CHAPTER 8

HORMONE THERAPY

Will I grow a beard? Will my beard just keep growing? Will my voice change? Will I start to grow breasts? Will I be happy with the physical changes I get from hormones?

These, along with A LOT of other questions, are what trans people wonder when it comes to accessing and beginning hormone treatment therapy. While the effects that hormones have on the body are different for everyone, there are some common changes that most trans people notice. In this chapter we will try our best to cover some of the more usual physical changes you can expect.

Note: The terms hormone replacement therapy, hormone treatment and hormone treatment therapy all refer to medical therapy where people take hormones that differ from those they produce naturally. All terms can be used interchangeably and their use varies across countries, regions, languages and cultures.

When trans people begin their hormone therapy and start taking hormones that differ from the ones they produce naturally, it is often said that they are taking cross-hormones.

The terms hormone blockers/stoppers or puberty blockers refer to hormones that put your puberty on hold. Hormone stoppers can also specifically refer to testosterone or oestrogen blockers, but those can be given alongside cross-hormones (especially testosterone blockers as testosterone often overpowers the effects of oestrogen).

THE CHOICE IS YOURS

A lot of trans people decide to undergo medical interventions in order to feel like their authentic self and alleviate dysphoria. This includes some forms of hormone treatment and/or various surgeries. As always, it’s important to remember that you should never feel pressured to take any interventions you don’t want or are not sure about. Everyone’s experience is different, there is no one way to be trans and you don’t have to have any interventions to be more valid. Be sure that what you choose is what you really want and need. And don’t worry – it’s something you will just know.

CROSS-HORMONES: THE O AND THE T

A rather persistent and false myth states that trans children and trans teenagers are being given access to cross-hormones and surgeries in droves. This couldn’t be farther from the truth, as in most countries trans children and teenagers (and trans people in general) don’t even have access to such health care. There is only a handful of countries that actually offer services to trans children and teenagers, and in the UK there are no medical interventions provided until after a teenager hits puberty. And even then, they are certainly not given access to cross-hormones that alter their body, nor are they given any type of surgeries. Instead, those who are able to access the services are given what are called puberty/hormone blockers or hormone stoppers (see Chapter 2).

Getting access to hormone therapy is often a vital step in a trans person’s life. Hormone therapy can have various physical effects on your body – quite simply, it puts you through a second puberty (or the first real one if you had access to hormone blockers at puberty). It’s important to mention that the greater the effect your first puberty has had on you and the more your body has developed, the smaller the effects of hormone replacement therapy might be. Hormone therapy cannot change major physical attributes such as bone structure. Examples of things it can affect are fat distribution, skin, hair growth, deepening of the voice, sex drive and mood, to name a few.

People are generally prescribed either O (oestrogen) or T (testosterone), depending on which path they want to take. Often they are also given blockers to block the current hormone production of the body. These differ slightly from puberty blockers as they are different types of drugs that block out oestrogen or testosterone specifically and allow the administered cross-hormones to do their magic. This is done so that the hormones you are taking can have maximum effects. It’s much more common for those who take oestrogen to be given testosterone blockers than the other way around as testosterone is generally more dominant and prevents the physical changes of oestrogen.

It’s important to say that eventually the effects of hormone replacement therapy can make you infertile. Taking hormones for long periods of time can affect your reproductive organs so that you can no longer produce eggs, carry children or produce sperm. Therefore it’s extremely important to consult with your doctor and perhaps think of ways to freeze your sperm or eggs in case in the future you want to have children that are biologically yours. People feel differently about this and it’s common for young people to think they will never want children. Having kids is a big deal and it might seem bizarre to you to have to think about it at this point. But you’re not thinking of now, you’re thinking of the future. Things could change and it is often better to keep your options open. This is definitely something to keep in mind and we encourage you to have this conversation with your doctor and check out what is possible.

T-GEL AND T-SHOTS

Testosterone, or T as it’s more often referred to, is a hormone that is usually prescribed either as gel (T-gel) or as injections (T-shots). T-gel is most often applied to your body daily whereas T-shots last from a few weeks up to a few months, depending on what type you are injecting. Both of these options have their pros and cons and what suits people is always different.

As mentioned above, T-gel is usually applied daily but it can be applied less often if you need a smaller dose. It’s normally put on the chest and shoulders. The gel is absorbed through the skin and it’s important to give it time to soak in. You will need to avoid sweating too much, and not take a shower or let other people touch the area for 4–5 hours after application, otherwise the effects might be lessened.

