Author Note: Since publishing this, it’s been circulated in a number of contexts that may misconstrue my original intent. I wrote a short follow-up clarifying that intent here.
Like many communities, the transgender community has its share of controversial subjects. One in particular firing people up over the years is the concept of detransition. Detransition, or the halting or reversal of social and/or medical transition procedures, is a concept that frightens people. Framed as being about “transgender regret,” the idea of no longer pursuing transition or even one’s identity changing is intimidating because it implies that being transgender is not a fixed state for many. This poses a challenge when attempting to broach otherwise relevant subjects, such as the implications of stopping hormone replacement therapy (HRT) for females.
With controversial subjects comes myths. One such myth is that transsexual individuals typically detransition due to social or familial pressure. The idea is that some people can’t handle the pressure of being visibly transgender, thus opting to go “back into the closet” and reversing changes so as to reduce it. That explanation is also used to highlight why so few transmen come forward about detransitioning, as we pass more readily thanks to the wonders of testosterone. I would argue that for transmen, we’re faced with a different kind of pressure, one centered on minimizing concerns surrounding the complexity of transition and living as FTM. Additionally, the charged nature of the subject makes it harder to connect with people with similar experiences, even if they understand themselves differently. The fear, reinforced by myths and black-and-white approaches, drives peers to avoid the mere mention of detransition. It’s difficult to discuss transmen stopping HRT if we’re unwilling to bridge the gap between groups.
Truth is, there are more similarities than differences. A singular, unified identity isn’t necessary for multiple groups to connect about shared concerns. A transman who stops HRT for medical reasons will be faced with similar challenges to a detransitioned woman no longer on HRT, particularly if both parties had hysterectomies and can’t produce sex hormones of their own. Complications in surgeries, such as excessive scarring, loss of sensation, tissue necrosis, or infection, don’t discriminate between groups. Discrimination, including the risk of assault, is also a serious concern for both groups. Harassers don’t ask people what their pronouns are before targeting them. Additionally, a peer-operated survey by Cari Stella found that the majority of detransitioned women had both social and sex dysphoria, not unlike many transmen, and said dysphoria wasn’t readily distinguishable from descriptions by transgender individuals. In terms of health care, discrimination, and equal rights as individuals, the needs of transgender and detransitioned females are inextricably linked.
Thus, in an effort to get that ball rolling, I’ll be open about being a transman who’s detransitioning. Here are the five main reasons why.
Needles suck, and the alternatives are too expensive to be worth it.
Let’s be honest. Dealing with injections is a nightmare. There’s safe injection practices you have to tend to, storage and disposal of sharps, and balancing injection and lab schedules for accurate tests. Sourcing sterile needles of the right gauge and length can also be a serious pain (pun unintended). Some of the needles or syringes can be hard to come by, particularly if you’re doing intramuscular injections. What’s more, using needle exchange programs can be a mixed bag depending on where you live, if they exist at all. Stigma surrounding recreational drug use persists, and there’s no guarantee you’ll get the same length and gauge of needles as the ones you exchanged. Some of this hassle is offset if the person gets their shots done at a clinic, but with that option comes the need to have stable transportation. For people in rural communities, with limited or no public transportation, or those without their own vehicle, it’s hardly a comprehensive solution. Similarly, there’s ordering online, but this requires patient knowledge that people in the early stages of transition may not have yet. That is, supposing you can even get them shipped to you.
Another factor to consider: the public health impact of regular injections. Sharps are considered medical waste because of the joint risk of injury due to needle sticks and, subsequently, the potential spread of blood-borne pathogens. Additionally, improper disposal of sharps can prompt people to reuse needles, putting them at risk of infection. As a result, the Environmental Protection Agency released community guidelines in 2004 for developing safe disposal programs, but they are by no means mandatory or reliably used. Maine is one state where we’ve fallen short. Even though Maine has task forces dedicated to harm reduction, the state still doesn’t have a consistent disposal program available for sharps. In lieu of needle exchanges and hospitals willing to accept medical waste, many are stuck tossing their containers in the trash. Doing so puts both their own household and the sanitation workers collecting their trash at risk of needle sticks. Some good Samaritans develop grassroots exchange programs, with one person running one out of the trunk of his car, but they risk being shut down. The burden of safe disposal thus falls on the individual receiving care instead of the system providing it.
