A medical information page: it describes treatments and their risks according to published guidance (WPATH SOC 8, NHS specifications, learned societies), without replacing the teams that practise them. Transition is a personal, multi-year journey, none of whose steps is compulsory.
The steps, and what is not compulsory
A medical transition is made of building blocks each person chooses: hormones (the great majority), chest surgery (frequent among trans men), genital surgery (a minority: a quarter to a third of trans women, fewer than one trans man in ten, given its weight), facial surgery, voice, hair removal. In the UK, hormones are prescribed by NHS gender clinics after assessment — with waits of two to five years for a first appointment, which pushes many to private providers such as GenderGP or Gender Plus — and genital surgery is NHS-funded after two referrals; in the US, insurance coverage depends on the plan and the state; Canada's provinces fund genital surgery; Medicare in Australia covers part.
Hormones and their side effects
- Feminising: oestradiol (tablets, gel, patches, injections) and an anti-androgen (spironolactone in the US and UK, cyproterone in Europe, or GnRH analogues). Effects over three months to two years: skin, breasts (final stage in two to three years, often modest), fat redistribution, lower libido and erections, progressive infertility (sperm banking before). Risks: venous thrombosis (especially with smoking), raised prolactin and meningioma with high-dose cyproterone, high triglycerides, gallstones, a small but real breast-cancer risk. Blood monitoring every three to six months in the first year. The voice does not change.
- Masculinising: testosterone (injections every two to twelve weeks, gel). Effects within months: voice, hair, muscle, clitoral growth, periods stop (but no contraception!), acne, male-pattern baldness. Risks: polycythaemia (thickened blood, haematocrit monitoring), raised cholesterol, hypertension, vaginal atrophy, a possible rise in cardiovascular risk; effects on fertility partly reversible.
- Puberty blockers (GnRH analogues, in adolescents): pause development, reversible on stopping according to available data; effects on bone density and psychosexual development are debated — the subject of the current worldwide debate, and banned outside trials in England since 2024 (see Being transgender).
Feminising operations
- Vaginoplasty by penile inversion (the reference technique, 4 to 6 hours, 7 to 10 days in hospital, daily dilation for months then for life) or with a segment of sigmoid colon (deeper, self-lubricating, but abdominal surgery). Complications: stenosis or loss of depth (10 to 20%), rectovaginal fistula (1 to 3%), partial necrosis, urinary problems, pain; high satisfaction, orgasm preserved in most. Cost: NHS-funded in the UK; $20,000 to $35,000 in the US; £15,000 to £25,000 privately.
- Orchiectomy alone: simpler, removes the need for anti-androgens.
- Breast augmentation with implants (the same as for any woman, with the same risks: capsular contracture, rupture, the rare BIA-ALCL lymphoma).
- Facial feminisation (forehead, jaw, nose, Adam's apple): major, expensive ($20,000 to $50,000), rarely funded; voice surgery (glottoplasty) after speech therapy.
Masculinising operations
- Chest surgery ("top surgery"): double incision with nipple grafts or periareolar; scars, frequent nipple numbness; the most requested and most satisfying operation.
- Hysterectomy and oophorectomy: often after some years on testosterone.
- Metoidioplasty: release of the enlarged clitoris (4 to 6 cm), with or without urethral lengthening; natural erection, penetration rarely possible, fewer urinary complications.
- Phalloplasty: radial forearm free flap (visible scar, better sensation) or thigh flap, in two to four stages over one to two years; erectile and testicular implants afterwards. The most complex surgery of the whole transition: urethral fistulas and strictures in 20 to 40% of cases, flap loss (2 to 5%), implant complications; cosmetic and functional results vary widely between teams, hence the importance of a high-volume centre.
The minimum age
International guidance (WPATH SOC 8, 2022) no longer sets fixed ages, except 18 for phalloplasty, and leaves assessment to each case; in practice and in the law of most countries, genital surgery is reserved for adults, chest surgery is possible from 16 or 17 with parental consent in a few countries (some US states, the Netherlands, Belgium), and hormones from 15 or 16 after assessment. The NHS reserves all surgery for adults; England banned puberty blockers outside trials in December 2024; 27 US states have restricted treatment of minors by law (25 bans in force), upheld by the Supreme Court in 2025; Australia and Canada continue under multidisciplinary protocols.
