On Trans Feminine Healthcare: 5+ Super Relevant Tidbits the Doc Failed to Mention

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CW: sex, genitals, GAHT/HRT, cissexism, discussion of medical transition

In the following piece, I share some relevant information, tips, and tricks that I’ve learned by navigating medical transition as a trans feminine non-binary person. Some of this information is also relevant to trans masculine and/or other non-binary experiences (in many of the examples I list, trans masculine folks experience a near inverse of what I describe), while some is far too specific to be applicable.

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A little under 4 years ago, I stepped into my doctors’ office to discuss starting GAHT (formerly called “HRT”).

For a trans feminine person like myself, GAHT typically means the administration of estradiol (estrogen), either sublingually or injected. For some folks, GAHT also includes an anti-androgen (testosterone blocker) called Spironolactone (sometimes pronounced spee-roh-lack-tone, lol don’t ask me why the “n” gets ignored).

During my first appointment, they shared a general timeline of common bodily changes. They cautioned me about some potential side effects, the most life-threatening of which is an increased chance of pulmonary embolism. They gave me a script for bloodwork to confirm that I could safely take hormones, and thus concluded my appointment. 

From what I understand, my experience is pretty standard. Most doctors basically just read directly from pages 37-38 of the WPATH Standards of Care, which provides an uncomfortably rudimentary overview of medical transition. This is primarily because the medical and mental health industries are just profoundly lacking in research on trans people. 

Outside of the WPATH, a lot of “research” on trans folks is purely anecdotal, which can often be tricky to navigate. While anecdotes are great, because they give you a chance to connect with individuals about their personal experiences, you can’t always take them at face value—and just because one person experienced, say, increased sex drive with the addition of progesterone, that does not necessarily mean everyone will. 

Scientific findings don’t always accurately reflect individual experiences, either—but studies track larger sets of data and make conclusions that are sometimes reasonable to generalize to a population. Shockingly (or not, depending on who you are lol) much of the research used as the scientific basis for trans healthcare was actually conducted on cisgender people (e.g. a study in the 90’s concluded that one form of progesterone might have dangerous side effects for cis women, which is the primary reason it is not not widely used for trans women). This is highly illogical, and contributes to the massive body of scientific misinformation about the effects of hormones. As a result, a lot of us turn to our community to fill in information we are otherwise missing. 

Over the past four years, I’ve learned a ton about trans healthcare that I wish I had known when I set out on this journey. I hope that fellow trans people, along with those who love and care about us, can learn something helpful from my experience.

1. We need to talk about orgasms.

Before launching into this section, I want to define and explain the reasoning behind some terms I use:

Estrogen-fueled people — individuals whose dominant sex hormone is estrogen

Testosterone-fueled people — individuals whose dominant sex hormone is testerone

*In speaking about our bodies, I believe it crucial to de-gender our language and be super specific and intentional in the words we choose. When working to describe bodies, the question I often ask myself is, “What specifically am I trying to communicate here?”

Myth-busting time: There is this widespread notion that vulva and/or vagina havers reach and experience orgasm differently than penis-havers, simply by merit of having those parts. 

This is inaccurate. Or rather, it is a gross oversimplification of our physiology.

Hormones, far more than parts, determine how someone reaches and experiences orgasm; Estrogen-fueled bodies experience orgasm differently from testosterone-fueled bodies, independent of any anatomical differences between these bodies.

What’s wild to me is that literally no one told me this. To this day, I hear very few people talk about it, largely because discussions of sexual pleasure (especially for trans people, and especially especially for trans feminine people) are highly stigmatized.

I couldn’t orgasm for two years after starting GAHT (gender-affirming hormone therapy, previously called HRT). I thought my inorgasmia meant there was something wrong with my body—a thought that’s alarmingly common among women, and particularly among trans feminine people.

Turns out, I just had no idea that my body would work so differently from what I was used to.

First off, the penis and the clitoris are analogous structures (TW: this link uses highly gendered genital terms)—therefore, in much the same way that estrogen-fueled vulva-havers may require prolonged stimulation of the clitoris in order to orgasm, many estrogen-fueled penis-havers require prolonged stimulation of the head of the penis.

Estrogen-fueled bodies may also require more full-body stimulation in order to reach orgasm (ear-biting, nipple play, etc.) These bodies are often far more sensual, and require far more tender and precise touch to feel sexual pleasure. Much the same way that many estrogen-fueled vagina-havers cannot reach orgasm solely by way of penetration, most estrogen-fueled penis-havers cannot reach orgasm with the “grab it and tug” method nor solely through penetrative sex.

In fact, many trans feminine people (myself included) lose the ability to maintain an erection after being on estrogen, and thus are often unable to have penetrative sex without the addition of erectile dysfunction meds, such as Viagra. For many trans feminine folks, the experience of accessing and taking Viagra can be extremely anxiety-inducing and dysphoric, because erections (and by extension, ED med advertising) are aggressively male-coded. Thus, many of us don’t even attempt this.

