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Asleep not night-time blood pressure as prognostic marker of cardiovascular risk. Transgender adolescents may want to preserve fertility, which may be otherwise compromised if puberty is suppressed at an early stage and the individual completes phenotypic transition with the use of sex hormones. Limited data are available regarding the effects of GnRH analogs on brain development. A single cross-sectional study demonstrated no compromise of executive function , but animal data suggest there may be an effect of GnRH analogs on cognitive function Our recommendation of GnRH analogs places a higher value on the superior efficacy, safety, and reversibility of the pubertal hormone suppression achieved as compared with the alternatives and a relatively lower value on limiting the cost of therapy.
Of the available alternatives, depot and oral progestin preparations are effective. Experience with this treatment dates back prior to the emergence of GnRH analogs for treating precocious puberty in papers from the s and early s — These compounds are usually safe, but some side effects have been reported — Only two recent studies involved transgender youth , One of these studies described the use of oral lynestrenol monotherapy followed by the addition of testosterone treatment in transgender boys who were at Tanner stage B4 or further at the start of treatment They found lynestrenol safe, but gonadotropins were not fully suppressed.
The study reported metrorrhagia in approximately half of the individuals, mainly in the first 6 months. Acne, headache, hot flashes, and fatigue were other frequent side effects. Another progestin that has been studied in the United States is medroxyprogesterone. This agent is not as effective as GnRH analogs in lowering endogenous sex hormones either and may be associated with other side effects Progestin preparations may be an acceptable treatment for persons without access to GnRH analogs or with a needle phobia.
If GnRH analog treatment is not available insurance denial, prohibitive cost, or other reasons , postpubertal, transgender female adolescents may be treated with an antiandrogen that directly suppresses androgen synthesis or action see adult section. Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs If the gonadal axis is not completely suppressed—as evidenced by for example menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased.
During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. Table 7 illustrates a suggested clinical protocol. Adapted from Hembree et al. Anthropometric measurements and X-rays of the left hand to monitor bone age are informative for evaluating growth. To assess BMD, clinicians can perform dual-energy X-ray absorptiometry scans. Protocol Induction of Puberty. We suggest monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment Table 9.
Adolescents develop competence in decision making at their own pace.
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Ideally, the supervising medical professionals should individually assess this competence, although no objective tools to make such an assessment are currently available. Many adolescents have achieved a reasonable level of competence by age 15 to 16 years , and in many countries year-olds are legally competent with regard to medical decision making However, others believe that although some capacities are generally achieved before age 16 years, other abilities such as good risk assessment do not develop until well after 18 years They suggest that health care procedures should be divided along a matrix of relative risk, so that younger adolescents can be allowed to decide about low-risk procedures, such as most diagnostic tests and common therapies, but not about high-risk procedures, such as most surgical procedures Currently available data from transgender adolescents support treatment with sex hormones starting at age 16 years 63 , However, some patients may incur potential risks by waiting until age 16 years.
These include the potential risk to bone health if puberty is suppressed for 6 to 7 years before initiating sex hormones e. Additionally, there may be concerns about inappropriate height and potential harm to mental health emotional and social isolation if initiation of secondary sex characteristics must wait until the person has reached 16 years of age.
However, only minimal data supporting earlier use of gender-affirming hormones in transgender adolescents currently exist The MHP who has followed the adolescent during GnRH analog treatment plays an essential role in assessing whether the adolescent is eligible to start sex hormone therapy and capable of consenting to this treatment Table 5. Prior to the start of sex hormones, clinicians should discuss the implications for fertility see recommendation 1.
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Throughout pubertal induction, an MHP and a pediatric endocrinologist or other clinician competent in the evaluation and induction of pubertal development should monitor the adolescent. In addition to monitoring therapy, it is also important to pay attention to general adolescent health issues, including healthy life style choices, such as not smoking, contraception, and appropriate vaccinations e. It is increasingly used for pubertal induction in hypogonadal females. However, the absence of low-dose estrogen patches may be a problem. As a result, individuals may need to cut patches to size themselves to achieve appropriate dosing In transgender male adolescents, clinicians can give testosterone injections intramuscularly or subcutaneously , When puberty is initiated with a gradually increasing schedule of sex steroid doses, the initial levels will not be high enough to suppress endogenous sex steroid secretion.
