Low T: A Tale of Two Hormones (Gender Analysis 01)

hq-av-1200px

Hi, welcome to Gender Analysis. In recent years, prescription testosterone has become a booming industry around the world. From 2001 to 2011, the percentage of men over 40 in the US who were prescribed testosterone replacement grew from about 0.8% to 2.9% – more than a threefold increase. And data from 41 nations shows that yearly testosterone sales have increased from $150 million in 2000 to $1.8 billion in 2011. Meanwhile, chains of “low T clinics” focusing on testosterone therapy have opened dozens of locations across the country.

So what’s behind this growth? Let’s take a look at one commercial for prescription testosterone gel:

“I have low testosterone. There, I said it. See, I knew testosterone could affect sex drive, but not energy or even my mood. That’s when I talked with my doctor. He gave me some blood tests – showed it was low T. That’s it. It was a number.”

Companies selling these medications increased their spending on testosterone ads from $14 million in 2011 to $107 million in 2012, using a snappy new name like “low T” and the promise of a quick and easy pick-me-up for older men. If your T is low, you feel bad; if your T is higher, you feel good – right? This is the approach that’s fueled an explosion in testosterone usage. The problem is, it’s not just a number. In reality, “low T” levels are uncertain, the symptoms are vague, and the relationship between levels and symptoms really isn’t so direct. [Read more…]

Darker shades of pink: Having depression when you’re transgender

1522095_10152076191576077_222205893_n (1)The past few years of my life have featured various events that repeatedly force me to update significant parts of how I understand myself.

I used to see little purpose in life and no path forward for myself, until I created an ongoing open-ended project to direct my energies toward, and coincidentally slid into utter femininity in a matter of months. I’ve gone from coasting on the decades-long assumption that I was still a guy – just an extremely femme one – to realizing that no part of me bristles against womanhood. I thought I didn’t have any gender dysphoria, and medically transitioning was simply a matter of taking things from “good” to “even better”. Then I started HRT and gained the perspective to see just how awful, how suffocating, how unbearable things were before – and how it brought me to a place where I was finally a happy, functional person who truly loved life.

About that last one…

You’d think, after all this, I’d understand that things are always going to keep changing. I should realize by now that if I believe the current state of my life will persist forever, I’m almost certainly wrong. Many of my writings should be considered mostly obsolete for that very reason. They’re snapshots of a certain time in my life, not conclusions meant to persist for all eternity – and as more time passes, they’ll become more divergent from reality.

Still: I thought I had fixed this. I thought I had found the answer – the reason why I had felt so pervasively uncomfortable for all of my life, and the solution that did what nothing else could and actually made everything better. I thought I was in the clear to check that off as decisively handled.

I’m now having another one of those moments where I’m forced to realize: I was wrong. I was wrong about having fully understood the nature of my problems. And I was wrong about the extent to which transitioning could adequately address them.

1. How I experience dysphoria

For the most part, my dysphoria typically doesn’t feel like discomfort with the physical form of my body. My dysphoria feels like depression. I wasn’t aware of this similarity at first, because I didn’t yet have an understanding of what depression feels like. Other people had to tell me.

When I wrote “8 signs and symptoms of indirect gender dysphoria”, I aimed to offer a description of the emotional problems which I experienced prior to transition, and which went away after I transitioned – experiences that had also sometimes been relayed by other trans people. I did my best to convey how this felt for me:

  • “I could force myself to get things done, but it would take a lot out of me. I would be irritable, snappish, annoyed by everything, and in anywhere from a mildly bad mood to a very bad mood almost every day.”
  • “As a child, I would cry almost every day at the drop of a hat. Anything could trigger it – being even mildly reprimanded, getting a wrong answer on schoolwork, the sort of insignificant things that no one else around me ever cried so frequently about.”
  • “A feeling of just going through the motions in everyday life, as if you’re always reading from a script.”
  • “When I worked on things, there wasn’t any higher sense of eventually working toward anything.”
  • “Nothing made me feel truly fulfilled, like I was accomplishing anything meaningful.”
  • “I often wondered how other kids could just go about their lives, talking and laughing and being so calm and happy, like nothing was wrong.”

Many trans people told me that this article resonated strongly with them; some said it was as if they were reading what could have been their own journal. Others pointed out that there was substantial overlap between what I described, and the symptoms of depression. Some felt that this overlap was so complete, the article was not a meaningful description of dysphoria at all – one trans woman called it “frankly, bullshit”.

To show a connection between these experiences and gender dysphoria, I had to rely on one key point: that these issues were present before I transitioned, and they unexpectedly subsided once I began to transition.

So what does it mean when they come back?

2. The limits of my understanding

Before transitioning, I had concluded that these pervasive negative feelings were simply an innate aspect of my personality, and something I’d have to learn how to live with:

I figured all I could do was ignore it as much as possible and focus on whatever positives I could find – I gave up hope of ever truly fixing this.

So, having decided that this is just how I am, I didn’t think to consider whether these issues might be due to an actual, knowable cause like dysphoria or depression. Even as I developed a better sense of my gender, it didn’t occur to me that there could be a link between finding a more suitable identity for myself and resolving my emotional problems. I saw these things as two parallel lines, each progressing on their own path but never intersecting. I didn’t regard transitioning as a way of fixing my mood issues – of all the reasons I was driven to do it, this just wasn’t one of them.

So it came as a surprise when these two things began to interact: I started HRT in 2012, and almost immediately felt free of all the crushing negativity for the first time in my life. Thus, I learned to recognize dysphoria. I did not learn to recognize depression.

This would prove to be a major deficiency in my understanding of the problems I’ve faced. Around the end of 2013, I started experiencing what seemed like the same thing all over again:

  • Being exhausted by everything, and irritable all the time
  • Feeling unable to handle the basics of everyday life
  • Becoming stressed to the point of crying at the end of every day
  • Seeing no ultimate point to anything I did, and feeling it was all meaningless
  • Wondering why I even had to be alive

Because I had previously associated these feelings with dysphoria, my first guess was that all of this had to be linked to gender-related factors. So that was where I started: Was it my recently-adjusted progesterone dose? Is it that I just haven’t had the right surgeries? I switched back to my previous dose – but the relief was only temporary. (Surgeries, obviously, are not quite so accessible or easy to experiment with.)

It just didn’t make sense – I didn’t understand why everything suddenly felt so horrible, even though very little had changed. I was starting to get scared. Things were fine before. What is this?

3. Looking beyond gender

My fiancée Heather has often provided a useful outside perspective on my issues. That just sounds really abstracted, though. The truth is, she’s the reason I realized I’d rather be someone’s girlfriend than their boyfriend. She was the first person to call me “she” all the time and make it feel normal, a simple fact of who I am. She started a new life with me, in a place where everyone knew me as a woman. She let me know that starting hormones would make me even more desirable in her eyes, not less.

Without her, much of my transition wouldn’t have happened with such efficiency, or happened at all. We’ve been together for nearly three years, and Heather knows me very well. She’s also struggled with depression throughout her life, and this provided her with some degree of insight into just what the hell was going on with me this time.

When she noticed I’d been miserable for weeks, and asked me what was wrong, I told her how all of this felt – how everything just seemed like too much, and I didn’t feel like I could handle it anymore, and I didn’t know why. It sounded familiar to her, and she raised the possibility of depression. I asked her: is this what depression feels like? She confirmed this. My next, even more desperate question: just how helpful is her medication?

4. Navigating healthcare as a trans woman

I only go to my gynecologist for HRT and the associated check-ups and blood monitoring. I’d have to find someone else for this new… thing. (I still wasn’t certain of how to name it, and I’d talk about it in terms like “this stuff” or “dealing with things”.) Before this, I actually didn’t have a regular physician, largely because I just didn’t want to deal with doctors. It’s not due to some arbitrary aversion – it’s because receiving appropriate and sensitive healthcare when you’re trans, even healthcare completely unrelated to transitioning, is a minefield.

Trans people have often found that when they seek care for any sort of illness, their doctors advise them to discontinue HRT regardless of whether their current health problem has any connection to this. Some of us don’t even get that far – one of my friends was unable to receive any medical attention for her asthma simply because her doctor refused to treat trans people at all.

This issue is more than anecdotal: in a national survey of over 6,000 trans people, 19% reported they had been denied service by a healthcare provider due to being trans. 28% had been harassed in a medical setting because they’re trans. And 28% also reported that because of disrespect and discrimination from providers, they delayed or avoided treatment when they were ill.

