Trans 101: How Transgender Hormone Therapy Changes Body and Brain

For decades, doctors tried to psychoanalyze trans people out of being trans. Spoiler: it didn’t work. This episode dives into the medical reality of gender transition—from how hormones actually work at the cellular level to the emotional rollercoaster of a second puberty. You’ll learn what estrogen and testosterone really do to the body, what bottom growth actually means, and how modern surgery can create everything from boobs to fully functional penises with hydraulic erections. We cover the psychological shifts, the physical changes, the hilarious terminology trans people have coined, and why medical transition isn’t about “fixing” anyone—it’s about letting people finally be themselves.

Video version:

No Title
No Description

More from Charlie James:

Website
Order his book, I’m Just a Little Guy: How to Escape the Horrors and Get Back to Dillydallying
TikTok

Citations and further reading:

TRANSCRIPT

[00:00:00] Ashley: For most of the 20th century, when someone went to a doctor to say they felt like they were the wrong gender, the medical establishment had a clear answer: change the mind, not the body.

[00:00:25] Ashley: Psychiatrists would try psychoanalysis, convinced that gender dysphoria was a mental illness that could be talked away. They tried behavioral modification, reward systems, electroshock therapy. The logic seemed sound—if someone’s brain didn’t match their body, surely it would be easier to “fix” the three-pound organ upstairs than to change someone’s entire physical form.

[00:00:55] Ashley: But over decades of failed attempts, it became clear: you can’t therapy someone out of being transgender. You can’t cure gender dysphoria with antidepressants. You can’t shock someone into a different identity.

[00:01:19] Ashley: What finally worked was the opposite approach—helping the body match the brain. In 1966, endocrinologist Harry Benjamin published “The Transsexual Phenomenon,” where he argued that since there was no cure for transsexualism—the word they used at the time—it was in the best interests of transsexuals and society to aid in sex reassignment. That same year, the first gender clinic opened in the US. The medical paradigm had officially shifted from trying to cure transgender people to helping them transition.

[00:01:53] Ashley: Today, medical gender transition includes hormone therapy, a variety of surgical procedures, and other medical interventions that help align someone’s physical form with their internal sense of self.

[00:02:14] Ashley: What researchers discovered along the way was fascinating: these treatments don’t just change the body. Hormones work in the brain, too. They cross the blood-brain barrier and bind to receptors in the brain that affect cognition, mood, and emotional processing. Gender affirming care isn’t just about looking more like another gender—it’s about aligning body, brain, and identity in a way that years of talk therapy never could.

[00:02:39] Ashley: It turns out that when you stop trying to fix people’s brains and start supporting their bodies, something remarkable happens: they thrive.

[00:02:43] Ashley: In this episode, you’ll hear exactly how modern medical transition works—from the cellular level where estrogen and testosterone bind to receptors in tissues and organs, to the practical challenges of learning to live in a new body. You’ll learn about the biological changes, the emotional shifts, and the individual paths that people take through medical transition.

[00:03:04] Ashley: I’m Ashley Hamer Pritchard, and this is Taboo Science, the podcast that answers the questions you’re not allowed to ask.

[00:03:31] Ashley: When you’ve never felt gender dysphoria, it can be easy to think that therapy is the cure. A good therapist can reorient your perspective and help you accept the things you can’t change. But gender identity isn’t like your fear of blood or your relationship with your dad. It’s deeper than that.

[00:03:48] Michelle Forcier: You’re not just saying brain be male. You’re talking about cognition. You’re talking about emotion. You’re talking about someone’s spiritual life force. Do you think it’s easy to change people’s spiritual life force? I think it’s really easy to change hair growth.

[00:04:21] Ashley: That’s Michelle Forcier.

[00:04:21] Michelle Forcier: I am a physician, a pediatrician who’s been doing gender, sex, and reproductive justice work for about 25 years. And I have the best patients in the world and I have the best job in the world, so it doesn’t get any better than that.

[00:04:51] Ashley: And she knows what’s possible—and what isn’t.

[00:04:51] Michelle Forcier: As a physician, I know that I can help someone with hair growth, but I don’t have that power to say, you’ll now be comfortable in your assigned gender. Go forth. That’s a bold, big statement to say medicine and science and other people should have to change your brain. Don’t you get to pick?