Gonadotropin secretion and endogenous production of testosterone may resume and interfere with the effectiveness of estrogen treatment, in transgender female adolescents , Therefore, continuation of GnRH analog treatment is advised until gonadectomy. Alternatively, in transgender male adolescents, GnRH analog treatment can be discontinued once an adult dose of testosterone has been reached and the individual is well virilized.
If uterine bleeding occurs, a progestin can be added. However, the combined use of a GnRH analog for ovarian suppression and testosterone may enable phenotypic transition with a lower dose of testosterone in comparison with testosterone alone. If there is a wish or need to discontinue GnRH analog treatment in transgender female adolescents, they may be treated with an antiandrogen that directly suppresses androgen synthesis or action see section 3. The recommendation to initiate pubertal induction only when the individual has sufficient mental capacity roughly age 16 years to give informed consent for this partly irreversible treatment places a higher value on the ability of the adolescent to fully understand and oversee the partially irreversible consequences of sex hormone treatment and to give informed consent.
It places a lower value on the possible negative effects of delayed puberty.
Before starting sex hormone treatment, effects on fertility and options for fertility preservation should be discussed. Adult height may be a concern in transgender adolescents. In a transgender female adolescent, clinicians may consider higher doses of estrogen or a more rapid tempo of dose escalation during pubertal induction. There are no established treatments yet to augment adult height in a transgender male adolescent with open epiphyses during pubertal induction.
It is not uncommon for transgender adolescents to present for clinical services after having completed or nearly completed puberty. In such cases, induction of puberty with sex hormones can be done more rapidly see Table 8. Additionally, an adult dose of testosterone in transgender male adolescents may suffice to suppress the gonadal axis without the need to use a separate agent. At the appropriate time, the multidisciplinary team should adequately prepare the adolescent for transition to adult care. The timing of these two goals and the age at which to begin treatment with the sex hormones of the chosen gender is codetermined in collaboration with both the person pursuing transition and the health care providers.
The physical changes induced by this sex hormone transition are usually accompanied by an improvement in mental well-being , We recommend that clinicians evaluate and address medical conditions that can be exacerbated by hormone depletion and treatment with sex hormones of the affirmed gender before beginning treatment Table It is the responsibility of the treating clinician to confirm that the person fulfills criteria for treatment.
The treating clinician should become familiar with the terms and criteria presented in Tables 1—5 and take a thorough history from the patient in collaboration with the other members of the treatment team. The treating clinician must ensure that the desire for transition is appropriate; the consequences, risks, and benefits of treatment are well understood; and the desire for transition persists.
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They also need to discuss fertility preservation options see recommendation 1. Clinical studies have demonstrated the efficacy of several different androgen preparations to induce masculinization in transgender males Appendix A , , — Regimens to change secondary sex characteristics follow the general principle of hormone replacement treatment of male hypogonadism Sustained supraphysiologic levels of testosterone increase the risk of adverse reactions see section 4.
Similar to androgen therapy in hypogonadal men, testosterone treatment in transgender males results in increased muscle mass and decreased fat mass, increased facial hair and acne, male pattern baldness in those genetically predisposed, and increased sexual desire In transgender males, testosterone will result in clitoromegaly, temporary or permanent decreased fertility, deepening of the voice, cessation of menses usually , and a significant increase in body hair, particularly on the face, chest, and abdomen.
Cessation of menses may occur within a few months with testosterone treatment alone, although high doses of testosterone may be required. If uterine bleeding continues, clinicians may consider the addition of a progestational agent or endometrial ablation Clinicians may also administer GnRH analogs or depot medroxyprogesterone to stop menses prior to testosterone treatment.
The hormone regimen for transgender females is more complex than the transgender male regimen Appendix B. Treatment with physiologic doses of estrogen alone is insufficient to suppress testosterone levels into the normal range for females Most published clinical studies report the need for adjunctive therapy to achieve testosterone levels in the female range 21 , , , — , , Multiple adjunctive medications are available, such as progestins with antiandrogen activity and GnRH agonists Spironolactone works by directly blocking androgens during their interaction with the androgen receptor , , It may also have estrogenic activity Cyproterone acetate, a progestational compound with antiandrogenic properties , , , is widely used in Europe.
