Transition

« I see transition as a type of rebirth, a reincarnation within our lives. It can be painful, and we need to let go of the past which weighs us down. But we can still carry the positive with us, value everything we can, regardless of gender. » — Cora, 37 (Nonbinary)

Transition is a term that is used to describe the process that individuals typically experiencing gender dysphoria go through to reach their desired social role, and/or physicality; there is no single definition of transition as the term is based on the unique requirements of each individual.

Healthcare services

A diagnosis of gender dysphoria that is congruent with the diagnostic criteria of a recognised 'gender identity disorder' is the typical prerequisite for the treatment of persistent gender dysphoria in those countries which offer such services. Healthcare professionals typically reference either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) in order to confirm a diagnosis of gender dysphoria.

Before the 1960s few countries offered safe, legal medical options for people experiencing gender dysphoria and many criminalized gender-nonconforming behaviours or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association now known as the World Professional Association for Transgender Healthcare (WPATH) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfilment". The WPATH 'Standards of Care' are the most widespread clinical guidelines used by professionals working with transsexual, transgender, or gender variant people, and have undergone several revisions since its initial publication. Traditionally these guidelines have been structured in relation to the Transsexualism diagnosis and as such have presented a dilemma for non-transsexual individuals who have been unable to meet the eligibility criteria for medical treatment.

In 'Archives of Sexual Behaviour (Volume 16), "Heterosexual and homosexual gender dysphoria"' (1987), Dr Ray Blanchard (who served on the DSM-IV Subcommittee on Gender Identity Disorders) wrote, "(there is a) well-recognized tendency of applicants for sex reassignment surgery to distort their histories in the direction of 'classic' transsexualism in an effort to gain approval for such surgery".

Gender dysphoria Vs. Gender Identity Disorder

Main article: Gender dysphoria

The diagnosis of 'Transsexualism' was introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) compiled by the American Psychiatric Association (APA) in 1980 for individuals who had experienced a minimum of two years of continuous interest in reconstructing their sex-physicality and assigned gendered identity. The criteria of the diagnosis focused on individuals whose identities resembled a male-to-female (MTF) or female-to-male (FTM) paradigm. Others experiencing gender dysphoria, but whose identities did not fit the MTF/FTM paradigms could be diagnosed with 'Adulthood Nontranssexual Type', or 'Gender Identity Disorder: Not Otherwise Specified' (GIDNOS). In 1994 the DSM-IV committee replaced the transsexual diagnosis; for individuals with MTF/FTM type identities a diagnosis of 'Gender Identity Disorder' (GID) would be applied instead. The diagnostic criteria of GIDNOS was left undefined, bar that the diagnosis be given to those whose 'gender identity disorder' cannot be defined within a MTF or FTM paradigm. Though a gender dysphoric nonbinary individual may use the term 'transsexual' to describe themselves, they are not considered to be transsexual within a clinical context.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in May 2013 which replaced the gender identity disorders with Gender Dysphoria[1]. "The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated... In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria... However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis. More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments. This contradiction may be used to support gender conversion/reparative psychotherapies – practices described as no longer ethical in the current WPATH Standards of Care"[2].

U.K.

Main article: Nonbinary healthcare (UK)

Historically, eligibility criteria for medical treatment has presented a barrier for nonbinary individuals, specifically the 'real life test' (RLT) component which was later renamed the 'real life experience' (RLE). The website of the London NHS gender identity clinic states, "There is a two year Real Life Experience (RLE) of living in the reassigned gender role at the GIC for people who want to have genital reconstruction surgery (GRS). This is dated from the start of full-time gender role transition after which they can be assessed for referral for GRS. The RLE includes at least a year in some form of agreed occupational activities." [3]. Nonbinary individuals requesting genital reconstruction surgery (GRS) are generally unable to satisfy clinicians in relation to the RLE criteria as there is little social or legal recognition of the nonbinary demographic. On the 1st December 2010, the University of Cambridge Centre for Gender Studies hosted the final public forum in its series on gender and radical biomedical advances, “Transitioning gender: the challenges of radical technologies”, in association with the Guardian and supported by Cambridge University Press [4]. One of the speakers was Dr Richard Green, former research director and consultant psychiatrist of the London NHS gender identity clinic, who referenced “third gender or no-gender person(s)” seeking surgery to “remove breasts or male genitalia” and calls this a “medical dilemma for physicians because there’s no real life experience. Its either surgery, or not”.