That may not be wise, but when cis people go to a clinic for a flu or a broken toe, they generally don’t have to worry about being turned away just because of who they are. We do, so seeking care can be a difficult thing to contemplate. When going to a new and unfamiliar doctor, we never know what kind of ignorance or hostility we’re going to face. It’s an alarming unknown.

So I went with the option that we already knew the most about. Heather’s family doctor had treated her depression and anxiety, and he knows that she’s queer – she told me of how she’d started crying in his office while talking about how her co-workers called her a “fag” every day. She’s never had problems with him. I’d also met him when we took our son for check-ups, and he was really friendly toward all of us. To me, he seemed like the best bet. Heather reassured me: “If he gives you any trouble, we’re all firing him.”

5. “Mild depression”

Outness is a risk factor for refusal of service: 23% of trans people who are out to their medical providers have been denied service, compared to only 15% of those who aren’t out. Nevertheless, I still listed my current medications on the intake form, and left helpful notes like “I am a transsexual woman (male-to-female)” in the “other information” section. I didn’t want to have to deal with any surprise issues if they only realized I was trans later on, nor did I want to see someone who would only be willing to treat me under the pretense that I’m cis.

Fortunately, all of this turned out to be a non-issue. Other than asking whether I was taking hormones under the supervision of a doctor and whether I’d had a blood test recently, the topic didn’t even come up. He asked how I was feeling, and I told him everything – the way that life had somehow become unbearable for no apparent reason, and the dread I felt at having to face every single day. And I made sure he knew that it wasn’t like this before, that transitioning had helped me more than I ever expected, that it really did make things so much better and I didn’t know why this was happening now.

He seemed to know exactly what I was talking about, even identifying the feelings I hadn’t yet mentioned: the monotony of everything, and the difficulty with finding the motivation to get started on almost any activity. Everything he said gave me the impression that he understood this well. He concluded that because this appeared to be a more recent and transient problem rather than a lifelong issue, it was likely a kind of “mild depression”.

We worked out a balance of which medication would be both affordable and effective for me, and ended up settling on his first recommendation – something he felt would give me more energy. “I take it myself”, he reassured me as he wrote the prescription.

6. Anything but trans

People widely regard being trans as an undesirable existence. Often, cis people just don’t want the people around them to be trans – whether this comes from a place of overt intolerance, or just pity and regret for the hardships we face. And trans people, sometimes to an even greater extent than cis people, have also been known to seek out any potential reason to conclude that they’re not actually trans and therefore won’t need to face expensive procedures and near-universal hostility from society.

This urge to avoid the possibility of transness manifests as a staggering variety of excuses and denials. The cis people around us, often our parents and relatives, may claim that our gender-related feelings can instead be explained as a product of:

  • Childhood bullying
  • Sexual abuse
  • Negative experiences with other members of one’s assigned sex
  • The influence of supportive therapists and other professionals
  • Following a trend among a social circle
  • Viewing pornography
  • Homosexuality
  • Unspecified “confusion”
  • Demonic supernatural influences
  • Low testosterone (for trans women)
  • Traumatic brain injury
  • Autism
  • Depression

These are all things that trans people have actually reported hearing from various cis people, and this is not an exhaustive list. Given the prevalence of these creative explanations, trans people in search of reasons to doubt their own transness have ample opportunity to seize on them as well. But this fervent effort to locate any possible alternatives to transness extends beyond the poorly-informed folklore of laypersons. It’s also visible in the poorly-informed folklore of certain medical professionals.

7. Trans-negativity in medicine

Dr. Kenneth Zucker is head of the Gender Identity Service for children at Toronto’s Centre for Addiction and Mental Health. Under his direction, this program has subjected children to a form of reparative therapy to discourage them from being trans or questioning their gender. This includes taking away “girlish toys” like dolls from male-assigned children and encouraging more stereotypically masculine interests, an approach resembling the techniques of discredited “ex-gay” programs.

Zucker contends that cross-gender identification in children is driven by other issues not directly related to their gender, and calls their feelings “a ‘fantasy solution,’ that being the other sex will make them happy” – in other words, a misguided answer to a separate problem in their lives. He posits that their desire to live as another sex is instead largely rooted in family issues:

First, he thinks that family dynamics play a large role in childhood GID—not necessarily in the origins of cross-gendered behavior, but in their persistence. It is the disordered and chaotic family, according to Zucker, that can’t get its act together to present a consistent and sensible reaction to the child, which would be something like the following: “We love you, but you are a boy, not a girl. Wishing to be a girl will only make you unhappy in the long run, and pretending to be a girl will only make your life around others harder.” So the first prong of Zucker’s approach is family therapy. Whatever conflicts or issues that parents have that prevent them from uniting to help their child must be addressed.

Zucker is open about his belief that transness should be avoided if at all possible:

Despite these difficulties, Zucker clearly feels it’s important to at least attempt change. He points out that the burden of living as the opposite gender is great, and should not be casually embraced.

“We’re not talking about minor medical treatments. … You’re talking about lifelong hormonal treatment; you’re talking about serious and substantive surgery,” he says.

Failure to intervene increases the chances of transsexualism in adulthood, which Zucker considers a bad outcome. For one, sex change surgery is major and permanent, and can have serious side effects. Why put boys at risk for this when they can become gay men happy to be men?

(In fairness to Zucker, he is noted as “the first to acknowledge that no scientific studies currently support the effectiveness of what he does.”)

Alice Dreger, a bioethicist who previously compared gender-questioning kids to children who unseriously pretend to be train engines, promotes a similar idea. She’s cited unnamed clinicians as agreeing that these children are the product of “dysfunctional” families:

Here’s more unwelcome news from Ms. Dreger. A child’s gender issue may merely be a symptom of other family problems. “The dirty little secret is that many of these families have big dysfunctional issues. When you get the clinicians over a beer, they’ll tell you the truth. A lot of the parents aren’t well in terms of their mental health. They think that once the child transitions, all their problems will magically go away, but that’s not really where the stress is located.” Clinicians won’t say these things publicly, she says, because they don’t want to sound as if they’re blaming gender problems on screwed-up families.

Dreger likewise depicts transitioning as undesirable, and endorses alternatives where possible:

Sex-changing interventions are nontrivial. They involve substantial physical risk, including major risk to sexual sensation, and a lifelong commitment to trying to manage hormone replacement. …

But somehow if we wrap these major interventions around gender identity, we’re supposed to believe they are not that big a deal in terms of planning for a child’s future? And the clinician who tries to get a gender dysphoric kid to learn to like her or his innate body really is a Nazi? Not buying it. …

What if a boy could go to school in a dress and still be a boy? What if a girl could declare she’s going to grow up to be a man without being dragged to a clinic for a cure and/or prep?

effexor-poster-2As a trans woman, my diagnosis of depression exists within the context of these widespread attitudes. We live in a society where transitioning is regarded as a “bad outcome”, a last resort, only to be pursued when all other avenues for dealing with this discomfort have been exhausted. Are you sure you’re not just gay? Maybe you only think you’re trans because you’re afraid of other men. Can’t you wear a dress and still be a boy?

We’re warned that this may be no more than an illusory “fantasy solution” to our real problems. Commonplace medical practices reflect this overabundance of caution, something which became all the more striking when compared to my recent experiences. Unlike in 2012, I did not need to find one of the few therapists in a city of millions who would evaluate me and provide a lengthy referral letter for treatment. Instead, I was able to go to the same doctor as the rest of my family, and soon found myself sitting in an exam room full of detailed posters about depression and the drugs that might help. Within 30 minutes, I walked out with a prescription in hand. Trans people are often asked to consider whether they may just be depressed cis people – but depressed cis people are rarely asked to consider whether they might be trans.

Yet I’ve now found out that my ongoing unhappiness has persisted through transition, and so I’ve opted to receive treatment for depression. What am I supposed to make of that? And what will others make of it?

8. Relationships between dysphoria and depression

Actually, there are some critical (and obvious) flaws in the notion that other mental health conditions may serve as an “alternative explanation” to apparent gender dysphoria.

For one, there is no reason why gender dysphoria and other mental illnesses should be seen as mutually exclusive. If you’re trans, having depression doesn’t suddenly make you no longer trans. (For that matter, neither does childhood bullying, sexual abuse, autism, and so on.) Would anyone ever make a similar argument about physical conditions – that, say, you can’t have both Crohn’s disease and migraine headaches? Those also make me feel pretty terrible, but it would be absurd to claim that only one of these is responsible for the entirety of my physical pain. There is no reason they can’t coexist as contributors to that pain. And just as I’ve had to acknowledge that my gender dysphoria alone isn’t sufficient to explain all of my mood issues, it would be equally faulty for someone else to claim that my depression alone would suffice to explain this.

