A lot of the specifics of my medical transition are not as relevant to male-assigned-at-birth (MAAB) people. Since I haven’t yet found an equivalent transition blog that covers all the facets in detail, it is hard for me to refer readers who request this information to a specific outside source. But I have done lots of research! From articles to surveys to personal inquiries, here’s what I’ve compiled thus far.
Hormones
If you have no idea how hormone replace therapy works or even what it is, I recommend starting with this very detailed article from Open Minded Health.
The hardest thing about being neutrois/agender/androgyne and taking hormones is that we have to compromise. Your body needs sex hormones – estrogen or testosterone – primarily for bone health but for a myriad other reasons as well. Therefore, you will have to gain secondary sex characteristics of the opposite sex in order to lose or mask the ones of your natal sex. Ideally we achieve a middle ground where we have lost enough and not gained too much, a place where we find comfort in being less physically gendered.
For female-assigned-at-birth (FAAB) people, this is not as much of a problem, because estrogen is produced naturally, but estrogen does not continue to feminize the body once puberty ends. That is, breasts don’t keep growing indefinitely. So, there is really no need to block estrogen. To masculinize this body towards androgyny, one only needs to take testosterone, which affords flexibility in dosage and frequency. One can stop taking testosterone and it will leave the body with most of the permanent masculinized changes (like lower voice, and hair) and the body will not feminize further (again, breasts won’t grow, even with continued endogenous estrogen and no additional testosterone I have written about this in my hysterectomy posts, which deal with hormones or the lack of.)
For MAAB persons, it gets more complicated because testosterone masculinizes indefinitely. This means your voice will continue to deepen, hair will continue to grow, skin will thicken. To stop this masculinization, you get block your endogenous testosterone production by taking an anti-androgen. Consequently, because it is unhealthy for the body to remain without any sex hormones, you will need to take estrogen as well. And estrogen will feminize your body, including breast growth, curviness, softer skin, lower libido, among other effects. This is where the compromise comes in.
As with testosterone HRT, you can take low-dose estrogen, and feminize very gradually, slowly, at your own pace. However there is added complexity in that you are balancing this with an anti-androgen to block testosterone (not to mention some people have reported bad side effects with anti-androgens). Although I know there are a lot of people who use forums online and self-regulate their dosages successfully, I always recommend approaching HRT with the guidance of a doctor, preferably one who is attuned to your physical goals and/or identity.
Genital Surgery
There are some “neutralizing” genital surgery options for MT* people.
An orchiectomy removes the testicles and scrotum sack (see Open Minded Health again for a more info on this surgery). The primary benefit of an orchiectomy would be to remove endogenous testosterone production, so you do not require an anti-androgen anymore and there will be no further masculinization of your body. The side effect, as we saw before, is that you will need to be on HRT for the rest of your life, and this will most likely be estrogen (which can be low-dose). There is also the aesthetic benefit of less bulk, which some people seek as well.
A penectomy removes the penis as well as the scrotal sack. It is sometimes considered a full castration (search for “eunuch” and you’ll find much more on this). This would essentially leave your genital area neutral. But one potential complication is long-term urinary problems. From the self-reports I’ve gathered, this is quite difficult to obtain, primarily because surgeons will insist on building a vagina, and are incredulous or uncomfortable of leaving this area neutral and devoid of genitalia (even if it’s what you want). There are one or two cases I’ve read about who have gotten a neutral or “nullification” option, but I don’t know the details.
This is where my knowledge officially stops in terms of bottom surgeries. I am going to make a big assumption that there are other viable options which a skilled surgeon could be willing to explore. The catch is in finding that open minded skilled surgeon. [Update: Dr. Crane, a well-known surgeon in the trans community, is open to discussing these options.]
How to Access This
As I’ve previously summarized, WPATH Standards of Care no longer encourage therapy as a requirement to access hormones. You just need to find a clinic or a trans-friendly general practitioner (it does not even have to be a specialized endocrinologist) who will prescribe these for you.
Bottom surgery is a much more serious undertaking. Doctors will often require a letter (or two) from a therapist and/or medical doctor, along with ongoing hormone treatment. The prior hormone therapy is necessary considering you will have to be on HRT afterwards.
Financially speaking hormones can be cheaply obtained through insurance if you have a plan that covers them, and doctor and/or therapist visits can be covered as well. Bottom surgeries are usually never covered by insurance, and even if they are it’d be strictly for MTF/FTM GRS procedures, usually requiring a long and arduous process of paperwork. I do not know exact costs, but orchiectomies can be from $5K (in Thailand) to $50K in the United States. Also bear in mind this information is very US-centric, and does not apply to countries with national healthcare systems.
