Thoughts about hormones for transwomen

Jed Bland

Issue 28
Winter 2004

 
For some years now, in common with many others, I have felt discomfort about the myths surrounding hormones for transwomen, in the way they are portrayed in the trans community, the media and even some technical books.

The prescription of hormones is, of course, a controversial area. Some consultants suggest the effects are reversed once medication ceases (for males) Others insist that they are not. Much depends, one supposes, on the dosage and the length of time the person has been taking them. Some say they have a self-diagnostic effect, others deny it. Many cross dressers (and some consultants) are appalled at the idea of a man emasculating himself.

Some consultants will prescribe after the first three months. Others insist on a wait of two years, often after the person has burnt his bridges and transitioned. Some of the latter, however, have been heard to suggest that their patients will have already self-medicated, as if that allows them to cover themselves, and absolves them from responsibility to think about the issues.

Self-medication

Of more concern, perhaps, are the many internet pharmacies.

There are all sorts of dire warnings, but very little detail. Just as athletes and body-builders take anabolic steroids in spite of the risks, so will transsexual people. We know that those who are gender dysphoric will still go ahead, but clear information is far better than vague warnings.

There is also a quality problem with hormones from irregular sources. They may be contaminated or simply ineffective. There is also a worrying rise of counterfeit versions of brand name medication. The New England Medical Journal⁽¹⁾ recently reported that, even with the checks on procurement, samples of a drug which combats anemia, under the label Procrit were found to be grossly diluted and, in some cases, contained "nothing but Miami tap water". In February 2004, several Web sites sold unsuspecting consumers contraceptive patches, under the Ortho Evra brand name, that contained no active ingredient.

What are hormones?

The main hormones we are concerned with are the so-called gonadal steroids, testosterone and estradiol. Testosterone is an end product of cholesterol, and is converted as necessary into estradiol, or into two types of dihydrotestosterone. Type one is best known for its role in male-pattern baldness, while type two seems to be mostly expressed in the prostate where it is involved in male sexuality. However it is increasingly clear that all of the gonadal steroids have other functions all through the body.

The amounts of testosterone produced by males in their testes, and estradiol produced by females in their ovaries, is controlled by a gland at the base of the brain, the pituitary, and a portion of the brain itself, the hypothalamus. As the concentration of gonadal steroids increases so the pituitary reduces production, a so-called 'feedback' mechanism.

Hormone Medication

There are a number of different classes of drug administered to gender dysphoric people. LHRH analogues act directly on the pituitary, while others such as Androcur block the receptors that testosterone acts upon. 5alpha reductase blockers, such as Finasteride, inhibit only the production of type 2 dihydrotestosterone. They may help with prostate problems, but are of little help, even, for thinning hair!

The most usual, because of its least potential harm, and its so-called 'feminising' effect, is estradiol in one form or another. It will be clear to the reader that the administration of exogenous (from outside) estrogen interferes with the feedback mechanism, as it does with the contraceptive pill for women. In males, it causes the pituitary to reduce the output of testosterone from the testes, while the level of estrogen is increased by the medication.

Medicinal Effects.

Bancroft⁽²⁾ distinguishes between sexual appetite and sexual interest, the latter being cognitive. The first effect of administering estrogen, then, is loss of sexual appetite, which some experience as a relief, but it does not affect sexual interest.

To more completely reduce the libido, Androcur is often prescribed in addition, hence the feelings of depression that some people feel. No amount of medication can suppress the libido entirely, hence the controversy about its diagnostic value. Clearly it is a matter of self-diagnosis, and self-evaluation of one's motivations.

The changes in body shape are grossly oversold. There is a website by someone who claims to be a retired medical doctor that has on its homepage a picture reminiscent of the Venus de Milo. There are admittedly helpful changes in the body's metabolism, softening of the skin and hair, with the onset of male pattern baldness being arrested.

There is an increase in fat, such as over the pectoral muscles and the lower abdomen, unlike women who tend to put it on their behinds. The emotional effects are more difficult to quantify, and no two people respond in the same way.

However, one is never going to look like a page three model from hormones alone. Professor Gooren⁽³⁾ of the Free University of Amsterdam suggests that the maximum after two years is a "hemicircumference" of about 18cm, about enough for a "A" size bra, the exact amount depending on genetic factors, as it does for the person's female siblings. For transsexual people, of course, size isn't everything. It is merely an affirmation of their identity, and those who wish to be more curvaceous have silicone implants.

The Downside

There are those who think they will be different, and often take excessive doses. Some articles on the subject have quoted a dose rate of estrogen of up to 40 times more than the naturally occurring level (not forty times the female hrt dose) In fact, when taken orally, most is disposed of by the liver on "first pass" As the dose is increased, there is a saturation point, where the excess is simply excreted, with corresponding damage to the liver.

