The Deal With Hormones

Cate Sullivan (she/her)

Hormone replacement therapy (HRT) has been in the news lately due to a slew of bills aiming to make it more difficult for trans people to use HRT for gender-affirming care. But what is HRT, and why is it so contentious?

Estradiol, a common form of estrogen supplement.

What is HRT?
    HRT is a plan for treatment to alter a person’s hormones, typically referring to estrogen or testosterone. As it refers to trans people, it’s one form of medical transition that many trans people see as key to living a happy and fulfilling life, and its use is highly correlated with reduced risk of suicide. It has two parts: hormone blockers and hormone boosters.
    Hormone blockers are medication that prevent certain hormones (either estrogen or testosterone) from reaching their receptors. They are used to prevent the effects of the hormone, whether to prevent the development of secondary sex characteristics during puberty or as part of regular maintenance of a particular set of body attributes. They are used by trans people of all ages after starting puberty, unless other treatment has prevented them from producing the hormone intended to be blocked. Hormone blockers are also used by children experiencing precocious puberty to delay the effects of puberty until a more typical age. The effects of hormone blockers are non-permanent⁠—a person that uses blockers to prevent puberty can later go off blockers and resume puberty. This means that if someone changes their mind about their gender while on blockers, they can easily stop taking them and revert to presenting as their gender assigned at birth. On the other hand, many of the effects of puberty are permanent. While puberty causes irreversible, sometimes harmful changes, hormone blockers provide more freedom for younger people to explore their gender identity and presentation in a reversible manner if need be. 
    Hormone boosters are medication to increase the effects of a particular hormone. Though both estrogen and testosterone are present in males and females, the amounts vary greatly and account for differences in secondary sex characteristics. Hormone boosters are also used for anyone with reduced hormone levels, including cis people, whether due to menopause or absent or ineffective reproductive organs. Since sex hormones are used to regulate bone density, it is critical that the people receiving care for these reasons have access to hormone boosters, whether their need is due to natural medical causes or the alteration of reproductive organs as part of transition care.
    Together, hormone blockers and boosters form the HRT aspect of transition care. The effects of HRT take 3-5 years to finalize. Many of the effects are reversible if the hormone use is discontinued. HRT as part of gender-affirming care can cause the following changes:

Feminizing therapy:

• Breast growth*
• Fat redistribution (legs, hips, face)
• Reduced muscle mass
• Reduced body hair growth
• Softer, smoother skin
• Emotional changes
• Reduced fertility*
• Changes to sex drive
• Reduced penis and testicle size

Masculinizing therapy:

• Deeper voice*
• Fat redistribution (abdomen, face)
• Increased muscle mass
• Increased facial and body hair growth
• Thicker skin
• Emotional changes
• Reduced fertility
• Stopping of menstruation
• Changes to sex drive
• Clitoris growth*

*Permanent change

How do you get HRT?
    Getting HRT largely depends on your local laws and healthcare systems. The most popular trans healthcare guideline (WPATH) requires a psychologist’s letter of recommendation before beginning treatment under an endocrinologist’s care. Getting the letter sounds like a small step, but it’s frequently been a source of medical gatekeeping and prevented trans people from receiving care for reasons other than the best interests of the patient. Letters are frequently denied on the basis of a patient not conforming well enough to their desired gender roles. Some clinics require six months to a year spent publicly out. Another healthcare guideline (and the one I support) is the informed consent model. In this model, the patient meets with a doctor to discuss the effects of HRT, signs that they understand the effects and risks, and begins treatment without a letter. In either model, once the treatment is approved, the patient will frequently have bloodwork done to ensure their hormone levels stay on track. 
    The difficulty of obtaining HRT has led to a prominent black market in hormone medication. “Self-medding” can lead to the same positive outcomes, but increases the transition time and severely increases the risk of health complications, in addition to being outside the law.

What’s going on with anti-HRT laws?
    A person’s ability to get HRT has always been challenged by legal and medical institutions, but the past year has seen a dramatic rise in anti-HRT laws. In December 2020, the English High Court of Justice ruled that minors under 16 are too young to receive hormone blockers. So far this year, similar bills in five US states have reached the voting stage. These bills aim to prevent anything from minors under 18 receiving transition care to adults receiving transition care from public facilities, employees, or insurance. Last July, the U.S. Department of Health and Human Services ruled that anti-discrimination policies did not apply to trans people seeking healthcare, meaning that a patient could be denied treatment of any kind on the basis of being trans alone. At this point in time, none of the recent bout of US anti-trans legislation has been signed into law, but the dramatic increase in political activity on the subject demonstrates the very real power transphobia holds in this nation.

Refuting prejudice
    Below are several real arguments used by US politicians to justify this legislation in the past year, and some explanation into their flaws:
    Some argue that transition care doesn’t meaningfully improve the lives of trans people. However, many, many scientific studies have shown that transition care improves the well-being of trans people. Additionally, transition care has a dramatic positive impact on the typically-high suicide rate. It is critical to psychological health that trans people are able to access the transition care they need.
    Some argue that children can’t know what they need. However, enough of them are willing to commit suicide that we can objectively say there is a problem. On an individual basis, choosing to pursue transition care is a difficult decision to make, but that does not mean the decision should be made by politicians.
    Some argue that most trans people change their minds later on. However, this is a common myth, propagated through prejudice and poor methodology. This article delves into the details, and this study suggests that only 5% of trans people change their mind by their own accord.
    Some argue that allowing children to be trans causes permanent damage. However, hormone blockers are completely reversible; puberty is not. Many of the effects of HRT are reversible. Surgical transition care is not typically recommended until growth stops, by which point the patient is no longer a child. For prepubescent children, there is no medical aspect to transition, only social.
    Some argue that there are health risks to HRT. However, there are health risks to many other medical treatments. The risks should be understood, but the treatment should not be banned simply because risks exist.
    Some argue that trans people make up an insignificant percentage of the population. However, 0.7% is a significant population, and regardless, we don’t need large numbers to be treated fairly. Murderers represent 0.00005% of the population, and we still legislate them carefully.
    Some argue that a trans life is an undignified life and should not be supported by the government. However, being marginalized, forced to use black market medication and left with few options to engage in society positively, can be an undignified life, but the problem lies in society’s transphobia, not in the existence of trans people. Regardless, making life harder for trans people is not going to solve the problem. Conversion therapy does not work and it certainly doesn’t work through broad legislation.
    Some argue that transition care falls in the realm of activism and is not medically serious. However, Transition care is supported by the American Psychological Association, American Academy of Pediatrics & the American College of Osteopathic Pediatricians, UK National Health Service, American Psychoanalytic Association, and World Health Organization.

Conclusion
    ​With only a little background on the issue, it becomes clear that more so than any named concern, transphobia is at the heart of this bout of legislation, plain and simple. In an interview with the American Civil Liberties Union, state senator Sarah McBride asserted, “It’s not about access to care, it’s not about competitiveness in sports. What it is truly about is making life so difficult for trans young people that they never grow up to be trans adults. And that doesn’t mean they grow up to be cis adults. It means they never grow up at all.”

---