By Matt McMillenWebMD Health News

Reviewed by Brunilda Nazario, MD

April 22, 2015 — As many as hundreds of thousands of Americans don’t feel they fit the gender they were born with, and some take steps to change that.

People who wish to live their lives as the opposite sex are known as transgender. A report from The Williams Institute at UCLA School of Law estimates that about 700,000 Americans identify this way. But it’s unclear exactly how large the transgender population might be.

We do know, though, that physically changing your sex is a complex process, and not everyone follows the same path. Some people choose hormone therapy alone. Others go further, getting major surgeries to make the transition. Here are the steps involved.

Step 1: Mental Health Evaluation

Many doctors require that you first talk to a psychologist or other mental health professional who specializes in gender issues.

First, the therapist will confirm you have gender dysphoria, which used to be caused “gender identity disorder.” People with this condition feel they should be the opposite sex, which causes them distress.

After that, the therapist will gauge your understanding of what’s involved, including the risks and limitations of gender reassignment surgery, and your ability to give informed consent for hormone treatment and, potentially, surgery.

“They also can evaluate whether their patients have a social network that is going to support them or determine that they have enough internal strength to manage on their own,” says Jamison Green, PhD, president of the World Professional Association for Transgender Health (WPATH).

Green says most people have two to three visits. If all goes well, the therapist then refers you to an endocrinologist or hormone specialist.

Step 2: Hormone Therapy

Hormones control what doctors call secondary sexual characteristics, such as body hair, muscle mass, and breast size.

Women making the transition to men take male hormones, or androgens. These hormones make them appear more masculine. The treatment:

• Deepens the voice
• Enhances muscles and strength
• Boosts the growth of facial and body hair
• Enlarges the clitoris

Female hormones can make men appear more feminine. This treatment:

• Decreases muscle mass and strength
• Redistributes body fat
• Increases breast tissue
• Thins and slows the growth of body and facial hair
• Lowers the level of testosterone

Some of the physical changes begin in as little as a month, though it may take as long as 5 years to see the maximum effect. For example, men transitioning to women can expect A-cup and occasionally larger breasts to fully grow within 2 to 3 years.

But hormone therapy does more than alter your appearance. It can also dramatically and quickly ease feelings of gender dysphoria, Green says.

“Within a few weeks of starting hormone therapy, people begin to feel more relaxed, less intense and uptight,” he says. “What some people say is, ‘I now feel normal, I feel balanced.’ It’s very subjective, of course.”

Hormone therapy comes with risks, though, says surgeon Sherman Leis, DO, of The Philadelphia Center for Transgender Surgery.

“Before they start therapy, we have to make sure they are healthy,” Leis says, “and we have to be sure that they take enough (hormones) to be effective, but not too much to be dangerous.”

Hormone therapy can boost the risks of high blood pressure, weight gain, sleep apnea, elevated liver enzymes, heart disease, infertility, tumors of the pituitary gland in the brain, blood clots, and other serious conditions.

Leis says you must get regular and frequent checkups, especially in the early months of treatment, to be sure you’re adapting well to their hormone regimen.

Also, some people also feel anxiety and uncertainty when starting a hormone regimen. So it’s important to keep getting counseling with a mental health professional and see your endocrinologist or hormone specialist.

Step 3: Surgery

As many as 75% of people who transition to a different gender never pursue surgery, Green and Leis say.

For some, it’s a matter of cost — the full range of surgical procedures can cost tens of thousands of dollars, and insurance coverage may vary. But for many people, hormone therapy is enough to relieve feelings of gender dysphoria.

In cases where hormones alone aren’t enough, surgery is an option. But it’s a major and, depending on the procedure, irreversible choice. Both patients and their surgeons must be certain it’s the right decision.

Guidelines recommend people spend 12 months on hormone therapy before they get genital reassignment surgery (GRS). This operation involves recreating a person’s genitals to that of the opposite sex. Removal of the gonads may be done as well.

“We like our patients to use hormones for at least a year, living full time and presenting as their identified gender,” Leis says.

The guidelines are less strict for other procedures, such as breast implants for men and mastectomies for women. In rare cases in which people change their minds, chest surgeries can be reversed. For men, implants simply need to be removed, Leis says, while new breasts can be constructed for women.

Like all surgeries, gender reassignment procedures carry risks. For men who transition to women, complications may include:

• Tissue death of the skin — typically from the penis and scrotum — used to create the vagina and vulva
• Narrowing of the urethra that can block the flow of urine and lead to kidney damage
• Fistulas, or abnormal connections, between the bladder or bowels and the vagina

For women who transition to men, complications may include:

• Narrowing, blockages, or fistulas in the urinary tract
• Tissue death of the new penis

Men transitioning to women can have vaginas constructed that can be used for sex.

Because of the high risk of complications with surgery to make a new penis, called phalloplasty, many women who transition choose not to have one. Instead, they often opt only to have their ovaries and uterus removed.

Women who transition to men and want to have a penis surgically created should be warned “there are several separate stages of surgery and frequent technical difficulties, which may require additional operations,” according to the WPATH guidelines.

Leis estimates that only one woman undergoes genital reassignment surgery for every 15 men who have the procedure.

“It’s not because there aren’t as many women who want it,” he says. “It’s because they don’t get as good a cosmetic or functional result.”

Life After Transition

Both Leis and Green say that as few as 1 in 100 people regret their genital reassignment surgery. But that doesn’t mean they don’t need ongoing assistance. Along with follow-up medical care, they may need counseling to address common issues like depression and anxiety.

“It’s extremely helpful if you run into social issues to be able to have someone knowledgeable to talk to,” Green says.

SOURCES: Jamison Green, PhD, president, World Professional Association for Transgender Health. Sherman Leis, DO, surgeon, Philadelphia Center for Transgender Surgery. WPATH Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender- Nonconforming People, volume 7.

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