Transgender-Specific Issues

This section describes choices related to physical appearance:

• Gender expression.
• Hormones.
• Surgery.

Gender expression

Gender expression, as opposed to gender identity, is what is on the outside. It is how people express their gender to others.

All people make daily choices about what clothes to wear; whether and how to use or not use accessories, jewelry, and/or makeup; and how their hair is cut or styled. Most people have a specific look or style that is personally comfortable. This may also include how individuals walk, sit, or carry themselves.

In the United States, women and men often are expected to make appearance-related choices from mutually exclusive sets of options. For example, although women may wear feminine-tailored clothing, use makeup, have a feminine hairstyle, and act "femininely," these gender expressions are very rarely considered acceptable for men. Other examples include separate women's and men's clothing departments, jewelry and watch display cases, and hygiene-related store shelves.

A growing number of non-transgender individuals are breaking traditional gender norms. Male goth youth, for example, wear eyeliner and fingernail polish; business women wear pantsuits without makeup or jewelry; metrosexual men use moisturizing products and get manicures. Although gender expression is less rigid with each passing year, in large part expectations to conform to the stereotypes remain in place.

Transgender people may decide to consistently present as male or female in alignment with societal norms. They may also deliberately choose both male and female gender expressions and thus have mixed, gender non-conforming, or genderfluid presentation. Some are more fluid about their gender expression, which they may change from day to day, hour to hour, or setting to setting either because they feel they have to (e.g., an individual chooses not to transition at work) or because they want to.

Some transgender people express gender in very traditional or overt ways to better "pass" as the gender with which they identify. For example, a male-to-female (MTF) transgender person may always wear skirts and stereotypically feminine blouses, paired with matching earrings and pristine makeup. A female-to-male (FTM) individual may wear a pressed oxford shirt and tie, dress pants and buffed shoes, and neatly trimmed short hair. In these cases, there is an intentional effort to send very clear, gendered messages to others.

Often, as people are in the process of figuring out what feels most comfortable for themselves, they may experiment with styles and looks. They may later relax into more comfortable clothes, or clothes that reflect their own personal sense of style, rather than basing their choices on rigid cultural norms.

Body image can play a role in how people express their gender. Transgender people generally have an even more uncomfortable or negative relationship with their bodies than non-transgender people. Some create a literal armor to hide or alter their bodies or to create a different bodily contour:

• Some FTMs (or other people on the trans-masculine spectrum)—
• Bind their chests.
• Wear baggy or multiple layers of clothing to help flatten the appearance of their chest.
• Wear self-made or store-bought penile prosthetics.
• Use prosthetics to allow them to urinate while standing.
• Slouch or intentionally gain weight to add mass to their midsection, altering their feminine contour.
• Some MTFs (or other people on the trans-feminine spectrum)—
• Use breast or hip forms to create a more feminine contour.
• "Gaff" or "tuck" (i.e., pull back their genitals to create a smoother line).
• Wear wigs.
• Dress in a highly stereotypical feminine way to create an outward appearance of undeniable femaleness.

Safety can also be a major component of how gender is expressed. More detail about safety is found in the Passing section of this e-pub.

Hormones

Some transgender people—but by no means all—use hormones as part of their medical transition. According to the National Center for Transgender Equality's (NCTE) groundbreaking study of 6,450 transgender individuals, 62 percent of respondents have had some hormone therapy and 23 percent hope to have it in the future.¹⁰ Hormones are available in injectable, pill, patch, and gel/cream formats.

Hormones help shift bodies into a more traditionally masculine or feminine form. Using testosterone, for example, can deepen the voice, activate facial and body hair growth, redistribute fat, cause the clitoris to enlarge, and may stimulate male pattern balding. Vaginal tissue typically becomes more fragile and less elastic and may not lubricate easily. The vaginal opening may become smaller and tighter, especially if the person does not use their vagina for consensual sexual penetration. Testosterone use usually, but not always, results in the cessation of menstrual cycles and renders the individual infertile. Using estrogen, progesterone, and anti-androgens can cause breast growth, reduce body hair, redistribute body fat, soften the skin, cause some loss of muscle mass, and increase the risk of blood clots, particularly following surgery and in people who smoke. Although mood swings are a typical side effect of hormones in the first few years of use, people who use them frequently report that hormones make them calmer and happier.¹¹

Because some of the changes from hormone use are permanent, some transgender people stop using hormones once they have achieved specific physical goals. Others stop for health reasons or because they become unable to afford hormones (which may not be covered by health insurance, even for those who have insurance). Others continue lifelong use, which is generally recommended for anyone who no longer generates their own hormones due to a hysterectomy (removal of the ovaries and uterus) or orchiectomy (removal of the testes), or due to age (when hormone levels naturally decline).

