Updated September 30, 2026

There is no one-size-fits-all approach for the gender affirmation process. Surgery can be expensive and time consuming, recovery can be demanding — and it may not be part of your transition process at all. Your path to gender affirmation may focus on hormone therapy, voice therapy or other options instead.

Fan Liang, medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health, stresses that while surgery can be a part of the transition process for some, it’s not for everyone. “Each patient needs to consider their personal goals and decide whether surgical options will improve their quality of life and lessen their gender dysphoria.” She adds, “It’s very possible that surgery is not in the transition plan for someone in the gender affirmation process. There are several nonsurgical services that may help transgender patients achieve their transition goals.”

What are nonsurgical services for gender affirmation?

Gender-affirming care is individualized. Some transgender and gender-diverse people pursue surgery as part of their care, while others do not. Nonsurgical options can help people align aspects of their body, voice or appearance with their gender identity and personal goals.

Nonsurgical gender-affirming care can include hormone therapy, voice therapy, hair removal, primary care, reproductive and fertility care, and behavioral health support. Some people use several of these services, while others use only one or none.

There is no single pathway that is right for everyone. Your health care team can help you understand the available options and develop a plan based on your individual needs and goals.

Hair Removal for Gender Affirmation

Hair removal can be used to change facial or body hair patterns or as preparation for certain gender-affirming surgeries.

The two primary methods used for long-term or permanent hair reduction and removal are laser hair removal and electrolysis. The most appropriate method depends on the area being treated, skin and hair characteristics, treatment goals and whether hair removal is being performed in preparation for surgery.

Laser Hair Removal

Laser hair removal uses light energy that is absorbed by pigment in the hair follicle, damaging the follicle and reducing future hair growth.

Because hair grows in cycles, multiple treatment sessions are generally necessary. Laser treatment is most effective for pigmented hair and is not effective for gray or white hair. Effectiveness can also vary with hair color, skin type and the laser technology being used.

Modern laser systems can be used safely across a wide range of skin tones when treatment is performed with appropriate equipment and settings by an experienced clinician.

Temporary redness, swelling and skin irritation can occur after treatment. Less common complications include burns, blistering, changes in skin pigmentation and scarring.

Laser hair removal generally produces long-term hair reduction, but some hair may remain or regrow over time and additional treatments may be needed.

Electrolysis

Electrolysis treats individual hair follicles using a small probe placed into the follicle to deliver electrical energy that damages the hair-producing cells.

Unlike laser hair removal, electrolysis does not depend on hair pigment and can be used to treat blond, red, gray or white hair.

Because individual follicles are treated separately, electrolysis can require many sessions, particularly when treating a large area.

Temporary redness, swelling and discomfort can occur after treatment. Less common risks include changes in pigmentation or scarring.

Hair Removal Before Gender-Affirming Surgery

Permanent hair removal may be required before certain gender-affirming surgeries when hair-bearing skin will be used to construct structures such as a urethra or vaginal canal.

The specific area requiring hair removal depends on the planned operation and surgical technique. If you are preparing for surgery, follow the hair-removal template and instructions provided by your surgical team rather than beginning treatment based on a general diagram or information found online.

Hair removal can take many months to complete, so it is important to discuss requirements with your surgical team early in the planning process.

Gender-Affirming Hormone Therapy (GAHT)

Gender-affirming hormone therapy uses medications to produce physical characteristics that are more aligned with a person's gender identity or goals.

Hormone therapy can be used independently or in combination with other gender-affirming care. It is not necessary to undergo surgery, and hormone therapy is not required for every person seeking gender-affirming care.

A primary care clinician or endocrinologist experienced in gender-affirming care can discuss treatment options, expected changes, potential risks, monitoring and reproductive considerations.

Testosterone-Based Hormone Therapy

Testosterone can produce changes such as:

• A deeper voice
• Facial and body hair growth
• Increased muscle mass
• Changes in body fat distribution
• Increased skin oiliness and changes in sweat or body odor
• Clitoral growth
• Changes in libido
• Decreased or absent menstrual bleeding
• Vaginal dryness
• Hairline recession or androgenic hair loss in people who are genetically predisposed

The timing and extent of these changes vary among individuals. Some changes, including deepening of the voice and some hair growth, may be permanent even if testosterone is later discontinued.

