As I get closer to my appointment to start hormone therapy, I have been forced to confront one of my biggest fears regarding testosterone: hair loss, also known as male-pattern baldness or androgenetic alopecia. I have been reluctant to admit this fear of hair loss, even to myself, because it seems like such a minor and superficial concern compared to so many other aspects of hormone therapy and gender dysphoria. I have been uncomfortable accepting that this fear is largely driven by vanity. I would like to think I am above such petty obsession with external appearance. But the intensity of my fear of hair loss suggests otherwise. So I have investigated strategies to prevent – or at least minimize – the extent of hair loss while taking testosterone.

Androgenetic alopecia affects approximately 50% of cisgender men by age 50 and approximately 90% of cisgender men in their lifetime (Kabir 2013). One study demonstrated that among Caucasian cisgender men, androgenetic alopecia was present in approximately 50% of those 30-35 years old, 60% of those 36-40 years old, and 70% of those 40-45 years old (Shankar 2009).  Androgenetic alopecia is less prevalent, but still relatively common, among cisgender men of other ethnicities (Feinstein 2015). Men with visible hair loss are perceived as older and less physically and socially attractive (Mella 2010). The prevalence of androgenetic alopecia in female-to-male transpeople (FTMs) is similar to that for cisgender men, occurring in approximately 50% of FTMs after 13 years on a physiologic dose of testosterone (Fabris 2015, Gooren 2008, Meriggiola 2015).

Androgenetic alopecia is influenced by hormonal factors. Testosterone is converted to dihydrotestosterone (DHT) by the enzyme 5-alpha-reductase. DHT has five times greater affinity for androgen receptors than testosterone. Hair follicles in the scalp produce 5-alpha-reductase which converts testosterone (produced elsewhere in the body) into DHT (which acts locally in the scalp). When DHT binds to androgen receptors on hair follicles, it results in a shortened anagen phase (the phase of hair growth) and decreases hair follicle size. This ultimately results in follicular miniaturization and the growth of shorter, thinner hair shafts. As more and more follicles undergo miniaturization, hair coverage of the scalp progressively decreases (Kabir 2013). Genetic factors also play a role. Androgenetic alopecia seems to be highly heritable, with complex polygenic inheritance and variable penetrance. Hair loss is more extensive in men with a genetic predisposition for greater numbers of androgen receptors on hair follicles and/or increased sensitivity of follicles to the effects of DHT (Kabir 2013).

One strategy to minimize hair loss that has been mentioned occasionally in articles about testosterone therapy is concurrent administration of finasteride. Finasteride selectively inhibits the 5-alpha-reductase enzyme, which decreases the concentration of DHT in the scalp and in the blood by approximately 60-70%. Because it reduces the amount of DHT, finasteride prevents or reverses hair follicle miniaturization as demonstrated in scalp biopsy studies (Mella 2010). Finasteride can be taken orally at a recommended dose of 1mg/day; studies have not demonstrated greater improvement in hair growth at higher doses (Mella 2010). Reported side effects of finasteride in cisgender men include decreased libido, erectile dysfunction, and ejaculation dysfunction; all of these side effects are very rare (Mella 2010). Presumably, erectile and ejaculation dysfunction would be of little concern in transgender men, even those who have had phalloplasty (given the current anatomical limitations of that surgery). Side effects of finasteride that are relevant for transmen include slowed or decreased growth of facial hair and body hair, and slowed or decreased clitoromegaly (TransHealth UCSF 2016). The blog American Trans Man has a post describing finasteride in more detail (Beards, Baldness and What’s in Your Pants).

Since I was a small child, my hair has been the source of great pride for me and much friction between my mother and I. For years I begged her to let me cut it short, but she refused on the grounds that it would make me “look like a boy.” She didn’t seem to understand that looking like a boy was precisely what I wanted. When she finally and reluctantly relented in 2006 and allowed my 14 year old self to get a short haircut, my hair became one of the first and one of the most important ways for me to exert some small measure of independence from my parents. Now that I am 24, my haircut is one of the only healthy ways I can modify my body and create a more masculine physical appearance to ease chronic physical dysphoria. (Obsessive exercise, excessive dietary restriction, self-induced vomiting, and painfully tight clothing are other strategies that I rely on to maintain a sufficiently masculine appearance but obviously I do not recommend these strategies).