“...Young people are eligible for treatment in the adult NHS clinics (once they are 18 years old) or by private practitioners (from 16 years old)” .

Changing your name

Main article: Names

« Introducing myself to people is less "Hi, my name is __" and more "Hi, my name is __, and by the way I'm here to break your fundamental understanding of your world and how it works." Every introduction, every interaction, I have to make a choice on whether to correct people, whether to explain things. Sometimes it's just not worth it. » — Anonymous, 26 (Genderqueer)

In most societies, a personal name is a fundamental component of social identity. The naming of infants by humans throughout history has typically followed local cultural traditions which have emphasised familial connections, also commonly inferring that the owner of a given name is either 'male' or 'female'. Many individuals go on to adopt an alternative to their birth-name, or replace it altogether; individuals experiencing gender dysphoria may regard such an act as constituting the whole, or part, of their transition.

Changing ones name within an everyday social context can be as simple as informing others of your choice, however in societies with a complex legal system (or equivalent) there can be conditions that place limitations on the individuals right to self determination which can be especially problematic for nonbinary individuals. For example, in Germany the Standesamt (Office of Vital Statistics) typically refuses to recognise in German civil registration law names that are gender-ambiguous; a given name must indicate that the owner is either 'male' or 'female'.

State of Address

Main article: Gender neutral titles

Many societies formally recognise various states of address (commonly referred to as ones 'title'), which in many instances indicate a 'male' or 'female' identity; such as 'Mr' in the English vocabulary, 'Madame' in French, and so on. Many individuals changing their name as part of their transition also change their state of address, or attempt to remove such references from their personal identity documentation altogether.

Some individuals adopt a gender neutral title such as 'Mx', 'Misc', or 'Pr'. For the most part, gender neutral titles without qualification/career connotations are not recognised by the general public or businesses/organisations. Activists and supporters are working toward awareness and acceptance of alternative titles. For some nonbinary folk, being referred to with a gendered title can trigger gender dysphoria.

Personal pronouns

Main article: Pronouns

Pronouns are a part of language used to refer to someone or something without using proper nouns. Proper nouns are the names for things - for example, "Pat" for a person or "Husky Tower" for a downtown building. The most common use of pronouns in the singular of the English language for people is gendered - for example, he/him/his for men and she/her/her for women. However, there is an increasing demand for singular gender neutral pronouns, such as they/them/their in the singular or the Spivak set, ey/em/eir.

Changing your presentation

See also Nonbinary expression and Gender expression.

Some nonbinary individuals intentionally present an androgynous or gender neutral personal aesthetic by removing, replacing, or blending gender cues in their general presentation. For many, adopting such a personal aesthetic can ease the symptoms of gender dysphoria, while others may be motivated primarily by a desire to make a political statement; each individual typically has their own unique reasons for adopting any particular 'look'. However, it is no more true to state that 'all nonbinary individuals want to appear androgynous' than it is to state that 'all women want to appear feminine'. Though they may not apply binary gender stereotyping to their own presentation, some nonbinary individuals seek a personal aesthetic that is considered by their own culture as being variously congruent with binary stereotypes, the affected nonbinary individual may then experience gender dysphoria triggered by the resulting cognitive dissonance.

Public reactions to individuals whose presentation, for whatever reason(s), appears to challenge binary-gender stereotypes varies widely. Some models, musicians, and other celebrities are known internationally and celebrated specifically for having an androgynous appearance (see notable nonbinary people). Meanwhile, many people receive negative reactions for challenging binary-gender stereotypes. Safety is a concern for many nonbinary individuals attempting to transition to a socially visible nonbinary status.

Changing your legal identity

Main article: Legal gender

The majority of contemporary national legal systems operate according to a standard wherein each citizen must be registered as either 'male' or 'female', however an actual definition of those terms may be lacking in legislation. For example in Britain the terms 'male' and 'female' are not mentioned in registration law, the individual is solely referred to as either 'person' or 'the child' although there are some gendered references such as 'mother', 'father', etc. However, the terms (male or female) are usually required to be visible on personal identity documentation which is necessary to access many essential public services.

