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 182016

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

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

Mar 282016

In the United States, spironolactone is the oral anti-androgen of choice for trans women. It’s the cheapest and is well tolerated by most people. Outside of the United States cyproterone acetate, also known as Androcur, is the preferred drug. This week I take a look at this drug, how it works, and why it hasn’t been approved for use in the United States.

The chemical structure of cyproterone

The chemical structure of cyproterone

Cyproterone is an anti-androgen. It blocks androgen receptors, preventing testosterone and other androgens from having their effects. By blocking those receptors, it reduces the amount of testosterone in the body through a mechanism called negative feedback. Cyproterone is chemically similar to progesterone and has some progesterone-like effects as well. Outside of transgender care it’s also used for prostate cancer, as combination antiandrogen and hormonal birth control for cis women (e.g., Dianette), and for chemical castration of sex offenders.

It’s available both as a pill and intramuscular injection. The pill form should be taken every day at the same time after a meal. The dose often used for transition in the literature is 100mg/day. Anecdotally I’ve been told that lower doses, such as 25-50mg/day, have been used. The injection is given once every 1-2 weeks.

Cyproterone acetate is not risk-free and is definitely not for everyone. Most seriously, cyproterone is associated with liver damage. That damage can be severe. It can lead to liver failure even after the drug is stopped. Damage has been reported with doses over 100mg/day. Because of this, people on cyproterone should have their livers regularly monitored with blood tests. The drug should not be combined with other drugs that can cause liver damage. That includes alcohol and many prescription drugs. Individuals with known liver damage/disease should not take cyproterone.

There is also some question of whether the drug is associated with some cancers. In particular, liver cancer and some brain cancers. Specifically, hepatocellular carcinoma and meningioma are the cancers of concern. Researchers are still exploring this connection. Other negative side effects of cyproterone include allergic reactions and worsening of depression.

Many trans women are concerned about fertility. The effects of cyproterone alone, without estrogen, on fertility are somewhat known. Sperm count goes down with oral doses as low as 50mg. Infertility can happen in as little as 2 months. The infertility is reversible once cyproterone is stopped. Fertility returns anywhere from 3-20 months. But remember — no anti-androgen is a birth control method. Please use birth control if you or your partner are at risk of pregnancy.

In the literature, 100mg/day is the dose that seems to be preferred for transition. No cases of liver cancer in trans women have been reported. However some women do have higher levels of liver enzymes. That’s a sign that the drug is causing some damage to liver cells. Transdermal, instead of oral, estrogen is recommended to reduce potential liver damage and blood clots.

Cyproterone is a potential alternative for trans women. So why hasn’t the FDA approved it? That’s a little murky. I wasn’t able to find public document describing the reasoning. But the biggest reason cited by other sources is the concern of liver damage. The FDA is likely trying to do its job and protect the population from drugs that cause more harm than good. In its efforts it may well overstretch. Cyproterone only rarely causes liver problems, and those problems can be screened for with regular blood tests. However it’s important to remember that there are safer alternatives still available. Spironolactone and the GnRH agonists (puberty blockers) are generally safer and mostly well tolerated. Other androgen receptor blockers (e.g., bicalutamide), while not in common use for trans care, are also available and have lower rates of liver damage. So there’s little pressure on the FDA to approve a riskier drug.

So in summary — cyproterone is an androgen receptor blocker in use outside the United States for trans care, prostate cancer, and birth control. It’s biggest side effect is potential liver damage. It’s not FDA-approved for use in the US probably because of that liver damage. People currently using the drug should be under a physician’s supervision.

Want to learn more? The wikipedia article on this drug is super excellent!

Note on references — I pulled most of my information from LexiComp, which I have access to through my university and can’t easily reference. However, prescribing information is publicly available and has much of the same information.

Jan 112016

Happy new year! I hope everyone had a safe and relaxing holiday season. And welcome back! Thanks, as always, for sticking around while I took care of other business. Let’s get started.


Vocal cords -- the source of our voice and pitch

Vocal cords — the source of our voice and pitch

This week’s article comes out of Sweden, and asks the question “When we measure voices in the lab, how quickly and how well does testosterone change the voice of trans men?” Testosterone’s effects on voice have been the subject of blessings and curses (by trans men and trans women, respectively) but have received little attention by researchers.

This study was relatively simple — invite 50 trans men to participate, ask them to read into a machine every 3 months as they start testosterone, survey them, and look at their testosterone blood levels.

The men in this study varied in age, from 18 year old men just swapping from puberty blockers to testosterone to 64 year old men. All had never taken testosterone before. Testosterone forms included both intramuscular injection and transdermal (patches/gels/creams). By 3 months into treatment all the men had male testosterone levels in their blood.

So now that we know a bit about who participated…what happened in this study?

