Trans Summer School: The Magic of Hormones!
After social transition, many people face the question of whether they also want to pursue medical (hormones) and/or surgical transition. In this post, we’ll be discussing hormones — our following post will delve into the nitty gritty details of “the surgery” (starting with the fact that there’s not just one).
The first thing you need to know about medical transition is this: You are not required to transition. Not now, not right away, and not ever. You may choose to start taking hormones to address your dysphoria, and there are lots of options available for you, but not taking hormones doesn’t mean you don’t qualify as trans, and deciding to go off them if they don’t work for you doesn’t mean you lose your union card. I keep saying “there’s no such thing as ‘trans enough’” for a reason, and that reason is...there’s no such thing as “trans enough.”
Some people opt not to take hormones for a huge variety of reasons, including health issues, concerns about future fertility, and disinterest in hormones. Some people may struggle to afford or access hormones, which brings me to the second thing you need to know about medical transition: hormones are complex and potentially dangerous medications that can cause serious side effects. You must take them under a doctor’s supervision. Please do not buy hormones online or from other people, and don’t trade for them either. If you don’t know the provenance of a medication, it could be adulterated or contaminated and it might make you very sick. Even if a medication is pharmaceutical-grade, if you take it incorrectly, it could endanger your health.
Callen-Lorde Community Health, NY
Dimensions Clinic, San Francisco, CA
Howard Brown Health, Chicago, IL
Children's Hospital Los Angeles Center for Transyouth Health and Development, CA
Cincinnati Children’s, OH
Pediatric and Adolescent Transgender Health (PATH) Clinic, Madison, WI
Gender Identity Development Service, London
More US and Canadian clinics
Australian clinics and support groups
More UK clinics
We also strongly recommend against what some people call “natural transition,” in which people attempt to use herbs and supplements to mimic the effects of hormones. We’re aware that there are plenty of guides discussing this subject, and we’d like to reiterate what’s discussed above: Hormones are complicated and potentially dangerous, “natural” compounds can still be harmful, and you could do your body serious damage. As if that wasn’t enough, there’s no evidence to suggest that this approach actually works — but it can make you very sick.
We recognize that it can be heartbreaking, frustrating, and agonizing to feel your body changing without your consent in ways that make you deeply uncomfortable. Managing your dysphoria can be extremely difficult, though we do offer some advice on helping you feel more at home in your body elsewhere in this series. Don’t despair: real live trans adults are here to tell you that you will be able to live the life that you want. Hang in there.
There are a lot of safe and legal options for obtaining hormones and some, such as free or low-cost clinics, may be available in your area. Sometimes that unfortunately means having to wait, which we know is incredibly difficult. Ask your doctor for help, and if that’s not an option, do some scouting around. Please be safe!
Now, onto the goods. Want to jump to your main area of concern? Prefer to read in smaller chunks? We've got you covered:
...Or you can just scroll on and read the whole thing here!
Depending on how old you are, where you live, and the specifics of your situation, you may start with “blockers,” also called puberty blockers or puberty inhibitors (or, more formally, GnRH agonists). These drugs do pretty much exactly what it sounds like they do: They block the release of hormones from the pituitary gland, thus putting a pause on puberty. More precisely, they suppress luteinizing hormone (LH) and follicle stimulating hormone (FSH), the hormones responsible for triggering the production of estrogen and testosterone. Patients on blockers won’t go through puberty and develop tell-tale signs like breasts, larger testes, more body hair, and fat redistribution.
Here’s the cool thing about blockers: they let you take a developmental time out. While on blockers, you can get to know your body and get more comfortable in yourself as you decide which steps to take next. At any time, you can go off blockers, and allow your body to progress through puberty. You can also opt to switch from blockers to hormone replacement therapy (sometimes called “cross-sex hormones,” a terminology I don’t favor because, among other reasons, all you’re doing is replacing the hormones your body doesn’t produce naturally). Once you switch to HRT, you’ll start going through puberty.
Like social transition, hormone blockers are fully reversible. A lot of adults seem to think that they know all about trans kids, and that trans kids will experience “regret” later. They are wrong. Researchers at Northwestern University conducted an extensive research review looking at trans kids and hormone blockers, and they found that early intervention is tremendously beneficial for trans youth. Plus, one tremendous advantage of blockers is that you don’t have to go through costly and frustrating transition procedures like top surgery, laser therapy, and so forth later on.
If you are under 18, depending on where you seek treatment, blockers may be the only thing available to you. Before prescribing blockers, your physician will want to meet with you and your family to discuss your needs and determine how much support is available to you during what can be a stressful time.
