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A Comprehensive Guide to MTF Transition

Medically reviewed by Jennifer Richman on September 17, 2024.

What is “male to female” (MTF) transition?

MTF transition stands for “male to female” transition. Traditionally, this term refers to the various legal, social or medical steps that people who are assigned male at birth take to transition to female. While some people feel “MTF” accurately describes their experience, it is largely considered to be antiquated. Terms such as “trans women” and “transfeminine” are more widely accepted. This is because many transfeminine people consider that they were never men, but rather, have always been women. Transition, then, does not turn men into women, but rather, allows trans femmes to feel greater gender congruence with their bodies, names, pronouns, etc. Likewise, the steps commonly associated with “MTF transition” are not exclusive to trans women as many non-binary folks can undergo the same hormonal treatments and surgeries listed in this article.

The guide below is not meant to be a checklist that every transfeminine person must aspire to fulfill in their transition. There is no one right way to be a woman or feminine. Rather, the purpose of this article is to inform readers of available avenues or options for gender affirmation, such as:

1. Exploring Gender Identity: There is nothing wrong with feeling gender dysphoria or aspiring towards having a different gender expression. Exploring which identity resonates most with you can be an ongoing process; you do not need to be completely sure of your identity to pursue gender affirmation.
2. Social Transition: Some transfeminine people chose to adopt a new name, pronouns, and gender expression that are more aligned with their gender.
3. Medical Transition: For some transfeminine people, undergoing hormone replacement therapy (HRT) and/or gender-affirming surgeries is essential to help them feel a greater sense of gender congruence with their physical appearance.
4. Legal Transition: Changing legal documents, such as birth certificates and identification cards, to reflect the correct name and gender marker.

Medical MTF Transition

Hormone Replacement Therapy (HRT)

HRT, also known as gender-affirming hormonal therapy (GAHT), is one of the most common forms of medical transition pursued by trans feminine communities. Note that you do not need to undergo GAHT to be transfeminine or be a woman. It is a tool for eliciting physical, emotional and sexual changes in the body. At the GCC, we only require that patients be on GAHT if they are seeking an orchiectomy, as testicles are a primary source of testosterone production and you will need an external source of hormones if they are removed. 

There are many reasons trans feminine people undergo HRT. Those looking for feminizing results can utilize feminizing hormones such as estrogen or progesterone. These may also be used in conjunction with testosterone blockers, which prevent testosterone from causing changes in the body. Feminizing hormones are complex, and your individual plan will vary depending on your goals.  The information below is primarily cited from Plume’s Guide to GAHT and UCSF’s Overview of Feminizing Therapy, both of which contain more information about feminizing or estrogen + HRT.

Estrogen + Hormone Overview

*The results of progesterone vary from patient to patient. It is best to speak with your provider about your individual plan.

“Microdosing” Estrogen

If you are looking for more subtle changes, microdosing estrogen HRT is an option that involves taking lower doses of medication. Many transfeminine and non-binary patients microdosing estrogen HRT allows them to experience changes slower, which can be preferential for medical or other reasons. For example, some patients do not feel safe enough to exhibit faster changes while others simply do not not want the full extent of bodily changes that come from estrogen HRT. Alternatively, many opt to only use androgen blockers without estradiol. For more on microdosing, click here.

HRT Timeline

The following is a general timeline of changes that patients undergoing full doses of estrogen on HRT can expect:

1. 1-3 months: At this point, the early effects you may notice are decreases in pattern baldness and libido.
2. 3-6 months: Around this time, patients will begin to note breast growth and decreased skin oiliness. You may also notice changes to your body’s fat distribution as fat may begin to accumulate more around your cheeks, your underarms, hips and glutes. This is usually accompanied by decreases in overall muscle mass.
3. 6-12 months: Thinning and slowing of growth of facial and body hair gradually becomes more noticeable.
4. 3-5 years: Most estrogen HRT treatments take 3-5 years on full dosages for a patient to see the maximum extent of their effects on the body. For more information on which effects are reversible and how long they might take to be noticeable, click here.

