Many trans people experience relief from the negative symptoms of gender dysphoria through gender affirming strategies like transitioning. Some find social strategies like adopting new pronouns and a new name alleviates their symptoms, while for others, it’s not enough. Physical gender affirming strategies might include surgeries but often begins first with hormone therapy.
Hormone therapy is the first step in affirming one’s gender physically.
The Role of Hormones
Hormones are described as regulating substances. They are carried by the blood to stimulate specific cells or tissues into action. Hormones are also sometimes considered chemical messengers, because they are created in the endocrine glands, which control bodily functions like hunger, reproduction, and one’s mood and behaviour.
Even in infants, sexual differentiation resulting from influencing genetics and hormones is evident as early as the third week of development. In males, the testes begin to secrete testosterone, resulting in the development of primary sex characteristics, where female sex develops as a result of the absence of these male hormones.
Hormones continue to play a crucial role in the functioning of the human body. As adolescent males approach puberty, usually between the ages of nine and fourteen, hormones begin to signal the development of secondary sex characteristics. In males, the scrotum and testes grow. They also experience a growth spurt. Hair development begins on the face, arms, and legs too. And, the voice deepens including the development of the Adam’s Apple.
Puberty and Secondary Sex Characteristics
For transgender children, their existing primary sex characteristics are often misaligned with their preferred gender. For example, those assigned male at birth might have a strong desire to identify as female in addition to appearing female too. As such, impending puberty is especially stressful for transgender children.
While some children might be prescribed puberty blockers, temporarily preventing the development of unwanted secondary sex characteristics, those facing puberty often become creative in their efforts to hide their secondary sex characteristics. Those assigned male at birth, but identifying as female, might wear underwear meant to flatten the groin area and create space for hip and buttock padding. The child may also use bras which accommodate wider rib cages in addition to space for padding.
While these creative measures can help foster a more feminine appearance, they are temporary. Thus, some turn to hormones which physically change the body in ways that clothing can’t.
Hormone therapy is specific for either feminizing or masculinizing. In feminizing hormone therapy, the existing male sex characteristics are minimized with the goal of enhancing female sex characteristics. Existing male sex characteristics are blocked using testosterone blockers with female sex characteristics enhanced or developed through estrogen and possibly progesterone. The combination of prescribed hormones—including dosages—is highly individual and should be determined under the guidance of a physician only.
Unless otherwise noted, the following information is from Trans Care BC:
Common combinations of hormone therapy include:
- Estrogen and Testosterone Blockers
- Estrogen and Testosterone Blockers and Progesterone
- Only Testosterone Blockers
With each hormone, there are various advantages and disadvantages. The following are some of the pros and cons of each. Please keep in mind, the advantages, disadvantages and risks listed below are not exhaustive and are intended only as informative.
One brand name of oral estrogen is Estrace, but there are many more. Oral Estrogen is dissolved under the tongue or is a pill that’s swallowed. Its advantage is that’s it’s cost-effective, roughly 14 CAN per month. However, there are cardiovascular risks for those over 40 who also have pre-existing risk factors.
Brands of estrogen patches include Estradot, Estraderm, and Oesclim. The patch adheres to the skin and is changed twice per week. It is advantageous in that it has a lower cardiovascular risk for those over 40. It is slightly more expensive than oral options (roughly 25CAN per month) with some individuals having allergic reactions to the patch itself.
Also known by one of its brand names as estradiol valerate, this type of estrogen is injected twice per week. Like an estrogen patch, it too has a lower cardiovascular risk for those over 40. Not only is this form of estrogen more expensive, but injections are also painful with possible danger from incorrect injection techniques.
Commonly known as Aldactone, Spironolactone the most common testosterone blocker and is a pill that’s swallowed 1-2 times per day. It’s relatively inexpensive at 22CAN per month and is tolerated well by most. Some disadvantages include increased frequency of urination, the pills being challenging to swallow and, in some cases, dietary restriction are required.
