Transgender Teen Survival Guide

Lee says:

One of the reasons people often struggle with questioning their gender identity or sexual orientation is because they have a certain mental self-conception of who they are and it can be difficult to shift that view. If you've always thought that you were an X, and maybe you've even found community and solidarity in being an X, it can be hard to suddenly realize that maybe you're actually a Y.

In my personal experience, as someone who did actually identify as a lesbian for a number of years, I did have a similar experience as what you're describing. I was completely unaware of the LGBTQ+ community in elementary school and I didn't even know that lesbians existed until middle school.

I know there's a lot of 'discourse' on the concept of compulsory heterosexuality, but that term kind of describes what I experienced as someone who had grown up just assuming I was straight because it didn't occur to me that there were any other options.

After I realized that being gay was A Thing That Is Possible, I still thought of it as something that other people did. I had a lot of internalized homophobia because I learned about being gay from peers who made jokes about hoping there were no lesbians in the locker room. I hadn't met any other LGBTQ+ person at all in real life who had come out to me.

This was genuinely not that long ago, but it was still a particular moment of time when middle schoolers often said "That's so gay" as an insult, we debated about whether same-sex marriage should be legalized in classes and explicitly homophobic statements were normalized, and casually throwing around the f-slur was much more common than it is now (although it still happens, those saying it tend to know that they're being offensive and say it to purposefully be edgy and offend).

So two big things had to combine for me to figure out my sexual orientation-- 1) I had started to go though puberty & experience sexual attraction for the first time, so that was a big component, and 2) I had also learned that a label for what I was experiencing existed.

When both of those criteria were met, it still took a while to put two and two together and figure out that maybe I was attracted to women and then even longer to actually admit it to myself that I was a lesbian and actually accept myself and let go of the shame/internalized homophobia.

I was the first person to come out publicly in my grade at school which wasn't always easy, but being an advocate and activist was a big part of my journey because standing up for my community helped me to grow into a "loud and proud" embrace of my own identity.

Being a lesbian was a really big part of who I was, and the lesbian community was a lifeline for me when I felt alone and needed to have a community and connection to others and see that there was hope for the kind of future I wanted to have.

That meant it was really difficult for me to start the journey of self-exploration and questioning again. I knew who I was! I had fought for it! Everyone else knew too! How could I reconsider, after all that energy and time I put into insisting I was a lesbian? What would happen to my place in the community?

When I came out as non-binary, I kept identifying as a lesbian for a while because I didn't want to let go of an identifier that was so meaningful to me, or a community that had formed part of my sense of self and my cultural references. Long-time followers might remember that I introduced myself as a genderqueer lesbian in my first post on this blog!

But eventually, I decided that I no longer felt comfortable self-identifying as a lesbian because it felt like I was trying to hold onto something that wasn't mine anymore. I couldn't reconcile strenuously rejecting being categorized as female in any way while also claiming a spot in the lesbian community.

I'm not passing judgement on anyone else's decision to identify as a non-binary lesbian-- everyone's gender/identity/experiences are different-- but personally, I felt that my sexual orientation label was in conflict with my newly found gender identity categorization as a transmasculine person.

Being a lesbian just didn't feel comfortable for me anymore, it didn't feel like my home anymore. And that hurt! It was my decision to change the labels I used, and I still feel that it was and is the right choice for me, but that doesn't make it any easier to feel like you're giving up a part of who you are.

So I get it, because I've been there. I understand why you might be afraid of something that might cause you to lose that piece of your identity and your community. But even if it happens, I promise you'll be fine in the end. I came through to the other end and I'm doing better than ever because I'm happy with my body and who I am.

What you gain through hormonal transition is often worth the discomfort/stress/etc of questioning gender/sexuality labels again-- if medically transitioning is the right path for you. While I am biased because of my own experience, I am also the first to admit that medical transitioning isn't right for everyone and that's okay and valid.

