11 months ago

3.83K

Tik Tok Watched Dylan Mulvaney Become a Woman One Day at a Time
Mulvaney's "Days of Girlhood" documented—and paid for—her transition. Hormone replacement therapy (HRT) is a treatment that supplements women with hormones that are lost during the menopausal transition. It includes an estrogen and progesterone component to mimic hormones created by the human ovary. HRT is the most effective treatment for menopause symptoms, including vasomotor symptoms like hot flashes and vaginal dryness.

This story was initially published in The Creators — a newsletter about the people powering the creator economy. Get it sent to your inbox.

During the pandemic, Dylan Mulvaney started making content on Tik Tok—videos with animals or of her singing—and her posts regularly amassed a few hundred thousand views. But it was coming out as a transgender woman to her TikTok audience in March that catapulted her followers into the millions.

Hormone therapy for transgender men aims to increase testosterone levels to the normal male physiological range (300–1000 ng/dl) by administering testosterone. Masculinizing hormone therapy helps gender nonconforming people who are designated female at birth (DFAB), including transgender men and nonbinary individuals, achieve a more traditional masculine appearance by spurring the development of secondary sex characteristics like facial hair, more muscle mass, and a deeper voice. The administration of exogenous virializing hormones is considered medically necessary for many transgender individuals. Exogenous testosterone is used in transgender men to induce virilization and suppress feminizing characteristics. In transgender women, exogenous estrogen is used to help feminize patients, and anti-androgens are used as adjuncts to help suppress masculinizing features. Starting hormone therapy in the 40s, 50s, or beyond may bring less drastic changes than starting transition at a younger age due to the accumulated lifetime exposure to testosterone and declining responsiveness to hormone effects as one approaches the age of menopause.

Mulvaney is a 25-year-old San Diego native—a professional actress and comedian—who lives in West Hollywood, California. After her initial announcement in March, she began a series she dubbed “Days of Girlhood” that cataloged each day during the early stages of her transition. She talked about why she decided against changing her name and her experience with hormone replacement therapy. She shared mostly highs, including on day 54 when she was crowned the “diamond of the season” at The Queen’s Ball: A Bridgerton Experience, a Regency era-themed show that immerses visitors into the world of Netflix’s Bridgerton.

She also shared lows, like on day 71 when an Uber driver made her feel uncomfortable while she rode in his backseat. Daily updates filled with optimism, sensitivity and humor accrued Mulvaney a following of 7.3 million and ad deals with companies such as CeraVe, MAC, Neutrogena, and Kate Spade.

Today is Mulvaney’s 183rd day of being a girl. Since her 100th day, Mulvaney has slowed posting in her “Days of Girlhood” series and continues making other content on a regular basis. Mulvaney’s virality—with some videos at more than 20 million views—is helping advance trans visibility and acceptance in a world where hate and violence against the LGBTQ community still exist. The Observer’s Rachyl Jones spoke to Mulvaney about her transition and TikTok fame.

How did you get started online?

When the pandemic hit, I was doing the Broadway musical Book of Mormon. I found myself jobless and without the creative means to do what I loved. I downloaded Tik Tok, assuming it was a kids’ app. Once I came out as a woman, I made this “day one of being a girl” comedic video. And it blew up. I really don’t know another place online like Tik Tok that can make a creator grow at the rate that it does. Some of these other apps really celebrate perfection and over-editing and flawlessness. I think with Tik Tok specifically, people love the rawness. They love people just talking to the camera. I try to approach every video like a FaceTime with a friend.

Why did you decide to have such a public transition?

Because I had never seen a trans person start from day one. I was seeing all these incredible trans women, and I was very intimidated because I wanted to be like them but didn’t know how to. I decided to [make the series] for every future trans person and current trans people that need answers. And I also try to approach everything with empathy and comedy. I think that has really set me apart from some of the other trans creators on the app, because I’m trying to show the trans joy and not just the hardships of transitioning.

Your videos went viral pretty quickly, and they’ve reached audiences outside of the LGBTQ community. Why do you think there was such an interest in these “Days of Girlhood” videos?

Because even non-trans people felt like they were a part of the conversation. They felt welcomed into the journey. My content is for everyone. It’s not just for women or trans people or queer people. I want to be the person who brings these stories to the mainstream, because there is still so far to go with mainstream trans visibility. I knew I needed to share my story. I was in a good place emotionally, and I had the skillset with my background as a performer.

How did you begin monetizing your content?

I popped off online right before Pride month so a lot of the initial deals were tailored to my queerness and to my transness. For some of these major corporations, I was actually their first trans creator. It’s exciting to make money to support myself since I lost my job, and to have my transition surgeries be covered too.

Can you tell me more about that?

I knew there was an option for me to try to publicly raise those funds through a GoFundMe campaign, but I wanted to hold that space for other trans people on the platform that don’t have the [advertising] opportunities that I have. I made a video saying, “Hey, everyone, I’m going to be doing some ads this month. Just be aware that this is happening. And if you could, you know, support that.” That’s the way I wanted people to support rather than giving me money directly. I was able to raise quite a bit of money. It helped pay for my insurance, which covers my hormones. And it just was a real gift. Because right before I started creating content with “Days of Girlhood,” I thought, “What am I going to do to afford my rent this month?”

How expensive is transitioning?