Fox Fisher

T-gel is often a starting point for those starting T or those wanting to take smaller doses of testosterone. Some find that the physical changes from using T-gel happen more slowly and that it doesn’t quite have the same ‘power’ as T shots.

T-shots are administered to a big muscle (most commonly the buttocks) and the T is released into the body over time. It’s very important to inject into the right area – injecting T into a muscle that cannot handle the substance can cause serious health hazards, so it’s vital to get advice from health care professionals on how best to do it or have it done by a medical professional at a nearby clinic.

As T-shots are injected into a muscle and then released into your bloodstream, rather than being pills that your liver has to process first, they often have faster and more direct results. If you’re self-administering your T and unable to have your T levels checked through blood tests with a medical professional, be aware that if there is too much testosterone the body will convert it into oestrogen. However, if you’re also on hormone blockers, they should prevent your body from doing so. Anyone who’s experienced their hormones out-of-whack (moody, emotional extremes, spotty, unbalanced) will tell you how important it is to have your levels monitored. We highly recommend that you have your blood tested regularly, as it’s the only reliable way to check you have the right levels of hormones in your body.

Your doctor or a medical professional should ascertain what is most suitable for you. If you don’t feel supported by a medical professional and can get to London, cliniQ offers health support for all trans people (https://cliniq.org.uk).

Fox Fisher

THE EFFECTS OF T

Testosterone generally brings about more dramatic physical changes than oestrogen. When a trans masculine person first starts taking hormones, they may notice changes like increased hair growth, deepening of the voice, fat distribution, easier muscle building, increased libido and more. One of the first changes you will notice has to do with your genitals (discussed later in this chapter). The most notable changes won’t really start occurring until after at least three months.

After a few months, a trans masculine person will notice a deepening of the voice, which can lead to some awkward moments while your voice is adjusting. If you are a singer and are worried about losing your ability to sing, it is entirely possible to train your voice to continue singing. Your vocal range will inevitably change and you will have to re-learn how to best use your voice, but with practice, lessons and determination you can definitely continue your passion for singing.

The change most people go through is increased hair growth on most parts of the body. Some will become hairy creatures whereas others have little-to-moderate hair growth. It really depends on genetics and is different for everyone.

Early effects of T can include changes in fat distribution where fat will move from the hips, waist and chest towards your abdominal area. Testosterone makes it easier to build muscles, and often your muscles start to tone and increase in size. It is possible to build more muscle with exercise and by working out, and it should be easier to do this than ever before.

Testosterone also affects your pheromones, smell and skin. You might look down one day and notice a sea of dark hairs sprouting in places which used to have nothing at all or just light fur. You may also notice your skin is coarser and you have raging acne. You or lovers may notice the smell of your sweat and more intimate areas has changed, especially just after having injected or applied testosterone to your body. Those who have their T-shots every 10–12 weeks may have four or five days after their shot where their smell changes significantly as the testosterone is released into the body again.

HAIR GROWTH AND ENCOURAGING MORE OF IT

Most trans masculine people taking hormones will enjoy hair growth on their face (including a moustache, sideburns, eyebrows), legs and stomach. Unfortunately, once hair begins to grow, it may also sprout on unwanted places (or maybe you love all the hair!), such as your shoulders, back, nose, ears and toes. You may wish to introduce a grooming session with some clippers every couple of weeks (dubbed ‘manscaping’, although it works for any trans masculine person) to adjust your hair length based on what you feel is comfortable. People taking testosterone may sprout hair in all sorts of places, including butt cracks, only to start losing hair on the head. Luckily there are effective ways to improve your chances of keeping or even growing back your luscious locks, through a combination of destressing, vitamin supplements and topical treatments. There are many alternative options too, from hair transplants (not recommended) to hair pieces (made from real human hair!), growing a long, flowing beard, wearing a hat or simply embracing your egg head.

Hair loss probably won’t affect you as a teenager, but if you’re in any way concerned about it, we can recommend searching for some tips online or even consulting a doctor.

BUM FLUFF AND OTHER FACIAL FUR

What facial hair you have depends entirely on your genes. Once you begin taking testosterone, you will definitely notice hair beginning to sprout. Some people say that shaving helps your hair to become more coarse and thick. Going to a barber’s to get your beard groomed is a rite of passage for many masculine people. Before the day you sprout a bushy beard, which could be anywhere from one to six years (if at all), there are a few things you can do to increase the hair you have.