India recognises one of its trans demographics (Hijra) in law, giving them a status besides 'male' and 'female' in legal documentation, however as the rest of the legal system is designed to accommodate only 'male' and 'female' citizenship the Hijras' legal recognition can at times prevent affected individuals from enjoying the equality their legal status was originally intended to secure.

Physical changes

Just as with other kinds of transgender people, some nonbinary individuals want to make certain kinds of changes to their bodies. This can be in order to relieve a distressing sense of gender dysphoria, or for practical reasons, or by personal choice. This article tells about some kinds of changes that some nonbinary people can want, and practical things they can do to achieve those changes. Physical gender transition is never "one size fits all." A nonbinary person does not have to make all or any of these changes in order to be nonbinary. There are nonbinary people who go on hormones and get surgery, and there are nonbinary people who only go on hormones without getting surgery. There are nonbinary people who go on hormones temporarily, in order to try to get some changes they want, and avoid some changes they don't want. There are nonbinary people who do not change their bodies at all, because they do not feel a need to do so.

Postpone or temporarily suspend puberty

There is more information about this topic here: puberty blockers

Puberty blockers are drugs that postpone or temporarily suspend puberty in children and teenagers. They are used for transgender children, including those who identify as nonbinary, to stop the development of features that they consider to mark the wrong sex, with the intent to provide transgender youth more time to explore their identity. the studies that have been conducted indicate that these treatments are reasonably safe, and can improve psychological well-being in these individuals. In 2019, a study in the journal Pediatrics found that access to pubertal suppression during adolescence was associated with a lower odds of lifetime suicidality among transgender people.

Change your voice

There is more information about this topic here: voice and speech

Many societies recognise certain ranges of vocal communication as being typically "masculine" or "feminine." As a result, a given person's own vocal range can trigger an uncomfortable or distressing feeling of gender dysphoria in that person. That person may try to alter their vocal range or voice in order to resolve those feelings.

There are several factors which contribute to how a voice is interpreted with regards to gender, and these factors vary between societies. The most commonly recognised of these factors is pitch, which can undergo a dramatic transformation during ones lifetime due to the physical changes associated with puberty or endocrine therapy, for instance. Several studies have identified a gender-ambiguous average pitch at 155-187Hz, a feminine average pitch at 220Hz, and a masculine average pitch at 120Hz .

Hair gain

There is more information about this topic here: hair gain

Some nonbinary people want more facial and body hair. Nonbinary people who are on the female-to-male transition spectrum can take masculinizing hormone therapy to grow more facial and body hair. This gives them the same amount of facial and body hair that they would have had if they had been assigned male at birth. People who aren't taking hormones can simulate facial and body hair by makeup methods, though these tend to be more effective for stage performance, rather than in everyday activities that are seen up close. Makeup methods for this include using makeup, sticking tiny hair clippings to their skin with gum arabic, and using mascara on existing hairs. These makeup methods are popular with drag kings and male impersonation performers.

Some nonbinary people want to avoid, halt, or reverse male-pattern hair loss. People who are on the male-to-female transition spectrum can take feminizing hormone therapy to halt male-pattern hair loss. In the future, people who prefer to take masculinizing hormone therapy may be able to choose a version of it that might have less risk of causing male-pattern hair loss, called Selective Androgen Receptor Modulators (SARMs). SARMs are not yet officially available. Once male-pattern hair loss has happened, it can't be reversed. Surgical treatments for male-pattern hair loss try to move the hairline, or move hair into the place where it is needed. Non-surgical treatments for it include wigs and hairpieces.

Hair removal

There is more information about this topic here: hair removal

Some nonbinary people want to hide or get rid of some or all of their facial and body hair. Temporary methods for this include bleaching, shaving, plucking, threading, waxing, topical treatments, or using an epilator. Laser hair removal and intense pulsed light are more permanent. Electrolysis is the most permanent.