Other
I encourage you to do more research on this, including in MTF as well as Eunuch forums. Do not fret if people say it is impossible or can’t be done, they just haven’t done enough research 🙂
Corrections are more than welcome, as is any additional information. If you are willing to share your experiences about this with someone (I know some of you who are), please leave a comment and/or privately email me so I can have your information handy for future referrals.
genderqueer.me 
does orchiectomy remove the scrotum sack? i thought it only removes the balls but leaves the scrotum untouched unless there’s something wrong with it
I am not totally sure. From the ones I have read about / seen pictures of, the entire scrotum is removed.
As far as I know, orchiectomy typically only removes the testes themselves. The scrotum is retained – that’s why you can go in and do a vaginoplasty later if desired. 🙂
I believe the medical term for removal of the scrotum is scrotectomy but I don’t know if that word actually gets used…
Orchiectomy alone does not remove the scrotal sack. However, it will dwindle and shrink over time with nothing inside. If a vaginoplasty/labioplasty is eventually desired, however, the skin can be stretched back out.
Orchiectomy itself is just the removal of the testes. Scrotal tissue can be removed at the same time or later; often later is better, because orchiectomies tend to result in a lot of swelling. The extra skin helps avoid complications with popped stitches, etc.
Hey,
I find the last part of this sentence a bit misleading (or just under-emphasised that only the really permanent masculinisation effects remain):
“One can stop taking testosterone and it will leave the body with most of the permanent masculinized changes (like lower voice, and hair) and the body will not feminize further”
The body does feminise “back” in some degree if one stops taking testosterone and stays on estrogen. The muscle mass decreases and the fat goes back to the hips&ass&thighs, so it’s probably quite noticeable for people with high body fat percentage.
Yes, thanks for pointing this out.
To clarify a little further, indeed the body will revert to its pre-testosterone state once you stop taking T. What I meant here is that the body will not continue to feminize beyond what it already has before HRT began.
(I explain the distinction between permanent and non-permanent effects in previous articles, so I didn’t want to cover it in-depth again.)
A firsthand account from an anonymous commenter:
My doctor prescribed to me a fairly high dose of anti-antrogen. She did not prescribe any estrogen. I asked her about that since you had written before about how the body NEEDS sex hormones. She didn’t seem to agree with that. She said she would watch my bone health closely starting around age 45 or so (which is earlier than usual), but that was it. I am 38 years old now.
On the other hand, I can attest to the fact that it is possible to feminize very slowly by keeping doses of estrogen low. About 5 years ago, at a time when I did not yet understand my true gender and also did not have the courage to speak to anybody about it, I did take feminizing hormones obtained without prescription on the Internet. I kept the dosage low because I wanted to keep the risks low, considering that I was doing this without medical supervision. The effect was indeed slow, gradual, and not very pronounced, feminization.
There is a paper called “The Development of Standards of Care for Individuals with a Male-to-Eunuch Gender Identity Disorder” that was published in the International Journal of Transgenderism in 2010. This is a fantastic resource for people to point their doctor so if their doctor is ignorant or doubtful about neutral genders and MTN requests. My doctor seemed to appreciate having something semi-official containing guidelines she could follow.
I had great difficulty finding a surgeon who was willing to consider doing both penectomy and orchiectomy without vaginoplasty. In fact, I could find nobody at all in Canada […]
This surgeon required a letter of recommendation from a psychiatrist due to the rarity of this procedure. My understanding is that recommendations are usually sought from doctors and therapists only. It was a lot harder to find a psychiatrist willing to take my case!
So it’s not impossible!
The main problem with anti-androgens is that there aren’t any drugs that are specifically designed for that in mind – instead, all the ones that are prescribed just happen to have that as a secondary side-effect from their primary intent. The most commonly-prescribed one, spironolactone, is intended as a potassium-sparing diuretic, and taking it when your potassium levels are normal can cause them to spike, causing hyperketosis, which causes all sorts of other problems. The fact that it’s a diuretic can also cause major problems; in my case it dehydrated me significantly and I ended up with severe constipation that turned into an impacted bowel that led to all sorts of other “fun.”
I’m finally scheduled for an orchiectomy in the middle of January, so I can provide some more first-hand accounts for you, Micah. 🙂
Interestingly, I’m noticing that finasteride (generic for Propecia) is also starting to be used as an anti-androgen. Again, taking it for the side effects, but it might be an option for people who don’t tolerate spiro well.