[00:05:17] Michelle Forcier: What our patients are asking for is when they tell us they need to do it physically, and again, don’t forget the hormones are in the brain, so they are changing the brain too. But they’re asking us for that opportunity to change the parts that they believe need to be adjusted so that they are living with brain and body and heart and soul congruent. Who am I to say no, and why would I?

[00:05:21] Ashley: So the standard practice is to start hormones, also known as HRT, or hormone replacement therapy.

[00:05:41] Ashley: Hibby Thach is a third year PhD student at the University of Michigan’s School of Information who you heard in the last episode. She’s got a hazy recollection of when she started on estrogen.

[00:05:45] Ashley: I think the exact date’s like July 8th, 2022 or something like that.

[00:05:45] Ashley: Hey, the day you start becoming who you are is an important one to celebrate.

[00:06:03] Ashley: How easy it is to access hormones depends on a lot of things—where you live, who your doctor is, the political climate—but Hibby used something I didn’t realize existed: a telehealth app for gender affirming care.

[00:06:08] Ashley: I’m really glad we have telehealth services like Plume and whatnot.

[00:06:14] Ashley: Folx Health is another one, which I mention because Michelle Forcier, who you just heard, is a clinician there.

[00:06:27] Ashley: Because sometimes there are people in states where you can’t get access to like meds easily as a trans person. So it’s really nice to be able to have those telehealth services to just meet providers anywhere and talk about hormones and transition and stuff like that. So I did that for a couple years and we were just like adjusting my hormone level, like my hormone dosages, what hormones I was taking. And it was a learning curve.

[00:06:39] Ashley: Riley Black, the author and paleontologist you heard from last episode, had a more involved process.

[00:06:45] Riley Black: For HRT I had to do an intake interview and that was one of the most terrifying things because I felt like I’m being assessed whether what I feel is real or not, and if this comes back in the negative, I don’t really know what I’m going to do with that. This kind of feels like the one last shot that I have to work myself out. So even though I understand its purpose, it’s also incredibly scary to feel like, okay, this feels right, that I need to try this. But I don’t know if they’re gonna let me. And thankfully, I got the approval a little while later, but still it took at least two months to even get that initial intake and then get the approval and you have to go in multiple times for blood testing and make sure that you know, your body’s reacting well or that at least it’s not doing anything harmful.

[00:07:36] Ashley: The hormone prescribed to transfeminine or transfemme people—that is, people who started out with the physical characteristics of a man and are transitioning to a more feminine gender presentation—is most often 17-beta estradiol, or just estradiol for short. But that’s not its only name. As a viral footnote from a law journal puts it:

[00:07:58] Ashley: Hormone replacement therapy has many nicknames among transfeminine people, including titty pills, titty skittles, smartitties, chicklets, anticistamines, mammary mints, lifesavers, tit tacs, breast mints, femme&m’s, antiboyotics, transmission fluid, and the Notorious H.R.T.

[00:08:34] Ashley: As you might guess from those names, it’s often delivered in the form of a pill, but you can also get it via a transdermal patch or by injection, and less often by a gel or spray you put on your skin. This estrogen is bioidentical to the stuff that comes from human ovaries, and it’s also the exact same thing cis women take to reduce the symptoms of menopause.

[00:08:59] Ashley: And just as in menopausal cis women, the dose a transfemme person takes is completely individual—there can be a lot of trial and error involved in finding a dose that’s high enough to create the changes they want but low enough to not cause side effects.

[00:09:18] Ashley: Some also take progesterone—another hormone they’ve got in common with menopausal cis women. This can tend to help with breast development and may reduce some of the less desirable side effects of estrogen.

[00:09:18] Ashley: What about transmasculine people? What if you want to change your feminine characteristics into more masculine ones? When comedian Charlie James started hormones, he was lucky enough to live in a city with resources.

[00:09:24] Charlie James: When I first started testosterone, I was living in Chicago and they have a great LGBT center, Howard Brown, and they do a lot of medical care, like hormones. I don’t think they do surgery, but they do lots of like referrals and tons of trans care there. So I first went there, and it was relatively easy to start.

[00:09:45] Ashley: However, not everyone has that experience—especially if they transitioned decades ago. If you’re a regular listener, you might remember Benny from last season. He’s a transmasculine nonbinary person who started on testosterone in the 90s, and he went through a much lengthier process.