You may have heard of minoxydil, a topical liquid, which is often used by pre-T trans masculine people to grow better facial hair. While it has had some good results, creating darker hair where there was nothing there before, there are many side-effects to minoxydil, including a burning, stinging sensation, redness, a faster heartbeat, early ageing of the skin, chest pain, swelling, weight gain and difficulty breathing. There are alternatives you can use, such as serioxyl, which can also be taken topically and have no known side-effects. Be sure you do some proper research before using things to increase hair growth.

Some trans masculine people like to dye or tint their facial hair with mascara or special beard-care products, which makes existing hair more prominent. Just be careful not to dye your skin too, or you’ll have to really scrub your face to remove it!

EFFECTS OF T ON YOUR JUNK

One of the first things that those taking T will start to notice is changes to the genitals. What is conventionally referred to as the clitoris will start to enlarge, which can cause some discomfort. This part of the body is absolutely packed with nerve endings and is one of the most sensitive parts. Now that it’s growing, this area can become sore and you might feel very sensitive and uncomfortable. It’s important to try to be comfortable and wear pants and trousers that allow a little breathing space, so that you don’t feel like things are constantly rubbing against you. In most cases a bigger clitoris will also increase sexual pleasure, and many people notice a big increase in sex drive during this time. Most of the growth will happen in the first year or so but can continue for a little bit after that. Another change that you’ll notice is to do with smell; and if you usually get very wet when you’re turned on, you may notice that you become less so or it’s different. You’ll need to re-learn how your body works to a certain extent, but it’s nothing to be worried about.

All these changes differ between people and it’s important to remember to stay clean, take good care of yourself and, most importantly, enjoy the ride. If you’re worried about anything (e.g. if you suspect you might have an infection), you should definitely contact your doctor, GP or medical professional and have them make sure everything is perfectly fine. Sometimes that reassurance is all we need.

OESTROGEN PILLS, PATCHES AND INJECTIONS

The effects of oestrogen on the body are often more subtle than the effects of testosterone and might not appear as dramatic physical changes. As with T, you won’t really start to notice any changes until after at least three months.

There are many different options when it comes to taking oestrogen, but the most popular is taking pills. These pills differ between countries and places but they generally all offer the same effects. Some people use patches that release oestrogen slowly into the body (you have to change them every few days). In some countries you can get injections that last for a few weeks at a time. Injections are generally more effective and exact less of a toll on the body than pills, which have to be processed through the liver. Health care systems may vary in which specific hormone administration methods they use or have access to, but all the methods have very similar effects. Some health care systems offer a range of different hormones (e.g. pills, injectables and patches) while others may be limited to certain types, so find out what works best for you in consultation with your doctor.

Along with oestrogen, some people also take the hormone progesterone. This has proven to be better for breast growth as it often produces a more round shape. Progesterone is also good for fat distribution in general and mood. So for those starting their medical transition, it is useful to consult your doctor and ask them if this is something that could work for you.

Very often those taking oestrogen are also given testosterone blockers. These are given to stop the testosterone production of the body and allow the oestrogen to have maximum effect. There are many different types of testosterone blockers, and they are most commonly given in pill form. If a person has had their testicles removed, there is no longer any need for testosterone blockers as most of the production of testosterone occurs there. However, it’s important not to feel pushed to have any surgeries you might not want to have. Many trans women or trans feminine people do not feel the need to get genital surgery and are perfectly fine with their body as it is.

THE EFFECTS OF O

What most people start to notice first is the change in skin and in fat distribution. Your skin will generally become softer and the oil levels in it might change. Fat will start to distribute in different places such as your breasts, hips and buttocks. Breast growth makes the area very sensitive and you might experience soreness. There might even be a little bit of fluid coming from your nipples at certain stages. This is all a part of breast growth, and your breasts can keep on growing for up to a few years. This depends on the types of hormones that you are taking. Obviously breast size varies between different people, and it does for AMAB people who take hormones, as well. This depends on a mixture of your body type, genetics, age, whether you had access to hormone blockers and more.

Other notable changes are nails and hair. The texture of your hair might change and hair growth in various places on the body might decrease a little. Unfortunately, oestrogen does not stop beard growth, so if you’ve started growing a beard and did not have access to hormone blockers to prevent that, you probably need to use other methods to get rid of stubble or hair growth on your face, which we will look into below.