Does it seem at all realistic that there would be no occurrence of depression among trans people? People sometimes get depressed, and trans people are people. Scientific studies confirm, rather predictably, that gender dysphoria and depression can coexist. A 1997 study of 435 trans people found that they experienced psychiatric conditions at a rate similar to cis people:

Specifically, gender dysphoric individuals appear to be relatively “normal” in terms of an absence of diagnosable, comorbid psychiatric problems. In fact, the incidence of reported psychiatric problems is similar to that seen in the general population. Similarities in incidence included depression, bipolar disorder, and schizophrenia. … Although a small percentage of gender dysphoric individuals in this sample had prior identifiable psychiatric problems (7-10%), this is not inconsistent with the general population.

And a 2010 study found comparable levels of mental health conditions in 579 people diagnosed with gender dysphoria:

Adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579).

Furthermore, studies of trans people undergoing medical transition have consistently confirmed that these procedures are significantly helpful in addressing the symptoms of other mental health conditions, and increase our general well-being. Hormone therapy, in particular, stands out as a key factor in reducing levels of distress. A 2013 study followed 57 trans people before and after HRT and genital reassignment surgery, and found that starting HRT was associated with a marked decrease in depression and anxiety:

A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated.

Another study of 70 trans people examined their self-reported stress and their blood levels of cortisol, a hormone associated with stress. Being on HRT was linked to a reduction in perceived stress levels and cortisol awakening response:

At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples.

And in another study of 187 trans people, initiation of hormone therapy was associated with reduced symptoms of depression and anxiety:

Overall, 61% of the group of patients without treatment and 33% of the group with hormonal treatment experienced possible symptoms (score 8–10) or symptoms (score >11) of anxiety. The same pattern was found for symptoms of depression; the percentages were significantly higher in the group of patients without treatment (31%) than in the group on hormonal treatment (8%).

A study tracking 118 trans people before and after hormone therapy found that their levels of depression, anxiety, and functional impairment were much lower after HRT:

Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment).

And a study of 67 trans people found that those who received HRT had a higher quality of life, reduced depressive symptoms, and better self-esteem:

After adjusting for age, gender identity, educational level, partnership status, children at home, and sexual orientation, hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and higher psychological-like dimensions of QoL (psychological well-being and taking care of oneself of the SQUALA).

These studies suggest that the relief of depressive and anxious symptoms I experienced upon starting HRT was not something I only imagined – it is a phenomenon that has been repeatedly observed among many other trans people. Conversely, those trans people who did not receive HRT were noted to have higher levels of these depressive and anxious symptoms. This doesn’t bode well for the notion that trans people should first seek relief from their distress through means other than transitioning; medical transition may be exactly what they need.

This is not a mere “fantasy solution” as described by a handful of bombastic personalities who traffic in media controversy. This is real: for trans people, transitioning works. That doesn’t mean it’s a miracle cure-all – and really, what is? – but it does mean that it helps.

9. How transitioning helped me

For trans people who are depressed, treatment for depression is not a substitute for transitioning – it is an additional treatment for an additional condition. Being treated for depression hasn’t made me feel that my transition is any less necessary, or that my womanhood is any less important; I continue to be far more comfortable than I ever was as a “guy”. If anything, I know that the experience of transitioning has put me in a far better position to handle a challenge like depression.

Before I made the decision to start HRT, I saw it as something to put off for as long as possible: it was a last resort, to be used only in the event that any further physical masculinization became intolerable. Eventually, I took a more proactive stance, realizing that it would be better to avert those changes as early as possible. And when I finally started transitioning, I was astonished that I had been missing out on the mental benefits of HRT for so long.

What I learned was: don’t wait. I didn’t have to spend all that time enduring daily discomfort when there was a treatment right in front of me that could have helped. And I wasn’t going to make that mistake again. As soon as I recognized that I was likely experiencing depression, I made an appointment – there was simply no good reason to put it off. The sooner I received treatment, the sooner I could start getting better.

Transitioning taught me what it was like to feel truly good for the first time in my whole life. And this contrast showed me that what came before, the fog of constant unease and dissatisfaction and emotional numbness, was not normal. If I hadn’t transitioned, I might never have learned that there was an alternative – that I didn’t have to feel that way. I wouldn’t have known that this perpetual struggle to cope with my own existence meant that something was wrong.

So when my depression set in, I realized that my search for answers shouldn’t stop at “I guess that’s just how it is”. I knew I had to do something to fix this. As I described it to my doctor: “it feels like before I transitioned.” I have that frame of reference now, with an intimate understanding of just how awful and terrifying that feeling is.

Transitioning, quite simply, improved me. It made me into a more confident, capable, perceptive, outgoing, and overall emotionally well-rounded person. And it made me realize that I matter. At last, I love the person I am, the face I see in the mirror, the mind that can finally work at its full strength. Transition made me care about myself, and now I know that I deserve the best in life. I don’t deserve to suffer.

10. The story so far

Like HRT, I had no idea how this would feel before I started, and I wasn’t sure if it would even make a noticeable difference. But, also like HRT, I’ve now found that it makes a very noticeable difference. By the end of the day, the stress usually hasn’t overwhelmed me, and it fades more quickly rather than sticking around indefinitely. I’m getting more things done, and I’ve even started to write again. I’m just plain happy – or, at least, content.

Before, I’d been struggling to stay above water; now, it’s like sitting in a glass-bottom boat. I can still see and contemplate all the things that had dragged me down before – the sense that I’m worthless, the apparent pointlessness of existence, the question of why I keep going, the knowledge that my body is still wrong – but the dark things are behind a barrier now, and they’ve mostly lost their power to lash out and sink their teeth into me. I could choose to think about them, but I usually don’t; my mind isn’t drawn to them because there’s very little appeal there. Those thoughts rarely arrive uninvited, and they don’t stay for long.

Heather says that my mood is more like that of when I first transitioned. And it does feel like that. I once described HRT as like running my consciousness through a noise removal filter, and my antidepressants seem to have a similar effect. It makes me confident that I’ve made the right decision. It isn’t perfect – I’ve also had a moderate increase in panic attacks, and I’m now being treated for that as well. But, altogether, things are improving. My doctor agrees, and says I can stay on it for as long as I feel it’s helpful. He’ll see me again in three months.

I realize that these are still the early days and anything I say about depression and its treatment still comes from a place of inexperience. There’s certain to be surprises ahead, just as my first excited videos about HRT only offered a snapshot in time that couldn’t predict all the changes that would follow. It could get worse, like dysphoria can get worse. My current medications could eventually stop working, like hormones did. As always, things are going to keep changing, and I won’t know how until it happens.

I still worry that this pattern will keep repeating – that my entire life will just be a constant sprint from one apparent solution to the next, without ever being able to settle on any final answer. But hormones bought me a good year, and hopefully this will too. Transitioning meant checking one thing off the list. Treating my depression is checking off another thing. However long that list may turn out to be, I’m chipping away at it.

Hormones and transition: What would you like to know?

I’ve been on hormone therapy of the “male-to-female” variety for about a year now, and I’ll soon be putting together an in-depth review of its effects during that time. This is still a pretty uncommon thing, and it’s been a really neat experience with a lot of unexpected changes, so I want to make this as useful as possible for others who want to learn about it. So before I get started on it: What aspects of this process do you want to know about?

Whether you’re cis and just curious about what HRT can do, or you’re trans and considering it yourself, I’d like to hear what you’re interested in. The effects are surprisingly wide-ranging and span many areas of the body (including the mind!), so you can really ask about anything and there’ll likely be some notable changes.

In this limited instance, it’s okay to let good-faith curiosity prevail over tact. If there’s something you genuinely want to know, but normally wouldn’t mention because you have no idea how to phrase it inoffensively or you’re not sure it’s appropriate in polite company, just ask anyway. “Ask an adult question, get an adult answer” protocol is in effect – if you really want to go there, I’ll probably go there.

I started this for the very simple purpose of finding out what it was actually like to experience it. Now that I’ve done this, I’d like to share what I’ve found. So what do you want to know?

“That was dysphoria?” 8 signs and symptoms of indirect gender dysphoria

I am not a doctor, and none of this should be taken as medical advice or as diagnostic of any medical condition. These are anecdotes sourced from my experiences and those of others.

