Welcome to Debbie Ballard's Transgender Information Site.

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Paul McHugh has a long history of opposing transsexuality, claiming that gender identity and gender preference is malliable.

McHugh makes valid assumptions, because about two-thirds of the population is bisexual and two-thirds are gender-fluid. 

1/6 are inflexibly heterosexual.  Men who would prefer Kellyanne conway to Tatum Channing.  And women who would prefer Donald Trump over Emma Watson.

1/6th are exclusively homosexual and would prefer almost any guy over almost any woman.

The folks in the middle will usually be conformant to cisgender-heterosexual norms if the social pressure is intense enough. 

Outdated Research

Paul McHugh bases his conclusions on surgeries performed by Johns Hopkins university by doctors who based their methods on hand-drawn notes.  From the late 60s to 1972.

There were no WPATH screening, no Standards of care, no therapist before and after surgery.

As a result cross-dressers who were still in the closet were getting "the sex change operation" with zero real life experience. 

Botched Operations

Hopkins operations were notable because the vagina was too far forward, there wasn't enough dilation, and depth was minimal.

There was minimal follow-up so when people DID come back to John's Hopkins for follow-up support, it was usually because they didn't have a support network,  lost jobs, families, and homes.  They also had difficulty in relationships with men because their plumbing was so unnatural. 

New Standards of Care

Today we have WPATH Guidelines and Standards of Care,  candidates for surgery have already been on hormones at least a year and living full time as women for at least two.  Most do therapy or support groups or both.  They have built up an environment that supports them as women even before the operation. There are books about the whole process.

Better research on more subjects

Unlike McHugh, who bases his conclusions on a small group of "dissatisfied customers", the last two decades have provided empirical research on thousands of respondents to over dozen surveys of transgender people ranging from cross-dressers to post-op transsexuals.  Furthermore research on suicide lines, including lines dedicated to serving the transgender community,  have provided insights into those who actually end their lives.

As a result, the diagnosis,  treatment,  and effectiveness of treatment for transgender people has been vastly improved since McHugh retired.

McHugh was treating people with a hammer and punch, modern treatment and diagnosis includes blood tests, CT scans, online training and support, thousands of books and online articles, and better legal protections in many states.

What we do know now is that 2 to 3 million people struggle with gender dysphoria.  Of those, roughly a third are seeking transition in some form.  The most common being hormones and breast modification.  Of those, about a third actually undergo "bottom surgery".  Most MTF transsexuals want the surgery but have obstacles that may take years to overcome.  These include lack of insurance coverage,  shortage of surgeons, medical issues such as weight, and lack of "raw material" needed for penile inversion.

As a result,  those who succeed in completing the surgery are always happy to have the completed operation.

We know that half of all transgender people attempt suicide prior to transition.   Those with unsupportive families and friends are at the highest risk, over 80%.  Of those who attempt suicide, over a third will eventually succeed.   Again,  the highest risk are the most repressed.

Transgender people have higher intelligence and are very good at keeping secrets,  especially their Gender Dysphoria,  if they experience rejection, condemnation,  or lack of support.

90% or more experience harassment, assaults, sexual assaults, and threats BEFORE THEY TRANSITION, most before even telling their own families.

Many have been in traditional therapy and were shut down if they talk about wanting to be the opposite sex.  The result is that the dysphoria gets worse and they stop trusting their therapist. 

McHugh bases his observations on a passive view of a few hundred subjects in clinical summaries.

The findings I'm citing are based on 30 years of active interaction with thousands of transgender people over extended periods.

Right wing groups cite McHugh and the American College of Pediatricians, because both offer outdated studies that support the notion that gays and transsexuals should be subjected to conversion therapy.  A combination of various brainwashing techniques that is marginally effective on bisexual and gender fluid subjects.   The remainder usually end up dead or institutionalized.   The only reason practitioners aren't arrested is because the torture and abuse is done in the name of "Religious Counseling".  Most have no medical credentials at all.

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Too often, society and even therapists tend to focus on only one dimension of the transgender person, I came up with this matrix to help people understand the broader dimensions of transgender people.

