Hormone Replacement Therapy
Some transgender people choose to undergo hormone therapy (HRT) to masculinise or feminise their bodies. In many cases, this also has positive effects on physical and mental health.
(For ease of reference, ‘trans men’ here includes non-binary people seeking masculinisation, and vice versa.)
- Getting Started
- Physical Effects
- Mental Effects
- Permanency of Effects
- Allergy Alert
- Puberty Blockers
If you wish to pursue HRT, please seek a qualified health professional. HRT is safe when done under proper medical supervision with regular blood tests to ensure that everything is fine. If cost is a concern, consider going through the public healthcare system rather than seeing a private doctor.
We strongly caution against obtaining hormones through the black market, due to the high potential for dangerous side-effects. As an example, one batch of testosterone purchased online was tested and discovered to be petrol. Other sources may be severely watered down and consist primarily of oil, or be mixed or laced with dangerous substances such as mercury that could cause serious damage to your body. In other cases, consistency may be an issue, such that what seems like the same dosage may end up introducing wildly different levels of hormones into your body each time.
Your doctor will assess your suitability for hormone therapy and discuss the risks and benefits of treatment. Ideally, you’ll be given baseline laboratory blood tests to determine if you have any concurrent medical issues that may affect your suitability for HRT or your dosage level. These should be repeated a few times after treatment is initiated to ensure that everything is going fine, after which the frequency can be decreased to once every year or two.
Some doctors recommend starting on a low dose and gradually ramping up to normal dosage levels so as to give your body time to adapt. In the case of trans male singers, this can help protect your singing voice by slowly breaking it in.
HRT changes your biological profile to that of the sex you are transitioning to, and this includes the respective health risks for each sex. For example, trans women develop a higher risk of osteoporosis, while trans men develop a higher risk of heart disease. HRT thus also affects blood test results, which should be measured against that of others of that sex.
In 2014, a long term study of 1,600 transgender people on HRT established it as safe. HRT is recommended by medical authorities as the appropriate treatment for transgender people with body dysphoria.
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Physical effects of HRT
Feminising Hormone Therapy
HRT for trans women may include anti-androgens as well as estrogen, both administered in pill form (usually daily). There are different combinations of these available, and your doctor will prescribe the one best suited for you.
Effects of feminising HRT include: breast growth, softening of skin and hair, reduced musculature and strength, fat redistribution to hips and thighs, increase in fat to muscle ratio, thinning/loss of facial and body hair, slowing or stopping head hair loss, decrease in size of testicles and genitalia, decline in gross motor skills with increase in fine motor skills, decreased bone density.
Potential side effects include erectile dysfunction, loss of ability to ejaculate, loss of libido, infertility, weight gain, mood swings, depression, increased risk of deep vein thrombosis, increased risk of breast cancer.
Masculinising Hormone Therapy
HRT for trans men consists of testosterone administered most commonly through injections (the cheapest, safest option) in periods ranging from one week to four months depending on the formulation.
Testosterone can also be administered via patches (daily), gels (daily) or subcutaneous implants (twice a year), all of which cost a lot more and are not presently available in Singapore. While pill options are available, they are advised against due to their connection to liver damage.
Effects of masculinising HRT include: deepening voice, increased muscle growth and strength, increased energy and appetite, enlarged clitoris, shrinking breasts, cessation of menstruation, growth of facial and body hair, increase in libido (especially with respect to visual stimuli), increased sweating, rougher and more oily skin, reduction in fat to muscle ratio, fat redistribution away from hips and thighs to the abdomen, increase in gross motor skills with decline in fine motor skills, increased bone density.
Side effects include acne, mood swings, anxiety, loss of fertility, increased risk of heart disease, polycythemia (overly high red blood cell count), male pattern baldness.
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Mental and other effects of HRT
Many transgender people report positive mental effects from HRT including being cured of depression, increased sense of calm, increased confidence, having a clearer mind, being more in tune with one’s emotions, greater sense of connection to one’s body, and an overall sense of well-being. These differ from person to person.
Testosterone is associated with more intense but shorter-lived emotions, and vice versa for estrogen. Contrary to stereotype, testosterone does not increase aggression and may lower it.
HRT changes pheromone production and body odour to that of the sex you are transitioning to. This may affect the behaviour of pets and other animals, but in the case of your own pets, they should eventually adapt.
Sexual orientation occasionally changes, though it’s uncertain how much of this is due directly to HRT and how much due to repressed feelings finally set free, or approaching relationships from a different sexed perspective. In some cases, prior relationships were more compensatory in nature: e.g. a trans man dating women because it made him feel male, when he may in fact have been more attracted to men; once he is consistently perceived as male, he no longer feels that same need to date women. Likewise, a trans woman may have mistaken the desire to be female for attraction to women, and find that once she has transitioned, that attraction no longer exists. In yet other cases, trans people retain patterns of sexual attraction rather than objects of attraction: a trans man previously in a ‘same-sex’ relationship with a woman might find that, after transition, he’s still exclusively oriented towards same-sex relationships, which would now mean being with a man.
