So I’m at this Christmas party thingy for a trans support group last month, and I’m catching up with a girl I know, and she begins asking me weird, akward-ish questions, like “how are your boobs doing?”

These kinds of things tend to go with the territory at trans support groups.

Providing my usual evasive, non-committal response, she proceeds to inform me that her own have been developing fantastically. First, she explains that she’s been taking progesterone. I reply that I’ve heard mixed things about it, that it, more than any other HRT medication, tends to be a bit unpredictable and rather on the “your mileage may vary” side of things- negative effects being reported just as often as positive ones. She then says that she’s on the “brand” of progesterone that has “only two side effects”, one of which she claims is breast growth. I begin to become a bit suspicious of whether she wholly understands the concept of “brand” as applied to medication (particularly a hormone like progesterone, which is going to be progesterone no matter who is actually manufacturing it) and also how much she understands what “side effect” means.

And then it got worse.

Apparently she owed much of her growth and success to additional, supplementary “medications” she was taking- herbal, natural, and homeopathic. She described it as “covering all my bases” and taking “both western and non-western approaches”. When I tried to begin discussing the actual efficacy of such supplements, she simply replied “I’m not a skeptic” (her being aware of my work with Skepchick) and left it at that.

I didn’t even get a chance to point out how given that she was taking her herbal supplements along with the proven, clinical hormones like estrace and prometrium, she had no way of being able to tell what was causing any of the growth she was experiencing.

“I’m not a skeptic” … *sigh* … might as well be saying “I don’t really care if it has any evidence or not. I’m not going to bother questioning it. Leave me alone with your annoying ‘facts’ and ‘science’.”

So this got me worried. Worried and thinking. A state I spend far, far too much time in, as a general thing.

Given the rarity of transsexuality, the lack of attention paid to the subject in medical school and the medical community as a whole, the immense amount of misinformation floating around on the subject, its politicized nature, and the degree to which cultural biases and incentives impact and distort the medical and scientific discourse on the subject, trans people are typically put in the position of having to educate themselves about the nature of transition and treatment, what to expect, what treatment to pursue, what is dangerous or contra-indicated, and then often have to educate their own healthcare providers on how to effectively treat them (for at least two of my own doctors, I was their first ever transsexual patient and had to take on this role). Generally we have to at least partially assume the role of being our own doctors.

This ends up putting us in a uniquely vulnerable position in terms of quacks and alt-med providers. Since we have very, very good reasons to not wholly trust the medical establishment, we are that much easier to convince that doctors don’t know what they’re doing or don’t really care about us and these people, over here in the nag champa scented strip mall, they know what’s best for us. We do have to conduct our own research and make our own decisions on how to pursue our transitions, which makes it very dangerous if we don’t have the skeptical background or critical thinking skills to be able to notice the warning signs when a website, source of information or care provider is not acting in our best interest or their claims aren’t scientifically substantiated or based on real evidence. On top of all that, we often have many fears about transition, fears of what it entails and the permanent changes it will render to our bodies, and often want to start out with less scary, smaller steps… small steps that the herbalists are all to happy to market their ineffective treatments as. And all the while we are immersed in a culture hell-bent on convincing us that transition is an unnatural process, a fiendish and Frankensteinian invention of modern science that turns us into freakish abominations of medicine gone horribly wrong. All of that creates a perfect recipe for those in the early process of transition to be highly vulnerable to being exploited or taken advantage of by those peddling “natural transition” and other “alternatives” to the “unnatural” treatments offered by Big Pharma.

One of these is the herbal “natural transition” packages being offered to FtM transitioners (discussed very, very well here by Debbie Goddard). These are typically the same sorts of herbal supplements taken by body builders that are designed to boost the body’s production of testosterone. I’m not quite sure how if the end goal is simply to end up with more testosterone, people would prefer this complex method (with numerous complications and potential dangers and side effects) rather than simply taking the typical testosterone injections most trans men pursue… except if they, perhaps, in the cases where they’re unable to do things “above board” through doctors and are instead forced into the position of DIYing their transition (in which case I still think it would be simpler, more efficient, and less dangerous to simply order testosterone from the internet, if possible). Another “natural transition” technique that especially concerns trans women is phytoestrogens, or compounds derived from plants that are very similar to the estrogens found in the human body.