Severity

Social

Personality

Expressions

Sexuality

Dysphoria

0-Cisgender homosocial, alpha, popular Aggressive, violent, bullying, Extreme cases become criminals. Sexist, Elitist,views opposite sex as inferior. Excessively masculine or feminine, conforming to birth gender. Views opposite sex as playthings, objects, or alien creatures. Very comfortable with birth gender, threatened by those who aren't
1 – Stealthy beta, friendly, heterosocial, mix of friends, boys and girls. Friendly but withdrawn around alphas of their gender. plays games with both genders, enjoys both. may dress in a few items of the opposite sex, privately. Mild, mostly normal, bullying usually limited and infrequent.
2 – Masked beta, mostly heterosocial, most friends are opposite sex, close friends of same sex. Isolated, socializes when needed, but avid reader, games, private activities. Intelligent, prefers company of opposite gender, enjoys company of same gender. limited sexuality, confused, occasional cross-dressing, limited in scope, usually private or descreet. Mild dysphoria, frequently bullied, puts on “Act” to prevent abuse (clown, smart, goofy)
3 – Emerging Most friends are opposite sex, only a few friends of same sex. Isolated, avoids recreational activities and sports, avoids, same-sex activities most. Isolated, avoids social interaction with same sex peers, avid reader, often trying to figure out EVERYTHING because nothing makes sense. Isolated sexuality, may even avoid sex with partners, cross-dressing for both sexual and nonsexual satisfaction. May dress for extended periods privately. Severe, struggles with attempts to emulate birth gender, chameleon, evasive, deceptive. Dislikes birth gender but struggling with the idea of transition.
4 – Public Nearly all friends are opposite sex, same sex relationships may be romantic. Isolated, mood swings, unusual wisdom, avid reader, researcher, seeks to understand people. Refuses to participate in same-sex athletics, especially team sports. Everything seems unreal, isolated even in a crowd, focused, studies same sex & opposite sex. May act or dress more like opposite gender.
May be gender fluid, doing both masculine and feminine things in behavior and appearance.
Avoids sexual and romantic encounters with partners. Dislikes being recipient, dislikes genitalia. Masturbation fantasies are as the opposite sex. Self-abusive, genital mutilation, binding, tucking, drugs, alcohol, suicidal, dare-devil, doesn't care about dying, but not actively persuing.
5 – Transsexual Very few friends, nearly all friends are opposite sex. Avoids contact with same sex, except maybe romantically. Until transition, isolated, alone, socially “retarded”, rude, intellectual bully, lonely. Until transition, almost autistic, depressed, lethargic, argumentitive, drives people away. Pre-transition – sexually giving, but derives little or no satisfaction as receiver. Avoids sex. Critical – suicidal and secretive, drug addiction, alcoholism, overeating, high risk behaviors, often without telling anyone about the pain they feel has been ignored.
6 – During Transition After starting transition, more social, more friendly, more fun to be around, more friends. Very social, especially with other opposite sex people. Enjoys flirting, socialization, and cares about people. Friendly, outgoing, caring, compassionate, kind, loving, able to experience love. Sexually generous and enjoys receiving, often adventurous and creative, may enjoy sex with more kinds of partners, bisexuals may start gravitating toward opposite sex of their target gender. Much happier, enjoys life, enjoys people, service oriented, helps others. More interested in health, fitness, and staying healthy and happy.
6 – Post Transition homosocial with target gender, popular, friendly with both genders. Outgoing, pleasant, polite, happy, supportive, kind, enjoys a happy life more like a cisgender person of the target gender. Consider themselves their target gender, more like cisgender member of the opposite sex. A bit stealthy about previous life. Genuinely cares about both genders, treats partners as special gifts, generously return love when given. May struggle with PTSD, fear that they will have to go back, grieving lost youth in wrong gender.. Generally much happier and healthier, may even look and act younger.

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Evolution
In a completely uncivilized society, the weakest males would have been killed off before they could reproduce. Male aggression would have been similar to other mammals where only the strongest men and the best hunters were allowed to SURVIVE let alone reproduce.

Yet even in ape and monkey cultures, the omega males survive by emulating the behavior of females. They help with the children, they act subservient, and they REPRODUCE by having sex with a female while the alpha males are fighting it out.

 
Ancient Cultures
India has had Hajiri, boys who become women, often running away from home to join the Hijri before they go through puberty.

In many cultures, those who voluntarily had themselves castrated were considered mystical, magical, and wise. Many of the Oracles in various cultures may have been castrati, transgender people who had themselves castrated. Much easier to guard the virginity if she is incapable of having vaginal sex.