Estrogen-fueled people also experience orgasm differently. Whereas testosterone-fueled people often experience orgasm as being very intensely centralized to the genitals, estrogen-fueled bodies often experience a more full-body sensation. Wild, huh?

And before someone inevitably asks—yes, some estrogen-fueled penis-havers can have multiple orgasms in a row, while others cannot. The same is true of vulva-havers.

We need to share this information more readily—not only so trans folks know what to expect from our own bodies, but also so we don’t have to bear the sole burden of rewriting years of sexual misinformation for each new partner. I can’t tell you the number of times I’ve had to say, “hey, it doesn’t work like that” and people have totally recoiled in shock. 

As a more general note: end the stigma about discussing sexual pleasure!!!! Trans folks are not alone in dealing with widespread misinformation about our orgasms!!! It’s a problem, y’all!!!

2. My doctor told me I might have a decreased libido. I didn’t know that decreased meant potentially nonexistent. I also had no idea anyone had found solutions.

Testosterone level is pretty consequential in determining libido for people of any gender. When you take Spironolactone, which reduces your testosterone by roughly 50%, your libido may take a nosedive.

This much, my doctor told me. For some, this decrease is temporary (~3 years, according to research); For others, like myself, it is seemingly permanent. My doctor also failed to provide solutions to the issue.

I want to preface this by making clear that the following is meant only to convey personal anecdotes from trans feminine people and does not constitute medical advice.

There are two common steps I’ve seen trans feminine folks take when seeking to restore their libido: decreasing their spiro dosage, or introducing progesterone into their hormone regiment. If you’re experiencing a loss of libido, I highly recommend presenting these options to your endocrinologist or GP.

The issue with decreasing spiro is that this will slightly increase the amount of testosterone flowing through your system. While this may produce some unwanted changes, it can allegedly do wonders for your sex drive. 

As for progesterone, anecdotes often run counter to current scientific conclusions, which typically suggest that libido and progesterone level are inversely correlated (progesterone goes up, libido goes down). However, the science also shows that libido in estrogen-fueled bodies may be the result of a delicate balance between estrogen and progesterone.

After reading up on progesterone, I began to wonder why it’s not more commonly prescribed to trans feminine folks. Unsurprisingly, the reasoning behind this is super silly! 

Apparently it all goes back to one random study of cis women from the 1990s. Findings suggested that progesterone might have harmful impacts on one’s health, such as cardiac events, stroke, etc. However, besides the fact that it’s utterly illogical to generalize this research to trans women, this reasoning has another major flaw—the study used a totally different form of progesterone than that prescribed to trans women!

Which brings me to my next point…

3. You’re allowed to ask your doctor to add progesterone to your hormone regimen!

Progesterone can have so many positive impacts on your transition progress (and, according to the above link, your health). 

For a number of reasons, not everyone has access to progesterone. For starters, the price of hormones creates a significant financial barrier. Doctors also have a tendency to regard themselves as the gatekeepers of medical transition, even (and especially) when they lack knowledge about the specific medicine or procedure being requested. 

Those who are able to access progesterone often report really affirming changes to their bodies. Progesterone, coupled with estrogen, can more quickly advance the feminization of your features, such as thinner body hair and softer skin. It can also reduce testosterone production, improve bone and cardiovascular health, improve sleep, decrease frequency of hot flashes, and more.

Most notably, progesterone allows many trans feminine people to advance to the later stages of breast development—stages that are often not possible without this drug. In many cases, progesterone helps trans femmes achieve their desired breast size without having to budget for breast augmentation. That is HUGE! And we should absolutely be screaming about progesterone from our rooftops! (From a socially-safe distance, of course… be smart, y’all.)

Sure, as with any medication, there are possible side effects—information that you deserve to have as well. But based on what I’ve read, it really does seem worth it.

*Update: As I was editing this piece, I finally made an appointment to chat about progesterone with my doctor! I’ll post updates both here and on my personal Instagram.
**Update update: From my nurse friend Em, “And make sure the rx is for: Micronized progesterone (somewhere between) 100-300mg nightly. Might be listed as “progesterone micronized” but needs to have both. None of the fucking progestins. NOT depo provera.”

4. If you’re having tons of next day soreness, massage your injection site after you pull out the needle.

Contrary to my own assumptions, when you inject a thick, viscous fluid into a muscle, it doesn’t actually just rapidly distribute throughout your body. If you don’t massage your injection site, the estrogen takes longer to distribute, often resulting in increased soreness and bruising at your injection site. This soreness does not impact everyone equally, but I personally suffered from extremely painful bruising until I added a leg massage to my routine.

For the same reason, you should also alternate legs each time you inject. This gives each thigh muscle more time to heal between injections, thus reducing soreness and bruising. 