Which brings us to the less pleasant effects. There is much in the news about the possibility of a slight increase in risk of breast cancer among women taking hormone replacement therapy, which incidentally also applies to the contraceptive pill. Less has been heard about the risk of heart disease, strokes and, particularly, deep vein thromboses, or blood clots in the legs. This may well be less of a problem in someone who is young and fit and takes plenty of exercise. It is also true that most of the effects of hormones have been extrapolated from studies in women. It may also be that, in an androcentric culture, the dangers have been understated in females and overstated in males. However the Free University in Amsterdam has studied transwomen and have suggested that "the dangers are real."

One reason for medication to be supervised by a general practitioner is said to be that annual blood tests will be provided for liver function and lipid profile.

Unfortunately this doesn't usually happen unless the person asks for them, which she is unlikely to do if she feels her medication is at risk.

Sometimes prolactin is also measured, something we will come back to later. It is usually raised, which often alarms GP's, but a grossly elevated level may be a sign of trouble.

The post operative transwoman

Another function of medication is to prepare the person physically, as well as psychologically, for the effects of almost total loss of gonadal steroids. It will be apparent from the above that, post-operatively, a transwoman has less testosterone than even someone born female.

It is likely that there will be residual testosterone in the system, bound to the blood plasma. If so, one might expect that its gradual disappearance might lead to a period of depression some weeks post-operatively.

It is usual nowadays for the surgeon to fashion a clitoris, although it should be noted that a natural female clitoris is a complex structure, extending deep into the vagina, with about three times as many nerve endings. The nervous system associated with ejaculation is still in place, so many post operative people can experience orgasm, as can those who have had an orchidectomy, if they wish to. However it is clear that this must be cognitively rather than hormonally driven.

The 'body map' in the sensory cortex is also still in place. This perceived as a clitoris by the transwoman, though in at least one case, one disgruntled patient, currently in the news, complained "It still feels like a penis" Clearly he was either not properly briefed by his surgeon or he didn't listen.

While it is true that very few agonadal males get prostate cancer, there are rare forms that do not appear to be associated with hormones, and some doctors believe that post operative transwomen should continue periodic examinations. This means that they have to reveal themselves, firstly to make their doctor aware they have a prostate, secondly that they now have a neovagina between it and the rectum.

A few years ago there was a scare about the possibility of prolactinomas, tumours surrounding the pituitary. Various small pituitary tumours are common in all people, though they only very rarely become malignant. However, with an unusual hormone environment (including pregnancy in women) they can, again very rarely, become so large that they interfere with the visual cortex, giving sight problems.

All post-op people should, however, take account of the likelihood of bone loss, or osteoporosis. This affects all people who have low levels of hormone, both androgens and estrogens. Estradiol valerate, the medicinal form of 17beta estradiol, tends to be prescribed nowadays, since its concentration in the blood can be measured, though it never is. A study by the Free University of Amsterdam confirms that "bone loss is prevented by estrogens in the absence of testosterone if estrogens are properly taken."⁽⁴⁾ It seems bone health may require both estrogens and testosterone, Since, in fact a small amount of testosterone continues to be produced by the adrenal cortex, thus one might think that the continued administration of Androcur may be contra-indicated.

Hormone metabolism in bone health is complex and subtle, and this is one area where further research would be not only beneficial, but 'doable'. It might even have relevance to the population at large. The bulk of transsexual research so far has been in the Netherlands. Although GIRES has money available, and could probably find more, the only interest in this country seems to have been studies of handedness and fingerprints.

Conclusion

It is quite clear that there are those who have always been at odds with their body and the gender label that has been imposed on them. It is equally clear that there are those who, for whatever reason, are in conflict with the gender role in which they are living. The reduction in sexual appetite brought about by medication may well give a respite in which people can more clearly assess their motivations.

The bottom line is that the diagnosis depends on a life history account which the psychiatrist has no way of confirming. Each person's transition therefore is entirely their own responsibility.

Bibliography.

1. Rudolf, P.M., Bernstein, I. B.G. (2004) Counterfeit Drugs, New England Journal of Medicine, 2004 Number 14, 350:1384-1386
2. Bancroft J. (1989) Human Sexuality and its Problems, Edinburgh: Churchill Livingstone
3. Assheman, H., Gooren, L.J.G., (1994) Hormone Treatment in Transsexuals. Gendys Conference 1994, Manchester.
4. Gooren et al, (2002) Prospective study of the effect of sex steroids on bone metabolism and bone density, http://www.niwi.knaw.nl/en/oi/nod/onderzoek/OND1260231/