It’s always going to be expensive when it comes to trying to align to the binary. As much as I call myself a trans woman, I just want to call myself a woman. I want to be seen as a woman. I can’t really speak to transitioning to being a male, but as far as going to the feminine, women’s clothes are more expensive than men’s. Now I’ve got hair products and makeup. And these are all things that don’t define my gender, but they’ve really helped me in my euphoria. When it comes to those procedures, they can be very costly—especially if you don’t want to wait years to jump through insurance hoops, you often are paying out of pocket.

How would your transition have been different if you didn’t have your presence on social media and the money from ads?

Well, it would have taken a lot longer. And it would have been more financially and emotionally taxing. I think about all the trans people that have to wait years to save up those payments. Actually, one of my dreams in life—you know how there’s bridal showers and baby showers? I want to do trans showers for new trans people when they come out. You gift them clothes they’ve always desired and starter kits, or maybe a down payment for a surgery.

What’s next for you?

Oh my gosh, we’ve got a lot in the works. I’m thinking about pitching a talk show and writing books. I definitely am going to continue creating content, maybe not quite on a daily basis. This feels like just the beginning. It feels like I’m creating a lifelong relationship with my followers.

Cringeworthy … Privileged … Obnoxious … Maybe Not Even Truly Trans,’: Trans Views Of Dylan Mulvaney Tik Tok influencer Dylan Mulvaney has few fans of the political right. This week, everyone from Kid Rock to Caitlyn Jenner and country singer Travis Tritt made a fuss about her endorsement deals with Nike and Bud Light.

It’s no surprise that those three celebs are going on a rampage against corporate wake ups. What is notable about Mulvaney is how she not only irritates conservatives, but also harasses many members of her own transgender community.

The trans forums on Reddit.com are abuzz with chatter about the 28-year-old, often focusing on whether she’s really trans, whether she’s a money-making scammer, and whether she’s a good face for the movement.

The comments, posted under anonymous usernames, vary. To some, Mulvaney is just not my cup of tea. To others, she’s a “little cringe,” “annoying,” “privileged,” and even “obnoxious.”

“Nobody I know can put up with her,” one user posted on the “ask transgender thread, a forum of some 264,000 members — representing one-sixth of the estimated 1.6 million trans Americans.

Mulvaney makes it clear in her Tik Tok skits that she is a true trans person, using female hormones to ease her unusual transition from male to girl.

Mulvaney currently has 10.8 million Tik Tok followers – which is impressive, but still not in the top 10 on the platform

“Dorky, campy theater kid,” another posted, referring to Mulvaney’s background as a performer. One user, even more agitated, wrote that “her vibes are insanely unpleasant.”

“I blocked her and found her content cringing,” said another user, who compared Mulvaney’s skits to the television comedy Schitt’s Creek, which brought innocent gay characters into millions of homes.

Mulvaney’s hit series, Days of Girlhood, was “LGBT content for straight people,” they added.

Mulvaney, of course, also has millions of adoring fans. One commenter called her a “nice and genuine person,” albeit one whose energetic, high-pitched clips drain viewers’ energy.

“Maybe she could drink less coffee,” they added.

Like Mulvaney’s conservative celebrity critics, the trans bloggers also focused on the money she makes promoting sports brands, credit cards, clothing and cosmetics to her 10.8 million Tik Tok followers.

Industry insiders say Mulvaney earns a whopping $75,000 every time she pushes a product, bringing in more than $1 million a year. Her Los Angeles-based Creative Artists Agency did not respond to our requests for comment.

This puts her in a different league from mainstream trans Americans, who often struggle to afford the sex reassignment hormones and surgeries that Mulvaney had access to at the start of her wayward transition from male to girl.

“She’s had a lot of privilege going through the transition,” posted one user, noting that Mulvaney went through tens of thousands of dollars in December with her facial feminization surgery, which took less than a year into her gender journey.

“She seems very privileged though…and paints a picture of being trans, which is very ‘easy,'” another posted.

“This makes it easy for cis people to enjoy her content, but can come across as a bit out-of-touch at times.”

This leads to the burning question at the heart of the debates about Mulvaney: whether she really is a trans person.

Assil Dayri, a social media expert and founder of AMD Consulting Group, said Mulvaney was turning into a “public figure rather than a content creator.”

The comments, posted under anonymous usernames, vary. To some, Mulvaney is just not my cup of tea. To others, she’s a “little cringe,” “annoying,” “privileged,” and even “obnoxious”

Orange Is the New Black’s trans star Laverne Cox appeared in one of Mulvaney’s Tik Tok skits — an awkward appearance where she advises the Tik Toker that “not everything can be for the public”

Although Mulvaney, a biological male, wears girly outfits, uses female hormones, and underwent painful cosmetic surgery on her face, many compare her more to a drag queen, a pantomime artist, or even a con artist.

Chloe Cole, a prominent de-transitioner, stated that Mulvaney was not a “real trans kid.” Laverne Cox, the trans woman star of Orange Is the New Black, recently told Mulvaney that she was “insane” for exposing so much of her life on camera.

On the forums, users are wondering if she’s authentic or engaged in “some kind of act or joke,” one member posted. Others wonder if she’s a “troll,” who wants to “own” liberals and conservatives alike.

