Masculinizing hormone therapy
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Masculinizing hormone therapy, also called masculinizing hormone replacement therapy, androgen hormone therapy, transgender hormone therapy of the masculinizing type, transmasculine hormone therapy, or female-to-male (FTM) hormone therapy, is a form of hormone therapy or hormone replacement therapy (HRT). Masculinizing hormone therapy means taking certain kinds of medicine to make a person physically look, sound, and even smell masculine, so that one is generally seen as a man by most people.
Some nonbinary people who were assigned female at birth go on this hormone therapy as part of their transition, and this article focuses on that. Such nonbinary people are said to be on the female-to-male transition spectrum, and that they are trans-masculine. Masculinizing hormone therapy is also a common part of transition for transgender men, who experience it in much the same way as trans-masculine nonbinary people. The category of "trans-masculine" also includes trans men, and is the term used throughout most of this article for the people who take this therapy, except when referring to a specific group.[1] One shortcoming of using this term for this article is that not all people who go on masculinizing HRT consider themselves masculine, but the HRT itself is masculinizing.
Some other kinds of people who do not necessarily consider themselves trans-masculine may go on masculinizing hormone therapy, such as some intersex people, and people who were assigned male at birth who have had their testicles removed (which can be due to illness, injury, or gender dysphoria). Members of these two groups may or may not consider themselves transgender. For this reason, this article usually uses the language "masculinizing HRT" rather than terms that could exclude these groups.
The World Professional Association for Transgender Health (WPATH), which sets the standards for transgender care in all countries, says that HRT is "a medically necessary intervention for many transsexual, transgender, and gender-nonconforming individuals with gender dysphoria [...] Some people seek maximum feminization/masculinization, while others experience relief with an androgynous presentation resulting from hormonal minimization of existing secondary sex characteristics".[2]
Effects of masculinizing hormone therapy
When a trans-masculine person goes on masculinizing hormone therapy, this has a variety of physical effects that make the person look, sound, and even smell like a cisgender man. The person's risk for certain health conditions changes to that of the risk level of a cisgender man. Physical changes caused by HRT happen at different times, similar to the process by which a cisgender man goes through puberty.
Permanent and temporary changes
For transmasculine people, taking masculinizing hormone therapy causes some changes that are temporary, meaning that they will only last while they are taking that therapy. It also causes some changes that are permanent, meaning that they will last even if they stop taking that therapy. Depending on what changes they seek, some transmasculine people find that going on HRT for a specific period of time and then stopping is effective to give them some changes they want (such as deepening their voice to a degree they find satisfactory) while avoiding some other changes that they do not want (such as male-pattern balding).
Permanent changes
- deepening of the voice,
- growth of facial and body hair,
- male pattern baldness (in some individuals),
- an enlargement of the clitoris, and
- growth spurt and closure of growth plates if given before the end of puberty.
Temporary changes
- increased libido,
- redistribution of body fat,
- cessation of ovulation and menstruation,
- further muscle development (especially upper body),
- increased sweat and changes in body odor,
- prominence of veins and coarser skin,
- acne (especially in the first few years of therapy),
- alterations in blood lipids (cholesterol and triglycerides),
- increased red blood cell count, and
- shrinking and/or softening of breasts (in some individuals), though this is due to changes in fat tissue.
Voice deepening
Most individuals on testosterone will experience a gradual deepening of the voice,[3] caused by growth of the larynx (voice box). In most cases, this begins after 3 to 12 months, and finished after 1 to 2 years.[4] The changes are permanent, meaning a trans-masculine person's voice will stay as low as it got even if they stop taking HRT. Many individuals who do not want the full effect of voice deepening will take testosterone until their voice deepens to their desired resonance and then stop.
Skin changes
Masculinizing HRT causes increased activity of oil and sweat glands, like that of a cisgender man, especially during the first two years of HRT, similar to puberty.
Change in body odor: less sweet and musky, more metallic and acrid. If severe odor is a problem, an antibacterial soap like chlorhexidine may be used in the armpits when showering. After 1–2 weeks of daily use, a noticeable decrease in odor should occur.
Acne
The WPATH says that masculinizing HRT causes a likely increased risk of acne.[5] Acne is generally worse during only the first two years of testosterone therapy, as with puberty. Can be treated with standard acne therapy. Initial treatment is with increased cleansing (at least twice daily) with an anti-acne or oil reducing scrub. If this doesn't work, additional therapy may be prescribed by a physician. Some physicians see acne as a contraindication to increasing testosterone dose.
