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Pre-Operative Assessment and Goal-Setting for Gender Affirming Body Contouring: Masculinization and Androgenization

This article is an introduction for those interested in gender affirming body contouring to de-feminize, masculinize and/or androgenize their body shape–sometimes referred to as body masculinization surgery (BMS). We discuss the common effects of an estrogenic vs. androgenic puberty on bone structure and soft tissue–such as overall body shape, upper vs. lower body fat ratios and hip to waist ratios–to explain what gender-affirming liposuction can accomplish. We hope this information will help patients craft realistic goals and have more informed conversations with our surgeons about relieving gender dysphoria and achieving gender euphoria through body contouring the thighs, hips, buttocks, abdomen and/or the upper body. For questions about procedure cost and insurance coverage, refer to this article.

The Preoperative Assessment for Body Masculinization Surgery (BMS)

A person’s general body shape is largely defined by their skeletal frame, as well as their distribution of muscle and fat.  Some people who undergo an estrogenic first puberty tend to have more curves and a smaller stature.  Many trans men and nonbinary people desire surgery to change these traits. At the Gender Confirmation Center, our surgeons don’t require patients to be on hormones in order to undergo top surgery or gender-affirming body contouring. However, being on testosterone for a year prior to body contouring may help your outcome, as this would allow some natural fat redistribution to occur. Although, for most people, the full effects of fat redistribution from testosterone can take much longer than one year. While gender-affirming body contouring can remove and redistribute fat, it cannot alter the skeletal structure. For example, the bony structure of the pelvis, the common result of a first estrogenic puberty, is unlikely to be affected by testosterone hormone replacement therapy; however, there is still much we can do to change the overall figure of the body with body contouring. Below, we discuss some of the effects of estrogenic and androgenic puberties, the three most common conventionally masculine body shapes and how gender-affirming body contouring can change the upper and lower body. We hope this information can help patients craft realistic goals for their gender-affirming body contouring procedure(s).

Testosterone and the Distribution of Fat and Muscle

During puberty, the production of hormones increases, which usually causes rapid physical changes to occur. This results in the development of secondary sexual characteristics that society labels as masculine or feminine.

While testosterone is produced by nearly everyone, the rate of its production through a first puberty is responsible for many physical differences between estrogenic and androgenic development. For example, testosterone levels affect how fat is metabolized and carried. Estrogen-dominant people are more efficient in storing fat and are prone to weight in their hips, butt and thighs. However, testosterone-dominant people typically have lower percentages of body fat and are more likely to gain weight in their upper body, especially around the waist and abdomen.

Hormone replacement therapy (HRT) for testosterone can help create broader shoulders, an expanded chest, increased muscle mass, increased bone mass, thicker skin, more angular eyes and face, deepening of the voice, facial and body hair growth and more. It is common that individuals seeking to have a more masculine or androgynous appearance who are heavier or naturally curvy often wish to minimize certain characteristics. Despite the positive effects of hormone therapy, changes in body fat redistribution caused by HRT can sometimes not be enough to combat feelings of gender dysphoria or gender incongruence. This is why many of our  patients have chosen to move forward with gender-affirming body contouring.

Conventionally “Masculine” Body Types

While no two shapes or figures are ever the same, most conventionally “male”  body types can be placed into one of the three categories below. As a prospective patient you can use these shapes to help think through what your goals for body contouring might be. These templates are in no way guidelines for your surgery. We present them here for patients that might find them helpful in articulating what they would like out of surgery. Regardless if these models resonate with you, the sections that follow discuss what gender-affirming liposuction can do to create a more masculine or androgynous upper and lower body. If you’d like to discuss your body contouring goals with one of our surgeons, you can schedule a consultation with us here.

V-Shaped (Mesomorphic)

V-shaped folks can easily shift from being incredibly lean or very muscular. They tend to have very broad shoulders, a narrow waist and narrow hips. When V-shaped people gain weight, it tends to be around the abdomen, but it can also occur on the buttocks.

Apple-Shaped (Endomorphic)

People with apple-shaped bodies tend to be shorter and rounder than those in the other body types. They carry much of their weight around their abdomen, calves and ankles.

Rectangle (Ectomorphic)

People with a rectangular frame usually appear very muscular. They are prone to rounded, protruding chests and rectangular torsos, as well as thicker arms, thighs and calves. Rectangular-shaped body types sometimes carry weight in the hips, buttocks, upper back and stomach.

Achieving a More Conventionally Masculine Upper Body

Upper body liposuction is one of the many options we have for patients seeking to masculinize or androgenize their frame through body contouring. Upper body regions that are difficult to sculpt through diet and exercise are frequently targeted to create a squarer body shape and streamline waist measurements. In some cases, liposuction may also be used on the upper torso to define and contour the pectoral muscles or to remove stubborn fat deposits that reside near the armpits. The ultimate goal of this targeted liposuction is to create a squarer body shape for patients.

In addition to gender-affirming body contouring surgery, it’s recommended that transmasculine people who want more muscular upper bodies should focus on upper body weight training. Concentrating on building muscle in the back, neck, and shoulders can broaden and define the upper body–further enhancing waist-to-chest measurement discussed below.

Gender-Affirming Body Contouring and Waist-to-Hip Ratios

Someone who went through a full estrogenic puberty uninhibited by hormone blockers has on average 10% more body fat compared to someone who underwent an androgenic puberty. The difference in fat deposition leads to varying degrees of waist-to-hip ratio (WHR). Often, the WHR for someone who went through an estrogenic puberty is larger than people who went through an androgenic puberty.  Depending on the amount of time an individual lived as their assigned sex and the amount of fat they deposited in certain areas, the extent to which these soft tissue characteristics can be changed varies.

Approaches to body contouring to obtain a conventionally “masculine” body shape should aim to obtain a WHR range that is close to the WHR those who went through an androgenic puberty have. Specifically, the WHR most commonly associated with a masculine figure falls within the 0.85-0.95 range, with differences being accounted for by varying degrees of fat deposition. If you are curious, you can measure your own WHR by dividing your waist measurement by your hip measurement.

Creating a Conventionally Masculine Waistline

The waistline of people who went through an androgenic puberty is significantly higher than those who went through an estrogenic puberty. This is largely because of bone structure; an estrogenic puberty widens or expands the pelvis, bringing the waistline further down on the body. Below, figure A shows the pelvis of an adult who went through an androgenic development, whereas figure B shows a widened pelvis resulting from an estrogenic development.

Liposuction is one of the most viable options for lifting the appearance of the waistline. Hormone replacement therapy such as testosterone cannot change the bone structure of the body, and the currently available options to change the pelvis have risks significant enough as to make them untenable.  Lifting the waistline through liposuction of the abdomen, hips, and lower back can have a significant positive impact on the fit of male clothing. When done appropriately, contouring will decrease the hourglass silhouette featured in figure B below so that the body looks more like figure A below. Thus, liposuction and possibly fat grafting can be powerful tools for androgenizing the body’s frame.

Gender-Affirming Body Contouring and Gluteal Forms

Below you’ll see that the androgenic body form featured in figure C has a concave/flat appearance. Body contouring of the gluteal region would aim to remove the fullness of figure D so they have an appearance more like figure C. Overall, buttock as well as thigh liposuction can help de-feminize the appearance of the lower body by eliminating or reducing curves so that a more squared-off body shape prevails.