Searching YouTube for the word “transgender” yields more than a million results, many of which are personal “before and after” photo lineups or time-lapse videos of transition. YouTube and social networking sites like Facebook and Instagram allow trans people to document the experience themselves and to share the changes with their friends, family, other trans people, and the general public. Much of this material focuses on physical transformation, but other posts document the psychological experience of transition—the joy, the sadness, the frustration, and often the peace that result from a decision to take a leap.
Emotional changes during transition vary considerably. Relief is common, as is decreased depression and anxiety. Some trans men report feeling more angry or irritable after starting testosterone or find they can’t cry as easily. Trans women on estrogen or progesterone sometimes feel their mood shifts more easily or that they’re tearful at times when they might not have been before. Because there are so few studies of the emotional effects of hormones during transition, most of what we know is anecdotal, and it’s hard to say which experiences are most common. In a culture that expects men and women to conform to gender norms, it’s important to question if we expect (and, in turn, pay more attention to) hormonal effects that match what we think those hormones will do.
Testosterone is associated with masculinity and evokes images of muscle-clad young men pounding weights, soldiers going off to war, anger, fights, and sexual prowess. Estrogen and progesterone, on the other hand, are associated with femininity and call to mind a sense of comfort, warmth, motherly love, and kindness. We also think of them as causing stereotypically female emotional responses, like mood swings and tearfulness. Without scientific studies, we don’t know if most people who transition experience hormones in these ways. Even with studies, we may never know if all the effects of transitional hormones are directly related to the hormones themselves or whether our beliefs about how they will affect us end up shaping the way we experience them.
The concept that chemical messengers could travel through the body to affect organs remote from their source originated in ancient China. However, it wasn’t until the 1930s that researchers were able to isolate hormones such as testosterone and estrogen in order to use them medicinally. These two hormones in particular became known as “sex hormones” and entered into popular culture as symbols of masculinity and femininity. However, everyone’s body, regardless of biological sex or gender identity, produces both of these chemicals. Though the typical male range for testosterone is higher than the typical female range, and vice versa for estrogen (until menopause), testosterone is not an exclusively “male” hormone and estrogen is not exclusively “female.”
Many people are surprised to learn that estrogen is produced by cells in the testicles and that the chemical structure of testosterone and estrogen is similar, so much so that it takes only one enzyme (aromatase) to convert testosterone to estrogen. Not only are these hormones present in everyone’s bodies, but their functions are not limited to sex and reproduction. Among other things, testosterone helps build muscle mass and increases the production of red blood cells, and estrogen improves bone health and cholesterol levels.
What does all this mean for transgender people who decide to take hormones as part of transition? What kinds of effects should they expect? Most commonly, transgender men take testosterone to transition. In the United States, injectable testosterone is frequently used, though patches and gels are also available. Within the first month or two, the menstrual cycle stops. Over the first six months, many trans men begin to have more oily skin and may develop acne. Then they may start to see facial hair, as well as increased body hair, and they may experience their voice “cracking” and then lowering permanently. Muscle and fat distribution can change significantly, and it can be easier to build muscle mass. Some trans men notice the emergence of male pattern baldness, which, depending on age, can happen very quickly during transition. Testosterone levels do not always have to be monitored if the desired effects are occurring. However, there can be some rare, serious side effects, such as a thickening of the blood due to increased red blood cells.
Reproductive issues for trans men became news in 2007 with the public story of Thomas Beatie, “the pregnant man.” Though he may be the most famous, many other transgender men have also given birth. It is possible to become pregnant by accident while on testosterone, though this is unlikely because ovulation is usually shut down. Trans men should be careful that fertilization does not happen because testosterone is a pregnancy category X medication, meaning that it can cause damage to the growing fetus. Many trans men desiring to become pregnant stop using testosterone and wait for the return of their menstrual cycle. This has resulted in many healthy babies.