Prevent or undo breast development

There is more information about this topic here: top surgery

Some nonbinary people want or prefer to have a flat, masculine chest. For transgender children and teens, going on a prescription medicine called puberty blockers can postpone or pause puberty, which prevents or reduces the amount of breast growth they would have. The effects of puberty blockers are temporary, so breast growth will resume whenever the person stops taking that medicine. For people who have already had breast growth, going on masculinizing hormone therapy such as testosterone may reduce breast size just a little bit, if at all, but it does not get rid of breasts. There are also nonbinary people who go on feminizing hormone therapy in order to get other body changes that they want, but who do not want breasts. Wearing a well-fitted sports bra or binder can reduce how large the breasts look, and temporarily make a flat, masculine chest shape. The only way to permanently get rid of breasts is through surgery. Surgery to take away the entire breast is called mastectomy. For transgender men and transmasculine people, mastectomy is also called masculine chest reconstruction, to emphasize that they don't see it as a loss, but as fixing a problem.

Mastectomy or masculine chest reconstruction

There is more information about this topic here: mastectomy

Mastectomy for trans people is not as painful or traumatic as mastectomy to remove breast cancer or lumps, because the latter usually has to remove lymph nodes. For trans people, mastectomy is a short, single-stage procedure done under general anesthesia at a cosmetic surgery clinic or hospital. The patient goes home the same day. The recovery process depends on which method for mastectomy the patient had.

Breast reduction

There is more information about this topic here: top surgery

Some transgender and/or nonbinary people have larger breasts than they want. If the temporary methods such as sports bras and binders do not meet their needs, then they may prefer to get surgery to reduce the size of their breasts. The variety of methods for breast reduction are very similar to those for mastectomy described above. Larger breasts or those that need to go down more sizes will be reduced by the T-anchor method. Breasts that only need to be a little smaller can be reduced by the peri-areolar or keyhole method. Breast reduction is also commonly sought by men and women who seek a smaller breast area for a variety of reasons.

Preventing breasts from developing

Some nonbinary people who have not yet developed any breasts already know that they do not want to have any. If they can prevent their breasts from developing in the first place, then they will not have to get surgery to remove them. If someone knows that developing breasts would be a significant source of distress (gender dysphoria), then preventing breast development can be better for their longterm mental health.

• Breast ironing is a non-surgical procedure that attempts to destroy the breast bud, so that breasts cannot develop.
• For children and teens, puberty blockers can postpone or temporarily stop the development of breasts for as long as they are on that therapy.
• For people who are on the female-to-male spectrum, or whose bodies do not naturally produce much testosterone: taking Testosterone or otherwise being on a masculinizing hormone therapy can prevent or temporarily stop the development of breasts, for as long as they are on that therapy.
• For people on the male-to-female spectrum, or people whose bodies do not naturally produce much estrogen, some types of feminizing hormone therapy make it possible for someone to have a feminine appearance without developing breasts.

Growing breasts

Some nonbinary people want to have breasts. For people who are developing breasts without having to take any hormone therapy, breasts can continue to grow during puberty until about the mid-20s. For people who take feminizing hormone therapy, this causes the exact same kind of breast development as happens naturally for women, just not necessarily at the same age. If either of these processes has finished, and the person still wants to have larger breasts than what they have, then they have a variety of options, non-surgical and surgical. They can temporarily make their breasts look larger by wearing a more supportive bra, a push-up bra, or padded bra. They can wear breast prostheses, also called fake breasts. For people who want to permanently make their breasts larger, then they have the option to get breast augmentation surgery.

There are several things one has to take into account when looking for breast augmentation surgery options:

• Type of implant: there are two types of implants: silicone implants and saline (i.e. saltwater) implants. While silicone feels and looks more natural, it also requires bigger incisions, which means bigger scars.
• Shape: the shape of the implant can be round or like a teardrop. Round implants are the most popular choice, because they are symmetrical and rotation is not a problem. However, teardrop implants can give a more natural look.
• Incision location: there are three ways to insert an implant: through a periareolar incision around your areola, an inframammary incision just below your chest muscle or a transaxillary incision through your armpit. With silicone implants, an inframammary incision is normally the best choice, as they are inserted fully inflated. With a saltwater implant there are more possible choices.

