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~ Part 1 in the Testosterone Series ~
Part 2: Assumptions and Questions
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When I initially reviewed the literature on hormone therapy for FTMs over a year ago, I hoped to find quick and easy answers about testosterone. At that time, I had a simplistic and optimistic belief that gender dysphoria was the main issue contributing to depression and other life issues, so I felt a desperate urgency to start medical transition as soon as possible. But because I was still so unsure about my own transition goals, my research felt disorganized and overwhelming and served only to magnify the intensity of my uncertainty.

But after resolving my chronic confusion with the concept of “gender identity,” deconstructing many of my own illusions about my appearance, creating a more concrete mental image of my “ideal” body, and gaining a greater measure of acceptance of my current body, I was finally able to consider hormone therapy with more clarity. As I described previously, my “ideal” body does not align with that of typical cisgender men. Rather, my “ideal” body would have somewhat more masculine facial features and a slightly more masculine silhouette than my current female frame (broader shoulders, more upper body muscle mass, wider waist, narrower hips), but would otherwise be more androgynous than masculine. So I revisited my old research with this new lens, and I was able to create what seemed to be an optimal hormone therapy plan to accomplish my desired physical changes.

It is beyond the scope of this post to summarize all of the published information regarding hormone therapy for FTMs. I present here my own tentative prescription plan with reference to information most relevant to my situation. I hope this may be valuable to others seeking to achieve slight and gradual physical masculinization outside standard FTM hormone therapy protocols. Recent publications have acknowledged increasing diversity in transition goals among gender dysphoric individuals. (Fabris 2006)

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Testosterone (T): 1-2g/day transdermal

Transdermal T is available as a gel or as a patch. I planned to consult with my prescribing physician about the availability and cost of those options in my area. Injectable (intramuscular) T formulations are most commonly preferred and prescribed for FTMs. (Simpson 2006, Meriggiola 2015) However, compared to the various injectable T formulations, transdermal T has several advantages with respect to my own transition goals.

First, transdermal formulations are associated with more stable serum T concentrations over time that mimic the physiologic secretion of T in cisgender men. (Simpson 2006, Meriggiola 2015) Intramuscular injections of T every 1-4 weeks cause supraphysiologic serum concentrations in the first few days after the injection, followed by a rapid decrease in T concentration. (Meriggiola 2015) Some studies report changes in energy and more pronounced mood swings associated with these rapid fluctuations in T concentration. (Simpson 2006, Meriggiola 2015) Mood changes include more frequent irritability, frustration/anger, and aggression as well as decreased positive and negative affect intensity. (Slabbekorn 2001, Simpson 2006) Maintaining a more consistent T concentration may help reduce mood changes, which is an important consideration for me given repeated episodes of severe depression.

Second, transdermal T may be associated with more gradual physical changes compared to injectable T. (Simpson 2006) “Transdermal formulations are recommended if slower progress is desired or for ongoing maintenance after desired virilization has been accomplished.” (TransHealth UCSF 2016). However, at comparable doses, transdermal and injectable T are associated with a similar overall degree of physical masculinization despite the slower progression of changes occurring with transdermal preparations. (Merrigiola 2015) Many FTMs hope to achieve pronounced physical masculinization as quickly as possible, but given my more conservative transition goals, I would prefer more gradual changes so that I have a longer period of time to evaluate whether the physical changes are truly desirable.

Third, transdermal T eliminates the requirement of giving myself intramuscular injections. I have an embarrassingly low pain tolerance, so I will admit that the prospect of injecting several millilitres of viscous oil into myself every few weeks is very unappealing.

Disadvantages of transdermal T in my situation include increased cost (my current health coverage is limited and does not include the off-label prescription of T for gender transition) as well as possibility for delayed cessation of menstruation (menstruation has always been a core source of body dysphoria for me and is one of the primary motivations to seek hormone therapy). (Simpson 2006) However, other studies have found that transdermal T induces amenorrhea on a similar timeline as injectable T. (Pelusi 2014)

The recommended maintenance dose range of transdermal T for FTMs who want to achieve considerable masculinization as quickly as possible is 2.5-10g per day. (Simpson 2006, Fabris 2015, Meriggiola 2015) A dose of 1-2g per day would likely allow even more gradual progress. Lower starting doses, such as 2.5g per day, are also recommended if there are concurrent psychiatric problems.(Simpson 2006)

Finasteride: 1mg/day oral

I previously discussed my desire to avoid hair loss by using finasteride concurrently with T. In addition to reducing male-pattern baldness in FTMs, finasteride can also be associated with slowed or decreased facial and body hair growth and slowed or decreased clitoromegaly. (TransHealth UCSF 2016) These effects are usually listed as disadvantages in articles about hormone therapy in FTMs. However, given my desire for only slight physical masculinization, these side effects are actually advantages because they align closely with my transition goals. The recommended dose of oral finasteride is 1mg/day. (Mella 2010)

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In the process of more seriously considering hormone therapy and trying to develop my own prescription plan, I returned to an important question from a previous post:

In an XX person, would long-term administration of low dose T ultimately lead to complete physical masculinization, but at a much slower pace than higher doses of T? Or would long-term administration of low dose T lead to partial masculinization that would be sustainable and non-progressive past a certain point? I am hoping very strongly for the latter. I have started looked for published data to answer this question, but so far I have only found articles describing the effects of long-term administration of high dose T in FTMs or describing the effects of short-term administration of low dose T in women (including the effects of exogenous T administered to treat various medical conditions as well as the effects of endogenous T in women with polycystic ovarian syndrome). However, there seem to be no studies describing the effects of long-term administration of low dose T in female-bodied people without concurrent medical issues.

I want to achieve a sustainable, non-progressive, partial physical masculinization. But I am not sure to what extent this goal is possible, even with conservative use of low dose hormones.

The scientific literature regarding long-term outcomes of low dose T administration in healthy XX individuals is almost non-existent. The literature regarding the extent and timeline of physical and psychological changes on low dose T is also extremely limited. Virtually everything currently published in scientific journals about T-induced changes in FTMs describes study participants on doses of T that are 2-10 times higher than the doses I’m considering. (Fabris 2015, Meriggiola 2015, Slabbekorn 2001, Pelusi 2014) There are some anecdotal reports of the effects of low dose T on blogs and YouTube videos by transmasculine people, but their comments tend to be sporadic, unstructured, and inconsistent.

This scarcity of published information about the short-term and long-term effects of low dose T contributes to my chronic difficulty imagining a future version of myself. For those of us with atypical transition goals, most of the existing medical knowledge and established hormone protocols are simply not applicable. This creates a painful sense of isolation and confusion, as though I’m peering out at the rest of the world from behind a foggy looking-glass.

“It’s dreadfully confusing!” 
– Alice (Lewis Carroll, Through the Looking-Glass and What Alice Found There, 1871)

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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. Note: see Table 3 for an extensive summary chart regarding testosterone doses and formulations.

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. 

Pelusi C, Costantino A, Martelli V, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. 2014. Journal of Sexual Medicine 11(12): 3002-3011. 

Simpson AJ, Goldberg J. Trans Care: Hormones – A Guide for FTMs. 2006. Trans Care Project.Vancouver, BC, Canada. Accessed through Rainbow Health Ontario. Note: see page 5 for a brief summary chart regarding testosterone doses and formulations. 

Slabbekorn D, van Goozen SHM, Gooren LJG, et al. Effects of cross-sex hormone treatment on emotionality in transsexuals. 2001. International Journal of Transgenderism 5(3):2. 

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