T+5

Reflections on five years of testosterone therapy

Self-portraits of the author comparing one month vs five years on testosterone therapy.

Content note: Sexual and weight issues.

This week marked a significant milestone in my gender transition. Five years ago, January 3, 2014, I received my first injection of testosterone. While this date was not as important as my nameday, August 23, it was an important step toward reducing the gender dysphoria that stemmed from having a body dominated by estrogen.

After five years of hormone therapy, my appearance has more or less “masculinized”, and my testosterone levels are currently in the normal range for a cisgender man in my age group. This is a relief considering the many challenges my doctors and I have faced along the way. But until I hit menopause — which could be any day now, as I’m about to turn 49 — I know I won’t be out of the woods entirely.

In my transition-related posts linked above, I talked primarily about my feelings about gender and the medical interventions I’ve undergone. In this post I’ll focus on the specific physical and psychological changes that I’ve noticed since beginning hormone therapy.

Day 1 vs Day 365. I took a selfie every day the first year, but didn’t notice much of a difference by the end of it.

One of the first changes I noticed was in the genital region; my clitoris grew noticeably larger. I was expecting this, and wasn’t alarmed or bothered by it; I enjoyed the growth. I began to think of my clit as a small penis, as it became erect when I was sexually aroused.

The frequency of my sexual arousal has greatly increased, almost to the point of distraction. Orgasms are much more focused and intense. My sexual attractions and desires have also changed somewhat, though I won’t go into specific details on that here.

Another early change was an increase in irritability. This was also expected, though, obviously, unwelcome. The depression that I’d lived with for decades continued, but my emotions tended more to anger rather than sadness. I very rarely cry anymore, which is something of an improvement considering the volume of tears I shed previously.

I remember reading some time ago, in The World Peace Diet by Will Tuttle, a troubling quote from Ken Wilber about testosterone:

Studies on testosterone — in the laboratory, cross-culturally, embryonically, and even what happens when women are given testosterone injections for medical reasons — all point to a simple conclusion. I don’t mean to be crude, but it appears that testosterone has two, and only two, major drives: f*ck it or kill it.

This summary is indeed crude, and gives too much credence to those who insist that all male-assigned people are compelled to “think with their dicks”. Regardless, part of why I named myself Pax Ahimsa was to ensure that whatever anger I felt, I would always strive to to live peacefully and do no harm — the literal translation of my name. I’ve found my resolve to not act out in anger sorely tested on many occasions since beginning my transition.

Two years on. Receding hairline is now apparent.

Hair loss, though not immediate, was another expected change, and not entirely unwelcome. I knew that showing signs of male pattern baldness would make me less likely to be addressed as “Ma’am” or “Miss”, though I usually wear a hat outdoors, making my growing bald spot and receding hairline less obvious. Though I do miss my long curls sometimes, I’m glad that hair care now takes a negligible amount of time, which is a welcome change from my previous routine.

Growing a beard was what finally stopped strangers from misgendering me as female, for the most part. It took years to fill in, and is still patchy in places, particularly on the right side. I normally trim both my beard and scalp hair very short, but left them untouched for a couple of weeks prior to taking the photo at the top of this post, to make the extent of growth and baldness more apparent.

Having a beard coupled with visible breasts is unusual, and has caused some confusion, which exacerbates my dysphoria further. I am trying to take heart from activists like Alok Vaid-Menon, who is challenging the expectation that non-binary people should not have facial or body hair. (I’ve grown some hair on my chest and back, but not nearly as much as Alok.)

Being a singer, voice changes were one of the things I was most concerned about. My voice was fairly low (for a female-assigned person) to begin with; I sang in the low alto-high tenor range. I worried about my voice cracking, but didn’t have much of a problem with this, and didn’t notice any significant changes for the first few months. But I was on a low dose of testosterone at first.

After six months my hormone dose increased, and my voice began to drop more noticeably. I stopped singing entirely for awhile, which was a mistake; I should have continued through the transition, painful as it was to produce notes in the awkward parts of my range. I took some lessons with a trans male voice teacher, which was very helpful, and eventually rejoined my chorus as a baritone in our bass section.

While I’ve been praised for my baritone singing, I feel my voice has a lot less power than it did prior to starting on hormones. Part of this is simply not practicing diligently enough. I miss being a tenor, as I got to sing the melody more often in choral arrangements, and felt I had a wider choice of solo material. But I need to get over those feelings, and work on finding more solo pieces in my new range.

Three years on. Weight gain more apparent.

Weight gain is one effect I read that I should expect from testosterone. However, I’m convinced that in my case, the extra fat has been almost entirely due to becoming more sedentary and eating more junk food. I began my gender transition during the fittest year in my life, having run my first full marathon at the age of 43. By the day of my first injection, I weighed about 120 lbs and had a waist size of about 27 inches, which for a 5' 4" person of either binary sex is rather slim by any reasonable standard.

I continued working out and racing for awhile, but in time increased depression and dysphoria, despite the hormone therapy, made me more withdrawn and less willing to go out running or to cook and eat healthy foods. I had to buy larger clothes; the plus side to this was that it had been difficult to find men’s pants with a waist size smaller than 30 inches.

Testosterone therapy typically causes the fat distribution of a female-assigned person to shift from the breasts and hips to the midsection. This increased girth has made me feel heavier than I actually am. After not weighing myself for months I stepped on the scale the other week, expecting a large number, and saw that I weighed 132 pounds. This is still not overweight by any reasonable standard, particularly for a male, nor is my current waist size of about 31 inches (measured at the navel).

But as I used to be far more athletic and the weight gain has been fat rather than muscle, the extra pounds and inches are still bothersome to me. Having larger breasts (despite the shift in fat) also makes my chest more difficult to conceal, as I still refuse to wear a bra or binder. Body-positive people can say all they like about loving yourself regardless of size or appearance, but trans folks dealing with dysphoria often have extra hurdles to get over in that regard.

Four years on. With the closely trimmed hair and beard, this is basically the same as how I look today.

Summarizing my first five years on testosterone: The physical changes have been, for the most part, expected. Though my depression has not lifted and I experience more anger, my moods are more even overall. My primary goal was to stop menstruating, and (after a setback) that has happened without resorting to surgery.

For any female-assigned people considering testosterone therapy, I caution you to educate yourself as much as possible on the effects. Bioidentical testosterone is not a designer drug. Though you can adjust the dosage and timing, you cannot guarantee exactly which changes you will experience.

In particular, if you are only interested in lowering your voice a bit, and really don’t want, for example, increased body hair, a receding hairline, or a larger clit, you should strongly consider alternatives. All of these changes — genital growth, hair growth/loss, and voice lowering — are irreversible. Keep in mind that male-assigned people cannot make their voices higher by taking estrogen; they typically need to undergo voice training to accomplish this.

In giving this advice I am addressing adults and older teenagers considering a hormonal transition, not children. Younger folks can be prescribed hormone blockers to delay puberty until they are ready to decide if they want to transition. Taking such measures is not damaging or irreversible, despite what some trans-antagonistic “well-meaning” people might tell you. Trans writer Julia Serano has a lot more material on the subject of transgender children.

Though my post today might sound more cautionary than enthusiastic, I am glad I made the decision to medically transition. Having an estrogen-dominant body was simply wrong for me. Testosterone therapy is an important part of my toolkit for reducing gender dysphoria. Whatever the next five, ten, or twenty years bring, I am hopeful that I can continue on this path.