Still, most of the members confirm Mulvaney’s female identity. The trans movement is based on the principle that people decide their own gender identity, and anyone who questions that is rude.

“Whether I like her or not, if she says she’s trans, she’s trans,” one user wrote.

Another said it “feels odd that this question is being asked so often.”

Mulvaney, who was left unemployed when the musical she starred in, The Book of Mormon, closed during the Covid-19 pandemic. She launched her Tik Tok series last year to document her transition from man to “girl.”

It was always controversial, but it turned out to be a surprise hit. It earned Mulvaney promotional appearances with dozens of brands, millions of followers, famous friends, and even a performance with President Joe Biden at the White House last year.

Mulvaney recently sparked controversy again, after Bud Light, a popular but watery beer, sent the Tik Toker a caseload to celebrate the first anniversary of her transition from man to girl Visibly offended by the beer company’s ties to the trans Tik Toker, Kid Rock, a conservative singer-songwriter, posted a video of him firing a gun at crates of the low-calorie drink

She has many detractors, from conservatives, who worry she’s foisting radical gender ideology on impressionable young Tik Tok viewers, to old-fashioned feminists, who resent her strident approach to femininity.

In recent days, Kid Rock, a conservative singer-songwriter, posted a video of him firing into crates of Bud Light after Mulvaney promoted the beer. Jenner, a former athlete, has criticized Nike for a similar “awake” sponsorship deal with the Tik Toker.

Reddit’s transgender forums also addressed the anti-Mulvaney backlash.

A user on the forum, who calls herself a “cis woman,” slammed Mulvaney for the “incredibly sexist views she has on femininity.”

Another wondered why the people on the right were so irked by her antics.

“The conservative moral panic and affectation about its existence is super bizarre,” they posted.

“Some cis people go crazy over her for no reason.”

DailyMail.com was unable to verify the identities, gender or otherwise, of those posting to Reddit.com, though the comments still show the variety of opinions about Mulvaney on a trans-friendly platform. Mulvaney’s latest endorsement to anger conservatives is with the sportswear brand Nike. Critics say her endorsement deal should have gone to an athlete, and one born female Mulvaney holds up footage of her quirky transition from man to girl at her one-year anniversary party at New York City’s Rainbow Room this month “I felt like I had been stung by 1,000 bees.” One of Mulvaney’s rawest moments of the past year was her “feminizing facial surgery” in December, which left her with “insane swelling.”

Masculinizing hormone therapy Masculinizing hormone therapy typically is used by transgender men and nonbinary people to produce physical changes in the body that are caused by male hormones during puberty. Those changes are called secondary sex characteristics. This hormone therapy helps better align the body with a person's gender identity. Masculinizing hormone therapy also is called gender-affirming hormone therapy.

Masculinizing hormone therapy involves taking the male hormone testosterone. It stops menstrual cycles and decreases the ovaries' ability to make estrogen. Masculinizing hormone therapy can be done alone or along with masculinizing surgery.

Not everybody chooses to have masculinizing hormone therapy. It can affect fertility and sexual function, and it might lead to health problems. Talk with your health care provider about the risks and benefits for you.

Why it's done
Masculinizing hormone therapy is used to change the body's hormone levels. Those hormone changes trigger physical changes that help better align the body with a person's gender identity.

In some cases, people seeking masculinizing hormone therapy experience discomfort or distress because their gender identity differs from their sex assigned at birth or from their sex-related physical characteristics. This condition is called gender dysphoria.

Masculinizing hormone therapy can:

Improve psychological and social well-being
Ease psychological and emotional distress related to gender
Improve satisfaction with sex
Improve quality of life
Your health care provider might advise against masculinizing hormone therapy if you:

Are pregnant
Have a hormone-sensitive cancer, such as breast cancer
Have problems with blood clots, such as when a blood clot forms in a deep vein, a condition called deep vein thrombosis, or a there's a blockage in one of the pulmonary arteries of the lungs, called a pulmonary embolism
Have significant medical conditions that haven't been addressed
Have behavioral health conditions that haven't been addressed
Have a condition that limits your ability to give your informed consent

Risks
Research has found that masculinizing hormone therapy can be safe and effective when delivered by a health care provider with expertise in transgender care. Talk to your health care provider about questions or concerns you have regarding the changes that will happen in your body as a result of masculinizing hormone therapy.

Complications can include:

Weight gain
Acne
Developing male-pattern baldness
Sleep apnea
A rise in cholesterol, which may increase the risk of heart problems
High blood pressure
Making too many red blood cells — a condition called polycythemia
Type 2 diabetes
Blood clots in a deep vein or in the lungs
Infertility
Drying and thinning of the lining of the vagina
Pelvic pain
Discomfort in the clitoris
Evidence suggests that people who have masculinizing hormone therapy don't have an increased risk of breast cancer, endometrial cancer or heart disease when compared to cisgender women — women whose gender identity aligns with societal norms related to their sex assigned at birth.

It's unclear whether masculinizing hormone therapy raises the risk of ovarian and uterine cancer. Further research is needed.

To minimize risk, the goal for people taking masculinizing hormone therapy is to keep hormone levels in the range that's typical for cisgender men.

