Jan 042015

8787343055_a2a6eb06bf_mIt’s a new year here at Open Minded Health. I hope you all had a safe, fabulous, and fun new years celebration. Here at OMH it’s time for the yearly questions and answers post.

For the unfamiliar — once a year I take a deep look at all the search queries that bring people here. Often, they’re questions that I didn’t completely answer or that need answering. So in case anyone else has these questions — there are answers here now that Google can find. The questions are anonymous and I reword them to further anonymize them.

This year is all questions about transgender health issues. There’s been a lot published and a lot in the news about trans health issues lately. This next year I’ll try to find other articles to post about too, though. ūüôā


What are the healthier estrogens that a transgender woman can take?

In order from least risk to most risk: estrogen patch, estrogen injection sublingual/oral estradiol, oral ethinyl estradiol, oral premarin.

But¬†note that that’s an incomplete picture. The estrogen patch isn’t the best for initial transition and is very expensive. Injectable estrogen means sticking yourself with a needle every 1-2 weeks and needing a special letter to fly¬†with medications. By far the cheapest of these options is oral estradiol.

Ethinyl estradiol is the form of estrogen used in birth control. Premarin is conjugated equine estrogens, meaning they’re the estrogens from a pregnant horse. Neither should be the first choice for transition. They’re both higher risk than estradiol.

For transgender women, how long does it take to see the benefits of taking spironolactone?

The rule of thumb is 3 months before changes on hormone therapy.

Where is the incision placed in an orchiectomy for transgender women?

That depends on the surgeon. But I’m know¬†you can find images and personal stories on /r/transhealth and transbucket.

Does a trans man have to stop taking hormones to give birth?

Yes. Trans men and others who can become pregnant who are taking testosterone must stop testosterone treatment before becoming pregnant. Testosterone can cross the placenta and cause serious problems for the fetus. Once the child is delivered and no longer breast feeding testosterone can be resumed.

Once you’re on female hormones, how long does it take to get hair down to your shoulders?

My understanding is that the speed that hair grows doesn’t change. It grows at roughly 1/2 an inch a month. Expect growing it out to shoulder length to take 2-3 years.

As a trans woman on estrogen, are there foods I should avoid?

If you’re on estrogen only, there are no foods you should avoid. Instead eat a healthy varied diet.

If you’re on spironolactone you may need to avoid foods that are high in potassium. Potato skins, sweet potatoes, bananas, and sports supplements are foods you may need to limit or avoid. Ask your physician if you need to avoid these foods.

Is there a special diet that can help me transition?

In general, no. Any effect that food may have is, in general, too subtle to make a difference. The possible exception is foods that are very high in phytoestrogens — like soy. Phytoestrogens are chemicals in plants that act a little like estrogen in the body. There are a few case reports in the medical literature of people developing breasts when they eat a lot (and I do mean a lot) of soy. But they’re unusual. Ask your physician before you make radical changes in your diet. In general — just eat a healthy, varied diet.

I’m a trans guy taking testosterone and having shortness of breath. Do I need to worry?

See a physician as soon as you can. Shortness of breath may be a sign of something serious. Taking testosterone raises your risk for polycythemia (too many red blood cells in the blood), which can manifest as shortness of breath.

How often do trans women get injections of estrogen?

Most women have their injection every week to two weeks.

Can I still masturbate while I’m on estrogen?

Yes. Many trans women have difficulty getting or maintaining an erection though.

Can I get a vaginoplasty before coming out as transgender or transitioning?

Generally speaking, no. Surgeons follow the WPATH standards of care which require hormone therapy and letters of recommendation from physicians and therapists before vaginoplasty.

Are there risks to having deep penetrative sex if you’re a trans woman?

I’m assuming you’re referring to vaginal sex post-vaginoplasty. The vagina after a vaginoplasty is not as stretchy or as sturdy as most cis vaginas. It’s possible to cause some tearing if the sex is vigorous or if there are sharp edges (e.g., a piercing or rough fingernails).