The magical and mystical characteristics may have happened because they would help the women gather food and plants, learning which would be good and safe to eat, and which could make you sick, and which could kill you. With such knowledge, it would be easy to put a bully in his place by making him deathly ill with tainted food prepared by others, then to "Cure" him, because only you know the antidote.

On the flip side, alpha males, in civilized societies, often were quick to go to war. They could fight and kill each other, and the result would be a shortage of alpha males. Even beta males would be killed because they were less able to fight in wars. This would result in a few alpha males, and many omega males who were clearly unfit to fight in a war.

Given 20-30 thousand years of this kind of evolution, the omega males would reproduce more often, with their sons being even more feminine. The violent and aggressive alpha male would be considered a criminal. United States prisons are full of alpha males who could not control their aggression and their anger.
 
Medicine and Technology
Even the hormone therapy was possible. For many years, transgender women used to take a medication called Premarin, which actually stand for PREgnant MARe urINe. Castrati who wanted to grow breasts and live in a harem, usually as servants, would drink the urine of pregnant animals to enable themselves to grow breasts, because it was extremely high in estrogen. This may also have been used to prevent pregnancies - the earliest version of what we now know as birth control pills.

We know that there are genetic conditions such as XXY chromosomes, Androgen Insensitivity Syndrome, and a few other genetic disorders that can produce an omega male, which would most likely prefer life among the girls to life among the boys.

In addition, modern medicine has also been a contributing factor. From the early 1950s until the early 1980s, many women who were at risk of miscarriages were given an extremely strong dose of estrogen known as DES. The medication flooded the mother's bloodstream with estrogen which got passed on to the baby. If the baby was a girl, no problem, except a higher risk of breast cancer, uterine cancer, and ovarian cancer. If the baby was a boy, the body would be so flooded with estrogen that the baby would form not only a female brain, but a female skeletal structure. Many transgender women had the biological characteristics of women even though they had male reproductive organs.

Transgender Girl Biology
The male reproductive organs are formed late in the pregnancy, and many of those with any of the biological indicators have smaller than normal penis and the testicles are still up inside, sometimes not even in the inguinal canal. in some cases, the doctors may not even know, without an MRI or CAT scan whether the reproductive organs are ovaries or testes.

The shocking part is that there are about 100 different forms of "gender ambiguity" with almost as many different causes, often a combination of factors.  As many as 1 in 15 males may have been born with some version of gender ambiguity.

The biological brain of a transgender woman very similar to the brains of MOST cisgender women. They have a smaller limbic system, which means they are more calm, more observant, less inclined to fight, less violent, and less competitive.
 
Cultural Issues - Bullying
This can be a big problem for a transgender girl who is still living as a boy. Because they don't fight back, they are often the target of ALL of the other boys in a group. The alpha considers him an easy target, someone who can be easily intimidated. The beta male considers him an easy way to gain rank within the male hierarchy. As a result, as omega males, they are often violently attacked on a very regular basis.

If it's just slapping or taking a toy, it's not a big deal, but often the damage is far more severe. Ruptured spleen, damaged kidneys, damage to liver, intestines, and other vital organs are entirely possible. Examine school records and you will often find that transgender girls living as boys have been to the nurse's office, doctor's office, and hospital far more than normal. Often they are sick more often and for longer periods as well.

Most transgender girls living as boys don't tell their parents or teachers or other authorities anything about the attacks. The other boys make it quite clear that any attempt to report them will result in even worse violence. Furthermore, because the attacks usually involve a large number of boys, many of whom have influential parents, the school authorities can do very little to prevent such attacks or to prosecute the group of violent criminals.

Socialization Issues
Transgender girls living as boys often prefer the company of other girls whenever possible. They prefer the games the girls play, and often act like girls even though they appear to be boys.

ALL of this is biological, not social. The irony is that trying to make the transgender girl look more like a boy, by shaving his head, putting him in over-sized pants and flannel shirts, just makes the problem worse.

During this pre-transition phase, which can last anywhere from a couple of years to several decades, transgender girls become very isolated. Parents often don't like that their daughters are playing with a boy, the girls often "close ranks" and exclude transgender girls who appear to be boys.

The result is that transgender girls become very perceptive. They are keenly aware of what boys do (they hate it but have to participate due to social pressures) and what girls do (they love it but are usually forbidden), and they struggle to understand this strange world that treats them like a boy.