Gender dysphoria is widely described and experienced as distress due to discomfort with one’s assigned sex, and the desire to live as another sex. The condition of gender dysphoria is common among transgender people, although being transgender is not itself a condition or disorder, nor is the presence of gender dysphoria required in order for someone to be transgender. Not all trans people have significant gender dysphoria or experience their dysphoria in the same way: different trans people may be uncomfortable with different aspects of their assigned sex, their body, their presentation, the gender role expected of them, and so on.

Nevertheless, the common thread of gender dysphoria is that it is linked with our gender and the various components of this. The distress of dysphoria, and hopefully its resolution, are contingent on how closely the overall situation of our gender aligns with what we need it to be. For this reason, people typically understand the experience of gender dysphoria as being very clearly and self-evidently centered on gender. The most widespread notion is that we become aware of our dysphoria in very direct, gender-related ways, such as knowing from a young age that we’re actually women or men despite the sex we were assigned, feeling “trapped” in our bodies due to their inappropriate sex characteristics, needing to make our “outside” match our “inside”, and strongly wishing to present and live as another gender.

Diverse experiences of dysphoria

This understanding of gender dysphoria is an incomplete one. A largely unrecognized facet of dysphoria is that not all trans people initially recognize or experience this as being unmistakably connected to our genders. Some of us suffer the distress that stems from dysphoria, but without many clues that this is about gender, and its relation to our genders may be obvious only in retrospect. Much attention is focused on the “gender” part of this, the well-defined cross-gender identities and needs and feelings. Less is given to the experience of more general dysphoria.

What is dysphoria? Outside of gender dysphoria, it’s hard to find much useful information on what dysphoria itself is supposed to mean. It’s certainly not limited to gender dysphoria – it can be a symptom of various other conditions as wide-ranging as anxiety disorders, personality disorders, major depression, bipolar disorder, schizophrenia, insomnia, PMS, and stress, and it can also be a side effect of antipsychotic drugs.

But what does dysphoria actually feel like – how does it present itself? You won’t find much more detail than a simple list of other symptoms. Wikipedia describes it as “a state of feeling unwell or unhappy; a feeling of emotional and mental discomfort”. Another page lists anxiety as a symptom of dysphoria, and dysphoria as a symptom of anxiety. As a 2007 paper in Australasian Psychiatry concluded:

The current semantic status of dysphoria is most unsatisfactory. Its definitions are usually too broad or too simplistic and, therefore, not clinically useful. There is no agreement on what the term means.

People in distress want to understand exactly what it is they’re experiencing and why they’re experiencing it, and vague references to “feeling unwell” are not helpful. We already know we’re not feeling well. Why? And what can we do about it?

That’s the question faced by trans people whose gender dysphoria doesn’t present in ways that are directly and plainly connected to gender. My gender dysphoria primarily took the form of this indirect dysphoria, and I’ve spoken with many other trans people whose dysphoria also did not initially have a clear and unavoidable association with gender. Due to the lack of strong indicators that these “unwell feelings” are actually a matter of gender, it can take us quite a long time just to realize that we’re trans or that what we’re feeling is dysphoria. This can be so non-obvious that even as some of us do begin to explore the possibility of transitioning, we still might not make the connection that our unwell feelings are a symptom of dysphoria, or that transitioning is something that could help with this.

The importance of recognizing dysphoria

When you don’t know what this is, or that it’s even an actual condition, it’s easy to mistake it for who you naturally are. You might think it’s part of your innate personality and disposition, and something you just have to learn to cope with. This can delay recognizing that you’re trans or that transitioning is an appropriate choice for you. Because I viewed my lifelong unease in this way, I initially believed that I didn’t even experience dysphoria, and that I was already okay. I didn’t know there was anything wrong with me.

The real extent of my dysphoria only became clear after I began to transition (motivated largely by the desire to induce physical feminization and prevent further masculinization, rather than the need to treat a clear dysphoria), and these feelings dissipated for the first time ever. Once I had this basis for comparison, I could see that I was indeed experiencing gender dysphoria all along – it was just so indirect that I had failed to recognize it as specifically gender-related.

Trans and questioning people sometimes doubt that they’re trans simply because they don’t have distinct feelings of gender-related unease. They might otherwise face a great deal of confusion about what it is they’re feeling, but they can be aided in their self-understanding by the insight that gender dysphoria doesn’t always manifest as a neon sign flashing “FIX YOUR GENDER”. For them, it can help to realize that their less specific feelings of discomfort might also be due to gender dysphoria. It can give them a possible answer to explore. It can give them hope.

But they won’t get that from uselessly opaque lists of symptoms like “discomfort” and “unhappiness”. Words like “anhedonia” and “malaise” don’t capture the detailed, visceral, day-to-day reality of this indirect dysphoria. Here, I aim to define it ostensively, with real-life examples of this dysphoria that seem broadly common to the experiences of myself and others.

Again, not all trans people will necessarily have all or any of these signs, as everyone’s gender dysphoria is different. Some people have more obviously gender-related symptoms than others. Similarly, not everyone with these signs is necessarily trans. They aren’t inherently limited to sufferers of gender dysphoria and can potentially be due to any of the other conditions previously listed, like garden-variety depression or anxiety disorders – but for some trans people, these are indeed symptoms which resolve once the dysphoria is addressed.

This is an initial attempt to feel out a phenomenon that isn’t yet widely known, named, or defined. Some trans people may recognize their experiences in this list, and others may not. But if I had known these things, it would have made my transition a lot easier. And perhaps cis people, too, can start to understand just how damaging dysphoria can be – and how important it is to treat it.

Signs of indirect gender dysphoria

1. Continual difficulty with simply getting through the day. For most of my life, everything was inexplicably stressful, and it was hard to work up the effort to do even the smallest everyday things. Going to the store, cleaning up the house, getting in the shower, any little thing people asked of me… it all just felt like too much. Even when there was no situational cause for this stress, nothing came easily to me. It was more than a mere habit of laziness – it was like I was so mentally fatigued that everything was a constant burden and a struggle.

I could force myself to get things done, but it would take a lot out of me. I would be irritable, snappish, annoyed by everything, and in anywhere from a mildly bad mood to a very bad mood almost every day. What happiness I did experience was typically short-lived and compromised by the ongoing undertone of dissatisfaction and, well, grumpiness. I didn’t like this at all. It was a constant tension, and I wished more than anything that I could find some way to relax and unwind. I didn’t want to be this way.

2. A sense of misalignment, disconnect, or estrangement from your own emotions. I was always on an unsteady footing with my feelings. As a child, I would cry almost every day at the drop of a hat. Anything could trigger it – being even mildly reprimanded, getting a wrong answer on schoolwork, the sort of insignificant things that no one else around me ever cried so frequently about. It really was abnormal, and eventually most of the people around me got pretty tired of it. It was so embarrassing and I tried to stop it because I didn’t want to cry so much, either. But I couldn’t control it.

In my teen years, this shifted: I could almost never cry at all, even when I wanted to. I would feel like crying, I would know on some level that I should be crying, but I just couldn’t make it happen. When I rarely did manage to cry, that was even worse. It was too much, and I would be overcome by it to the point of uncontrollable wailing sobs. There was no in-between, no moderate amount of tears. I cried as much at the death of a month-old pet rat as I did at my grandmother’s funeral.

And I dreaded crying, because afterward and for the next day or so, I would be smothered in this horrible feeling of emotional deadness. It felt like my head was full of concrete, like my consciousness was trying to wade through molasses, and it was a feeling that seemed to be genuinely physical in nature. It seemed as though my brain simply ran out of whatever fueled my ability to feel anything at all – like I had no emotions left. There was no way to “get over it” or force myself to perk up, I just had to wait it out. I resented anyone or anything that made me cry. I feared the awful choking numbness that was bound to happen next time.

3. A feeling of just going through the motions in everyday life, as if you’re always reading from a script. Everything always seemed like it was somehow less real than it ought to be. I didn’t feel like I was my own person – I had no sense of myself as someone who could make my own choices and decisions as I wished. I often lacked that internal initiative that wants things and seeks things for no reason other than the fact that you simply want them and that’s that. I didn’t even think of that kind of wanting as a feeling I was capable of – there was just no drive for it.

In the absence of a well-defined identity and a strong sense of self-direction, other people’s obligations filled the void. Since I didn’t want to do anything, I just did whatever was expected of me and said whatever was expected of me. That was all I ever did. I felt like an actor, being handed my lines by someone else, and I didn’t know how to be anything other than that. I didn’t know I should be anything other than that. I often thought of wanting to tear my face off to see if there was anything real underneath.

