Hormonal affirmation | Transgender, non-binary and gender diverse children

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This blog post is a part of the resource – Supporting Transgender, Non-binary and Gender diverse Children & Young People, created by Felicity St John and Felicity’s collaborator and fellow Master of Sexology student Lindsay SmithFelicity, during a placement with Sex Ed Rescue in 2024.

Felicity St John has a Master of Sexology (Professional) with Distinction and a Bachelor of Human Services – Child and Family Studies. She currently works for an NGO as a supervisor of four practitioners, coaching and case managing families facing complex challenges. Felicity also offers professional development and consultancy. Her professional interest areas are sex education, puberty, LGBTQI+ people, child development, transgender/non-binary/gender-diverse people, relationship coaching, family coaching, and parenting psychoeducation. Felicity has a passion for supporting people to step into their capacity. When she’s not working Felicity loves to laugh, play, be with loves ones, rock climb, SUP board, explore nature, read, write, hike, cycle, swim, and laze about like a cat. You can contact Felicity via email.

Hormonal affirmation is the use of hormones that bring about secondary sex characteristics that line up with the person’s gender. At the same time, the hormones partially suppress the sex characteristics of the person’s sex at birth. 

Transmasculine and transfeminine youth and adults may seek to try and shape their bodies to look, feel, and function more like their gender and less like the sex they were assigned at birth. For trans boys/men and transmasculine people, this is called masculinising. For trans girls/women and transfeminine people, this is called feminising. Taking hormones is a way transgender people may attempt to masculinise or feminise their bodies, depending on what outcome they desire. Non-binary people may also use hormones to try to shape their bodies to fit their gender as well. This can include masculinising and/or feminising. 

Hormonal affirmation for transgender youth is associated with:

  • Improved mental health
  • Less depression
  • Less anxiety
  • Less suicidality 
  • Better life satisfaction and quality of life
  • Reductions in gender dysphoria 
  • Less body dissatisfaction

The timing of hormonal affirmation can be critical. Starting hormonal affirmation when puberty has already been completed in the sex assigned at birth can have lifelong impacts on the person, such as the increased costs (time, finances, use of holiday/sick leave) of surgical affirmation and requiring more surgical procedures. 

Previously, hormone affirmation was recommended from 16 years of age where the young person had the capacity to provide consent. There is some research that for some people commencing before 16 may be indicated. One study looked at the impact on the mental health of transgender people of accessing hormonal affirmation between the ages of 13-15, between the ages of 16-17, and adults (18 and over), and compared to the same ages for transgender people who wanted to access hormonal affirmation but couldn’t. Earlier access to hormonal affirmation was associated with

  • ‘Lower odds of…suicidal ideation’ in the past year
  • Lower ‘severe psychological distress’ in the past month
  • Lower ‘binge drinking’ in the past month
  • Lower ‘lifetime illicit drug use’

(Turban et al., 2022). 

The positive impact on mental health was greatest for those who started accessing hormonal affirmation between the ages of 13-15, and the 16-17year-olds had better outcomes than the adults.

If a young person is under 18, there will likely be legislation around whose consent is needed for a young person to commence hormone affirmation. For example, some jurisdictions require the consent of both parents.

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Testosterone

Testosterone is one of the androgen sex hormones the testes make, which helps the body physically develop male sex characteristics. Testosterone is something everyone has, even females, but males typically have more testosterone. Testosterone is the hormone that can also be repeatedly administered to masculinise the body. Testosterone is often shortened to just “T”.

Testosterone can be administered by 

  • Applying gel or cream 
  • Intramuscular injections
  • Transdermal patches

Testosterone is repeatedly administered. Some people may choose lower doses of T, which change their bodies less, with changes occurring more slowly over time. This is sometimes called micro-dosing.