Fertility
Masculinizing hormone therapy might limit your fertility. If possible, it's best to make decisions about fertility before starting treatment. The risk of permanent infertility increases with long-term use of hormones. That is particularly true for those who start hormone therapy before puberty begins. Even after stopping hormone therapy, your ovaries and uterus might not recover enough for you to become pregnant without infertility treatment.

If you want to have biological children, talk to your health care provider about your choices. They may include:

Egg freezing. This procedure also is called mature oocyte cryopreservation. Egg freezing has multiple steps that involve triggering ovulation, retrieving the eggs and then freezing them.
Embryo freezing. This process also is known as embryo cryopreservation. If you want to freeze embryos, you'll need to have the eggs fertilized before they are frozen.
Ovarian tissue cryopreservation. With this procedure, ovarian tissue is removed, frozen, and later thawed and reimplanted.
Although testosterone might limit your fertility, you still can become pregnant if you have your uterus and ovaries and you have sex with a person who produces sperm. If you want to avoid pregnancy, use birth control consistently. Talk with your health care provider about the form of birth control that's best for your situation.

How you prepare
Before you start masculinizing hormone therapy, your health care provider assesses your health. This helps address any medical conditions that might affect your treatment. The evaluation may include:

A review of your personal and family medical history
A physical exam
Lab tests
A review of your vaccinations
Screening tests for some conditions and diseases
Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
Discussion about birth control, fertility and sexual function
You also might have a behavioral health evaluation by a provider with expertise in transgender health. The evaluation may assess:

Gender identity
Gender dysphoria
Mental health concerns
Sexual health concerns
The impact of gender identity at work, at school, at home and in social settings
Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
Support from family, friends and caregivers
Your goals and expectations of treatment
Care planning and follow-up care
People younger than age 18, along with a parent or guardian, should see a medical care provider and a behavioral health provider with expertise in pediatric transgender health to discuss the risks and benefits of hormone therapy and gender transitioning in that age group.

What you can expect
You should start masculinizing hormone therapy only after you've had a discussion of the risks and benefits as well as treatment alternatives with a health care provider who has expertise in transgender care. Make sure you understand what will happen and get answers to any questions you may have before you begin hormone therapy.

Masculinizing hormone therapy typically begins by taking testosterone. A low dose of testosterone is prescribed, and then the dose is slowly increased over time. Testosterone usually is given through a shot, also called an injection, or through a gel or patch applied to the skin. Other forms of testosterone that may be appropriate for some people include testosterone pellets placed under the skin, a prolonged action injection and an oral capsule taken twice a day.

The testosterone that's used for masculinizing hormone therapy is identical to the hormone that the testicles and ovaries make naturally. Don't use synthetic androgens, such as oral methyl testosterone or anabolic steroids. They can harm your liver and cannot be accurately monitored.

After you begin masculinizing hormone therapy, you'll notice the following changes in your body over time:

Menstruation stops. This will occur within 2 to 6 months of starting treatment.
Voice deepens. This will begin 3 to 12 months after you start treatment. You'll see the full effect within 1 to 2 years.
Facial and body hair grows. This will begin 3 to 6 months after treatment starts. The full effect will happen within 3 to 5 years.
Body fat is redistributed. This will begin within 3 to 6 months. You'll see the full effect within 2 to 5 years.
Clitoris become larger, and the vaginal lining thins and become drier. This will begin 3 to 12 months after treatment starts. The full effect will happen in about 1 to 2 years.
Muscle mass and strength increases. This will begin within 6 to 12 months. You'll see the full effect within 2 to 5 years.
If menstrual bleeding doesn't stop after you've taken testosterone for several months, your health care provider might recommend that you take medicine to stop it.

Some of the physical changes caused by masculinizing hormone therapy can be reversed if you stop taking testosterone. Others, such as a deeper voice, a larger clitoris, scalp hair loss, and increased body and facial hair, cannot be reversed.

Results
While on masculinizing hormone therapy, you meet regularly with your health care provider to:

Keep track of your physical changes.
Monitor your hormone levels. Over time, your dose of testosterone may need to change to ensure you are taking the lowest dose necessary to get the physical effects that you want.
Have lab tests to check for changes in your cholesterol, blood sugar, blood count, liver enzymes and electrolytes that could be caused by hormone therapy.
Monitor your behavioral health.
You also need routine preventive care. Depending on your situation, this may include:

Breast cancer screening. This should be done according to breast cancer screening recommendations for cisgender women your age.
Cervical cancer screening. This should be done according to cervical cancer screening recommendations for cisgender women your age. Be aware that masculinizing hormone therapy can cause your cervical tissues to thin. That can look like a condition called cervical dysplasia in which unusual cells are found on the surface of the cervix. If you have questions or concerns about this, talk to your health care provider.
Monitoring bone health. You should have bone density assessment according to the recommendations for cisgender men your age. You may need to take calcium and vitamin D supplements for bone health.

Information on Estrogen Hormone Therapy Overview of Feminizing Hormone Therapy Hi, I'm Dr. Maddie Deutsch, Associate Professor of Clinical Family & Community Medicine at the University of California – San Francisco (UCSF), and Medical Director for UCSF Transgender Care. In this document I will review various aspects of feminizing hormone therapy, including, choices, risks, and unknowns associated with feminizing hormone therapy.

