A Feminist’s Primer to Hormone Replacement Therapy

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htBy Ellie Reilly

Unlike 10 or 20 years ago, many of us today have at least heard of transgender people. As a quick reminder, these are people whose gender identity (a topic complex enough for several articles on Feminist Wednesday) doesn’t match up to the gender that they were assigned at birth. Many transgender people choose to undergo hormone replacement therapy (or HRT) in order to correct this mistake, become more comfortable in their own bodies, and make a smooth transition into living as their actual gender.

Unfortunately, the mysteries of HRT are poorly understood. Trans patients often find themselves picking up scraps of treatments designed for other conditions. For example, many trans women take spironolactone to block the body’s production of testosterone. However, spironolactone was never intended for this purpose. Spironolactone is typically prescribed to treat conditions like heart failure, liver disease, and hypertension.

Other treatments that fall under the umbrella of HRT have come about under similar conditions. Estradiol pills, creams, and patches are typically used to treat menopause in cisgender women, and testosterone shots have historically been used to treat low hormone levels in cisgender men.

HRT treatments largely involve drugs that have been retooled from other purposes, but their effects on and proper usage for trans patients are poorly understood. For this reason, it is critical for allies to understand how HRT works, why it’s so important, and, finally, what kinds of barriers trans people face in accessing it.

How HRT Works

Basically, HRT breaks apart into two categories: feminizing treatment for trans people who were assigned male at birth (AMAB) and masculinizing treatment for those who were assigned female at birth (AFAB). Let’s tackle these both separately.

HRT for AMAB trans people typically involves an androgen blocker, like spironolactone from above, to block the effects of testosterone; and a source of estrogen. This one-two punch basically kickstarts female puberty, causing physical changes such as:

  • Breast growth
  • Softening of the skin
  • Redistribution of fat in the body and face towards more stereotypically feminine patterns
  • Decrease in muscle mass
  • Lightening and diminishing of body hair
  • Decreased sex drive

As with nearly any medical treatment, no two patients are likely to react the same. This means that any list of HRT effects is general; some trans people may experience changes that others haven’t even heard of, and vice versa.

While AMAB trans people have to block testosterone for estrogen to take effect, the reverse is not true of AFAB people looking to transition towards a more masculine appearance. Instead, testosterone shots are usually enough to block the effects of estrogen, while making changes of their own. For example:

  • Increased sex drive
  • An increase in thickness and amount of body hair
  • Increased muscle mass and upper body strength
  • Voice changes consistent with male puberty
  • Facial hair growth
  • After some time, menstrual periods will stop

As with above, no two trans men are likely to experience HRT in exactly the same way.

Why HRT is Important

Hopefully I’ve shed some light on what HRT does to trans people who undertake it, but you still might be wondering how much it matters and why it does. I’m afraid that I’m going to start sounding like a broken record, but not every trans person has the same desire to undergo HRT and reap the changes that it brings about.

That said, many trans people experience gender dysphoria, an innate feeling of discomfort with one’s body, particularly when it comes to primary and secondary sexual characteristics. For an expert’s view on this, I spoke to my friend Maggie, who came out several years ago. She says: “I’m a fan of the hand analogy. How does somebody know that they’re right or left handed? They just feel it. I just felt that my body wasn’t right.”

Dysphoria can cause trans people immense amounts of psychological distress. A 2015 study determined that 39 percent of trans people experienced serious psychological distress around the time that they were surveyed. Compare that to 5 percent of the general population. Related to this distress is the attempted suicide rate among trans people, an incredible 40 percent, compared to 4.6 percent among the general population.

For many trans people, HRT offers a way to at least begin to address this dysphoria, making it a critical treatment tool for transgender patients. “When I started HRT it was like a lightbulb lit up in my head,” reports Maggie. “Everything felt clearer and lighter. I’m not gonna say that it fixed everything, because it didn’t, but it was a huge step in the right direction for me.”

Finally, HRT plays an important institutional role. Many surgeons who perform gender-confirming operations will require that their patients have been on HRT for at least a year before even considering them as surgical candidates. In order to compete in sports as their actual gender, trans women must have undergone HRT for a certain length of time. The requirements of the International Olympic Committee state that transgender women must demonstrate typical female hormone levels for at least a year leading up to an event and throughout the competition. Since Title IX protects trans students, we can expect similar hormone requirements to fall into place at the collegiate level.