For me, short hair is not just about gendered physical appearance. It is also about practicality. I hated long hair! I hated having to wash all that hair every evening in the shower. I hated having to towel-dry the soggy dripping mass. I hated how it took so long and hurt so much to comb out all the knots. I hated the way long tendrils of hair would end up everywhere – everywhere! – coiled in the shower drain, stretched out on my pillow, draped across my keyboard, poking out between the pages of a textbook like a tiny thready bookmark. I hated putting my hair in a ponytail, always conscious of the irritating tension, unsettled by how the sleek flatness of the pulled-back hair left my face so stark and open, like a picture without a frame. But I also hated leaving my hair free from the ponytail elastic, when it became a heavy hanging curtain that obscured my view and insisted on creeping into the corners of my mouth, my hands perpetually occupied in batting it away.

When I got it cut short, all those long-hair annoyances vanished. Then the only problem was that to maintain a shorter style, haircuts become necessary more frequently. The one advantage of long hair was that I only needed a haircut once or twice a year. My short style required a trim every eight weeks. I hated haircuts. I hated the inconvenience of having to schedule an appointment or waiting as a walk-in with nothing to do but browse through battered People magazines. I hated that I always gave the stylists the same description of what I wanted and got different cut every time.

I scrupulously avoided developing a long-term relationship with any of my hairdressers, taking pains to visit different salons on a rotating basis. Because once you’re beholden to one particular stylist then that’s it for you! No longer are you free to walk in whenever you choose – you have to make an appointment that works with their schedule, which is a chafing restriction of freedom for a busy person. No longer are you free to fend off small talk – you have to engage cheerfully and energetically to preserve this superficial relationship on good terms. After all, they are wielding sharp instruments in the vicinity of your jugular veins. No longer are you free to tip according to the quality of service – you now feel compelled to tip extra to ensure ongoing consistency in the style they deliver, tip extra to appear appreciative that they remember the random details of your life that they’ve extracted from you during reluctant small talk.

How I hated salon small talk! My silent salon-chair prayer: I’m paying you to cut not talk, so please, leave me be, focus on my hair, I don’t have anything to say. But stylists are relentless conversationalists, far more skilled in the art of superficial niceties than my awkward introverted self, leaving me always feeling two steps behind in a complicated and unwanted dance. “Ohmygod, has anyone told you how much you look like Miley Cyrus?” No. No, they haven’t. But we’re both female-bodied and we both have short hair so yeah, we’re, like, totally twins. Please. Do shut up. “So do you have any plans for the weekend, hon?” No. Well yes, but not plans I want to share with you. “Are you planning any fun vacations this summer, sweetheart? Gonna travel somewhere nice?” No. I don’t take vacations and I don’t travel. And if I say so, this is just going to get more awkward. “Are you excited for grad? Have you picked out your prom dress yet?  You must be so excited!” No. I graduated from high school eight years ago and when I did, I wore pants. And, worst of all, “So where do you work?” Usually I avoided that question by being deliberately vague. But if, caught off guard and overwhelmed by social anxiety, I admitted the truth – that I recently graduated from veterinary school – I would inevitably hear about her friend’s cousin’s English Bulldog – or maybe she’s a French Bulldog? you know I never can remember the difference, dear – anyway, she has terrible dermatitis and do you think it could be a food allergy and should he try feeding her a strict diet of carrots and cottage cheese?

What I hate most of all – with a cold, hard, brittle anger – is the fact that women’s cuts cost more than men’s cuts irrespective of style and complexity. This is true even at bargain hair salons (Ultracuts: women’s cut $17.95, men’s cut $15.95), with the price differences exaggerated in higher-end salons (Euphoria: women’s cut $35-55, men’s cut $30-35). What epic bullshit this is! Not only is this pricing unfair and discriminatory, it is completely ridiculous considering that many women’s haircuts require little more than snipping a half-inch off the ends while men’s haircuts typically involve more extensive shaping and require the use of multiple tools (scissors, clippers, texturizers).

