Episode 44: ASAB Presents the Science… Hormone Therapy
Image: A 3D model of gonadotropin releasing hormone. (Source: Wikimedia Commons)
Our new episode is available from our Podcast host here: Episode 44
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The “everything” we’re responding to (here in the USA, where we both live)
- “Texas isn’t the only state denying essential medical care to trans youths. Here’s what’s going on.” (Washington Post, 10 March 2022)
- “Understanding Florida’s ‘Don’t Say Gay’ Bill” (10 March 2022)
- “Idaho bill would make medical treatment for trans youth punishable by life in prison” (The Hill, 9 March 2022)
- “A Texas judge blocks the state from investigating parents of transgender youth” (NPR, 11 March 2022)
- “Judge temporarily blocks Texas investigations into families of trans kids” (The Texas Tribune, 11 March 2022)
- “Rapid onset gender dysphoria” isn’t real
- “Everything You Need to Know About Rapid Onset Gender Dysphoria” (Julia Serano, 22 August 2018)
- “New paper ignites storm over whether teens experience ‘rapid onset’ of transgender identity” (Science, 30 August 2018)
- This article is a good overview of the paper and response that was a lightning rod for this in 2018, but, it also treats Ray “Autogynephilia” Blanchard as a credible source on trans people so go with caution
- What “sex hormones” are and how they work
- “Gender basics: How sex hormones work, and their use by trans people”
- “How do your hormones work? – Emma Bryce” (TED Ed on YouTube; not trans inclusive but a nice visualization)
- Intersex variations on the human body referenced
- X/Y Chromosomes and Sex Determination
- “Y Chromosome Infographic” (NIH National Human Genome Research Institute)
- “SRY gene” (NIH National Library of Medicine)
- “Genetics | X-chromosome Inactivation, Barr Bodies, and the Calico Cat” (YouTube, 2018)
- “X-chromosome inactivation: the molecular basis of silencing” (Journal of Biology, 27 October 2008)
- Puberty Blockers
- *** Thorough Review “Puberty Blockers: A Review of GnRH Analogues in Transgender Youth” (Transfeminine Science, 30 January 2022)
- “Refusing puberty blockers to trans young people is not justified by the evidence” (The Lancet, September 2021)
- “Gonadotropin-releasing hormone analogs: Understanding advantages and limitations” (Journal of Human Reproductive Science, 2014)
- (Long-term) effects
- “Significant adverse reactions to long-acting gonadotropin-releasing hormone agonists for the treatment of central precocious puberty and early onset puberty” (Annals of pediatric endocrinology and metabolism, 2014)
- “Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up” (Archives of Sexual Behavior, 19 April 2011)
- “Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects” (European Journal of Endocrinology, November 2006)
- “Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents” (Bone, 2017)
- How long has modern medical transition been happening?
- Anti-androgens are commonly prescribed to those on E, but anti-estrogens are rarely prescribed to those on T – why?
- Trans people who have got on E have histologically identical breasts to cis people who went through estrogen-predominant puberty
Hello, and welcome to Assigned Scientiat at Bachelor’s. I’m Charles and I’m an entomologist.
And I’m Tessa, and I’m an astrobiologist.
And today it’s just the two of us for a special episode. Inspired by everything that’s happening, we thought that it might be useful to do a series of episodes talking about the actual science of transition from both psychological and physiological perspective. So to borrow a question from another podcast I listen to – Tessa, how’s your heart?
Like literally or metaphorically?
Literally, it seems to be doing just fine. Metaphorically, it’s been through a lot last couple days, you know, between creeping fascism abroad and creeping fascism at home, all that fun stuff.
That’s great. Actually, on the subject of hearts, in researching for this episode, I did see a lot of research on relative cardiovascular health risks for people who go on testosterone versus people who go on estrogen. And something that I didn’t know is that the life long risk of for example, heart disease, is not actually that divergent between quote unquote men and quote unquote women. It’s just that the onset of heart problems is much earlier in people with testosterone predominant systems.
Tessa, you are trans.
I am indeed.
You are a transgender person. And you have been on estrogen for how many years?
About, a little over seven years now?
Congratulations. Why did you start taking estrogen?
Well, I had a lot of dysphoria about how my body was before. And I had done enough research to known that estrogen could drastically change the phenotype of my body into something that I felt I would be more comfortable in. And also, I’d heard that for transfeminine people, the psychological benefits could also be quite significant. I will say, though, that at first, I was pretty uncertain about it. You know, I was terrified I was making a mistake somehow. But I also figured, you know, it’ll be at least a month, probably closer to three months before I see any really drastic, noticeable and difficult to reverse physical changes. So you know, I figured I’d almost kind of give it a trial run.
