Have you questioned your gender identity? Have you realized your gender identity does not match your biological sex? Are you ready to take the next steps to affirm your gender identity? This article discusses the process of gender-affirming hormonal treatment. You will find the information necessary to start the series of steps to receiving hormonal treatment. Throughout the hormone therapy process, informed consent is extremely important, meaning you should know the risks and benefits to treatment. Within gender-affirming hormonal treatment, masculinizing and feminizing hormone therapy will look different. We will review both in order to have realistic expectations. Your health is important! Careful monitoring of your hormone therapy is necessary to achieve your goals safely. The process of gender-affirming hormonal treatment will hopefully allow you to realize the version of yourself that makes you feel your best.

Stay Strong

Congratulations on taking a step in affirming who you are by researching how you can become the person who you want to be. Most likely, your journey has not been easy. First, it may have taken you some time to understand and make sense of your experience of gender dysphoria (Discomfort experienced when gender identity does not match biological sex). You might have felt alone in this experience. Society doesn’t make this experience any easier by meeting transgender people with discrimination and at times, violence. It is not just society either, you may have the added stress of not being accepted by your family. It takes an immensely strong person to believe in their experience and to affirm their gender in the face of such an invalidating world. Try to remind yourself that your community is out there. There are people who accept you just as you are. There are wonderful doctors and mental health professionals out there who want to help you through the process of gender affirming treatment.

Hormonal Treatment Criteria

Wherever you are in your process of discovering your gender identity and/or transition, it is important to know there are criteria that need to be met in order to receive hormonal treatment. Below, the criteria requirement to start the process of gender affirming hormonal treatment are listed.          

  1. At least six months of gender dysphoria that can be documented by provider such as MD or TX
  2. You must not be compromised in your ability to make a fully informed decision and to consent to treatment (i.e. be capable of reality based reasoning, know who you are, where you are, and what the time, day, and date it is, be alert (not unconscious). 
  3. You must be of legal age for your country and state. 
  4. If you have any medical or mental health conditions they must be well-managed meaning you keep up with and comply with effective treatment for your condition.

What to expect in your doctor visits: 

In your initial visit to the MD expect to have a full history taken. This history will include your experience of gender dysphoria, sexual history, and medical history. This may be difficult to share, so it is a good idea to prepare what you want to say and ask, and process any emotions that may come up possibly with your therapist. There will be lab work that needs to be completed before starting hormone therapy. This will look slightly different for those looking to masculinize versus feminize. Both individuals looking to masculinize or feminize will need a basic lipid profile, fasting glucose levels, and liver enzymes. Additionally, for masculinizing treatment, you will need lab tests for complete blood count (CBC) and screened for polycystic ovaries (PCOS).

Hormone Therapy Regiment

Once you are ready to start hormone therapy, your regiment will be different depending on if you are a  transmasculine or transfeminine individual. Treatment for transmasculine individuals will include testosterone while transfeminine treatment will include Estrogen and potentially spironolactone (anti-androgen (male hormones)). 

Masculinizing Hormone Therapy

Injection

There are different methods for administering hormones. The most popular way to administer testosterone for transmasculine people is through injection. Testosterone can come in Enthanate or Cypianate. The difference between these two testosterones is what the testosterone is suspended in- Enthanate is suspended in sesame oil and Cypianate in cottonseed oil. The hormone can be injected intramuscularly (meaning in the muscles). People tend to inject in the thighs because they are easy to access with both hands. Subcutaneous injection (injected into the layer of fat below the skin) is also an option, though not FDA approved.

When you administer testosterone injections, you have the choice to dose weekly or biweekly. Dosing biweekly means fewer injections per month but you may need higher doses. With the higher dose, there may be some withdrawal symptoms. Weekly dosing creates a more consistent level of testosterone and thus might feel better for some people. According to Doctor Julie Thompson, PA-C Medical Director of Trans Health, Fenway Health, if getting weekly dosing, it is suggested to do so subcutaneously to reduce irritation. 

Mental Health and Dosage

Mental health diagnosis should also be considered. If you are someone who struggles with emotional ups and downs due to underlying mental health issues, biweekly might be too much of a roller coaster for you. A standard dose for weekly dosing would be between 50 mg and 100 mg, starting at 50 mg and increasing in a month. The biweekly dose would be about double that so starting at 100 mg and in a month increasing and eventually getting between 150 mg and 200 mg.