As you prepare to begin treatment, now is a great time to think through what your goals are. Do you want to get started right away on a path to the maximum degree of medically appropriate feminizing effects? Or, do you want to begin at a lower dose and allow things to progress more slowly? Perhaps you are seeking less-than-maximal effects and would like to remain on a low dose for the long term. Thinking about your goals will help you communicate more effectively with your medical provider as you work together to map out your care plan.

Many people are eager for hormonal changes to take place rapidly – which is totally understandable. It is important to remember that the extent of, and rate at which your changes take place, depend on many factors. These factors primarily include your genetics and the age at which you start taking hormones.

Consider the effects of hormone therapy as a second puberty, and puberty normally takes years for the full effects to be seen. Taking higher doses of hormones will not necessarily bring about faster changes, but it could endanger your health. And because everyone is different, your medicines or dosages may vary widely from those of your friends, or what you may have seen on YouTube, or read in books or in online forums. Use caution when reading about hormone regimens that promise specific, rapid, or drastic effects. While it is possible to make adjustments in medications and dosing to achieve certain specific goals, in large part the way your body changes in response to hormones is more dependent on genetics and the age at which you start, rather than the specific dose, route, frequency, or types of medications you are taking.

While I will speak about the approach to hormone therapy in transgender women, my comments are also applicable to and inclusive of non-binary people who were assigned male at birth and considering femininizing hormone therapy.

There are four areas where you can expect changes to occur as your hormone therapy progresses. Physical, emotional, sexual, and reproductive.

The first is physical.
The first changes you will probably notice are that your skin will become a bit drier and thinner. Your pores will become smaller and there will be less oil production. You may become more prone to bruising or cuts and in the first few weeks you’ll notice that the odors of your sweat and urine will change. It’s also likely that you’ll sweat less. When you touch things, they may “feel different” and you may perceive pain and temperature differently.

Probably within a few weeks you’ll begin to develop small “buds” beneath your nipples. These may be slightly painful, especially to the touch and the right and left side may be uneven. This is the normal course of breast development and whatever pain you experience will diminish significantly over the course of several months.

It’s important to note that breast development varies from person to person. Not everyone develops at the same rate and most transgender women who begin hormone therapy after puberty, even after many years of treatment, can only expect to develop an “A” cup or perhaps a small “B” cup. As with all other women, the breasts of transgender women vary in size and shape and will sometimes be uneven with each other. It is usually a good idea to wait until you have been on hormones for at least a year before pursuing breast augmentation surgery.

Your body will begin to redistribute your weight. Fat will collect around your hips and thighs and the muscles in your arms and legs will become less defined and have a smoother appearance as the fat just below your skin becomes a bit thicker. Hormones may not have a significant effect on the fat in your abdomen, also known as your “gut”. You can also expect your muscle mass and strength to decrease. To maintain muscle tone, and for your general health, I recommend you exercise. Overall, you may gain or lose weight once you begin hormone therapy, depending on your diet, lifestyle, genetics and muscle mass.

Your eyes and face will begin to develop a more feminine appearance as the fat under the skin increases and shifts. Because it can take two or more years for these changes to fully develop, it is a good idea to delay a decision on seeking facial feminization surgery until you have been on hormone therapy for at least 1 year. What won’t change is your bone structure, including the bones of your face as well as your hips, arms, hands, legs and feet.

The hair on your body, including your chest, back and arms, will decrease in thickness and grow at a slower rate. But it may not go away all together, and some may choose to pursue electrolysis or laser treatment. Remember that all cisgender women also have some body hair. Your facial hair may thin a bit and grow slower but it will rarely go away entirely without electrolysis or laser treatments. If you have had any scalp balding, hormone therapy will usually stop it, however the extent to which it will grow back is variable.

Some people may notice minor changes in shoe size or height. This is not due to bony changes, but due to changes in the ligaments and muscles of your feet and spinal column.

Feminizing hormone therapy does not have any effect on voice pitch or character. For those of you seeking to modify your speaking voice, I recommend you consult with a speech and language specialist who has expertise in this area.

Emotional state changes
The second area of impact of hormone therapy is on your emotional state

Your overall emotional state may or may not change, this varies from person to person. Puberty is a roller coaster of emotions, and the second puberty that you will experience during your transition is no exception. You may find that you have access to a wider range of emotions or feelings, or have different interests, tastes or pastimes, or behave differently in relationships with other people. For most people, things usually settle down after a period time. I encourage you to take the time to learn new things about yourself, and sit with new or unfamiliar feelings and emotions while you explore and familiarize yourself with them. While psychotherapy is not for everyone, many people find that working with a therapist while in transition can help you to explore these new thoughts and feelings, get to know your new body and self, and help you with things like coming out to family, friends, or coworkers, and developing a greater level of self-love and acceptance.

Sexual changes
The third area of impact of hormone therapy is sexual in nature.

Soon after beginning hormone treatment, you will notice a decrease in the number of erections you have; and when you do have one, you may lose the ability to penetrate, because it won’t be as firm or last as long. You will, however, still have erotic sensations and be able to orgasm. For those who are concerned about reduced erections, medications such as slidenafil (Viagra) may be helpful.

You may find that you get erotic pleasure from different sex acts and different parts of your body. Your orgasms may feel like more of a “whole body” experience and last longer, but with less peak intensity. You may experience ejaculation of a small amount of clear or white fluid, or perhaps no fluid. Don’t be afraid to explore and experiment with your new sexuality through masturbation and with sex toys such dildos and vibrators. Involve your sexual partner if you have one.