In terms of the emotional effects of testosterone, what is true for one trans man may not be true for another. Some do experience increased anger or irritability when starting testosterone, but others report the opposite—feeling calmer. There are, on the other hand, studies that confirm another belief about taking testosterone: it is well documented that trans men first starting testosterone often experience an increase in libido (sexual arousal). Most importantly, across multiple studies in many areas of the world, trans men report increased quality of life and decreases in depression, anxiety, and suicide rates on testosterone.
Trans women starting hormonal transition have a few choices. Most trans women who will not or have not yet had vaginoplasty (i.e., surgery that transforms a penis and scrotum into a vulva, clitoris, labia, and vaginal canal) take both estrogen and an anti-androgen medication. Anti-androgens are meant to block the effects of hormones such as testosterone, which is still produced by the testicles even while on estrogen. The most common anti-androgen in the United States is a pill called spironolactone. Estrogen comes in various forms, including pills, patches, and injections. Together, estrogen and an anti-androgen can help to smooth the skin, redistribute the body fat and muscle ratio in a more feminine pattern, decrease body hair, and cause breast growth, but they do not stop the growth of facial hair or increase the pitch of the voice. They also do not generally improve male pattern baldness if that has already occurred. In addition to estrogen and spironolactone, a minority of trans women also take progesterone. There has been some debate over whether progesterone provides additional benefit, and most studies suggest that it does not.
For trans women on hormones, counterintuitively, testosterone levels are often tracked to make sure they have decreased to within the female range. It is also important to follow the potassium level while on the anti-androgen spironolactone because it can become dangerously high under certain circumstances. The most well-known serious side effect from estrogen treatment is the development of blood clots, which often start in the legs and can move to the lungs (pulmonary embolism), causing respiratory failure and death. Trans women who smoke can lower their risk of blood clots by cutting down or quitting. Both testosterone and estrogen use can, in some cases, severely impact cholesterol and triglyceride levels, and these should be monitored closely.
Although trans women with children have not featured as prominently in major news sources, many do have biological offspring. Often, their children were “fathered” before the women medically transitioned. Once trans women start on estrogen and anti-androgens, their sperm production and ability to have children decreases. These changes may be irreversible. For many people, this is a desired effect of taking hormones. However, others delay taking hormones or choose sperm banking prior to starting hormones and later have children with womb-bearing partners.
Like the stereotypes about testosterone, there are myths about the effects of estrogen. Many trans women expect that they will become more emotional or tearful when they start taking estrogen, and though some report these feelings, others do not. As with testosterone, “your mileage may vary.” Many trans women also report that their sex drive decreases, although some say the opposite—that they experience more sexual feelings, not fewer, and often attribute this to finally getting to be who they are. Most studies of trans women and hormones have focused on psychological health and demonstrate comparable increases in quality of life and decreases in depression, anxiety, and suicidality to testosterone in trans men.
Some trans people, many of whom identify as genderqueer and don’t fit into the categories of trans man or trans woman, may want to take hormones that will allow them to look androgynous or to have certain characteristics but not others. Some people take lower dose hormones or take hormones for a short time and then stop. Many are happy with the results. Unfortunately, the effects can be unpredictable, and the outcome may be a combination of both desired and undesired effects.
The unsupervised use of hormones carries risk. Taking higher than advised doses of either testosterone or estrogen, with the hopes that the effects will occur faster, is known to cause emotional instability and an increase in side effects, as well as a variety of health issues, such as increased risk for blood clots.
Though no such experience is universal, trans people taking hormones at prescribed doses do very well emotionally. Some trans men do experience feeling more angry and some trans women cry more, but just as many people seem to have the opposite reactions. A common refrain that comes both from trans men and trans women is “I feel more calm” or “I feel more like myself.” The studies that do exist related to the emotional effects of hormones are limited (one to two hundred people per study). However, they seem to show that overall psychological functioning, anxiety, depression, and quality of life are improved on hormones. Because these studies are small, they don’t tell us much about the more subtle effects that these treatments may have. Hopefully, increasing interest in transgender health may generate more research grants in this area. What we do know is that trans people are generally satisfied with their choice to take hormones, and that hormones such as testosterone and estrogen are just part of what makes us masculine and feminine.