Training
- Social transition (formerly known as "Real Life Experience", or RLE)
- Genital/Sex Reassignment Surgery (GRS/SRS)
- Facial Feminisation Surgery (FFS) ((an uncommon procedure, but one which can have significant effects on physical appearance and quality of life))
Although the details vary hugely from individual to individual,
there is sufficient commonality that an individual can have a fairly
good idea of her path through transition, and what is likely to be
required for her to succeed. I'm sure I was no exception in that
Hormone Replacement Therapy
MtF transsexual patients are usually prescribed female hormones
from early in the transition process. If necessary, an anti-androgen
may also be prescribed to suppress the effects of male hormones
(which are still in the body prior to surgery).
Female hormones affect the body in numerous subtle ways:
- The growth of body hair reduces drastically (although facial
hair is not significantly affected, unfortunately)
- The skin softens and becomes more ?feminine? in texture
- Breast tissue starts to grow
- Facial appearance becomes more feminine
- Fat distribution changes throughout the rest of the body
adopt a more "feminine" pattern (for example the hips widen,
whilst abdominal fat deposits reduce).
Unfortunately, hormones will not affect bone structure
(although cartilage can shrink a little, so expect your feet in
particular to get a bit smaller!), or the size of the voicebox.
When a patient has been on hormone therapy for several months and
her appearance has changed sufficiently, a full-time change in
gender role becomes possible. At this point, a period of "Real Life
Experience" (which will be described shortly) is usually started.
It is worthy of note that even after surgery, transsexual people
(both men and women) must continue to take hormones since their own
bodies will not produce them in the correct amount or balance to
maintain their health.
As previously mentioned, female hormones do not have any
observable effect upon facial hair growth in MtF transsexuals, and
therefore it must be removed in some manner for transition to be
Although short term hair removal methods (through methods such as
plucking, waxing etc.) may be practical for some in the short term,
a long term solution must inevitably be found. Two of the most
common methods available at present are electrolysis and
laser hair removal.
Both techniques rely on causing damage to the root of hair cells,
thus retarding or stopping hair growth.
Electrolysis achieves this by applying a measured electric
charge via a needle inserted into each follicle in turn. Since each
follicle must be treated individually, treatment can take a very
long period of time (it is not uncommon for facial hair removal by
electrolysis to take several years in total).
A further problem is that for treatment to be effective,
significant hair growth must be present (at least 2 days, depending
on the growth rate) which is obviously a major problem for anyone
presenting as female.
Laser hair removal is a newer technique, in which a
measured pulse of laser energy is applied to a small area, causing
thermal shock to the hair follicles in that area.
In order to transmit the laser energy to the hair follicles
rather than the skin (which would cause burns), the wavelength of
the laser used is selected to match the absorption frequency of
melanin present in the hair follicles. As a result, this technique
is only suitable for individuals with dark hair and fair skin.
Although the long term results are not yet proven, laser
treatment is much faster than electrolysis due to its speed and the
minimal hair growth which must be present for treatment to be
Vocal Training and Speech Therapy
Like facial hair removal, voice training is pretty essential in
order to transition successfully. However, unlike hair removal a
degree of voice training can be undertaken by an individual without
outside assistance, although formal speech therapy may be beneficial
or required, it really depends upon the individual.
In some cases, vocal surgery is undertaken. However, as the
techniques involved are still very new and the results
unpredictable, most patients generally try to avoid vocal surgery
if at all possible.
Real Life Experience
Before being accepted for reassignment surgery (see below), a
transsexual patient must undertake a period of "Real Life
Experience" (also sometimes known as the "Real Life Test", or RLT),
during which they live completely in the desired gender role for a
period of at least a year.
During this period the patient will be, to all intents and
purposes, female. Throughout, her progress is monitored by their
doctor and psychiatrist, and assuming it is completed successfully
and the patient is confirmed to be physically suitable, a letter
will be issued certifying that the patient is a suitable candidate
Among private patients the Real Life Test commonly starts after
several months of Hormone Replacement Therapy. I started on
Christmas Day 2002 - just under 7 months after starting HRT.