Leuprolide and transdermal estrogen were as effective as cyproterone and transdermal estrogen in a comparative retrospective study Among estrogen options, the increased risk of thromboembolic events associated with estrogens in general seems most concerning with ethinyl estradiol specifically , , , which is why we specifically suggest that it not be used in any transgender treatment plan.
Injectable estrogen and sublingual estrogen may benefit from avoiding the first pass effect, but they can result in more rapid peaks with greater overall periodicity and thus are more difficult to monitor , However, there are no data demonstrating that increased periodicity is harmful otherwise. Clinicians can use serum estradiol levels to monitor oral, transdermal, and intramuscular estradiol. Blood tests cannot monitor conjugated estrogens or synthetic estrogen use.
The transdermal preparations and injectable estradiol cypionate or valerate preparations may confer an advantage in older transgender females who may be at higher risk for thromboembolic disease Our recommendation to maintain levels of gender-affirming hormones in the normal adult range places a high value on the avoidance of the long-term complications of pharmacologic doses. Those patients receiving endocrine treatment who have relative contraindications to hormones should have an in-depth discussion with their physician to balance the risks and benefits of therapy.
Clinicians should inform all endocrine-treated individuals of all risks and benefits of gender-affirming hormones prior to initiating therapy. Clinicians should strongly encourage tobacco use cessation in transgender females to avoid increased risk of VTE and cardiovascular complications. We strongly discourage the unsupervised use of hormone therapy Tailoring current protocols to the individual may be done within the context of accepted safety guidelines using a multidisciplinary approach including mental health.
No evidence-based protocols are available for these groups We need prospective studies to better understand treatment options for these persons. Physical changes that are expected to occur during the first 1 to 6 months of testosterone therapy include cessation of menses, increased sexual desire, increased facial and body hair, increased oiliness of skin, increased muscle, and redistribution of fat mass. Changes that occur within the first year of testosterone therapy include deepening of the voice , , clitoromegaly, and male pattern hair loss in some cases , , , Table Estimates represent clinical observations: Physical changes that may occur in transgender females in the first 3 to 12 months of estrogen and antiandrogen therapy include decreased sexual desire, decreased spontaneous erections, decreased facial and body hair usually mild , decreased oiliness of skin, increased breast tissue growth, and redistribution of fat mass , , , , , Table Breast development is generally maximal at 2 years after initiating hormones , , , Over a long period of time, the prostate gland and testicles will undergo atrophy.
Although the time course of breast development in transgender females has been studied , precise information about other changes induced by sex hormones is lacking There is a great deal of variability among individuals, as evidenced during pubertal development. We all know that a major concern for transgender females is breast development.
If we work with estrogens, the result will be often not what the transgender female expects. Alternatively, there are transgender females who report an anecdotal improved breast development, mood, or sexual desire with the use of progestogens.
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However, there have been no well-designed studies of the role of progestogens in feminizing hormone regimens, so the question is still open. Our knowledge concerning the natural history and effects of different cross-sex hormone therapies on breast development in transgender females is extremely sparse and based on the low quality of evidence. Current evidence does not indicate that progestogens enhance breast development in transgender females, nor does evidence prove the absence of such an effect.
This prevents us from drawing any firm conclusion at this moment and demonstrates the need for further research to clarify these important clinical questions Transgender persons have very high expectations regarding the physical changes of hormone treatment and are aware that body changes can be enhanced by surgical procedures e. Clear expectations for the extent and timing of sex hormone—induced changes may prevent the potential harm and expense of unnecessary procedures.
Hormone therapy for transgender males and females confers many of the same risks associated with sex hormone replacement therapy in nontransgender persons. The risks arise from and are worsened by inadvertent or intentional use of supraphysiologic doses of sex hormones, as well as use of inadequate doses of sex hormones to maintain normal physiology , Pretreatment screening and appropriate regular medical monitoring are recommended for both transgender males and females during the endocrine transition and periodically thereafter 26 , Table 14 contains a standard monitoring plan for transgender males on testosterone therapy , Key issues include maintaining testosterone levels in the physiologic normal male range and avoiding adverse events resulting from excess testosterone therapy, particularly erythrocytosis, sleep apnea, hypertension, excessive weight gain, salt retention, lipid changes, and excessive or cystic acne Adapted from Lapauw et al.