And if I decided I didn’t like what was happening after three months, I could just stop and you know, be fine. As it turned out, within about a week or two of starting it, I noticed mentally, I was calmer and my mind was quieter than I had been pretty much my entire adult life. And I’m like, Well, okay, I’m glad I’m sticking with us. And yeah, that’s how I got to be where I am now.
Follow up question. Why do you hate women? [both laugh]
I actually have realized, in the mushrooming of public, anti trans sentiment and subsequent legislation and attempts at legislation, that my story actually would, to detractors, be a perfect fit for rapid onset gender dysphoria, because I never voiced you know, I feel like I’m a boy, I want to be a boy, ever before I figured out that I was trans. So in the space of a year, I went from not even being sure, if I identified very, very strongly with being trans to being on testosterone, which to many people is a nightmare. But to me, it was a beautiful dream. I’m just kidding. As, as you very well know, going on testosterone is a bit of a roller coaster.
I can attest to that.
Yeah, it evens out… one thing that I was thinking about this week is that we both have the experience of basically going through a testosterone puberty and then going through an estrogen priority. And it’s just that we switched.
Pretty much, yeah.
I would not trade places with you back again, for the whole world.
Likewise, yes, no offense.
But I validate, I validate your journey. And I’m hoping that these episodes that we release this month will be, best case scenario, a resource for people who genuinely are uninformed or under informed but open minded, and want to know more about the reality of what we’re actually talking about, to be able to ground the conversations that are happening. And sort of the, what from the outside might seem like overblown, apocalyptic forecasting from trans individuals in what are people actually arguing about? And are their arguments actually grounded in anything scientific? And spoiler alert, the answer is no. Then to begin with… Tessa, why don’t you start us talking about what are quote unquote sex hormones, and what do they do in the body.
So sex hormones, technically speaking, they’re steroid hormones. But that makes them sound a lot scarier than they are, it basically just has to do with their chemical structure. And generally speaking, how signaling molecules work is that they float around in your bloodstream, and then they land on a cell and at the cell has the right type of receptor or dock for that hormone, it bonds to the hormone secreted into the cell that starts a sort of chain or pathway of signaling molecules that are released within the cell that generally then go and cause certain genes to be activated and usually produce some sort of protein or, or change in cellular behavior, you know, whether that’s to reproduce, or if they’re an immune cell to start secreting antibodies, or, in some cases, shut down. Sex hormones, in particular control a lot of things. That’s also why, contrary to what a lot of people seem to think, every human being on the planet, with a few exceptions, has both what are commonly thought of male and female sex hormones, you know, all cis men have at least a little bit of estrogen in them and all or almost all cis women have a little bit of testosterone in them.
And crucially, both of them are important.
Like, you don’t want to be net zero on either one, if at all possible.
Yes, because turns out men with zero estrogen end up developing bone problems. And women with zero testosterone end up developing other problems, usually with energy levels and metabolism. And though I should note, this varies tremendously from person to person, there isn’t really even, for example, like a established upper level for the amount of testosterone that is, quote, unquote, normally supposed to be in women, you know, there’s a general idea, but it varies so much from person to person.
And you also have people who have, due to a genetic mutation, for example, don’t have functional, say, testosterone receptors, and so their body doesn’t respond to it at all. However, they usually have pretty normal lives other than the fact that they’re infertile. Biology, it’s messy, you’re never almost never going to find like one rule that is accurate and correct all the time. But generally speaking, yeah, people need at least a little bit of both in order to be fully functional.
And I think another thing that we’ve talked about, that I think is a very crucial idea that goes along with there being both estrogen and testosterone in essentially every human person, is that when people go on, quote, unquote, cross sex hormone therapy, meaning if you have an estrogen predominant system, you go on testosterone, or if you have a dosterone, predominant system, you’re going on estrogen, aka, if you are perceived as female, and you go on quote, unquote, male hormones, that’s cross sex hormone therapy, the people who do this, including you and I, are not introducing a foreign object into our system that then causes a cascade of quote unquote, unnatural physical changes, it is adding something in a higher amount that’s already present, that then acts on the genes that you already have to express them in the way that they would have been expressed if you had that high amount of that hormone to begin with. Right, exactly.
I don’t know if this is a misunderstanding that people have because it feels so obvious to me. But it’s… you’re not defying God’s legacy or whatever, you’re just adding in, you’re changing the balance of hormones, and thus changing the expression of different traits in your body, but in a way that is not foreign to your body. The possibility is in you all the time and your DNA. It’s just that you might have started out with more estrogen than testosterone or more testosterone than estrogen.
