Comfortable In Their Own Skin

Feminizing Hormone Therapy Helps Many Trans Women Feel Like Themselves

By Jane Latus

Proverbially dissatisfied with their looks, cisgender women have no idea how lucky they are. For many transgender women, appearing as they envision themselves is essential to avoiding emotionally paralyzing dysphoria. And for many, especially trans women of color, looking “like a woman” may literally save their lives.

Trans women likely won’t find a fiercer advocate for their needs, or greater fan of their beauty, than Kathryn Tierney, medical director of the Transgender Medicine Program at Middlesex Health. “In our culture we do not do a very good job of celebrating the beauty of trans women. They are stunningly beautiful,” she says. “I hope in the future that trans women don’t have to look a certain way in order to be celebrated.”

Tierney is driven to ease the distress of the trans patients who come to her, and continually refueled by their life-changing – and sometimes lifesaving – successes.

“Success” in this field of medicine is helping trans patients “to feel like themselves for the first time. Or, even, to be seen by others as themselves,” says Tierney.

Success also is what Tierney’s patient Karleigh Webb, of New Britain, sees in the mirror. “What I saw in my head, I wanted to see reflected in my body,” says Webb, 49. “Now I look in the mirror and I like what I see.”

But appearing more feminine was just a start, says Webb. “The results of this process have really unlocked me as a person. I have confidence.”

Webb is one of approximately 1,200 trans patients at Middlesex Health, which offers a comprehensive range of care including primary care, hormonal therapy, behavioral health services, continence and pelvic health, gender transition surgery, physical rehabilitation, infectious disease testing and treatment, and voice therapy.

Webb sees Middlesex’s Emily Mellor, a nurse practitioner specializing in endocrinology, and primary care physician Kristen Donato. Webb also is contemplating obtaining the services of Middlesex’s nutritionist; Webb is an athlete who is continually looking to boost her health and performance.

Webb calls her providers at Middlesex an integral part of “Team Karleigh” and says she chose Middlesex because “their reputation preceded them. You have people who are well-versed in health care, but also in what trans people go through. And they listen to you. That’s one of the greatest things about them. With them, I’m more empowered to be an active participant in my own health care.”

“They Need to be Themselves”

Feminizing hormone therapy is just one component of the care Middlesex provides, but it is crucial for the women who receive it.

“The gist is that they need to be themselves,” says Tierney. Most patients receiving feminizing hormone therapy are between the ages of 18 and 30, she says, but “I’ve seen patients as young as 16 and as old as 80 begin hormones. The older you are, we’re looking at multiple complications, but sometimes gender dysphoria outweighs the other risks.”

Not all trans women want to take feminizing hormones, and some may go on and off them for personal reasons, including changing circumstances and identity fluctuations. For those who take them, feminizing hormones can reduce gender dysphoria and emotional distress, and improve social functioning, sexual satisfaction and quality of life.

As of press time in late October, at least 28 trans women had been murdered so far in 2020. According to the Human Rights Campaign (HRC), advocates have never seen such a high number at this point in the year since it began tracking this data in 2013. At least 20 transgender women were murdered in 2019.

Tierney is motivated by the determination, desperation and bravery of the trans women she sees. “A lot of my older patients have been waiting for their parents to die, or their kids to grow old, or to retire” before beginning estrogen,” she says. “It’s incredible to see the lengths they will go to protect others,” she says, before taking care of their own needs.

She also sees patients who are eager to begin hormones, but who live or work in unsafe situations. Patients’ entire circumstances – not just their medical ones – have to be factored into their care, says Tierney.

Before starting a patient on hormone therapy, says Tierney, “The most important thing to know is safety – physical and emotional. We need to know that beginning hormones is safe in the situation they’re in, and that they have the support they need.”

The next step is determining how to proceed. “We have so many different ways to approach feminization. It can be tailored to desired changes, and you can assure you aren’t causing negative side effects or medication interactions,” says Tierney.

“I always say to patients, coming in to see me is like walking into a candy store and being told you can have everything,” she says. “I engage them in a conversation about what parts of their body create the most dysphoria.” She and the patient put that list (frequently, unwanted body hair, unwanted erections, and the desire for breasts) in priority order to help determine which hormones to take.

They then decide which form the hormones (typically, estrogen and spironolactone) will take: pill, patch or injection.

Because estrogen is associated with deep vein thrombosis and pulmonary embolism, says Tierney, much of the treatment focuses on risk-reductions like smoking cessation, weight loss and increasing physical activity.

After starting feminizing hormones, “For the first year, patients come in every three months to make sure side effects aren’t happening, and we can adjust the dose if necessary,” Tierney says. From then on, they are typically seen twice a year.

“The first change for sure is an internal change,” says Tierney of patients who begin hormones. “That can’t be minimized. Most people feel like themselves for the first time. There’s an internal sense of calm.”

Physical changes usually start with softening of skin and facial and body hair, and later, development of breast tissue. “When someone genders you, they’re gendering you off your face and breasts, primarily,” says Tierney.

She loves hearing patients share their how they feel when others, especially strangers, accept them as women. “It’s that feeling that what you’ve been seeing in yourself is real. You are validated in a way you may not have felt before.”

Partly because Tierney sees so many patients starting out in unhappy and unhealthy situations, she savors seeing them thrive, and is especially delighted for patients who begin with a bang in the form of full-throttle family support. “My favorite visits are when moms come in with young adults, and the mom is just grilling me. I love to see that happen. If the kid had any other diagnosis, it’s what you would expect them to do.”

Sacrifices Worth the Rewards

“One thing I think about a lot is that trans women of color bear the brunt of this. They get the most harassment, physical violence and the most murders. And that’s just what we see. They face violence at home, and poverty, and are more unable to access care,” says Tierney

You don’t need to tell any of this to Webb, who says, “As a black trans woman, every time I walk out the door, my head is on swivel.”

When she began hormone therapy in January 2018, Webb wanted to start with a conservative approach of estrogen via a patch. “The first thing I noticed was my skin got softer.” She told her  endocrinologist  that she was ready for more aggressive treatment and was prescribed injectable estrogen and shown how to inject herself weekly.

Webb says that starting on injectable estrogen is when “the changes became a rocket ride, and people started noticing.” She continues to see welcome changes in her body.

As an athlete, Webb has learned how to cope with estrogen’s negative effects on her performance. “It’s been an adjustment. I’ve lost some muscle mass. I’ve lost some VO2 max (aerobic capacity). My mile time has gotten slower. My recovery time is slower. But at the same time, I’ve never stopped trying. I push harder.”

Before she started taking it, Webb thought that estrogen’s emotional impacts were overhyped, but now says, “I have a greater range of emotion. Crying comes easier, but laughing does, too. I smile a lot more. I am happy. Emotionally, mentally, spiritually, it’s beautiful. I’m comfortable in my own skin for the first time in my life.”

Middlesex Health recently earned its fourth “LGBTQ Healthcare Equality Leader” designation from the Human Rights Campaign Foundation. The Human Rights Campaign Foundation is the nation’s largest LGBTQ civil rights organization.

Middlesex Health offers a comprehensive Transgender Medicine Program. Its network of medical providers work with transgender persons to meet specific needs, and services are coordinated throughout the health system.

For more information about Middlesex Health services specifically designed to help LGBTQ patients, visit middlesexhealth.org/lgbtq.