Because oral alkylated testosterone is not recommended, serious hepatic toxicity is not anticipated with parenteral or transdermal testosterone use , Past concerns regarding liver toxicity with testosterone have been alleviated with subsequent reports that indicate the risk of serious liver disease is minimal , , Table 15 contains a standard monitoring plan for transgender females on estrogens, gonadotropin suppression, or antiandrogens Key issues include avoiding supraphysiologic doses or blood levels of estrogen that may lead to increased risk for thromboembolic disease, liver dysfunction, and hypertension.
Clinicians should monitor serum estradiol levels using laboratories participating in external quality control, as measurements of estradiol in blood can be very challenging VTE may be a serious complication. A study reported a fold increase in venous thromboembolic disease in a large cohort of Dutch transgender subjects This increase may have been associated with the use of the synthetic estrogen, ethinyl estradiol The incidence decreased when clinicians stopped administering ethinyl estradiol Thus, the use of synthetic estrogens and conjugated estrogens is undesirable because of the inability to regulate doses by measuring serum levels and the risk of thromboembolic disease.
In a German gender clinic, deep vein thrombosis occurred in 1 of 60 of transgender females treated with a GnRH analog and oral estradiol The patient who developed a deep vein thrombosis was found to have a homozygous C T mutation in the methylenetetrahydrofolate reductase gene. In an Austrian gender clinic, administering gender-affirming hormones to transgender females and 89 transgender males was not associated with VTE, despite an 8.
A more recent multinational study reported only 10 cases of VTE from a cohort of subjects Thrombophilia screening of transgender persons initiating hormone treatment should be restricted to those with a personal or family history of VTE Monitoring D -dimer levels during treatment is not recommended Estrogen therapy can increase the growth of pituitary lactrotroph cells.
There have been several reports of prolactinomas occurring after long-term, high-dose estrogen therapy — In most cases, the serum prolactin levels will return to the normal range with a reduction or discontinuation of the estrogen therapy or discontinuation of cyproterone acetate , , The onset and time course of hyperprolactinemia during estrogen treatment are not known.
Clinicians should measure prolactin levels at baseline and then at least annually during the transition period and every 2 years thereafter.
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Given that only a few case studies reported prolactinomas, and prolactinomas were not reported in large cohorts of estrogen-treated persons, the risk is likely to be very low. Because the major presenting findings of microprolactinomas hypogonadism and sometimes gynecomastia are not apparent in transgender females, clinicians may perform radiologic examinations of the pituitary in those patients whose prolactin levels persistently increase despite stable or reduced estrogen levels.
Some transgender individuals receive psychotropic medications that can increase prolactin levels Administering testosterone to transgender males results in a more atherogenic lipid profile with lowered high-density lipoprotein cholesterol and higher triglyceride and low-density lipoprotein cholesterol values — Studies of the effect of testosterone on insulin sensitivity have mixed results , A randomized, open-label uncontrolled safety study of transgender males treated with testosterone undecanoate demonstrated no insulin resistance after 1 year , Numerous studies have demonstrated the effects of sex hormone treatment on the cardiovascular system , , , Long-term studies from The Netherlands found no increased risk for cardiovascular mortality Likewise, a meta-analysis of 19 randomized trials in nontransgender males on testosterone replacement showed no increased incidence of cardiovascular events A systematic review of the literature found that data were insufficient due to very low—quality evidence to allow a meaningful assessment of patient-important outcomes, such as death, stroke, myocardial infarction, or VTE in transgender males Future research is needed to ascertain the potential harm of hormonal therapies Clinicians should manage cardiovascular risk factors as they emerge according to established guidelines A prospective study of transgender females found favorable changes in lipid parameters with increased high-density lipoprotein and decreased low-density lipoprotein concentrations However, increased weight, blood pressure, and markers of insulin resistance attenuated these favorable lipid changes.
Thus, there is limited evidence to determine whether estrogen is protective or detrimental on lipid and glucose metabolism in transgender females With aging, there is usually an increase of body weight.
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Therefore, as with nontransgender individuals, clinicians should monitor and manage glucose and lipid metabolism and blood pressure regularly according to established guidelines We recommend that clinicians obtain BMD measurements when risk factors for osteoporosis exist, specifically in those who stop sex hormone therapy after gonadectomy. Baseline bone mineral measurements in transgender males are generally in the expected range for their pretreatment gender However, adequate dosing of testosterone is important to maintain bone mass in transgender males , In one study , serum LH levels were inversely related to BMD, suggesting that low levels of sex hormones were associated with bone loss.