Potential Risks

Every medication has associated risks, and you should be mindful of certain side effects while on estrogen. These can be mitigated and monitored by scheduling regular appointments with a provider to check your dosing and request basic lab work. While many cite improved mental wellbeing due to HRT, estrogen and/or progesterone may often cause mood changes. For this reason, you may find it helpful to seek support from a licensed mental health professional with experience accompanying trans people. Other effects to watch for are possible liver inflammation, weight gain, elevated fats in blood, elevated blood pressure and migraines.

Surgical Gender-Affirmation

While hormone therapy can create noticeable changes, some patients may find it necessary to also undergo gender-affirming surgical modifications. Gender-affirming surgery is a tool used by many transfeminine and non-binary patients to experience greater gender euphoria and treat gender dysphoria. Gender-affirming surgery provided by qualified surgeons to qualified patients is shown to have very high satisfaction rates and measurable improvements on a variety of patients’ quality of life factors. 

Again, for many trans and non-binary people, surgery is not necessary to affirm their femininity. That said, when patients ask about MTF surgery, the following procedures are often what they are asking about. If you have questions about which procedure would be right for you, you can request a free consultation at GCC with one of our board-certified surgeons. 

Before undergoing gender-affirming surgery, patients should review requirements on the following factors: BMI, hair removal and HRT.

Facial Feminization Surgery (FFS)

While estrogen HRT can alter the soft tissue of the face, it cannot change bone structure or undo some effects of a first, testosterone dominant puberty, like a receding hairline. For this reason, some patients find it necessary to undergo facial feminization surgery (FFS). FFS refers to a menu of procedures that you can choose from to alter the appearance of any or all of the following areas: the hairline, nose, brow bone, brow, cheeks, lips, chin, Adam’s apple and jaw. Generally speaking, patients choose which procedure(s) to undergo based on what parts of their face provoke dysphoria, what changes would maximize their euphoria and/or based on pictures (e.g., family photos) that reflect what appearance would make them feel greater gender congruence. After receiving FFS, your end result may be obscured by post-operative swelling, which can take up to a year to fully resolve.

Breast Augmentation

Some patients wish to change the shape, size or fullness of their breasts in ways that HRT alone may not accomplish. Breast augmentation involves using implants or fat grafting to enlarge or construct breasts. Note that surgical inserts may affect nipple sensitivity. While estrogen HRT often helps patients develop mammary ducts that can produce milk, breast augmentations may impact the ability to breastfeed. If you have questions about these effects or would like to create a plan for your breast augmentation surgery, you can request a free surgical consultation with the GCC.

Body Feminization Surgery

Body feminization (BFS) involves the use of liposuction, fat grafting and/or skin excision to change shape of the body. For example, this often involves adding fullness to the hips or buttocks, such as in a Brazilian Butt Lift or hip dip fat transfer. You can learn more about what these procedures can accomplish here.

Bottom Surgery

For some transfeminine and non-binary people who experience dysphoria with their genitalia, feminizing bottom surgery may be a necessary part of their gender-affirmation journey. The most common surgeries in this category are a vaginoplasty and vulvoplasty, also known as a zero-depth vaginoplasty. A vaginoplasty creates a functional vaginal canal that can be used by a patient for receptive, penetrative sex. To maintain the vagina, lifelong dilation is required. A vulvoplasty, on the other hand, creates a vulva without a vaginal canal. While these procedures do not require a penectomy or removal of the penis, most patients opt to undergo this procedure so that their penile glands are reconstructed as a clitoris. Bottom surgery from an experienced, board-certified surgeon will maintain high levels of erotic sensation, allowing patients to experience orgasms. To prevent complications, most bottom surgery procedures have BMI and hair removal candidacy requirements.

Social and Legal Transition

Social and legal transition refer to the ways that someone may “come out” to the world as their gender identity. This may or may not include legal processes such as changing documentation of your identity. 

Coming Out

One of the most significant parts of your transition can be coming out and telling your loved ones and the world who you are. There is no single timeline to come out of the closet. As your understanding of your identity changes over time, or as your environment changes, you may never come out or come out multiple times in your life. People choose to come out at a safe and comfortable time in their lives, and many benefit from building a robust support system first. To understand more about the coming out process, many find the Coming Out Handbook by the Trevor Project to be informative.

