Walking In The Median Strip: Life After Gender Transition At Age 60
A look at trans life and HRT from two different perspectives: full gender transition vs. living as a bi-gender person
In my lifetime, I lived 59 years thinking I was a cis-het guy, and now, these last four years, I’ve been a full-time trans woman. I’ve walked both sides of that road, male and female, but now I wonder if it would be more accurate to say I’m walking in the median strip between the two?
I recently watched a YouTube post made by a trans person, Vera Wylde. Vera is amab (assigned male at birth), but she identifies as “gender fluid.” Vera usually presents as androgynous, or fully en femme, depending on the subject of a particular video. I’ve been following Vera on YouTube for more than four years, and in the early stages of my own transition, I learned a lot about what was going on with myself from her videos.
In the late summer and autumn of 2015, I was cross-dressing most of the time, I didn’t know why I was being driven to do it, and I was becoming very frightened; I wasn’t sure of my own identity any more. Was any part of me still “Larry,” or if not, just who was I?
Vera is in her early 40’s, closer to my own age than most trans people who are active on YouTube, and her style of presentation is very low-key, quiet, matter-of-fact, and soothing. For a trans person like me, living with a lot of fear and uncertainty, Vera’s factual videos were just what I needed to begin the process of figuring out who I was.
Most of what I want to say here revolves around Hormone Replacement Therapy for transgender people, specifically male-to-female trans: meaning testosterone blockers and estrogens, most often in the form of spironolactone and estradiol valerate.
Vera has been taking spironolactone for a while, but apparently not estradiol. “Full gender transition” isn’t something she is planning to do, at least not in the near future. Vera appears to have found a space to live in that encompasses both the male and female sides of the gender spectrum, with all of the gender-related components of her personality existing together in relative harmony.
I know a few people in my trans women’s support group here in Sacramento, the River City Gems, who have also managed to find that same balance. But when I tried to live “part-time” in the spring of 2016, it didn’t take long for the days when I had to present as male to become painful and depressing. I’m a trans woman, my pronouns are she/her, and while I certainly remember the 59 years I was a he/him, I know very clearly that I can’t ever go there again.
The particular video of Vera’s I was watching that prompted me to write this discusses a period of a few weeks during which she had to go off of spironolactone, due to a lapse in her prescription. She discusses what it felt like to be subjected to testosterone again after three years on androgen blockers — in a word, it was distressing.
So, I want to share my own experience of MtF hormone replacement therapy. Every individual trans person seems to have a unique story describing what HRT feels like. Some of what Vera gets from her HRT is similar to my own reaction to it; other effects that I’ve seen, she didn’t mention at all. Is there a “typical” experience that we all have with HRT? There are some common effects that most of us experience, and other effects that seem to be felt, or noticed, by only a few of us.
This is aimed especially at those of you who are just in the beginning stages of the journey along this road of gender identity discovery. Maybe you are just starting your initial therapy, and are considering MtF gender transition, but haven’t started taking HRT yet. Or perhaps you are gender fluid: you want to retain that part of your life that you live as a male, at least part of the time, and don’t want to force your body into transition, thus having to live full-time as female.
Believe me, after four years of interacting with a lot of different people in the trans-femme community, I have come to realize that every one of us has a different story to tell. Regarding the possibilities of transition, the path that a trans person takes from living as a man to living as a woman is not one path. Some of the roads we walk are far longer than others, some have a lot of potholes and wash-outs that have to be dealt with along the way, some people live in places where transition services are covered by insurance and the process is easy, others have no insurance coverage at all, or they live in societies where the LGBTQ community is about as welcome as bubonic plague.
And not all who walk this path intend to arrive at the same destination, or intend to “fully transition” to living as women full-time. It has taken me the full four years that my own transition has been going on to comprehend this, but I think I finally “got it.” There are a lot of us that live under the trans flag that actually prefer “they/their” to “she/her.”
Hormone replacement therapy, for either gender transition, or as a treatment for gender dysphoria holding short of full transition, consists of two main components:
1. reduction of your naturally produced testosterone using androgen-blocking drugs, most often spironolactone, and
2. replacement of your natural testosterone with the primary female hormone estrogen, in the form of estradiol valerate or estradiol cypionate.
Note that these are two independent but related therapies, and not all MtF trans people take both: Vera Wylde is an example of someone who wants to be free of the effects of testosterone on her personality, but who is not in actual gender transition, and is therefore taking spironolactone, but not estrogen.