Genital or Sex Reassignment Surgery (often referred
to as GRS or SRS) is often the final (and irreversible) part of the
physical treatment process.
By the time a patient has been accepted for surgery, she must
have been living full time "in role" in the community for (according
to the Harry Benjamin Standards of Care) at least a year, and have
demonstrated her suitability as a candidate for such a major step.
In practice the RLE period is usually significantly longer:
patients undergoing NHS treatment have to contend with long waiting
lists due to the high demand and small number of NHS surgeons
qualified to perform GRS, whilst private patients must save up to
pay for the costs of surgery.
In order to further soften the facial appearance, and improve
their ability to be accepted by society, some patients may also
undergo Facial Feminisation Surgery (FFS). FFS surgery
typically involves the reduction of the size of the eyebrow ridges,
chin/jawline and nose. The results can have an enormously beneficial
effect on the self-esteem of the patient and therefore her ability
to fully function in her new role.
GRS/SRS and FFS surgery may be undertaken simultaneously in some
cases. Depending on the techniques used, recovery after FFS is
normally fairly quick, but GRS/SRS surgery can require a long
recovery time (between 6 months and a year to heal full) and a
significant time off work (8-12 weeks is commonplace).
NHS and Private Treatment
There are two roads through transition in the UK - via the NHS or
privately. From the perspective of the patient, the treatment regime
followed in the two cases is significantly different, as will be
seen in the following sections.
If you opt for NHS Treatment, funding varies considerably between
areas. In the past, some would provide funds for psychiatric
counselling, but not for treatment. This is now illegal. All
Clinical Commissioning Groups must provide treatment, although they
may impose unreasonably low quotas or insist patients follow a
specific treatment regime. It's a bit of a mess, quite frankly.
As far as I am aware, one essential treatment - facial hair
removal - is not generally available on the NHS, so this must
be paid for by the patient regardless of whether she transitions
under NHS care or privately (this is especially crazy when you
consider that it has a profound effect on how well the patient).
Furthermore, the NHS Gender Clinics themselves tend to have long
waiting lists, which often results in the transition taking a
greatly extended period of time. Possibly as a result of the volume
of demand, NHS Gender Clinics tend to require patients to undergo a
Real-Life-Experience before receiving hormone therapy, which
obviously makes it much more difficult for the patient to be
accepted by society.
As a result of these problems, many patients (myself included)
attempt to fund their transition privately. Unlike the NHS regime
(which tends to be rigidly structured), private treatment places
more of the responsibility for her progress through transition on
the patient. Hormone therapy is usually started within three months
of the first consultation with a consultant psychiatrist, and the
Real-Life-Test typically starts several months later.
If the patient copes well with the Real-Life-Test, approval for
surgery is likely to follow a year or so after it was started. Since
the costs of surgery must be met by the patient herself, in many
cases patients will not seek surgery as soon as approval is given -
a two year period from the start of RLE seems to be fairly typical.
My Own Transition and Treatment
Since my skin and hair colour is suitable for treatment by Laser
Hair Removal, I initially opted to use this technique in preference
to the much slower method of electrolysis. From March 2002, each
month I visited
Christianos Laser clinic in London, with each treatment taking
up to 50 minutes including preparation, and costing £220.
Unfortunately, my facial hair proved to be pretty resistant - I
had 16 treatments before switching to electrolysis in October 2003
to deal with the remaining hairs. Since hair removal by electrolysis
is much more commonly available than laser treatment, I was able to
have treatment locally (with
Appointments with Vanessa in Farnborough) rather than travel
into London, which of course made things easier.
Be warned though: Ten year later, I still see Vanessa for an hour
or so a month. Facial hair removal is a very long term process!
I've also had chest and abdominal hair removed by laser
treatment, this time by Hairaway (since rebranded as Lasercare) in
Shaftesbury Avenue, London. A full treatment cost me £140, and
needed to be done every 8 weeks or so. After six treatments of my
chest and five on my abdomen, I was largely clear, and I've not had
any issues with regrowth in that area.
