A Comprehensive Guide to Social, Legal and Medical FTM Transition

Medically reviewed by Jennifer Richman on February 21, 2025.

What is “Female to Male” (FTM) Transition?

FTM transition stands for “male to female” transition. This term generally refers to the various legal, social, or medical steps that people who are assigned female at birth take to transition: to live in a way that is more aligned with their masculine gender identity.

While some people feel “FTM” accurately describes their experience, it is largely considered to be an antiquated term. Meanwhile, “trans masculine” and “trans man” are more widely accepted. This is because many transmasculine people consider that they were never women trying to become men, but rather, have always been transmasculine or men.

The purpose of transition is to allow transmasculine to feel greater gender congruence with their bodies, names, pronouns, etc. Likewise, the steps commonly associated with “FTM transition” are not exclusive to trans men 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 transmasculine person should aspire towards to “complete” their transition. There is no one right way to be a man or masculine. Rather, the purpose of this article is to inform readers of available avenues or options for gender affirmation, such as:

• Exploring Gender Identity: There is nothing wrong with feeling discomfort with your gender presentation, name, or pronouns. In fact, it is a normal part of the human experience for many people; an estimated 2.3 million people in the US identify as transgender. Exploring what identity and gender expression resonates most with you can be an ongoing process. You do not need to be completely sure of your identity to begin to pursue gender affirmation.
• Medical Transition: While hormone replacement therapy (HRT) and/or gender-affirming surgeries are medically necessary for some transmasculine people, they are not an essential part of everyone’s gender-affirmation process.
• Social Transition: Some trans men and transmasculine people choose to adopt a different name, pronouns, and gender expression (e.g., clothes, haircut, etc.) that are more aligned with their gender.
• Legal Transition: In some states, changes can be made to legal documents, such as birth certificates and identification cards, to reflect the correct name and gender marker.

Frequently Asked Questions about FTM Transition

Is it too late for me to transition?

There is no right time to transition and it is never too late to come into your authentic self. Some people know they are transgender as early as 3 years old, whereas others may not be able to put words to their gender identity until later in adulthood. People transition whenever they feel ready, have the means to and have the proper support to make social, legal or medical changes.

How do I know if I am a trans man?

Generally, mental health professionals identify someone as trans when they are insistent and persistent (over the course of several months or years) that their gender is different from what they were assigned at birth.

To reach conclusions about your gender identity, it can be essential to have a space to explore and question free of judgment or pressure. Making the time to reflect on how you feel about your gender––e.g., parts of your body that you associate with a certain gender, what you would like to look like when you are older, what pronouns cause you discomfort, etc.––can help you reach clarity. Not to mention, reading about and listening to the experiences of trans people might help you reach an understanding of what resonates most with you–e.g., identity labels, wanting to pursue a certain surgery or not, etc. Some people benefit from using a gender workbook, whereas others may want to see a gender-competent therapist, counselor or gender doula.

How do I know if transition (e.g., hormones and surgery) is right for me?

Evaluating the effects (both reversible and irreversible) of treatments and surgical procedures, as well as their benefits and risks, is a great place to start. There is no one way to transition: not all transmasculine people need testosterone or surgery to affirm their gender.

For many, gender transition is guided by getting to know what provokes gender dysphoria and gender euphoria in you. Gender dysphoria is a persistent discomfort that comes from the misalignment between someone’s gender identity and the gender that was imposed on them at birth; gender euphoria describes the feelings of joy and contentment from living as a version of yourself that is aligned with your gender. If hormones or surgery will bring you significant euphoria or help you significantly reduce dysphoria, it might be a good option for you.

Will insurance cover FTM transition?

Insurance coverage for FTM transition procedures such as HRT and gender-affirming surgeries will depend highly on your individual insurance plan. In states like California, state law requires insurance providers to cover certain gender-affirming services. Still, insurance carriers vary in the type of services they cover as well as requirements for coverage, such as support letters.

At the Gender Confirmation Center (GCC), our insurance advocacy team has a 90% success rate for securing coverage for interested patients.

Is FTM transition reversible?

Certain effects of testosterone HRT and gender-affirming surgery are either irreversible or would be very difficult to reverse through a revision surgery. For example, while the long-term permanent effects of testosterone HRT on fertility vary from patient to patient, procedures like an oophorectomy can permanently leave a patient infertile.

Many patients ask this question due to concerns regarding post-transition regret. 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. 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%.

Medical FTM Transition

Hormone Replacement Therapy (HRT)

HRT, also known as gender-affirming hormonal therapy (GAHT), is one of the most common forms of medical transition. You do not need to undergo testosterone (aka. androgen) HRT/GAHT to affirm that you are transmasculine or a man. Testosterone is a treatment that can elicit physical, emotional and sexual changes in the body. The information below is primarily cited from UCSF’s Overview of Masculinizing Therapy and Plume’s Guide to GAHT.

The Effects of Testosterone: Is HRT Right for Me?