[00:10:03] Benny: So I needed to be in therapy for six months. And then you’d get a letter from that psychologist to take to a doctor who would then evaluate whether or not they think that you’re ready for testosterone, et cetera. The expectations with the therapists who were doing that kind of work at the time was that you couldn’t have any other mental health conditions. So I had to lie a lot about my, for example, history in the troubled teen industry and diagnoses of depression and anxiety as a teenager. And there were a lot of other expectations like that you had no history of sexual assault. So I had to lie about that part of my adolescence. And there was, and I think still is today an expectation that really powerful dysphoria is an essential part of being trans.

[00:10:45] Benny: And dysphoria wasn’t so much my experience. It was more an experience of gender euphoria. It wasn’t so much, I hate my body, but every time I move in this direction, I’m happier, healthier, more comfortable. And so I had to say a lot of things about my own past and my own experience of my body that didn’t really feel true at the time, but it was the only way to get access. I’m really glad I did that even though I did a lot of lying, because it got me the thing that I definitely actually needed.

[00:11:12] Ashley: And the thing that probably fixes a bunch of the things that you had to lie about anyway.

[00:11:16] Benny: Yes. Yeah. Oh, for sure. Yeah.

[00:11:20] Ashley: Testosterone therapy, also known as T, gender fluid, proboyotics, boy goo, mandaids, man juice or dude juice, dick sauce, and hand manitizer—these are just the ones I found on Reddit; get at me, trans men—is usually delivered via injection or gel.

[00:11:56] Ashley: Unlike estrogen, testosterone is classified as a controlled substance in the US, mostly because of its history of abuse by athletes. They’re literally steroids—the stuff some bodybuilders use and abuse to get swole. The jocks ruined it for everybody.

[00:12:13] Ashley: That means it’s a little harder to get testosterone than estrogen—even telehealth clinics can’t administer it to everyone in some states.

[00:12:13] Ashley: But once a trans person gets hormones, what exactly do they do in the body?

[00:12:14] Michelle Forcier: Oh, what do they do for you and me and what do they do for cisgender folks out in the world?

[00:12:16] Ashley: That’s Michelle Forcier again.

[00:12:16] Michelle Forcier: How hormones work are when people go through puberty, their sort of ovaries and testes wake up and they start secreting higher levels of either estrogen for ovaries and testosterone for testes. And what these hormones do is they go into the bloodstream from the endocrine organ, the ovaries or the testes, and they find all the different cells in the body that have a receptor for them. Okay, so you’ve got like say skin cell or breast tissue cell with an estrogen receptor. The estrogen molecule sees in the bloodstream that cell with that receptor, and it sort of latches on. And when it latches onto that receptor, it starts cell membrane communication changes. It starts cytoplasm function changes, and it starts nuclear production changes that are consistent with estrogen effects or feminization.

[00:13:19] Ashley: That was a lot of big words, but suffice it to say, estrogen finds every cell in the body with an estrogen receptor—which includes reproductive organs and breast tissue, but also the bones, brain, liver, colon, skin, and even salivary glands, whether you were assigned male or female at birth. Once it’s there, estrogen basically changes the way those cells do their jobs.

[00:13:42] Ashley: Now it’s the same thing for testosterone. That is, we all have testosterone receptors all over our bodies, and testosterone triggers its characteristic biological effects in those cells. It doesn’t matter what sex you were assigned at birth—the hormones act the same way whether they’re made in-house or storebought.

[00:14:00] Ashley: The difference is, though, that trans people are also producing the opposite hormone in their own bodies. Doesn’t that get in the way?

[00:14:08] Michelle Forcier: We use a high enough gender hormone level to fool those glands in the brain, the hypothalamic pituitary glands, to say, oh my gosh, like we are reading that there’s lots of hormones. It’s called a negative feedback loop. And they get this negative feedback loop that there’s a lot of gender hormone and they just don’t need to send that luteinizing hormone message to the testes or to the ovaries to make more gender hormone. They’re reading the environment as lots of gender hormone, testes and ovaries can sort of secrete less, take a break.

[00:15:05] Ashley: So taking one little hormone does two major things: It tells the brain, you’re good, we’ve got plenty of sex hormones floating around, no need to make more. And it does all its characteristic things to the cells all over your body.