Cyproteroine is also known as Androcur, is a pill that’s swallowed once per day. It’s more than double the cost of Spironolactone, at approximately 50CAN per month. It has the potential to cause liver inflammation when taken in higher doses and depression occurs in some individuals.
Finasteride, or Proscar, is usually not administered solely on its own; it is often prescribed in conjunction with one of the two methods listed above. It comes in pill form, is placed under the tongue, and taken once per day or once every other day. On a positive note, it seems to help slow hair loss but is the most expensive testosterone blocker at approximately 60CAN per month.
Common hormones therapies don’t necessarily include the use of progesterone. The administration of progesterone in hormone therapy remains controversial, but it’s administered to enhance one’s libido while aiding in the development of the nipple and areola. Combining estrogen with progesterone when compared to solely estrogen is thought to increase the risk of strokes, breast cancer and heart disease. Progesterone therapies are administered for limited times only. Again, due to an abundance of risks, it is crucial to commence hormone therapy only under the guidance and direction of a physician.
Common Progesterone Therapies
This daily pill, commonly known as Provera, costs roughly 33CAN per month. As mentioned, it is meant to help breast development, but the risk associated is ‘higher.’
Also administered as a daily pill and commonly known as Prometrium, this medication costs more than Provera (medroxyprogesterone), approximately 90CAN per month, and the risk is thought to be lower.
Expected Effects of Feminizing Hormone Therapy
The permanency of changes occurring from hormone therapies are not entirely known. Those which are permanent will continue to exist in the absence of the hormones, where those considered non-permanent will revert to their original states in the absence of hormones.
The development of breasts occurs after 3-6 months of therapy, reaching their full or maximum potential size in 2-3 years. Expected breast size varies, but A to B cup size is usual.
Changes in fertility vary, but eventually, sperm no longer reaches their maturity because of the hormone medications. The amount of semen produced declines, and many individuals will no longer be able to impregnate someone; however, birth control is always recommended.
Body Fat Distribution
Like breast development, the re-distribution of body fat also occurs after 3-6 months of hormone therapy; the maximum effect occurring between 2-5 years. Fat moves from the abdomen, appearing instead on the butt, hip and thighs.
Reduced Strength and Muscle Mass
Strength and muscle mass lessen in 3-6 months of therapy; the maximum effect occurs between 1-2 years.
Less Body and Facial Hair
In time, the growth of body hair will slow considerably, until it becomes less noticeable. Even though one’s beard and mustache will appear less noticeable, they do not entirely go away. Lost hair will not regrow, but pattern hair loss will slow. Noticeable changes to hair growth begin in 6-12 months, and the maximum effect occurs after three years.
Reduced Sex Drive
In 1-3 months, with maximum effect in 1-2 years, sex drive will diminish with fewer morning erections and fewer spontaneous erections.
The testes will begin to ‘shrink’ in 3-6 months with their smallest size achieved in 2-3 years. It’s expected they’ll shrink to roughly half their original size.
Emotional changes are highly personal with some individuals experiencing no changes at all. Some individuals though report developing a wider range of feelings with others experiencing a narrower range of feelings.
Potential Risks of Hormone Therapies
While the risks associated with hormone therapy remain controversial, there are certain health condition risks thought to increase with hormone therapy. These include:
- Blood clots
- Elevated liver enzymes
- Weight gain
- Cardiovascular disease
- High blood pressure
- Type 2 Diabetes
Breast cancer is frequently listed as a risk, but the research is inconclusive on this topic.
Variations in mood are also thought to be a risk. While some individuals experience an adjustment period, some struggle with negative emotions. Again, any alarming mood changes should be discussed with a doctor immediately.
The Bottom Line
Feminizing hormone therapy is meant to create gender congruence; aligning one’s gender with their body. The risks of hormone therapy should be cautiously weighed. It’s hard to ignore the benefits associated with hormone therapy and the resulting hormone therapy which include a reduction in psychological and emotional distress. And, by generally feeling good, social and psychological function will likely improve too. Overall, there is the chance for improvement in one’s overall well-being, self-esteem, and ultimately, their quality of life.