Yeah, and it’s really interesting to see how people are almost kind of astounded at this idea, because they seem to think, oh, you know, there’s vast genetic differences between men and women. And there really isn’t. Biology is very conservative, and really loves redundancy. So theoretically, any human being on the planet has the genetic capacity to develop every single trait that we associate with one sex or another. Generally, it just doesn’t happen because the right hormone messages aren’t present at the right time for you know, whatever trait and specifically to develop, yeah, we’re not doing anything unnatural by having trans people take replacement hormones. We are just exploiting this fact. And the fact that again, biology has… there’s a lot of redundancy.
And we love an efficient force of nature. And speaking of genetic expression. [cat meows in the background] [to cat] Yeah?
And cat expression.
Alan sounding off about transphobia. And cat expression… well, speaking of cats, and speaking of chromosomes, it is less specific to hormones, but I think it’s also an interesting thing, if not an important thing, to bring up the extent to which your chromosomal makeup is important in your expression of sexualized traits. And specifically humans, we function on the XY sex determination system, meaning if you have two X chromosomes, one from the sperm, one from the egg, then you develop into quote unquote, biologically female sex. If you have an X and a Y, then you develop testes, basically, in embryonic development.
However, well… two things: one is, the Y chromosome doesn’t have a whole lot on it, which if you think about it make sense because it would, it would be bad for, again, we love an efficient system. Evolution loves redundancies, and it loves not having to make… it doesn’t like to make extra stuff. So the Y chromosome doesn’t have a whole bunch of genes on it, that would then have to be compensated for in people who don’t have the Y chromosome.
The primary function on the Y chromosome, with a few exceptions, is basically starting the developmental cascade that results in the formation of testes. It’s also why that, in XX people, only one X chromosome is ever active. The other is sort of like bundled up into this teeny little ball called a Barr body. And that, if you were to switch out your your adult person who has two X chromosomes, if you were to switch out all those inactivated X chromosomes with a Y chromosome, it would make literally no difference in your current state of your body, or really anything noticeable about you physiologically. The Y chromosome, for all the ballyhoo that it gets, really doesn’t play much of a role in human sexual differentiation past in utero.
Well, a lot of the work of sexual differentiation just happens not during puberty, but during embryonic development, you get your template all set, and then puberty is when hormones come in to do the job of sort of coloring it in and adding shading and putting hair in various places where it wasn’t before, etc. And when I say speaking of cat…
And to make it absolutely straightforwardly explicitly clear, the crumpling up of one X chromosome happens because you only need one X chromosome to be active and expressing its genes to get all the good of genetic expression. Because otherwise, if you were an XY individual, you would be missing a lot of stuff. So the system we have is everybody gets an X, because all of the eggs have an X, some people get a Y, but the Y is mostly unnecessary. It mostly just has the SRY gene, which then kicks off that cascade in embryonic development towards testes, etc. And then, instead of having the Y chromosome have all of the same kind of genes that are present on each X chromosome, the body just says we’re going to need one X chromosome, the Y chromosome is going to have very few genes on it. It has like 55 genes versus hundreds on X chromosomes. And then we’re going to take the redundant X chromosome, crumple it up in a process called X inactivation.
And I say speaking of cats, because this is a great cat fact, the pattern of cats in tortoise shells and calicoes, almost every single calico cat you will ever see in your whole life is a female cat, aka an XX cat. And what causes the calico pattern is that they have the genes for orange coloration and black coloration. And it’s just that during development, some of the black x’s are turned off, some of the orange x’s are turned off. And you get this patchwork pattern of colors all throughout the coat. But you will see a couple of male Calico cats who are XXY individuals and XXY chromosomal configurations also occur in humans. But yeah, so cats are the best, first of all, and also X inactivation.
So basically, the Y chromosome gets a lot of attention in certain circles as a sort of like marker of shame. People like to throw this back on the face of trans people like chromosomally, you will always be whatever. And it’s like Yeah, but I’m also not a developing embryo. So like it doesn’t really matter to me anymore.
Yeah, you know, if you and I were just raised x’s and y’s, as long as your X’s were on activated, it would make zero difference and how your body physically works. And likewise for me.
So then talking about early development, a lot of the ballyhoo has been about puberty blockers. So to set the stage for anybody who doesn’t know, which is not shaming, we don’t shame ignorance, we encourage curiosity. So puberty blockers are something called gonadotropin releasing hormone analogs. And they are administered, they were actually originally developed for cis men to treat prostate problems. And then were later used to treat precocious puberty, which is just the onset of naturally occurring puberty, but at an age that is considered precocious…
We’re talking like 6, 7, 8.