Other Administration Methods for Masculizing Hormonal Treatment

Patch

Other than injections, there are other methods of testosterone hormone therapy that might be a better fit for you. For example, you might prefer a testosterone patch such as Androderm. The patch may be preferable if you are someone who has trouble tolerating emotional ups and downs. The patch contains anywhere from 2- 8 mg a day. However, there are some pitfalls to this treatment, too. Reports of skin irritation are common and the patch tends to be more expensive than other options.

Gel

Another non-injectable option could be a topical gel that comes in packets or pumps. Keep in mind that this gel can transfer to partners during physical intimacy. Therefore, it is important to be mindful of washing your hands and allowing time for it to dry into your skin, which can take 3-4 hours. Additionally, there is a kind of “deodorant” that can be rubbed into your armpits. However, this option also tends to be expensive as well.

Implant

Finally, there is an implant that can be implanted beneath the skin of the buttocks and lasts about 3-4 months. This also tends to be expensive (about $1000 per implant) but is sometimes covered by insurance. 

Feminizing Hormone Therapy

Estrogen and Anti-Androgens

For feminizing hormonal treatment, Estrogen can be administered in similar ways as testosterone: oral, injection, and transdermal. In some cases, estrogen is not enough and an anti-androgen can be added to treatment. Spironolactone is one of the anti-androgens that can be used and is usually given at 50 mg up to 400 mg. However, another anti-androgen, Casodex, has become more popular in treatment over spironolactone. Lupron is another safer option, however, it can be expensive.

Estrogen and Progestins

Estradiol is an oral estrogen that is often administered at a starting dose of  2-8 mg. Moreover, injectable options include estradiol valerate (5-20 mg) and estradiol cypionate (2-10 mg). This can be administered weekly or biweekly for the same reasons discussed earlier. A transdermal option includes estradiol patch. These tend to be the safest. Progestins can benefit breast development. There are potential risks and benefits which can include weight gain and depression or improved mood and libido. Progestins include: prometrium (100 mg- 200mg), provera (2.5 to 10 mg) and depo-provera (150 mg).

Which Method Should You Use?

As you think about these different methods of hormone treatments, ask yourself these questions to see what one could be right for you: 

  1. Is cost an issue for me? 
  2. Will my insurance company cover one or all of these? 
  3. What type of lifestyle do I lead, how will my testosterone treatment impose upon that? 
  4. Which of these methods is least imposing upon my normal daily life? 
  5. Do I deem myself as fairly emotionally stable or do I have abnormal ups and downs? (If you don’t know the answer to this question you should journal and track your emotions for at least a month before deciding which method could be a best fit for you.)
  6. If you have a partner, will any of these impose upon my partner’s health? 
  7. What method feels most comfortable to me (e.g. if you are afraid of needles, you may not want to use the shots form). 

Checklist for your process of gender-affirming hormonal treatment:

1.Explore and document gender dysphoria with a trained professional such as a psychotherapist, psychologist, or psychiatrist for at least 6-months. Be sure they will provide you with the appropriate documentation necessary for your transition. Also, confirm that they are certified to doing so

2. Determine if this process is necessary for you to live your best life.

     2a. What is your best life? 

     2b. If you stayed in the body that you are currently in, how will that impact your     perceived best life? 

     2c. What do you need from the start to finish of this journey in terms of your mental and physical health? 

     2d. Is now the best time for this transition? Or, is there a better time (e.g. when you graduate? When you have a job that offers insurance that covers some of the expenses. When you move to a different state with different laws.)

3.Figure out what the legal age of consent is in your state/country.

4.Find a doctor who you feel comfortable with and will thoroughly explain the process. During your visit, check in with your feelings. If a doctor makes you feel judged or leaves you with unanswered questions you might want to find a different doctor.

5. Get lab work (basic lipid profile, fasting glucose levels, and liver enzymes) and be upfront with medical and mental health treatment in order for the doctor to give you the best treatment.

6.Decide on your best course of treatment (injection, patch, implant, gel) by weighing the pros and cons of each.

You are Unique

Bear in mind that you are a unique individual. Perhaps you identify as non-binary or somewhere along the gender spectrum. You can tailor your treatment to best suit you! For example, this may look like lower doses of hormones, surgery without hormones, or short term hormone use. Remember to closely monitor your mood and symptoms. Take into consideration the social impact this may have on your life. As discussed earlier, there are societal and familial influences you may encounter. Finding your community and making your mental health a priority is essential. Remember, whatever vision you have of yourself is acceptable and lovable.

If you’ve read this article and put into practice the tips listed above you may benefit from having a therapist hold you accountable while also helping you to process barriers to your success. Call us today at 267-495-4951 to see how we might be able to help.