Though your testicles will shrink to less than half their original size, most experts agree that the amount of scrotal skin available for future genital surgery won’t be affected.

Reproductive system changes
The fourth area of impact of hormone therapy is on the reproductive system.

The impact of feminizing hormone therapy on fertility is unclear. While some data suggest that stopping hormones for 3-6 months can allow sperm counts to return, it is best to assume that within a few months of starting hormone therapy you could permanently and irreversibly lose the ability to create sperm. Some people may maintain a sperm count on hormone therapy, or have their sperm count return after stopping hormone therapy, but it is best to assume that won’t be the case for you.

If there is any chance you may want to parent a child from your own sperm, speak with your medical provider about preserving your sperm in a sperm bank. This process generally takes 2-4 weeks and costs roughly $2000-$3000. It is best to store your sperm before beginning treatment, to avoid any risk of reduced sperm count due to hormone therapy that could impact your ability to conceive a child. Storing sperm in advance also avoids the stress of having to stop hormones at a later time to allow testosterone levels and sperm counts to come up; often this involves a return of some masculine characteristics during the time off of hormones.

On the flip side, because feminizing hormone therapy does not always lower sperm count , If you are sexually active with someone who is able to become pregnant, you should always continue to use a birth control method to prevent unwanted pregnancy.

Risks
The risk of things like blood clots, heart attacks, strokes, diabetes, and cancer as a result of hormone therapy are minimal, but may be elevated, especially for those with co-existing health conditions or starting hormone therapy after age 50. Generally, the size of any increase in risk for those in good health is small, and may be offset by improvements in quality of life and reductions in stress levels once they taking hormone therapy has begun. The biggest increase in risk when taking estrogen is when it is combined with cigarette smoking. In this case there is an increased risk of blood clots, and probably strokes and heart attacks. For those with an elevated risk of these conditions, or over the age of 50, forms of estrogen that are delivered through the skin, such as a patch, are generally the safest option.

There is not much scientific evidence regarding the risks of cancer in transgender women. We believe the risk of prostate cancer will go down, but we can’t be sure. The risk of breast cancer may increase slightly, but will still be at less of a risk than a non-transgender female. Since there is not a lot of research on the use of estrogen for feminizing treatment, there may be other unknown risks, especially for those who have used estrogen for many years.

In particular for those trans women over the age of 50, it might be appropriate to use testosterone blockers only, or with a lower dose of estrogen. Since most non-transgender women go through menopause with declining estrogen levels at age 50, this approach is similar to the natural female life course, and may be of particular value in those with other health risks.

If your testicles are removed through an orchiectomy or vaginoplasty, you will be able to stop taking testosterone blockers, and may be able to take a lower dose of hormones, but should remain on at least a minimal dose hormones until a minimum age of 50. This will help prevent a potentially severe weakening of the bones, otherwise known as osteoporosis, which can result in serious and disabling bone fractures.

While gender affirming hormone therapy usually results in an improvement in mood, some people may experience mood swings or a worsening of anxiety, depression, or other mental health conditions as a result of the shifts associated with starting a second puberty. If you have any mental health conditions it is recommended you remain in discussion with a mental health providers as you begin hormone therapy.

Other medical conditions may be impacted by gender affirming hormone therapy, though research is lacking. These include autoimmune conditions, which can sometimes improve or worsen with hormone shifts, and migraines, which often have a hormonal component. Ask your medical provider if you have further questions about the risks, health monitoring needs, and other long term considerations when taking hormone therapy.

Modern, healthy approaches to estrogen therapy have no risk of causing liver injury. However, in some cases, the flow of bile from the liver through the gallbladder may be slowed which can lead to an increased risk of gallstones. The degree of this increased risk is small.

Many of the effects of hormone therapy are reversible, if you stop taking them. The degree to which they can be reversed depends on how long you have been taking them. Some breast growth, and possibly reduced or absent fertility are not reversible.

Treatments
Feminizing hormone therapy may include three different kinds of medicines: Estrogen, testosterone blockers, and progesterones.

Estrogen
Estrogen is the primary “female” hormone. It is involved in many of the physical and emotional changes seen in transition. Estrogen may be given as a pill, by injection, or by a number of skin preparations such as a gel, spray or a patch.

Pills are convenient, cheap and effective, but are less safe if you smoke or are older than 35. Patches can be very effective and safe, but they need to be worn at all times. In a small number of cases they can cause some skin irritation.

Many trans women are interested in estrogen through injection. Estrogen injections tend to cause very high and fluctuating estrogen levels which can cause mood swings, weight gain, hot flashes, anxiety or migraines. Additionally, little is known about the effects of these high levels over the long term. If injections are used, it should be at a low dose and with an understanding that there may be uncomfortable side effects, and that switching off of injections to other forms may cause mood swings or hot flashes. Some trans women have encountered difficulties obtaining a consistent supply of injected estrogen due to ongoing problems with the supplier. Realistically, there is no evidence that injections lead to more rapid or a greater degree of feminization. In my practice, I generally avoid prescribing injections unless under very specific circumstances.