Yes, like very young. And I think that was… the prostate stuff, I think it was in the 70s, the precocious puberty stuff, I think was more in the 80s, and then in the 90s, they started being applied to children expressing quote unquote, gender identity disorder, and gender dysphoria, to prevent the onset of unwanted unwanted sexual characteristics occurring during natural quote, unquote, puberty.
And the mechanism by which they work is that gonadotropin releasing hormones are hormones which are released from the hypothalamus. And I’m not going to get too deep into the weeds because I think it’s it’s, it’s really technical in a way that would be… I don’t think a lot of us learn about like hormone signaling pathways necessarily, but basically, gonadotropin releasing hormones then cause the release of luteinizing hormones and follicle stimulating hormones, which are both, they’re both connected to the onset, and then continuation, of pubescent changes. Depending on whether you are going with an estrogen predominant puberty or a testosterone predominant puberty, the exact mechanisms will differ a little bit, but that’s basically it.
And so then gonadotropin releasing hormone analogs, GnRHas, are either agonists or antagonists. And their application can be used to effectively just slam the brakes on pubescent changes, and create a sort of non pubescent state in somebody who might be experiencing them. This is of course in people young enough to be going through puberty versus like 60 year old men who are having prostate problems. And listen, we’ve all been there… I haven’t been there, because I don’t have a prostate, but I know some 60 year old men.
Basically the way that they work, quote, “Pituitary gonadotropin secretions are blocked upon desensitization when a continuous GnRH stimulus is provided by means of an agonist or when the pituitary receptors are occupied with a competitive antagonist.” These can either take the form of an agonist, which binds to all of those receptors and sort of causes a desensitization because they are continuously connected to versus in the sort of, quote unquote, natural course of puberty, their pulsatile increases of GnRH, which then causes the release of luteinizing hormone and follicle stimulating hormone or when it’s an antagonist, it blocks those receptors, preventing the action of GnRH even initially. And the major difference here is that if you have the agonist version, which I think was more in use earlier, and is less in use now, there is a temporary spike, and then the desensitization causes the fall – versus if you start out with an antagonist, it just can’t kind of get anywhere and it can’t get the ball rolling on those pubescent changes. And essentially, a lot has been said, this is a very sort of inflammatory area right now. Hormone blockers were never available to me and I assume they were not available to you?
No, and honestly, at the time, I didn’t even know enough to know that they existed, and it would have been an option for me or that, for that matter, that I was actually even trans.
Yeah, well, because this is very personally upsetting. I mean, it’s all personally upsetting, because fundamentally, what is at risk is bodily autonomy and trans affirmation. And I, as a trans adult, I care very much about both of those things. But it is especially frustrating to me this argument over puberty blockers, because when I… when I was like, all these people saying, you know, if I had been 12, and people had made trans a possibility for me, I would have gone on testosterone or whatever. And it’s like, would you have? And maybe they would have – like, people who go on hormones and then decide that they wish they hadn’t gone on hormones are not an impossibility, like they’re out there. So maybe that would have happened. But thinking back to me when I was 12, if you had asked me, Do you want to go on testosterone? I don’t know that I would have said yes. If you asked me, do you want to go on puberty blockers? No question. Absolutely.
I knew that I didn’t want to go through the puberty I was going to go through before I could conceive of myself as somebody who would go through a different puberty. It would have been unbelievably, it would have been invaluable to have that opportunity to see Stop something that I was so afraid of, and so viscerally uncomfortable with, and that people want to take that option away from children, who would benefit from it unbelievably, is so infuriating, it really belies any sense of actually caring about the well being and safety of children. Because it is… arguably letting children go on puberty blockers is the more conservative option. It is, specifically and explicitly, giving them an opportunity to have nothing happen. And think about what they want.
Yeah, essentially, you know, it gives them more time to decide.
But then the question is, so I went, and I tried to look for articles on long term prospects for children and young teenagers who go on puberty blockers for a relatively long period of time, and I found a lot of garbage and ultimately not scientific, but ideological arguments over not, is this safe physically in the long term? could this disrupt crucial developmental stages in the long term? Like, for example, it’s now recommended that you don’t spay or neuter your dog before they like reach their full adult size, because interrupting the accessibility of sex hormones can like disrupt their ultimate development and then cause long term problems, right.
So that’s not an absurd idea that preventing the presence of these hormones in the body during a crucial stage of development could cause long term developmental issues. Like that’s not a completely out of pocket concern. But a lot of the arguments that are being made are not about that. They tend to frame puberty blockers as a kind of radical step, in a way that just simply does not make sense to me. Does it make sense to you?