Phytoestrogens are found, or claimed to be found, in a variety of sources, notably mint tea (this is supposedly the reason that the common anti-androgen, spironolactone, is strongly flavoured of spearmint. Between that and the sweet, sugary taste of estrace, and the seemingly miraculous degree to which HRT calms dysphoria and makes one feel happy and at peace, it can make HRT seem rather like Magical Candy That Makes Everything Better). Phytoestrogens may cause some mild feminization in individuals with otherwise low levels of feminizing hormones, but in women and trans women with higher levels of endogenous feminizing hormones (or synthetically produced analogs of the same), it actually can cause a risk of decreased efficacy of feminization. The phytoestrogens, in sufficient quantity, can bind to the receptors that would normally receive estradiol or other estrogens, and end up blocking their effect, thereby diminishing the effectiveness of a clinical HRT regimen.

On the question of the degree to which HRT, or transition as a whole, is “natural” (relative to treatments billing themselves as such), it’s worth considering the nature of human sexual differentiation, which I’ve outlined before . Basically, the genetic potential for feminization or masculinization already exists in any human being, regardless of their chromosomes. Hormones simply act as messengers that trigger the appropriate traits to be expressed. In the case of contemporary HRT, treating with medications like micronized estradiol, the hormones you are taking are the same hormones that occur naturally in the human body. Herbalists may point to the means of production, synthetic in laboratories, as indication of why these medications are “unnatural”, but when comparing the actual chemicals you are putting in your body, I fail to see how taking the hormones of a different species is in any way more “natural” than taking actual human hormones (or how the arbitrary distinctions of “factory” or “lab” causes any actual change in the product or its effects).

Anti-androgens also have a fairly simple, “natural” process… they generally just bind to testosterone receptors, thereby blocking the testosterone from being able to have it’s effect (much like phytoestrogens can end up blocking other feminizing hormones), and gradually the body begins producing less of it. I’m not certain, but I think that atrophy also contributes to the gradual, more long-term impact on testosterone production… that producing testosterone is sort of necessary in order for the organs that produce it to maintain their optimal functioning. And of course, those particular organs typically end up eventually removed altogether.

Even sexual reassignment surgery isn’t a particularly “unnatural” thing. Vaginoplasty constructs the new female genitalia out of tissues that are biologically almost perfectly analogous to the one’s that comprise a cis woman’s vagina and vulva. Male genitals develop in utero from proto-female components. SRS kind of just reverses this process, reconstructing those tissues into the female shape. Your natural human body is simply reconfigured, re-sexed.

For a comparison in terms of the “natural” method of taking hormones derived from other species rather than synthetically derived human hormones, we can consider one of the early drugs provided to trans women, premarin. This drug was basically manufactured from the urine of pregnant horses (premarin = pregnant mare’s urine). It ended up not working particularly well. Amongst numerous unpredictable side effects, one of the more strange and noticeable ones was that breast development typically visibly differed from that of cis women, producing an almost conical or “pointy” shape. Thankfully, premarin has since been almost entirely edged out in favour of synthetic human analogs, most commonly estrace / provera (micronized estradiol), often supplemented with prometrium (progesterone). It does, however, serve as a reminder of why taking hormones “naturally” derived from other species might not be the wisest bet when attempting to trigger the natural potential for feminization or masculinization in a human body.

I’m not an endocrinologist, pharmacologist, doctor or healthcare professional of any kind, so I’m not really qualified to give you guys a full run-down on exactly what forms of treatment are legitimate and can produce actual results, and which are ineffective scams, or worse, dangerous or likely to inhibit your transition. In fact, I can’t even necessarily vouch 100% for the information in this post, derived as it is from memory and second-hand sources and filtered through a layperson’s understanding of the actual medicine behind it (an enthusiastic, relatively scientifically literate, and very curious layperson, but a layperson nonetheless). But I can strongly encourage you to approach your transition with care, and to develop your critical thinking skills.