How are they administered?
You have two options, an injection and an implant. The injection (Leuprolide or Depot Lupron), is delivered once every three months, and your doctor may teach your family to do it at home. If you decide to go off blockers, it’s as simple as not taking your injection and letting your body do its own thing, or stopping blockers and going on HRT. The implant (Suprellin or Histrelin) delivers a slow dose of hormones and needs to be changed annually under local anesthesia (unless you like the thought of a doctor digging through your arm without anesthetic). Patients using the implant can have it removed and start HRT or allow their bodies to start producing hormones on their own.
What are the risks?
Administration of blockers in trans youth is what’s known as an “off label” use of these drugs. While they were recognized as safe after rigorous testing and evaluation, they weren’t designed for kids, and they weren’t tested with puberty suppression in mind. Physicians follow standards developed within their community, rather than by the manufacturer. That means we don’t know all the risks — for example, hormone blockers may have an impact on brain development as well as bone density, because testosterone and estrogen have an influence on these things. There’s not enough research available to show us how trans youth react to blockers, though that will change in coming years.
That’s why it’s particularly important to take them under supervision. A doctor can monitor your health and levels of hormones and other indicators in your blood, as well as talk to you about any emotional changes you may be experiencing. This will help keep you healthier and happier, but it will also add to the overall body of experience and research on blockers, to make them safer for future generations. You should always report side effects, even if you’re afraid your doctor may take you off your blockers. It’s possible you won’t need to stop the medication, and if you do, you may be able to work with your doctor to resolve the problem quickly and pursue an alternate medication — you may be reacting badly to one blocker, but could be fine on another one!
If you’re a little older, or you feel confident and ready to transition after being on blockers and your doctor thinks it's reasonable to do so, you may start taking estrogen and an androgen blocker if your body would otherwise naturally produce testosterone. You may hear estrogen referred to as a “feminizing hormone” or “female hormone,” which is a term I dislike because you may not necessarily be taking it to achieve a “feminine” body if you’re nonbinary or otherwise gender nonconforming, and lots of people who aren't women produce estrogen naturally. You can just call it estrogen!
Before starting HRT, your doctor will order some blood work (or a “blood panel”) to check out your current hormone levels, liver and kidney health, cholesterol levels, and other major health indicators. They may want to conduct a physical, and they will also review the effects, risks, and benefits of hormones. Requesting information about hormones doesn’t mean you need to start right away: You (and possibly your parents) may sign an informed consent form indicating that you understand the details of the treatment, and you may be able to get a prescription that day, but you can also wait! Hormones are a big decision, and no one wants to push you into it.
Estrogen has a number of effects on the body. It will cause breast development (we can’t guarantee your cup size, though!), will force fat to redistribute (giving you fuller hips, among other things), and tends to soften skin. A number of chemical formulations are available and the one your doctor recommends will depend on where you are and the specifics of your case. 17-beta-estradiol tends to be quite popular at the moment.
Androgen blockers (anti-androgens) are usually prescribed alongside estrogen. They offer benefits that estrogen can’t, like stopping or preventing baldness, limiting facial hair growth, and reducing spontaneous erections. They offer another benefit, too: when you take anti-androgens, you can reduce your dose of estrogen, thereby avoiding some potential side effects. You can also take an anti-androgen alone, without estrogen, if you want to block testosterone in your body but not develop the physical traits associated with estrogen therapy.
Progestagens may come up as well in discussions about your HRT, though they aren’t in widespread use. Some physicians may use them to supplement estrogen, or as an estrogen alternative if they’re concerned about side effects.
How is it administered?
Estrogen is available in a number of formats, including pills, gels, patches, and injections. Researchers have found that when estrogen is delivered transdermally (gel or patch), the risk of blood clots and elevated triglycerides (bad fats) tends to be lower. For this reason, trans people over 40 who use estrogen often take it transdermally, and your doctor may recommend this method for you if you have a family history of these problems.
Anti-androgens are delivered in pill format, and progestagens come in both pill and cream form.
What are the risks?
HRT can be risky, and the best way to reduce that risk is to work closely with your doctor. You may need to try several drugs and a variety of dosages to find the ones that work for you, and you will need regular blood work to monitor your hormone levels. Never take more than prescribed, even if you’re impatient for some changes, because you can experience serious side effects. Among other things, if you have too much estrogen in your body, an enzyme called aromatase can actually convert it into testosterone, which is the last thing you want! If you choose to have an orchidectomy (removal of the testicles), you will be able to reduce your hormone dosage since your body won’t be producing testosterone anymore.