Oestrogen does not affect your voice, and a lot of trans feminine people therefore take voice-training lessons instead or even have vocal cord surgeries. This is always a personal choice and everyone’s voice is different.

BREAST SIZE AND HOW TO MEASURE YOUR BRA SIZE

Fox Fisher

If you’re taking oestrogen and progesterone, you’ll start to notice breast growth. While some people don’t wear bras at all and find them very uncomfortable, others find that they help prevent back pain and they like using them, especially when working out.

So how on earth do you measure your bra size? Fear not, for we have a simple guide for you!

First, you need to figure out your band size. This is done by using a measuring tape and measuring just under your bust (as the illustration shows). Make sure it’s level and snug and round it up to the next whole number. If the number is even, add 4 inches. If it’s an odd number, add 5 inches (for example, if you had 34, then your band size is 38). Tadah! You got your band size.

Secondly, you need to figure out your bust measurement. So wrap the measuring tape quite loosely around your bust (at nipple level) and round it to the nearest whole number (see illustration). Tadah! You got it. Yes, it’s that easy.

Thirdly, you need to do some calculations for your cup size. In order to figure out the cup size, subtract your band size from your bust measurement and refer to the chart (see illustration). As an example: 37 inches (bust) – 34 inches (band) = 3 inches. That’s a 34C!

Of course there are a lot of different types of bras out there, so there are a few things to keep in mind. Make sure you bend forwards when putting on the bra and that your breasts fall well into the cups. Then adjust the band properly (you should be able to run one finger under the band comfortably) – make sure it’s not too loose by tightening the straps if necessary. If your breasts are falling out a little bit, you might need a different size bra. If you’re trying a different size, remember that if you go down a cup size, you need to go up one band size and vice versa.

HAIR GROWTH AND HOW TO COMBAT IT

The most common method is simply to shave. It goes without saying that constantly shaving can take its toll on your skin (especially the skin on your face) and it’s important to be very mindful when you’re shaving on such a regular basis. Always make sure you are using good shaving creams, aftershaves and other products to keep your skin moisturised, and avoid using the same razor several times. This method generally isn’t viable for long because it can really affect your skin over time.

Other less invasive and easy methods of removing hair are waxing or sugaring. Both offer short-term hair removal (up to a few weeks) but many people find it painful to remove hair this way. You can buy strips in most stores or pharmacies, but be aware that the cheaper ones are usually of lower quality and therefore less effective. We recommend getting someone to assist you as doing that rip can be quite difficult and scary!

Another method is to use tweezers or threading to pluck away hairs. Obviously this will only be a very short-term solution, but it is helpful with certain areas such as eyebrows and with persistent facial hair. Many people that have had success with hair removal through laser or electrolysis use tweezers to keep their hair growth at bay.

The other most common method to try to decrease or get rid of hair growth is laser hair removal. This treatment uses a laser to burn hair follicles and can be painful if the area being lasered isn’t cooled down enough beforehand. There are many places that offer laser treatment, but it can be quite costly. It’s important to seek out places that have a good reputation – it’s even better to ask around and go to places where other trans people have had success. It’s important to note that laser hair removal generally only works on dark facial hair and is much less effective (if at all) on blonde hair. The number of sessions required varies – some people find that once they have got rid of most of their hair, they only need to go back a few times a year just to keep things in check.

There are other, more invasive methods of getting rid of body hair, such as electrolysis. This is a complicated treatment that can be described in great scientific detail, but the short version is that the hair follicles are zapped with an electric current. This method has proven to be more effective than laser treatment, but takes more time, is more costly and is generally more painful. People usually have to spend a lot of hours/sessions on treatment and it might take a few years to complete. As with laser hair removal, it’s important to seek our clinics or salons that have experience with treating trans people, so asking around in various circles is always useful.

EFFECTS OF TESTOSTERONE BLOCKERS AND OESTROGEN ON YOUR JUNK

The effects of testosterone blockers and oestrogen on your junk can, of course, differ between people. The most general effects are that what are conventionally referred to as your testicles will start to shrink and your sperm production will stop. For many people it is a source of joy that they no longer have to endure morning wood or random boners, and this will most likely be the case for you too. It is also common to experience a decrease or even a steep drop in sex drive.

