Gender Affirming Care: Non-surgical

What is gender-affirming care?

Gender-affirming care (GAC) is an umbrella term for health care that aims to help a transgender or gender diverse person’s body better align with their gender identity. You might seek out GAC if you experience gender incongruence—the state in which the gender you identify with conflicts with the sex you were assigned at birth. There are many different forms of GAC, including both lifestyle changes and medical interventions. The World Professional Association for Transgender Health (WPATH)—the organization often recognized as the gold standard for GAC— outline guiding recommendations for GAC. Additionally, it’s helpful to keep in mind that medical transition isn’t necessary to identify as transgender or gender diverse. Reflecting on your goals and speaking with a trans-competent health care professional (more on this later) might be the best way to figure out what GAC (if any) may be appropriate for you.  

What are non-surgical GAC options?              

There are several non-surgical GAC options. They range from medications and procedure options, to practices you can try on your own. These could include: 

• Gender affirming hormone therapy (GAHT) 
• Binding, tucking, padding, and packing 
• Hair removal 
• Voice therapy 

What is Gender-affirming hormone therapy?  

Gender-affirming hormone therapy (GAHT) is used to suppress secondary sex characteristics—like the growth of facial hair, pubic hair, and breasts, as well as the deepening of your voice and menstruation—that don’t match your gender identity. It also helps promote those that do. Before you can start hormone therapy, however, WPATH recommends that you meet a few criteria: 

• Demonstrate gender incongruence: You must demonstrate gender incongruence—sometimes with diagnosis 
• Provide consent: You must provide consent for any treatments that may be necessary to support your transition 
• Understand the mental and physical impacts of GAHT: It’s recommended that your mental and physical health be evaluated and that you’re informed how your mental and physical health, including your reproductive capabilities, would be altered from GAHT

If you meet these requirements, GAHT can be prescribed by endocrinologists (hormone doctors) as well as providers in primary care fields and obstetrician gynecologists (OB-GYNs) who specialize in trans-competent care.

There are two primary forms of GAHT—testosterone therapy and estrogen therapy. Testosterone therapy suppresses menstruation, lowers the voice, redistributes fat, and increases facial and body hair, libido, muscle mass, skin oiliness and acne. In the United States, testosterone is available via injection and gel. Patients taking testosterone should be monitored, especially for cardiovascular health, every three months for one year and then every six to 12 months after.  

Estrogen therapy reduces body and facial hair and increases breast formation and levels of body fat. Estrogen is often combined with therapy that blocks androgens, the family of sex hormones that include testosterone. Androgen blockers help balance the amount of testosterone in the body and therefore often reduce the size of testicles and suppress erectile function.  

Finally, GAHT can also be used by gender diverse individuals. Treatment doesn’t have to be an all-or-nothing endeavor. Some individuals may want to preserve certain physical traits of their sex assigned at birth but use hormone therapy to reduce the presence of others. While there are “standard” hormone dosing regimens, there are also alternative hormone regimens that might involve adding or subtracting medications or changing the amount that is prescribed. While it's impossible to perfectly pick and choose what effects you'll experience, your health care provider may be able to vary the regimen to achieve your desired results. For example, it might be possible for non-binary individuals assigned male at birth (AMAB) to develop breasts and reduce face and body hair and preserve erectile function. For non-binary individuals assigned female at birth (AFAB) it may be possible to alter testosterone levels such that they have increased muscle mass and a lower voice without increased facial or body hair. 

What is binding, tucking, padding, or packing? 

Binding, tucking, padding, packing are ways that can change how clothing looks on your body.  

• Binding, which involves using tight fabric to flatten your chest, might be appealing if you’re trying to minimize the appearance of breasts or experience dysphoria when wearing a bra. But binding can be painful and even cause difficulty breathing, restricted blood flow, and bruises if the binder is too tight, worn too long, or made from a material that’s not breathable. 
• Packing entails wearing a “packer”—commonly either a prosthetic penis or doubled-up unlubricated condoms filled with hair gel—to create the appearance of a penis. 
• Tucking aims to conceal a penis bulge by hiding the penis and testes either between the legs or butt or inside the inguinal canal—the passageway where the testes originally descend from the abdomen into the scrotum. It’s recommended to only tuck for short periods of time because tucking regularly can affect fertility.  
  Padding helps create or enhance the appearance of breasts, hips, and a butt through padded underwear and bras. 

What are some hair removal options?

Hair removal is a way to manage facial and body hair in a way that aligns with your gender identity. There are two main ways to correct hair growth: laser hair removal and electrolysis hair removal. 

• Laser hair removal involves shining light on dark hairs, which absorb the light and turn it into heat. The heat destroys the hair follicle and prevents future hair growth. Unfortunately, because of the way this mechanism works, it’s ineffective on lighter hair. 
• Electrolysis, on the other hand, uses an electric current at the root of hair follicles and can be used on all hair types.  
  Sometimes these two practices are used in tandem. Laser hair removal can be used as a first pass, and electrolysis after to destroy the hairs that laser couldn’t get rid of. It might be good to know that hair removal treatments can be both time- and cost-intensive. 

What is voice therapy?

Voice therapy is an option if you feel like the pitch, cadence, or resonance of your voice doesn’t match that of your gender identity. Of course, there’s no one way to sound like a particular gender. But learning how to change the pitch or tone of your voice, with the help of a speech therapist or an otolaryngologist (an ear, nose, and throat doctor), may help you feel more in control of your gender presentation. If you want to have a lower voice, voice therapy can help you speak with a certain rhythm, rate, and pitch variability. If you want to have a higher voice, it's less straightforward. Testosterone causes the voice to drop in pitch whether during puberty or through hormone therapy later in life. Once this pitch drop happens, it's irreversible except with surgery, even if you suppress testosterone levels or take estrogen hormone therapy instead. That said, pitch is only one of the many qualities that influence how others interpret voices. Other qualities, such as resonance and intonation can be changed through voice therapy. If you’re gender-diverse, voice therapy can help you transition between different patterns of speech and pitch.  

Will your insurance cover non-surgical GAC?

If you’re hoping to use insurance to pay for non-surgical GAC, it can be helpful to research what you’re hoping to do, and how much is covered. Some insurance plans may not cover some forms of non-surgical GAC. For example, materials needed for binding, tucking, packing, and padding are rarely ever covered. Other insurance plans may limit what they cover based on your reason for needing it. While electrolysis and laser hair removal might be covered when they’re required for another surgery (like a skin graft), they likely won’t be covered if deemed voluntary. Another consideration to be aware of is that while most insurances cover GAHT, testosterone is a controlled substance. If your GAHT involves testosterone, you may have to work with your health care provider and insurance company to get pre-authorization done annually.  

If you want to know whether your insurance will cover non-surgical GAC, consider searching for your plan on your insurance company’s website. There may be information included under headings like "Evidence of Coverage," or "Certificate of Coverage." You can also call the insurance company directly for more information. If you’re still unsure about whether your insurance will cover your GAC, consider checking other online resources about which major insurance companies cover care. If your insurance doesn’t cover costs or if you don’t have insurance, you might consider financial assistance programs for non-surgical GAC. Doing an internet search for ‘financial assistance programs for gender affirming care’ may get you started with resources in your area. Additionally, there are a variety of websites with lists of different funds to search through that may align with the type of care you are hoping to pursue. Some of these websites include: 

• Campaign for Southern Equality 
• Trans Lifeline 
• Point of Pride