One significant risk of estrogen therapy is blood clots, a known issue in people who produce estrogen on their own as well. If you smoke, that risk is greatly elevated, which is another excellent reason not to start smoking. People on estrogen therapy can also experience a loss of bone density, and your doctor may recommend supplements to address this problem. That fat migration that many people are excited about, because it changes their shape, can cause abdominal fat deposits, which are potentially dangerous. Estrogen can also contribute to the development of gallstones and high blood pressure. Some patients develop nausea, vomiting, or headaches — if these are severe, or they don’t stop as you get used to the medication, you should talk to your doctor.
Liver stress is another issue, because your liver is responsible for processing these drugs, so your doctor may recommend periodic liver enzyme level testing to keep an eye on things. You may also want to discuss whether you should make some lifestyle or health care changes, like drinking less or avoiding certain medications, to protect your liver. This can be especially important with psychiatric medication, as many psychiatric drugs, like depakote, interact with your liver. Make sure all members of your health care team know you are on HRT so they can work around potential drug interactions.
Anti-androgens, which are processed by your kidneys, can carry a separate risk of kidney problems. It’s important to stay hydrated, discuss potential drug interactions with your doctor, and get regular bloodwork to check your levels. While estrogen can cause high blood pressure, anti-androgens can potentially cause low blood pressure and cardiac arrythmias. Some people develop skin rashes, which should always be reported to your doctor.
Fertility is also a concern. Though changes from hormones are theoretically reversible, we don’t know enough about fertility after cessation of HRT, because it’s not an issue that comes up very frequently. We do know that estrogen and anti-androgens make it harder to produce sperm. If you are worried about contributing your genetic material to a child in the future, you should talk about sperm banking before you start HRT. If thinking about that seems a little intense right now, you might want to take some more time to think!
What are the side effects?
I’m separating these out from “risks” because they involve the effects of estrogen and anti-androgens on your body. Some side effects, like breast growth, softer and more sensitive skin, and fat migration, are desirable. You will also notice a decreased sex drive, fewer erections, a reduction in ejaculate volume, slower facial and body hair growth, and a reduction or complete stop in balding — something you probably aren’t experiencing yet, we hope. These changes (with the exception of breast growth) are reversible; if you stop taking estrogen, your body will reorient itself, and you need to stay on HRT for life.
Many people experience emotional changes on HRT, and no, not for the stereotypical reasons. With the right hormones in your body, you may feel calmer, more relaxed, and better able to handle the problems of the world. The physical changes may also be very affirming, and while HRT can’t magically fix body image issues, it can definitely be a step in the right direction: being more comfortable with who you see in the mirror can make you feel a whole lot more confident. Simply progressing on the pathway to transition also makes a difference for some people, who may find that HRT helps with depression and anxiety by giving them something positive to focus on.
It usually takes about two years for your body to “settle” on HRT, which is good to keep in mind if you are considering breast augmentation. It’s a good idea to let your breasts fully develop so you know what you have to work with before you meet with a reconstructive surgeon.
One “benefit” of growing breasts is that you may be at risk for breast cancer, although the jury is still out. We do know that people with a family history of breast cancer are at higher risk, and adding estrogen to your body could elevate that risk. Talk to your doctor about your family history to determine if you need to take special care with screening or preventative care. You just grew those babies, you don’t want to have to send them back to the factory!
If your body is longing to pump out some estrogen and you’d rather it didn’t, your doctor will start you on testosterone therapy. Estrogen blockers are also available, but they aren’t widely used — usually your testosterone will be enough to do the trick. You may also hear testosterone discussed as a “masculinizing” or “male” hormone, but it doesn’t have to be either of those things for you unless you want it to be. Not everyone who produces or takes testosterone is a guy, and not everyone who takes testosterone is doing so to cultivate a “masculine” appearance.
Before your doctor will prescribe testosterone, they will request some tests to get a baseline idea of your hormone and cholesterol levels, among other things. They’ll also discuss the risks and benefits, go over an informed consent form, and possibly conduct a physical. You may be able to get hormones immediately, or you can wait: no one will ever push you into taking hormones, and if you feel pressured, find a new doctor!
Taking testosterone will have a number of effects on your body including causing you to grow more body hair, making your skin a little thicker and coarser, increasing your sex drive, increasing the chance of balding later in life, and lowering your voice. Be advised that if you have androgen insensitivity syndrome (AIS), you will not respond to testosterone therapy.