No, a lot of it, though, I think, is from the idea that, (A) somehow, you know, I think a lot of the resistance to it comes down to the assumption that a it’s just a phase, quote, unquote, which is, of course, the same thing they said about gay people, you know, back in the 70s 80s 90s., and therefore, you know, as soon as you hit natural puberty, you’ll just grow out of it, or that (B) and this one I’ve always found extremely bizarre is the idea that there’s no such thing as a transgender child, or teenager. And I assume the assumption is, oh, it’s because kids can’t make those sorts of decisions, because they’re not old enough and mature enough yet and don’t have the cognitive capacity to make those decisions. But on the other hand, that raises the question, where do trans people come from? You know, do we just sort of…?
Well, it’s the perverts, Tessa.
Yeah, I know. That’s the real answer is that they think it’s a lifestyle or a sexual deviancy but, you know, I have had fun poking at them. Occasionally, those sorts of people occasionally online saying, okay, so you do honestly believe that trans people just kind of, you know, sprang into existence fully formed at age 18, like Athena out of Zeus? And usually they don’t answer, which is unfortunate, because I would like to see someone defend that.
I mean… So then speaking about this, I decided to take these concerns at face value. Is this a safety concern? Is this going to disrupt development of children in the long term, if they’re on puberty blockers for a relatively long period of time, because the sort of medical procedure that is suggested in a lot of cases is like, allow kids to get on puberty blockers at the onset of natal puberty, and then wait several years, to see if they want to go on cross sex hormones, quote, unquote. Is a period of being on these for years, going to be detrimental to long term health?
First of all, it’s hard to determine this robustly, because there just isn’t a lot of research, which is a problem that we run into again and again, with trans people and long term health outcomes, because we just haven’t been doing this with enough people for a long enough amount of time to do a lot of really robust longitudinal studies, which is getting better now. Because there has been an influx of more people being on hormone therapy, especially in the last couple of decades versus like in the 50s, it was extremely rare for people to physically transition in a way that is familiar to us now. Now, we got 14 year old on TikTok talking about microdosing testosterone, and God bless them, but 20 years ago…
Living in the future in the best way possible.
Honestly, I don’t know… to be clear, in case any curious transphobes are listening, I don’t know that the 14 year olds ARE microdosing testosterone. I know that they are talking about micro dosing testosterone, so.
But from the information that I was able to find, have relatively long term studies with both cis kids who went through precocious puberty and were put on puberty blockers and trans kids who were prescribed puberty blockers to prevent the development of quote unquote, unwanted sexual characteristics. It seems to be there are short term, quote unquote, adverse effects while you are on puberty blockers that then are basically reversed once you get put on sex hormones either proceeding through puberty as it occurs naturally or being put on quote unquote cross sex hormone.
So there was one study from Korea that found basically in four events out of 621 patients sterile abscess resulted from an administration of gnrha which demonstrated point 6% prevalence rate anaphylaxis happened in one patient and unilateral CS Fe and another patient relatively. I don’t remember what CSFV stands for, but it was a one off in over 600 patients. And this was in a published a study called “Long acting gonadotropin releasing hormone agonists are considered as a treatment for choice for pediatric CPP.” So for precocious puberty in cis children, prolonged administration of GnRHa suppresses the pituitary gonadal axis activity with a subsequent decrease of sex hormones. So in these kids who were put on GnRHA is to prevent precocious puberty, literally four out of 620 ones. And this was called an adverse effect, like a significant adverse effect. And that was that.
And then there is one study of a 22 year follow up from a trans man who was put on puberty blockers when he was 13, then was put on testosterone when he was 16. And then there was a 22 year follow up looking at his mental and physical health. And basically it found, and I will link this in the show notes, other than being a little bit shorter than Dutch men, on average, his health indicators were pretty much good or normal, like he was basically just some guy, and I’m happy for him.
And then in others, it found sort of particularly looking at bone density, which can be you know, it’s one of the reasons why it’s often not recommended that transmasc people who get a hysterectomy don’t get a total hysterectomy, like they keep their ovaries so that they can get a little bit of endogenous estrogen going to prevent further like bone density loss. So bone density is a big thing that comes up and looking at long term health effects of hormone therapy. And a couple of studies I found which again, I will link in the show notes found that like, while kids were on puberty blockers while they were on the GnRHas they had like a decrease in bone density, they had a couple of quote unquote, adverse effects, right. But then soon, very soon after they went on hormones, like they then added a form of sex hormone to their system, whether it be cross sex or not, that pretty much reversed itself.
