Getting started or maintaining your Hormone Replacement Therapy (HRT) as transgender men can be complicated, overwhelming and difficult. Sometimes the process is made needlessly cumbersome with lots of extra criteria that aren’t necessarily “required.” It is important to note, however, that these added steps are there to protect you as HRT can have permanent results. There are now more cases (whether it’s because there are more instances of it happening or just because we’re more visible now) of people starting HRT and transitioning only to realize it wasn’t really what they wanted. That, perhaps, they’re more gender neutral than truly FtM/MtF or they started young and didn’t realize down the road that this wasn’t necessarily the course they wanted to go. Whatever the personal reasoning, the extra steps in place are there to help you determine if HRT is right for you and how to go about it safely. There are a lot of extra steps, though, that people are made to believe are required and that isn’t always the case, or they used to be requirements but have since been determined to be unethical or antiquated. The more we become visible and demand proper treatment, the easier it will become.
Important Note: Always check with your local regulations. Some states/towns/countries will have their own requirements that a physician or patient must adhere to. Additionally, many insurance companies may have “requirements” that you must follow in order for your policy to cover your trans-related care. It’s important to check with the company and read the fine print (and check with your local laws that may offer protection against insurance companies) to determine what is and isn’t mandated.
- WPATH v. ICATH
WPATH – World Professional Association for Transgender Health: WPATH has been the source for guidelines and Standards of Care (SOC) for the trans community with the first version dating back to 1979 (Version 7, the most current, was released in 2011). Most medical professionals (and insurance companies) use the WPATH guidelines as their basis for establishing and maintaining care for transgender people.
ICATH – Informed Consent for Access to Trans Health: ICATH is a much newer model (not an organization) that is more current to the “non-cis” community and attempts to include all trans, fluid, intersex, non-binary, etc. people. It is not an organization but is an on-going and more frequently updated model to determine that we should not have to jump through needless hoops just to get medical care.
The difference: The WPATH is a long-established guide but it can be slow-moving to adopt new guidelines and standards in a fast-changing world. What has happened within the trans-community and society between 2011 and 2016+ has been exponential growth in visibility and medical professionals willing (and able) to work with trans clients. WPATH has not updated itself to these rapid changes. It also does not take into account those who are not cis and not trans but may still need gender-related treatments or gender-aware physicians. ICATH attempts to train professionals about the wide gender spectrum and how to provide the most up-to-date care for the entire community. When professionals site WPATH as their “bible” for practice, use caution because it is not current and is a guideline, not a strict regimen.
- Therapy/Gender Therapy First
While therapy is probably a good idea for the vast majority of society these days, it’s not necessarily a requirement. Minors are an exception and may be required to undergo approximately 3-6 months of therapy prior to being allowed to start HRT given that they are, in fact, so young. This may vary depending on insurance carrier and state requirements. It also may not be an actual “requirement” at all. For minors, be sure to research according to your area. For adults, however, therapy is not a requirement in order to begin HRT. There is “Informed Consent” although some physicians may not accept informed consent for their own protection against potential lawsuits. That is a doctor preference, not a medical requirement. Be sure to check with your doctor(s) to determine if they operate within informed consent or not. While I do not want to discourage therapy, as it can be incredibly helpful, it should be noted that it’s not a requirement in most instances. It is a good idea to establish a relationship with a strong therapist that is trans-aware/gender specializing even for periodic check-ins as your body will undergo a vast array of changes over time and pre/post-surgery changes if you go for any operations. It’s a nice safety net to have on your side.
- Testosterone Will Make Me – (Big, Fat, Muscular, Angry, Aggressive, Sexual, etc.)
Testosterone does have a wide range of effects but it’s impossible to tell who will experience what and when (if at all). It’s one of the few substances out there that has a truly broad spectrum of effects that are never the same from person to person. It CAN make you any number of things, but it’s not guaranteed to do it either. Odds are your appetite will increase but if you maintain a healthy diet you will gain appropriately. Muscle mass is gained if you work for it. Aggressive behaviors can happen, especially if you’re predisposed to it, but dosing and method of administration can make a huge difference (see below). Sexual libido can drastically increase but it could also do nothing. Clitoral growth may happen tremendously for a few guys while others may not notice much growth at all.
- Intramuscular (IM) Injections are your only option
While this may have been true in earlier years this is no longer your only option although many doctors are slow to realize this. For those who are concerned with aggression issues, an IM injection every other week may cause spikes/dips and that has been known to deter many guys from ever getting started on HRT. There are actually several options now besides IM/biweekly. You can do Subcutaneous (SubQ) weekly injections wherein you take “half” your biweekly dose and do it weekly as this will help stave off those high peaks and deep lows as you’re now getting a steady dose. Gels are also an option for steady administration as you use them daily but you’re not entirely sure of the exact dose your body is truly absorbing with this method along with the fact that you cannot touch a female for up to 6 hours (pay attention tomorrow to see just how many women you really come into contact with). Surgical Pellets, this option is not discussed that often, but you can have small pellets surgically placed under the skin of your butt where they create a slow and steady release of HRT. It’s typically an in-office procedure and it’s a minor slice that doesn’t go too deep and can be done several times, although each procedure should last roughly 6 months (sometimes more, sometimes less). This seems to be a newer option that many doctors aren’t aware of and may take more studying to determine its true effectiveness.
- Need to be blood tested once a year
Your doctor should always blood test you with a full and comprehensive panel before you begin any HRT so that you have an established baseline. When you’re just starting HRT it is recommended that you actually get blood tests done every three months so that they can establish your levels and see if your dose is too high/low or if there are any negative impacts such as high blood pressure, high cholesterol, liver or kidney issues, etc. After the first year and having an established dosage you can then usually go to testing once a year as a manner of maintenance. Of course, if you have medical conditions, your testing should be either more frequent or at the discretion of your doctor. If you see a doctor who does not want to test prior to starting HRT, you may want to get a second opinion as you now will never have an existing baseline.
- I will go bald (or other negative side effects)
Male-pattern baldness can be a side effect along with several other negative side effects like increased heart risk. It’s impossible to tell who will and won’t experience the negatives, as it seems to be based more on your personal genetic makeup and history that the testosterone will enhance or “turn on” than the HRT itself. If the men in your family are predisposed to balding or if you have a personal or family history of cardiac issues, there is a chance these could happen to you. Some recommend Biotin vitamins as it helps strengthen hair and nails – this is typically a safe option as it’s a vitamin but check with your doctor for recommended dosage (usually what’s on the bottle is too much for daily intake). Baseline blood work and continued monitoring is important if there’s any history of disease, especially cardiac, in your family line. This is why it’s so important to get connected with a well-versed doctor. And yes, you may sweat more and your scent may change – although these aren’t necessarily “negative” effects.
Overall you should seek out words of wisdom from those who have gone through these hurdles, read medical reports, and utilize reputable resources to research. Don’t take any single answer as the “end-all, be-all” as there is simply no one way, method, option, opinion, or process when it comes to transitioning. (You may also find “Doctor DOESN’T Know Best” interesting)