These divide into hormonal (endocrine) and surgical treatments. This article discusses the former.
Hormonal or endocrine therapies and treatments have three basic strategies.
- Preventing or delaying the onset of puberty. These are known as ‘puberty blockers’
- Preventing the body’s natural sex hormones from inducing physical changes. These are known as ‘hormone blockers’ or, in males, ‘testosterone blockers’ (T-blockers)
- Introducing cross-sex hormones, ie those typical of the opposite sex, to induce physical changes more like those found in the opposite sex. In males the principal one will be oestrogen and in females, testosterone.
The differences between adult men and women exist mainly because of the actions of sex hormones on their bodies, during the pre-natal period, then in childhood, adolescence and young adulthood. This is what causes the noticeable physical differences between the sexes and also most of the psychological ones, though some people dispute this.
Transgender homosexuals are individuals who have one sex but whose sexual orientation is similar to that found normally in the other. So, boys are attracted to males and girls to females. However, in addition to this sexual orientation, they have strong cross-gender ideation, that is to say they identify, either wholly or partly, as the opposite sex. They are likely to show significant gender non-conformity (GNC) indulging in cross-sex role play and appearance and this will be consistent and persistent, that is, not a passing phase; and they are likely to show more or less childhood gender dysphoria, that is, feelings of strong discomfort at being identified as the sex they were born.
Usually, in transgender homosexuality, this manifests prior to puberty and in those most likely to be HSTS, as young as 2-4 years of age. But this is a scale of variation; some transgender homosexual males, while feminised on some parameters, are less so on others. At the same time, they may feel a sense of discomfort at the mismatch between what their sexuality makes them feel they should look like and present as, and their actual appearance and presentation, which is called Gender Dysphoria. This too, is on a variable scale, so some people feel this very strongly and others less so.
If these parameters come together such that the individual’s Gender Dysphoria is stronger than his or her fear of social rejection or intolerance, that individual is likely to desire to transition.
To do that, HSTS desire to modify their bodies and faces so that they appear to be of the opposite sex. This goes far beyond cross-dressing or wearing feminine make-up (for a male). They desire to ‘pass’ in society and they know that in order to do so, their resemblance to conventional opposite-sex models must be convincing.
The place they usually will begin is with growing their hair, if male, or cutting it if female. Then they will explore feminine, for males, or masculine, for female, clothing styles. HSTS MtF might grow their hair long and wear dresses and heels, for example. This can work as long as the individual is young, but, especially for MtF, their natural sex hormones make it increasingly difficult to maintain a cross-sex appearance.
The way to combat this to impact the endocrine system. Today, in the West, this is done using a two-prong approach: firstly to counter the effects of the natural sex hormones and secondly to introduce cross-sex ones.
In this, the sexes are not equal.
Male-to-Feminine (MtF) or Transfeminine
The primary sex hormone for males is testosterone, which is, unsurprisingly, produced in the testes. For females there are two, oestrogen and progesterone, but the former has far greater effect on physical appearance.
Endocrine therapy for males consists of two stages. The first sets out to prevent a male puberty occurring, to minimise its effects or to delay it.
This is the first step for most MtF HSTS. These are male and testosterone is extremely powerful. It masculinises a boy rapidly. Although HSTS MtF are often remarkably neotenous, or baby-faced, eventually testosterone will catch up. But in order to pass successfully as a woman in society, the exposure to the masculinising effects of testosterone must be limited. This means that puberty-blockers should be prescribed as soon as a confirmed diagnosis has been made. In order to initiate the system that allows for bone growth to be halted and to avoid excessive tallness, puberty should be allowed to initiate and then be stopped. The height-limiting function is not affected by the puberty-blockers and any increase in tallness will be minimal.
Testosterone’s ongoing effects can be suppressed using three different drugs. These are Cryptosterone acetate, Spironolactone and Finasteride. The last was developed as a counter to male-pattern baldness and is usually not used alone, in transitioning.
Using testosterone-blockers like these allows a far lower, and therefore less risky, dose of oestrogen and still produce significant feminisation. It is important, however, to realise that the feminising effects of oestrogen apply only to bodily soft tissues and not to bones.
This means that an MtF using oestrogen, with or without a t-blocker (although the dose will have to be much higher in this case) can look forward to, for example: softening of facial features through changes in fat distribution; similar effects to the hips, legs and buttocks, some thinning of the waist and the development of breasts, which are mainly made up of fat. At the same time, she can expect to acheive a softer, smoother skin. Finally, through time, some changes to musculature may occur, leading to reduced upper-body strength and muscle mass.
What she cannot expect to change is her skeleton. Bony material, once laid down, is fixed, more or less for life. Some minor adjustments may be achieved through cosmetic surgery, such as reshaping jaw or brow lines, reducing a prominent nose and so on, but things like overall height, shoulder width and so on are not mutable.
This means that, for the MtF HSTS, time is of the essence. As she progresses through adolescence, she will rapidly masculinise and this may reach a point where it becomes so marked that it will be impossible for her to pass successfully as a woman. This means that, as soon as an the MtF HSTS is identified as such, hormonal treatment should begin. It is unwise to begin t-blockers prior to puberty, for the reason of possible height increase, but as soon after puberty, with a confirmed diagnosis of homosexual Gender Dysphoria, they should begin. By age 16, if possible, full doses of feminising oestrogen should be administered.i
Female-to-Masculine (FtM) or Transmasculine
For FtM, something similar is indicated, but parents iun particular ahould remember that genuine HSTS in females is far more rare than it is in males. Why this should be is not clear. However, another condition, called ‘Rapid Onset Gender Dysphoria, can easily be mistaken for genuine homosexual Gender Dysphoria. As we explain in the diagnostic guide, however, genuine homosexual GD, in almost all cases, gives many years of forecast, in childhood GNC, childhood Gender Dysphoria and in their expressions of sexuality. It almost never sets on quickly and in cases where it does, especially in females, extreme care should be taken.
While Mtf cross-sex therapy does have some raised risk of certain complications, like various cardio-vascular diseases,ii the effects of the treatment are mainly cosmetic. Despite the known tendency for feminising HRT to reduce the size of the penis and testes and render the subject unable to gain an erection or to ejaculate, there are reported cases of MtF transwomen getting women pregnant, even after many years of cross-sex HRT. (Clearly, these are not HSTS.)
For the female body, however, testosterone is a literal poison. It will effectively destroy the ovaries in short order, rendering the subject permanently sterile. This makes accurate diagnosis of Gender Dysphoria that much more critical in young females. At present, we advise that no cross-sex HRT should be administered to any female whose claim of Gender Dysphoria is suspected to be ROGD.
The simple fact is that the transition window of opportunity for females is much longer than that for males. There is not the time pressure, but instead significantly raised risk of misdiagnosis and harm.
i In some circles, today, there is an unfortunate move by some to delay t-blocker and oestrogen treatment, for MtF HSTS, until after the age of 18 or even later. This is a catastrophic approach that must be resisted. Doing so will compromise the individual’s ability to pass as a woman, perhaps to the extent that she abandons hope of a successful transition. We strongly suspect that this is, in fact, the covert intention of those who propose this.
It is definitely the case that, while some individuals may be able to transition successfully without beginning HRT before 18, most will have a happier result if they do and parents and carers of MtF HSTS, and the individuals themselves, may have to strongly oppose attempts by ‘gender critical’ individuals, be they therapists or others, to delay beginning the process of transition.
ii This elevation of risk is tiny: according to a recent study, around 0.16% over 8 years.