I’m sitting at my local, friendly bar chatting with a couple of the guys when I realize neither of them is looking me in the eye. They’re looking at my tits, or more accurately, my cleavage.

“Hey, up here” I say, snapping my fingers and pointing to my eyes. “And by the way, you’re gay, you know,” I add, pointing to my breasts. “What do you care about these? They’re not even real!”

One of them shrugs. “All guys like tits,” he says. And damn it, he’s right.

There are days when I would love to have real breasts. And then there are days when I’m perfectly happy not to. Maybe that makes me less transgender than some. Many transwomen I know are very concerned about breasts. It’s probably because they are a defining element for women in our culture. To be a woman, we’re taught, is to have breasts, despite all logic.

Male-to-female trans people (MTFs) on long-term hormone therapy get some breast development, but usually not more than an A-cup. A transwoman I knew was so frustrated at not developing more that she doubled her hormone dose, but the only thing that increased was her mood swings. Her endocrinologist explained that breast size depends to a large extent on genetics. If your mother was large-chested, you are more likely to be so. As a result of this, many transwomen look into having breast augmentation surgery: a breast implant is inserted under the existing breast through an incision in the crease under the breast.

The American Society of Plastic Surgeons reports that every year American women undergo some 300,000 breast augmentations; the average cost is $3,678. It’s not covered by insurance, so many transwomen seek out risky and illegal alternatives. One such option is a “pumper”, a medically untrained person who injects silicone into the breast area. Too often, the silicone migrates to other areas of the body, causing infection, disfigurement, scarring, and even death. Of course, the FDA prohibits marketing or promoting products like liquid silicone (some have been known to use brake fluid), and the horror stories of the black market are legion.

Then there are the breast creams and magic herbal feminizing pills, breast pumps, and body wraps. None of them delivers on its promises, but there are no laws specifically aimed at the unscrupulous who are more than willing to exploit desperate transgender folk.

The fascination with breasts also affects the transman who desires to be rid of his breasts. That procedure is even more costly. The average price of “top surgery,” as it is known, is $6,000. A cheaper alternative is called “binding.”

The process of flattening one’s breasts in order to create a male-appearing chest can be done a number of ways, depending on variables like the size of one’s breasts and the materials and methods used. Many of the synthetic materials used for binding don’t allow skin to breathe, and that sometimes leads to rashes and infections. Binding too tightly can cause pain and can restrict breathing, and tight binding is especially dangerous for young transmen because it can affect the growth of ribs and lungs.

Riki Wilchins, author and transgender activist, is credited with the comment that sex refers to what’s between your legs, while gender refers to what’s between your ears. But, to a large extent (no pun intended), it’s what’s between your shoulders that counts.

What we transwomen don’t like hearing about is the down side. There’s no data on the incidence of breast cancer in the transgendered, but studies of non-transwomen indicate hormone therapy brings a higher level of breast cancer risk. So MTFs who used estrogen and/or progestin for five years or more are probably at a higher risk than non-transwomen (the risk is probably even greater if they started hormones when they were young). Breast implants show no increased risk for breast cancer for either MTFs or non-transwomen, but implants do make cancer harder to detect on a mammogram.

Female-to-male trans people who use testosterone and have had “top surgery” might have a higher risk of developing breast cancer than the non-transman, because there’s always some breast tissue left behind. For the same reason, non-trans women who have had mastectomies still have a small risk of developing breast cancer.

All of this is good to know, but unfortunately, it doesn’t stop those who see having breasts as essential to their womanhood from taking the risks. Those men—gay, straight, or other—who continue to be obsessed with breasts don’t help the situation. And, like the man said, “All guys like tits.”