Barriers to Entry

Since HRT plays such a vital role in the lives of many trans people, it must be readily available to those who seek it out, right? Not so, unfortunately. Transgender patients and prospective patients face enormous barriers to entry, as well as ongoing derision and demoralization throughout their treatment. This is especially significant given that trans people usually continue some form of hormone therapy throughout the remainder of their lives.

Perhaps the most common institutional barrier to entry for trans people seeking HRT is the gatekeeper role played by therapists. In order to receive HRT in the United States, a trans person must receive a formal letter of recommendation from a therapist clearing them for treatment. While deciding to receive hormones is a serious decision with lasting implications, casting therapists as gatekeepers disrupts the doctor-patient relationship. Instead of working with a therapist on the issues that come with a lifetime of self-denial and fear, transgender patients become fixated on the recommendation and are eager to work towards that as quickly as possible.

If no such recommendation requirement were in place, trans people might feel more comfortable seeking out a therapist on their own terms and taking time to work through the things that bother them, rather than sprinting for the finish line.

After receiving their prized letter, transgender patients continue to face discrimination and hardship from medical doctors and nurses. Says Maggie: “I remember my first HRT doctor. She was a gynecologist who worked in the school clinic, and of course she was the only one who I could see at the time. With her I particularly remember feeling demeaned and invalidated. I would bring up a health concern of mine and she would decline to comment, saying that she only felt comfortable caring for female patients. Whenever she did that I felt like she didn’t take me seriously, but there was no one else I could go to. It sucked.”

Maggie goes on to describe another doctor who treated her for a while. “After school I ended up with another physician. On her website she said that she specialized in working with trans patients, but in person she didn’t seem to know much. She would take blood samples and flip-flop on the results. On one day she would say that hormone levels didn’t matter much, but on the next she would be really concerned that my levels were too low. I don’t think that she valued my opinion about how I felt very much.”

As Maggie describes it, transgender patients seem to know more than their doctors about the right kind of treatment for their own bodies. The fact of the matter is that there isn’t very much research available right now about how to treat transgender patients and how HRT affects them. Most treatment knowledge is passed around in the form anecdotes (among patients) and hunches (among doctors). In this sort of situation, however, it seems clear that the right way forward is to trust a patient’s judgment. Doctors and nurses should work to develop a better rapport with patients who belong to vulnerable groups.

Medical details aside, trans patients also face misgendering and disrespect in doctors’ offices. Trans men who visit a gynecologist for a checkup find that doctors and their staff are totally unprepared to handle male patients, and it shows in the quality of treatment they receive.

Even offices that try to do well handle patients awkwardly, sometimes creating more problems than they solve. Maggie recalls one such case. “For a while I had a doctor who insisted on having a female name to call me by. At the time I wasn’t comfortable being addressed as a woman and I hadn’t settled on a name yet, so I just threw one out to get her to stop. It really sucked because that’s how the office workers would address me in the waiting room, in public! I tried correcting them, but it didn’t seem to have an effect.”

Transgender patients don’t just face difficulties in and around doctor’s offices. Although the Obama administration was generally friendly towards trans people, the present administration has not been so kind. Section 1557 of the Affordable Care Act (or Obamacare, as it’s sometimes known) protects transgender patients against healthcare discrimination, among other things. While this section has not been repealed yet, the Trump administration has taken steps to cut back on enforcing protections for transgender patients.

If trans people don’t have these protections, the already astronomical cost of transition could skyrocket. The ACA forced insurance providers to cover treatments without discriminating against the sex of the patient. With an ACA repealed, a patient who was legally male (but transitioned to female) could be denied coverage to birth control, which is her only source of estrogen. Even more dangerously, trans men could be denied treatment for gendered diseases such as ovarian cancer. Without insurance coverage, the financial barriers can become untenable for trans people.

What Can Allies Do?

One thing that makes it easy to pick on trans people is the fact that there are so few of them. When trans people stand up for themselves, their voices aren’t heard. It is critical for allies to step up and make some noise when and where they see trans rights being violated. Hopefully now that you understand hormone replacement therapy better, you will be better equipped to recognize these rights violations and stand with trans people against them.

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