I was pretty depressed pre-medical transition and knew that medical transition was something that I needed to do, although I didn't always know exactly what transition options I wanted as my goals shifted over the course of my transition. But for me, seeking medical transitioning wasn't a choice, it was a necessity for my mental health.

If you feel similarly, and know that medically transitioning is going to improve your quality of life, then it is probably the right path for you, even if it means giving up a fragment of your identity and losing a community you used to belong to because you will (hopefully) be gaining peace of mind and an ability to live your daily life without feeling crushed by gender dysphoria.

Ultimately, you have to decide what is most important to you-- taking hormones and getting to have a body that you're comfortable with and exist in for the rest of your life, or trying to freeze your sexual orientation in place because you're afraid of change (which can be valid-- as I explained, I also felt like the decision to let go of the lesbian community was really tough and it can be a real loss!).

However, it's important to remember that changes in sexual orientation on HRT aren't guaranteed or universally experienced. Sexuality can be fluid for some people and changes (if they occur) may be more about discovering new aspects of oneself rather than losing existing traits. For others, HRT brings a greater alignment between their emotional state and physical body, which can clarify feelings that were always present but perhaps obscured.

I've seen people immediately try to smack down the idea that taking hormones can change someone's sexual orientation, and that's also not right-- I believe that is invalidating to those who do feel that their sexual orientation changed after hormones. It's good to remember that while hormones can influence feelings or attractions, they don't redefine your core identity. You are still the same person, even as some aspects of your experience might shift.

There are many reasons why someone might change their label after starting hormones. Some people may have had certain attractions they didn't feel comfortable acknowledging or expressing until they felt comfortable in their body and life and gender roles etc, but after they started hormones and grew comfortable with themself, they also became comfortable with the idea that maybe they had certain attractions that they didn't recognize before.

For example, I once spoke to a trans man who didn't feel attracted to women before hormones because he felt so dysphoric comparing his body to theirs that it overwhelmed all his other feelings on them until after he started T and became comfortable with his own body. It felt like he had a sudden change in his sexual orientation because all of a sudden he became attracted to features on women that formerly had only had triggered his own dysphoria. That's just one example-- there are, as you seem to have seen online, multiple folks who have shared their experiences about how hormones have affected their sexuality and sexual orientation.

The article Research Shows Many Trans Folks' Sexual Attractions Change After Transition is a great read if you're looking for more information about folks who feel that taking hormones changed their sexual orientation.

But as I mentioned, taking hormones won't necessarily change your sexual orientation. I wasn't attracted to men before I started testosterone, and now that I'm on testosterone... I'm still not attracted to men! Testosterone did not change my sexual orientation one bit.

While there are definitely folks who report feeling that their sexual orientation shifts after starting hormones, there are also many people (like me) who have a pretty consistent orientation over the years. It's totally valid and normal to experience anxiety/fear/concern about major changes to your life, and you aren't 'wrong' for worrying about how hormones might change your life and identity. Holding onto your identity as a lesbian can be a significant and empowering anchor.

Your feelings are always valid, but if these fears about losing yourself become overwhelming, it can help to speak with a mental health professional like a therapist who can help you work through them and help guide you to weigh your options.

I don't really have a ton of advice other than to say that I've been there too. Although we obviously don't have exactly the same journey, I shared my experiences because I feel like a lot of us go though similar things, even if it's not exactly the same, and it can be useful to connect with other folks who have navigated the experience of choosing a transition path that has the potential to lead to a change in the label they use for their sexual orientation.

I would recommend thinking about what changes you hope to get from being on estrogen. It can be really helpful to consider what you would like to look like in 5 years or 10 years, and what you hope transitioning medically will do for your mental health and your life. You can make a list of the physical changes (e.g. increase in breast growth) and emotional changes (e.g. reduction in gender dysphoria) that you hope to undergo after starting hormones.