This is true, “anti-androgens” aren’t really meant to block testosterone, they just happen to do it.
As an interesting anecdote, I learned that I was given spiro when I was 18 to counteract supposed low blood pressure, even though it is given to treat high blood pressure. This might explain why I felt so miserable that year, and why I feel like I went through a second puberty… my hips widened, my breasts grew more, and I gained lots of weight!
The real problem ended up being my thyroid, for which I had already been diagnosed, but the endocrinologist who prescribed the spiro clearly wasn’t treating me properly. Goes to show you can’t trust doctors…
Thank you for the link to Open Minded Health! I’m so glad that’s being helpful. 🙂
Penectomies are super rare – I’ve really only seen/heard of them for penile cancer. Any idea of anyone who’s doing them?
The major risk I know of with having no circulating sex hormones is the bone health risk. That *may* be preventable with weight-bearing exercise and calcium supplementation. I wish there was a study, that’d be really cool….
I’m rambling. Apologies. 😉 Anyway – lovely post!
Actually the anonymous commenter mentioned their upcoming surgery was similar to the one done for penile cancer. The surgeon does SRS; I imagine anyone who is experienced with SRS, vaginoplasty, etc can perform any variation of these surgeries as well.
Just a quick suggestion – a lot of trans people, especially nonbinary people avoid the terms male bodied and female bodied in favour of assigned male/female or male/emale assigned at birth.
There are a number of reasons but personally I don’t want my body described as being a gender other that mine, assigned is not about the body but what it is seen as.
I understand. The phrasing has been updated in accordance with your suggestion, to be “M/F-assigned-at-birth.”
Most surgeons who do GRS will also do orchiectomies. The trick is some of them will only do it for MTF patients. Some surgeons are more flexible on this than others. The best way to do it is to be persistent and keep contacting surgeons until you find one who will do the procedure. Marci Bowers is one surgeon who will, if you can provide the usual letters from a doctor and therapist.
Penectomy is much tougher. If there’s a legitimate surgeon doing it in the US, I would like to hear about it. So far everyone I’ve talked to who’s had it done either went to an unlicensed “cutter” (not recommended) or did it themselves (REALLY not recommended.)
This whole “protecting people from themselves” attitude has got to stop.
Not sure who did fluffy’s surgery (or what the details are). And see anonymous commenter above, their surgeon does SRS in Florida.
If you email me I can provide more details, and refer you to these people in private.
A reader pointed me to a resource explaining a possible HRT combination of anti-androgen without breast growth (estrogen):
Interesting, while I know this information will be helpful for many, I want to point out that some of us who are dmab and are genderqueer/agender choose to use non-hormonal/non-medical ways of expressing our gender identities. It seems this post was mainly for people who are dysphoric about their body. As you know, some of us, while wishing some things were different, nonetheless work with what we’ve got. For me being non-binary is more about my internal mindset. Using clothing, make up and hairstyles is the way I’m creating an external reflection of my gender identity. For me age and disability figure into this. I have low testosterone levels now anyway thanks to aging and my disabling conditions make medical interventions difficult to impossible. I just accept that I’m a fairy bear, after all there are mama bears and bearded ladies.
There’s also a variation on vaginoplasty that’s primarily the labioplasty for external appearance, with no or very little vaginal canal constructed. I’m personally interested in it as an in-between for full vaginoplasty and a nullo (which I want depends which flux I’m in…), without the chore of dilation, but it’s hard to find any information on who actually does it and I don’t know if there’s even any generally accepted term.
Have you ever found evidence that it is possible to have a vaginoplasty while maintaining the function of the penis (likely with orchiectomy)? The new surgical technique with using the peritoneum instead of the penile tissue to construct the vagina makes me think that nonbinary, bi-genital surgical transition may be possible. https://www.wired.com/story/a-patient-gets-the-new-transgender-surgery-she-helped-invent/
I personally would like to have a conversation about my desire for having bilateral orchiectomy and penectomy nullification surgery and eureathra reroute to permanently prevent myself being limited to the male genitailia and not having to be expected to be labeled as a female or male. I would like to find out what I can do to help discover if I’ve lived my life without my being open about my desire to be free of limitations on informed consent contract for immediate appointment with certified surgeon. I’m happy to hear from anyone who’s willing to help me find a doctor or urologist willing to help me be me. Douglasbayne79 at yahoo dot com my body, my choice, my voice, myself