Trans Men Together

Transition Map

To quote someone else, transitioning on the NHS may not cost much money, but it can cost a lot of time, in the sense that if you choose to take this path, your transition may go slower than you wish. On the other hand, the financial costs of private transition are high, especially if you do not have a GP willing to prescribe on the recommendation of a private doctor. The appointments, blood tests and testosterone costs can quickly add up, and if you’re looking at getting top surgery privately, that’s another few grand on top of the grand or so you’ll spend on medications. Having phalloplasty privately can set you back up to 50,000 pounds, so unless you’ve got a lot of money to spare, most people enter the NHS transition path at some point.

Step one of this path is going to your GP and saying “I consider myself to be trans[gendered/sexual] and request a referral to a Gender Identity Clinic”. In an ideal world your GP would know the procedure for your area, but the chances are that they won’t. This means you may have to, by using google, find out which gender identity clinic you wish to go to. Some, the most notable being the Portman and Tavistock, which works with under 18s, will accept a self referral, negating the need to go via the GP, they can be difficult about this but you do have the right to self-refer. In most cases, your GP should refer you directly to a Gender Identity Clinic or to a local mental health team, which will assess your suitability to attend the Gender Identity Clinic (GIC). If they fail to do this, arm yourself with the appropriate guidance from the GIC you wish to be referred to, and take that to your GP.

Step two often involves going through the community mental health team for your area. If you’re lucky enough to be attending a GIC that doesn’t demand this, skip straight to step three, otherwise, best of luck. Community health teams vary dramatically. Some are positive, helpful, and ensure that your referral goes through as quickly as possible, others are less so. Their main role is to assess whether you have a condition such as schizophrenia, or dissociative identity disorder, which would need to be well managed to ensure that transition was a true desire, and a positive step. They are not meant to assess whether you are trans or not, that is the role of the specialist consultants at the gender identity clinic. If they are unaware of this fact, again, inform them of this information, and do not allow them to slow the process, as this will make life more difficult in the long run. The goods and services act, recommendations, recommends that they use your preferred name and pronouns, and you have every right to tell them that you wish them to. If your mental health seems stable or well managed you probably have little to worry about at this stage, if it is less so they may wish to do work with you before referring you to the gender identity clinic for treatment. If this happens, don’t panic, it might slow things down but won’t stop them without very good reason, and is designed to help ensure that the people who transition are the people for whom it is essential and will  benefit them in the long run. If you feel able to go to this appointment wearing clothing appropriate for your affirmed gender, this may help, but is not essential at this stage.

Step three will be the dreaded GIC, possibly after a long waiting list. Their guidance suggests that they should not prescribe hormones without either three months of intensive counselling or three months of “real life test” – where you live, including a job, voluntary post, or education, in your affirmed gender. Normally however, they demand the real life test, over the counselling, although that can be a bonus. The real life test can be problematic for people with a disability or mental health issues that preclude any kind of work position (it demands that you hold down a full or part time job (voluntary or paid) or are in full time education), but GICs tend to be very firm and restrictive on this rule, though some can be more flexible than others. Therefore, after the first appointment, they may well advise you to change your name, will ask you to begin the real life test, and to come out to family, friends, and colleagues.  If you have already lived in your affirmed gender for over three months and have documentation of this then they may consider this part of your real life test, but that doesn’t mean that you’ll get hormones on your first appointment, as the gender identity clinics tend to recommend a second appointment/opinion prior to beginning hormones. When they ask you to do this, it can be done for free by deed poll (see link). If you can also persuade your doctor to write a letter that states that your gender identity is stable and your gender role change to male is permanent, at this point you can get the gender marker on your passport, and gendered number on your driving license changed. The second appointment tends to be within three – eight months of the first one, and if you are seen to have a stable gender identity and desire to transition there’s a realistic chance you will get hormones on the second appointment. Before this appointment you will also have to have blood tests to ensure that you are healthy and your hormone levels are correct. This also provides a baseline to show clear changes in the testosterone levels in your system.

Within the first week you will notice no real changes, within the first month you might have slight voice changes and facial changes, and changes will keep occurring quickly for the first year. After that they will slow although changes continue to occur for about 5 years on testosterone. It might take a while for your hips to diminish, but fear not, that is very likely to happen eventually.

Step four is the year visit to the GIC, where they say “so, have you considered top surgery?” They’ll discuss your needs, wishes and options, and talk you through the procedure. They will give you a list of surgeons that your PCT funds, typically, and you can choose which of these you feel does the best work for what you need. There are two main types of top surgery, peri-aerolar and double incision. Peri tends to be more appropriate for men with a smaller chest size – typically no larger than a small B,  although the smaller your chest is, the better it works to achieve a flat result. The main advantages of peri are that you’re more likely to retain sensation (touch, and erotic) and that you’re less likely to have visible scars, but a revision may well be required due to puckering around the nipple where the skin was drawn in, especially if you’re larger. Double incision has the disadvantage of leaving scars – two horizontal scars at the base of the pectoral muscle, and a longer recovery time, but can achieve flatness on any size chest, although sensation is often lost, and may return years later or never. The main reasons for a revision being necessary in the case of double incision are either dog ears, where there is excess skin to the side of the chest, often on larger guys, or unevenness on the two sides. For either form of top surgery (or others) it is highly recommended that one ceases smoking as far beforehand as possible to aid in recovery.

Step five, the next stage, tends to be a hysterectomy. If you are considering metoidoplasty or phalloplasty later on, it tends to be a good idea to have an intravaginal hysterectomy. This means that you will never again have a period, even if you stop taking testosterone, but also means you will never be able to carry a child. It can be a difficult decision, but is recommeded after five years on testosterone due to the rising risk of cervical cancer. This is a relatively common and straightforward procedure when performed on women, and is just as straightforward although a little less common when performed on men! It may be necessary to be firm with medical staff to ensure that you have male pronouns used, and your trans[gendered/sexual] status is not revealed to other patients on the ward. This may necessitate a side room.

Step six will probably be application for a gender recognition certificate, which grants you all the rights and responsibilities of your affirmed gender, and with which you can get a new birth certificate issued, with your chosen name and a “M”! More information can be found on the gender recognition certificate website.

Step seven may or may not be phalloplasty, metoidoplasty, or some variant thereof. Here, I’ll focus on phalloplasty and metoidoplasty, the former being rather easier to get in the UK on the NHS due to them believing that a lot of trans men who opt for metoidoplasty later wish for phalloplasty, feeling that the size and appearance of the phallus are in fact not what they feel they wish for. There are two main types of phalloplasty that the Andrology Clinic do (have a look at their “Patients Guide to Phalloplasty” if you’re interested in it, it has a lot more information than I shall disseminate here. There are two main types of phalloplasty that they offer – pubic flap phalloplasty and radial arm graft phalloplasty. With the pubic flap option there is less visible scarring, as the scars are hidden under pubic hair, but electrolysis is needed to remove the hair that will be on the neophallus. The downsides of this are that the clitoral hookup (which is successful 50% of the time, in linking one of the clitoral nerves to the neophallus for erotic sensation, but removes half the sensation of the neophallus) is impossible, and if standing to urinate is important, often the hole for urination can only be half way down the phallus due to using hairless labia to create the urinary tube.

Radial arm graft phalloplasty takes a split skin thickness graft from the forearm to create the phallus, and then a graft from the backside to cover the arm wound. Sensation is more likely with this method, and standing to urinate is easier, however there will be a arm scar and there are a lot of risks with both methods. The clitoris can be buried either under the phallus between the phallus and the scrotal sac, or above the phallus.