Can You Get SRS Without HRT?
The Role of HRT in Sex Reassignment Surgeries
For this particular question, there is not a direct all-encompassing answer. Certain gender-affirming surgeries can be performed without hormone replacement therapy. Still, there are some that require hormones simply due to the nature of the surgery itself and the effect that it has on natural hormone production. The first port of call for surgeons is the WPATH Standards of Care (SOC), and most surgeons will follow those care guidelines.
The SOC underpins that some of these surgeries are permanent (non-reversible), especially bottom surgery, as it involves removing and destroying tissues. For this reason, surgeons want to make sure that you are absolutely certain, that you have considered your options and possible outcomes, and are committed to the outcome for life.
This means they at least want to see that you are taking other long-term steps to transition to another gender. If you are not on hormone treatment, you will need to show commitment to the transition in different ways. The goal of surgeons in seeking this kind of commitment is directly related to improving your quality of life through surgery. They want to be absolutely sure that you will not regret such drastic measures later on in life.
A more pertinent medical reason for the importance of hormone replacement therapy is that sex reassignment surgery sometimes involves the removal of gonads (testes or ovaries) which leads to a steep and immediate drop in sex hormone production.
This can be dangerous if not treated, so whether you take hormones to maintain your gender assigned at birth or whether you take hormones to change your secondary sex characteristics, some kind of hormone therapy must be taken for the maintenance of your physical health. The only time that hormones are not administered for these purposes is in the case of a medical condition that negates the administration of hormones.
Generally, surgeons require at least one year to go by after you start taking hormones before they will consider performing surgery; this is because it can take that long for fat distribution and breast/chest changes to fully settle. Surgeons would need to see the extent of those changes before they can come up with a comprehensive surgical plan. If you are not taking any hormones and you are not willing or able to take hormones, then there might be limits to which surgeries you can have.
Standards of Care on Sex Reassignment Surgery
A Word From The World Professional Association for Transgender Health
The SOC states that hormone therapy is recommended for some, but not all, forms of sex reassignment surgery. This opens the floor to interpretation, which means that you will likely be able to find some surgeons who are willing to undertake surgeries without HRT. However, this would preclude surgeries involving the removal of gonads for the reason stated above, unless there is a medical reason not to administer HRT.
While WPATH indicated psychiatric assessment as a requirement for HRT and sex reassignment surgery, it specifies that psychotherapy is not a requirement. This means that a person does not need to be in regular psychotherapy but will need to attend an assessment, which is usually once-off and involves consultations and several tests to be taken. These tests are performed and analyzed by a mental health professional.
Results are then presented to the patient and healthcare providers who requested the tests. It is often not necessary to repeat such tests unless there is an unusual reason for repetition at a later date. That being said, the SOC does highly recommend regular therapy with a licensed mental health care provider long before, throughout, and following sex reassignment surgery. This recommendation, again, is made with your quality of life in mind, and this includes your mental health.
Transgender men and women can hugely benefit from attending regular therapy throughout their transition process and even beyond that. Regular therapy can also improve coexisting mental health conditions, and many surgeons will likely feel more comfortable performing sex reassignment surgery on someone who is in regular therapy just because of the increased level of support available to that person.
Furthermore, an experienced surgeon who adheres very strictly to the SOC will require two letters from two different therapists before undertaking permanent alterations to your body. An alternative option that an experienced surgeon can be comfortable with is to follow the informed consent route, which involves tests and consultations within an interdisciplinary team that the surgeon works with regularly. It might not involve long-term therapy.
Something that is a requirement for all surgeries is that the patient should have lived as their desired gender for at 12 months before surgery. This seems to be a hard requirement and is not easily avoided. It is indicated because it gives the patient a good idea of what it is like to live as their desired gender, and if they have serious doubts, they can reevaluate their plan before any irreversible surgery is performed.
Hormone treatment is indicated for similar reasons related to understanding what type of changes will happen to your body and what it might be like transitioning completely.
Furthermore, it also causes some changes that will change the surgical plan somewhat. There are two important contraindications to the hormone therapy requirement; if HRT is not indicated for a documented medical reason or surgery is indicated for a reason other than treating gender dysphoria. We must remember that gender-affirming surgery can sometimes be a medical treatment for other medical conditions recognized in sexual medicine.
Overall the goal of any gender affirmation surgery will be to improve quality of life, and if that is not the outcome of steps taken, then the plan should be reevaluated. Some plastic surgeons monitor an individual for over a year before gender affirmation surgery is entirely completed (there are usually a series of surgeries involved). People who have undergone SRS will thus attest to the importance of a good rapport with your surgeon.
Which (Male to Female) MTF Surgeries Require HRT?
HRT is strongly recommended for breast augmentation but is not a strict requirement. It is recommended that a transgender woman maintain at least one year of Estradiol before considering breast surgery. This is due to the degree of breast tissue growth associated with Estradiol administration. It tends to peak within one year, and these changes need to be factored into the final surgery plan in order to achieve optimal results.
A minimum of 12 months continuous HRT is a requirement for an Orchiectomy and Vaginoplasty for trans women. This requirement will stand unless there is another condition that precludes the administration of HRT.
Which (Female to Male) FTM Surgeries Require HRT?
For transgender men, HRT is not a requirement for chest surgery, and although it is recommended, the recommendation is not as strong as for transgender women.
Furthermore, a minimum of 12 months continuous HRT is a requirement for Salpingo-Oophorectomy and Metiodioplasty or Phalloplasty for trans men. This requirement again is only in place unless another condition precludes HRT, and its purpose is to maintain hormone levels following the removal of gonads, which is an important part of transgender healthcare.