So the health effects of puberty blockers from the evidence that I was able to find, sparse as it is, seems to indicate that the adverse effects of being on puberty blockers are temporary to their administration and are not causing significant identifiable long term health problems, once you then have a certain quote unquote, normal level of sex hormones in your body, which is great news. On the other hand, my sort of cynical existential dread tells me none of it really feels like it matters because ultimately, the argument over puberty blockers is not about physical health, it is about the demonization of transness and the positioning of a trans body as repulsive.
And you can’t fix that with robust longitudinal studies, unfortunately.
A lot of people seem to think… the retort about puberty blockers, you almost get the impression that these people think people will be on puberty blockers indefinitely, which is no that that’s not how any of this works, they are not going to be permanent children. It is literally just to buy them time until you know they’re 17, 18, whatever and decide, do I want to go through sort of my endogenous puberty or do I want to go through a different puberty?
That’s the other thing, is that part of what is underlying these efforts at limiting access to gender affirming care is in this forced infantilization of trans people of this, you do not deserve to have meaningful autonomy over your body and choices about your body and the… there’s kind of a, just the, the creep of, well, you can’t decide until you’re 16, then you can’t decide until you’re 18, then you can’t decide until you’re 21, then you can’t decide until your frontal cortex is done developing when you’re 25. And it’s like, there is this push of trying to kind of breadcrumbs that of, well, it’s not so outrageous to say the 12 year old may not have, you know, fully developed capacity to make really significant medical decisions about the rest of their life. Okay. 12. And then it’s like, well, 16 year olds are still pretty immature, and then it’s like, okay, well, 16 to 18 not a huge amount of difference for a lot of people, people can start when they’re 18. And then it’s well, huh, you can when you’re 18, you know, you can’t buy cigarettes, you can’t drink until you’re 20. Right, and it gets to 21. It’s like, the frontal cortex thing again.
Yeah. And yeah, you can’t, you know, you shouldn’t be allowed to transition until you can rent a car without using a credit card at age 25. And, honestly, let’s be real here, like the goal was to, if possible, roll it back completely.
Right? Well, it’s, cynically, and I haven’t explicitly seen the statement so I can’t say that this is absolutely underlying a lot of the thought process, but I think – I suspect – that a lot of these efforts to make it harder and harder and harder to access, gender affirming care, until you’re older and older and older, is the attitude that a lot of people have, that it’s kind of pointless to transition once you’ve researched certain age. And so trying to get people to age out of it, so that they will just seem, you know, why didn’t you do this when you were younger? And then it’s like, well, why are you bothering to do this now that you’re old?
Oh, yeah. Yeah, I mean, a lot of it, andd actually, in the case of, you know, some of the more extreme fringes and this is like, especially true with like, say groups, like the Family Research Council, which are, you know, unapologetically opposed to LGBT liberation in general, they have explicitly said that they view people transitioning as like a tragedy, and that by making as difficult as possible, and ideally impossible, you are saving them from themselves.
And then of course, when you ask, well, what are trans people supposed to do instead, they on ironically, refer you to conversion therapy ministries, and the assumption that, you know, basically find God and that will fix you. So a lot of it yeah, basically is, you know, we want to not enable trans people because by doing so, we are enabling them harming themselves when they could, you know, just become normal, straight conservative Christians like us, because that’s the one thing in life that doesn’t make us viscerally uncomfortable, but which, for a variety of reasons, we can never admit to ourselves.
Yeah. Well, moving from puberty blockers to hormone blockers – it’s very common for people going on estrogen to be prescribed not just estrogen in the form of estradiol, but also to be prescribed and anti androgen, or an androgen blocker androgens being the class of hormones that testosterone belongs to, but it is not equally or in fact, I think almost ever prescribed, that people going on testosterone also be given estrogen blockers. And we both tried looking into why this is like mechanistically – why is there a, quote unquote need or a perceived need for there to be androgen blockers but not estrogen blockers.
And there are a couple things that kind of came up. One is, some people suspect that the prescription of anti androgens most sort of classically in spur on a lactone, which I I’ve never taken because I haven’t had a desire to prevent androgens from working in my body. But I know it’s sort of a classic trans women talk about it a lot. And then they talk about like, Oh, I love pickles…
Yeah, it has some interesting side effects.
So we kind of found… some people think that it might be an outdated practice of, this is how people have been doing it. It’s just kind of accepted. Like it could just be medical conservatism in the sense of medicine as a pretty conservative practice, not necessarily socially conservative, but like wanting to keep doing things the way people have been doing them. And then one person suggested under your tweet that it was, it came from the days of most estrogen being Premarin and there being…
… a higher likelihood of negative side effects with a really high dose and thus needing anti androgens so that you wouldn’t have to over prescribe estrogen. But now the source of estrogen has changed but people are still often prescribed the low doses of estrogen paired with anti androgen And then secondarily, there is often this explanation that is given in kind of an unquestioned way that I find very weird, that testosterone is just, quote, stronger acting than estrogen, which is very like… way to project.