When a child in 3 or 4 years old, she might say "I'm a GIRL", but if adults try to correct them, to humiliate them, or to punish them, they may change this to "I wish I was a girl", wishing on stars, wishing on birthday cakes, wishing for Christmas, going to church and praying, yet publicly saying "I want to be a girl"

With enough negative reinforcement, they will stop talking altogether. They may even appear slightly autistic, avoiding people, avoiding eye contact, reading intensely, writing, music, computers, technology, a variety of hobbies, sciences, and so on. They may even become a bit like Sheldon Cooper on Big Bang Theory, intellectual and full of factoids, so they can keep people from finding out the secret they are forced to keep.
 
Puberty is a Death Sentence - or 50 years in Solitary Confinement
Often, as puberty starts, a transgender girl who has been repressed will become self destructive. They may try to castrate themselves, they may start drinking and drugging, often to the point of overdose. Only their closest few friends will realize how close they come to killing themselves or having someone else kill them. Police investigations of teen suicides suggest that more than half are gay boys or transgender girls who have been bullied and harassed.

To a transgender girl, the prospect of growing hair all over, of a deep voice, of erections and ejaculations, is a nightmare, a fate worse than death, because it could mean spending the next 50 to 60 years in the horrible isolation they have already experienced.

The more severe the dysphoria, and the more repressed, the higher the risk of suicide. A transgender girl who secretly would castrate herself, living in a Fundamentalist Christian home where there is zero tolerance for any LGBT issues, has nearly a 100% chance of being dead before their 30th birthday.

Those who do find support, even if only from a spouse or one parent, have a better chance. Often, a mother will encourage the feminine expression in socially acceptable ways, doing housework, helping with shopping, and encouraging socialization through music, theater, dance, and other non-threatening environments.

The transgender woman living as a man is more likely to suffer from obesity, alcoholism, heart conditions, stroke, and cancer, because he is living in constant stress.

Transition can reverse many of these issues.  Once they are perceived as being girls, they will tend to be happier, more socially interactive, they listen more, they laugh more, they care about their bodies, so they may exercise more and eat a healthier diet .  I've seen 60 year old men transition and literally get younger and younger, medically as well as physical appearance.

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Most, but not all transgender children are fully aware that they are not like others of their own gender by the time they are old enough to talk. Often, their parents can see the indicators by the time the child learns to walk.
 
What complicates things is when adults try to repress a transgender child. Sometimes the parents don't even realize the child is being repressed. For example, a father may make homophobic statements or call the boy a "sissy faggot" when mom's not around.
 
By first or second grade, transgender kids are already struggling with their forced gender. Transgender girls forced to live as boys are often severely bullied, suffering frequent violent attacks. Transgender boys forced to live as girls also find themselves frustrated, often getting into fights with other girls and even other boys.
 
Many non-transitioning children begin to isolate. Sometimes this is mistaken for some form of autism such as autism. They may become avid readers, spend hours at the computer, or bury themselves in music. Ways to avoid people and still put their excess time to some productive use.
 
Spotting the transgender girls is pretty easy, look for multiple visits to the nurse's office, especially after gym, lunch, or recess. Watch for who leaves the school an hour or more after the other kids have left (staying after class means less risk of being attacked on the way home).
 
Doctors often see patients with bruises on arms or face, but bruises on the torso and thighs a a good indication of an attack by a large group of boys, going after targets where the bruises won't show.
 
Unfortunately, all this violence, almost ALWAYS unreported, tends to make it even harder for a transgender girl to admit that they are transgender. They may deny it because they are afraid of being a target for more violence. They may say to someone they trust "I WANT to be a girl" rather than I AM a girl, because they have been told they are not a girl so many times that they no longer know how to describe the struggle between their girl brain and their (barely) boy body.
 
A child who has been battered and abused daily, with no intervention by teachers will find it nearly impossible to to ANYONE, because they are so traumatized.
 
All this only makes the dysphoria worse. The isolation becomes more consistent and persistent. During puberty, they are often moody, even suicidal. Too many are misdiagnosed with clinical depression when the real problem is situational depression. Their bodies are changing in ways they don't want. Transgender girls see hair growing and they see themselves as monsters, like werewolves. Transgender boys see their breasts developing and see themselves becoming street whores.
 
Those who actually kill themselves are only 1/3 of the gender dysphoria population. Others turn to alcohol, drugs, sex, and overeating, suicide on the installment plan, often in a self-destructive spiral.
 