In your message to us, you only listed your fears-- you didn't note any of the reasons that you're interested in hormones at all. When you're exclusively focusing on the potential negatives (losing part of your identity/community) you aren't considering the potential positives which may be significant. Take some time to reflect on your feelings about your gender and body, not just your sexual orientation label.

In your case, you have one hypothetical negative to starting estrogen (potentially becoming attracted to men) which isn't a guaranteed outcome. Does that risk outweigh the other changes that you will experience on hormones?

Thinking about what you can do to bring your current-you closer to your ideal future-you might help you to make a decision today, if that makes sense. You will often have to make decisions in life that have trade-offs. You rarely face options that make you choose between something that is 100% perfect and something that is 100% awful. Usually things are more shades of grey.

When all's said and done, I'd like you to remember that you're not alone-- Many folks in the trans community have also dealt with changing their sexual orientation labels at some point or another during their transition so there is community out there for you to lean on, and seeing a therapist can also help you talk through your options regarding starting hormones.

I'm confident that you'll find the right path for your needs and identity-- and there's no rush! Everyone has a different journey.

Followers, feel free to add on!

Lee says:

Hi my friend! Navigating your gender identity and the decision to undergo hormone therapy can be complicated.

It's sometimes possible to start hormones if you're 100% sure that you want hormones, even if you aren't 100% sure what your gender identity is, but support from a therapist who specializes in gender identity issues can be invaluable.

They can help you explore your feelings about your gender and your body, expectations, and concerns about taking estrogen and the changes it brings, and I would really recommend looking into finding a supportive therapist.

You don't always need to be diagnosed with gender dysphoria by a mental health provider to access HRT if you see a provider who uses informed consent, and not everyone feels therapy is helpful in this area-- it really depends on whether you can find a trans-friendly, competent, and affirming therapist.

But if you don't see a therapist (And even if you do!) finding support from the trans community can be super helpful if you're questioning being trans, or considering medical transitioning.

Looking for local support groups that meet in-person or online can be a great opportunity to hear from people who have similar experiences as you do because they can provide useful insights and helpful information.

With all that said, it isn't possible to pick and choose what changes you will get when you start hormones. It's an all-or-nothing thing. If you choose to start estrogen, you may experience some breast growth. For reference, this chart lists some of the major changes that you can expect from estrogen!

You can't anticipate how much chest growth you'll get- some people have minimal growth and others develop a C cup or larger-- so if the breast growth is a deal breaker, estrogen may not be the right option for you.

There is a type of medication called SERMs which might allow you to take estrogen without breast growth, but there isn’t enough research on the effect of taking SERMs and I don’t have personal experience with it either, so I can’t provide much information on that— you’ll need to speak to a medical provider about it.

Because the effects are not fully known, I would assume that there’s a chance that even if you take them you could still have some amount of breast growth, and make your decision based on that assumption unless your provider says otherwise.

You may choose to wear a binder for the rest of your life if you get breast growth and remain unhappy with your chest, but you might be swapping one form of dysphoria for another, so you should really consider whether all of the desired changes that you'd get from estrogen are more important to you than the one big change that you don't want.

You could also start estrogen and wear a binder until your chest has stopped developing (at least ~2 years) then undergo top surgery to get a flat chest again if you are uncomfortable with the breast growth from estrogen therapy. This is a significant decision and requires thorough consultation with both your hormone prescriber and a plastic surgeon.

If you feel that having breast growth isn't worth the other changes, you could explore other things.

While estrogen can slow down the growth of new facial hair, it does not typically eliminate existing facial hair, even though facial and body hair may become lighter and grow more slowly. It also doesn't reverse hair loss that has already happened, although it can slow or prevent future hair loss.

So removing facial and body hair with laser hair removal and electrolysis, and reversing and preventing further hairline recession and balding with a hair transplant, minoxidil, and finestride might mimic some of the hair-related changes that you might see from estrogen.