If someone stops taking testosterone, many of the changes that testosterone causes are permanent, such as:

  • The size of the clitoris being bigger (“bottom growth”), typically around an inch longer
  • A deeper voice (typically within a year, voice cracking typically by six months)
  • More body hair (within 1-4 years)
  • More facial hair (within 1-4 years)
  • Baldness (for some)

Other changes testosterone can induce are

  • Menstruation stops happening (typically within 1-6 months)
  • More energy
  • Stronger bone mass
  • Improved upper body strength
  • Greater muscle mass
  • Body fat can move from the hips, and more fat may be found around the waist and abdomen
  • Oilier skin and initial acne
  • Changes in body odour
  • More sweating
  • Changes in mood (can also fluctuate depending on how recently testosterone is administered)
  • Enlarged Adam’s Apple
  • Vaginal dryness
  • Pelvic pain
  • Less oestrogen
  • Higher sex drive
  • A shift to experiencing the desire for sex more spontaneously (spontaneous desire template) 
  • Changes in how orgasms are experienced
  • Increased sensitivity of the genitals
  • Changes in fertility

Additionally, if a young person hasn’t completed puberty yet, for example, due to their Tanner stage of development or use of puberty blockers, when they start taking testosterone, they may also experience 

  • Being taller
  • a more masculine face
  • a more masculine bone structure 

As people have different bodies, the effects may look different for different people.

Young people may want to know how their genital tissue will change on testosterone. These changes should be discussed by the health professional as part of informed consent before commencing testosterone, but sometimes, this may not include imagery. This can lead to searching the internet, and even porn, for images which may be a very distorted or inaccurate depiction of the impacts of testosterone. At times, this can be dysphoric for youth. Diagrams of the genitals before and after taking testosterone can be found in the article ‘Genital Changes, Periods, and Pelvic Pain in People Using Testosterone’, which there is a link to below. These give a more realistic understanding of growth. As other people in the community can ask invasive questions of trans people, which are some variations of “what’s in your pants”, young people will likely need support and go-to phrases to put boundaries in place with others.

Young people may also need resources due to the distress increased acne can bring.

Before commencing testosterone monitoring of testosterone may occur, while taking testosterone, monitoring levels via blood tests is done to ensure testosterone levels are in the desired target range. Monitoring also looks at blood pressure, lipids (for cholesterol), liver function, renal function, and full blood count. Depending on individual risk factors other monitoring may be done, such as glucose levels. Genetic and lifestyle factors can influence risk. Other specialists may be called upon to review the health of the person, depending on individual risk factors. For example, a cardiologist or endocrinologist. 

Known risks of taking testosterone include:

  • An increased risk of higher cholesterol and heart disease. (Similar to how males have this increased risk)
  • Increased number of red blood cells (polycythemia) which can result in high blood pressure and thickened blood, and if not monitored, an increased risk of stroke
  • Increased risk of obstructive sleep apnea (OSA). (Similar to how males have this increased risk)
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Feminising hormones and androgen blockers

Oestrogen is one group of hormones the ovaries make. One type of oestrogen, estradiol, helps the body physically develop female sex characteristics. Estradiol can also be repeatedly administered to people who want to feminise the body.

Oestrogen can be administered by: 

  • Oral pills 
  • Transdermal patches
  • Implants
  • Injections

Oestrogen is repeatedly administered. Some people may choose to have lower doses of oestrogen, which changes their bodies less, with changes occurring more slowly over time. This is sometimes called micro-dosing.

If someone stops taking oestrogen, many of the changes that oestrogen causes are permanent, such as:

  • Reduced ability to make semen and sperm (typically irreversible)
  • Breast and nipple growth
  • Reduction in the size of testicles 

Other changes oestrogen can induce are

  • Skin gets softer
  • Reduction in muscle mass
  • Body fat increases
  • Fat laid down on hips, bottom, and upper arms
  • The growth of hair on the body and face slows down
  • If balding was occurring, this may slow down or stop
  • Reduced sex drive
  • Reduction in spontaneous genital erections
  • Less firm genital erections
  • May lose the ability for genitals to become erect
  • A shift towards experiencing a desire for sex when ‘sexy things are already happening’ (responsive desire template) (Nagoski in Fielding, 2021).
  • In addition to oestrogen, some people who want to feminise the body may also use anti-androgens to block testosterone from further masculinising the body. Anti-androgens are repeatedly administered by a pill. 