Responsibility To Treat Gender Dysphoria
The Standards of Care is clear that both medical and psychiatric professionals have a responsibility to treat gender dysphoria appropriately when it presents. Professionals cannot deny patients access to treatment for any particular reason unless a comorbid disorder specifically negates common interventions. In such a case, alternative intervention needs to be explored.
Professionals also need to have a network to which they can refer patients who need additional treatments that are outside of their scope of practice. In such a case, there would be a primary physician in charge of the patient’s case, and they should monitor other treatments as well and should step in if they suspect that a particular treatment is not appropriate to the patient’s case. They should thus keep in contact with other treating professionals.
Gender Identity and Bottom Surgery
It is important to note that not everyone who has difficulty with gender identity will go on to undergo SRS, especially bottom surgery. There are various levels of transition that affect each individual differently, and where comparatively low levels of gender affirmation can be enough for some, others might need to go all the way before they feel secure in their gender.
Social transition is often one of the earlier steps in transition. It involves anything from ‘coming out’ as transgender to family, at work, to friends, and beginning to live as the desired gender in public. Some transgender people might do this in stages, while others could prefer to do it all at once (although this might be overwhelming). The real-life experience can vary wildly between individuals.
It often involves dressing as your true gender identity, adopting preferred pronouns, changing your legal name, and adopting the gender role and norms of your chosen identity.
Under some circumstances, these changes can be enough to significantly lessen gender dysphoria for some transgender patients, and they might not feel the need to start HRT or have surgery to express their gender.
Once transgender individuals have socially transitioned, they might still be experiencing dysphoria, in which case they usually plan on starting HRT. There does not explicitly need to be a linear split between social transition and the starting of HRT.
Furthermore, while it is advised that HRT should be maintained long-term, there are transgender people who do not wish to rely on hormone therapy for the rest of their lives. So they might opt for short-term hormone treatments. These usually span a year or two in order to allow for maximum benefit from sex hormones. It is important that these individuals understand that some, but not all, changes that occurred due to HRT might regress when HRT is stopped.
Should an individual opt for long-term HRT, they are monitored throughout their lives, and hormone levels are adjusted to remain within normative degrees for their age. This is done because even in cisgender individuals, hormone levels change with age, and it would be the goal of a doctor to keep hormone levels in transgender people at normative levels. An example of such age-related changes is menopause in cis women.
Changes associated with hormone treatment can be relatively simple, such as growing facial hair or changes in body hair distribution, or they can be more complex such as changes to the voice and breast tissue. As long as HRT is maintained, these changes will likely stabilize within the first year or two of HRT; after this time, the dose might be adjusted for the purpose of maintenance. It is important to discuss which of these changes are irreversible, should a patient want to undergo HRT only for a set time, or in the unlikely event that they might develop a condition that would require the cessation of HRT.
Sex Reassignment Surgery
“Other” gender-affirming surgery
In addition to the expected chest and genital surgeries, there are some other procedures that can be used for the treatment of gender dysphoria. These can involve redistributing fat, and/or changes to hands, neck, and facial features to better express features more readily associated with the desired sex.
These surgeries can often be performed if a trans person is uncomfortable with chest or genital surgery. There is no prerequisite of chest or genital surgery for these procedures, and there is likely also not a requirement for HRT. A popular example of this type of gender affirmation surgery for a trans woman is the reduction of the appearance of the adams apple. This is important for the enhancement of feminine characteristics as women who are assigned female at birth do not have visible adams apples at all.
Top surgery involves either a mastectomy and reshaping of the chest to appear more masculine or breast implants and reshaping of the area to appear more feminine. This is often a considerable milestone for trans people, and for many, it marks the end of their transition.
It makes it much easier for individuals to ‘pass’ and makes everyday life easier. Many never go on to undergo further reassignment surgery. There are many reasons why a person might not want to undergo genital surgeries, and they are not required to if they are satisfied with results of surgical procedures they have already undergone.
Genital surgery is by far the most personal and serious decision for transgender individuals in most cases. It is the most extreme form of gender expression and is not reversible. This type of surgery also involves the removal of the gonads (most often), which makes it difficult for people to live without hormone replacement for the rest of their lives.
Genital surgery for a transgender woman involves the construction of a vagina and the removal of the testes. This is the first kind of genital gender affirmation surgery that was explored in depth throughout the history of gender affirmation surgery and was a significant step in the right direction of the transgender community and transgender equality at large. For trans men, it involves the removal of the uterus and ovaries and the construction of a penis.
There are also other long-term practices that transgender individuals need to adopt, such as the maintenance of depth and width of a vaginal canal for trans women. There are also several surgical complications that can be associated with genital surgery. These possible complications are discussed with patients in advance of sex reassignment surgery.
Interestingly, even when complications arise, most people still report that they do not regret undergoing genital reassignment surgery, and many report high surgical satisfaction.
Gender reassignment surgery, even in its simplest and least invasive forms, are a very personal choice. It makes sense that surgeons would want to ensure that undertaking SRS is the best possible step for you. They want to ensure that any changes that they make to your body will not cause you further distress, and they realize that intervention is a requirement, so even if surgery is not the way for you, medical professionals will be able to provide you with valuable information and support so that you can live the best possible version of your life.
Advocacy for transgender people can involve anything from making sure that the term “transgender” is used appropriately to ensure that other professionals are providing appropriate care. Everyone has the right to sex reassignment surgery; they have a right to mental health care; they have a right to improve their quality of life through gender reassignment surgery to their body. These are fundamental rights that should be respected and defended wherever possible.
Currently, the stance that is being taken by the transgender and ally communities is to challenge binary views and definitions of biological sex. There are professionals in the scientific community who agree with the challenge to definitions of biological sex, citing the vast variations in characteristics used to categorize biological sex. It is not uncommon for a male of the same gender biologically as another male to display differences in their biological sex representation.