Pharmaceutical companies have been developing alternative forms of testosterone therapy but with limited effectiveness and coupled with a sharp price increase. Alternatives include: topicals in the form of gel, cream, or patches (e.g. Androgel, Testim, Axiron, or Androderm); oral medications (e.g. Andriol); pellets inserted under the skin (e.g. Testopel); and dissolving tablets placed in the gums or cheek (e.g. Striant). Most of these have to be applied once or multiple times a day, minus Testopel. Some of these, such as Androgel and Androderm, can cause skin irritation or secondary exposure if someone comes in contact with it, and Testopel pellets can break out from under the skin. As for effects, some individuals report hitting a plateau after the first year, prompting them to switch to injections. The cost is another barrier. Compared to injections, estimated costs listed on my forms for alternatives ranged anywhere from $150-550 a month. It can be lower if you have insurance, but when one in four trans people report being denied insurance coverage for care, it’s not a reliable solution. If I can make do without it, then the public health and financial hit of continuing HRT just isn’t worth it.
The long-term health risks of testosterone use in females is largely unknown.
To date, there are few longitudinal studies done surrounding the potential health risks of HRT for females. A handful of studies have been done surrounding various issues, such as mitochondrial damage in white blood cells and vaginal atrophy. However, little followup has been given to determine the true rate of occurrence or long-term impact. A review by Cécile Unger, the Director of the Cleveland Clinic Transgender Surgery & Medicine Program, cautions that “[l]arge-scale prospective studies are lacking. […] It is therefore, not possible to draw definitive conclusions about the adverse effects of long-term cross-sex hormone use.” She also noted that most long-term studies done measuring quality of life focus on “sexual function and mood” while ignoring the health risks that can decrease that quality of life later. In many instances, public awareness of these issues again falls on individuals faced with them. Peers become tasked with reporting their own complications, as well as cautioning other peers of the risks and when to seek care.
One health risk that is known is polycythemia (i.e. erythrocytosis), or an elevated hematocrit due to increased production of red blood cells. Polycythemia is a potentially life-threatening adverse reaction to testosterone use that puts individuals at risk of pulmonary embolisms, heart attacks, or strokes. Yet despite this known risk, large-scale studies analyzing the risk factors, what kinds of testosterone therapy are correlated with them, and the hematocrit levels to watch for are lacking. The risk is known largely through individual case studies or meta-analysis of studies on males using injectable testosterone. In the context of gender dysphoria, we have no idea what the risk level is.
The fight to include females in pharmaceutical research isn’t new. Feminists raised the alarm in the mid 1980s about how new medications were only being tested with male subjects. Originally, females were excluded from clinical trials because of the belief that hormonal differences would skew results and the potential impact on fertility. However, males and females respond differently to medications, so it became essential to explore how females are impacted by medication. Generalizing data from studies done in males doesn’t carry over to female populations, particularly surrounding reproductive health. Use of testosterone would be no exception. In reviewing the cardiovascular risks of HRT in transgender individuals, researchers noticed how most data is being extrapolated from studies done with participants of the opposite sex. Given the differences in response to medication, as well as the unique path of treatment for gender dysphoria, it’s crucial to have research tailored to the needs of the transgender community.