Contrary to what many may have heard, you can achieve the maximum effect of your transition with doses of estrogen that result in your blood levels being similar to those of a pre-menopausal, cisgender woman. Taking high doses does not necessarily make changes happen quicker. It could, however, endanger your health. You may encounter claims of complicated and at times questionable dosing regimens, or intensive monitoring of various blood tests, that make promises of drastic, almost magical effects. High doses of estrogens or other complicated hormonal regimens are not given to cisgender women who are seeking more exaggerated feminine features. In reality, beyond getting your hormone levels into the somewhat wide range of levels seen in pre-menopausal non-transgender women, there is no evidence at this time to support higher doses or complex regimens over straightforward and appropriate dosing schemes, as recommended by the Endocrine Society and our own UCSF Transgender Care Guidelines. The bottom line is that the primary predictor of feminizing effects is likely the lack of testosterone rather than levels of estrogen. Blood tests for estradiol, the most important estrogen in the body, and testosterone will be performed periodically to insure your treatment is aligned with your goals.

Testosterone blockers
Testosterone blockers are also known as anti-androgens. Androgens are the class of hormones that cause male or masculine features. There are a number of medicines that can block testosterone.

Spironolactone is the most commonly used anti-androgen in feminizing hormone therapy. Spironolactone works by both blocking the production of and action of testosterone. Spironolactone can cause you to urinate excessively and feel dizzy or lightheaded, especially when you first start taking it. It’s important to remain well hydrated when taking this medication. Potassium levels should be monitored while taking this medication, though elevated potassium levels with spironolactone is very rare and usually only in people with kidney disease or taking certain kinds of blood pressure medication. For people with no history of kidney disease or high potassium levels, there is no need to reduce the amount of potassium in your diet when taking spironolactone. Contrary to what you may read in chat groups or hear from others, spironolactone is a widely used, safe medication that is well tolerated by most. If spironolactone is not tolerable to you, it can be stopped and all of the side effects will resolve; none are permanent. Your medical provider will monitor your blood testosterone level while taking spironolactone to help guide dosing and meet your goals. Spironolactone is taken as a pill, usually twice per day.

A family of medications known as gonadotropin-releasing hormone (GnRH) analogs, such as leuprolide, brand name Lupron, may be used in cases where spironolactone is not appropriate or well tolerated. These medications work at your pituitary gland, and cause it to shut down the signals being sent to your testicles that tell them to make testosterone. These medications are very effective and well tolerated, but can be expensive, and not all insurance plans cover their use. In addition to monitoring your blood testosterone levels while taking this medication, your provider will monitor other tests to insure this medication is being dosed appropriately. In adults, GnRH analogs are most commonly injected, and sometimes taken as a nasal spray. Depending on insurance requirements, in-office injections by a nurse may be necessary.

Bicalutamide is an anti-androgen that some transgender and non-binary people ask about. This medication is typically used in the treatment of prostate cancer. This medication blocks the action of testosterone in cells, but does not block the production of testosterone. Because of this, testosterone levels in the body remain high, and measuring blood testosterone level is not useful for tailoring treatment. This makes it difficult to monitor whether this medication is being optimally dosed. Because bicalutamide has a risk of liver injury and because spironolactone and GnRH analogs like leuprolide are so safe and effective, bicalutamide is not recommended for use as part of a feminizing hormone regimen.

Finasteride and dutasteride are medicines which prevent the production of dihydrotestosterone, a specific form of testosterone that has action on the skin, hair, and prostate. These medicines are weaker testosterone blockers than spironolactone but have few side effects, and may be useful for those who can not tolerate spironolactone and are unable to use GnRH analogs. It is unclear if there is any added benefit to taking one of these medicines once your testosterone levels have been reduced into the female range through the use of other blockers.

Progesterone
Progesterone is a hormone present in cisgender women that is involved in maintaining balance in the uterine lining and supporting pregnancy. Though it’s commonly believed to have a number of benefits, including: improved mood and libido, enhanced energy, and better breast development and body fat redistribution, there is very little scientific evidence to support these claims. Nevertheless, some say they experience some or all of these benefits from progesterone. Progesterone may also be useful as a partial blocker of testosterone production in cases where other blockers can not be used or have not been effective. Progesterone should be used with caution as it can cause mood symptoms such as anxiety, depression, or irritability, and can cause weight gain. Progesterone can have a negative impact on blood cholesterol, though this is usually of minimal significance unless there is a pre-existing and poorly controlled cholesterol or cardiac condition. Progesterone is usually taken as a pill. Generally, progesterone would be added to a regimen after hormone levels have been stabilized after the initial startup period on estrogen and testosterone.

Final thoughts
Please remember that all of the changes associated with the puberty you’re about to experience can take years to develop. Starting hormone therapy in your 40s, 50s, or beyond may bring less drastic changes than one might see when beginning transition at a younger age, due to the accumulated lifetime exposure to testosterone, and declining responsiveness to hormone effects as one approaches the age of menopause. Taking higher doses won’t result in faster or more dramatic changes, however they can result in more side effects or complications.

Now that you have learned about the effects of feminizing hormone therapy, medication options, and risks, the next step will be to speak with your provider about what approach is best for you. I am so happy you’ve chosen to trust UCSF Transgender Care with providing for your health and gender transition. Please visit transcare.ucsf.edu for more information about our program and services. I wish you all the best as you begin this exciting new life phase of self-realization. Thank you for reading and for taking care of your health.

