The Lowdown on Low-Dose Testosterone

As hormone therapy (HT) becomes a more commonly offered medical service, and more research is done about HT, specifically in relation to gender nonconforming and trans folks, more avenues and options for engaging with HT have presented themselves. One of these avenues that I’ve seen a lot of discussion about lately is low-dose , or microdose, testosterone.

This is exactly what it sounds like: engaging with testosterone HT, but in a lower than “average” dosage. Due to a lack of extensive and sound research about trans- and/or gender-related care, there is not exactly a universally agreed upon “average” dosage for testosterone HT. Furthermore, because testosterone HT comes in multiple forms—injectable, implant, topical cream, topical gel, transdermal patches, etc.—defining “average” dosage is even more complicated. Therefore, it won’t be that helpful to define an “average” dosage here. However, if you are interested in determining what an average dosage might be for you and your preferred form of testosterone, your doctor or care physician should be able to outline that for you.

Reasons to Opt for Low-Dose Testosterone

There are many reasons why someone might be interested in low-dose testosterone. A big one is pacing. If you're interested in starting testosterone but feeling  nervous of a big wave of change hitting you all at once, low-dose testosterone might be something to consider. Changes happen more slowly and are far more subtle on a low dose.

Another reason someone might opt for a low dose is that perhaps they don’t want all of the change that comes with an average dose. This could be for many of reasons including not identifying as a transgender man, considering pregnancy soon or at some point in the future, needing to maintain a certain appearance for safety and/or survival, and simply not liking some aspect(s) of change known to come with taking a high(er) dosage of testosterone.

A third reason someone might want a lower dosage is if they are interested in experimenting with testosterone HT, but are unsure that it will be something they want to continue. Making small moves toward testosterone, like starting on a low dosage, allows you to test the waters, without committing to major and possibly irreversible changes. It is always possible to increase the dosage, or stop altogether, and, of course, it is always advisable to work with a care provider if at all possible.

Something Else to Consider: Method

As mentioned earlier, testosterone HT comes in various forms. If a low(er) dosage interests you, perhaps you might also be interested in learning more about the efficiency — that is, the body’s ability to absorb and respond to the testosterone — of various forms.

Injectable testosterone is the most common form of testosterone HT and also a highly efficient form: the body is typically able to absorb and respond to injected testosterone quickly and easily. Testosterone implants are similarly efficient to injectable testosterone. Topically applied methods, like gels and creams, are  less efficient and the transdermal patch’s efficiency falls somewhere between injection and the topicals, because it is protected by the backing and less likely to rub off on clothing or other surfaces.

Of course, and unfortunately, efficiency is not all you will need to consider when deciding upon your preferred method of taking testosterone. The injectable form tends to be the most affordable and widely available. The topical forms are less researched, more expensive, and depending upon where you live, you may be the first person your care provider prescribes them to, if you successfully seek them out. This means that getting access to the less efficient forms is definitely more difficult. However, if you find a helpful care provider who is willing to work with your insurance, these forms do exist and they can help in the process of engaging with testosterone HT in subtler and slower ways. If you are going to seek a topical form of testosterone HT, my advice is to do independent research as well as speaking with your physician and to remember that it is your body and well being on the line, and you are allowed to ask for what you want.

Navigating Fluctuating Feelings around HT

Let’s begin with the foundational reminder that it is absolutely valid for your feelings about HT to change and shift. That may be a long term shift or it may be day by day, hour by hour. All of these iterations are understandable and okay.

Think about the other decisions you make about your life: it is probably rare that you're able to make a decision clearly and decisively and never look back even once to reconsider or reevaluate. Add in the complication of HT being something you will continuously engage with (should you choose to sustain an engagement with it). It is like having to repeatedly make that decision again and again. Of course your feelings may change, and it’s okay f they do, including if you feel differently enough that you decide to go off testosterone or move up to a higher dose. Let me also say that it is also justifiable to feel firm and unwavering. Each of us is our own unique collection of stardust and germs. We will each have our own unique relationship to HT. There is no right way to feel and no wrong way to feel. Your feelings are your feelings and they are information that can help you make decisions about how to move forward.