[00:15:30] Ashley: Still, many transfeminine people also take a testosterone blocker to help that process along. That’s because testosterone naturally opposes estrogen’s effects, so the hormones their bodies make in-house can block the hormones they’re taking. Estrogen doesn’t do the same thing to testosterone, so trans men can take T without needing anything else. Yep, men even talk over women at the cellular level.

[00:15:38] Ashley: So, what does that feel like? For many of the trans people I talked to, the first change they felt was psychological. Here’s Riley.

[00:15:53] Riley Black: The internal experience of feeling like my head’s not full of static all the time. I can think, I can feel things, I don’t just feel like numb to the world around me. That came before even some of the physical changes, and that’s how I knew it was like, okay, yeah, a hundred percent let’s like hit the gas on this and keep going. And I’ve never looked back since.

[00:15:59] Ashley: Hibby’s early effects were more emotional.

[00:15:59] Ashley: I remember taking those hormones and just feeling immense euphoria. Like I was just so giddy. I was like, oh my God, oh my God, oh my God. And they hadn’t even like started acting yet ’cause I just took them. Not all trans women experience this, but when they’re taking like feminizing hormones, they will start to feel like maybe they have more access to their emotions. They might feel more emotional. And that definitely was the case for me. I cried so much more. I felt more emotional, had like these like mood changes.

[00:16:32] Ashley: The research backs this up. A systematic review published in the journal Nature in 2023 found that for trans people taking estrogen, emotions tend to become both broader and more intense—you get access to a wider range of feelings and more emotional expressiveness, but sometimes that comes with mood swings and emotional turbulence. The strongest psychological changes, though, were in wellbeing—trans people on estrogen tend to experience a decrease in depressive symptoms and psychological distress, and improved self-image and self-acceptance.

[00:17:10] Ashley: People on T can have emotional changes, too. Here’s Charlie.

[00:17:10] Charlie James: I know a lot of people on testosterone are like, I felt really angry at first, or like, I didn’t experience that, but it was like, oh, I am on testosterone, but I’m not far along. And so the first thing I’m experiencing is like frustration that people don’t already see me the way I want to be seen, because I’m like, but I’m doing it, I’m transitioning. And it’s like you just have to wait. This is like such a marathon, not a sprint. It’s long. Ideally, lifelong, you know, if you’re enjoying it.

[00:18:00] Ashley: That same review found some interesting patterns for people on testosterone too. There’s often greater anger expression—though the anger itself isn’t any more intense than before, people just tend to express it more. And in contrast to what happens with estrogen, testosterone can create what researchers call “affective dampening”—emotions become kind of muted, less open, like a flattening of both positive and negative feelings. But just like with estrogen, the most powerful change is in overall wellbeing: less depression, less psychological distress, and increased self-confidence and assertiveness.

[00:18:24] Ashley: The fact that many of these psychological changes tend to line up with gender stereotypes should make you wonder how much of this is cultural—it’s really hard to untangle the direct effects of hormones from the social effects of transitioning.

[00:18:45] Ashley: For example, our sensitivity reader Newt noted that when they started on T, they found they didn’t cry less, they just cried at different things—they used to cry really easily when they were sad or angry, but now they’re most commonly a happy crier. That points to how much of what we think are the direct effects of hormones might actually be about learning new social and emotional scripts.

[00:19:06] Ashley: So grain of salt, but still, I think it’s fascinating to think that one little hormone might have that much sway over how you experience emotions. And of course, greater wellbeing is what’s most important. Here’s Michelle Forcier again.

[00:19:08] Michelle Forcier: The energy that your brain and your heart and your body has had to put into managing a system that doesn’t match is tremendous. So when the brain and body are more on the same page of, okay, this is where I’m supposed to be, then a lot of times that is relief because again, you’re in the right hormone.

[00:19:49] Ashley: When we come back, we’re covering the physical changes from hormones, what surgery can and can’t do, and what it’s really like to live in a new body.

[00:19:55] Ashley: So, what physical changes do hormones create? Let’s start with the transfemmes. Here’s Hibby.

