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distortions, backaches, and trigger points that accompany the compression of body tissues and bony structures. 7 However, it is just as important to respect your clients' comfort levels and heed requests not to remove their clothing and/or compressive garments. Each person will be in a different stage of their personal evolution and have different needs and abilities to trust a practitioner. Demonstrating respect at all stages of the therapeutic session goes a long way toward building trust. The Effects of Hormone Replacement Therapy A common fear among health-care practitioners is that hormone replacement therapy (HRT) is dangerous for their clients. However, according to retrospective studies, hormone therapy was found to be safe and to have minimal adverse effects. 8 For a transgender woman taking estrogen and androgen-blockers, the most notable changes will be the development of breasts, loss of body hair and muscle mass, softer skin, and the redistribution of body fat from the abdomen to the hips, thighs, and buttocks. For a transgender man taking testosterone, the most noticeable effects will be the development of facial and body hair, an increase in muscle mass, and the redistribution of body fat toward the abdomen and around the internal organs. Many transgender men will have a hysterectomy within five years of starting hormone therapy because of severe, persistent pelvic pain. For both cohorts, there is usually a positive emotional effect from bringing the body more in line with the internal sense of identity. Nonetheless, hormone therapy will not solve all body-image problems, nor will it change the person into someone else. Likes and dislikes, talents, skills, and other attributes will remain consistent. Postsurgery Probably the one area of most prurient interest to the majority of cisgender people is gender confirmation surgery. As massage therapists, we are most likely to see only "top" surgeries, that is, mastectomies and breast enlargements. If you see a client with scar adhesions, loss of sensation, or blocked lymphatic flow, you can treat them just like you would anyone else. A transgender woman may elect to have breast augmentation surgery if she is not on HRT or wishes for larger breasts than what comes naturally from HRT. Implants are placed either subcutaneously or submuscularly, and have a lifespan of approximately 16 years. Revisionary surgery within five years occurs about 25 percent of the time, usually for requests in size change, leakage or rupture, or capsular contracture. Complications include seroma, hematoma, infections, changes in skin texture, rippling, displacement of the implant, rupture, or excess scarring; nipple numbness is also a somewhat common side effect. Generally, breast augmentation surgery has a shorter recovery time and fewer side effects than mastectomy, although if implants were placed submuscularly, the recovery time will be longer and the discomfort greater. Self- massage of the breasts will be recommended by the surgeon to start 3–5 days post-op. Typically, transgender men undergo bilateral subcutaneous mastectomy and nipple grafting, and will have a pair of scars from the removal, as well as a pair of scars from surgical drains. Larger breasts will most likely be removed via an incision at the inframammary crease, whereas smaller breasts may be removed via a keyhole-type incision or inverted T, or a side-entrance keyhole, depending on the underlying anatomy. A peri-areolar (keyhole) incision will not involve nipple grafting. Breast tissue is removed via liposuction, and excess skin is cut away. Nipple tissue, if grafted, will be relocated to the lateral lower quadrant of the pectoral area to create a more masculine chest configuration. A new (as of 2016) procedure, known as the "button-hole," relocates the nipples without removing them completely, which promises better postsurgical results both aesthetically and functionally. The patient will experience large areas of numbness in the surgical area, from about an inch inferior to the incisions all the way up to the clavicles and into the axilla, which will persist for weeks to months as the nerves regrow. Range of motion (ROM) will be limited for several weeks. Complications may include keloid scarring, rippling of the skin, seroma, hematoma, infections, or "dog ears," which are a buildup of extra tissue under the arms due to surgical error and a frequent cause for surgical revision. Possibly the worst complication would be tissue death, especially of the nipple grafts. Typically, a therapist can begin to gently work the scars after they have fully healed, around 3–4 weeks post-op. Avoid the nipple area until they are fully healed and have stopped peeling. Personally, I have found that gentle soma-type cupping has been very effective at mobilizing the tissue, increasing range of motion and the range of sensation, and decreasing adhesions. In all cases, watch for strange swellings or pockets of fluid, discoloration, heat, or inflammation. A seroma needs to be drained like an abscess; a hematoma needs surgical intervention. Refer your client back to their doctor if you see something irregular. Each side may show varying (and asymmetric) progress in healing. As stated earlier, many transgender men will have a hysterectomy within five years of starting testosterone because of persistent and severe pelvic pain. It is important for therapists to understand that transgender men can get their periods, get pregnant, grow uterine fibroids, suffer endometriosis, and have other concerns with their reproductive system if they still have a uterus, even if they are taking testosterone. Because of these concerns, we must word our intake forms in such a way as to alert us to the presence of a uterus and ovaries. 74 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 1 7