Part of the problem with developing longitudinal studies for cross-sex HRT is the fact that there’s so many options available. A review by Leighton J. Seal, a consulting endocrinologist based out of the UK, highlighted how each additional form of HRT added new confounding variables in research on both positive and negative effects. Each form has its own chemical compound, with differences in where the hormonal base was derived from. This poses a problem for studies where participants are using different forms within the same data pool, causing possible adverse effects to be missed or calculated at lower rates. It also poses problems when comparing research between different regions, as different forms have different rates of use or approval by clinicians between countries. The same review concluded that “[cross-sex hormone] therapies appear to be safe in the longer term,” yet that conclusion focuses primarily on health risks with data, again, extrapolated from subjects of the opposite sex. Said review also noted on multiple occasions how little research there was available in each possible health risk, despite the fact that cross-sex HRT has been used for transgender health care since the late 1910s.
The other part of the problem exists in the clinicians’ office. Transgender health care has been in constant evolution since it began. With that evolution comes experimentation, discrimination, and ultimately, distrust. Buck Angel, a prominent activist who transitioned in the 1990s, wrote about how he was treated by providers. He recounted how his doctor described him as “basically a guinea pig” while having him sign away his rights to sue. On top of that, a lack of knowledge in transgender health care needs meant that serious complications were missed, all while he was told that everything seemed fine. Presently, failure to communicate comes in the form of immediate affirmation, focusing on the positive effects of transition, and little (if any) discussion on the negative effects. This makes it difficult for people to trust their providers about their concerns or wanting to stop HRT, prompting some to drop off the radar entirely. Others, when they try to reach out to old providers about their experiences, are told that there were “no other cases” on record. In an otherwise well-meaning attempt to support transgender people in exercising their autonomy, many clinicians wind up contributing to harm they sought to avoid.
Considering the lack of data on the health risks of HRT for transgender individuals, it makes sense to find less invasive ways of getting my needs met. I don’t want to maintain a form of treatment that’s this consistently untested any longer than I have to.
There are other ways to manage my dysphoria.
I transitioned later than many of my trans brothers, instead opting to wait until my late 20s. This gave me time to accomplish two goals: determining my own path for recovery and developing a strong enough foundation to be able to pull that off. Not unlike nurturing a garden, I needed to focus on other areas of my recovery to approach my dysphoria from a holistic angle. As I worked through that, I had to learn the patterns of my dysphoria and how to manage it in the event that I couldn’t transition later. This included developing coping skills that I otherwise may not have explored.
One pattern that I noticed is that much of my dysphoria is contextual. It flares in response to reminders of trauma, threats to my safety, and stress levels. Each require a different approach for me to stay well. I can manage reminders of trauma through grounding techniques, taking a break from whatever is sparking them, and processing the root trauma by talking with supporters or studying Torah. Threats to my safety are trickier. I may not be able to remove myself from the situation as it happens. If possible, I can figure out an exit plan, but if not then I have to manage my fear as best as I can until I can leave. If those threats to my safety are explicitly gendered, then reframing my perspective to see the crisis as an opportunity can help. Finally, stress levels are something everyone has to manage. If my stress levels are too high and they’re causing other issues to flare, then the most effective response is to reduce that stress somehow. Whether that means reducing my responsibilities until things calm down, doing something I enjoy, or taking time off, it’s critical for my well-being to keep stress in check.
This isn’t to say that all of my dysphoria follows this pattern. Certain kinds, like dysphoria that’s triggered by the sound of my voice or dealing with periods, have been greatly reduced since starting testosterone. I was blessed to have notable changes in both after just two weeks. My voice settled within six months after dropping several octaves, far faster than many of my peers on testosterone. Period suppression happened just as rapidly; I haven’t had one since starting my transition. I’ve also had chest dysphoria since high school, though its intensity varied. This was one that followed me into private spaces, gnawing at me enough to bind even in the comfort of my home or dorm. While testosterone didn’t help with chest dysphoria, I had already worked on desensitizing myself to it after binding became impossible. There are still times where I long for a flat chest, but it’s manageable now compared to past years. Now, I focus on distracting myself from the feelings as best as I can until they pass.
