The visible man

(Note: There are serious risks to any hormone therapy. It should not be undertaken in the absence of a knowledgeable doctor's ongoing supervision.)

If you have male gender identity and yet were born female-bodied, you may determine that testosterone therapy can be helpful in realizing your true physical self. Once on testosterone, my female-to-male friends report the same sense of well-being and harmony that my male-to-female friends experience on estrogen therapy. But the effects of the two hormones could not be more different.

For this column, to supplement my own observations, I have relied on the terrific book Becoming a Visible Man, written by one of the most visible FTM activists, Jamison Green.

As an FTM, within a few months of starting your testosterone therapy, your voice will drop irreversibly. In time you will also find hair growing in places where men normally have hair, both on your body and your face. And you may even find your hairline starting to recede. All of these are welcome developments--well, except for maybe the balding--that provide "gender clues" helpful to the general public in perceiving you as a male. You're off to a good start.

There are some other effects of testosterone therapy that are less visible to the public but just as welcome. Most noticeably, your menstruation will stop. Menstruation served as an annoying monthly reminder of the incongruity between your body and your head, not to mention the incredible hassle with all those tampons or pads. Testosterone will also cause your body's pores to enlarge, and that will make your skin feel appropriately rougher. Your body fat will redistribute to the stomach and away from the hips, so that symbolic beer gut can now be more easily achieved (although that's not for everyone, of course).

Some effects of testosterone are not so welcome. One visible effect can be acne, even in older trans men. If a doctor is overseeing your hormone therapy, and hopefully that is the case, she or he can help control your acne. More significantly your LDL cholesterol level will likely increase, which will be enough to require cholesterol-reducing dietary habits, medication, or medical supervision for some.

An effect that seems to have surprised many of my FTM friends is the increase in sex drive and enjoyment. It's not that they hadn't expected or even desired the change; it's just that it has been way more intense than they even imagined. Personally, as one who has gone the other direction, I'm delighted that sex is no longer my number one priority each day. Of course, I am wired "female," and so it is now very clear how testosterone was tampering with my natural inclinations. It's powerful stuff, believe me.

But testosterone does nothing about your breasts, which probably clash with your desired masculine appearance. Many FTMs bind their breasts to hide them, but this doesn't help when your friends invite you to the beach. Binding is also terribly uncomfortable and can actually cause injury over time. Therefore, some choose "top surgery," a special kind of mastectomy where your breast tissue is removed and your chest and nipples are contoured to create a male appearance. Depending on the procedure performed and your family history, you may still need to have periodic screenings for breast cancer. Unfortunately, many mammography labs, as well as the patients in their waiting rooms, have a way to go before they understand why you would want to be a patient.

For some FTMs it is important to have the nonvisible female reproductive organs removed, both to feel most comfortable in their bodies and out of concern that there has been little research done on the impact of testosterone therapy on those organs. This procedure can be a good idea if you have a family history of disease in that area, and if, as a man, you want to avoid the otherwise recommended visits to a gynecologist.

Of course, testosterone does nothing to give you male sex organs. This is where choices get difficult for FTMs. There are two surgical options, each with issues, and so "bottom surgery" is rarely pursued. Neither procedure is covered by insurance.

The more commonly chosen option is called metoidioplasty. This procedure involves releasing your clitoris, which has become enlarged by testosterone. A scrotum can be formed by joining your labia majora and using silicone testicular implants. The result is a significantly smaller-than-average penis, although it is sexually sensitive and does get erect. Cost can run up to $20,000.

The other option is phalloplasty. In this procedure a flap of skin is taken, usually from your forearm or thigh, and fashioned into a penis that is attached above your clitoris. If implants are not used to create erection, a stent may be required to erect your shaft. The resulting penis is a more average size but is less natural looking and may not be sexually sensitive. The procedure is also riskier and more expensive--up to $40,000, not including the costs of revisions that are usually required.

In either procedure, some doctors will perform a urethral extension through your penis, although the techniques are not yet perfected. The urethral extension will typically allow you to stand at the men's room urinal.

As in the case of MTFs, the laws are unfairly focused on surgery as the defining moment that one switches gender. Many locales have accepted top surgery as sex-reassignment surgery, but some are now requiring more. This is a highly problematic state of affairs when the additional surgeries available for FTMs are expensive, are not covered by insurance, can produce results that are unacceptable, and can be risky. How sad, when testosterone alone can produce the gender clues that society reads as "male."