[00:19:55] Ashley: Usually there’ll be like some fat redistribution, you’ll like grow breasts of some sort, develop breasts and like if you don’t get bottom surgery, um, your penis, your phallus will sort of like go through changes as well. You may not easily be able to, um, orgasm. You may not feel the same sexual libido you did before.

[00:20:19] Ashley: Riley was lucky enough to have the opposite experience.

[00:20:22] Riley Black: How orgasms feel fundamentally changes. Pre-transition, they felt very, very localized, kind of just to like the pelvic area. Now it’s the full body experience and they widely vary from each other.

[00:20:57] Ashley: Estrogen, who knew it was doing so much? It also helps transfemmes grow breasts—real breasts. Because, fun fact, we all start with the same breast tissue. It’s only when cisgender girls hit puberty that that breast tissue starts to form breast buds and then full-on breasts, in a process that takes several years. Transfemmes who start estrogen go through a similar process, though a study suggests that their breast formation mostly happens in the first six months and usually ends up somewhere in the A-cup range. Adding progesterone after the first few months of estrogen has been shown to help them grow a little more. Still, genetics, body fat percentage and distribution, and even whether someone is taking a testosterone blocker can factor into breast size. And yes: because it’s all the same breast tissue, trans women can produce breast milk with the right effort. Bodies are amazing.

[00:21:42] Ashley: Transmasculine people taking testosterone go through a similar experience, but just in the opposite direction.

[00:21:42] Charlie James: You’re sort of swollen. You’re getting acne. Your face shape is changing. Your body is changing. I was experiencing bottom growth which is like the weirdest sensation.

[00:21:53] Ashley: I’ve actually never heard the term bottom growth.

[00:21:54] Charlie James: Really? Oh my gosh. Okay. This is fun. So bottom growth typically is one of the first things people notice on testosterone, although I think for some people it happens a little later. Basically, your clitoris grows in. I don’t know if it’s your just your clitoris. Basically you get somewhat of like a shaft. Um, you start to grow like a tiny penis.

[00:22:17] Ashley: The scientific term for this is “clitoral hypertrophy,” which brings to mind the image of a clit lifting weights. According to the few studies we have on this, a hypertrophied clit averages between 2 and 4 centimeters in length, or between the length of a single peanut and a walnut shell.

[00:22:35] Charlie James: And it’s extremely sensitive. Because, you know, just anatomy wise, like the most sensitive parts are all kind of pushed to the outside. It’s a really bizarre feeling, coupled with being just constantly horny because you’re going through puberty and I mean, you really, for the first year, I think you feel like a teenage boy. Like it’s just, it’s a wild experience to have as an adult.

[00:23:00] Ashley: For some trans people, hormones are all they want—they’re happy with the physical and psychological changes they get from HRT.

[00:23:18] Ashley: For those who aren’t—and for those who have the funds, the insurance coverage, and the access to qualified medical professionals—surgery is the next step.

[00:23:18] Ashley: And fair warning, I’m about to talk about surgery, so if you’re squeamish about surgical descriptions like I am, feel free to take plenty of breaks. Ah, the things I do for science.

[00:23:29] Riley Black: I did breast augmentation, vaginoplasty, and facial feminization in that order. Breast augmentation, oddly enough, was the easiest to go through. That was the first one that showed up and had the most availability.

[00:23:41] Ashley: Breast augmentation is where a surgeon places a silicone or saline implant under the mammary glands or chest muscles to create the appearance of fuller breasts. While there are some slight differences in the implant size and placement that transfemme people need, it’s basically the same as any cis woman’s boob job.

[00:23:59] Riley Black: It’s kind of interesting to me that all of the doctors that I saw for each of these procedures were in plastic surgery units that also serve cisgender women and people of other genders other than trans women that, like when I went in for vaginoplasty, that all the nurses are basically telling me that they went to the same surgeon that I’ll be seeing to get their own labiaplasty and stuff done.

[00:24:20] Ashley: Vaginoplasty is a surgery that creates a vulva and a vagina from the patient’s own tissues. Historically, surgeons have performed what’s called a penile inversion vaginoplasty, where they use skin from the penis, scrotum, and sometimes the abdomen or thigh to construct a vaginal canal that can be used for penetrative vaginal sex. The newest approach to this is something called robotic assisted peritoneal vaginoplasty, where a robotic surgical system goes in through the belly button and creates a vaginal canal from the peritoneum, which is the membrane that lines the abdominal cavity. There are a lot of benefits to this approach, not least of which is that the peritoneum doesn’t grow hair—people undergoing vaginoplasty sometimes have to do up to a year of laser hair removal before their skin is ready to be used as a surgical graft.