Country by country: allowed, funded, forbidden
United Kingdom: allowed and NHS-funded after two clinic opinions; genital surgery is done by a
handful of surgeons — Parkside Hospital and the private practice of James Bellringer in London, the
Nuffield Health Brighton team, St Peter's Andrology (London) for phalloplasty — with
waits of several years; chest surgery is more widely available privately (£6,000 to £9,000).
Ireland: no genital surgery in the country; the HSE funds treatment abroad (usually the UK or
Belgium) under the Treatment Abroad Scheme.
United States: allowed in most states for adults; coverage under Medicaid varies by state, the
Affordable Care Act forbids blanket exclusions in most plans; centres: Mount Sinai and NYU
Langone (New York), UCSF, Boston Medical Center, Johns Hopkins; the
federal government stopped covering care for military families and federal employees in 2025.
Canada: GRS Montréal (the Brassard-Bélanger clinic, the country's only genital-surgery
centre, 700 operations a year, funded by every province), Women's College Hospital (Toronto) for chest surgery,
Vancouver General for a growing programme.
Australia: allowed; Medicare covers hormones and part of the surgery; genital surgery in Melbourne
(Dr Andrew Ives) and Sydney, many go to Thailand. New Zealand: publicly funded but with a decade-long
waiting list; most go to Thailand.
India: legal, private (Delhi, Mumbai, Bangalore), $5,000 to $10,000; Pakistan: rare,
private; South Africa: Groote Schuur (Cape Town) is the only public programme, with a 25-year
waiting list; Nigeria, Uganda, Kenya, Ghana: no team, and the operation is illegal or impossible.- Bans: Russia (all medical transition banned since July 2023, except congenital anomalies), Hungary, the Gulf states, most of Africa and South-East Asia (except Thailand, Vietnam and the Philippines for surgery, without legal recognition); in China the operation requires family consent and a clean criminal record. Iran: legal since Khomeini's 1987 fatwa and state-subsidised — with pressure on gay people to use it to "become legal".
Destinations: where people go when their country does not operate
Thailand: the world's first destination since the 1980s — the Preecha Aesthetic
Institute (Bangkok, founded by the pioneer Dr Preecha Tiewtranon), Kamol Hospital,
Yanhee Hospital, Chettawut Plastic Surgery; vaginoplasty $10,000 to $20,000, two to three weeks of
follow-up on site, recognised quality but distance for aftercare.
Spain: Barcelona (Dr Iván Mañero, IM Gender), Madrid, Marbella; €15,000 to €25,000.
Belgium: UZ Gent (Prof. Stan Monstrey, one of Europe's most reputed teams, 3,000
operations) takes foreign patients; the Netherlands' Amsterdam UMC less so.
Serbia: Belgrade, the school of Prof. Sava Perović continued by Dr Miroslav Djordjević, known for
metoidioplasty and phalloplasty at moderate prices ($8,000 to $20,000).
Brazil, Mexico, India: many private teams, variable level, check real
experience. Turkey (Istanbul), South Korea: mostly facial and chest surgery.
Rules for going abroad: demand the number of operations of this type the surgeon has done, photographs of results and patient contacts; arrange for complications to be handled by a team at home (which is not obliged to); never operate before the agreement of the psychologist or doctor who follows you; and read the page Cosmetic surgery for the dangers of medical tourism, which apply here in larger measure.
Regret, detransition, and afterwards
Regret after genital surgery is rare in published cohorts — around 1 to 2% in Europe over several decades (Amsterdam, 1972–2015: 0.6% among trans women, 0.3% among trans men) — with complications and disappointing results far more frequent than regret about identity. Detransition (return to the birth gender) concerns a few per cent of those who began a transition, more among recently treated young people; it is also a medical journey deserving the same care. After transition, lifelong follow-up is needed: hormones, bones, screening (prostate kept in trans women, residual cervix and breast tissue in trans men). The section Transgender covers rights, couples and intimacy after transition.