Things you can do that might help prevent injury: Make sure you’re well healed after surgery. Dilate regularly as recommended by your surgeon. Use lots of lubrication, and try to go gently at first. Topical estrogen creams may also be helpful for lubrication and flexibility.

Is it safe to be on trans hormone therapy if you have a high red blood count?

Depends. If you’re a trans man looking for testosterone, you may need treatment first to control the high red blood cell count. Testosterone encourages the body to make more red blood cells, which would make the problem worse.

What kinds of injection-free hormone therapy are available to trans men?

Topical testosterone is available for trans men. It’s a slower transition and it’s expensive, but it exists and it works. Oral testosterone should never be used because of the risk of liver damage.

What can cause cloudy vision in trans women on hormone therapy?

Seek medical care. It could be unrelated, but changes to vision are not a good sign.


And that’s it for this year! Next week we’ll be back to normal posts. ūüôā

Aug 302014
Image of needle and syringe - click through to see source

Needles and syringes no longer look like this. Isn’t that wonderful?

Testosterone therapy for transgender men, and others who desire testosterone supplementation, typically involves intramuscular injections of testosterone. Intramuscular injections deliver the medication deep within a large muscle — typically a thigh muscle. From there the hormone can slowly work its way into the bloodstream to do its magic. Few other options exist, and those that do are either expensive or less effective (e.g., creams). Testosterone should not be taken as a pill because it’s very bad for the liver in that form. One possible alternative that has been discussed recently is subcutaneous testosterone injections.

Subcutaneous injections go just under the skin. Most people don’t get subcutaenous injections. The most common subcutaneous injection may be insulin injections for people with diabetes. Subcutaneous injections are also how fluids are given to cats in veterinary care.

Subcutaneous testosterone has been in sporadic recent use for trans men without any research showing how well it works. But that’s changed now with the publication of the article I’m going to summarize. ūüôā So let’s hop into it!

This was a study involving 36 male-identified trans youth from ages 13-24 (minors had parental consent). None had been exposed to hormones before. Hormone levels and other lab values were measured at the beginning and after six months.

For those interested in the specific technicalities of how the hormone was given, keep reading this paragraph. For those not, skip down to the next one! They were given testosterone cypionate suspended in sesame oil that was made at a local compounding pharmacy. The young men were given the injections by the clinical staff at first, but slowly taught to self-inject. Dosing was biweekly and started at 25mg per week, slowly increasing after that for some with a final dose ranging from 25-75mg.

So what did they find? How did it go? Positively!

About 92% of the young men in this study had testosterone levels in the “male” range at the 6 month check up. Similar goes for estrogen levels — by that 6 month check up their estradiol levels were down in the “male” range too. 85% of the young men who had been menstruating had stopped by that 6 month check up. Most periods stopped roughly around the 3 month mark. Other factors, like hemoglobin (red blood cell concentration) and cholesterol shifted but were not of clinical significance.

Two of the young men had allergic reactions to the sesame oil and were switched to cottonseed oil. This is a pretty well known reaction that happens in intramuscular injections too. Some also noticed small bumps around where they injected for a few days after injection. Those were the only reported side effects. Nobody reported unhappiness with their testosterone treatment method or asked to be switched to a different method.

All in all, a well put together study. Subcutaneous injection of testosterone so far appears to be a possible alternative to intramuscular injection. But it’s worth noting that commercial testosterone is intended for intramuscular injection and that type is not what was tested here. It may not be safe or effective to inject an intramuscular formulation as a subcutaneous one — ask your physician before changing how you use your medications!

As always: this is just one study. More need to be done to confirm these results. Regardless, I think these are good first results and look forward to seeing more.

Study was published in LGBT Health. Abstract is publicly available.

Disclaimer: I have personally met Dr. Olson (lead author of this study), worked with her in a small capacity, and have attended her talks at conferences. My interactions and impressions of her may have biased my interpretation on this study. However, I do my best to keep those preconceptions from affecting my judgment.

