FTM transsexuals have little in common with MTF patients other than their basic problem of gender dysphoria and confronting a society that is generally staunchly dichotomous in its approach to gender. Otherwise, they are distinct populations, as different from one another as women are from men. Specialized medical and physical examinations should be included in the overall evaluation and ongoing management of FTM patients, given the increased likelihood of polycystic ovarian disease (Futterweit and Deligdisch 1986; Futterweit and Krieger 1979; Futterweit et al. 1986) and other common hormonal problems (Bosinski et al. 1997) in this population.

Simply applying to FTM patients the treatment principles used with MTF patients is not enough; such a strategy will generally fall far short of providing the clinical empathy necessary to be effective. For example, it is not uncommon for families of FTM patients to be very supportive of transition in their GID children, as they have been fully aware of their “daughters’ ” gender transposition from their earliest years. This is generally not the case for males with GID. FTM patients usually pass very well after receiving testosterone and do not generally have to deal with gender rejection based on telltale physical reminders (e.g., large hands and feet, scarring from electrolysis) as do many MTF persons. One of the few autobiographies written by an FTM author discusses this in more detail (Sullivan 1990).

Although psychotherapy is no longer mandatory as a minimum requirement for referral for somatic therapy for either sex, many therapists and patients alike see the value in exploring transition issues with an experienced psychotherapist before, during, and after seeking somatic treatments. Individual therapists and gender clinics remain free to require a higher level of care than that listed in the Standards of Care. FTM patients often report positive changes in their lives as a result of psychotherapy (Rachlin 1999a, 1999b), citing improved relationships, reduced emotional discomfort, increased comfort with gender, and lessening of conflicts at school or work as important examples of progress made in psychotherapy. The goals of psychotherapy as previously listed by Levine are also applicable to FTM patients (Levine et al. 1998).

Anatomic females requesting somatic treatments for GID are far less common than males in clinical settings. Most estimates report ratios of 1 natal female for every 2-3 males (Weitze and Osburg 1996). FTM patients with less severe gender dysphoria are able to live androgynously in Western culture without any somatic treatments with far greater ease and societal acceptance than gender-dysphoric males. However, for some patients, nothing short of hormonal and surgical treatments will suffice in addressing their GID, even after extensive psychotherapy (Lothstein 1983). Testosterone treatment and bilateral mastectomy generally result in dramatic changes consistent with male appearance, including facial hair, male pattern baldness, increase in upper body musculature, permanent deepening of the voice, and reduction in subcutaneous fat. Chest reconstruction or “contouring” can result in a male-appearing chest after mastectomies that may pass in a locker room or beach setting in spite of some residual scarring. Many patients do not choose additional surgeries as listed in

Table 70-11. In the past this was partly due to the poor results obtained with some of these procedures, most notably in phalloplasties. With ever-improving surgical techniques, male genital construction is becoming a more viable option in spite of the remaining cosmetic and functional obstacles (Byun et al. 1994; Hage 1996; Sadove et al. 1993). Genital surgical options include not only phalloplasty techniques but also metaidoioplasty, generally with testicular implantation into fused labia majora tissue fashioned into a scrotum. Phalloplasty, a group of surgical techniques pioneered by surgeons treating war casualties, may involve using abdominal skin flaps or harvesting forearm or lower-leg full-thickness grafts containing their own arteries, veins, and nerves. Metaidoioplasty, a far less involved procedure, involves maximizing the appearance and prominence of a testosterone-hypertrophied clitoris (which may reach 5-6 cm in length) by “subtracting” the surrounding subcutaneous fat and releasing connective tissue that generally prevents the clitoris from protruding (Hage 1996). A type of micropenis is therefore formed, which is naturally erogenously innervated. Phalloplasty relies on maintaining the hidden clitoris as the source of erogenous sensation, as autologous grafts from donor sites have tactile sensibility that is generally not experienced as erotic (Gilbert et al. 1988; Gottlieb et al. 1994). Metaidoioplasty (Hage 1996) has the advantages of low cost, high safety, and retained erotic sensation, whereas phalloplasty is associated with a high complication rate (20%-100%), including the possibility of complete necrosis of the neophallus (H. Monstrey et al. 1999; S. Monstrey 1999); a high cost ($25,000-$100,000); and a less-optimal cosmetic appearance. Neither option allows for intromissive sex without resorting to implants or stiffeners in most patients. Placement of a neourethra to enable voiding while standing (the primary reason given by patients desiring this procedure [Hage et al. 1993a]) greatly increases the likelihood of complications, including stricture and fistulae formation.

Most observers would agree with Rachlin (1999a), who states that there is not yet a phalloplasty technique that can provide both full functioning and authentic appearance. Patient satisfaction with phalloplasty has been modest at best. Tsoi (1992, 1993) reported that only 39% of FTM patients were satisfied after a 5-year follow-up. Barrett (1997) noted that a group of 40 postoperative phalloplasty patients were more satisfied with their genitals than were comparable patients who had not received surgery. Recent surveys of preoperative FTM patients indicate a 2:1 preference for metaidoioplasty over phalloplasty due to patients’ concerns over the risks and poor cosmetic appearance of many phalloplasty procedures (Rachlin 1999a). Still others elect to not change their external genitalia in any way, citing costs and complications or a resistance to society’s attempts to dichotomize gender roles (Devor 1997).

Mastectomy for FTM patients is often a more critical treatment than genital reconstruction to enable patients to assume the male gender role. Uncomfortable chest binding, often with reusable elastic bandages, is employed to flatten and reduce the prominence of breast tissue. The breasts, especially when large, are the focus of self-hatred and loathing in FTM patients, analogous to the intensely negative feelings MTF patients report for the penis and testicles. Bilateral mastectomy, therefore, is often the first surgical intervention sought by FTM patients.