Yeah, yeah, there’s a lot to unpack there.
Yeah. But this notion that testosterone acts more strongly in the body, that it has stronger effects, that it is more noticeable. And to be fair, the reason that a lot of people who go on testosterone are not prescribed anti estrogens is that your estrogen levels kind of naturally just fall when you’re on a higher enough dose of testosterone. And my source for that is yearly bloodwork for the past decade.
Although I will note that some of the feedback I got when I was trying to like track this down is that there are some trans men out there who didn’t have their estrogen levels drop as low as they would like, for example, they were still having monthly menstrual cycles, who actually had to work very hard to get estrogen blockers prescribed to them.
Yeah, I think it’s… I think a lot of it comes back to what we mentioned before, which is that there is not as deep a body of research on the effects of hormone therapy and the best administrations of hormone therapy on in specifically trans individuals, because, and not to get cynical again, but frankly, it doesn’t seem like a lot of cis people particularly care about us all that much.
Yeah, and there aren’t a lot of us either, which also makes it a bit more difficult.
Although there are more of us every day, despite transphobes’ best efforts. Gotcha. But yeah, basically, that’s kind of still an open question of mechanistically. What is happening that would… well, (a) is it necessary? And then (b) if it is, in the cases where it is, why is it so much more common to necessitate anti androgens, but not as anti estrogens. And it doesn’t seem like anybody really, definitively knows on that one. Although if you’re listening to this, and you do, our email address is firstname.lastname@example.org.
And then the final thing that we have to talk about is circling back around to what we said before, which is that the traits that you develop, when you go on, quote, cross sex hormone therapy, are not traits that are alien to your body, you are developing the same thing that a cis version of you would have developed on those hormones.
Yeah, it’s pretty wild. And a lot of people don’t seem to realize this. I mean, I’ve encountered more than a few people who, usually more out of ignorance, not malice, but sometimes they’re malicious as well – either think trans women all get breast implants, or that the breasts we do develop under hormones are somehow different from those of cis women. And they aren’t – histologically they’re identical to each other, you know, in terms of the glands development, and the structure and the cells present. And you know, with the right hormonal triggers, we can quite easily breastfeed a child, it’s not uncommon. And again, it’s because biology loves redundancy. And you know, with the right hormone signaling, you will develop what your body would have normally developed, if you, as you said, gone through a cis version of puberty instead.
And it’s it’s also… crucially, it is acting on the potential that is inside of all of your cells to begin with, like you are going to express trait in accordance with the genes that you have inherited from your family. So like, if you come from I don’t know, a very hairy family, then if you go on testosterone, you are probably going to get much hairier than somebody who comes from a pretty hairless family, right. And that’s not because you are given more or less testosterone, it’s because the hormones are acting on the potential that was the… the sexual characteristics were the friends we made along the way and… no… the sexual characteristics were inside you all along. And they just had to be let out by exogenous hormones.
And this actually gets into something that maybe we want to save for later episode when we talk more specifically about misconceptions, but for instance, there are things that happen that trans people know about because of our experience with them that are sort of not acknowledged by the medical community, by “your guide to feminizing hormones,” etc. So you were saying to me the other day that there are a lot of trans women who against the apparent wisdom of the entire medical fields lose height and lose shoe sizes when they go on estrogen.
Yeah, and we’re not exactly sure why that happens, but it’s been reported anecdotally way too often for just to be, you know, people’s imaginations. The theory I’ve heard, which I think seems most realistic, it’s a combination of production and muscle density, which will happen when your testosterone levels are suppressed versus female levels. And also the thought that in the absence of testosterone, or high levels of testosterone, rather, cartilage will store less water. And as a result becomes less bulky. Again, you know, I don’t know enough about physiology to really critique these ideas if they’re accurate or not. I don’t know if anyone does, because as we’ve said, trans people are criminally under studied medically. I will say anecdotally, that while I did not really lose any height, I did go down two shoe sizes. And that is like an empirically measurable, you know, so it’s not just my imagination.
And I, very weirdly, in the last year, year and a half, I went up a shoe size, I’ve been on testosterone for over a decade at this point. So I kind of think that’s maybe a topical point to end at for this episode of, a message for hope for all people who are considering going on hormones.