When I consider the patterns of my dysphoria and resources for managing it, focusing solely on dysphoria becomes a surface level solution. If the root of one of my dysphoria flares is elsewhere, then changing myself or my presentation won’t help me as much in the long run. It can be beneficial in the short-term, but the path to wellness needs to focus on the long-term, as well. It’s also important to have backup tools for managing it in case something changes and previous coping techniques are no longer effective. Having a range of options to address dysphoria gives me a well-rounded approach in approaching transgender health care.
I’m critical of a system where alternative explanations aren’t explored.
There are typically two routes for accessing transgender health care in the United States (U.S.), the traditional route and informed consent. If you opt for the traditional route for HRT and/or blockers, you typically need a letter from a therapist stating they feel you’re a viable candidate. The amount of time a person needs to spend in therapy varies wildly from area to area, with some countries requiring a long-term relationship with a therapist. In the U.S., however, individuals may be cleared for transition within the first few sessions. Respondents to Cari Stella’s survey described how many of them were approved for transition during their first therapy session—so many, in fact, that including them in the analysis broke the graph. The seventh edition of the Standards of Care, released by WPATH, removed the therapy requirement entirely. Individual providers may still opt to require a letter, but it’s not consistently followed and doesn’t account for how much time the person spends with said therapist.
Informed consent clinics, the option I went through, can also bypass therapy requirements. Informed consent for HRT presumes that the patient knows the risks involved in pursuing care and that they are ultimately responsible for its outcomes. Intake appointments involve an interview with the person, which includes learning about their experience with dysphoria, how long its lasted for, and their understanding of how they’d be impacted by HRT. While clinics may refer a person to additional therapy or assessments if they suspect something is influencing their decision, it is by no means consistently followed. Few, if any, assessments for other explanations of the dysphoria are included in the intake itself. The underlying assumption is that if someone is pursuing HRT through informed consent, they know what they’re signing up for and the liability falls on the patient if it wasn’t the appropriate course. This creates an orthodoxy of care, where people in distress are given a singular explanation for said distress and not afforded the opportunity to explore their options. That orthodoxy of care can foster dependency on treatment options, including pharmaceutical and surgical intervention, that may not be in the person’s best interest.
This orthodoxy of care can interfere with trauma-informed care, a critical component to providing compassionate health care. Just like the failure to research health risks in females on T, there is a similar failure to research rates of interpersonal trauma. Preliminary data from FORGE suggests that “transmasculine individuals were actually more likely to be victims of childhood sexual assault, adult sexual assault, dating violence, domestic violence, and stalking than were transfeminine individuals.” Aaron Devor found similarly high rates of child abuse among transmen in 1994. Females with a history of childhood sexual assault are also more likely to experience dissociation, which can manifest as a disconnect from one’s body (depersonalization), from reality (derealization), or from one’s sense of self (identity confusion/alteration). There are also high rates of depersonalization in the transgender community, though exact prevalence rates are unknown. This is an issue because depersonalization in response to trauma can be interpreted as gender dysphoria, and confusion about one’s sense of self can lead to pursuit of transition. The current system of care offers few, if any, opportunities to explore trauma as a potential source for dysphoria. While this is done to avoid medical gatekeeping of a population that wishes to exercise their autonomy, the failure to address it as a possibility also limits that autonomy by not providing people with options.
A choice made up of one option is not a free choice. When we don’t explore alternative explanations for dysphoria, or analyze the pattern for a person’s dysphoria, we can’t provide people with options that can be tailored to their unique circumstances. Exploring alternative explanations is the key to finding alternative paths to wellness. The orthodoxy of transgender health care services cannot be addressed without first addressing the orthodoxy of explanations that prefaces it. We can’t respect the rights of the individual to make informed decisions about their care if they aren’t provided with information on possible alternative explanations and given the opportunity to explore those. Those seeking care have the right to choose what options they wish to pursue, and failure to present those options is ultimately a denial of that right.