4. A seeming pointlessness to your life, and no sense of any real meaning or ultimate purpose. Even when I did find things to do that I vaguely enjoyed, it still felt like I was just killing time. Each day was like checking off a box, knowing that eventually the days would run out, but not really knowing how else to spend the time. When I worked on things, there wasn’t any higher sense of eventually working toward anything.

You live for a while, and then you die, and that’s that. I didn’t think there was anything else to life. So why bother with any real long-term goals? When I did set goals for myself, it was just for the sake of it – not because I was motivated by any purpose that I genuinely cared about. Nothing made me feel truly fulfilled, like I was accomplishing anything meaningful. So why bother?

5. Knowing you’re somehow different from everyone else, and wishing you could be normal like them. I often wondered how other kids could just go about their lives, talking and laughing and being so calm and happy, like nothing was wrong. I don’t know what I really expected of them – I didn’t have the vaguest idea of what was “wrong”, either. I didn’t know why I felt so anxious all the time, I just did. I had no idea why the rest of the world didn’t feel the same way, and I wanted to know what that was like.

It felt like my mind was constantly talking to itself without any interruption, and it was overanalyzing everything around me. Some second, parallel existence seemed to be running alongside my direct experience of consciousness: an inner monologue of sorts, but a very toxic one. I couldn’t stop thinking about everything – it was as though this loud voice in my head kept me from simply existing in the moment.

There was no way to shut off that voice and just be, like everyone else. I wanted those two sides to line up and merge so I could feel natural and at ease too. But it wouldn’t go away, no matter how hard I tried. There always seemed to be some invisible skin separating me from the rest of reality – I could move around in the real world, interact with it, but never actually touch it or feel it.

6. A notable escalation in the severity of these symptoms during puberty. Around 12 or 13, things really started going downhill for me. While it was already difficult to cope with school, friends, and a troubled home life, I was able to handle it before the onset of puberty. Not anymore. For a few years, my emotions weren’t just blunted or dysfunctional – they went missing almost entirely. I felt nothing, day in and day out. And each day was the same, a robotic routine of just waiting for the time to pass. I couldn’t even force myself to care about anything. This, too, felt like a truly physical thing that I couldn’t fight.

I knew I was failing every class, and it just didn’t matter to me. I handed in blank tests without a care in the world. I was fully aware of what the long-term consequences would be, but none of it seemed real. I’d already hit bottom – nothing could make it any worse. I couldn’t bring myself to get anything done no matter how much anyone lectured or threatened or punished me.

They told me I was throwing away my future – I didn’t even see any problem with that. What future? Why did anyone care about me? I sure didn’t. My parents withdrew me after sophomore year because there was no point to keeping someone in school who just didn’t do anything. So I stayed indoors like a hermit for most of my teen years, and didn’t do anything there, either.

7. Attempting to fix this on your own through various coping mechanisms. I often wondered whether some substance, like cannabis, was what I needed to loosen up and finally relax. I tried that. I tried drinking, I tried Vicodin, I even tried nootropics like piracetam, all of it in the hopes that it could improve my mood and make life feel easier. I wanted to find something, anything, that would be the key to repairing what I increasingly saw as the broken parts of myself. Some of it helped for a short while, thought not significantly. By no means did it “fix” me in any meaningful sense – it took my mind off things for a bit, but the problem was still there.

When none of that worked, I tried to train my mind to shy away instinctively from negative thoughts so that I wouldn’t spiral off into depressive ruminations as I had for most of my teen years. This was mostly successful, and it wasn’t a bad idea by any means, though the fundamental unhappiness and anxiety remained. I figured all I could do was ignore it as much as possible and focus on whatever positives I could find – I gave up hope of ever truly fixing this.

8. Substantial resolution of these symptoms in a very obvious way upon transitioning, particularly upon initiating HRT. While this is somewhat of a diagnosis-by-treatment, this is what makes it clear that these difficulties are indeed specifically gender-related, and not due to other conditions. If we’re fortunate, then one way or another, we eventually start to pick up on our own personal hints that lead us in the direction of reconsidering our gender. And at a certain point in the process, we begin to realize that this might be what we’ve been searching for all our lives.

For me, as I transitioned a little, it helped a little. When I presented in a feminine way and took on a feminine identity, I started to come into my own and take shape as a real person. I began to steer my life in a direction that I wanted. It was easier to have goals and things I derived satisfaction from, and this encouraged me to start caring about myself more. I was able to fall in love and have a real relationship for the first time – something I never saw the point of before, and had resigned myself to doing without.

Still, my general sense of discomfort and irritability remained, and it kept making my life difficult. I was tired of feeling bad every single day. But as it turned out, when I transitioned a lot, it helped a lot. Once I started HRT, the effect was immediate: these symptoms totally dissipated. It was such a stark difference, it became clear that what I’d been suffering before likely was indeed physical and chemical in nature. I could tell it had been gender dysphoria, because it just wasn’t there anymore once I received the treatment for gender dysphoria.

Now, I could actually relax – it was so amazing to be truly calm for the first time in my life. And it lasted, and there was no more pain to hide. I could cry and feel good afterward, as if it replenished me rather than draining me of emotion. It was possible to feel things in all their detail and depth and texture, rather than being limited to either numbness or emotional overload. The skin of separation was gone, and life was a breeze: I was just happy, all day, without constantly intrusive thoughts distracting me and separating me from the world. I can truly care about everything I choose to work towards, because it matters now. I’m the normal person I always wanted to be, and I can get on with simply living.

Finally, I was a whole human being. Nothing was wrong and nothing was missing anymore. I found what I was looking for, and it gave me back the life that dysphoria had taken from me.

Again, these signs aren’t shared by all trans people – every person’s dysphoria is a little different, and transitioning can have differing effects on us. But it seems that a significant portion of trans people, whether their dysphoria is clearly gender-related or more subtle, report having feelings similar to these. If you’ve been reevaluating your gender, and these experiences seem relatable to you, it may be worth considering that this could be gender dysphoria – and that it’s potentially treatable.

Update, March 2014: Please see my followup post on my recent experience of being diagnosed with depression after transitioning, as it contains important additional material pertaining to these symptoms.

MetaMed: The best second opinion

There’s a pretty cool new company I’ve been working for lately. It’s called MetaMed Research, and it’s a concierge medicine service that researches treatment options for unresolved health problems. When someone has already seen several doctors, tried all the common treatments, and nobody knows why they’re still suffering, what can they do now? Is that the end of the line? It shouldn’t be. This is the role that MetaMed seeks to fill: finding possible solutions for unanswered questions. Not everyone has the resources to start a biotech company just to develop a treatment for their dying children, but we think we can provide people with the same kind of opportunity through personalized medicine and comprehensive research.

In addressing a client’s needs, we tackle multiple problems that come to bear on their health issues: giving them personal attention that takes into account their individual biological variations, separating relevant and valid literature from useless and poor-quality studies, and rationally evaluating the strengths and weaknesses of all of the available evidence. These are a lot of words to say that we do our best to figure out what’s true, what’s false, and how this can help someone with a particular condition.

Why is this necessary? First, people can miss things, even things that they really should not miss. When patients diagnosed with breast cancer were referred to a board of specialists, 52% had their surgical recommendations changed. 45% received a new interpretation of their imaging results – in some cases, second cancers were identified that had been missed the first time. For 29%, their test results were interpreted differently by pathologists, affecting the staging of their cancer. How many of these patients would have had improper or inadequate treatment if it weren’t for this second opinion? How many patients are getting the wrong treatment every day, when errors in diagnosis are this common even for deadly diseases like cancer? We believe that teams of specialists can similarly apply their expertise to a variety of health conditions and make better diagnoses that may have been missed.

Second, scientific studies aren’t necessarily reliable merely because they’re scientific studies. In 2010, a psychologist designed an experiment based on the idea that there would be an evolutionary advantage to being able to perceive the future possibility of sex – essentially, precognitive detection of sexually available partners would aid in successful reproduction, and thus select for itself. In the experiment, study participants were asked to select which of two concealed images they believed would contain “erotic stimuli”. Said stimuli was placed randomly, after a participant made their selection. The original study found that they were able to select the correct image – “predicting” events that had not yet happened – with slightly better accuracy than would be expected from chance alone. This was widely reported as evidence of human precognitive ability. However, even when numerous replications showed negative results, the original journal refused to publish them, simply because they were replications. It would seem that while “Porn Travels Backward Through Time” was an appealing headline for the Journal of Personality and Social Psychology, “Porn Does Not Travel Backward Through Time” was not quite so attention-grabbing. This isn’t just a one-off, anomalous disgrace. A majority of published research findings may actually be false, and it’s crucial to evaluate a study’s strength instead of taking it at face value. MetaMed weighs studies according to how well-supporting their findings are, taking into account any flaws or biases that would compromise their results.