There are three androgen-blocking drugs that are currently prescribed in the United States (and I think in Canada also): spironolactone, finasteride, and leuprorelin acetate (Lupron). Spironolactone and Finasteride are pills taken orally. Lupron, originally developed to treat prostate cancer, is only available as an injection and is thus more expensive than spiro or finasteride.
I’ve understood Spiro to be the safest of the three drugs, the most commonly prescribed anti-androgen for MtF transition patients, and also, has a dual benefit: it blocks testosterone uptake, and reduces blood pressure. Note that if you receive an orchiectomy, either by itself or as part of a vaginoplasty, you can quit taking anti-androgens completely.
First, a couple of facts about spironolactone:
It was originally developed as a diuretic to treat congestive heart failure and hypertension (high blood pressure); it’s androgen-blocking ability is a side effect. It has other side effects that can be dangerous: in particular, it can cause your body to retain too much potassium, and this can, in a few people, lead to life-threatening cardiac arrhythmia.
If you are taking spiro, you need to have your blood tested two or three times a year to make sure you aren’t developing hyperkalemia (high potassium). But spiro is actually a pretty safe drug, and hyperkalemia is relatively rare. For more information about how spironolactone actually works in the body, see this article in Wikipedia. (It’s very technical and is probably only of interest to uber-geeks), but in a nutshell, spiro blocks two specific cell receptors: the mineralocorticoid receptor in kidney nephrons, which is where it’s diuretic effects come from, and the androgen receptor, which is where it’s testosterone blocking effects lie.
When spironolactone is taken alone, without estrogen, the drug blocks uptake of testosterone and dihydrotestosterone by the AR receptors in cells that are sensitive to androgens. Testosterone is a major hormone with wide-ranging effects all over the human body, so without getting extremely specific, here are the primary effects of taking spironolactone that a MtF or gender fluid patient would usually be most concerned with:
Physical effects on the body
These may include some development of breast tissue (this effect would be increased when estradiol is added to the therapy). The patient is likely to experience some loss of muscle tone, especially in the upper body and arms. Again, this effect is increased if estradiol is added.
In patients experiencing male pattern baldness, the rate of hair loss may decrease, especially if the patient is taking finasteride in addition to, or instead of, spironolactone.
Effects on the brain
In the brain, the reduction of testosterone uptake usually affects the emotions: there is a sense of calmness, a lessening of irritability and aggression, and perhaps greater clarity and better focus on tasks at hand.
One other side effect of long-term use of spironolactone that I experienced, is that it made me crave salty foods, in particular, dill pickles.
In the final nine months that I took spiro, I was eating a full gallon jar of dill pickles every 4 to 5 days. Within a week of going off spiro, the craving disappeared and now I only eat pickles on the side, occasionally, with a cheeseburger.
As part of MtF transition (gender reassignment), spironolactone is usually taken with 0.2 to 0.6 mg/day of estradiol. The two work together as a team.
Some specifics about my own experience
Vera is quite correct in that anything you do that reduces your blood testosterone uptake, either by way of drugs, surgery to remove the testicles, or simply by getting old, will reduce or eliminate the male sex drive. In my case, all three apply.
First, I got old. By age 55, my sex life was pretty much over. I could watch X rated pornos without getting any more aroused than I would watching a golf game (and I don’t play golf). My testosterone level had probably fallen below 75 pg/ml naturally by then, simply because of age. Then, three months shy of age 60, I committed to transition and started taking HRT: 50 mg/day of spironolactone, and 0.2 mg/day of estradiol valerate.
As Vera says, HRT is a gradual thing: I didn’t stick estradiol patches on my tummy on Saturday, and by Monday get D-cup boobs sprouting out of my chest. It doesn’t work that way.
The HRT that you take as part of your gender transition is like going through puberty again. It takes at least several months, to maybe two years to see any noticeable changes.
As you can see in the composite photo below, the most visible outcome of my three years of HRT was that I gained about 30 pounds. The bib overalls I was wearing on that 2015 Death Valley hike I still have, but I can barely squeeze into them now. I hate to be the bearer of bad news, but if you are MtF trans and have been fighting weight gain as you get older, estradiol valerate and spironolactone are not going to make it any easier to slim down. The combination in fact slows your metabolism, and you will have to cut your calorie intake if you want to maintain your current weight, or lose some poundage.
When I started my HRT in July 2016, the first change I noticed was that my nipples got very sensitive to pressure; this began in about November 2016. My cat would sometimes step on one or the other of my nipples, and it hurt like hell. They also grew, a little. That effect lasted maybe 6 months, then faded away, and now, almost four years into my HRT, my nipples are no more sensitive than they were before I started HRT.