Your smell might also change, and the fluids released when you have an orgasm might seem less or different. This is because sperm production has decreased or ceased altogether. Everyone experiences this in different ways, and learning how your body works can be very exciting.

If you feel that something is not quite right or have any concerns, be sure to consult your doctor. Generally you shouldn’t have any problems related to taking testosterone blockers and oestrogen.

GETTING HORMONES ONLINE – DESPERATE TIMES LEAD TO DESPERATE MEASURES

In many countries, access to hormones can be limited or even impossible, or it can sometimes take up to a few years to get hold of them. It’s a well-known fact that you can get almost anything off the internet, and hormones are no different. Trans people sometimes resort to obtaining hormones online out of desperation (it’s often a matter of life and death for people to start a medical transition). While getting hormones online can help alleviate dysphoria, and people sometimes simply don’t have any other choice, it can be very dangerous. Taking hormones on your own without the supervision of a health care professional can lead to unexpected complications and there is no way for you to check your levels through blood tests. You can also never be sure about what you are getting and there are a lot of ineffective or dodgy hormones that you can buy online.

If you are thinking about getting hormones online without supervision, it’s important that you do your research properly and consult others who might have had to take that route. It can be counterproductive to take hormones that have negative effects on your health so you have to be sure that you are getting hormones that do not cause any serious threats to your physical health.

While we entirely discourage people to seek out hormones online without supervision, it is a reality that we must discuss and talk about. One of the authors of this book was once in a desperate place where they had to wait for up to two years to get access to hormones and they saw no other option than getting them online or getting leftovers from other trans people’s prescriptions. Eventually they ended up going private as they were able to, but this isn’t always an option for trans people.

This is why we encourage all trans people to try to come out as soon as possible so that they can access the medical interventions that they need as soon as possible. Waiting times and access can often be a complete nightmare, but if you can get access to professional services or health care that provide hormones, it is something you should always strive for instead of self-medicating.

HORMONES: PERSONAL STORIES

Zoë, 20-year-old trans woman

It was so, so important for me to start hormones, when the GIC refused to start them for at least another year I turned to ordering off the internet. I was 17 when I started. For me it meant feeling so much more comfortable in my body as the oestradiol made all these subtle changes that made me feel so much better, like softening my skin and hair and causing breast growth.

Emile Judson, 15-year-old trans man

I started hormones when I was 15, about five months after I came out. I started very quickly because I knew what I wanted to do and how to do it. It meant the world to me to be able to start hormones, because my mental health was really struggling at the time. I am now four months on testosterone and I have seen positive changes like voice and facial hair and my mental health has been so much better.

Elliot, 21-year-old agender

I started T in April 2015, over three years after I came out. To finally start felt so incredible that because of how excited I was I almost fainted getting my first injection! I had just turned 19, and I kept a book of changes that at first I filled in every day. After a little over 100 days, I started just updating it every week, then every month. I got a lot more comfortable with myself. It changed my moods at first but that stopped after a while. Now I have a masculine jaw, body hair, facial hair and it’s made my body fat a more masculine pattern with slimmer hips. It’s made me feel a lot better mentally. I feel like myself.

Michael, 15-year-old trans man

I started hormone blockers when I was 14, just over a year after my first appointment with Tavistock. I was already five years into puberty at that point and so most of the changes had already occurred, but it relieved my constant stress about the situation worsening. The cessation of my periods was the best part as they’d always been excruciatingly painful for me, both mentally, because of dysphoria, and physically. The fact that I no longer experience something that the vast majority of girls in my year but not the boys do is often greatly comforting to me.

Hastur, 17-year-old trans woman

Just getting hormones was a huge spike in happiness for me, even before I took the first dose. They made me emotional, and brought obvious changes like breast growth and body changes, and although the emotional part was tough to cope with sometimes, I had the support, so I’m happy with it. I was 16 when I started, and over a year on, I would never look back.

CJ, 19-year-old trans man

I started hormone blockers at the age of 16 (three weeks before I was 17), which I feel is far too late to have started them. However, they did stop monthly cycles, which I 100 per cent loved! They were important to me because I knew that one year of these and I could go onto T! I started T at 17 (three weeks before I was 18) and it made me so much happier with life. I could finally see myself becoming who I was meant to be. So far it’s made my voice deep, given me more hair, and given me a little bit of bum fluff on my face, which is nice because it means that I don’t look 10 anymore!