Hormone therapy involves blocking the body's sex hormones and/or replacing or supplementing these with a different sex hormone or set of sex hormones. Sex hormones include estrogen (aka oestrogen), progesterone and testosterone. Blockers include antigonadotropins such as danazol.
Many nonbinary, genderqueer or gender variant people opt not to undergo hormone therapy, or to follow a full hormone therapy regime equivalent to binary transition. However these are not the only options.
Some people take a low dose of their desired sex hormone, possibly combined with a hormone blocker. This may be intended to allow them experience changes very gradually or may be intended as a 'maintenance dose' designed to be the minimum required to maintain the strength of bones, hair and nails.
Each sex hormone has both permanent and reversible effects. Some people opt to take hormones until permanent effects (such as voice deepening or the growth of breast tissue or facial hair) are achieved and then stop so other nonpermanent effects are reversed. Some may combine this with hair removal or surgery to also remove some of the permanent effects, perhaps to achieve a more androgynous or gender neutral appearance, or to reduce gender dysphoria.
Some people opt not to combine hormone therapy with the equivalent binary social transition, or to socially transition in order to access hormone therapy from medical gatekeepers, then later 'de-transition' or 're-transition' to their preferred social role or presentation. This may also occur as an unplanned consequence of following whichever aspects of transition best minimize both social and physical gender dysphoria.
Transfeminine hormone therapy
Regular male-to-female hormone replacement therapy (HRT) has the goal of reducing testosterone and increasing estrogens until the level of an average AFAB body is reached. This is done through the administration of estrogens, which also reduce testosterone, allowing for physical feminisation, and sometimes with antiandrogens or progestrogens, which decrease testosterone in case the estrogen therapy wasn't enough on its own. Medications like estradiol in their full doses cause full feminisation (including breast development), and some nonbinary people might not mind these changes. This article, however, will deal with transfeminine transition where a fully feminine development is not desired.
One way of achieving an androgynous look through HRT is by depriving the body of testosterone. There are several ways to do so, which will be listed in this section. Keep in mind that this has health risks and you shouldn't do it without first talking to a professional.
- Progestogens: a high dose of progestogens will decrease testosterone levels by a 70% to 80%, which is a significant decrease (albeit not in the average female range). This is less than GnRH analogues, which can decrease circulating testosterone levels by 95%.
- Surgical castration: gonadectomy is the surgical removal of the gonads (primary reproductive organs). This process, however, is not reversible and results in the permanent loss of the testes and sterility.
- Low doses: a lower dose of some HRT medications will result in partial demasculinisation.
Risks of testosterone deprivation
Testosterone deprivation is not recommended by itself, because it will result in estrogen deficiency (because estradiol is produced from testosterone). Estrogens are necessary for both male and female bodies, and a deficiency of this hormone will eventually develop osteoporosis, as well as hot flashes, mood and sleep issues, sexual dysfunction, and accelerated skin ageing. The risk of weight gain, type 2 diabetes, cardiovascular diseases, and dementia is also increased. There are some ways to avoid these risks:
- Selective estrogen receptor modulators (SERMs) will reduce bone density loss and osteoporosis risk. However SERMs will also increase testosterone production in AMAB bodies with low T production (not taking into account HRT).
- A low-dose estrogen supplement is much safer than SERMs, but the dose required to avoid bone density loss is enough to cause full feminisation.
Prevention of breast development
There are some specific ways to avoid breast development while allowing for the rest of the feminisation process to happen:
- SERMs (mentioned in the section above) will completely block breast development.
- Topical non-aromatisable androgens (i.e. that can't be converted into an estrogen) applied to the breast will also block breast development, but it's not as effective as SERMs. There is also a risk of the androgen being distributed to other parts of the body and therefore causing masculinisation elsehwere.
- Mastectomy (i.e. surgical removal of breasts) will of course prevent breasts from developing. This is an irreversible option.
- Exposing the breasts to radiation is an irreversible process that might block breast development, although it's not as effective as SERMs. This treatment may increase the risk of breast cancer.
It's worth noting that most AMAB people will not experience a marked breast development regardless of medication. Likewise, breast development will stop and might even withdraw if the treatment is stopped.
Transmasculine hormone therapy
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- Testosterone: testosterone will prevent periods (although the changes won't be immediate). The recommended does will change depending on the person.
- Progestogens: these will also prevent (or, at least, decrease) periods, although they are not as effective as testosterone. However, they won't cause masculinisation.
- Aromatase inhibitors: aromatase inhibitors increase the testosterone that is already found in any person's body. However, it has menopausal-like side effects (such as fatigue, headache, etc.).
- Selective Estrogen Receptor Modulators: SERMs are not commonly used on transmaculine people for this purpose, as they also cause menopausal-like side effects.
- GnRH agonists: also known as "puberty blockers" within the transgender community, they are not recommended as a long-term solution, as they cause poor bone health.
Alternatively to hormone therapy, hysterectomy is the surgical removal of the uterus and is the definitive (and irreversible) option.
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