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Masculinizing Hormone Replacement Therapy Can Empower Trans Men

By Jane Latus

Even with his long eyelashes and beautiful eyes, the young man was able to pass as male in public – until he spoke. His high voice would betray him, and awkwardness or worse would follow. People who had addressed him as male would say, “I’m so sorry, ma’am,” and he’d have to reassure them. He was continually reminded that his identity – although certain to him – was questioned by others.

So, he went to Kathryn Tierney, medical director of the Transgender Medicine Program at Middlesex Health, and began masculinizing hormone therapy. “Within the first four weeks on testosterone, the voice drops, which is very important to a lot of patients,” says Tierney, MSN, APRN, FNP-BC, FAANP. “Going on testosterone, for him, was primarily to allow him to settle into his identity both internally and externally.”

For another of Tierney’s patients, 24-year-old Aidan Persaud of Vernon, taking testosterone was important mostly for their own reasons. “I don’t like the word ‘passing’ for myself, because it doesn’t apply. I don’t do this for others, but to be myself,” they say.

“Being on testosterone literally saved my life,” says Persaud, a college student studying critical psychology who identifies as non-binary. They add, though, “I hope people understand that hormone therapy isn’t a requirement to consider yourself trans. Trans simply means you identify as something other than the gender you were assigned when you were born.”

After coming out to their sisters, and experimenting with pronouns and names, Persaud reached what they call a “realization phase,” which ultimately led them to choose a name and pronouns – and Middlesex Health.

“I knew of Middlesex through a friend, and that they’re very LGBT friendly.” Persaud decided to check it out. “I drove around Middletown one day, went inside and talked to the person at the desk. They didn’t ask why I was asking these questions. I felt very respected. I felt listened to for the very first time.”

Before beginning hormone therapy, Persaud needed to obtain the requisite therapist’s go-ahead. “It was a very huge ordeal to me,” they say, because they couldn’t use their parents’ medical insurance without coming out to them. They worked for months to pay for the therapist. “I’d work 4 to 8 a.m., go to class 8 to 12, go back to work from 1 to 10, and then do it all over again, every day of the week except Tuesday.” But they finally got that piece of paper and made their first appointment with Tierney in November 2016.

Persaud left that appointment carrying a prescription for testosterone. They stopped at the pharmacy, went home and spread everything on a table. “I was just staring at it. Wow, it’s actually in front of me. I never thought I’d have this.”

The next time Persaud returned to Middlesex, for Tierney to teach them how to self-inject, they were so excited, they say, that “My palms were sweaty, my hands were shaking, I was so nervous. She comes in, she washes her hands, she puts gloves on, starts explaining – and I spaced out! She had to repeat herself, because I was so excited.

“Four years in, I feel very grateful for this opportunity and privilege, because I know there are people in other states and countries who can’t do this. I also feel very grateful to have someone like Katy. A friend sees an endocrinologist who’s just like, ‘Here are your hormones, have a nice day.’ I feel respected and heard.”

‘A Fighter and an Advocate’

Tierney has provided gender affirming hormone therapy to transgender and gender non-conforming patients from ages 16 to 80-something, although most patients are in their 20s or 30s. They come to Middlesex Health whenever that precipitating moment arrives that gives them the vocabulary to explain how they have been feeling, and the realization that they can own their identity and seek medical help to do so, if they so wish.

Middlesex Health serves approximately 1,200 trans patients. It offers a comprehensive range of care including primary care, hormone therapy, behavioral health services, continence and pelvic health, gender transition surgery, physical rehabilitation, infectious disease testing and treatment, and voice therapy.

In addition to receiving hormone therapy at Middlesex, Persaud also had chest surgery there in June 2020. Another service they appreciate is Tierney’s advocacy. “She’s a fighter and an advocate,” they say, recounting how Tierney battled with bureaucracies on their behalf. “Katy called [the pharmacy] and raised hell, for lack of a better phrase. She also fought with the insurance company because they were refusing to pay for [hormones]. She said, ‘This isn’t something you can go without. You need this to live.’ Within a week, it was rectified.”

It may take time before testosterone’s changes become apparent, but patients often benefit immediately, says Tierney. “There’s something to be said by being heard by the medical profession. It’s such a process getting to that point. It’s such a milepost in their life. Just receiving confirmation that they are who they are relieves a sense of anxiety. People come in with high blood pressure because they’re afraid they’re going to have to fight for what they need.”

Beginning on testosterone “is very much like going through a second puberty, but it’s the one they expected to have in the first place,” says Tierney. There may be unwanted acne temporarily, but otherwise the changes are usually welcome ones.

First comes the voice drop. Second comes what Tierney says is important to many patients: cessation of periods (usually within six months of starting testosterone). “Having a period can be really dysphoria-inducing,” she says.

Eventually, what happens is what Tierney calls “my favorite thing to see: they are happier. Ninety-nine percent of the time people’s depression improves and their anxiety improves.”

Also important is what doesn’t happen: the biggest myth about masculinizing hormone therapy is that it causes “’roid rage.”

“We’re not giving testosterone the way people are taking steroids,” says Tierney. “The goal is to match what people would be making on their own.”

Persaud says, “One of the first things I noticed was my eyebrows got thicker.” Then came more facial hair and a voice drop that was so gradual they didn’t notice it for months, although others did. The only downside, they say, was acne. “I got hit really hard with that. It’s starting to subside now, four years later.”

Four years into masculinizing hormone therapy, Persaud says they feel at ease, no longer guilty about disappointing their parents and ex-girlfriend for not being the person they hoped they would be. “From a physical standpoint, I feel like I could climb a mountain every day – and not beat myself down for being myself.”

Chest surgery was “like the icing on the cake,” they say. “I feel even better.”

Quality Care for All

Before beginning a patient on testosterone, Tierney conducts a mental and physical evaluation, to be sure the patient is “ready to go and that it will do no harm.” She also educates patients on the importance of exercise, adequate sleep, a good diet and, if necessary, smoking cessation. “I also educate people that they can still get pregnant if they have a uterus and ovaries.”

Testosterone is administered by weekly injections that patients can learn to do themselves. For those averse to needles, it can be applied topically. Blood tests are done every three months for the first year, and subsequently every six months, to look for uncommon side effects like polycythemia (an elevated hematocrit and hemoglobin count that can put a person at risk for deep vein thrombosis).

Some testosterone-induced changes are irreversible, including voice deepening, enlargement of the clitoris, and facial hair growth.

But should a patient decide to discontinue testosterone, reversible side effects include weight gain, acne and cessation of periods.

Some of the weight gain from hormone therapy is attributable to increased muscle mass. There are also changes in weight distribution. “Testosterone bodies tend to hold fat in their abdomen, while estrogen bodies tend to hold it in their hips and buttocks. A lot of people do list that as a positive change.”

Because many patients begin hormone therapy after their going through their first puberty, their height and facial bone structure are pretty set, so don’t change much.

If a trans man wishes to become pregnant, it typically takes 3-6 months after stopping testosterone before periods resume. Patients who make this choice are impressive to Tierney. “It requires a lot of emotional fortitude.” Consider omitting this – it’s really not up to me to be impressed or not impressed with people’s reproductive choices

“We’re seeing more trans guys deciding, after transition, to get pregnant. I’ve had three in the last two years, which is three more than in the previous 15 years. Our hospital is ready for that kind of thing, and has the background and resources to make it a positive experience.”

Middlesex Health in 2020 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.