Understanding the Transgender Community Transgender people come from all walks of life, and HRC Foundation has estimated that there are more than 2 million of us across the United States. We are parents, siblings, and kids. We are your coworkers, your neighbors, and your friends. We are 7-year-old children and 70-year-old grandparents. We are a diverse community, representing all racial and ethnic backgrounds, as well as all faith traditions.

The word “transgender” – or trans – is an umbrella term for people whose gender identity is different from the sex assigned to us at birth. Although the word “transgender” and our modern definition of it only came into use in the late 20th century, people who would fit under this definition have existed in every culture throughout recorded history.

Alongside the increased visibility of trans celebrities like Laverne Cox, Jazz Jennings or the stars of the hit Netflix series “Pose,” three out of every ten adults in the U.S. personally knows someone who is trans. As trans people become more visible, we aim to increase understanding of our community among our friends, families, and society.

What does it mean to be trans?

The trans community is incredibly diverse. Some trans people identify as trans men or trans women, while others may describe themselves as non-binary, genderqueer, gender non-conforming, agender, bigender or other identities that reflect their personal experience. Some of us take hormones or have surgery as part of our transition, while others may change our pronouns or appearance. Roughly three-quarters of trans youth that responded to an HRC Foundation and University of Connecticut survey identified with terms other than strictly “boy” or “girl.” This suggests that a larger portion of this generation’s youth are identifying somewhere on the broad trans spectrum.

What challenges do trans people face?

While trans people are increasingly visible in both popular culture and in daily life, we still face severe discrimination, stigma and systemic inequality. Some of the specific issues facing the trans community are:

Lack of legal protection– Trans people face a legal system that often does not protect us from discrimination based on our gender identity. Despite a recent U.S. Supreme Court Decision that makes it clear that trans people are legally protected from discrimination in the workplace, there is still no comprehensive federal non-discrimination law that includes gender identity - which means trans people may still lack recourse if we face discrimination when we’re seeking housing or dining in a restaurant. Moreover, state legislatures across the country are debating – and in some cases passing – legislation specifically designed to prohibit trans people from accessing public bathrooms that correspond with our gender identity, or creating exemptions based on religious beliefs that would allow discrimination against LGBTQ people.
Poverty– Trans people live in poverty at elevated rates, and for trans people of color, these rates are even higher. Around 29% of trans adults live in poverty, as well 39% of Black trans adults, 48% of Latinx trans adults and 35% of Alaska Native, Asian, Native Americans and Native Hawaiian or Pacific Islander trans adults.
Stigma, Harassment and Discrimination – About half a decade ago, only one-quarter of people in the United States supported trans rights, and support increased to 62% by the year 2019. Despite this progress, the trans community still faces considerable stigma due to more than a century of being characterized as mentally ill, socially deviant and sexually predatory. While these intolerant views have faded in recent years for lesbians and gay men, trans people are often still ridiculed by a society that does not understand us. This stigma plays out in a variety of contexts – from lawmakers who leverage anti-trans stigma to score cheap political points; to family, friends or coworkers who reject trans people upon learning about our trans identities; and to people who harass, bully and commit serious violence against trans people. This includes stigma that prevents them from accessing necessary services for their survival and well-being. Only 30% of women’s shelters are willing to house trans women. While recent legal progress has been made, 27% of trans people have been fired, not hired or denied a promotion due to their trans identity. Too often, harassment has led trans people to avoid exercising their most basic rights to vote. HRC Foundation’s research shows that 49% of trans adults, and 55% of trans adults of color said they were unable to vote in at least one election in their life because of fear of or experiencing discrimination at the polls.
Violence Against Trans People– Trans people experience violence at rates far greater than the average person. Over a majority (54%) of trans people have experienced some form of intimate partner violence, 47% have been sexually assaulted in their lifetime and nearly one in ten were physically assaulted in between 2014 and 2015. This type of violence can be fatal. At least 27 trans and gender non-conforming people have been violently killed in 2020 thus far, the same number of fatalities observed in 2019.
Lack of Healthcare Coverage– An HRC Foundation analysis found that 22% of trans people and 32% of trans people of color have no health insurance coverage. More than one-quarter (29%) of trans adults have been refused health care by a doctor or provider because of their gender identity. This sobering data reveals a healthcare system that fails to meet the needs of the trans community.
Identity Documents – The widespread lack of accurate identity documents among trans people can have an impact on every aspect of their lives, including access to emergency housing or other public services. Without identification, one cannot travel, register for school or access many services that are essential to function in society. Many states do not allow trans people to update their identification documents to match their gender identity. Others require evidence of medical transition – which can be prohibitively expensive and is not something that all trans people want – as well as fees for processing new identity documents, which may make them unaffordable for some members of the trans community.
While advocates continue working to remedy these disparities, change cannot come too soon for trans people. Visibility – especially positive images of trans people in the media and society – continues to make a critical difference for us; but visibility is not enough and can come with real risks to our safety, especially for those of us who are part of other marginalized communities. That is why the Human Rights Campaign is committed to continuing to support and advocate for the trans community, so that the trans Americans who are and will become your friends, neighbors, coworkers and family members have an equal chance to succeed and thrive.

Loading 20 comments...