My breasts grew a little, as well. Maybe to an “A” cup. People who transition as old as I was can’t reasonably expect any more than an “A.” If you transition at age 18, it’s different: you might get a “C” or even a “D” just from HRT and never need breast augmentation surgery.
There has been a little re-distribution of my body fat: my face looks a little softer and rounder, maybe. But no one should expect that HRT is going to transform your body radically. You aren’t going to become a Cosmo swimsuit model behind Climara estrogen patches.
Genetic females are typically going to develop a wider pelvic bone before they are even born, and a smaller, narrower ribcage. And if you have a “Y” chromosome and were born biologically male, no matter how young you are when you begin your transition, you are just not going to have the same body proportions of a typical born-female. Your hips will typically be narrower, your shoulders wider, and the bigger ribcage is likely going to make the spacing between your breasts enough that you won’t have as much cleavage as a genetic female even if your HRT does bless you with a set of D’s.
If you are a pre-teen trans girl reading this, or the parent of one, the one thing you can do before puberty that will help you later, if your parents will allow it, is to take male puberty blockers.
The most important effect of puberty blockers is to stop your voice from deepening, and stop your facial bones from thickening and developing obviously male shape characteristics (especially the brow and cheek bones and lower mandible).
Unfortunately, if you weren’t able to take blockers as a pre-teen, and your voice deepened into a baritone, your options are limited. A few trans women I know have been able to train their voices upward maybe 1 octave, into a tenor, or maybe a low alto if they were already a tenor, but if you are starting your transition after you reach adulthood, hormone therapy isn’t going to raise your voice pitch.
Trans men have an advantage here: most of them will experience significant deepening of their voices after 5 years (or maybe even less) of testosterone therapy.
Facial hair reduction: Almost all MtF transitioners will undergo laser and/or electrolysis hair removal. I started electrolysis in February 2017. After my first full year of HRT, my beard growth slowed down noticeably, and the facial hair got a little softer in texture, to where my electrologist was able to work faster than she had during the first year.
After September 2018, when I got my orchiectomy, my remaining facial hair became much finer, almost like my arm and leg hair, and I am hopeful that I can complete my facial hair removal this year — although the current COVID-19 virus emergency is going to delay me some unknown amount of time; my electrologist has shut down, like all other “non-essential” businesses, until the Government issues the all-clear and she can re-open.
But for me, the most significant effect of estrogen therapy happened to my mind, and Vera has experienced much of the “emotional benefit” with just spironolactone:
My emotional swings slowed down, I felt a “calming down,” and my thoughts and emotions became less typically “male.” I experience far less anger now than I did as a young man. I have a lot less annoyance with minor problems that aren’t really worth getting myself worked up over.
I used to be the kind of guy that would be yelling “Move it, you idiot! Step on the gas, dammit!” at other drivers on the freeway in a traffic slowdown. Traffic backups just make me feel tired now, and resigned to the fact that I might be late to wherever it is I am going. If I see an ocean of brake lights on the freeway ahead of me, I don’t pound my fist on the steering wheel or blast my horn any more. The emotions of anger and extreme frustration are far less likely to boil up in me now, thanks to HRT.
Anger clouds your judgement, and I feel much better emotionally, most of the time now, than I ever did before transition. I don’t get annoyed when some family in a restaurant brings in their baby or young child and it’s crying. Now, under the influence of estradiol, I want to pick up that baby and comfort it. And that’s a big change for me: crying babies in restaurants used to make me grit my teeth.
Your interactions with other people may become much more open, far less judgmental, and less nervous. If you are attracted to women (I consider myself to be a transgender woman who is lesbian), you can strike up a conversation with another woman, or a group of women, far more naturally than you ever could as a male.
Estrogen HRT can help you have relationships with other people that are just friendly, and not have that pressure of sex behind them. When I had my orchiectomy in September 2018, and got rid of the last of the testosterone, my estradiol therapy gained more effectiveness: my emotional balance became even gentler, if that’s possible. It softened my responses to stress. I became less frustrated when things don’t go my way. I became less in a hurry: I now find that I want to stop and smell the roses.
Everything that used to make me angry and frustrated, I can now see for myself that a lot of those were just stupid little annoyances that I got pissed off about, and lost sleep over, for no very good reason. Why get into a heated argument with someone you just met at a party over some dumb thing like the latest political tomfoolery out of Washington, DC? Under testosterone, you might go home seething and still feel pissed off the next day. Under estrogen, you might just shrug your shoulders, tell yourself, “Congress will do what it will, and there’s nothing I can do about it, so why get stressed. Not my problem!” Then you can go find someone else more amenable to enjoy the party with.