With all of these frustrations, the hair salon ordeal eventually became untenable. So I finally tried – with excitement and trepidation – to cut my hair myself. It was awkward and slow at first, trying to align the movements of my hands with the reverse image in the mirror, trimming conservatively in case of mistakes, making a hairy mess all over the bathroom counter. But I my system perfected now: #3 clipper guard (3/8 inch) on the sides, #4 guard (1/2 inch) to taper the sides into the top, scissor cut the top and bangs with practiced precision… and then the back, usually a #6 guard (3/4 inch) to leave it long enough to create a wide fauxhawk, but sometimes I let the back grow out for a few months into a baby rat tail (my dad says this looks like a mullet – business in the front, party in the back – but I say it’s a party in the front AND a party in the back).

I love cutting my hair. I love the feeling of accomplishment and competence when I see the finished product – damn girl, you did that! I love how it looks exactly as I had envisioned. I love the way the messy locks have a cocky character all their own, the way they frame my face in a way that feels so right. I love having the freedom to give myself a trim as soon my hair crosses my threshold of intolerable shagginess. I love the way the clippers feel moving across my scalp, the way the soothing vibration seems to penetrate all the way through to my brain. I love the way it feels when clumps of hair – spiky little dark brown mice – drop from the clipper blades onto my bare shoulders. I don’t even mind sweeping up these scattered clumps with my hands, flushing them down the toilet, vacuuming the bathroom afterwards. And I love how my mother hates my haircut. Perfect.

It is tempting to romanticize my hairstyle preference as an essential means of expressing some intransigent gender identity. I could perhaps pretend that my gender-non-conforming haircut has some important political significance, that it is a follicular feminist statement. If it were any of these things, my fear of hair loss would have a lovely self-righteous justification. But if I’m honest, I’d say my hair has no real significance beyond this simple fact: I love it. I love how it looks. I adore the feeling of my fingers running through the fresh-buzzed stubble. I enjoy the way the wind chills my exposed ears and naked nape, the way the breeze ruffles the hair on top like a friendly hand. If this is vanity, then fine – I’ll own that. I am vain. We all are, in different ways for different reasons. So I will explore the option of finasteride with an authentic shameless vanity.

Cordless hair clippers: $49.95
Haircut: $0
My hair my way: *priceless*

“Your hair wants cutting!”
– The Mad Hatter (Alice’s Adventures in Wonderland, 1865)

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References

Fabris B, Bernardi S, Trombetta C. Cross‐sex hormone therapy for gender dysphoria. 2015. Journal of Endocrinological Investigation 38(3):269-282.

Feinstein RP. Androgenetic alopecia. 2015. Medscape Drugs and Diseases. Accessed online 26-04-2016.

Gooren LJG, Giltay EJ. Review of studies of androgen treatment of female-to-male transsexuals: effects and risks of administration of androgens to females. 2008. Journal of Sexual Medicine 5(4):765-776.

Kabul Y, Goh C. Androgenetic alopecia: update on epidemiology, pathophysiology, and treatment. 2013. Journal of the Egyptian Women’s Dermatologic Society 10: 107-116.

Mella JM, Perret MC, Manicotti M, et al. Efficacy and safety of finasteride therapy for androgenetic alopecia: a systematic review. 2010. Archives of Dermatology 146(10):1141-1150.

Meriggiola MC, Gava G. Endocrine care of transpeople part I: a review of cross-sex hormonal treatments, outcomes and adverse effects in transmen. 2015. Clinical Endocrinology 83(5):597-606.

Shankar K, Chakravarthi M, Shilpakar R. Male androgenetic alopecia: population-based study in 1,005 subjects. 2009. International Journal of Trichology 1(2):131-133.

TransHealth UCSF. Primary care protocol for transgender patient care: hormone administration. Accessed online 26-04-2016.