Pronoun Changes

It can be a difficult process to begin asking loved ones and others around you––like coworkers, teachers, classmates, etc.––to refer to you by a different set of pronouns. People may purposely or accidentally misuse your pronouns. Throughout this, it is important to remember that pronouns do not have to “correspond” to your gender identity. While “she” and “her” traditionally have been used to refer to women, identifying with “she/her” pronouns is not the same as identifying as a woman. A trans woman can prefer “they/them” alone or along with “she/her”. Transfemminine and nonbinary people may also prefer pronouns such as “xe/xyr”, “ze/zie” etc. For more on pronouns and gender refer here. Despite what people around you may use, your pronouns are the ones that resonate most with you.

Legal Transition

In order to access government, medical or other services, legal documentation change can be a necessary step. This often includes changing your legal name to reflect a chosen name and changing your gender marker. Documents commonly changed include birth certificates, driver’s licenses, and passports. Changing these documents vary depending on where you live, but you can generally expect to need a court order for name and gender changes. While the GCC does not offer services to help our patients with legal document changes, you can find more information here on our website.

Community, Social and Mental Health support

Building up your community, social and mental health resources can be invaluable in transition. Working with WPATH certified and gender competent therapists can help in forming coping strategies to deal with the challenges that can come with transition. Additionally, finding community resources of other transfeminine and non-binary people who have experienced MTF transition can provide insight into your own journey. While undergoing medical, social or legal transition can be complex, it changes lives and vastly improves the mental wellbeing of transfeminine and non-binary people.

FAQ

• Should I transition?

• Choosing to transition is a deeply personal choice. Some find it helpful to ask whether you feel that you currently embody and live as the gender identity you wish to live as. In answering that question, it is important to consider how much daily, persistent discomfort you experience by not embodying your gender. Many people who detransition do so not out of regret, but rather because they lack the social and economic support to do so safely and/or securely. 

  Reasons for transitioning can include many things, from experiences of dysphoria to longing for a certain gender presentation. While for many, transitioning is an avenue to realizing their gender identity, you do not need to transition in order to be transgender. You may also view more on making this choice here.

• How long does the MTF transition process take?

• The length of your timeline may vary on a number of factors, from goals, to safety and your ability to access legal and medical changes if you choose to make those a part of your journey. Some people may not be in a safe environment to transition or gain access to resources. Forms of transition can vary in time as well. For example, depending on the state you live in, changing the gender marker on your license may take less time than the physical changes one experiences from HRT. To get a sense of what to prioritize, you may want to ask yourself what changes would help relieve the most amount of dysphoria? Likewise, what changes will bring you closer to gender euphoria?

• Is MTF transition reversible?

• Many patients ask this question due to worries around post-transition regret. This is very rare and according to the World Professional Association of Transgender Health (WPATH) Standards of Care 8 (SOC 9), regret rates of gender-affirming care are as small as 1%. Destransition is similarly uncommon. Those who detransition do so for complex and individual reasons and should be met with empathy; most often, these have to do with weak support networks and few financial resources to pursue transition safely. Ultimately, it is normal to feel nervous about making a large change in your life. It is important to remember that for many transitioning brings measurable benefits to quality of life.

• How will hormone therapy affect my ability to have children?

• Given that an orchiectomy or removal of the testicles is a sterilization procedure, it will irreversibly prevent having children. However, the long-term, permanent effects of HRT on fertility are less certain. Many people assigned male at birth seek out fertility preservation, often through sperm banking or cryopreservation. For more information on transfeminine fertility, you can check out this resource.

• Will insurance cover the costs of MTF transition-related care?

• Insurance coverage for MTF transition procedures such as HRT and gender-affirming surgeries will depend highly on your individual insurance plan. Many insurance plans now cover gender-affirming care, but vary in requirements and necessary documentation. At GCC, our insurance advocacy team has a 90% success rate for securing coverage for interested patients. For more information refer to our insurance coverage page.