Increased skin oiliness and acne happens only when the person is first starting HRT, similar to how cisgender men have oiliness and acne during puberty. Trans-masculine people usually see oiliness and acne start in 1 to 6 months of starting HRT. Then the oiliness and acne usually goes away after 1 to 2 years of HRT.[4]
Hair changes
The action of testosterone on hair follicles is mainly due to the more potent androgen, dihydrotestosterone (DHT). With androgen therapy, genetics primarily determines how much hair will develop, and where, as well as whether male-pattern hair loss will develop. Testosterone is converted (within the cells of the hair follicle's dermal papilla) by 5α-reductase to DHT. There are two forms of this enzyme: type 1 and 2. However, type 2 is the form that is most important to the development of male pattern hair loss. Males with congenital 5α-reductase type 2 deficiency (but functional 5α-reductase type 1) never develop male-pattern hair loss.[citation needed]
A trans-masculine person usually starts growing more facial and body hair in 3 to 6 months after starting HRT. When they reach 3 to 5 years on HRT, they usually have as much facial and body hair as they are going to have.[4]
Male-pattern hair loss, also called male-pattern baldness or androgenic alopecia, is a genetic condition that is expressed in people who have a hormone balance with more testosterone than estrogen, if they have ancestors who had it too, and once they are old enough for it to happen. Since it is genetic, people who do not have any ancestors who had male-pattern hair loss will most likely never have it themselves. Trans-masculine people who carry the gene for male-pattern hair loss will see a likely increased risk of expressing that gene when on masculinizing HRT,[5] and they will usually start seeing it happen more than 12 months after starting HRT. This varies a great deal depending on the person's age.[4]
Increased muscle mass and strength
People who have a hormone balance with more testosterone than estrogen tend to develop more muscle mass. The amount of muscle mass and strength that a trans-masculine person develops depends a great deal on how much exercise they get. Going on HRT alone will not cause a person to develop much muscle. It still requires some self-discipline to attain. A trans-masculine person usually starts developing more muscle mass and strength 6 to 12 months after starting HRT. When they reach 2 to 5 years on HRT, they usually have as much as they are going to have.[4]
Fat redistribution
Sex hormone balance determines the areas where a person's fat is located on their body and face. Fat distribution is one of the main sexual characteristics that people look at when they make a quick decision about whether they think someone looks like a man or a woman. A trans-masculine person usually starts seeing their fat redistribute in 3 to 6 months after starting HRT. When they reach 2 to 5 years on HRT, their fat has usually settled into where it is going to be from then on.[4] The WPATH says that trans-masculine people find that HRT causes them to have less body fat and more muscle,[3] but also that there is a likely increased risk of weight gain on HRT.[5] (Note that muscle is denser and weighs more than fat.) The fat redistributes away from the chest, thighs, buttocks, and hips, toward the belly and waistline. This raises the person's center of gravity, and changes the fit of the waistline of their clothes. Fat redistribution can make the breasts very slightly smaller. Masculinizing HRT can redistribute fat toward a person's face and neck in a way that can raise their risk for having trouble breathing while they sleep (sleep apnea) to what it would be if they had been assigned male at birth.[5]
Reproductive system changes
Menstrual changes
The menstrual cycle usually stops in 3 to 6 months after starting masculinizing HRT.[4] If bleeding continues past 6 months, this is a sign to check on one's hormone levels to see if the HRT dosage is too low to cause masculinization. This can also be a sign to see a gynecologist, to see if some other health condition is causing the bleeding.
Clitoris changes
The clitoris grows in size, called clitaromegaly. This eventually causes the clitoris to resemble a small penis (in cisgender men, called a micropenis). HRT cannot change where the opening for urine (urethra) is located. For people who were assigned female at birth, the urethra is a separate hole, between the clitoris and the vagina. A trans-masculine person usually starts seeing their clitoris grow in 3 to 6 months after starting HRT. When they reach 1 to 2 years on HRT, it has reached its maximum size.[4]
Vaginal atrophy
Masculinizing HRT can sometimes cause vaginal atrophy and dryness. Vaginal atrophy means that the inside of the vagina becomes more weak, delicate, fragile, and dry, and less elastic. On masculinizing HRT, the vagina and vulva are not as wet, but can still become wet when aroused. Vaginal atrophy is also common for cisgender women to have when they go through menopause. A trans-masculine person may start having vaginal atrophy 3 to 6 months after starting HRT, with maximum effect at 1 to 2 years after starting HRT.[4]
If a trans-masculine person receives vaginal penetration, this may be more painful (dyspareunia), which can cause tiny rips (microtears) in the skin inside the vagina. Microtears increase the risk of communicating sexually transmitted infections (STIs). It is important for trans-masculine people to use lubrication to help make sure that sex is comfortable, and to use condoms specifically to protect against STIs, even when using other forms of birth control.[citation needed]
Vaginal atrophy can be treated with topical estrogen cream.
Changes to feelings about sex
Many trans-masculine people report an increased desire for sex (libido) after starting HRT. Some report that this decreases somewhat after several years on testosterone, so this is equivalent to the raised libido that cisgender men feel during puberty. Some trans-masculine people do not notice that HRT causes any changes in their libido: those who were always disinterested in sex may remain asexual.
Some transgender people notice that after going on HRT, their feelings about sex change, they may feel more comfortable with having sex. Some transgender people say they see different kinds of people as sexually attractive than they had noticed before they were on HRT, that is, a change in their sexual orientation. These changes in feelings about sex is not necessarily caused by the HRT itself, but may represent a relaxing of a person's anxieties in response to HRT helping them to experience less distress from gender dysphoria.
Effect on ability to get pregnant
Masculinizing HRT decreases ovulation, and stops menstrual bleeding. However, masculinizing HRT can't prevent pregnancy. It is not an approved form of birth control (