9 Fascinating Facts About Transitioning From Male to Female

Since Bruce Jenner debuted as Caitlyn on the cover of Vanity Fair, there has been a lot of talk about what transitioning from male to female really entails. Caitlyn revealed that on March 15, she underwent a 10-hour facial feminization surgery, which is a group of procedures that can morph masculine features into something more feminine. After waking up from the procedure, she told the magazine there was a moment of regret. She thought, "What did I just do? What did I just do to myself?" She also had a breast augmentation, hormone therapy, and tracheal shave. But what do all these surgeries really entail?

Honestly, we had some questions about the process ourselves! So we called up Dr. Jeffrey Spiegel, a facial plastic surgeon in Boston who has done over a thousand procedures for his transgender clients, to help clarify these queries. So whether you are thinking about transitioning, know a transgender person, or are just curious about Caitlyn, you'll have the right information to be an ally!

First a vocabulary lesson is required. Transgender is more about gender identity than sexual orientation. It refers to who you are, not who you are attracted to. So a transgender woman is someone who was born a man but identifies as a woman inside (such as Caitlyn). It also works in the opposite way: a transgender man is a female-born person who identifies as a man (Chaz Bono, for example). A transgender person might wear different clothes, experiment with grooming routines, take hormones, and undergo surgery to make his or her outer appearance match his or her gender identity.

"A transgender woman knows she's a woman surely as you know you are a woman," Dr. Spiegel told me. "The problem a transgender woman has is that you don't see she's a woman. So the main goal is to make her facial appearance match her sense of self."

Every transgender person's journey is different. However, facial feminization surgery is typically one of the first considerations for someone looking to make a change. FFS can erase masculine features such as a strong jaw, prominent Adam's apple, or receding hairline. If all these procedures are done at once, it could take up to 10 hours on the operating table and cost up to $50,000. Continue reading to get the full spectrum of surgeries available to someone looking to undergo the male-to-female transition. While all of these are not required, each procedure serves to make a transgender woman feel more comfortable in her skin.

Dr. Jeffrey Spiegel

1. Hormones

Typically the first step in a transgender woman's process is hormone therapy. Aside from facial features, breasts are one of the first things that differentiate men and women. The estrogen and anti-androgen cocktail jump-starts breast development so that the areola are enlarged and the ducts begin to expand behind the nipple. The breast-growth process is similar to what might happen when a pubescent girl's mosquito bites develop into full-blown breasts. Between two months and two years, the area will expand to create a visible bosom. However, it's rare that the size will ever grow to anything over a B cup for a male undergoing the transition. Breast augmentation is a popular alternative.

You may have heard that birth control can clear up women's acne and improve skin tone, because the pill contains a high amount of estrogen and progesterone. Men transitioning to become women rely on hormones in a similar way. Guys naturally have thicker skin, larger pores, and an overall rougher complexion, and taking estrogen can counteract that.

In addition, men taking hormones will experience a decrease in body hair (on arms and legs). However, facial hair continues to grow. That's why many transgender women opt for more permanent hair removal solutions, such as laser or electrolysis.

After a year of taking hormones, those transitioning will find that fat gathers on different areas of the body, such as thighs, hips, and butt (re: the places us ladies usually want to lose weight). But this actually makes the body appear curvier — like a woman. As the waist slims down, the body takes on an hourglass shape. Upper-body muscle mass also decreases and genitals begin to shrink. All of these hormonal changes are subtle and can take up to two years to reach their peak.

2. Brow Lift and Forehead Recontouring

The last time you made a connection at a bar, we're guessing it was the simple come-hither stare and brow raise that initiated the first attraction. "The eyebrow area and the bone underneath is the most important area of our face," Dr. Spiegel explained. "It provides information such as are [you] a man or a woman, are [you] attractive, and are [you] familiar or not?" Humans (and other mammals) use the eyes and brow area to communicate without words. All of these things make the forehead area very important during FFS. Women typically have higher brows, whereas men have a more pronounced brow ridge (the bone just above the eyebrows). For a transgender woman, a brow lift raises the arches a few inches (similar to a face-lift), and a brow shave can minimize the prominence of the bone underneath arches. In more severe cases, patients can receive full forehead reconstruction in which the bone is removed, reshaped, and replaced.