May 082014

CC BY 2.0) - flickr user stevendepoloA little belated, but here’s the GSM health news that came out around April this year, in no particular order…

  • There was a new meta analysis of intestinal¬†vaginoplasties published in April. This meta analysis overall found that rate and severity of complications was “low”, with¬†stenosis the most common complication. There were no reports of cancer. Sexual satisfaction was high, but there were no quality of life measures reported. Quality of studies were reported to be low, though, and there was a distinct lack of use of standardized measures. Source.
  • Oncology Times released a review of cancer and cancer screenings in transgender people. Highly recommend you take a look at the source.
  • A study finds that trans men on testosterone have lower levels of anxiety, depression and anger than trans men not on testosterone. Source.
  • A review of current hormonal transition effects and aging determined that, based on current data, “Older [trans people]¬†can commence cross-sex hormone treatment without disproportionate risks.” They note that monitoring for cardiovascular health is especially important for trans women, especially those who are on progesterones. Strength or type of hormones may need to be modified in order to minimize risk. Source.
  • As much of the sex positive community has known for a long time, the BMI of cis women is (in general) not correlated with sexual activity. Source.
  • In Croatian medical students knowledge about homosexuality was correlated with positive attitudes. Source.
  • Science is awesome! The Lancet reported success in engineering vaginas for 4 women with MRKHS. No complications over the 8 years of follow up, and satisfaction with sexual functioning. Fingers crossed that this technique can be used in the future for many more women!¬†Source.
  • Remember that sexual orientation is not the same as behavior? In a recent analysis of previously collected data, 11.2% of heterosexual-identified sexually active (presumably cisgender) women reported ever having a same-sex partner. Another way of looking at it: 1 in 10 straight women have had sex with another woman. Source.
  • Don’t forget about aftercare and cuddling! Post-sex affection appears to be correlated with relationship satisfaction. Source.
  • Unsurprising but sad: Young LGB people are more likely to binge drink alcohol when they’ve been exposed to discrimination and homophobia. Source.


Nov 072013

Skin - CC BY-NC-ND 2.0 - flickr user zorro-the-catSummary: A Belgian study of trans men found that type of testosterone given does not affect hair growth, acne, or balding, and characterized further the skin changes that happen with testosterone therapy.

This was a study of the skin quality of trans men, performed in Belgium.¬†Why study this topic at all? Because some of the effects of hormone therapy for trans men are skin-related. The skin may get oilier, acne may increase, hair grows in places it didn’t before and gets thicker and rougher, and for some men they start to have male-pattern baldness or a receding hair line. These effects have also been seen in cisgender women with polycystic ovarian syndrome, where they have high levels of testosterone. Turns out, though, that it’s not so much testosterone itself that causes these effects. It’s dihydrotestosterone (DHT), which is made from testosterone. You can think of DHT like a super-powered version of T. This is why medications like finasteride can sometimes prevent hair loss, by blocking the conversion of T to DHT.

The WPATH Standards of Care estimates the following timeline for various skin-related changes from starting testosterone as such:

  • Acne increases in the first 1-6 months, peaking around 1-2 years on T
  • Body hair growth starts in 3-6 months, peaking around 3-5 years
  • Hair loss is highly variable, but would be expected to start after at least a year T.

So what about this study? What exactly were they looking at? This study looked at a long-acting form of testosterone which hasn’t been used in previous studies of trans men skin. Classically, hormone therapy for trans men is a weekly or biweekly intramuscular injection of testosterone cypionate or testosterone ethanate. Which testosterone you receive depends on the country (cypionate’s more common in the US), seed/nut allergies, cost, and personal/physician preferences. This study looked instead at testosterone undecanoate, which is given every three months. This study then asks two questions:

  1. Is there any difference in the effects of skin between testosterone undecanoate and the more common 1-2 week injections?
  2. What effects on skin can we see from long-term testosterone use?

To answer those questions the researchers did both a longitudinal and cross-sectional study. Remember, a longitudinal study is one where a a group of people is “followed” over a period of time. It provides a good picture of how things change over that time period, but can be expensive. A cross-sectional study examines people only once. It provides a lot less data but is cheaper.

