Nothing is prescribed once you decide to transition, because the path depends on your family, your access to care and your resources. Some people take tiny steps and some change everything at once. Take whatever steps you can to live authentically, whether that is a name, a cardigan or hormones.
Is there a set path I am supposed to follow?
I don't think there is a prescribed path that anybody goes on. Everybody is different. People have different families, different opportunities and different access to medical help and support. Some people want to take little tiny steps, really slowly. Others want the boulder to roll down the hill at the most amazing pace and change everything in one go.
So what happens next is your plan, your decision and your journey, shaped by what is actually available to you. Can you go to the shops and change your wardrobe? Can you borrow clothes from somebody? Can you get to medical care, and can you pay privately for it if you need to? Not everybody has access to every resource, and that is a problem with the world, not with you. What matters is that you take the steps that are open to you.
What can I do first, without any medical care?
A great deal, and none of it needs anybody's permission. You might change your name, your pronouns, or the way other people refer to you. You might change your hair, your makeup, or the accessories you carry. You might start at school or at work as yourself. You might do one of those things and nothing else for a long while.
Social transition is helpful, not harmful, and it is a very personal thing. There is no minimum and no correct order. Somebody who only changes their name has transitioned just as much as somebody who changes everything.
What if I get ready and then can't do it?
This happens far more than people admit. I have listened to people who spent the whole day getting ready for their first step outside the house, dressed as the woman they really are. They had rehearsed it, looked in the mirror a million times, found the outfit and felt confident. Then they got to the front door and could not do it. For some, it did not come until weeks or months later, and that is absolutely fine.
Maybe you make it from the front door to the car, shut the door and you are safe. Maybe you make it from the car to a shop and back again. Maybe you will not wear the whole outfit, just the nice cardigan you have been saving. It is scary, and you can always step back and try again. A pause or a retreat is part of the process, not a failure.
What does it feel like when you do it?
What I love hearing about is the joy and relief. The first time you step outside as you. The first car journey as you. Paying for a bag of crisps or a bottle of pop at the till as you. Going to your manager at work and saying, "I've got something to tell you: from this date, I'm coming to work as me." Each of those steps can feel immensely scary, and the joy they bring afterwards is amazing. Get the support around you that you need, and make your journey your own. I can't wait for you to do it.
How does medical transition actually work?
Medical transition has had so much bad press, when it is actually one of the simplest things you can do. In outline there are two steps: switch off or block your natural hormones, then give you the hormone that matches your gender identity.
Your body's natural hormone production comes from the testicles, which produce testosterone, or from the ovaries, which produce oestrogen and progesterone. There are simple, well-established medicines that either stop those organs producing hormones or stop the hormones working on your body. GnRH analogues, often called puberty blockers, stop the testicles and ovaries working. Raloxifene stops oestrogen acting on breast tissue. Spironolactone and cyproterone stop testosterone acting on the body.
Then comes the replacement. The hormone can be given as an injection, a gel, a pill or a patch. You will have heard of hormone replacement therapy for cisgender people, and this is the same idea: replacing a hormone your body is not producing when it should be. We have been manipulating hormones for decades, for contraception and for menopause. It is nothing new. It only feels odd when it is done for trans people, and I don't find it odd at all.
What changes with oestrogen?
Oestrogen starts a second puberty. Your breasts begin with little buds, then some fullness, then they develop into the size your genetics would have given you, so look at the women in your family for a rough idea. It takes time. It does not happen overnight, and it should not.
Oestrogen also softens your skin and changes where your body puts fat, on your arms, tummy and hips, which gives the curves we are used to seeing. What it cannot do for a trans woman is bring periods or eggs, because there is no womb and there are no ovaries to do that work.
What changes with testosterone?
Your voice will start to crack, squeak and break, just like a cisgender teenage boy's voice does in puberty, and then it will drop. Beard and moustache growth begins. Your muscles change, because they get bigger with testosterone, and the hormone shapes your skeleton, your body form and your body and chest hair.
Height is the thing hormones cannot change. If you have finished a puberty, your height is fixed, whichever puberty that was. Again, this takes time, and it should take time.
What about progesterone?
Oestrogen and progesterone are the two so-called female hormones. Both are vital to the reproductive cycle, and both also contribute to the shape of the body, breast development, fat distribution and skin. They also contribute to how you think and feel and experience the world.
Many trans women who use progesterone tell me their mood improves and that their breast development or shape is better. Where it works is mainly the breasts, the mind and the womb, and without a womb you do not need it there, but that does not mean you do not need it for your breasts and for how you feel. Why it is so hard to get, I don't know. Public services in many places rarely prescribe it, while private providers such as GenderGP use it much more freely. I would like to see it properly included in research, looking at the wanted and unwanted effects together.
What if I can't get medical care where I live?
Many people can't, and the reasons are structural. Very few clinicians take this work on, public waiting lists run into months or years, and in some places the law has closed routes altogether. In the UK, the sale and supply of puberty blockers on private prescription to trans young people has been banned, and public prescriptions are almost impossible to get. The cost falls on trans young people, who go through an unwanted puberty while they wait, and on their families, who are left with nowhere to turn.
If you are young, the pace of the social side is yours, but the medical side has a clock on it, because puberty does not pause while a process runs. Every month of an unwanted puberty is a permanent physical change. There is no age at which care begins, and a supportive parent makes everything easier without being the only way through. If you do not have one, that does not on its own put care out of reach.
If you decide you want to explore the medical side, GenderGP can help with access to affirming medical care, including hormones, blockers, prescribing and monitoring. In the meantime, you can talk any of this through with Sammy here: what to say to your family, how to plan a first step, or what a good conversation with a doctor looks like.
So what is the next step?
Whichever one you can take. A name, a pair of earrings, a conversation with the one person you trust most, an email to your manager, a booking for a blood test. Do whatever you want to do for you, and let the rest follow when it can. It is scary, and it is also, very often, the best thing people tell me they ever did.
Good luck.
If there is a topic that you would like me to cover, just let Sammy know.
Dr Helen Webberley
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