Ironically, at any stage, there is a simple treatment that is about 90% effective. Transition. Transition is a process that takes two to four years to complete. Step one is living full time at home, usually evenings and weekends at first, then through the summer, if the desire to transition persists, then going to school full time as a girl is recommended. Many children change schools for this process, or they have made friends with other girls their age who will help and support them.
 
Keep in mind, if a transgender girl decides she wants to go back to being a boy, that's it! Contrary to myths perpetuated by Conservative Christian Right Wing groups, the school programs to support transgender kids to not permit "commuting".
 
They don't get to be a girl for a week, then a boy for a week, and back and forth anytime they choose. Their behavior has to be persistent and consistent. They have to look, act, dress, sit, walk, and talk like a girl all day every day for the entire school year.
 
If someone is just a cross-dresser, the clothes will lose their power to thrill, and they will decide for themselves not to transition, at least not at that time. Many transgender girls get very confused about clothes vs social and behavioral patterns. It's only when they can accept themselves fully as girls that they are ready to transition. In the meantime, the clothes give them an outlet that can ease some of the pain and suffering of their dysphoria.
 
I know that no cis-gender person can possibly imagine what it is like to be transgender. I wouldn't wish that on my worst enemy (if I had any enemies), but I also know that I will never know what it is like to be cis-gender.
 
We know that there are real biological and physiological causes for gender ambiguity and gender dysphoria. Gender ambiguity is more common than cleft palate. When you combine all forms of gender ambiguity, the odds of having a dysphoric child are greater than 1 in 100.
 
Remember, most statistics only identify the most severe forms of dysphoria, those who seek HRT and GCS, which is currently estimate at 3 million in the United States. We know that this is only about 5-10% of the entire transgender population. Gender dysphoria in more mild forms may occur in as many as one in 15 children.
 
They may be hiding their dysphoria from an unsupporting parent, trying to avoid persecution by the peers they are forced to play with, or just have fears that once they do share their secret, they will be denied help, or denied help, love, and caring.
 
This is what makes Gender Dysphoria different from being transgender. There are millions of children with Gender Dysphoria who masquerade as cisgender children until they kill themselves. It's only when the police investigate the suicide that they discover the child's true nature, and the bullying related to it.
 
If your child had a deadly disease that killed 80% of it's victims, but could be treated with simple medications and a relatively inexpensive surgery when they reach the appropriate age, would you tell the doctor not to give your child the medication? Would you tell him not to do the surgery?
 
Acute Gender Dysphoria is a deadly disease that kills 80% of those who suffer from it. Those with the condition are not able to accept their birth designated gender and are not able to transition to their preferred gender. This may be due to parental non-support, peer pressure and persecution, or religious persecution.
 
Being transgender isn't the problem. Transgender kids who transition are generally quite happy and healthy and have suicide rates slightly lower than the general population.
 
If anything, the problem is not that kids are transitioning too soon, but rather they are forced to wait for the life-saving surgery. To have a normal sexual and social life, they need surgery when they are 16, but are forced to wait until they are at least 18 years old.

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Paul McHugh is a well known right-wing opponent of all transgender treatments, including HRT and GRS.
 
He bases his conclusions on operations done by Johns Hopkins in the early 1960s. However, within the community of GRS performing surgeons, the Johns Hopkins Surgeries were known to be flawed. They sent ONE doctor to observe a few operations in Sweden, document his observations, and then bring the notes back to JHU so they could perform similar surgeries.
 
It turned out that the surgeon took poor notes, ignored several key steps, and created inaccurate drawings. As a result most of the surgeries performed left those who received them looking a bit freakish. The vagina was forward and up, there was no sensation in the clitoris, there was little sensation in the shaft. Patients hoping for a naturally looking vagina were disappointed and some went to other surgeons to have the JHU surgeries corrected.
 
Unfortunately, many others did commit suicide.
 
At about that same time, Bill Masters, of Masters and Johnson believed that he could cure "sexual deviancy" using shock therapy, aversion therapy (electrocution of genitals and breasts), and sterilizing medication.
 
Unfortunately, this treatment was so unsuccessful and so ineffective that most of the patients treated required lobotomy to keep them from killing themselves because the suicide was so high.
 
Later, psychiatrists treated gender identity disorder with medications such as extremely high doses of Haldol, which only delayed the inevitable suicides, most had to be locked up or lobotomized.
 