[00:25:22] Ashley: There’s also a surgery called a vulvoplasty, where surgeons create a vulva without a vaginal canal—for display only, you might say. This has the obvious drawback of not allowing for penetrative vaginal sex, but it has a much faster recovery time, and anyway, not all transfemmes want to have vaginal sex—some just want to remove their male sex organs and move on with their lives.

[00:25:39] Riley Black: Riley was on a surgeon’s waiting list for over a year before she got her vaginoplasty. But finally, she got it—then came the surgical recovery.

[00:25:39] Riley Black: It’s one of the lengthier recovery processes. I was in the hospital for about five days afterwards. I actually needed a blood transfusion ’cause I lost a little bit more than I expected. And then it’s not learning to walk all over again, but you really are made aware of like what your physical capacity is. Like, you need to move, you need to get around a little bit, but you have to also be very, very careful with yourself and do a lot of maintenance.

[00:26:04] Ashley: Riley also got facial feminization surgery, which is more of an umbrella term for many different surgeries than a surgery unto itself. Patients might get a reshape of their forehead, brows, nose, cheeks, jaw, or all of the above. They might get what’s known as a tracheal shave, which reduces the size of the Adam’s apple. They might also get fillers and skin resurfacing. And it’s worth mentioning that every one of these procedures is also done on cis people. Gender affirming care is for everybody.

[00:26:40] Ashley: Including, of course, transmasculine people. The most common masculinization surgery is known as top surgery, where the breast tissue is removed to form a more masculine looking chest. As I mentioned in the last episode, the US Trans Survey found that 20% of transmasculine people had that surgery, with many more who want it. Benny told me about his experience with it back in the aughts.

[00:27:04] Benny: I had very large breasts. They were a barrier to my being interpreted as a man. And I was binding for a lot of years.

[00:27:12] Ashley: Binding is the process of flattening your chest to make it more male-presenting, which you do by wearing a binder. Binders come in a bunch of styles and compression levels—there are models for everyday use, working out, and even swimming.

[00:27:45] Ashley: Some people prefer taping, which involves using skin-friendly tape to move and secure the breast tissue into a flatter shape that looks more like a pectoral muscle. They might use KT tape, which is the stuff athletes use for physical therapy, or a purpose-made product like Trans Tape. These tapes tend to be waterproof and sweat-proof, and don’t compress the entire chest like a binder does, which some people find more comfortable.

[00:27:57] Ashley: That’s modern-day binding.

[00:27:57] Benny: But back then, they didn’t have nearly the binding technology that’s available today. Right. Like store bought binders were only just starting to be a thing. And they certainly weren’t affordable to me. So I was lucky enough to be able to sew and was using some stuff that I made, some stuff a girlfriend’s sister made for me, things like that. And I was in a lot of pain. Binding is really painful, especially if you’re doing it in a way that isn’t well designed. And eventually I, between myself and some friends, was able to save up enough money to get top surgery. I went to a surgeon who’d never worked with a trans person before, but had a lot of experience working with gynecomastia. So, excess breast tissue in men. And had done a lot of breast reductions. Uh, and so I felt like that was enough knowledge for me to be willing to see this doctor who was local and I could afford. I am very lucky. My experience of that was fantastic. That wasn’t true for everybody who was having these surgeries in 2006. I’m very happy with the shape of my body now. And it did what I wanted, which was stopped people from looking at me funny.

[00:29:00] Ashley: There are also surgeries to create a penis, called phalloplasty. Charlie is going through the early stages of that as we speak.

[00:29:08] Charlie James: I love tattoos. I have a lot of tattoos, and right now I’m trying to get phalloplasty using my leg. So basically they’re gonna like take a piece of the skin on my leg to make the like shaft of a penis. And something you have to do in preparation for that is get all of the hair removed from your leg. And most people do that with laser hair removal, which is usually covered by insurance if you’re getting phalloplasty. Really depends what insurance you have. Mine covers it. The problem is I can’t get laser because I have tattoos, and if you do laser on the tattoos, it will burn the skin. So instead I’m getting electrolysis and I’m having my increasingly hairy leg, because testosterone makes me hairier all the time, I’m having individual hairs electrocuted off of my leg.