For the longitudinal study they focused on testosterone undecanoate. They followed a group of 20 trans men over the course of their first year on testosterone (undecanoate), asking them back to do bloodwork and questionnaires every 3 months. For the cross-sectional study, they examined 50 trans men only once. These men were all post-hysterectomy/oophorectomy and had been on testosterone an average of 9.9 years (3.2 – 27.5 years range). 35 of them were on a mix of testosterone esters every 2-3 weeks, 7 were on testosterone undecanoate, and 8 were on topical cremes. Exclusion criteria were the usual, and quite reasonable: excluding those with endocrine problems, prolonged use of corticosteroids, and the like.

What did the researchers look at specifically?

  • Degree of hair growth on the lips, chin, chest, upper back, tailbone area, abdomen, arm, and inner thigh (“Ferriman and Gallwey” method)
  • Satisfaction with their hair growth patterns
  • Evaluation of acne, including the back/neck areas
  • Quantity of sebum production. Sebum is oil that skin produces.
  • Bloodwork, including: sex hormone-binding globulin, luteinizing hormone, follicle-stimulating hormone, estrogen, and testosterone

Results? Well let’s look at this one subject at a time…

  • Hair growth? For the longitudinal group, it appeared to increase most dramatically between 3-6 months. However hair growth appeared to continue to increase past that point. The type of testosterone did not appear to be associated with different levels of hair or satisfaction in hair amounts. There was a lot of variation in the fuzziness of the participants with some men not increasing their fuzziness at all.
  • Male pattern baldness? One person in the longitudinal group started balding in his first year. Among those on testosterone for more than a year, roughly a third has severe balding, a third had mild/minimal balding, and a third had no balding at all. There was not association between the type of testosterone and balding, though the older the man was the more likely it was he would bald.
  • Acne? For the longitudinal group, it was worst at 6 months but rapidly improved after that. At that 6 month mark, 82% of the men had facial acne. During the first year, roughly half of the men used various acne control products. For those in the cross-sectional group, roughly 1/3 did not have acne. 2/3rds had minor acne. 2/3rds of the group also had no acne scarring.
  • Sebum production? Was evaluated only in the cross-sectional group, and was not elevated. It also wasn’t associated with acne, or hormone therapy type/duration.
  • Bloodwork and hormone levels? No associations were found between any sex hormone levels and any of the skin factors measured (hair growth, baldness, acne, sebum)…. with one exception. In the cross-sectional group, estrogen levels were associated with hair growth. The authors are uncertain what that result might mean, and it may well be a fluke. Further research will have to find out.

But what does it all mean?! Well remember the original two things the researchers were investigating? Scroll up if you need to. Basically, it means that there doesn’t appear to be a difference in skin effects between the different types of testosterone therapy. And a trans man starting on testosterone can expect mild acne which peaks around the 6 month mark. Hair growth will accelerate the fastest during the 3-6 month period, but will continue afterward. But if he’s going to go bald, it likely won’t be in that first year.

Study limitations? The authors were pretty honest about the limitations of their measures. Some were subjective (e.g., the¬†Ferriman and Gallwey method used for hair growth) and did not assess all areas that may change (e.g., buttocks and hair growth). They also point out the usual limitations inherit to the cross-sectional part of their study – it’s very hard to determine causes. I would also add the limitations in their sample size (relatively small), ethnicity/race (not reported, but nearly all participants were from Belgium). I also did not see them account for smoking tobacco in their study, though they did report the smoking rates (25-28%) of their groups. A number of potential variables were not reported on, such as hygiene or familial hairiness.

However I don’t see any glaring errors in this study, and it seems to have been respectfully done. Its language usage is certainly more respectful than many studies I’ve read about trans health.

This article was published in the Journal of Sexual Medicine. Its abstract is publicly available.

May 012013

One way to reduce stress and cortisol - CC BY 2.0 - flickr user eamoncurry123Summary: Research now indicates that cross-sex hormone therapy is associated with a lower cortisol awakening response in trans people, regardless of attachment style. Many confounding variables, however, were present in this study.