Third, not all relevant information is taken into account when treating patients. Why do some drugs work only for some people and not others? It’s because there are vast individual differences in how people metabolize those drugs, and most medical treatment fails to recognize those variations. Patients are often treated with one-size-fits-all regimens, and their unique genetic and metabolic features aren’t taken into account. Doctors also don’t have the time to research every patient’s case individually, and there’s no way for one person to keep up with the volume of published literature that could be relevant to each patient. MetaMed can offer them a kind of support team, focusing on the details of a patient’s disease process and searching medical literature to find potential interventions.

It’s a pretty simple idea: more evidence, better evidence, better answers. Yet this kind of highly personalized medical practice is rare enough that there’s a niche for MetaMed to fill. That’s the service we offer, and I think we’ve got a decent shot at this.

Do you have a gender identity? Want to find out?

“How can you know that your gender doesn’t align with your body? What does it feel like to have a gender, anyway?” These are common questions from cis people who want to understand what it’s like to be trans. They want to know how we can be so aware of our gender that this internal sense of identity overcomes what our anatomy would seemingly dictate.

One of the usual replies is to turn this around and ask them how they know that they’re the gender they identify as. This is often explained through a thought experiment: we ask them to imagine how they would feel if they unexpectedly woke up in a body of another physical sex. Wouldn’t they still know that they were their true gender? And wouldn’t they be uncomfortable with a body that doesn’t match their identity?

While this argument may be elegant in its simplicity, it’s not always effective. Many cis people do realize that in this hypothetical situation, they would still have an awareness of their gender and its mismatch with their new body. But others don’t really think it would be a problem. They sometimes reply that they would be okay with this surprising turn of events, and that they wouldn’t have an issue with being another sex. This can make it difficult for them to understand why trans people can’t just accept having a body of any particular sex.

It’s sometimes tempting to tell them their answer is simply wrong, and that they’re lacking in the necessary experiences needed to understand our situation. It can be difficult to have an explicit awareness of your internal gender when it’s never bumped up against the confines of your body and you don’t feel constrained by the social roles attached to it. This is often compared to how people don’t pay much attention to the feeling of the clothes they’re wearing, unless their clothes are uncomfortable and poorly fitting.

That’s the standard response. But it’s also possible that these people may just have genuinely different experiences and understandings of what gender means to them. Ozy Frantz recently theorized that while some people, cis and trans, have a strong sense of their gender, it could be that others actually don’t feel like they have much of a gender at all.

This wouldn’t be unheard of. It’s a common misconception that trans people all share the experience of knowing our true gender from a very young age, and that it’s as unambiguous as a flashing sign that says “male”, “female”, “non-binary”, and so on. But it’s not like that for everyone. Plenty of trans people never had any awareness of gender incongruence in our youth, and it can take us a long time to figure out who we are and what we want to do with ourselves. Even among those of us who do decide to transtition, we might not always feel that life as the wrong gender is totally unbearable, and this can draw out the process of self-discovery even further. For some people, their gender might be clear as day, but for others, it’s a long road to being comfortably certain that our identities have more to say about who we are than our bodies do.

So I wouldn’t really be surprised that some cis people also don’t have a clear sense of gender identity. Just as I didn’t really mind being a man until I started to realize that there was a better option, they might not object to having a body of any sex. But while this could explain why they find it difficult to relate to those of us who are aware of our gender, it can still be frustrating when they question our own need to transition based solely on their own experiences, especially because there’s no way of testing how they really feel about the relationship between their gender and their body. We can go through any number of thought experiments, but there’s no concrete evidence we can gather to clarify the situation, and we end up at an impasse of subjective experience versus subjective experience.

Or not.

The people who ask these questions want to understand what it’s like to be trans. The matter of what it’s like to feel that you have a gender is merely a proxy for this, and there may be ways to simulate the experience of being trans more directly. For example, people who choose to transition often exhibit a distinctly different pattern of reactions to sex hormones. Before cross-sex hormone therapy, while we’re still experiencing the effects of the hormones that are native to our physical sex, many of us report feelings of depression, anxiety, stress, and general discomfort. Of course, much of this could be attributed to gender dysphoria itself, as well as its comorbidity with other mental health conditions, and the prevalence of negative attitudes and discrimination toward trans people in society. But after starting HRT, trans people often notice that this discomfort becomes less severe. This likely has something to do with the satisfaction of feeling our bodies take a more comfortable form, but even before the physical changes appear, many people experience a sense of relief and calmness. They simply feel better.

This stands in contrast to how cis people respond to the presence or absence of certain sex hormones. Cis men with low testosterone tend to experience anxiety, depression and fatigue, which can be relieved by testosterone supplementation. Cis women experiencing menopause suffer from various symptoms tied to a reduction in female sex hormones, and those symptoms can be alleviated by replacing those same hormones. However, despite sharing the same physical sex as cis men, trans women tend to do much better when their testosterone is suppressed by anti-androgens and replaced with estrogen. Trans men likewise respond well to testosterone, even as it suppresses the effects of estrogen.

Because of these clear differences between how cis and trans people tend to experience the effects of sex hormones, HRT is often administered to trans people on a trial basis to see how they respond to it. While not all trans people use HRT, it is a very common treatment, and it’s part of the established standards of care. If they find it helps them, they can continue it indefinitely, and if it’s not right for them, they can stop taking it. Many people don’t know this, but HRT doesn’t have to be a permanent, all-or-nothing decision. There is room for experimentation here.

So, what could this mean for cis people who don’t believe the sex of their body is important to them? Is there a way for them to put their money where their mouth is? Might we be able to show them, in some small but concretely biological fashion, what it’s like to be trans? Ozy noted that we can’t really go around covertly giving cis men HRT for trans women to see how it affects them. But I think we could circumvent most of these concerns if they agree to it first.

I must point out that I’m in no position to give medical advice, and nobody should start taking any kind of medication like this without the appropriate supervision and a full awareness of its possible risks. That being said, it would be surprisingly easy for cis guys to obtain HRT for trans women without once seeing a doctor. While testosterone is a controlled substance, limiting the options for trans men or curious cis women, estrogen and anti-androgens are not. They’re not over-the-counter, but they can be purchased from overseas at a rather low cost. There are even places where you can order the necessary blood tests to ensure that it’s safe for you.

Theoretically, it should be entirely possible for cis men to experience what it’s like to have a poorly-fitting set of sex hormones, without permanent effects. If they were to stop after perhaps a month, any physical changes should be minimal and fully reversible. There would likely be hardly any breast growth, and this would recede after discontinuation. Any erectile dysfunction or reduction in fertility would probably be temporary. Once their testosterone is no longer suppressed, everything should go back to normal, which is why it’s considered relatively safe for gender-questioning people to try out HRT for a short time without having to commit to it.

But while any serious physical changes are unlikely to occur within a month, mood changes are another story. As illustrated by cis women and trans men with their own monthly hormonal cycles, the mental and emotional effects of sex hormones can manifest on a scale of days. The self-reporting of their subjective experiences would obviously be compromised by a lack of blinding and other biases, but no more severely than the self-reported experiences of trans women on HRT. Without a randomized controlled trial to study the effects of cross-sex hormone therapy on cis people who either do or don’t feel a strong sense of gender identity, this may be the best we can do for now.

Again, I certainly can’t recommend that anyone should actually try this. But if they wanted to, the option is always there, and the results could be interesting. This isn’t just for the sake of proving a point – I’m in no position to predict how any one person would respond to cross-sex hormones, especially when they don’t even feel like they have a gender. For all I know, they might like it. But this is something they would have to find out for themselves – just like I did.

Fact-checking the 20/20 special on trans kids

Last Saturday’s 20/20 special on Jazz, a pre-teen trans girl, was generally better than most media coverage of trans people. It avoided most of the common pitfalls of trans documentaries, while being thoroughly humanizing and about as respectful as a mainstream story on the topic can be. For the most part, it wasn’t needlessly salacious, and where other news outlets might have been tempted to portray Jazz as somehow being damaged or raised inappropriately by her parents, the report made it clear that she’s very well-adjusted and happy.