Every three months the men came into the lab and were recorded reading. The pitch and force of their voice was analyzed. Most of the study’s details of how they analyzed it is beyond me (I don’t have a foundation in voice analysis), but the results are clear. By 12 months on testosterone their voices had stopped changing. The most change happened in the first 6 months. On average their voices went from a fundamental frequency of 192 Hertz (Hz) at the beginning to 155 Hz after 3 months and finally ended up at 125 Hz. If you want to hear what those sound like, plug those numbers into this website. There was a lot of variation where their voices started out at, and a lot of variation what their voices changed to. Six of the men stayed around 143-170 Hz. Ten men started out lower than 175 Hz.

Fundamental frequency is a fancy term for pitch. On average cis men range from 85 to 155 Hz, and cis women range from 165 to 255 Hz, for reference. The type of testosterone didn’t seem to have a big effect on when voices changed or what they changed to.

What about how the men felt about their voices and whether or not the change was heard by others? The lower the pitch, the more satisfied the men felt about their voice and the more likely they were to report that they were correctly gendered on the phone. By the end of 12 months satisfaction with their voice was higher, with the most change happening between 3 and 6 months.

But it wasn’t all positive for every participant. Twelve men of the 50 also sought voice therapy. Reasons varied from vocal fatigue to the voice not being low enough to instability, strain, or hoarseness. They attended an average of 3 vocal therapy sessions. How well those sessions helped wasn’t measured.

So what’s the important stuff to take away from this study?

  • After 12 months most trans men’s voices have dropped into the male range, but individual results vary.
  • The most significant change in voice happens in the first 6 months of testosterone treatment, but changes continue to 12 months.
  • Some trans men may desire voice therapy during that first year

It’s also worth noting that this was the first published longitudinal study of trans male voices and how they change on testosterone.

What do you think? Do the study results reflect your own experiences or the experiences of your friends and loved ones? Did the researchers miss anything big? Let me know in the comments!

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

Nov 162015

This week let’s take a break from genetics and ask: “Among transgender people seeking medical treatment, how many want what treatment? Among those who are not seeking out the traditional transition, what are their reasons?” As you might have guessed, a paper from the Netherlands was just online published ahead of print addressing these very questions.

360 people seeking treatment at a specific clinic in the Netherlands were surveyed; 233 (64.7%) of them were assigned male at birth (AMAB; mostly trans feminine) and 127 (35.3%) were assigned female at birth (AFAB; mostly trans masculine). Because this was a survey specifically asking about trans people who may fall outside the gender binary, I’ll stick to the AFAB/AMAB terminology.

The researchers also defined “full” and “partial” transition. For the purposes of this study, “full” transition was either:

  • Antiandrogens + estrogen + orchiectomy + vaginoplasty, for AMAB people
  • Androgens + mastectomy + hysterectomy/oophorectomy + phalloplasty or metoidioplasty, for AFAB people

Variations on these were considered “partial” transition, even if they included more surgeries (such as facial feminization surgery or breast augmentation). By using the terms “full” and “partial”, neither the researchers nor I are trying to imply that one form of transition is any better, desirable, or more “complete” than any other. It’s a historical term, and used here only as a label for one set of treatments that have been considered a “standard” treatment.

So — what did the 360 people want? 10 weren’t sure yet (2.8%). Overall, 253 (70%) wanted “full” treatment. and 97 (27%) wanted “partial” treatment. Of the 97 who wanted a “partial” treatment, 47 cited surgical risks and concerns about the ultimate result, 19 had no genital dysphoria and felt genital surgery wasn’t important for them, 5 felt they were too old, 4 had a non-binary gender identity, 1 was afraid of social rejection, 1 wanted to remain fertile, 1 wanted to go outside the country for surgery, and the others declined to answer.

If you look at the data differently, AFAB and AMAB people wanted different things. Among the 225 AMAB people who knew what they wanted, 180 (77%) wanted “full” treatment. Only 45 (19%) wanted a different treatment. 12 wanted hormones only, another 12 wanted hormones and breast augmentation, and another 10 wanted hormones and breast augmentation and facial feminization surgery.

AFAB people were less likely to want “full” treatment — only 73 of 125 (57%) wanted “full” treatment. Of those, 35 wanted phalloplasty, 12 wanted metoidioplasty, and 26 were uncertain. 52 of 125 (41%) wanted “partial” treatment, with the majority (31) wanting androgens, mastectomy and hysterectomy and 18 wanting androgens and mastectomy without hysterectomy.

That’s quite a difference between AMAB and AFAB people — 77% vs 57% wanting “full” treatment. When the reasons were compared, AFAB people were most likely to be concerned about the risks and results of surgery. AMAB people, on the other hands, were more likely to report feeling that genital surgery was unnecessary.

Of course, this was just one survey within one culture. However, it’s interesting food for thought and gives one set of ballpark figures for who wants what treatment.

Want to read the study for yourself? The abstract is publicly available!