What Is Feminization?

Feminization is the process through which a transfeminine person makes their face and body more feminine through hormone therapy and gender affirming surgery. A transgender woman (someone who was assigned male and is a woman) may seek out feminization because she wants her appearance to affirm her gender. The therapy and procedures she undergoes will focus on removing masculine characteristics (such as Adam's apple) and inducing or adding feminine characteristics (such as breast augmentation) to her appearance. This process is under the umbrella of medical transitioning.

Not all transgender people will want therapy or surgery as part of their gender transition (a process transgender people go through to align with their desired gender). Besides medical transitioning, transgender people may also go through social transitioning, which includes changing their name, pronouns, and gender expression (the way someone represents their felt gender to others).

Gender Identity

Gender theorist Judith Butler said that someone’s gender is socially constructed through their environment and the people who surround them. If someone’s family treats an individual like one gender, the individual may perceive their own gender that way. Transgender people struggle with gender identity early on in their childhood or later on in life and experience gender dysphoria (feeling like their gender assigned at birth does not line up with the gender they identify with).

Transfeminine people may choose to undergo medical feminizing procedures to express their gender in a more authentic way. These procedures and therapy can allow a transgender person to feel more comfortable with their body.

Hormone Therapy

Feminization through hormonal therapy, also called feminizing hormone therapy, is achieved by two mechanisms: suppressing androgen effects and inducing traditionally feminine physical characteristics. This is done by prescribing anti-androgens and estrogen.

To suppress androgens, a doctor will prescribe medications that:

• Suppress the gonadotropin-releasing hormone (GnRH), which regulates the production of luteinizing hormones
• Interrupt the production of luteinizing hormones, which cause the testicles to make testosterones in males
• Interfere with the production of testosterone and metabolism of testosterone to dihydrotestosterone, which helps in the development of adult masculine features
• Disrupt the binding of androgen to its target areas

To induce feminine physical characteristics, a doctor will prescribe an estrogen, which can feminize a person by changing fat distribution, inducing breast formation, and reducing androgenic alopecia.

Estrogen

Estrogen is a mainstay in feminizing hormone therapy, but it alone is often not enough to achieve desirable androgen suppression. Adjunctive anti-androgenic therapy is also usually necessary.

Estrogen can be taken orally, through injection, or with a skin patch. The pros and cons of estrogens vary. Oral estrogens, which are usually taken daily, are widely available to the public and inexpensive. Injecting estrogen is typically done once or twice a week. It may be inconvenient for long-term use. An estrogen skin patch or gel on the skin (usually once a week) is easily available because it has indications beyond hormone therapy. For example, menopausal women also use these products for hormonal replacement. However. the efficacy of skin patches and gels are more limited because the effects subside once use is discontinued, and these options are more expensive.

Antiandrogens

Anti-androgenic drugs are prescribed to reduce the production of testosterone for transgender women. Anti-androgens can reduce male baldness, facial hair growth, and erections.

Some anti-androgens are:

• Spironolactone (Aldactone) is used to treat body hair and hormonal acne
• Cyproterone reduces masculine traits. However, side effects include depression and liver enzyme elevation. It's currently not in the United States due to the concern of liver toxicity
• Histrelin is used for transgender youth to block puberty. Starting puberty blockers at a young age may prevent facial hair growth, broadening of the shoulders, and the enlargement of genitals

Side effects of anti-androgens include:

• Low libido
• Depression
• Fatigue
• Weight gain
• Liver injury
• Diarrhea
• Skin rash
• Hot flashes

Within the first year of hormone therapy, body fat will be redistributed, there will be a decrease in muscle mass, and the skin will soften. After three to six months, breast growth may occur.

Gender Affirmation Surgery

Gender affirmation surgery was previously known as sex reassignment surgery. This change occurred because a shift in gender identity prompts transgender people to want such medical procedures. Gender affirmation surgery is considered a more transgender-friendly term.

Typically, after a year of hormone therapy, surgical procedures can begin. Gender affirmation surgery encompasses many different types of facial and body feminization surgeries. Body feminization procedures are further subdivided into top and bottom surgeries.

Hospitals generally offer gender affirmation surgery through their department or center for transgender medicine.

Facial Feminization Surgery

Facial feminization surgery involves cosmetic surgeries that feminize facial characteristics. These procedures can be done over time or all at once.

Popular facial feminization surgeries include:

• Brow lifts: Feminize the shape and position of the eyebrows
• Jaw surgery: Includes shaving down the jaw bone to soften the angle
• Rhinoplasty: Narrows the nose
• Chin reduction: Softens the chin's angles
• Cheekbones: May be enhanced with collagen injections
• Hairline alteration: Reduces baldness
• Tracheal shave: Reduces the size of the Adam's apple

Gluteoplasty

Gluteoplasty is performed to create a more round and full butt using fat grafting from other areas of the body. The body takes time—up to a year—to form new blood vessels and before the results are noticeable.

Gluteoplasty can also be done with butt implants, which are inserted to enhance the area. This is an option for people who don't have as much body fat. Larger implants are associated with implant rupture and scar tissue around the implant, however.

Breast Augmentation

Breast augmentation surgery may enhance the size, shape, and fullness of the breasts of transgender women. During surgery, the saline or silicone implants are placed near the chest wall muscle. A week after the surgery, people may still feel soreness. Any type of strenuous activity should be put on hold until the patient is fully healed.

Penectomy

A penectomy removes parts or all of the penis. A total penectomy removes the entire penis, where the doctor will create a new urinary opening.

Orchiectomy

This surgery removes the testes, which reduces the production of testosterone. An orchiectomy is a great option for someone who isn't able to take hormone medications or testosterone blockers. Once the testes are removed, transgender women receive lower doses of estrogen.

Vaginoplasty

Also called transfeminine bottom surgery, vaginoplasty creates a vagina from the inverted skin of the penis. After the surgery, patients will begin to dilate their vagina with dilators, which are cone-shaped objects that keep the vaginal canal open. Typically, a set of dilators are provided by the surgeon. There will be tenderness when inserting the dilator with a water-based lubricant. After vaginoplasty, folks can still have orgasms through clitoral stimulation.

Vulvoplasty

A vulvoplasty procedure creates the areas outside of the vagina canal. The surgeon will create a clitoris, an inner and outer labia, an opening of the urethra, and an opening of the vagina.

Vocal Feminization

Transgender women may also opt to undergo feminization of the voice, or voice therapy, to modify the sound of their voice. Surgical procedures include shortening and thinning the vocal folds. This will make a person's voice a pitch higher. People who go through this type of surgery work with speech pathologists, and undergo vocal training or pitch-altering surgeries.

A Word From Verywell

Not every transgender person looks into surgery due to personal reasons—that choice is their own. However, many transgender people do consider surgical alterations to feel comfortable in their skin and in their body in order to align with their gender. Feminization procedures and therapies can reduce emotional distress and improve the quality of life for transgender women and transfeminine nonbinary people. Counseling, hormones, and operations, however, come with a huge price tag. Insurance may not cover the expenses.

If you're interested in feminization surgery or therapy, consult a doctor, educate yourself on options, and remember that this is your journey.