Their coverage was wholly sympathetic, never depicting this as some kind of tragedy, and with no token inclusion of “family values” bigots to offer some “other side” to whether this girl should be free to live her life. They didn’t insist on using her former name at any point, and there was no use of male pronouns. They let Jazz speak for herself, and she told them she didn’t see being trans as a “disorder”. They drew attention to the fact that transition-related treatments are mostly not covered by insurance plans in the US. And when they did insist on talking about genital surgery, they accurately described it as an inversion of the penis while avoiding ugly references to “chopping it off”.

It’s a sorry state of affairs when the most we can ask for is not to be treated as family tragedies, mutilated freaks or sexual perverts. Praising the good points of this report feels a lot like saying “hooray, this story on gay parents made no reference to pedophiles and didn’t include even one scene of bareback porn! Somebody get them a GLAAD award!” But at a time when much news coverage falls short of even that, and major papers still consider it acceptable to publish op-eds calling trans women “dicks in chicks’ clothing”, this stood out as an oasis of relative decency.

Nevertheless, as a mainstream report on trans people, it predictably contained several instances of misleading phrasing and inaccurate information. Jazz was twice described as “a boy living as a girl” and “a boy who wants to be a girl”1, as well as “a child born in the wrong body”2. There was a strong focus on her “pink cleats” and her bedroom “filled with girly things, dresses and dolls”3. There were references to an “ultimate surgery to become fully female”4, and breast augmentation was treated as a standard part of transitioning5. Viewers were told that “once Jazz begins taking estrogen, she will be permanently infertile”6, and that “the cross-hormone therapy is irreversible”7. And treatment with estrogen was described as costing more than $18,000 a year8.

If you’re not sure what’s wrong with these statements, you might want to try your hand at figuring it out before skipping to the footnotes for the answers.

Overall, this show still served a useful purpose, while mostly managing to avoid promoting harmful misconceptions. It showed that children who are trans can have a good life just like everyone else, and that living as their identified gender is healthy for them. It let a general audience know that there are treatment options available to correct these children’s bodies and help avert the damaging effects of puberty. For parents out there who don’t understand why their child seems to identify more closely with another gender, this story gives them the basic conceptual vocabulary they need in order to comprehend the situation and most effectively support that child.

The report could have been improved with more medically accurate information – as is, some aspects of transitioning were made to seem more imposing, epically significant, and financially inaccessible than they are in reality. The use of certain gender stereotypes was also troubling. But the central message was still one of normalcy, happiness, respect and empowerment, elements which have often been almost totally absent from many stories about us. Future media coverage of trans people would benefit from a similar approach.


1. Take away the qualifiers, and phrases like “a boy living as a girl” are still describing her as “a boy”. This suggests that a “boy” is something she is, whereas being a girl is merely something she does – an activity or ambition, akin to playing soccer. This downplays her identity as a girl, when the significance of her gender is clearly integral to the entire story.

2. The metaphor of having the “wrong body” is a simplified explanation meant to convey the fact that someone’s identified gender can indeed differ from their assigned sex. It’s intended to counter the notion that someone’s body cannot possibly be “wrong” and that a person must identify as what their anatomy would seem to dictate. However, while many trans people do experience significant distress at the state of their body, there are also many others who did not always feel that their body was strictly “wrong” for them.

The widespread promotion of this very basic explanation is not harmless – it has sometimes led trans people to believe that they couldn’t really be trans if they didn’t experience the sense of “wrongness” and overwhelming discomfort with their body that’s implied by this metaphor. Yet these trans people are still trans nonetheless, because they prefer to live as a gender other than their assigned sex. While the presence of this bodily dysphoria can strongly indicate that someone is trans, its absence does not preclude them from being trans, either.

3. The emphasis on Jazz’s interest in feminine-coded items is obviously meant to legitimize her identity as a girl. It’s intended to show that despite being told by her family, society, and her own body that she’s supposed to be a boy, her female identity was still strong enough to emerge in this fashion. And while that’s a valid and important point to make, demonstrating it with these particular examples runs the risk of delegitimizing the genders of other trans people who did not exhibit such gender-stereotyped interests at an early age.

Trans people who clearly and overtly identified as another gender from early childhood, like Jazz, are currently only a small minority. Not everyone “just knew” for as long as they could remember or had a strong sense of identifying as another gender. For many trans people, this realization does not occur until adolescence, young adulthood, or even later. Because this expectation of self-awareness in childhood is so prevalent, trans people and those around them may doubt that they could actually be trans if there was no indication of it in their youth.

But the absence of this early awareness or expression of their true gender isn’t because they’re not really trans. It can be due to the deficiencies of introspection that are common in children and people in general, or a lack of access to information about what it means to be trans, or their own conscious repression of any display of gender-transgressive interests – because they know they would face severe disapproval and consequences.

Conversely, there are boys who take a strong interest in pink things and other feminine-designated items, while still identifying as boys. There are also tomboyish girls who don’t consider themselves to be anything other than girls, regardless of their masculine-designated interests. Obviously, most cis people are not walking stereotypes of masculinity or femininity – people show diversity in their interests, behaviors and attitudes. Trans people are no different, and Jazz would be no less of a girl if her bedroom were full of motorcycles and football posters.

4. Genital surgery is neither an “ultimate surgery”, nor does it mean that someone is “fully female” or male. Most people still consider a vagina or penis to be the final word on whether someone is a woman or a man, so it’s easy to see why they chose to use this as a euphemism for the relevant surgery. (I’d imagine someone decided against calling it “having a vagina installed” in the promos.) But not all trans people pursue surgical transition, and there isn’t any one “ultimate surgery”. Full genital reassignment surgery isn’t the only surgery for trans women – there’s orchiectomy, facial feminization surgery, breast augmentation, tracheal shave, and vocal cord surgery as well.

Trans women may choose to have any combination of these surgeries (if they have a choice in the matter), or none at all. Not everyone wants them, not everyone is medically capable of having them, and not everyone can afford them. As was mentioned on the show, these procedures are often not covered by insurance, and can cost tens of thousands of dollars out of pocket. Many trans people are not in a position to pay for this.

But someone is not any less “fully female” or male just because of the configuration of their body. A trans woman who has a penis is still a woman, no less female or more male than women who’ve had genital surgery. That’s why Jazz, who hasn’t had any surgeries, is still a girl, and the show itself referred to her as such. Assuming that someone’s manhood or womanhood depends on their genitals just provides another excuse for misgendering trans people, calling women “he” and men “she”, despite the fact that their physical anatomy doesn’t define their identity at all. Wasn’t that pretty much the entire point of the show, anyway?

5. While some trans women seek breast augmentation, many are able to achieve breast growth that they consider satisfactory from HRT alone.

6. Trans women who begin HRT as adults, without having had any intervention in their own endogenous (“male”) puberty, have sometimes been known to regain fertility if they discontinue HRT. There is little data on why some regain their fertility while others don’t. Some trans women remain fertile even while on hormones. This is why trans women have to take the same precautions to avoid impregnating their fertile partners, if their sexual activities are of such a nature that this is possible. There seems to be no information about the effects on fertility for trans women whose first puberty has been entirely averted in favor of inducing female puberty, but it can’t be assumed that starting hormones is certain to deprive you of your fertility on a permanent basis.

7. Some of the effects of HRT are reversible, and others are not. Breast tissue grown while on HRT can recede somewhat if HRT is discontinued. Genital shrinkage can reverse. As mentioned above, fertility may or may not return, if it was ever lost. Without the suppression of testosterone, masculinization will resume, with the same effects as in cis men – facial and body hair growth, rougher skin, possible male-pattern baldness, and so on.

For trans women who transition early enough to avert endogenous puberty in favor of female puberty, their overall bone structure and body shape will be like that of a cis woman who’s been through puberty. That particular effect is indeed fixed and irreversible. But it should also be taken into account that allowing young trans girls to undergo their own uninterrupted endogenous puberty is irreversible in exactly the same sense as induced female puberty. In either case, they will have to deal with the permanent effects arising from this. In portraying this intervention as something that can’t be undone, it should be made clear that allowing endogenous puberty to proceed carries the same risks – it is just as much of a permanent step with permanent consequences.