Preventing periods

There is more information about this topic here: menstruation

Periods are often a source of distressing gender dysphoria for nonbinary people who were assigned female at birth. There are several ways of preventing periods:

• Transmasculine hormone therapy, such as Testosterone: Testosterone will prevent periods (although the changes won't be immediate).
• Progestogens: these will also prevent (or, at least, decrease) periods, although they are not as effective as testosterone. However, they won't cause masculinisation.
• Aromatase inhibitors: aromatase inhibitors increase the testosterone that is already found in any person's body. However, it has menopausal-like side effects (such as fatigue, headache, etc.).
• Selective Estrogen Receptor Modulators: SERMs are not commonly used on transmaculine people for this purpose, as they also cause menopausal-like side effects.
• GnRH agonists: also known as "puberty blockers" within the transgender community, they are not recommended as a long-term solution, as they cause poor bone health.

Methods for permanently stopping menstrual bleeding which are not a form of hormone therapy include uterine ablation, in which the inside of the uterus is cauterized to prevent it from developing or shedding uterine lining, and hysterectomy, the surgical removal of the uterus. Neither of these necessarily prevent other symptoms of menstrual cycles, such as mood swings during premenstruation.

Preventing pregnancy

Some nonbinary people do not want to be able to get pregnant, or to get others pregnant, and the possibility is a cause of distressing gender dysphoria. There are a variety of ways to temporarily prevent pregnancy, such as birth control. For those who are certain that they never want to get pregnant, or who have already had as many children as they want, there are permanent methods of sterilization, such as vasectomy for people who have testicles, and tubal ligation for people who have a uterus.

Masculinizing hormone therapy

There is more information about this topic here: masculinizing hormone therapy

Some nonbinary people who were assigned female at birth want to look and sound in such a way that most people will see them as men. Masculinizing hormone therapy such as Testosterone does this. It is a medicine that a person takes on a regular basis, which makes them go through many of the same changes that men went through at puberty. Some effects of it last only as long as the person takes that medicine, and will go away if they stop, such as looking like a man (due to skin texture, body odor, tending to have more muscle, and where the body stores fat) and having no period. Other effects of this medicine are permanent once they happen, such as growing more facial and body hair, and getting a lower voice. Masculinizing hormone therapy does not stop a person from being able to get pregnant.

Feminizing hormone therapy

There is more information about this topic here: feminizing hormone therapy

Some nonbinary people who were assigned female at birth want to look and sound in such a way that most people will see them as women. Feminizing hormone therapy does this. It is a medicine that a person takes on a regular basis, which makes them go through many of the same changes that women went through at puberty. Some effects of it last only as long as the person takes that medicine, and will go away if they stop, such as looking like a woman (due to skin texture, body odor, tending to have less muscle, and where the body stores fat), and some changes to the genitals and sexual responses. Other effects of this medicine are permanent once they happen, such as growing breasts. Feminizing hormone therapy does not make a person's voice get higher.

Hormone therapy to seem androgynous

There is more information about this topic here: hormone therapy

Some nonbinary people want to look and sound in such a way that most people can't categorize them as a man or a woman. There is no one widely recognized hormone therapy for this. Possible options for people who want to suppress both masculinizing and femininizing hormones at the same time are described in the Mad Gender Science Wiki.

Changing the genitals and reproductive organs

There is more information about this topic here: bottom surgery

Some nonbinary people want to make various kinds of changes to their genitals and reproductive organs. Hormone therapy can make some kinds of changes. For example, masculinizing hormone therapy can make a clitoris more like a penis, and feminizing hormone therapy can make a penis more like a clitoris. Hormone therapy can't make dramatic changes to the size of these organs, can't change where the urethra (pee hole) is located, can't cause or undo the descent of testicles, and can't change a person's ability to get pregnant. Many kinds of surgery to the genitals and reproductive organs is called bottom surgery. For nonbinary people who want their genitals to be more like those of cisgender women or cisgender men, there are surgeries for those. For nonbinary people who have more unique goals for their genitals, there are surgeries for those, such as having both a penis and a vagina, or having a vulva without a vagina, or having no genitals (genital nullification).

Changing face shape

Some nonbinary people want their face to have a more feminine, masculine, or androgynous shape. Hormone therapy has effects on face shape. Makeup can also create the illusion of different face shapes. People who find that this is not enough, especially those on the female-to-male spectrum, may seek facial surgery.

See also

• Practical resources for a list of related topics not covered in this article, such as coming out, relationships, intimacy, etc.

External links and further reading

• Trans 101 for Trans People has a nearly comprehensive list of physical transition options for trans people of all kinds, with lots of information about each.