[00:30:10] Ashley: And that’s just the start. Phalloplasty is a series of three or more surgeries to create a penis and scrotum, lengthen the urethra, place erectile and scrotal implants, and remove the vagina, uterus and ovaries. Each surgery is generally scheduled three to six months apart, so the whole process takes a year at the very lowest end and three or more years at the high end.

[00:30:33] Ashley: First, surgeons take not just skin, but also fat, nerves, arteries, and veins from either the forearm, thigh, or side. They shape that whole thing into a penis and then attach it to the groin, with the patient’s clitoris at the base to still allow for sexual stimulation. In that or subsequent surgeries, they might lengthen the patient’s urethra so they can use the penis to pee, along with creating the scrotum from the skin of the labia majora and closing up the vagina.

[00:31:03] Ashley: In the final surgery, the patient gets implants: silicone orbs to stand in for testicles, and one of several kinds of penile implants. The simplest kind is a bendable cylinder you can bend up for an erection and bend down when you’re done. But there are inflatable implants too, where the patient squeezes a pump buried in the scrotum to fill the implant with saline. To end the erection, they either press a release valve, if they have one, or bend the penis down for a few seconds to drain the saline.

[00:31:49] Ashley: I don’t know about you, but to me, this sounds like absolute science fiction. It’s amazing what’s possible with modern surgery. So imagine my shock to discover that the first phalloplasty was actually performed in 1936. They used rib cartilage as the implant. That was on a cis man, but the first gender affirming phalloplasty for a trans man was performed just 8 years later. Patreon members will hear all about that in the bonus content at the end. Medical science is incredible.

[00:32:09] Ashley: For decades, the medical establishment insisted that if your brain didn’t match your body, the brain must be wrong. But trans people kept saying: this isn’t a problem with my mind. This is a mismatch that medicine can actually fix.

[00:32:33] Ashley: And they were right. When you give someone’s body the hormones their brain expects, when you help align their physical form with their internal sense of self, something remarkable happens at the most basic biological level. Cells start responding the way they’re supposed to. The static clears. People can finally just be.

[00:32:45] Michelle Forcier: Think about it, if you were a saltwater fish and I put you in an aquarium in my house, and then eventually I say like, you need to swim in the ocean ’cause you’re a saltwater fish, you’re gonna feel better. You’re gonna be in the milieu that you’re supposed to be. And that’s, I think in some ways on a sort of a macro level, that kind of relief and peace and just feeling more comfortable and confident in themselves that patients tell me they experience.

[00:33:20] Ashley: The ocean was there all along. We just had to stop insisting the fish belonged in fish tanks.

[00:33:33] Ashley: Thanks for listening. If you’re a paid Patreon member, stick around until the end of the credits for that bonus content. If you’re not, head to patreon.com/taboo science to join for as little as $5 a month.

[00:33:54] Ashley: Thank you so much to Michelle Forcier, who I had the best conversation with. You’ll hear a lot more from her in the next episode.

[00:34:27] Ashley: Thank you also to Riley Black, Hibby Thach, Charlie James, and Benny. Riley Black’s latest book is The Last Days of the Dinosaurs, and you can learn more about her and her other books at RileyBlack.net. Hibby Thach’s website is HibbyThach.com. That’s H-I-B-B-Y-T-H-A-C-H dot com, where she shares her research about queer and trans people of color’s online experiences with platforms and technologies, often within gaming related spaces like indie video game development and video game live streaming. Charlie James is on TikTok at Male Cowgirl, and he just came out with a book entitled, I’m Just A Little Guy, How To Escape The Horrors And Get Back to Dilly Dallying. You can learn more at CharlieJamesComedy.com.

[00:34:45] Ashley: You’ll hear more from all of them later in the season. Taboo Science is written and produced by me, Ashley Hamer Pritchard. Our sensitivity reader is Newton Schottelkotte. The theme was by Daniel Lipka of DLC Music. Episode music is from Epidemic Sound. The next episode gets into one of the biggest issues in America’s legislative crosshairs: gender affirming care for youth. We’re getting into it. I hope you tune in. I won’t tell anyone.