Thus, LH levels in the normal range may serve as an indicator of the adequacy of sex steroid administration to preserve bone mass. The protective effect of testosterone may be mediated by peripheral conversion to estradiol, both systemically and locally in the bone. In aging males, studies suggest that serum estradiol more positively correlates with BMD than does testosterone , and is more important for peak bone mass Estrogen preserves BMD in transgender females who continue on estrogen and antiandrogen therapies , , , , Fracture data in transgender males and females are not available.
Transgender persons who have undergone gonadectomy may choose not to continue consistent sex steroid treatment after hormonal and surgical sex reassignment, thereby becoming at risk for bone loss. There have been no studies to determine whether clinicians should use the sex assigned at birth or affirmed gender for assessing osteoporosis e.
Although some researchers use the sex assigned at birth with the assumption that bone mass has usually peaked for transgender people who initiate hormones in early adulthood , this should be assessed on a case-by-case basis until there are more data available. This assumption will be further complicated by the increasing prevalence of transgender people who undergo hormonal transition at a pubertal age or soon after puberty. Sex for comparison within risk assessment tools may be based on the age at which hormones were initiated and the length of exposure to hormones.
In some cases, it may be reasonable to assess risk using both the male and female calculators and using an intermediate value. Because all subjects underwent normal pubertal development, with known effects on bone size, reference values for birth sex were used for all participants We suggest that transgender females with no known increased risk of breast cancer follow breast-screening guidelines recommended for those designated female at birth.
Studies have reported a few cases of breast cancer in transgender females — A Dutch study of transgender females followed for a mean of 15 years range of 1 30 years found one case of breast cancer. In transgender males, a large retrospective study conducted at the U. Veterans Affairs medical health system identified seven breast cancers The authors reported that this was not above the expected rate of breast cancers in cisgender females in this cohort. Furthermore, they did report one breast cancer that developed in a transgender male patient after mastectomy, supporting the fact that breast cancer can occur even after mastectomy.
Indeed, there have been case reports of breast cancer developing in subareolar tissue in transgender males, which occurred after mastectomy , Women with primary hypogonadism Turner syndrome treated with estrogen replacement exhibited a significantly decreased incidence of breast cancer as compared with national standardized incidence ratios , We need long-term studies to determine the actual risk, as well as the role of screening mammograms.
Regular examinations and gynecologic advice should determine monitoring for breast cancer. Prostate cancer is very rare before the age of 40, especially with androgen deprivation therapy Childhood or pubertal castration results in regression of the prostate and adult castration reverses benign prostate hypertrophy Although van Kesteren et al.
Studies have also reported a few cases of prostate carcinoma in transgender females — Transgender females may feel uncomfortable scheduling regular prostate examinations. Gynecologists are not trained to screen for prostate cancer or to monitor prostate growth. Thus, it may be reasonable for transgender females who transitioned after age 20 years to have annual screening digital rectal examinations after age 50 years and prostate-specific antigen tests consistent with U.
Preventive Services Task Force Guidelines Although aromatization of testosterone to estradiol in transgender males has been suggested as a risk factor for endometrial cancer , no cases have been reported. When transgender males undergo hysterectomy, the uterus is small and there is endometrial atrophy , Studies have reported cases of ovarian cancer , Although there is limited evidence for increased risk of reproductive tract cancers in transgender males, health care providers should determine the medical necessity of a laparoscopic total hysterectomy as part of a gender-affirming surgery to prevent reproductive tract cancer Given the discomfort that transgender males experience accessing gynecologic care, our recommendation for the medical necessity of total hysterectomy and oophorectomy places a high value on eliminating the risks of female reproductive tract disease and cancer and a lower value on avoiding the risks of these surgical procedures related to the surgery and to the potential undesirable health consequences of oophorectomy and their associated costs.
The sexual orientation and type of sexual practices will determine the need and types of gynecologic care required following transition. Additionally, in certain countries, the approval required to change the sex in a birth certificate for transgender males may be dependent on having a complete hysterectomy. Clinicians should help patients research nonmedical administrative criteria and provide counseling. If individuals decide not to undergo hysterectomy, screening for cervical cancer is the same as all other females.