Some trans people may also take progesterone. Progesterone appears to play a protective role for people with uteruses, but research on trans people using progesterone is in its infancy.

As people have different bodies, the effects of oestrogen and anti-androgens may look different for different people.

Estradiol is monitored to ensure the oestrogen dose is suited to the individual. 

If a young person has completed puberty in the sex that doesn’t align with their gender, oestrogen can’t take away a deep voice. Due to this, young people may need resources such as vocal training to feminise their voice.

Known risks of taking oestrogen include:

  • Reduced fertility, which may be irreversible even if oestrogen is stopped
  • Weight gain
  • Loss of muscle mass
  • Increased risk of blood clots (AKA deep vein thrombosis). Higher risk if there’s a history or the person is over 45 years of age. Lower risk with patches.
  • Increased risk of breast cancer

Known risks of taking anti-androgens/testosterone blockers include:

  • Dizziness
  • Urinating more

Some trans people may choose to have lower doses of oestrogen which change their bodies less with changes occurring more slowly over time. This is sometimes called micro-dosing.

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Non-binary

Some non-binary people may also choose to use hormones to masculinise or feminise the body. Non-binary people may seek levels of hormones that differ from those used by trans men and trans women. For example, taking a lower dose, not using all the time, or stopping using altogether, for example when a desired body change has occurred. As the same types of hormones are used, you can read above for the effects of different hormones. 

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Resources

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References

  • Accessing Gender-Affirming Hormone Therapy in Australia by Dr. Julian Grace & Dr, Sav Zwickl 2021.
  • Access to Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults by Turban et al., 2022.
  • Bottom Growth and Genital Changes on Testosterone by Get Plume 2018.
  • Feminising Hormones by Trans Hub 2021.
  • Gender-affirming Hormone Therapy Professional Association for Transgender Health South Africa (PATHSA) Webinar Part 3: Adolescents by Dr Ariane Spitaels, (Paediatric Endocrinologist) 2022. 
  • Genital Changes, Periods, and Pelvic Pain in People Using Testosterone by Dr. Sav Zwickl and Dr. Alex Wong 2023.
  • Hormone Use for Non-Binary People by Gender GP 2021.
  • Masculinising Hormones by Trans Hub 2021.
  • Options for Oestrogen, Anti-Androgen, and Progesterone Hormone Therapy in Australia by Stephanie Sheahan & Tomi Ruggles 2023.
  • Options for Testosterone Hormone Therapy in Australia by Dr. Sav Zwickl & Elliot O’Donoghue 2023.
  • Our Sexuality by Crooks, Baur, & Widman 2021.
  • Overview of Masculinising Hormone Therapy by Dr. Madeline B. Deutsch 2016.
  • Pediatric Endocrinology Fact Sheet -Feminizing Treatment for Transgender Females by Pediatric Endocrine Society 2018.
  • Pediatric Endocrinology Fact Sheet – Masculinizing Treatment for Transgender Males by Pediatric Endocrine Society 2018.
  • Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 by Coleman et al., 2022.
  • To Protect Evidence-Based Medicine and Promote Health Justice, Protect Gender-Affirming Medical Care by Center for Health Justice 2023.
  • Testosterone HRT and Bottom Growth by Folx 2021.
  • Trans Sex by Lucie Fielding 2021.
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Felicity St John holds a Master of Sexology (Professional) with Distinction and a Bachelor of Human Services – Child and Family Studies. She supervises a team in an NGO, coaching and supporting families with complex needs, and offers professional development and consultancy. Her interests include sex education, puberty, LGBTQI+ inclusion, child development, and family coaching. Outside work, Felicity enjoys time with loved ones, outdoor adventures, and creative pursuits.
You can find Felicity at LinkedIn - https://www.linkedin.com/in/felicity-st-john-726365256/