If you are contemplating testosterone HRT, it can be helpful to review which effects are reversible and irreversible to determine if treatment would be right for you. Please note that the effects of androgen therapy vary from person to person (meaning you might not experience significant changes in all of the following areas). Likewise, the dosage you are on can impact the speed at which the following changes occur:

• Irreversible effects: receding hairline, deepened voice, facial and body hair growth, and bottom growth (i.e., enlargement of the natal erectile tissue, “penis” or “clitoris”)
• Reversible effects: skin oiliness, increased muscle mass, fat redistribution, vaginal dryness, and/or atrophy

Androgen Therapy: Microdosing vs. Full Dosage Treatment

Trans men and transmasculine non-binary patients can choose between taking full dosages or microdosing testosterone. Microdosing leads to slower changes, which can be preferential for medical or personal reasons. For example, some patients do not feel safe enough to exhibit faster changes while others simply do not want the full extent of bodily changes that come from testosterone HRT. Likewise, microdosing can be a more affordable option for those with financial difficulties and/or difficulty accessing HRT.

Generally speaking, changes from full-dosage androgen therapy occur over the following timeline:

• • 1-3 months: At this point, the early effects you may notice are increased skin oiliness and occasionally acne.
  • 3-6 months: Around this time, patients will begin to note your voice drop, increase body and facial hair growth, bottom growth, and the cessation of menstruation. You may also notice changes to your body’s fat distribution as fat may begin to accumulate around your belly and decrease around your cheeks, underarms, hips, and glutes. This is usually accompanied by an increase in muscle mass.
  • 6-12 months: The voice will continue to deepen and settle; the voice is expected to continue deepening through the end of the first or second year of treatment. Bottom growth and experiences of vaginal atrophy or dryness may increase during this time. Depending on your physical activity, you may experience greater growth in muscle mass.
• 3-5 years: Most HRT treatments take 3-5 years on full dosages for a patient to see the maximum extent of their effects on the body–such as body hair growth, fat redistribution, capacity for increased muscle mass, and hair loss (i.e., a receding hairline).

The following table compares the differences between full and microdoses in the most common types of testosterone HRT in the US:

Puberty Blockers

With parental consent and the support of a multidisciplinary care team, children and adolescents that have persistent, documented gender dysphoria can opt for puberty blocker treatment. Once an adolescent shows signs of undergoing puberty, they may be eligible to start puberty blocker medications: most commonly, gonadotropin-releasing hormone (GnRH) analogues. These medications simply “press pause” on puberty by stopping the release of sex hormones. Unlike testosterone HRT, blockers do not have permanent, irreversible effects. Rather, they can help an adolescent relieve their gender dysphoria by pausing menstruation and breast growth until they are ready to continue puberty or start hormonal treatment.

Surgical Gender-Affirmation

While hormone therapy can create noticeable changes, some patients may find it necessary to also undergo gender-affirming surgical modifications. Remember that there is no one, correct way to transition. Surgery is not needed to affirm every transmasculine person, and it is normal to need to take time to save up for or even contemplate whether surgery is right for you.

When performed by qualified surgeons on qualified patients, gender-affirming surgery is shown to have very high satisfaction rates and measurable improvements in a variety of patients’ quality of life factors like reduction of gender dysphoria, improved body image, increased self-esteem and, in some cases, reduced risk of suicide.

If you have questions about surgery or would like to create a unique surgical plan, you can request a free consultation with one of our board-certified gender surgeons here.

Top Surgery

The most common surgical intervention for transmasculine patients is top surgery. Top surgery helps patients remove or reduce their breast tissue to have a flat(ter) chest.

As opposed to a traditional mastectomy for breast cancer, chest reconstruction top surgery techniques remove breast tissue, leaving patients with as flat of a chest as they would like to help affirm their gender. Top surgery patients can consider a nerve innervation technique if they would like their nipples to maintain sensitivity, a nipple graft technique to resize and relocate the nipples or a nipple removal technique.

At the Gender Confirmation Center (GCC), we have no BMI limitations for top surgery. Additionally, at the GCC and with most insurance providers that cover top surgery, there is no requirement that patients first be on testosterone HRT to undergo surgery.

Body Masculinization Surgery (BMS)

Body masculinization Surgery (BMS) utilizes body contouring techniques (i.e., liposuction, silicone pectoral implants, and/or skin tightening and skin excision procedures) to alter the frame of the body. Generally speaking, BMS helps patients target parts of their body that provoke gender dysphoria and have a body frame that feels more in-line with their gender identity (e.g., reducing the width of their hips in comparison to their shoulders).

BMS is not a weight loss procedure, but rather a way to remove stubborn fat deposits and unwanted skin overhang to affirm a patient’s gender. Pectoral implants or liposuction (of the abdomen, flanks, hips, thighs, buttocks, and/or arms) can alter the patient’s hip-to-waist ratio and/or give them a more top-heavy figure.