People can acquire hormones from a health care provider or clinic—the safest method—but they may also get them on the street, from friends, or online (frequently without any medical supervision or monitoring). Non-physician prescribed hormones are relatively common due to a lack of access to health care, an inability to afford physician visits and routine laboratory tests, a preference not to see a physician, or a preference to avoid or an inability to afford psychotherapy, which a physician may require prior to prescribing hormones.¹²

If people acquire hormones through a health care provider, that provider should monitor the individuals' laboratory results and physical wellness. Many providers adhere to a standard of care to guide their treatment of transgender patients, which requires that a mental health professional also be involved.¹⁵ Most standards of care require that transgender clients participate in therapy for a time, typically 3 months to 1 year, after which the mental health care provider will write a letter stating that the client is ready to start medical treatment. This "gatekeeping" model can create additional challenges. For example, transgender people who visit mental health professionals may omit certain details about their lives out of fear that they will be denied the letter required by the standard of care. Past traumas, current mental health issues, or drug or alcohol use are generally known to have been used as justification for withholding these letters. A growing number of LGBT community health clinics and individual providers, however, are moving from standards of care to informed consent models of care, giving both transgender patients and providers more flexibility, autonomy, and control over the health care process.¹⁶

The risks associated with medically supervised hormone use are in line with the risks of many other medications. Routine monitoring, moderate dosing, a healthy lifestyle (e.g., exercise, healthy diet, adequate rest, low-to-moderate stress), and well-managed medical conditions (e.g., diabetes, high blood pressure, other common or rare conditions) help to minimize the risks associated with hormone use.

Economics, access to medical care, and access to physicians who are willing to prescribe hormones often influence how and whether people obtain hormones as a part of their medical transition.

Surgery

Non-transgender people frequently believe there is one "transgender surgery," which involves the genitals. The reality is that there is no "one" surgery and that multiple options or combinations of surgeries can help people change their bodies to be more closely in line with their gender identity. As with hormone use, health care providers operating under standards of care may require their transgender clients to participate in therapy before surgery. In fact, surgeons specializing in gender-related surgeries often require letters from two mental health professionals rather than just one.

The following data on surgeries were taken from the National Transgender Discrimination Survey conducted in 2011¹⁷:

• The most common FTM surgeries are mastectomy or chest reconstruction (41 percent) and hysterectomy (20 percent). Few have phalloplasty (construction of a penis) (2 percent) or other genital surgery (e.g., metoidioplasty and/or construction of testes) (3 percent) because of their high cost and frequent complications, and dissatisfaction with the results.
• MTF surgeries can involve breast augmentation (18 percent), facial feminization surgery (e.g., creating a less prominent brow or chin, shaving the Adams apple), vaginoplasty (creating a vagina) (20 percent), and/or removal of the testes (21 percent). Because of the danger of attracting anti-transgender violence in public, some transgender women consider breast augmentation and facial feminization surgeries higher priorities than genital surgery.

Genital surgery, as noted above, is far more common for MTFs than FTMs. The difference in function and aesthetics may be among the reasons for this disparity, as well as the difference in cost for vaginoplasty (cheaper) versus phalloplasty (much more expensive).

On rare occasions, some transgender people who have been unable to access surgeries due to cost and/or surgeons' refusals to operate have attempted self-surgery to remove their breasts, penis, or testicles.

Contrary to popular belief, many transgender people do not feel the need to surgically alter their bodies. For that reason, combined with prohibitive costs, lack of access, and worries about functionality and aesthetics, FORGE believes that most transgender people do not have gender-related surgery. This underlying belief is supported by the National Transgender Discrimination Survey's broad sample of transgender individuals and their experiences and desires with/for surgery.¹⁹