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.