3. Scalp Advancement

Men's natural hormones cause their hairlines to slowly recede with age, creating an M shape. You've probably noticed your father is thinning around the temples, while your mother just complains about overall hair loss. Estrogen hormones help halt male pattern baldness for transitioning transgender women. However, scalp advancement surgery can also counteract hair loss and give the hairline a U shape, which is more common among women.

Dr. Jeffrey Spiegel

4. Rhinoplasty

Not only do men have larger noses in every aspect, but the angle of the nose also varies between the sexes. Most guys have a hump on the bridge, whereas ladies have a concave curve. Dr. Spiegel uses classic reduction rhinoplasty techniques to create a more feminine nose with an upturned tip. "You need to change the shape of the nostrils so that the nose has a feminine appearance, and I make the nose much smaller."

5. Cheek Implants

Women tend to have more prominent cheekbones that give a three-dimensional fullness to the face. So to emphasize a transgender client's flatter cheeks, Dr. Spiegel adds implants, fillers, or fat grafts from other parts of the body. Plumping the cheek in this way also bounces light into the eye, making the entire face appear more attractive. It's the same strategy women use when they apply highlighter to their cheekbones.

Dr. Jeffrey Spiegel

6. Jaw and Chin Contouring

The goal is to make the chin appear rounder, shorter, narrower, and tapered with a genioplasty (chin shave). You also want to erase the harsh, square angles associated with the male jaw. "We go in through your mouth so there's no visible scars and reduce the amount of bone," Dr. Spiegel explained. "It minimizes the heavy chin look and gives a nice delicate appearance to the face." The finished effect is actually similar to something a woman with a square face might use when contouring with makeup.

7. Tracheal Shave

During puberty, young boys begin to develop an Adam's apple. The thyroid cartilage is more prominent in men because males have larger voice boxes (and deeper voices). To correct an oversize Adam's apple in his transgender patients, Dr. Spiegel makes an incision just below the chin and removes any excess cartilage. The procedure is known as a tracheal shave. While this does change the outer appearance significantly, it has no effect on the voice box. To get the higher-pitched speech typically associated with women, an extra tightening of the vocal chords is required.

8. Lip Lift

As any Kardashian fan knows, plump lips have been gaining momentum thanks to Kylie Jenner, and while young girls are going to extreme lengths to get a voluptuous pout, transgender women also have to consider surgery to achieve more feminine lips. Men tend to have more space between the bottom of the nose and the upper lip. "I'll make the distance from the nose to the upper lip shorter," Dr. Spiegel explained. "So that more light will bounce off your teeth and you'll look more attractive." Lip fillers are also an option to get a more pronounced pucker.

Dr. Jeffrey Spiegel

9. Sex Reassignment Surgery

A transgender woman who is also attracted to men might want to take her male-to-female transition to the final phase — a vaginoplasty or sex reassignment surgery. In his interview, Bruce explained that even though he identifies with feminine gender norms, he is still attracted to women. However, converting a penis into a vagina is an option. The process removes the testicles completely and turns the shaft of the penis inside out. The surgeon must then create a new place to urinate and a neo-clitoris. "The hardest part with this procedure is that your body tends to create scar tissue after surgery to close the spaces," Dr. Spiegel explained. "So people need a series of dilators, which are almost like plastic rods that they need to put into the vagina to keep that area open."

A male-to-female transition can be an extensive and expensive process. However, finally having your gender identity match the outer appearance is something that is priceless. "After the transgender women who come to see me go off into world, you have no idea [they were ever men]," Dr. Spiegel said. "Some people want to disappear and be the girl next door and go about their business. They want to be ignored like the rest of us."