I believe in people’s capacity to be the catalyst for their own happiness.
One of the foundations of intentional peer support is the belief that people are capable of developing their own paths to wellness, including having the autonomy to decide what options they want to include. This is the same general belief that prompted implementation of informed consent clinics in the first place: the idea that trans people should have the right to pursue transition services without having their autonomy restricted. Yet with that right also includes the right to options so someone can make an informed decision about what path would suit them best. The one-size-fits-all approach to gender dysphoria can’t be said to apply to everyone. Sometimes happiness is found outside of traditional models of care.
This isn’t to say I believe halting or forgoing treatment, including transition, is the right path for everyone. Part of people’s capacity to be determiners of their own happiness means recognizing their right to choose the supports they feel would suit them best. If a person feels that social and/or medical transition is the path they need to take for their happiness, they should be able to pursue it, just as anyone who feels it wouldn’t be should be able to pursue a different one. I also recognize that the permanent effects of medical transition are likely a contributing factor to my being content with life. That said, said medical transition isn’t something I need to maintain long-term to stay happy. Ultimately, happiness is something I create for myself.
So if that’s the case, what do I do to create my own happiness? Most of it is centered on embracing spirituality; building meaningful connections in my community; developing a variety of supports for when I’m not well; and exercising my right to autonomy. Each of these influence and build on each other in different ways. After years of spiritual wandering, I found a community where I feel welcomed, respected, and recognized as who I am. I then fold that spirituality into the work I do with people. My work pulls from chesed, the fourth sefirot in Kaballah. Chesed can be understood as acts of loving-kindness that are actively sought, without ulterior motives, and without personal gain. In performing acts of loving-kindness, people embody the essence of the Divine and help in creating a better world for everyone.
Over time, my drive for chesed helped me build the connections in my community that I needed to thrive. I used my time, energy, and education to do volunteer work online and offline. I connected with local mental health organizations to give back to the community, as well as volunteering my services to my synagogue. Online, it primarily took the form of providing peer support and education for LGBT people and survivors of complex trauma. Now, it manifests as building community resources that don’t exist yet. This was what prompted my development of the In Our Words project. People from different groups, yet similar experiences, had been lamenting about the lack of spaces where they could connect with each other and work together for the greater good. The call went out to create that which did not yet exist.
Developing supports for when I’m not well and exercising my right to autonomy go hand-in-hand. For me to develop those supports, I had to find providers that understood my desire to be an active participant in care. This wasn’t easy, but it was critical to determining what I wanted in life and figuring out how to work toward that. One way of accomplishing that is through Wellness Recovery Action Plans (WRAP). WRAP goes beyond managing crises, as often seen in traditional crisis planning, to addressing the full spectrum of wellness. The focus becomes on recognizing what wellness looks like for each person, what is needed to maintain that, and how that person can work toward returning to wellness during difficult periods. It also means being able to have a laid-out plan for treatment, including providers or facilities to work with (or subsequently, which to avoid), what forms of treatment a person does or doesn’t consent to, and how different supporters in the plan can work together to recreate that state of wellness. By using WRAP, I not only develop a plan for maintaining supports I need to stay well, but also exercise my voice even when I struggle to express it. It was also WRAP that helped me decide that the path laid before me didn’t meet my needs. I had the option of constructing my own plan for dysphoria, using the foundations of wellness I had already developed for myself. If alternative paths weren’t being presented to me, then it was up to me to come up with them myself.
Something that people may note is that none of these reasons have to do with familial or societal pressure to stop being trans. Overall, they center around pragmatism, health risks, and opting for a more individualized path to wellness. These are reasonable, carefully thought out concerns that I’ve found among transmen and detransitioned women alike. Treating the concept as some kind of myth or rare occurrence that doesn’t warrant recognition erases the underlying concerns that impact all of us that stop transitioning, regardless of how we may identify. We have better odds if we work together than if we stand divided.