How is it administered?
This medication comes in the form of injections, pills, patches, creams, and gels. Depending on the format, you may take testosterone every day, every week, or every two weeks. Your doctor will use periodic blood tests to assess your hormone levels and determine if the dosage needs to be adjusted, especially if you have a mental health condition like bipolar disorder or schizophrenia, which can be negatively affected by peaks and troughs in hormone levels. (You may have heard that people with certain mental health conditions can’t take testosterone, or can only take low doses. That’s incorrect, but you do need to be more careful as you find a dose that works.)
What are the risks?
Testosterone can cause elevated cholesterol, especially in people with a family history of it. You may be able to make some dietary adjustments to address that problem, or you may need to go on medication to address your cholesterol levels. If you have an oophorectomy (removal of those pesky ovaries), you will need to stay on testosterone to preserve bone strength, although you can take a lower dose. (Fun fact corner: testosterone actually increases bone density, reducing your risk for osteoporosis later in life!)
People on testosterone are more likely to develop high blood pressure and insulin resistance. The redistribution of fat on the body is also associated with a buildup of abdominal fat — and we’re not talking about a beer belly, but so-called “visceral fat” around your internal organs. This has been linked with some health problems. Some patients also experience an increase in red blood cells and hemoglobin as their bodies adjust to this drug, and if levels get too high, they can create a risk of stroke. Headaches and migraines are also documented issues for some patients, and it may be necessary to explore another delivery method if they become persistent.
Getting your levels right is important. Some people like staying on a low dose for mild physical changes, while others like to go higher. “Stacking” (adding other drugs or increasing your dose) won’t make your body change faster — in fact, your body will start converting the excess testosterone in your body into estrogen!
There are potential fertility concerns with testosterone as well — we don’t know enough about the drug to be definitively certain about its effects on future fertility, but we do think there’s reason to be concerned. If you’re interested in lending your genes to a future human, you should discuss the possibility of egg banking with your doctor, just to be certain that you’ll have some material to work with when you’re ready.
However, while testosterone may make you infertile, some people continue to ovulate, and there is a risk of pregnancy, especially in the early months of HRT. You should always use a birth control method to prevent pregnancy, and of course testosterone doesn’t protect you from STIs, so you’ll want to use condoms every time you have sex, regardless as to any other birth control method you might use. Testosterone is a teratogen (it interferes with fetal development to cause sometimes fatal anomalies), and your doctor may refuse to prescribe testosterone without proof that you are using birth control — a long-acting reversible contraceptive (LARC) can be a great option for you.
What are the side effects?
Separate from risks, side effects are the things that tend to happen to your body on testosterone — many of which are desirable, and some of which are irreversible. Starting testosterone is a big decision, because some of these changes will emerge within months, and even if you go off the drug, these side effects will linger! One of the most immediate side effects for people on injectable testosterone is amenorrhea, which is usually highly desired. People using a transdermal (patch, cream, gel) formulation find that their periods stop a little later, but usually within six months.
Over time, people taking testosterone will experience some irreversible side effects including body hair growth, facial hair growth, rougher skin, a deeper voice, and clitoral enlargement. As you get older, staying on testosterone will also cause some balding (take a look at the heads on your maternal side to see what you can expect). Side effects that will go away after stopping testosterone include increased sex drive, vaginal dryness (lube is your friend!), redistributed body fat, higher muscle mass, and oilier skin, which tends to cause more acne.
You may have heard about ‘roid rage and absorbed stereotypes about testosterone and mood all your life, but you might be surprised by the reality. Many people on testosterone actually start to feel calmer, more focused, and happier, because they finally have the right hormones in their bodies, and the physical changes they experience may help mitigate their dysphoria and discomfort. That said, as discussed above, some people with mental health conditions need to be careful, especially at the start, to make sure that their dosage doesn’t conflict with their mental health needs. People who notice dramatic mood swings and personality changes should talk to their doctors about switching to a different delivery method or adjusting their dose.
Exhausted after all that reading? Imagine how we feel! The hormone bottom line is this: for some trans people, hormones radically improve quality of life, and when taken under medical supervision, they can be highly safe and effective. If you’re interested, seek out a clinic that works with trans youth — more and more are accommodating nonbinary and otherwise gender nonconforming youth as well, so don’t feel like you aren’t “allowed” to have hormones if you’re not a guy or girl.
Previously on Trans Summer School: Say My Name, Doc, and the Administrative Side of Coming Out
Coming up next time: The Wide World of Surgical Transition