You’ll likely smile more and frown less.
I suspect that testosterone, perhaps reinforced by societal expectations of what “real men” are supposed to be like, has an inhibitory effect on the male psyche: men are typically far more reticent than women. And far more than women, they tend to avoid eye contact with people they don’t know well. Men usually keep their emotions reined in as much as they can, and only extremely painful emotions will allow men to cry, like the death of a loved one.
I cry at stupid little things like happy endings in movies: Lassie finds her way home after being lost for a week in the mountains? I’ll be crying as her 10 year old owner gives her a welcome home hug. Thanks to my HRT, I get to experience the full range of human emotions now! For me, Estradiol makes sunsets more vivid, the soft green grass of a mountain meadow filled with wildflowers more worthwhile to stop the car and look at, and it has opened up a whole new world of social interaction with other women for me… which leads me to state: men know NOTHING about women, not even their own wives, sisters, and daughters.
I can’t claim that my transition and HRT have unlocked the location of that top-secret “women’s owners manual” that has all the Secrets of the Universe in it — the one that I suspect my cousin Andrea got from her Mom (my Aunt Bette) when she was 13, and that tells women stuff like, what color of blouse goes with which skirt pattern and lipstick shade, or how to keep three screaming kids ages 5, 8, and 11 from killing each other or driving you to drink, or how to tell if your husband would like a neck rub just by the way he “looks tired” when he gets home from work.
But I have found within myself that place that was missing for so many years during my youth, the place where my “happy person” lives, the Laura-Ann who comes forward to greet new friends with a hug, who smiles at strangers in shopping malls, who compliments other women on the amazing full-set and nail art they got at the salon that morning.
That’s my experience with HRT in a nutshell. Now, the context of my life is that of full MtF gender transition, and for someone who is not considering actual transition, but is maybe gender-fluid, and taking low-dose spiro and microdosing estradiol, their experience is going to be different.
I’m a trans woman, no question of it, and I’m grateful as hell to be able to live as a trans woman 100% of the time. That guy named “Larry” who I can still sense inside my head occasionally, only lives on for me in memory, as the guy I needed to be for the sake of my wife while she was alive. I have joyous memories of my life with Lynn, and I tried to be as good a husband and life-partner as I could be for her, but it’s my time to finally be who I really am, and that’s not a male. I am Laura-Ann, a trans woman, and I now have finally found peace and acceptance of myself as a human being who deserves to be alive; that’s something I often didn’t have for much of my youth.
Vera Wylde is finding her own way along a life path that may someday include permanent gender transition to female, or maybe it won’t. She is walking a path that is sometimes parallel to mine, but her destination might be off over the horizon in some completely different direction than where my life as Laura-Ann is. I have come to know several people in my city who are living very happily and successfully in a dual-gender mode; typically this means male on work days, female on weekends.
They don’t feel the pain I felt in the last couple of months of my pre-transition life, on those days when I had to go somewhere in male mode. During the final 10 days of my life as Larry, leading up to my “transition-or-die” gender crisis, I was crying at some point every day, and was suicidal several times.
When my TOD moment arrived, it was crystal clear to me that Larry was dead, a rotting corpse I had been dragging around for 5 months, and it was time to stop pretending that I could be two different people.
Some of you apparently can be two people; Vera appears to have found a place to walk in the median strip between male and female, as it were, and be happily gender fluid. And maybe that’s who I am in some ways: I lived as a cis-het guy named Larry for 59 years, and I am unwilling to go somewhere that might require me to forget that I was a man, married for 27 years to a woman I loved more than life itself, and who loved the man that she thought I was.
I am now a trans woman in a same sex lesbian relationship with another trans woman, and my relationship with her feels not one iota different than the relationship I shared with Lynn for those 27 years.
Larry, and Laura-Ann, two names for a human being who, at the end of the day, has always just been one person: me.
This imaginary, allegorical median strip is an interesting place: it joins that life behind me to the life ahead of me, while I walk along in the here-and-now, stopping to smell the roses growing here and there along the way, finding joy in each hug I receive from a friend, and sometimes hugs that come from strangers that I interact with for just a minute or two, and whom I’ll never see again.
Life is strange, and beautiful, and I now know that love knows no gender. Vera says, at the end of her YouTube videos, “You are beautiful, you are loved, you are valid,” and I heartily second that motion.