Similarly, facial feminization surgery and body contouring surgery can help to mimic the body fat redistribution that you'd experience on estrogen without also creating the chest growth that you don't want to experience.

However, these surgeries are more invasive than estrogen, so if you're considering estrogen, you may want to wait until after you've been on it for a couple of years before you decide whether you still need surgery or are satisfied with the changes.

If you're confident that you don't want estrogen then you could hop straight to those surgeries, but they may or may not be covered by insurance even with a diagnosis of gender dysphoria; some policies recognize that they are medically necessary interventions and others deem them cosmetic.

As you may have guessed, the vast majority of people who were assigned male at birth and express interest in taking estrogen are not cisgender men. Many end up identifying as transgender women or non-binary people. That doesn't mean that you are trans for sure, but just considering the overall probabilities, I'd say there's a good chance that you have more to explore to figure out about your gender.

But even if you don't end up identifying as part of the community, you can still consider medical interventions even if you identify as a cisgender man. It's your body, and you should do whatever you need to do to feel comfortable in it.

It's okay to look into starting estrogen (or any other medical transitioning step) while identifying as male. Just make sure you get the support you need from your medical providers so you know all the options available to you and the risks of each choice.

Lee says:

Lipofilling, or fat grafting, involves removing fat from one area and transferring it to another area, and it's often used for body contouring surgeries (this article has an example of that, heads up for surgical images).

Top surgery for people looking to have a flat chest often involves direct excision combined with liposuction to create a more masculine contour, but there are a lot of variations in how it's done which can depend on your goals and your surgeon's technique!

You should talk with your surgeon at your top surgery consult and make sure you are very clear on what your goals are in undergoing surgery (you can even bring a photo with your ideal chest outcome) and get clarification on what techniques they plan to use to help you to reach those goals.

Ask about anything that you're worried about, whether it's what type of scarring you'll have, how sensation will be affected, what complications are expected, whether you'll need drains, what activity limitations you will have, what recovery will look like for you, etc.

While we can provide general information about surgery, you really do have to talk about what your surgeon plans to do in your case with them specifically; everyone has different bodies and surgeons have different techniques, and you can't assume that your surgeon will do the same thing as another surgeon you've seen online.

Lee says:

TransBucket has been an invaluable resource for me throughout my medical transition.

I would spend hours on the site looking at photos that I’d already seen because it helped me prepare for my own medical transition and it helped me feel like what I wanted was a possibility.

Seeing the ‘before and after’ photos from other trans people who had gotten top surgery and phalloplasty gave me so much hope at a time when I was really struggling with dysphoria and depression.

I’m someone who has benefited in ways that I can’t even fully express from the post-op community’s generosity. I don’t know if I would have the life that I have now without it.

After I had my top surgery and hysterectomy, I chose to upload my photos to TransBucket to give back to the community (in a small way) and help others as I had been helped.

This is largely why I hesitated in sharing photos of vulnerable moments depicting surgical healing, although I ultimately did upload several photos showing the early weeks and months of recovery.

I didn’t upload any photos after I had fully healed and gotten tattoos to hide my surgery scars because I was worried about my privacy, which is something I still struggle with, and I ultimately decided to not upload photos of my genitals after phalloplasty for the same reason.

While I always knew TransBucket was publicly accessible, the mention of the site in the news made me reconsider whether I wanted to continue having my images hosted there.

The site being down for the past couple of months has given me some pause, but today, 5+ years after getting top surgery and making my first TransBucket submission, I have gone back and deleted some (but not all) of my post-top surgery and post-hysterectomy images.

I’m still considering what the best way is for me to protect myself from transphobic cisgender people who might use my images in ways that are incompatible with my views and how I feel about my body, and also protect myself from some of the hate coming from within the community as many of the most hurtful comments about about post-op bodies like mine are often made by pre-op and non-op trans people.