For many transgender adults, genital gender-affirming surgery may be the necessary step toward achieving their ultimate goal of living successfully in their desired gender role. The type of surgery falls into two main categories: Those that change fertility previously called sex reassignment surgery include genital surgery to remove the penis and gonads in the male and removal of the uterus and gonads in the female.
The surgeries that effect fertility are often governed by the legal system of the state or country in which they are performed. Other gender-conforming surgeries that do not directly affect fertility are not so tightly governed. Gender-affirming surgical techniques have improved markedly during the past 10 years. Reconstructive genital surgery that preserves neurologic sensation is now the standard. The satisfaction rate with surgical reassignment of sex is now very high Additionally, the mental health of the individual seems to be improved by participating in a treatment program that defines a pathway of gender-affirming treatment that includes hormones and surgery , Table Surgery that affects fertility is irreversible.
Gender-affirming genital surgeries for transgender females that affect fertility include gonadectomy, penectomy, and creation of a neovagina , Surgeons often invert the skin of the penis to form the wall of the vagina, and several literatures reviews have reported on outcomes Sometimes there is inadequate tissue to form a full neovagina, so clinicians have revisited using intestine and found it to be successful 87 , , Some newer vaginoplasty techniques may involve autologuous oral epithelial cells , The scrotum becomes the labia majora.
Surgeons use reconstructive surgery to fashion the clitoris and its hood, preserving the neurovascular bundle at the tip of the penis as the neurosensory supply to the clitoris. Some surgeons are also creating a sensate pedicled-spot adding a G spot to the neovagina to increase sensation Most recently, plastic surgeons have developed techniques to fashion labia minora.
To further complete the feminization, uterine transplants have been proposed and even attempted Neovaginal prolapse, rectovaginal fistula, delayed healing, vaginal stenosis, and other complications do sometimes occur , Clinicians should strongly remind the transgender person to use their dilators to maintain the depth and width of the vagina throughout the postoperative period. Genital sexual responsivity and other aspects of sexual function are usually preserved following genital gender-affirming surgery , Ancillary surgeries for more feminine or masculine appearance are not within the scope of this guideline.
Voice therapy by a speech language pathologist is available to transform speech patterns to the affirmed gender Spontaneous voice deepening occurs during testosterone treatment of transgender males , No studies have compared the effectiveness of speech therapy, laryngeal surgery, or combined treatment. Breast surgery is a good example of gender-confirming surgery that does not affect fertility. In all females, breast size exhibits a very broad spectrum.
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For transgender females to make the best informed decision, clinicians should delay breast augmentation surgery until the patient has completed at least 2 years of estrogen therapy, because the breasts continue to grow during that time , Another major procedure is the removal of facial and masculine-appearing body hair using either electrolysis or laser treatments. Other feminizing surgeries, such as that to feminize the face, are now becoming more popular — In transgender males, clinicians usually delay gender-affirming genital surgeries until after a few years of androgen therapy.
Those surgeries that affect fertility in this group include oophorectomy, vaginectomy, and complete hysterectomy. Surgeons can safely perform them vaginally with laparoscopy. These are sometimes done in conjunction with the creation of a neopenis. The cosmetic appearance of a neopenis is now very good, but the surgery is multistage and very expensive , Radial forearm flap seems to be the most satisfactory procedure , Other flaps also exist Surgeons can make neopenile erections possible by reinervation of the flap and subsequent contraction of the muscle, leading to stiffening of the neopenis , , but results are inconsistent Surgeons can also stiffen the penis by imbedding some mechanical device e.
Because of these limitations, the creation of a neopenis has often been less than satisfactory. Recently, penis transplants are being proposed In fact, most transgender males do not have any external genital surgery because of the lack of access, high cost, and significant potential complications.
Some choose a metaoidioplasty that brings forward the clitoris, thereby allowing them to void in a standing position without wetting themselves , Surgeons can create the scrotum from the labia majora with good cosmetic effect and can implant testicular prostheses The most important masculinizing surgery for the transgender male is mastectomy, and it does not affect fertility. Breast size only partially regresses with androgen therapy Not Enabled Word Wise: Enabled Amazon Best Sellers Rank: Amazon Music Stream millions of songs. Amazon Advertising Find, attract, and engage customers. Amazon Drive Cloud storage from Amazon.
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