8. The treatment to delay puberty tends to be more expensive than standard HRT regimens (estrogen, anti-androgens, and optionally progesterone) for trans women, and there is no conceivable scenario where estrogen alone would cost more than $18,000 a year. To put this in perspective, at the going rates for neovaginoplasty, this is roughly equivalent to having one neovaginoplasty in Thailand a year. This number seems to be off by a factor of 10 to 100. In some areas, oral estrogen can be obtained for less than $20 a month. Even subdermal pellets, the most expensive method of administration, would have to cost $1,500 a month for this to add up.

And I’m not going to miss it

It looks like Anderson Cooper’s talk show is being canceled. And I’m happy to hear it. On one occasion, Cooper used his new platform to publicize the claims of a trans woman who’s suing drug manufacturer Merck because she believes their hair loss medication made her trans, citing unnamed and likely nonexistent “thousands” of men who have allegedly experienced the same thing. This kind of sensationalism can ultimately be more harmful to us than the Jerry Springer “my girlfriend is really a man!” style of overt transphobia. In this case, it served to promote absurd, unproven, and completely impossible ideas about what it means to be transgender, by seeking to tie it to a pathological origin.

The drug in question, finasteride, reduces male-pattern baldness by blocking the action of testosterone. This is why it’s also sometimes used in hormone replacement therapy for trans women – women who could potentially lose their access to this medication if a ridiculous lawsuit like this were to succeed. The reduction of testosterone in cisgender men does not turn them into transgender women. Indeed, cis men who suffer from low testosterone often experience something similar to the dysphoria that can occur in trans people who are missing the hormones specific to their gender identity. Likewise, their symptoms can be relieved by replacement of those hormones. Trans men without testosterone don’t just become women for lack of male hormones. Neither do cis men. Gender identity simply doesn’t work like that – hormone deficiencies can result in or amplify dysphoria, but they don’t cause people to flip genders. And the relief of dysphoria that comes from transitioning isn’t typically accompanied by trying to sue the pants off the people who supposedly cursed you with this terrible fate.

Anderson Cooper willingly allowed this woman to spread bizarre misconceptions about being trans to the wider public. It’s a relief to see that the show’s ratings now reflect how empty-headed its content was. Good riddance.

Sometimes, ADHD is real

A lot of people seem to have the idea that attention deficit hyperactivity disorder is something less than a real condition. Many have claimed that the diagnosis of ADHD pathologizes what’s actually normal childhood behavior, or that it’s presented as a problem in order to sell a solution in the form of unnecessary medication with unknown long-term effects. Others say that ADHD is real but overdiagnosed, and medication is used where changes to the child’s environment would be more appropriate. Most recently, the New York Times reported on a doctor who prescribed ADHD medication to children who are struggling in school, regardless of whether they actually have ADHD. He believes that the school system is poorly suited to children, but that people are unwilling to make changes on a systemic level, and so they resort to medicating their children.

The problem is that many of these folk theories about the reality, causes and proper treatment of ADHD are mostly nonsense, perpetuated by people who think they’ve uncovered some grand conspiracy but have very little understanding of what they’re talking about.

Our 9-year-old son has ADHD, and he takes medication for it. His mother has ADHD, his father has ADHD, and his younger brother sometimes appears to have symptoms of ADHD – although this can be largely indistinguishable from the typical range of toddler behavior. And anyone who believes that ADHD is a hoax or can be addressed solely by environmental changes should really try spending some time with our son when he’s unmedicated.

While it’s certainly possible that children have been inappropriately diagnosed with ADHD in some circumstances, this does nothing to show that ADHD does not exist in other children. This also isn’t a matter of making an exclusive choice between either medication, or alternative means of support. There’s no reason why we can’t use everything at our disposal to treat this. And while the side effects of medication always need to be taken into account, it’s also crucial to consider the effects of withholding treatment that works.

We waited for as long as possible before looking into medication for our son. We explored every other option that was available to us. He had a specialized plan at school and extra tutoring, and he still does. We worked closely with him every day to help him understand his work, and we gave him extra practice in every subject. And it wasn’t enough.

This was not just an instance of a child chafing against the unreasonable constraints of standardized education. His environment was not the problem, and shaping his environment around him would have meant letting him flounder. This was a second-grader who would often spend three hours trying to complete a single sheet of simple addition, with the help of two adults. This was a child who had to be reminded a dozen times before he would even remember how to complete a basic task like setting the table – let alone actually getting it done. This was a kid who could not stop himself from talking, yelling, and running wildly around the house. His insomnia would keep him up all night, doing nothing but talking to himself in bed, until he was so tired that he fell asleep almost every day in school. His teachers would make him sit through 40 minutes of reading class, 15 minutes of recess, and 50 more minutes of science class just trying to get him to write a single sentence.

His eyes would glaze over halfway through trying his best to add 5 and 4, when he lost track of what he was doing and had to start over for the third time. He would stumble through trying to read short sentences, and couldn’t tell us what they actually meant even after we read them back to him. He continually failed to be influenced by incentives or even understand their purpose. He forgot to bring home his work, and he didn’t turn it in when it was finished. He would burst into tears every day when trying to do his homework. He told us he was “the worst kid ever” and that he wanted to kill himself. This was a child who was going to be held back a grade, again. And he knew that he had a serious problem. He did not like how he was, and he did not want to be like this. He just wanted to be good, and he couldn’t, no matter how hard he tried.

His instructors and evaluators refused to believe that he could have ADHD, because they thought it was “overdiagnosed”. They laughed at my partner when she suggested it, even when she told them that his father had been successfully treated for ADHD. Instead, they claimed he was mentally handicapped, and that was why he was consistently performing more slowly than the other children. We knew that couldn’t be the case, because in those brief moments when we could get him to focus, he could understand his work. Something was just getting in the way. Only after intelligence tests found him to be above average did his teachers admit that ADHD was a possibility.

We had already figured this out, and we still didn’t want to have to medicate him. We were worried about the long-term effects, too. We didn’t want him to have to rely on medication instead of developing coping strategies. But we were wrong. Eventually, we had to recognize that this constant pain was not encouraging him to develop coping strategies. It was only making him miserable. This wasn’t helping him to grow – it was destroying him. Those who criticize parents for supposedly “taking the easy way out” when they have their children treated for ADHD have made the mistake of thinking that struggle must always be virtuous. They want to believe there must be some great payoff in proportion to all the trouble. But sometimes there’s not. In reality, his ongoing struggles weren’t good for any of us. We had to accept that when it came to the well-being of our son, it wasn’t our principles that mattered – it was the results.

Has his medication been a cure-all? Of course not, and this was by no means an excuse to stop helping him. He still gets all the support he needs from his family and from his school. The difference is that now, it’s actually working. Instead of running just to stay in place and still falling behind, this makes progress possible. He remembers to bring his work home and turn it in. He can finish his homework on his own without requiring constant attention, and he gets it right. He doesn’t fall asleep in school, and when he stays up late, he actually chooses to read books. He can focus and tell us what the sentences mean. He listens to us, he can control himself, and he can behave himself. And he smiles so much more! He’s happy now, he’s less anxious, and his attitude toward school has improved remarkably considering how difficult it had been for him. He’s passing instead of failing, because he finally has the basic abilities that are required to learn and succeed.

The inertia of the status quo often gives it a certain privilege in people’s minds. They set higher standards of justification for switching to an alternative than they would for simply staying on the present course. But when we put our options on an equal footing and considered them fairly, we could not justify depriving him of the treatment that would actually help. This isn’t just a matter of how it’s affecting him now. When ADHD isn’t properly treated, it can lead to higher rates of substance abuse, anxiety, depression, dropping out, car accidents, unwanted pregnancies, STDs, unemployment, and everything else you might expect to result from being chronically unable to think clearly. And we’re not willing to stand by and watch him fail over and over while we try to find alternative treatments, when we already have one that works.

This was not our first choice, and if other means were sufficient to control his symptoms, we wouldn’t have chosen to medicate him. But as of right now, this is not possible. Do we enjoy paying for expensive medication? No, but there is absolutely no way I can regard it as some kind of scam. The value to our entire family has been incalculable. ADHD had made our above-average child seem like someone who was mentally challenged. This is what finally worked to undo that, and I could never expect other parents to forgo a treatment that’s had such a transformative effect.

Regardless of what anyone else may think, this is a personal decision to be made by the family based on their situation and their needs, and I don’t find it at all appropriate to issue blanket condemnations of medication for ADHD when this may be exactly what someone’s child needs. Everyone wants what’s best for kids, and certainly nobody wants what’s worse for them. But when people are unclear on how to achieve this, their ignorance can lead them to conclusions that fail to respect the reality of what these children are dealing with. We would know – we’ve been there.