I became a mod on this blog when I had just turned 16 and I had top surgery at 18. I shared things online that I probably wouldn’t have shared if I had been if I had become a mod at my current age in my early 20’s, but the internet is forever and I can’t take it all back, even if my feelings on my online privacy have changed.

I would like to encourage our followers to take a moment and reevaluate their internet privacy as well, and think about what things they’re comfortable with sharing going forward.

I’m not saying that you should delete your images from TransBucket specifically— I might even end up reuploading mine there at some point, with some redactions for privacy. But you should think about what photos you are okay with sharing online a lot longer and harder than I did.

All that said, I’d like to circle back to my original point— that TransBucket has been an incredible resource for me (and many others) and it continues to be one of the first things that I recommend to anyone who is considering gender-affirming surgery (and is not a minor in the jurisdiction in which they reside as the site hosts images of genitals and it is against the terms of service for minors to join).

I would like to thank the admin of @transbucket for all the work they’ve done, and encourage our followers to assist them if they are able to:

Lee says:

Hi everyone! I'm posting today to specifically point out an awesome resource that more people should be aware of.

The Gender Affirming Letter Access Project (GALAP) is an organization of independent clinicians who help transgender people access gender-affirming medical treatment like hormone replacement therapy and surgery by providing free letters using the informed-consent system.

The providers listed in the GALAP directory have pledged to complete at least one free informed-consent session and subsequently write at least one free letter per month.

This is super important because many people aren't able to get insurance coverage for the treatment they need without getting a WPATH-compliant letter, and that can make it difficult for someone to be able to start their transition.

For example, many low-income trans people aren't able to afford multiple therapy sessions which makes getting the WPATH-compliant letter difficult for them.

Similarly, trans people living in rural areas face more barriers in being able to find therapists near them who are trans-friendly and currently accepting new patients.

In my own personal transition, I've needed to get...

For anyone keeping a tally, I needed to get 10 mental health letters saying that I am trans and need to transition before I could get the medical care I needed, not including the “proof of HRT” letters.

It’s ridiculous— If I had needed treatment for any other reason, I wouldn’t have needed to jump through so many gatekeeping hoops where cisgender medical professionals were the arbiters if I was trans enough and deserve care.

For example, my stage 3 phalloplasty surgery is just having an erectile implant placed because I have erectile dysfunction. This is true of all post-phalloplasty patients as a result of the way our penis is structured.

If I were a cisgender man getting the same surgery for erectile dysfunction and having the same device implanted, I would not need to see two mental health professionals first who would judge me on my gender identity before deciding whether I should be allowed get the implant.

The urologist would just use their best medical judgement in determining whether the surgery would be a good idea and then explain the risks and benefits of the procedure and let me decide if I wanted to go ahead and do it. Then the doc would send the insurance the preauthorization info and codes for the procedure based on the diagnosis, and no required mental health evaluation or therapist letter would be involved at all.

But because my surgery is a “gender affirming surgery” for “treatment of gender dysphoria,” I have to see two therapists first and they will judge if I’m “trans enough” and then they have to write a letter saying that I need the surgery because I’m mentally ill (aka diagnosed with “gender dysphoria”) before my insurance will cover the surgery that’ll let me have an erection.

In my opinion, that’s paternalistic, demeaning, unnecessary and a waste of everyone’s time. And it isn’t just weird, invasive, and annoying— it can determine whether you’re able to access necessary medical care.

The GALAP also addresses how requiring a letter is a form of gatekeeping which can negatively impact multiply marginalized minorities, stating, "We are aware that people who do not fit a certain narrative about what it means to be 'transgender' often receive subpar care and face more barriers to receiving the care they need. We acknowledge that this greatly impacts people of color and indigenous communities, nonbinary people, and neurodivergent people."

The provider will have an interview session with you, using the informed consent approach in their interviewing, and then will write a letter, again using the informed consent approach in their letter writing process.

The interview session, the letter (and any additional copies of the letter) are all supposed to be pro-bono, which just means it's free. They aren't supposed to charge you for anything, like additional time on letter writing outside the therapy session, any clinical consultation they need to perform, or any communication with your surgeons and medical staff.

I believe that majority (or possibly all) of the providers in the directory will only provide informed consent letters for legal adults as the wesbite says "writing letters for youth brings up complexities since minors may assent but not consent without parent/guardian support to move forward with any medical interventions," so it's a resource that is more useful for those who are 18 or older.

You'll also need to discuss with your letter writer if they are comfortable officially diagnosing you with gender dysphoria if your medical provider/s and/or insurance company requires a formal a diagnosis of Gender Dysphoria to access gender-affirming medical services.

You should also check whether your letter writer needs particular credentials.

My insurance said:

“One of these letters must be from a psychiatrist, psychologist, nurse practitioner, psychiatric nurse practitioner, or licensed clinical social worker with whom the member has an established and ongoing relationship.

The other letter may be from a psychiatrist, psychologist, nurse practitioner, physician, psychiatric nurse practitioner, or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the member.”

Your insurance company may have more rigid requirements and need a letter from a medical doctor or doctor of osteopathic for example, and may not accept a licensed clinical social worker, or they may allow any mental health practitioner.

So it’s good to double-check that the person you’re contacting in the directory has the license you need for your requirements.

The GALAP site says:

The (current as of 04/2022) list of states that currently have a provider who has agreed to write free letters is below:

Most providers can only provide a letter to people residing in their state(s) of licensure, and there are some states that don't have any providers listed at all, so hopefully more providers will sign the pledge and get listed in the directory in the future.

But even as it is today, this is a super-useful resource for trans people who are looking to medically transition, and hopefully more people become aware of it and are able to make use of it going forward!

Our post on how to start HRT in the USA has linked to the GALAP website so this isn't the first time I've mentioned their directory, but I felt like the GALAP directory deserved its own post, so here it is!

Lee says:

Research on transgender health and wellness after gender affirming surgeries can be helpful for transgender people who want to learn more about what their options for medically transitioning are.

Knowing the potential outcome of these interventions can help inform and guide the decisions of people who are considering getting these surgeries— and it can also help inform cisgender healthcare providers too.

As someone who had bottom surgery myself (I had ALT phalloplasty) I took a deep dive into the current research on the procedure before making my decision, and while the research was helpful, talking to people who had the surgery I was planning to have equally important.

That being said, if anyone is considering getting peritoneal flap vaginoplasty, this new study should have interesting results and is worth reading!

There isn’t enough knowledge out there about this topic, especially given the relative newness of the peritoneal pull-through procedure as a vaginoplasty option.

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Here is the primary author’s Twitter summary of the study:

“📊Retrospective review of 199 peritoneal flap vaginoplasty patients

⏲️Median time to orgasm = 6 months

🚭Any smoking history = correlated with less orgasm recovery

Among those with minimum one-year follow up (89%):

🔀Orgasm pre-op not significantly correlated with orgasm post-op

🎆Rate of post-op orgasm was 86%, however,

🌷Not all anorgasmic patients were attempting to orgasm

📈Patients continue to become newly orgasmic past one year

Interventions for anorgasmia post-surgery include:

🔧Pelvic floor physical therapy for scars, hypersensitivity, or dilation difficulty

🩺Testosterone rx (orchiectomy is hormone intervention!)

👂Sex therapist with 🏳️‍⚧️ competency

❤️‍🩹Trauma informed care

We examined a rudimentary outcome (orgasm: yes/no). There is so much more to learn about the sexual health of transgender women and nonbinary people after surgery! It is a privilege to work for this community under the mentorship of Dr. Zhao and Dr. Bluebond-Langner at NYU Langone”

Full publication here: https://doi.org/10.1016/j.jsxm.2022.02.015

(It costs $31.50 to purchase access to the full article, but if you are in school you can request that the research librarians help you gain access to a copy of the full text of the study)