So, now that we’ve established that whatever your feelings are about HT and however they do or don’t change over time is legitimate, we come up against the tricky precipice that is decision-making.

How do you make decisions about something that your feelings may or may not be constantly in flux about? Well, if your feelings are not constantly in flux, you’re in a slightly easier position, at least as long as your feelings remain constant. You can take the information of your constant feelings and act in accordance with them, like, if you constantly feel a desire to engage with testosterone, then making the decision to do so might feel simple. And vice versa, if you constantly feel a lack of desire to engage with testosterone, then making the decision not to do so, or to stop using it, might feel clear.

How do you begin making the decision if your feelings fluctuate? There’s no sure fire answer here. One important piece to remember is that if you start HT, you are not locked in for life. You can stop HT after starting. Opting for a lower dose and/or less efficient form of HT might help alleviate some anxiety about fluctuating feelings as well. Because there are some irreversible changes that testosterone can manifest in a body (to varying degrees these include bottom growth, facial hair growth, vocal changes, and hair loss), taking a lower dose and/or a less efficient form can slow the onset of these irreversible changes, at least buying you some more time than you would have if you were on an average or high dose and/or the very efficient, injectable form of testosterone. In this lengthened period of time you can sort of “try on” the early and subtler effects of testosterone to see how those make you feel and continue to process your potentially fluctuating feelings about long term and/or irreversible changes that testosterone may eventually manifest.

Micha Cárdenas sums it up well when she writes, in I Am Transreal: a reflection on/of Becoming Dragon, that transition is “willfully stepping into the unknown.” While we can imagine, project, hope and dream about what testosterone will bring us or make us feel, we cannot know until we are living that embodied reality of engaging with testosterone. And while that could be thought of as a beautiful leap of faith, it can also be scary to choose to engage with something without the promise of our desires coming true. And I’m here to tell you that worrying, having anxiety, or doubting yourself about your desire or decision to engage with (or not engage with) testosterone means that you are grappling with that factor of the unknown. And grappling with that factor means that you are taking this decision seriously. Which is great. And also hard. But still great.

The Question of Regret

Regret is a slippery thing. For one thing, it’s often unstable—sometimes we feel regret very strongly and after some time goes by, that regret fades; other times we don’t feel very much regret for a long time and then we are caught off guard by it. We have a fairly negative cultural connotation of regret, that tells us experiencing regret is a sign we made a mistake. And in some cases that may be true.

Let me pause here to remind you that making mistakes is how we learn and grow. It is okay to make mistakes. But, it also may be true that regret exists along a spectrum, and that it could indicate a variety of things from longing to sadness to rage, and those feelings may have nothing to do with anything you can control.

Beyond not being a fixed thing itself, regret can play many roles in relation to the question of HT. After starting HT, one may experience regret that they did not start it sooner, something like feeling a loss of the time they spent wondering or waiting, and thinking that that time would have felt more meaningful had they already been engaging with HT. One may experience regret over starting HT at all, perhaps feeling like it wasn’t actually something they wanted to do and it was a mistake. One might experience regret over engaging with certain forms of HT because of undesirable effects that specific form had on their body, that another form might not have had. Ultimately, there’s lots of potential for regret here and there’s no sure fire way to avoid experiencing regret. That is uncomfortable but it can also be motivating and informative. I’m going to encourage you to take in a fear of regret right alongside your other feelings about testosterone HT, treat it as information that can help you make your decision, but don’t let it be the guiding factor, if you can help it.

I will leave you with another helpful point of Cárdenas’:

a choice not to transform is of course still a choice to transform into a different state, as our bodies are all in permanent transition…”

The choice not to engage with testosterone HT does not equate to the choice not to transition. We are all always, already transitioning. Testosterone HT is but one tool we have in our transition repertoire. There are many others.

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