Prior to my reassignment surgery I also had two sessions of hair
removal on my bikini and genital area, and several after.
Hormone Replacement Therapy (HRT)
I started hormone therapy under the care of Russell Reid (of the
London Institute) at the end of May 2002. Below are details of the
hormone regimes I've been prescribed.
Original privately prescribed regime (prescribed by
- A now discontinued birth control pill (Ovran)
containing 50µg ethinylestradiol (a synthetic form of oestrogen)
levonorgestrel (a synthetic progesterone), taken twice daily
- An externally applied gel (Oestrogel) containing 0.75mg 17ß
oestradiol, to assist in body hair reduction and breast
development, applied twice daily.
Second privately prescribed regime (prescribed by Russell
Reid after the withdrawl of Ovran):
- A combined birth control pill (Yasmin)
containing 30µg ethinylestradiol (a synthetic form of oestrogen)
and 3mg Drospirenone (a progesterone with anti-androgenic
properties), taken three times daily.
At this point my local GP was refusing to convert prescriptions,
possibly as a result of a misguided policy (reversed after I
challenged it) by the local Primary Care Trust. This was a
particular issue because of the cost of Yasmin - then around £182.50
for a 3 month supply, or around £60.83 a month.
Eventually (with the aid of the Patient Advice Liaison Service or
PALS) the PCT relented and agreed to fund it directly - though my GP
would still not convert the prescription. The arrangement they came
to was quite novel - they arranged for a particular local pharmacy
to convert the prescriptions and invoice them directly for the cost
of doing so.
Third, abortive regime (it seems I couldn't metabolise
Estradiol valerate, and after 3 months on this regime I lost most of
my breast development!):
Progynova (Estradiol valerate) 2mg three times daily
Duphaston (synthetic progesterone) 10mg twice daily.
Current regime (prescribed by my current GP, with my
Zumenon (Estradiol Hemihydrate) 2mg three times daily
Utrogestan (natural progesterone in a peanut oil suspension)
10mg twice daily.
I'm glad to say that throughout my time on HRT I've not noticed
any side effects (other than increased appetite). Aside from the
brief period on Estradiol Valerate the HRT has done its work well -
I have ended up with a food figure and a natural 36B bust.
Real Life Experience (RLE)
When I moved out of the family home at the end of October 2002 I
changed my role "part-time" - which effectively meant presenting as
female at weekends and in the evening if I was going out. Over time,
my confidence improved immensely - I no longer felt self-conscious
or anxious by the time I transitioned
For some time beforehand I'd been buying clothes and learning
makeup skills, which gave me time to make and recover from the
inevitable mistakes along the way, and increase my confidence in my
ability to survive the experience and rebuild my life.
I officially started my Real Life Experience on Christmas Day
2002, and I'm glad to say that I didn't encounter any major
problems. The problems I did have were emotional in nature
rather than to do with others perception of me...I "pass" fairly
well and have not faced any hostility. The fact that my appearance
and mannerisms have now changed to such a extent that the transition
appeared so natural probably helped a great deal in that.
Vocal Training and Speech Therapy
Aside from a handful of Speech Therapy sessions at the local
hospital, I've not undertaken any formal Speech Therapy. Instead, I
researched the techniques involved, ordered a voice training CD and
started practicing (by singing in the car while driving to and from
work!), with reasonable results.
Based upon what I learn, I came to the conclusion that I could
achieve the results I needed to be accepted by society without any
form of vocal surgery (which given how risky that is is probably a
good thing). In practice, I have found that despite limited success
in this area it hasn't been a problem; any fear I had of speaking in
public has long since faded, and I've not had any problems from
My reassignment surgery took place on 14th
November 2003 with Dr. Suporn in Aikchol Hospital, Chonburi,
Thailand, and returned for Facial Feminisation
(FFS) on 21st January 2004.
The results are far, far better than I ever dreamed possible, and
I'm now just getting on with life.