Transgender people have long asserted that gender dysphoria can be extremely distressing and that transition, including hormone therapy, helps relieve that dysphoria. Hormone therapy is known to improve self-reported quality of life, as measured by questionnaire. To my knowledge no other study has looked at stress-related biological factors in trans people. Biological factors are important because self-report is notorious for validity problems. This study looked at one such biological factor, called the cortisol awakening response.

What is the cortisol awakening response? Readers of the blog may remember the last time I spoke about¬†cortisol¬†(paragraph #2). For those who don’t remember…. cortisol is a “stress hormone.” When we’re stressed, whether by speaking in public or running from a lion, cortisol is released. It helps our body be ready for immediate survival by increasing blood sugar and helping with metabolism.¬†High cortisol levels over a long period of time can have many negative effects on health, including weakening the immune system. The cortisol awakening response is part of the¬†daily cycle, when blood levels spike about 20-30 minutes after waking in the morning.¬†The cortisol awakening response is larger in stressed people than in non-stressed people and can be affected by many things, including burn out, fatigue, aspirin, and sleep schedule. Awakening response is thought to be a good indicator of general stress levels and as a good indicator for stress-related disease risks.

Participants in this study were 70 trans people seen at the Gender Identity Unit of the University of Bari Psychiatric Department, roughly 64% trans women. All the participants had the same hormonal treatment; transdermal estradiol gel and cyproterone acetate (an anti-androgen) for trans women, intramuscular testosterone esters for trans men. They were assessed before hormone therapy and 12 months after starting hormone therapy. There was no significant difference in age, education, or occupation between the two groups.

The researchers measured perceived stress (a self-report of how stressed a person feels) in addition to the cortisol awakening response. The cortisol awakening response was measured by a blood test at 8:00am on three consecutive days, 1 hour after waking.

The results were striking. Before treatment, both perceived stress and cortisol levels were above the ¬†“normal” range. After twelve months of hormone therapy, both were much lower and back within normal ranges. There were no statistically significant differences between trans men and trans women.

However there are a number of confounds for this study. Cortisol levels vary with sex hormones. For example, the cortisol levels of menstrual women will vary depending on which part of the menstrual cycle they’re in. Could cross-sex hormone therapy have caused this change in cortisol levels? Maybe, but then I’d expect there to be a difference between the trans men and trans women in this study and there weren’t.

The researchers also did not appear to attempt to control for other factors which could have impacted the cortisol awakening response. Changes in sleep patterns (e.g., naps) or sleep quality (e.g., a noisy environment) have effects on the cortisol awakening response. As far as I can tell the researchers did not screen for these changes.

Cortisol and stress were not the only things measured in this study. The researchers also looked at attachment styles. Attachment styles are a psychological concept. The idea is that when we are children our interactions with parents, and how they respond to our needs, affects the type of “attachment” we have. Attachment styles are secure or insecure. A secure attachment often results in happy adult relationships. Insecure attachments include avoidant, anxious, and unresolved/disorganized styles.¬†Attachment styles may influence how we respond to stress, so they could have been a confound in this study if not examined.

The researchers determined the attachment style of the participants with a structured interview. They found that trans people are more likely to have an insecure attachment (70%) than the general population with no psychiatric diagnoses (44%). Attachment style did not, however, appear to be correlated with cortisol awakening response or perceived stress.

In other words, the relationship trans people have with their parents did not appear to affect the stress-reducing effects of hormone therapy.

I do not really understand why these researchers chose to examine attachment style in this study. I think that knowing attachment styles may be useful for therapy or for the development of effective variations on therapies for trans people. But I don’t feel that the inclusion of attachment style was sufficiently justified in this study. Why look at attachment and not, for example, socioeconomic status or social support? I would think either of those would be more likely to have an impact on stress levels than attachment.

On the whole: I think that the cortisol results of this study are decent validation of the anecdotal evidence from trans people themselves, but that the exploration of attachment style in this context is a red herring.

The abstract is publicly available.