Meanwhile, back at the ranch, Harry Benjamin began to do more comprehensive research, distinguishing degrees of transsexuality and appropriate treatment for the various degrees.
 
Benjaman, like McHugh recognized that not all transgender people needed gender change therapy and surgery. He broke the patients into six degrees of severity. To reduce confusion, I will refer to birth assigned males who show female or feminine desires.
 
0 - Cisgender men - these are men who have no desire to transition, have no desire to dress up, and if they have dressed up, did not particularly enjoy it. They socialize primarily with men, and their interest in women is primarily sexual. Surprisingly, very few men are zero.
Often, these men struggle with issues such as violence and sexism which needs to be dealt with in conventional therapy.
1 - Infrequent mildly trans - This would include fetish dressers and men who enjoy socializing with both men and women, and prefer the company of men. This group is actually rather large.
2 - Privately trans - These are men who maintain a public male persona and may enjoy crossdressing, but don't want to transition, they struggle with informing a spouse or lover. They are also more likely to spend more time socializing with the opposite sex, enjoying the company of both men and women equally.
3 - Periodic trans - If crossdressing, enjoy occasional outings in a safe environment, such as parties for crossdressers, usually held in private locations or in hotels where special accomodations such as restrooms have been arranged. They tend to socialize with both men and women, including topics that are usually of more interest to women, such as cooking, childcare, housekeeping, and fashion.
4 - Mild Dysphoria - These are people who want to be girls, but often only on a part time basis. They take great effort to look as much like natural women as possible, yet also maintain their male lives, often keeping the two lives very separate.
5 - Severe Dysphoria - These are people who consider themselves more female than male. They often have difficulty functioning as boys and men, and often have more female friends than male, and many of their male friends may be gay. Often has very little interest in traditionally male activities such as hunting, fishing, and competitive team sports. They are often uncomfortable when other men start talking about women in sexual terms. Most of these should transition, but there is no urgency.
6 - Do or die Dysphoria - these are the most severe cases. They are often dysfunctional as males socially. They often have professions that involve extended periods of solitude such as computer programming, accounting, or scientific research. They are often severely bullied as children and as a result, tend to avoid most male companionship. They often have a history of suicidal attempts, often associated with belief in reincarnation. Often, they will attempt self-castration, and self-medication using herbal or mail-order medications to attempt to induce transition. For these subjects, transition is urgently needed. They should start real life experience as soon as possible followed by hormones on an accelerated schedule. Surgery is almost always required and is considered required therapy.
 
To help with diagnosis, and to facilitate a safe and successful transition, Benjamin created a protocol now known as the WPATH guidelines that involve the following steps.
 
1 - Real life experience - This may include coaching on outings ranging starting with short outings such as a walk to the car, and a drive around the block to going out to various clubs. The therapist discusses the outing to help address what feelings came up, and to make sure that the assignments were actually done.
2 - Full Time (sorta) - typically this would include all time not at work or commuting. Therapists like to see someone doing 80-100 hours a week as a woman before starting therapy. Again, the therapist will discuss feelings and experiences. She make additional assignments, especially to address family, work, and social structures.
3 - Hormone therapy - This is usually the point where hormones are started - and the therapist is observing to see if there are regrets, if situations are being avoided.
4 - Consequences - At this point, the client becomes aware of the negative consequences of transition, the therapist helps address these. This is pretty much the "point of no return" since breasts, once grown, must be surgically removed to revert.
5 - Legal status and Full Time - this is usually when the client comes out at work. At this point, the client will start the process of legal name change, legal gender change on social security card, driver's license, and passport.
6 - Gender Confirmation Surgery - it is usually only at this point that the client can even consider confirmation surgery. 
 
At this point, the client has already lived for a year or more as a woman, and is able to blend with other women.  Often, by the time a trans-woman gets the surgery, she is merely confirming the live she has been living.  Due to financial requirements, fitness requirements, and the WPATH requirements, many women have  been living as Eunuchs for 3-5 years. 

Hormones reduce the size of penis and testicles to the point where even finding them is difficult.  Ejaculation is no longer possible.  Orgasms are possible, but very different, more like those of a woman.  Some trans-women find that they aren't in that much of a rush to get surgery once they are living full time on hormones.

As you can see, the treatment protocols are vastly improved from the days when Johns Hopkins would just perform surgeries on any woman who requested the procedure, paid for it up front, and met minimal screening criteria.