Estrogen-Based Hormone Therapy

Estrogen-based therapy, often used together with medication that reduces testosterone production or activity, can produce changes such as:

• Breast development
• Changes in facial and body fat distribution
• Decreased muscle mass
• Softer or less oily skin
• Reduced body hair growth
• Changes in libido and erectile function
• Reduced sperm production and fertility
• Decreased testicular volume

Estrogen does not substantially raise the pitch of a voice that has already deepened during testosterone-driven puberty. Voice therapy or, for some patients, surgery can be considered when voice change is desired.

The timing and extent of changes from hormone therapy vary among individuals.

Your clinician will discuss which medications and monitoring are appropriate for you based on your health, goals and medical history.

Gender-Affirming Voice and Communication Therapy

Voice and communication are important aspects of gender expression for some people. Gender-affirming voice therapy is individualized and does not require a person to adopt a particular "masculine" or "feminine" way of speaking.

A speech-language pathologist with expertise in gender-affirming voice care can help you explore changes that align with your individual communication goals.

Voice therapy may address:

• Speaking pitch
• Resonance
• Intonation and prosody
• Vocal quality
• Articulation
• Speech rate
• Volume
• Communication style
• Nonverbal communication

Testosterone typically lowers vocal pitch, although some people may still benefit from voice therapy to address resonance, intonation or other aspects of communication.

Estrogen and testosterone-blocking medications generally do not raise vocal pitch after the voice has deepened during puberty. Voice therapy can therefore be particularly important for people who would like a higher or differently gendered voice.

For some people, voice therapy alone achieves their goals. Others may consider gender-affirming voice surgery after evaluation by a multidisciplinary voice team.

Fertility and Reproductive Health

Gender-affirming hormone therapy and some gender-affirming surgeries can affect fertility.

If having genetically related children may be important to you now or in the future, your health care team can discuss reproductive options before starting treatments that could affect fertility. Options may include sperm cryopreservation, egg or embryo cryopreservation, or other fertility-preservation services.

Not everyone wants fertility preservation, and choosing not to preserve eggs, sperm or embryos should not prevent access to gender-affirming care.

Gender-diverse people may also need routine reproductive and sexual health care based on their individual anatomy, medical history and health needs. Your health care team can help coordinate appropriate gynecologic, urologic, contraceptive and reproductive care.

Behavioral Health and Gender-Affirming Care

Transgender and gender-diverse people seek behavioral health care for many of the same reasons as anyone else. Some people may also want support related to gender identity, coming out, relationships, family, discrimination, social transition or decisions about medical or surgical care.

Behavioral health care should be individualized, affirming and supportive of each person's goals.

A behavioral health professional can provide support when desired and can also help address depression, anxiety, trauma or other mental health concerns unrelated to gender identity.

Requirements for behavioral health evaluation or documentation before some gender-affirming treatments may vary according to the treatment, health care system and insurance requirements.

Primary Care for Transgender and Gender-Diverse People

Good primary care is an important part of lifelong health.

Primary care clinicians experienced in transgender health can provide routine preventive care while taking into account a person's anatomy, medications, surgical history and individual health risks.

Primary care may include:

• Routine health screening and preventive care
• Gender-affirming hormone therapy and monitoring
• Sexual and reproductive health care
• Cancer screening based on the organs and tissues that are present and individual risk factors
• Management of chronic health conditions
• Coordination with surgical and other specialty teams

Preventive health recommendations should be individualized rather than based solely on the sex listed in a person's medical record.

Choosing the Gender-Affirming Care That Is Right for You

There is no required sequence of gender-affirming treatments and no single definition of a successful gender affirmation journey.

Some people use hormone therapy but do not undergo surgery. Others pursue surgery without long-term hormone therapy. Some people use voice therapy, hair removal or other services without medical or surgical treatment. Others do not desire any medical intervention.

Your care plan should reflect your individual identity, health, priorities and goals.

Talking with clinicians experienced in transgender and gender-diverse health can help you understand the benefits, limitations and potential risks of different options and decide which services, if any, are right for you.

Medically reviewed by Fan Liang, M.D.