Sadly there is, at this point, no way to really avoid the “be your own doctor” aspect of transitioning. There’s simply too much misinformation, and too little education on transgender care, for us to be able to wholly put our own education aside at this point and trust in our doctors enough to expect them to know everything about transgender care. It’s simply too dangerous. We absolutely SHOULD trust doctors on general principle, and SHOULD undergo transition under their care, but we have to conduct enough of our research that we can help guide them and so we can know when they’re making a mistake (as a scary warning story: I’ve heard stories of endocrinologists literally telling their patients that estrogen will raise their voice). Your research, however, shouldn’t lead you to believe you’ve surpassed the doctors (all that time in medical school was for a reason), only to help and to let you know when might be a good time to seek a second opinion, or get care elsewhere. Think of it like visiting a mechanic: ultimately, you defer to their knowledge, but you try to know enough about your car that you can help them out and avoid getting scammed.

An important starting point is to familiarize yourself with the WPATH Standards of Care, so you can know when a doctor is being inappropriately gatekeeper-y, to familiarize yourself with what effects can and cannot be expected from HRT, knowing what medications or lifestyle choices are contra-indicated and what the most common risks are (for instance, estrogen carries a risk of blood-clots and stroke, which is worsened by smoking, lack of physical exercise or poor cardiovascular health), knowing where your serum testosterone and estrogen levels “should” be, what standard doses are for your body type and intended results, etc.

But when conducting this research and familiarizing yourself with the medical aspects of transition, you need to be on your toes, be aware of the risks of being taken advantage of, be aware that a lot of the information floating out there is NOT accurate, and that there are people who are really only interested in your money, not your successful transition and your long-term happiness. This is why it’s extremely important to develop some basic critical thinking skills, keep a rather skeptical frame of mind and learn to understand what does and does not constitute evidence for a treatment or medication’s efficacy. Learn a bit about the scientific method and double-blind studies, control groups, how to isolate a variable for study and comparison, things like that. Learn about common research mistakes, or common misinterpretations of data.

Another important thing is to learn to spot the more common “red flags” that may indicate quackery. A few examples are: the presence and foregrounding of testimonials and “evidence” based on personal anecdotes describing the treatment as effective, claims that a given treatment has improbably great or improbably broad effects, such as “cure-all” treatments, especially when the “cure-all” is described as being able to treat forms of disease that are utterly different from one another in pathology or effected systems or the actual category of disease itself (viral, auto-immune, cancerous, bacterial, etc. nothing can really treat both an autoimmune problem and an infectious problem at the same time), claims that the treatment or medication has been “suppressed” in some kind of unfair way, such as by a “cartel” of pharmaceutical corporations or the “dogma” of mainstream medicine, or that the developers of the treatment have been “persecuted”, terminology that is derisive of conventional medicine such as the “allopathic” / “non-allopathic” dichotomy, setting up other dichotomies such as between “Western” and “Eastern” or “Holistic” approaches, claims that conventional medicine is biased and unable to think outside the box of it’s own terribly terrible scientific principles, argument from nature or argument from tradition, use of buzzwords like “natural”, “toxins”, “energy”, “chakra”, etc. dubious explanations or none at all for the actual mechanism by which the treatment is supposed to work, emotional language playing upon feelings of fear, shame or anxiety surrounding transition, and also presenting inefficient or highly particular means of attaining what are functionally the exact same results as those more simply (and cheaply) provided by the conventional means (like with herbal means of increasing your body’s testosterone production).

This is by no means an exhaustive or complete list of the things to be careful about, or the tactics of critical thinking required when put in the difficult situation of having to navigate your own medical care. But hopefully it will help some of you set yourselves on the right path towards developing the necessary skills. There is no one, singular path through transition, and it’s a process we all need to figure out for ourselves. But there are good decisions and there are bad decisions, and the more tools you have at your disposal to help make the good ones, the better off you’ll be and the better your chances of arriving expediently at the end point of a happy, successful transition, feeling comfortable and at home in your body and gender. I wish you all the absolute best, and promise you that although it can be confusing, difficult, terrifying, exhausting and cost you an immense amount of energy (physical, emotional, intellectual) and resources, it is completely and absolutely worth it, the best and most rewarding thing you will ever do for yourself.

Just be careful out there.