Oct 172016
Barriers are not always as obvious as a wall

Barriers are not always as obvious as a wall

Although many want to, not all transgender people are able to medically transition. The transgender community has been vocal about their needs and the barriers to medical care. However we still need research literature on the topic. Some research has been done, but not enough. Today’s study looked closer at who is receiving medical transition treatment and who hasn’t, and why they haven’t been able to get treatment.

As a quick reminder, medical transition is the medical treatment transgender people receive to treat gender dysphoria. Medical transition physically changes a person’s body from looking like one sex to looking like another. It usually includes hormone therapy and surgery. For more information, I recommend reading Trans 101 for Trans People.

Back to our study! Sineath et al polled transgender people who attended the Southern Comfort Conference (SCC). SCC is a yearly conference dedicated to education and networking in the transgender community. Of the 453 participants who stared answering the survey, 280 completed it. Participants answered demographic questions. They also answered questions about the medical therapy they had received and wanted to receive. There was a free writing section where participants could detail why they had not received any treatments they wanted.

That’s rather striking change between those who started the survey and those who finished it. And unfortunately there were differences between the group who finished it and the group who did not. Those who finished it were more likely to be college educated and trans women. That means that trans men and less well educated people were under represented in this study. While I don’t think there was much that Sineath et al could have done to prevent it, this does mean that the results should be taken with a grain of salt.

What did Sineath et al find?

Of the 280 participants who completed the survey, the majority (84%) were trans women. The rest (16%) were trans men. In this sample, trans women were more likely to be white, in a relationship, and over the age of 40 than trans men.

59% of participants had used, or were currently taking, hormone therapy. Roughly equal percentages of trans men (63%) and trans women (58%) had ever had hormone therapy. Among those who had never had hormone therapy, 53% of trans women and 76% of trans men planned to have it.

Trans men were far more likely to have gotten chest surgery (26%) or want it (88%) than trans women (5% and 40%, respectively). Of all 280 participants, only 11 (3.9%) had received genital surgery. All 11 were trans women. Roughly equal proportions of trans men and trans women wanted genital surgery.

Interestingly, nonwhite and single participants were more likely to have received hormone therapy than white and partnered participants.

I confess, I would have thought that the white people would have had more hormone therapy than non-white people. White people tend to have more resources. Perhaps there are also more barriers though? There are resources specifically aimed at non-white trans people, and perhaps they’re being especially effective. I am not entirely certain what to make of this. If you have ideas, let me know in the comments!

As for single trans people being more likely to have hormone therapy than partnered, that is more immediately understandable. Married or partnered trans people may be negotiating their transition with their partner. Or they may be waiting for children to grow. Either way, a delay makes sense.

What barriers were keeping people from getting medical transition?

There was also a significant difference in why participants had not received medical care between trans men and trans women. For trans men, lack of qualified care was the most dominant factor. 41% of trans men in this study cited that reason. Another 29% cited cost. A scattering of others cited fear of surgery (6%), employment issues (6%), and “other” (18%).

Trans women had a different distribution of concerns. Cost was the most commonly cited reason for not getting medical transition (23%). Employment issues was second largest, at 19%. Others cited age (9%), readiness (9%), needing a psychiatrist letter (7%), not feeling like they needed surgery (6%), fear of surgery (4%), and inability to access qualified care (2%). 21% cited “other” reasons.

What does all this mean?

This study found that 59% of trans participants use hormone therapy. That’s much lower than other studies. According to Sineath et al, previous studies found rates anywhere from 70% to 93%. Why the discrepancy? Studies with high levels of hormone therapy usually were conducted at clinics. Clinics are where participants actively seek hormone therapy! That explains why 93% of trans people in some studies were on hormone therapy. But why the 70%? That number came from a one-time survey that wasn’t clinic specific. It’s difficult to say how many trans people actually do get hormone therapy across the entire US. The real number may be somewhere between 59% and 70%.


This study also found pretty significant differences in the barriers trans people reported. Trans men cited the lack of access to qualified care far more than trans women did. That makes sense. Trans women are far more represented in both popular and medical media. The medical care of trans women is often talked about. I see far more papers and case reports about trans women in the medical literature. More surgeons offer vaginoplasties than metoidioplasties or phalloplasties.

Trans women experienced issues with employment more than trans men. Again, this makes sense. Trans women typically have a harder time “passing” than trans men. Women are subject to employment difficulties and interpersonal violence more because they’re more visible.

I, personally, look at how many trans men are struggling finding qualified care. I’m listening most strongly to that. So much of the talk around transgender care is about trans women. It really is past time that trans men get as much, or more, focus.


Ultimately, this study is a solid contribution to our understanding of medical transition. Thank you to Sineath et al and all the participants at the Southern Comfort Conference!

Want to read the article for yourself? The abstract is publicly available.

Citation: Sineath, R. C., Woodyatt, C., Sanchez, T., Giammattei, S., Gillespie, T., Hunkeler, E., … & Sullivan, P. S. (2016). Determinants of and Barriers to Hormonal and Surgical Treatment Receipt Among Transgender People.Transgender Health, 1(1), 129-136.

Jul 132015

Soybeans, a common source of phytoestrogens

Have you heard that some herbs and foods contain chemicals called “phytoestrogens” that work like estrogen in the body? Ever seen products being sold over the counter advertised to “feminize naturally” or “prevent hot flashes during menopause”? Or read conversations online about using over the counter products to feminize instead of prescribed hormones? Did you stop and wonder if there was truth to the claims? Let’s do a quick overview and do some debunking!

What are phytoestrogens?

