There is no one-size-fits-all approach for the gender affirmation process. Surgery can be expensive and time consuming, recovery can be demanding — and it may not be part of your transition process at all. Your path to gender affirmation may focus on hormone therapy, voice therapy or other options instead.

Fan Liang, medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health, stresses that while surgery can be a part of the transition process for some, it’s not for everyone: “Each patient needs to consider their personal goals and decide whether surgical options will improve their quality of life and lessen their gender dysphoria.” She adds, “It’s very possible that surgery is not in the transition plan for someone in the gender affirmation process. There are several nonsurgical services that may help transgender patients achieve their transition goals.”

Liang shares insights into the many choices available to patients who wish to use nonsurgical options to express their gender identity. Doing your own research and talking to experts will help you decide which options are best for you.

Hair Removal for Gender Affirmation

As part of the gender affirmation process, you can choose to undergo permanent hair removal for both aesthetic reasons and as preparation for some surgeries. Laser and electrolysis are the recommended methods.

During electrolysis, your dermatologist may use chemical or heat energy to destroy hair follicles and tweezers to remove the hair. Possible side effects of the treatment are pain, swelling or redness.

Laser Hair Removal for Gender Affirmation

Laser hair removal uses infrared light to destroy hair follicles. Laser hair removal can cover a larger area more quickly than electrolysis. Possible side effects include skin irritation and redness. Some hair could be resistant to the laser treatment or grow back, although it is usually finer and lighter. Laser is not an option for every skin and hair type (for example, gray hair and/or fair hair).

• If you are planning to undergo laser hair removal, it is best to limit other forms of hair removal for six weeks before treatment. Before the procedure, your dermatologist will trim the hair you want removed to a few millimeters in length.
• A dermatologist moves a low-energy beam laser over your skin. Pigments in your hair follicles absorb the energy, which results in long-term or permanent hair reduction and removal. 
• This procedure takes several minutes to hours, depending on the area treated. Your skin may appear slightly sunburned after treatment, and your doctor may give you an ice pack or anti-inflammatory lotion.
• Most patients feel very little discomfort or pain and can return to regular activity immediately. Usually, a series of laser hair removal appointments are recommended for best results.

Gender Affirming Hormone Therapy (GAHT)

Hormone therapy can help you achieve more masculine or feminine characteristics. Commonly prescribed by a primary care physician or endocrinologist, hormone treatments can be part of a presurgical plan or a stand-alone service.

These medications work to more closely align outward secondary sexual characteristics, such as enlarged breasts, body fat distribution or facial hair, with someone’s gender identity.

• Masculinizing hormone therapy: used to minimize feminine characteristics and promote masculinization. As a result, you may notice changes in your voice and development of facial and body hair, sweat and odor patterns. You may also see an increase in your muscle mass, a redistribution of facial and body subcutaneous fat, frontal and temporal hairline recession and, possibly, male pattern baldness. Additional sexual effects may include an increase in libido, clitoral growth, vaginal dryness and cessation of menses. Talk to your doctor about any additional side effects you can expect.
• Feminizing hormone therapy: used to reduce masculine characteristics and promote feminization. As a result, you may notice breast development, redistribution of facial and body subcutaneous fat, reduction of muscle mass, reduction of body hair and a change in sweat and odor patterns. Additional sexual effects include reduction in erectile function, changes in libido, reduced or absent sperm count and ejaculatory fluid, and reduced testicular size. Talk to your doctor about any additional side effects you can expect.

Speech Therapy for Gender Affirmation

Designed to meet the individual needs of the transitioning individual, your voice therapy plan may include changes to:

• Habitual speaking pitch
• Resonance (the way sound is shaped to produce a vocal quality)
• Inflection/prosody (the melodic ups and downs of the voice)
• Rate of speech
• Volume/intensity
• Articulation (how speech sounds are produced)
• Pragmatics (social rules of communication)
• Nonverbal communication

If voice therapy is not by itself enough to help achieve the desired voice outcome, vocal cord surgery can be considered. Many of the surgeries to help change vocal pitch can be done on an outpatient basis and without scarring. Talk with your doctor about surgical options to achieve the vocal identity that is right for you.

Fertility and Gender Affirmation

Some transgender people aspire to have biological children or be parents. Because of this, all reproductive options and future plans, such as egg banking, sperm banking and pregnancy, should be discussed with your doctor before getting trans-specific medical care and surgical procedures that may reduce your future reproductive options.

Mental Health and Gender Affirmation

Transgender people have specific needs for mental health care that focus on the exploration of gender identity, coming out and social transition, preparation for gender reassignment surgery, family support systems and more. Transgender patients may also have mental health needs not specific to their gender affirmation process for which they would prefer to see a mental health expert specializing in transgender care. Discuss your individual mental health needs with your doctor. Both a primary care doctor and a mental health specialist are good places to bring up any mental health concerns you have.

“As you consider your options, remember that the journey is your own,” says Liang. Knowing what is available, talking to other people who have transitioned and meeting with transgender health care experts can help you make an informed decision on which procedures, if any, are right for you.