Patients who are on testosterone HRT may want to wait at least one year on full-dosage treatment to see the extent of fat redistribution. Testosterone may be required for insurance coverage. Additionally, liposuction patients with BMIs over 32 may have limited or minimal results.

Facial Masculinization Surgery (FMS)

Facial Masculinization Surgery (FMS) describes a menu of procedures that patients can choose from to alter the appearance of their facial features. Traditionally, FMS procedures tend to augment the face: creating more angular, prominent facial and/or neck contours, mimicking the effects of a first, testosterone-dominant puberty on cartilage and bone. Facial masculinization can include any of the following:

• Brow bone augmentation
• Eyelid surgery
• Rhinoplasty (nose reshaping)
• Jawline augmentation
• Genioplasty (chin reshaping)
• Tracheal augmentation (Adam’s Apple implant)

Patients often choose which procedure(s) to undergo based on what parts of their face provoke dysphoria or what changes would help them feel more euphoria (e.g., having a jawline similar to that of a male family member). The final results from FMS can take up to 12 months to be visible.

In order to obtain insurance coverage, many providers require that patients be on continuous testosterone HRT for at least 12 months to first see the extent to which hormones change the soft tissue of the face. Likewise, the GCC has no BMI limitations for facial surgery.

Bottom Surgery

Bottom surgeries are procedures that remove and/or reconstruct existing genital tissue. Generally speaking, bottom surgery procedures help patients who would like to experience any of the following:

• The removal of organs (such as the uterus, vaginal canal, or the ovaries) that are a source of gender dysphoria
• Facilitate the ability to urinate while standing
• Facilitate the ability to have penetrative sex (e.g., erections)
• Making the natal erectile tissue more prominent and/or constructing a penis
• Constructing other genital tissue such as a scrotum with silicone testicle implants

For transmasculine patients, the most common options are:

• Hysterectomy, oophorectomy and vaginectomy: Patients can have their vaginal canal, uterus, and/or one or both of their ovaries removed.

• Metoidioplasty: A metoidioplasty involves releasing erectile tissue (clitoris), from restraining structures, allowing it to move into a more forward and elevated position. Patients can opt for a urethral lengthening procedure if they would like to be able to urinate while standing up.
• Phalloplasty: This surgery involves the creation of a penis using a tissue flap from the patient’s groin, outer thigh, or forearm.

Please note that many of these procedures, particularly phalloplasty, require multiple stages of surgery for patients to achieve their final results.

Since some of these procedures result in infertility, we recommend that patients first look into fertility preservation options. Please note that to prevent complications, several bottom surgery procedures have BMI limitations. Other requirements include:

• Patients will need to present 1-2 support letters from a licensed mental health provider, depending on provider and insurance requirements
• Most insurance providers that cover bottom surgery require patients be on testosterone HRT for at least 12 months
• Hair removal is required for some phalloplasty patients
• Phalloplasty is only performed on patients with insurance coverage due to hospital limitations.

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.

Gender Pronouns

For trans people in particular, coming out often involves asking people to refer to you with different pronouns. While “he” and “him” traditionally have been used to refer to men, identifying with “he/him” pronouns is not the same as identifying as a man. Trans men and transmasculine non-binary folks may use masculine and/or neutral pronouns. For more information, click here.

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 you build coping strategies to deal with the challenges that can come with transition. Additionally, finding community resources for other transfeminine and non-binary people who have experienced FTM 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 well-being of transfeminine and non-binary people.

Legal Transition

In order to access government, medical, or other services, legal documentation change can be a necessary step. New federal restrictions to gender marker changes can limit your ability to change your other documents, depending on your state’s requirements. While the GCC does not offer services to help our patients with legal document changes, you can find more information on what your state’s policies are here.

Conclusion: FTM Transition Timeline

Overall, there are a variety of social, legal and medical options for pursuing a gender transition. Coming out to your family or at work, asking trusted loved ones to refer to you with different pronouns, changing your gender marker on your driver’s license, or undergoing top surgery are all examples of forms of transition. We encourage you to keep in mind the following:

• There is no one-size-fits-all checklist or timeline for transition. For example, some trans men and transmasculine folks do not need puberty blockers, hormones or surgery to be affirmed in their gender. Your transition will be guided by your unique needs (e.g., what changes will bring you gender euphoria) and limitations (e.g., medical history, financial constraints, being in an unsupportive environment, etc.).

• It is never too late in life to make an effort to live as a more authentic version of yourself. For some, financial barriers or safety concerns make it necessary to delay certain important steps in their transition. Whereas some begin transitioning in childhood, others may not start until late in their adulthood.
• Maintain realistic expectations. Peer-reviewed research on gender-affirming medical care has shown the most positive patient outcomes for those who have realistic expectations for what medical transition can accomplish for them. For example, liposuction patients with a BMI over 32 are likely to see minimal changes after surgery in the long term. Likewise, facial surgery patients may not be able to see their final results until a year after surgery. During your consultation, it is important that you receive clarity from your board-certified surgeon or hormone provider about what surgery or treatment can and cannot do for you.