What Is Gender-Affirming Hormone Therapy?

Gender-affirming hormone therapy helps transgender and other gender-diverse people align their bodies to better match their gender identity. Not all individuals who are gender diverse are interested in gender-affirming hormone therapy. However, many transgender people, particularly binary transgender people, will use hormones to affirm their gender.

The 2015 National Transgender Discrimination Survey (the most recent one for which statistics are available) found that 95% of transgender men and women, and 49% of non-binary respondents, were interested in hormone therapy.

Hormone Therapy Types and Variations

Gender-affirming hormone therapy fundamentally comes in two types—masculinizing hormone therapy and feminizing hormone therapy. Puberty blockers, which are used to delay the onset of puberty in young, gender-diverse people before the start of hormone therapy, affect the hormone system but are normally considered to be a different type of care.

For both masculinizing and feminizing hormone therapy, most endocrinologists aim to get blood levels of the various hormones into the same range that would be expected for a cisgender person of the same gender identity as the individual being treated.

In other words, transgender women are usually treated with medication to get them in the same range of estrogen and testosterone as cisgender women.

Masculinizing Hormone Therapy

Masculinizing hormone therapy uses various types of testosterone to promote masculinizing changes in both binary and non-binary individuals. Testosterone is most often given as an injection, but other formations are available, including pills and creams.

There has been growing interest in the use of subcutaneous pellets for testosterone treatment, as they only need to be inserted two to four times a year. However, they are not always available or covered by insurance.

Changes that can be induced by masculinizing hormone therapy include:

• Facial and body hair growth
• Increased muscle mass
• Lowering of the pitch of the voice
• Increased sex drive
• Growth of the glans clitoris
• Interruption of menstruation
• Vaginal dryness
• Facial and body fat redistribution
• Sweat- and odor-pattern changes
• Hairline recession; possibly male pattern
  baldness
• Possible changes in emotions or interests

Masculinizing hormone therapy cannot reverse all of the changes associated with female puberty. If transmasculine individuals have experienced breast growth that makes them uncomfortable, they may need to address that with binding or top surgery.

Testosterone will also not significantly increase height unless it is started reasonably early. Finally, testosterone should not be considered an effective form of contraception, even if menses have stopped.

Feminizing Hormone Therapy

Feminizing hormone therapy uses a combination of an estrogen and a testosterone blocker. The testosterone blocker is needed because testosterone has stronger effects in the body than estrogen, and it will continue to have those effects if it is not suppressed.

The blocker most commonly used in the United States is spironolactone, a medication also used for heart disease. Histrelin, or supprelin, the medication used as a puberty blocker, can also be used to block testosterone.

Various forms of estrogen can be used for feminizing hormone therapy. In general, injectable or topical forms are preferred by doctors, as they are thought to have fewer side effects than oral estrogens. However, some women and transfeminine people prefer oral estrogens.

Changes that can be induced by feminizing hormone therapy include:

• Breast growth
• Softening of the skin
• Fat redistribution
• Reduction in face and body hair (but not elimination)
• Reduced hair loss/balding
• Muscle-mass reduction
• Sweat- and odor-pattern changes
• Decrease in erectile function
• Testicular size reduction
• Possible changes in emotions or interests

Estrogen cannot reverse all changes associated with having undergone testosterone-driven puberty. It cannot eliminate facial or body hair, which may require laser treatment for permanent removal. It cannot remove the Adam's apple or other bony changes to the face and neck. It also cannot reverse changes such as shoulder broadening or vocal pitch.

For women and transfeminine people who are bothered by these features, they may need to be addressed through facial feminization surgery and/or tracheal shave. Breast augmentation may also help some women feel that their bodies are more proportional and feminine and, depending on a person's insurance, may be considered a medically necessary procedure.

Relevant Terminology

Transgender medicine is a quickly evolving field, and, as such, the terminology changes quickly.

Indeed, the term transgender is often seen as insufficiently inclusive, which is why there has been a move toward referring to it as gender-affirming medical care. However, that can obscure the fact that, ideally, all medical care should be gender-affirming, even if it is not directly related to a person's gender.

Gender-affirming hormone therapy may also be referred to as:

• Transgender hormone therapy
• Cross-sex hormone therapy
• Masculinizing hormone therapy
• Feminizing hormone therapy

People may also refer to their hormone therapy by the primary component. For example, individuals taking masculinizing hormone therapy will sometimes say they are on T, which is short for testosterone.

Health Care and Discrimination

Until relatively recently, access to gender-affirming hormone therapy was largely managed through gatekeeping models that required gender-diverse people to undergo psychological assessment before they could access hormone treatment.

However, there has been a growing movement toward the use of an informed consent model to better reflect access to other types of medical care. This change has been reflected in the standards of care for transgender health produced by the World Professional Association of Transgender Health.

Gender-affirming hormone therapy is considered to be a medically necessary treatment for gender dysphoria. It should be covered by most insurers in the United States after legal changes that occurred as part of the passage of the Affordable Care Act.

However, state laws vary substantially in terms of transgender protections, and some states do allow policies to exclude various aspects of transgender health care, including gender-affirming hormone therapy.

Access to hormone therapy can be prohibitively expensive for many people if they need to pay out of pocket, which may lead some people to try to get these medications from friends or other unlicensed sources.

In addition, individuals who are involved with carceral systems such as immigrant detention may be denied access to hormones. This can have significant negative physical and psychological effects.

A Word From Verywell

Access to gender-affirming hormone therapy is associated with significant psychosocial benefits. For transgender and gender-diverse individuals, being able to socially and medically affirm their gender can be critical for physical and psychological well-being.

Furthermore, hormone therapy is the only medical intervention that many gender-diverse individuals either want or need. Improving access to gender-affirming medical care, and reducing barriers to competent care, has the potential to profoundly improve people's lives.