Trans women report increased sensitivity to heat and cold, and vice versa for trans men. Based on anecdotal reports, testosterone dulls perceived temperature by about two to three degrees. Testosterone may also have a slight dulling effect on senses of smell and touch, and vice versa.
Handwriting may be affected due to changes in musculature and fine motor skills.
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Permanency of Effects
Almost all the changes from feminising HRT are reversible, other than breast growth. For masculinising HRT, voice changes, genital growth and body/facial hair growth are not reversible, and going off HRT may stop but is unlikely to reverse male pattern baldness.
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The optimal dosage for HRT is different for everyone, which is why it is important to have a doctor that will give you regular blood tests to monitor your hormone levels while you work out which dosage works best for you. Trans men in particular may find their mood and energy levels tanking towards the end of each shot cycle, which is one sign that dosage should be increased or injections made more frequently; likewise if menstruation starts to return.
However, taking higher doses than necessary is both bad for your heath and counterproductive. For trans men, excess testosterone will be converted into estrogen, which would slow down or reverse the changes you want. For trans women, excess levels of estrogen may lead to breast cancer and necessitate breast removal; blood clots (that may result in strokes) are also a risk. In both cases, liver damage may occur.
Stay within the normal hormone ranges for the sex you’re transitioning to, and you’ll be safe.
Surgical removal of the gonads is likely to affect HRT dosage, and it’s strongly recommended that you do blood tests to readjust your dosage after surgery. Trans women who have removed their testes would no longer need anti-androgens.
After gonadal removal, HRT is necessary for proper health function, as your body would no longer produce its own sex hormones, and without HRT will result in health problems similar to that experienced at menopause and andropause.
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The cheapest and most common form of testosterone, testosterone cypionate (of which Depo T is a branded version of) is suspended in cottonseed oil, which some people are allergic to. Testosterone enanthate is a similarly-priced alternative suspended in sesame seed oil, but is not presently available in Singapore.
Sustanon 250 is suspended in arachis (peanut) oil. While it is tentatively deemed safe for those with peanut allergies, caution is still advised, and if you have a severe allergy to peanuts (or soy), it is best you stay away.
Signs of an allergic reaction include spreading redness and swelling at the injection site as well as itching. Some soreness is normal after an injection and should go away after a couple days.
Speak to your health provider should you have any concern about allergic reactions to HRT.
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HRT usually but not always results in infertility. For trans men, there is still a very small chance of getting pregnant even while on testosterone. Take all necessary precautions, especially since cessation of menstruation would not be available as a sign of pregnancy.
Loss of fertility may or may not be reversible upon cessation of HRT, depending partly on how long it has been. Some trans people thus choose to bank their sperm or eggs prior to undergoing HRT. Others temporarily pause HRT while they attempt to have a child, with success varying on a case-to-case basis. Trans men on HRT who wish to get pregnant have to stop T for several months to a year (testosterone could harm the child) and undergo a regiment of female hormones.
Advances in medical technology may in the near future allow sperm cells to be created from bone marrow stem cells, or implant a uterus for trans women to give birth to a child created from an externally fertilised embryo.
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Transgender youth who desire medical transition and who have been assessed by doctors as suitable candidates for treatment may choose to undergo reversible puberty suppression with puberty blockers, which will solely halt the development of secondary sex characteristics while allowing them time to physically and mentally grow and mature. Puberty blockers have been used safely for decades to halt precocious puberty in children.
This process buys them time to decide when they are older (age 16 in most places) whether or not they wish to proceed with medical transition. If they should decide not to, they can go off the blockers and proceed with normal puberty. However, if they choose to pursue transition, HRT will then allow them to develop bodies that – genitalia aside – are phenotypically identical to others of their gender. Trans women will be able to retain high voices; trans men will not have to grow breasts. Both will develop the height, musculature and skeletal structure typical for their identified gender.
This effectively eliminates most sources of body dysphoria and will make it much easier for them to blend into society and live a normal life, should they so choose.
Long-term studies of transgender youth under such treatment have produced extremely positive results. 55 transgender youth were monitored over a period of about 8 years from the administration of puberty blockers at an average age of 13 to hormone therapy at ~17 to surgery at ~21, after which they scored equal or better on assessments of mental health compared to their non-trans peers. This is especially significant in light of the astronomical rate of mental illness and suicide that has long been observed in transgender youth denied treatment until adulthood.
Puberty blockers are not currently available in Singapore, and their cost (about USD$1.5k a month) puts them out of reach of most people. Some insurers in other countries cover the full cost of treatment.