Any person on hormones is a chemistry experiment. It is very important to listen to the FTM (or MTF) as they tell you what is occurring for them physically and emotionally. FTMs have learned to watch and monitor the changes they experience over time. On this note, it is very important that if you have a pre-op transsexual come to you for help, you educate that person to listen to their body and know how to monitor changes. It will be up to them to guide you through their changes so that you can help them navigate their future health as safely as possible. This is also true for the individuals who choose not to do hormones or surgery. Transsexuals are often dissociated from their bodies due to the schisms they experience between the way they feel and the way their bodies are (sometimes) perceived by others, or the way they know their bodies are. Many transsexuals have extremely high thresholds for pain, or cannot differentiate pain from other experiences.
It is important for every FTM to get a complete blood work-up before even beginning hormone therapy. Those who decide to go through the black market to obtain hormones are at risk for a variety of health problems. Even if someone comes to you who is not receiving injections through a program or doctor following the Harry Benjamin Standards of Care, it is important to listen closely to what they tell you. They will often times be able to tell you what it is that they need from you. (We do not wish to imply that we are telling you to throw out your knowledge or ideas. We simply ask that you not throw out the information and knowledge being given to you by the FTM in your office.)
Once hormone therapy has begun, it is a good idea to do blood work-ups every three months for the first year. If there are no indicators of complications, this can be changed to every six months in the second year. After the third year, unless complications arise, once a year is not unusual practice for blood work-ups. The blood work-ups should not only monitor bilirubin levels for the liver, but should also monitor the cholesterol level. An occasional check of the serum testosterone level is a good idea, to be certain that the level is within the normal range for a male of the patient’s age.
In the United States, the most common approach to hormone therapy for the FTM is intramuscular injection. This is usually prescribed at 200 ml/cc, lcc every two weeks. This can vary between individuals, and it will take time to determine the proper dosage and frequency of injections. Testosterone Cypionate, a cottonseed oil suspension, and Testosterone Enanthate, a sesame seed oil suspension, are the two most common forms prescribed. There are doctors who insist on administering the shots. However, most doctors will do so only for the first few injections, and will then teach the FTM how to inject himself so the FTM can take care of this at home. Most doctors who insist on injecting the hormones themselves are also charging higher rates for the injections as well as the office visits. This usually occurs in rural areas or isolated areas where the FTM has little choice but to comply. Oral Testosterone is still sometimes prescribed, but is strongly discouraged. The high doses of testosterone administered through this method are harmful to the liver. This method has also caused high blood pressure in many FTMs.
A growing number of FTMs who have been on hormones for 4 to 5 years who have not had hysterectomies, have developed intrauterine complications. These range from endometriosis to fibroid cysts, to fibrous scar tissue forming around the reproductive organs, to absorption of the organs into the abdominal muscles or even, in a couple of cases, into the intestines. The rising number of FTMs who have been experiencing these complications has pushed many of us to ask for an hysterectomy earlier in our transition. Many FTMs, however, do not experience these problems, and for them hysterectomy may be an unnecessary surgery. Some FTMs require hysterectomy/oophorectomy for psychological reasons.
Some FTMs may experience migraines in the first few months of hormone therapy. This can sometimes be alleviated by adjusting the dosage or the frequency of injections. Whether the dosage should be raised or lowered varies from person to person. This is a totally experimental stage, and also a very important time for the doctor to be listening to the instincts of the patient. Many FTMs choose to weather the headaches. They usually dissipate after 3 – 6 months. Others may experience cold-like symptoms in the first few months; others may be at a higher risk for yeast infections for the first few months.
Diet is very important. Lowering fat intake will reduce the risks of high blood pressure and heart disease. Taking supplements of milk thistle can assist the liver in processing any toxicity. Smoking and drinking should be discouraged. If the FTM intends to pursue any kind of surgery, he should be educated on the damage smoking does to the vascular system. Most surgeons performing any of the alterations sought by transsexuals insist that the patient quit smoking 6 to 9 months before surgery.
Hormone therapy begins at different times in life for different people. Those who start at a very early age will probably notice a variety of changes at several stages of their lives. Even people who do not walk this path experience hormonal fluctuations throughout their lives. Those who begin hormone therapy later on in life will probably have fewer fluctuations, but will need to pay closer attention to the changes that do occur. Anybody is at risk of arthritis and heart disease, but with the added factor of hormone therapy, the usual course of events may not apply. It is also important to note that all of this information will vary from person-to-person depending on age, ethnicity, diet, and current health.
Listed below are some of the differences between the cypionate and enanthate suspensions.
Testosterone cypionate&emdash;This form brings on the secondary male characteristics sooner than enanthate. However, since this is a cottonseed oil suspension, more guys have a variety of allergy reactions to it. These reactions can manifest in the form of mild rashes or itching at the site of injection. Acne is usually more prevalent and harder to control. Muscle and bone density increase is fairly rapid. However, ligaments and tendons are at risk of damage or injury because they take longer to “beef up” in correspondence with the muscle/bone increase. Any sport activity for the first two years of hormone therapy should be approached with this in mind. The voice usually begins to change at two months and settles at about nine months. Body hair appears within the first two months and can continue to grow in new places up to seven years. Balding is a very real possibility. It can begin as soon as three months into hormone therapy. Fat distribution shifts: thighs and hips may flatten out. However, fat frequently does not disappear, it merely shifts to the sides and the gut. Depending on the FTM’s body type and diet, the person will gain or lose weight.
Testosterone enanthate&emdash;Since this is a sesame seed oil suspension, it is usually easier for the body to absorb. The secondary male sex characteristics usually take longer to manifest than with the cypionate – usually the process is 3 – 6 months behind, though this can vary, too. This slower body adjustment can make it easier on the tendons and ligaments, however, the risk for injury still exists. Acne is less of a problem, and for some has been non-existent.
Notes on Gender Transition
Revised September, 1997
FTM 101 — The Invisible Transsexuals
By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor