*Biological Content* My Transition - Introduction

BIOLOGICAL DETAILS AHEAD!

[Edited 12/30/17 to correct and add some updated content.]

This post series is going to be about details regarding my experience undergoing hormone therapy as a transgender woman. I am writing this primarily for other trans people, so they can see my journey as a reference. I believe education is in everyone's best interests. I think that knowing one girl's experience through this journey could benefit trans and cis people alike, helping us all to better understand and accept one another.

I am not going to shy away from the details regarding my reproductive organs. These parts of the body are a fact of life, and it's silly to make them taboo in my opinion. If you don't want to hear words like penis, vagina, boobs, sex, masturbation, sterility, orgasm, semen, erection, and other similar words, then you probably best not proceed through the entire series. Especially if you don't want to hear those words within the context of referring to my body.

All posts that contain explicit biological and/or sexual content will be labeled as such. This particular post contains some minor sexual words and references within the context of referring to my body, but it's pretty tame. That being said, I will now continue...

Trans female readers considering hormone therapy: 

There is a condensed synopsis of advice I wish to pass on to you at the bottom of this post.

I've been on hormones for nearly 8 months now, as I type this post. It has become abundantly clear to me that practically nobody, not even many doctors, know what in the heck that really means. So I think I should, perhaps, document some of the details before they fade into memory. I will try to write down, to the best of my memory, all of the changes I have experienced since I began.

First of all, I'd like to complain about how difficult it was to actually start hormone therapy. I spent 6 years questioning my identity and gender before I actually got the guts to ask my doctor about hormones. This is not a decision that I took lightly, and I don't think anyone even could take this lightly, considering how slowly the changes occur and how difficult it is to do it. Lucky for me I live in a fairly accepting area of Washington State, so I didn't run into many of the roadblocks that trans people might typically run into elsewhere in this country. My primary care doctor was very accepting of my identity.

I spoke to my primary care doctor about how I wanted to undergo hormone therapy, and she referred me to an endocrinologist (hormone specialist), because she could not prescribe the hormones herself, apparently. Given what I know now, I'm actually not sure why she couldn't. The endocrinologist I was referred to refused to prescribe me anything because, apparently, I needed a note from a therapist that I have been seeing consistently for at least a year. I had been seeing therapists for a long time, and luckily I had been with the one I was seeing at the time for over a year.

At this point I think it was October of 2016. Almost a month passed, and I had burning questions I needed answered. I was still juggling whether I wanted to do this or not. I requested an appointment with the endocrinologist, stating that I wasn't looking for her to prescribe medication on that visit, but rather I was merely looking for information. I needed to talk to someone because I knew nothing of this process. We had to schedule my appointment a month out, so my appointment didn't happen until December. That was a very difficult wait. When I got to meet with her, I had a list of questions for her to answer. Our visit took over an hour. Here is a summary of the questions, and the answers I got:

• How will the hormones affect my orgasms?
• This is a gray area. Most people can still achieve orgasm after hormone therapy, but some people cannot. It's individual. You will, however, become sterile.
• Will this cause penis shrinkage?
• No, it will not. But your testicles will shrink.
• Will this affect my body shape?
• Yes, fat redistribution will reshape your body to give you a more "hourglass" figure, but your bones will not change shape. Your hips and thighs will get wider purely from fat redistribution.
• How will that affect my body weight?
• You will potentially gain weight, but you will also be losing muscle mass, so your weight may not change at all.
• How will this affect my emotions?
• You will have stronger emotions, and the hormones will likely cause mood swings. How this affects each person, however, is individual and difficult to say for sure.
• I heard hormone therapy increases the risk of breast cancer. Is this true?
• Yes, there is an increased risk of breast cancer. There is also a risk of blood clotting.
• Hormone therapy will cause breast growth, correct? And they will look just like regular breasts?
• Yes, you will grow breasts, and they tend to be most noticeable by month 6. They tend to be smaller than breasts that grow naturally from puberty, but they do grow.
• What about the nipples? Will my nipples become larger with the breast growth?
• No, your nipples will not change.
• How will this affect my body hair?
• The hair on your arms, chest, and face will thin out over time, but some people never lose the facial hair and have to undergo electrolysis.
• Will this regrow the hair in my receding hairline?
• No, it will not.
• Will hormones change my smell? Will my body odor smell different?
• No, I do not think that will change.
• Will the hormone therapy change my voice.
• Maybe. It makes it easier to speak in a softer tone, but it will not actually change your voice.
• Have you had any trans patients before, and if you have, did they ask any questions or go through any changes that we haven't talked about?
• No, I think we covered pretty much everything.

You may have noticed I marked some of those answers in red, and some in green. The red answers were the ones that were flat out incorrect, and the green answers were the questions that I have personally confirmed  during my transition later on. Everything else was a gray area. I'll give you a more accurate list of factual changes based on my experience later in this post, but as you can see, I was given an alarming amount of misinformation at this early stage. Despite the misinformation though, despite the uncomfortable feeling I got about that doctor, and despite the fact I felt like she was harshly judging me, I decided I wanted to start hormone therapy after this visit.

What finally made my mind up was the realization that this is not immediate. These changes happen slowly over a period of 1 to 2 years, and none of the changes are even permanent until after you pass the 3rd month on hormones. 3 months is a long time, and that gives you a good amount of time to change your mind. All I had to do was stop taking the hormones and the changes would reverse themselves naturally. Experiencing the changes first hand was going to be the only way I'd know if they would really scare me off. 

I told myself that if I felt unsure by month 2, I would stop taking them and rethink what I was doing. The endocrinologist also informed me that, in addition to a therapist's note, I needed to "identify full-time as a female for at least 1 year." I don't know how the hell they planned on proving whether I did or didn't. That was such a vague and insulting condition, I don't even really know where to begin...

So let's move on to my therapist for now...

My therapist, Fred, referred to himself as a "Christian man," (that's in quotes because that's exactly how he used to say it) and he tried to keep as open a mind as he possibly could around these issues. I think he did a great job, actually, in keeping an open mind, and I think he was an overall good person. He did great work, and he had helped a lot of people. But there was definitely still some ignorance in there, and I doubt he actually had any validation for my identity in his head. He had never met a trans person before, let alone helped one to come out of the closet and begin hormone therapy. The two of us had debates regarding gender identity on a fairly regular basis, some of which actually got a little emotionally charged. Rather than using him as a means of support in the matter, I actually was using him to keep myself in check. He questioned many things, which forced me to question myself in order to answer him. I believe the experience helped me to solidify myself in my gender identity partly because of how much I heard him say that I knew was wrong. However, not everyone's brain works like mine, and some of the things he said could easily have made another trans woman suicidal.

That being said, Fred said he would write me a letter, but he made it abundantly clear that he would write it not as a recommendation, but as a synopsis of our visits. Purely informational with as little bias in either direction as possible. I agreed, and figured that's totally fair. Unfortunately, his boss did not think so, and refused to let him send the letter. Not because of the content of the letter, but because the organization, COMPASS Health, did not "specialize in gender identity" and therefore could not comment on, or help with, anything regarding my transition. Even though this very clearly affected my mental health, Fred was forbidden from taking any action of any kind.

That is the reality we live in. This wasn't even about approving me for medication, this was about giving a doctor a report on my mental health, and Fred was forbidden to do so because the company couldn't "take sides" in the politics of gender identity. By not "taking sides" however, they took a side. They were a roadblock, and this journey needed to happen. If I couldn't do this, my depression would get worse. Things like this are why the suicide rates for trans people are so alarmingly high.

So without Fred having the ability to do anything at all to help in my situation, I started looking for another therapist who could. During one of our sessions, Fred helped me find someone who specifically listed "transgender" on their list of specialties. Out of all the people we sifted through online, we only found 2 people who might be covered by my insurance. I gave them a call, and one of them did not take my insurance, but she started the application to take it after I called. I was going to wait for her application to finish, but after waiting 2 months, I got extremely impatient and found another therapist.

But then something unexpected happened. My boyfriend introduced me to another trans girl, I'm going to call her Mia, and she told me about how she bypassed the need for a therapist's letter and the "full-time girl for a year" stuff by requesting an "informed consent form." This was a form that spelled out and explained all of the general changes the medical community knows about. By signing it you confirm that you read through all of it, and despite the potential side effects and the number of irreversible long-term changes, you agree that you still want it. By this point I had been waiting 3 months for this, and I was ready to jump at anything I could to get this ball moving.

Mia was also the first other trans person I had met in real life (that I knew of). When I first saw her in person it was an interesting mix of emotions, and I kind of wanted to cry. She looked amazing. Seeing how her journey was going made me very excited to start my own.

The endocrinologist I met with earlier refused my request for an informed consent form. The only reason I was given was yet another bullshit "company policy" reason, and it was clear to me after that point that I was never going to have anything to do with that clinic ever again. I contacted the clinic that Mia had suggested, but they didn't take my insurance. However, they were very helpful and referred me to three other places that do! I was so happy that finally somebody actually helped me through this process rather than just acting as a roadblock and pushing me away from what I want. After contacting Swedish Family Medicine, I scheduled an appointment for as soon as I could get one, WHICH WAS YET ANOTHER MONTH OUT. I was so frustrated with having to wait so bloody long jumping through so many hoops that I was starting to feel extremely depressed and suicidal. If this next opportunity didn't work out, I might have actually harmed myself.

Luckily it did work out. I went into the Swedish clinic and everybody was very friendly, even giving me the opportunity to give them a preferred name. At this point I hadn't yet legally changed my name, but I was going by Josephia. My new doctor, Dr. Wakeman, was amazing. In our first visit I brought my question list and I was ready to put up a serious fight to get this ball rolling. She confirmed that they accept informed consent forms, and I began to rant about all the reasons why I need this done as soon as possible. She stopped me for a moment during my rant and said,

"Whoa, whoa, you don't have to defend yourself to me! I'm not going to get in your way, I'm just collecting information. We'll set up your prescriptions today."

I cannot tell you how happy I was to hear that. But there was no way I could let myself relax until I had the prescriptions in my hands, because I knew that somehow, something was going to get screwed up again. Dr. Wakeman had me fill out the informed consent form and gave me some time to read through it. I requested a copy to take home, since it provided a great list of changes, and the information on it was more accurate to what I was seeing in the various trans community online forums. We had my blood drawn to check my base hormone levels, and we scheduled another appointment for me to come in after another week, so they could have my test results ready and the consent form processed. I actually took time off from work so we could schedule my appointment to be the absolute soonest we could get it.

While I was waiting for the next appointment I went over, in great detail, all of the information on the informed consent form, and developed another list of questions for the doctor, to clarify some things. At our second appointment, she clarified everything I asked, and she only got one or two things wrong, unlike the previous endocrinologist. I didn't know those things were wrong at the time, but she, at least, exuded an air of acceptance and friendliness that nobody else provided. She made me feel comfortable and confident that everything was going to work out, and that we were going to get this done.

After that visit, we processed my prescriptions. I picked up my testosterone blockers later that day and took my first one on February 23rd, 2017. The estrogen, however, required more time for the insurance to process, apparently, because I was listed legally as being male at the time. I was very nervous that they were going to refuse me and be just as transphobic as the rest of the bureaucracy. But thank god, after about two weeks, it got processed, and my estrogen prescription was ready for pickup. I put my first patch on close to midnight on March 5th, 2017. I was supposed to apply my first patch on Monday, not Sunday, but I was too excited, so I started early. I have taken monthly transition pictures on the 6th or 7th of every month since then.

So that's how long this took. I started in October of 2016, and didn't get both prescriptions in my hands until March of 2017. It was such an excruciating wait, and I had to fight nearly everyone through the whole process. If it wasn't for Mia, and if it wasn't for Dr. Wakeman, the delays might have meant more self harm for me. I was in horrible pain. But I digress a bit, I think you get the picture now.

My prescriptions were 100mg of Spironolactone (testosterone blocker in pill form), and 0.1mg of Estradiol (estrogen, in patch form). For the estrogen I had three options: pills, a patch, or injections. I hate needles, and there was a slight increase of clotting risk from the pills, so I went with the patches. I took 2 Spiro pills per day, morning and night, and I replaced my Estradiol patch twice a week, on Sundays and Wednesdays. We scheduled occasional check-up visits with Dr. Wakeman as I started on the hormones, and we did more blood tests to check how things are going.

Here's a rundown of some basic information about these medications. This is based on my personal experience, how my body has reacted to them, and from what I remember from the handouts. So you can trust that this is true within the realm of my personal experience:

• Spironolactone
• Take it with food, otherwise it can cause some nasty nausea.
• Makes you have to pee a lot.
• Makes your body not absorb salt quite as well, so you crave salt a lot.
• Smells minty, but is the opposite of refreshing. Like, radioactive mint flavor mixed with rotten cabbage. It's awful. Swallow it quickly before you can taste it.
• Causes infertility and testicle shrinkage.
• Shrinks and thins the hairs that rely on testosterone to survive. These hairs include:
• Arms
• Upper thighs
• Face
• Neck
• Chest (including nipples)
• Stomach
• Butt
• Changes your libido. The doctors say it lowers it, but I disagree. My libido hasn't lowered, it has changed. I am more in control of it. Instead of random erections deciding when I want to have sex, I decide when I want an erection. They no longer happen randomly.
• Is literally a medication used to help treat enlarged prostates, and therefore defends against prostate cancer. But at the expense of weakening your bladder. So you not only have to pee more, but you have trouble holding it in, and right when you stand up thinking that you're done, you may find out the hard way that you're not. You get used to it after a while and it becomes less of a problem by the 3rd month.
• Is also used to treat high blood pressure. My blood pressure dropped.
• Estradiol
• Causes breast and nipple growth. As your breasts grow, the nipples also expand and develop, just like a girl going through puberty. The breasts actually develop mammary glands. By all accounts, these ARE female breasts. Trans breasts are just like any other woman's breasts, including functionality.
• Does not cause breast cancer, but can contribute to the growth of existing breast cancer tissue. The only increased risk of breast cancer comes from whether you already have it.
• Changes your skin to become softer and more delicate. All of your skin, not just arms, legs, chest, etc... All of your skin is affected. Butt, penis, face, feet, everything. I bruise easier, but I'm so soft it just doesn't matter, because my skin feels amazing. I still rub my arms and smile sometimes because they feel so good.
• Helps regrow the hairs that get killed off by testosterone. The only area I know of that contains these hairs is at the hairline on your head. If the hair follicles are dying, but aren't completely dead yet, they can actually regrow. Some of my hair is growing back, but only the follicles that weren't completely dead.
• Contributes to the change in libido. Large amounts of estrogen, in my experience from a dosage increase, can cause an increase in libido.
• Penis shrinkage. Yes, it shrinks. All my doctors were incorrect on this point, and the online trans community agrees with me on this. It. Fucking. Shrinks. Not as much as I'd like it to, but it does. Refer to my future month 8 post for details on erection pain from the shrinkage.
• Causes fat redistribution across the whole body, in various ways. I used to have a little tummy gut that stuck out. It's gone to my thighs, hips, and butt now.
• Changes the way you process emotions. I cannot think of a better way to list that without going into great detail.

Remember, this is entirely based on my experience, and therefore I have no scientific studies to back me up. There are lots of details here I haven't listed. I don't know which medications the other changes fall under, so I'm going to try and remember how my experience went month to month and tell you everything I can remember has changed. This way you'll see how these changes I listed above are truly applied. Honestly, it's easier to list the things that don't change, because everything seems so different now.

I will post these month-by-month changes as individual blog posts, because my transition is ongoing. So I will continue writing these as I experience changes! The further I get into the transition, the fewer changes I see, so by the end of my first year they will probably just be transition journal stories and thoughts regarding my experiences on the journey.

Trans female readers who haven't begun hormone therapy, this is the message I want to pass onto you:

• Gather information. Google things, and search on forums to hear about other people's experiences. Do research on Estradiol, Spironolactone, and Progesterone, since those are the three most commonly used medications in hormone therapy. The more you know the better, and as you do the research it will help you to further determine whether you want to go through with it.
• I suggest reading this blog series up to about month 8, so you can find out some of the lesser talked about long-term medical issues I ran into.
• When asking doctors (in the US) about hormone therapy, ask if they accept informed consent forms. That form makes this whole process vastly more simple. Seriously.
• Call your insurance company and ask if they cover hormone therapy. I have Washington Apple Health (Medicaid) through Amerigroup, and my transition has thus far been fully covered.
• See a therapist regularly through all of this. It's important that your physical state and your mental state be monitored through your transition. Female puberty is a rough ride of mood swings. Even though I have zero regrets about this, I can't deny that it's been hard being a teenager again.
• Ask yourself the difficult questions, and make sure you separate what you want from what you think anyone else wants.
• This is hard to think about critically, because it's truly questioning yourself and your motives, but I think it's important: try to recognize whether you're fetishizing being a woman or not. Being a woman is far more than your body parts and hormones. It's who you are, every moment of every day. 
• Do you want to actually live as a female, or do you just think being a woman in bed would be hot?
• Do you want to have a period every month?
• Do you want to have hot sweaty boobs in the summer?
• Do you want people to treat you the way women are treated outside of the bedroom?
• Do you like it when people use female pronouns with you?
• Have you picked out a feminine name? How do you feel about people calling you by that name on a regular basis?
• How would you feel about being a female in the workplace?
• There is a surprising number of people out there who have no problem dating or sleeping with trans people :)
• Try to be open to experimentation with your identity. This is about you, not other people. Don't let romantic partners, friends, or family tell you who you are. Only you can do that.
• Above all, be open and honest with yourself, and be safe. Know that there are other trans people out here to support you.

This continues with my Month 0 post. You can view it by clicking here.