Testosterone for Transgender Men and Transmasculine People

Transgender men and other transmasculine people may use testosterone to masculinize their bodies in order to align their bodies with their gender identity.

The effects of testosterone therapy include physical changes, like increased facial and body hair, increased muscle mass, and lower vocal pitch. There are several types of testosterone and ways to deliver hormone therapy, including injections, pellets placed under the skin, topical creams, and oral formulations.

Learn more about the types of testosterone, as well as the effects, safety, and what to expect when taking testosterone.

Effects of Testosterone

When people take testosterone to affirm their gender, it can lead to a number of permanent, irreversible changes in the body. (This is in contrast with puberty blockers, which are reversible.)

Desirable physical changes that can be caused by testosterone include:

• Increased face and body hair
• Increased lean mass and muscle growth
• Lowering of vocal pitch
• Increased interest in sexual activity
• Stopping menstruation
• Clitoral growth

Methods of Delivery

Different testosterone formulations have different methods of delivery. The most commonly used formulations in the U.S. are testosterone enanthate (Delatestryl) and cypionate (Depo-Testosterone) injected into the muscle or under the skin.

While injections are the most familiar methods, advances in therapy have led to topical and oral formulations as well.

Intramuscular Injections

Testosterone can be injected into the muscle (intramuscular or IM injection). Intramuscular injections have historically been the most easily available, but can be more painful than subcutaneous (under the skin) injections.

In addition, they may need to be administered by a medical provider or family member. Intramuscular testosterone injections are commonly used every one to two weeks.

Subcutaneous Injections

Testosterone can also be injected under the skin (subcutaneous or sub-q injection). Subcutaneous injections are easier for people to give themselves, but they may not be a good option for those with needle anxiety.

However, they are less painful and easier to manage, due to less frequent medical visits, and are only used every one to two weeks.

Subcutaneous Pellets

This is a way to deliver long-lasting pellets of testosterone under the skin, reducing the frequency of treatment to once every three to six months. Sold under the brand name Testopel, the subcutaneous pellets allow for easy, long-term dosing without the need for repeated doctor visits or self-injection.

However, the dose is fixed after implantation. This can be a problem if dose changes are needed to either raise or lower the amount of testosterone in the body.

Topical Testosterone

Testosterone can be delivered topically through gels, creams, and patches. Testosterone gels and creams are easy to use. However, they generally must be used daily.

In addition, it is important to keep other people from touching the gel or skin after gel application. Otherwise, they may also get a dose of testosterone.

There is a risk for a local skin reaction or rash with topical testosterone. This includes testosterone patches, which can also be difficult to find and/or to get covered by insurance.

Oral Testosterone

Oral testosterone formulations were a less common option in the past and ones that were associated with liver toxicity. However, the release of the oral capsules Kyzatrex, Jatenzo, and Tlando allayed those fears significantly. Although not formally indicated for testosterone replacement therapy in transgender men, it has become an increasingly popular option for some.

Risks of Testosterone Use

Testosterone treatment is not without side effects. Some are mild to acceptable. Others may become intolerable and require the adjustment (or even discontinuation) of treatment.

Possible side effects of testosterone replacement therapy in transgender men include:

• Acne and skin reactions
• Enlarged breast tissues (gynecomastia)
• Male-pattern baldness (androgenic alopecia)
• Worsening sleep apnea
• Blood lipid abnormalities, including reduced HDL cholesterol and increased triglycerides
• High blood pressure (hypertension), including an increased risk of heart attack or stroke
• Liver problems
• A high hematocrit count, which can cause a stroke, heart attack, or blood clots, including pulmonary embolism
• Mood swings or worsening of anxiety, depression, or other mental health conditions
• Malignant hypertension when taking testosterone undecanoate (Aveed, Kyzatrex, Jatenzo, and Tlando)

Long-term risks of hormone treatment for transgender men may include:

• Increased risk of heart disease and stroke
• Weight gain
• Blood clots in the veins
• Bone fractures
• Hormone-dependent cancers 
  

Although hormone treatment is generally considered safe for transgender people, the long-term effects for transgender men include a higher risk of heart attack, so monitoring for heart disease is important long-term.

What to Expect When Taking Testosterone

Transitioning to a transgender male can take anywhere from several months to several years, depending on factors like the age when transitioning begins, when hormone therapy is started, and whether gender-affirming surgeries are to be done.

Transitioning usually begins by taking testosterone, starting with a low dose and slowly increasing the dose over time. Testosterone can be given as an injection, through a gel or patch on the skin, or through pellets placed under the skin.

There isn't a recommended age for transitioning from female to male, but there are aspects of gender affirmation that testosterone treatment cannot manage on its own. For example, if you've gone through puberty and grown breasts, testosterone may somewhat shrink the breast tissue, but won't remove the breasts entirely.

And testosterone can't make you grow taller if your bones have already matured from early estrogen exposure.

Testosterone therapy is considered a lifelong treatment to maintain masculine physical characteristics.

Things to Consider

Testosterone is generally considered to be a safe and effective way for transmasculine people to affirm their gender identity. However, it’s not something that should be undertaken without adequate information and consideration.

In particular, it’s important for transgender men and non-binary people considering testosterone to think about their fertility prior to starting testosterone. It is much easier to undergo any desired fertility preservation before hormonal gender affirmation than after.

Although testosterone is somewhat effective at stopping menstruation, it should not be used as the sole form of contraception for transmasculine people who have penetrative sex with partners with penises. Although it may not be common, it is possible to get pregnant if you don’t have periods.

Therefore, those who are at risk of unintended pregnancy should consider using additional forms of contraception, such as condoms or an intrauterine device (IUD).

The cost to transition from female to male will vary depending on several factors, including:

• The type of testosterone therapy and administration method
• Whether gender-affirming surgeries are done
• Your geographical location
• Insurance coverage

Typically, most healthcare providers prescribe the type of testosterone that comes in the format the patient wants to use or is covered by insurance.

Prescription choices may be limited by the availability of certain types of testosterone. There can also be substantial cost differences, and not all formulations are covered by all insurers.

Summary

There are several factors to consider before starting testosterone therapy. Talking with a healthcare provider can help you understand the risks and benefits and determine the right type of testosterone for you and when to start testosterone therapy.