Phytoestrogens are estrogen-like chemicals made by plants. Just like how the tobacco plant makes nicotine to defend itself against insects, phytoestrogens are thought to have a protective effect for the plant. One of the most commonly known phytoestrogen is soy isoflavone, which is found in soy beans and soy products. However other plants produce this compounds too. Red clover is another commonly found herb in herbal products.

As a side note: There are three forms of estrogen in the human body that are commonly talked about. Estradiol is the strongest. The type of estrogen used in modern-day hormone therapy is estradiol. So when you see estradiol in the rest of the article, feel free to mentally substitute “estrogen”.

Is it possible that phytoestrogens can feminize?

All things are possible.

First, let’s talk about dose. Phytoestrogens are found in very small doses in foods, or in slightly higher doses in supplements.

Medical transition requires high doses of hormones. A typical dose of estrogen today, when combined with an anti-androgen is around 4mg a day. Before antiandrogens were introduced, doses equivalent to 12mg of estradiol a day were used*. That’s a lot of hormone.

Phytoestrogen products do not come with an anti-androgen. Is it possible that they’re reaching the equivalent dose of 12mg of estradiol a day? Doses found in Canadian products ranged from 1mg to 35mg of phytoestrogens. So if phytoestrogens are equal in strength to estradiol, perhaps.

But that’s a big assumption. The body absorbs different drugs from the digestive tract in different amounts. Then that drug goes through the liver, where some portion may be activated or deactivated. And then it has to circulate around in the blood stream, find its way into the tissues of the body, and find its target. Pharmaceutical drugs have all these factors measured and calculated, so that the dose you’re given should ensure a certain dose is delivered into your tissues in the end. These herbs have not been studied in that way — so until more research is done, it’s difficult to know how much actually gets to the tissues. And it’s known that phytoestrogens bind to estrogen receptors only weakly, so they’re likely to have a weaker effect than estradiol.

In the doses that are being taken, do they have any effect?

As far as I can tell from the evidence, no. Phytoestrogens are marketed to cis women for relief from hot flashes. A study from 2003 published in JAMA found that they do not provide significant relief from hot flashes. Most of the clinical evidence that I’ve seen agrees with that study.

In cis men, phytoestrogens do not affect testosterone levels and does not feminize.

Worse, one study found that among cis women, those who were taking phytoestrogens had lower levels of estrogen in their blood than women who were not taking phytoestrogens.

While in theory phytoestrogens may possibly help with feminization, I see no medical evidence to suggest that they actually do.

Do phytoestrogens provide a consistent dose? Do the pills contain what they say they contain? Is there any regulation?

No. The dose ranges from company to company, pill to pill, season to season. Companies all have their own special formulations with different sources and types of phytoestrogens.

In the United States, supplements are not regulated by the FDA like drugs are. They’re in a special category. There are no independent checks to make sure the supplement is safe before it goes to market. There are no guarantees that the bottle actually has what it says it has. A Canadian study found wide variation in the amounts of phytoestrogens in various products.


Phytoestrogen supplements may seem to offer an accessible, easy way to feminize. However, there’s little to no evidence behind their use. And since they’re supplements, you’re never sure of what you’ll be getting. If you want to eat foods that are high in phytoestrogen, they’re not likely to do you harm. But from what I can tell of the literature, you’re better off saving that $20 to pay for an estrogen prescription.

If you’re having difficulty finding a physician who’s will prescribe hormone therapy, I urge you to call your local transgender or LGBT center, or visit the WPATH or GLMA website for provider listings.

*: These formulations were often from conjugated estrogens, which use a slightly different dosing. Doses of conjugated estrogens ranged from 7.5 to 10mg/day, and .625mg of conjugated estrogens is roughly equivalent to 1mg of oral estradiol. My figure of 12 mg of estrogen was using the “low” dosage of 7.5mg.

Jun 032014

6763959_10420a4b6a_mThe biggest news for May of 2014 is really that Medicare lifted the blanket ban on covering genital surgeries for trans people. The National Center for Transgender Equality has a good summary (PDF) of what the decision actually means. If you’re trans and interested in surgery and are a Medicare recipient, I recommend calling the physician who’s prescribing your hormones and consulting with them about next steps. The news was covered in multiple outlets including the NY Times and CNN.

The other piece of news I spotted that is not getting as much traction as I’d like is this: Urine is NOT sterile! For a long time it’s been believed that urine produced by healthy people is sterile – at least until it passes through the urethra. Turns out not to be the case. Something to keep in mind if you have contact with urine. Source

Interested in the other news? Read on!

  • Work continues on the possibility of three-parent babies. While much of the research and reporting talks about preventing mitochondrial diseases, I still think it opens a wonderful door for three-parent poly households. The latest news is fairly political, but supportive.
  • Another study out of Europe indicates that transgender hormone therapy is safe. This was a 1-year study of both men and women, just over 100 people total No deaths or serious adverse reactions were reported. Highly recommend you skim the abstract for yourself! For US readers, please do note though that the hormones used in the study were different formulations than those used in the US. Source.
  • A published case study reminds us that not all “odd” physical things during medical transition are related to transition. This was a case of a trans man who had undiagnosed acromegaly from a benign brain tumor. Eek! He was correctly diagnosed and treated, thankfully. Source.
  • A Swedish review of transgender-related records found a transition regret rate of 2.2%. Other prevalence data, including the usual male:female ratios, are included. Source.
  • A study of gay men found that they have worse outcomes from prostate cancer treatments than straight men. Source.
Sep 052013
CC BY-NC 2.0 flickr user greenplasticamy

Some doctors are pretty cool.

This post is a legacy page, and was part of an on-going series, Trans 101 for Trans People. It covers questions about medical transition, hormones, surgeries, or seeking health care for transgender people.

For the material that once lived on this page, please see this page.

Please update your links to the full Trans 101.