No joke, I have almost no next-day pain anymore. It’s wild. Try it now, thank me later.

Please note: This method is totally safe for estrogen injected in the thigh, but not necessarily safe for injections at other sites! If you’re unsure whether or not this method is okay for you, substitute a warm compress (or check with your doctor!)

5. Spironolactone, AKA “spiro,” is—and this is the technical term here—a Poo Poo Trash Garbage Dumpster Fire. 

Spiro isn’t, like, the worst thing in the world. But it has some less than ideal side effects.

Among the remarkably few anti-androgens approved for use in the US, however, Spiro is supposedly the least offensive. The side effects have never deterred me from transitioning, but they’re definitely something to be aware of.

You are going to pee. A lot.

Spiro acts as a diuretic, as it substantially impairs your sodium reabsorption. Because of this, you end up constantly craving salty foods, which naturally leads to dehydration. *Note: I am not a medical doctor, so this is a very watered down version of the science (pun fully intended)

Drinking beverages that are high in electrolytes (e.g. Gatorade, Nuun) can be super helpful, but they don’t fully quell Spiro’s diuretic properties. 

I’ve fortunately never peed myself (though I’ve gotten dang close several times, most recently on a car ride home from Milwaukee with my friend Em!) So, uh, buckle up… but make sure it’s somewhere close to a bathroom.

You may feel extra lethargic and/or tired.

Testosterone revs you up—it gives you more energy. Increased testosterone is even linked to increased feelings of aggression, and though this does not excuse anyone’s aggressive behavior, it can certainly explain why certain types of aggression are more common among folks with high testosterone levels.

What happens when your testosterone tanks, you ask? Often the exact opposite—Lethargy! Exhaustion! Perhaps even reduced feelings of aggression! It’s not constant, and you eventually kind of get used to and learn to compensate for your reduced energy level, but it can be a bit challenging at first.

But here’s your minder that even if you experience some frustrating side effects from spiro, you absolutely can and will get through them—and they get easier to manage over time.

Spiro can suck, but rapidly going off spiro can suck even worse!

I was super frustrated with spiro’s side effects from the start. About 6 months in, I asked my doctor if it would be a big deal for me to just stop taking it. She didn’t think it would, so I immediately removed it from my pillbox.

Some people go off spiro and they’re totally fine. Unfortunately, I was not “some people.”

See, when you suddenly stop taking anti-androgens, your body is soon flooded with roughly twice the amount of testosterone it’s used to processing. In addition to raising your blood pressure, testosterone revs you up—and not always in a good way! 

My rapid increase in testosterone sent me into a complete anxious spiral. It got so bad that some of my closest friends didn’t want to spend time with me because I was making them so anxious. It was increasingly difficult to practice impulse control, and I nearly lost my job for “unprofessionalism” (a wholly discriminatory concept, by the way, but I’ll leave this critique for Part 2 of my Glitter Cat series).

It took quite a while before I recognized these as withdrawal symptoms, but as soon as I resumed taking my spiro, my mood leveled out.

These days, I can tell if my dose is even a few hours late, because I suddenly feel bursts of nervous energy coursing through my veins like lightning. 

This is a long way of saying: if you’re planning to take yourself off spiro, please proceed with caution! Plenty of folks have no issue with it, but definitely consider and plan for possible side effects.

Better Anti-Androgens Exist, but Approving Them is Not a Priority for the FDA.

In most of Europe, Canada, and several other nations with adequate access to gender-affirming healthcare, Cyproterone is a common anti-androgen prescribed to trans feminine people. Based on anecdotes from friends (h/t Julia, my trans Toronto BFF), Cyproterone’s side effects are far less intense than spiro’s. 

It’s evidently just as safe, if not safer, than spiro. So, why hasn’t it been approved for use in the US? Well, based on my research, it’s for two very silly reasons:

• Remember how I said that a lot of what doctors think they know about HRT is generalized from samples of cis folks? Well, apparently, due to rare case reports of “hepatotoxicity in men receiving high doses [of cyproterone] for prostate cancer,” the medical industry worries Cyproterone may be dangerous. 
  
  Most places list this as the primary reason that Cyproterone isn’t available here. However, I’d be remiss not to mention: 

• the probable role of the medical-industrial complex. This is mostly an internet theory, but it tracks. A number of folks propose that a significant factor behind the lack of Cyproterone in the US is that drug companies do not view its production as profitable or necessary. Since spironolactone technically works, and has reasonably little risk of death, adding Cyproterone to the mix just doesn’t seem all that important to them.

All this to say—trans healthcare has come a long way over the past few decades, but there is still a long way to go for the future we deserve. In the meantime, I’m grateful to my trans community for helping to fill in the gaps. This article is my way of paying it forward, sharing what I’ve learned in order to arm other trans folks with some of the knowledge they need to move through their medical transitions.