There is this common perception, even among trans people, hopefully less and less now, but I think still is very common that, after a certain age, it, it kind of feels pointless to go on hormones, because the sort of plasticity of your body kind of decreases as you age, right? Like, it’s commonly thought, you know, the younger you start, the better your outcome is going to be, because you have sort of more potential at those ages. But the thing that I never saw mentioned when I was desperately reading, all of the pamphlets published online about testosterone therapy 10 years ago, is that I had this image in my head of like, if all the changes that I want don’t happen within three years, I’m never going to get there. And I lived in fear of this, like, arbitrary deadline in my head of like, that’s when all the major changes happen. And after, then you might as well be dead, if you aren’t satisfied.
But the reality of the human body concordant with the reality of the world in the universe as a whole, is that it never stops changing. And the most exaggerated sort of noteworthy major, obvious changes may happen, all clustered together towards the beginning of your hormone therapy journey. But your body is a dynamic object, and the hormones that are in your body going forward in your life are going to direct the changes that keep on happening until you’re dead in the ground. So it’s never too late to start. And it’s like I am still experiencing like changes, significant changes. Even now, like I went up a shoe size a year ago, like I didn’t start getting chest air until three years ago, like things are gonna keep on chugging.
Puberty takes a while.
It takes a while!
When I went through like the first round of puberty, I guess, the endogenous one, like I didn’t develop chest hair until I was 18, 19, 20, really. And by the same token, you know, my experience, I still experienced, like noticeable breast growth, even though I’ve been on estrogen for again over seven years now. You know, I had to go up a cup size not too long ago. So yeah, you know, these changes will continue.
Yeah. And I think I felt so hopeless about it when I was just starting out, probably partially also, because I was 18. And that’s a very dramatic age to be alive.
Indeed it is.
And also, I think another thing is that you can get used to a lot of stuff. Now, I don’t really feel dysphoria in the way that I did. I still, listen, I still feel bad about myself a lot of the time, because there’s a little thing called gay body dysmorphia. Don’t think about it too much. It’s sad. But it’s… now I am not dysphoric about the things that I’m unsatisfied with, I am just comparing myself against unfair cultural beauty standards.
So a message of hope for all trans young people someday, you too can still be insecure, but not dysphorically.
But not because you’re trans.
That’s the… just insecure the way a cis guy, or cis woman… And again, I think saying that now very clearly both you and I are binary trans people, we have pretty straightforwardly binary trans experiences. So I hope that we are not over generalizing to the point that non binary people feel really alienated. And one topic that I started looking into but then thought was kind of too large for the scope of this episode was, alternative approaches for specifically non binary hormonal transition but I, I didn’t think that we could really do it justice.
And specifically, if you are a non binary person who knows a lot about this and has done research or… daydreamed about it, definitely email us, again, our email address is email@example.com
We would love to have you on.
We’d love to have you on.
[interstitial] Hypothetical question. So actually kind of relevant to the topic. A lot of people, I think, even well-meaning people, tend to conceptualize of the processes that we use in medical transition of being very new and kind of untested and experimental, but they aren’t. People have been going through hormone therapy for a century, people have been doing surgery for a century. And puberty blockers are relatively new, but they have been used consistently, you know, to prevent precocious puberty in cis children since the 80s, at least. So a lot of what we have experienced is not really remotely experimental at this point. So would you be willing and/or interested to be involved in more experimental procedures, for example, a lot of trans women talk about the possibility of uterine transplants. And the concept of uterine transplants is not new – like a failed surgery for a uterine transplant is what killed Lily Elbe – but it has not gotten to the point where it is right around the corner, but maybe it’s a few blocks away. And so would you ever be willing to be engaged in something that is genuinely new and untested?
Yeah, I totally want In fact, I’ve actually like signed up. You know, there was a group that was looking into uterus transplants for trans women a few years back, and they sent out like an email request list, you know, sign up if you’re interested in participating in future research, and I definitely signed up for it. I don’t know if it’s gonna happen. And to be honest, practically speaking, it would… I would prioritize more like a synthetic ovary for hormone regulation over a uterus transplant, but you know, still same basic thing. Yes, I would absolutely sign up for experimental medicine.
Wonderful. I, I honestly, I think I am more conservative on this point. But mostly just because I live my life in a state of constant low grade terror, which discourages a lot of risky behavior. But we’ve also established that you would go into space.
Which I refuse to do, so. I think this matches our psychological profiles to a T. Ba-dum-tsch.
[interstitial] Well, that is an episode of a podcast. If you want to find me online. I am on Twitter @cockroacharles.
And I am on Twitter at @spacermase or on my website tessafisher.com.
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And until next time, keep on science-ing.