So I was asked recently to blog about the transition process for males to females (MTF). So while transition is different for everyone, there are certain timelines many of us follow as set forth by the World Professional Association for Transgender Health (WPATH) Standards of Care. These include: Psychotherapy, Hormonal treatments, Surgeries, etc.  I am going to discuss these major concepts and my thoughts on them, including benefits/hassles of the “real life experience”.

Psychotherapy – There is still a lot of stigma in the world regarding psychotherapy within the general population.  If one goes to see a therapist, it is often concluded there must be something wrong or pathological occurring. When we combine this with the pathological stigmas surrounding gender dysphoria, a good deal of resistance may come up for the prospective client.  However, within the therapeutic process it is important to identify particular mental health areas that may be a challenge or affect the client moving forward; An example of this may include depression or anxiety.  While these health issues are often very treatable, they can and are often exasperated during the transition process for many.  As a therapist, it is not my responsibility to challenge one’s Transgender identity, but to explore it and find ways to relieve distress and help my clients attain a personal authenticity that is safe, comfortable, and conducive to growth and happiness.  If I can assist them in identifying pitfalls that we can treat before any transition occurs, chances of that transition going smoothly are greatly increased.  This treatment phase generally lasts for 12 weekly sessions. However, while it is important to note that not all clients may need or benefit from this timeline, therapists must act in an ethical and professional manner as determined by their professions guidelines. My experience shows the Standards of care to be appropriate guidelines for Therapists to consider.

Hormones – Once a client has attended the required 12 weekly sessions of therapy, they may be eligible for a hormone referral letter to a local Endocrinologist.  Regardless of determination made by a therapist, the endocrinologist will ultimately have the final say regarding hormone distribution.  So clients should be prepared for a series of tests which include blood work and other means of measuring physical aptness to hormone replacement therapy(HRT).  In the MTF client, the goal of hormones is to lower Testosterone levels to that of a ‘normal female’ range, while increasing Estrogen levels. In most cases, Gender Dysphoric individuals should experience some relief to symptoms before any permanent effects occur. This is often used as a diagnostic tool for many endocrinologists. While regimens may vary, the standard time-cycle for HRT is anywhere from 18-24 months from when Testosterone levels reach female norms. This is often described by many as a second puberty.  However, while the average genetic female pubertal cycle lasts 4-5 years, an MtF’s cycle is roughly two years.  Needless to say, a lot of changes happen in a very short amount of time.  It is important to note and discuss with clients that the closer they are to their fist puberty cycle, the more physical effects they will achieve with HRT.  Drastic physical changes tend to taper off after about the age of 35.

Surgical procedures – There are a large variety of surgical procedures available to MtF individuals including: Facial Feminization Surguries (FFS), Breast Augmentation, and GenderAffirmation Surgery (also known as Gender Reassignment Surgery-GRS) to name a few.  I feel it is important to discuss an important concept here.  Roughly 60% of Trans individuals never undergo surgical procedures.  There are many reasons that may affect this number, but many Trans-identified people live perfectly happy lives with only hormonal interventions (or no interventions whatsoever for some). It is also important to never question someones surgical status as a representation of gender.  To do so, would be to dismiss one’s internal gender identity.  Often the first question that is asked of a Trans person upon coming out is, “Have you had surgery?” Regardless of the fact that it is no one’s business, it is a question that could easily undermine the work people go through to discover their authentic self.

Real Life Experience – Before Gender Affirmation Surgery can occur, the Standards of Care suggest a period of at least one year wherein the individual can live in the opposite gender role full time.  For many Trans people, this period of time is unnecessary as simply getting this far in the transition process seems test enough.  However, in a patriarchal society, there are many experiences  of male privilege that may have gone unseen or even unexperienced that can potentially cause distress for some. It is also important to note that depending on the area one lives in, Trans-phobia may still be quite alive and well. This often makes it difficult to attain and maintain employment, romantic relationships, and handle certain legal aspects of life in the United States. While surgery is improving almost daily, once GRS has been completed, it is not so easy to go back to a premature physical status.  Thus it is important for clients to be absolutely sure surgery is right for them. It is also ethically responsible for a physician to make sure there client has explored all aspects before performing an extensive and expensive surgical procedure. Ultimately, I know MtF’s who could simply go through these steps quickly without any Real Life Experience and be perfectly happy and content.  However, as professionals, we need to maintain appropriate ethical standards and practices in order to give our clients optimal treatment…regardless of its controversial nature within the Trans community.

There is so much more to the transition process than I could have explained here.  I hope this has at least given you an outlook into the general phases of a male to female transition.  Should you desire consultation on any of these areas, please contact me at the information below.


Cameron Duvall, MS
MFT registered intern (IMF#65656)
30 N. San Pedro Rd, Suite 160
San Rafael, California 94903
(415) 968-9591