A trans male history of blood, hormones, and the U.S. medical establishment
Content note: Medical issues, including blood and needles.
Home this morning from my biweekly testosterone injection at the doctor’s office, I shift uncomfortably in my desk chair. A circular Tweety Bird bandage adorns my right butt cheek. “You did great. Do something nice for yourself today,” the lab technician had encouraged me when it was all over, with a sympathetic smile.
As uncomfortable as plunging a one-inch needle into your muscle might sound, this procedure is virtually painless when done properly —as long as the patient is relaxed. I must not have been very relaxed today, as I’m feeling pretty sore. But as resentful as I am to be dependent on regular injections of this viscous substance, I’m grateful to have a medical professional now filling that syringe and plunging that needle, rather than having to do it myself.
How did I get to this point?
Age 11, 1981. It’s a typical school morning, except not, as there is blood on my underwear. Fortunately, my mother has prepared me for this moment, so I don’t freak out. I alert her, and she brings out the sanitary napkins that will be familiar, though unwelcome, companions for many years to come.
At the time, starting menstruation before age 12 was considered pretty young; not exactly precocious puberty, but young nonetheless. I understand nowadays more female-assigned children in the U.S. are experiencing their first menses before that age, due to dietary and other factors. This is not really a good thing.
For the first year and a half, my periods were very regular and predictable, occurring the last week of each month and lasting for four days. I had some cramps and episodes of heavy bleeding, but no significant PMS symptoms.
But then, my periods started coming later and later, and lasting longer and longer. Before long, it was common for me to go three months without a period, which would have been great except that when the blood did come, it would continue to flow for three full weeks.
Bleeding every day for weeks — five at the worst point — was a terrible experience. Having a bloody rag constantly between my legs, always worrying about leakage on heavy days, wondering when it would be actually actually over or if I still needed to wear pantyliners just in case… this was no way to live, especially while dealing with the angst of my teen and young adult years.
And considering that I knew from an early age that I never, ever wanted to have children, having to cope with a menstrual cycle at all really did seem like a curse.
While I was not yet sexually active, I clearly needed the attention of a gynecologist. My first vaginal exam was so distressing that I literally went into shock. I had never had anything inserted up there before, not even tampons.
Though I told the doctor I was a virgin and she used the smallest available speculum, having that rigid instrument inside me was still awful. It was many years before I could have receptive intercourse (or, indeed, use tampons) without pain, and I’m sure some of that discomfort stemmed from the memory of that first exam.
I was prescribed birth control pills, which I was resistant to using as, again, I was not yet sexually active. I was also very concerned about the potential side effects. But a doctor told me that I was at greater risk of becoming anemic from bleeding for weeks on end.
So I eventually relented and started taking the pill. After some initial headaches, I had no further significant side effects, and my periods became regular again. I still resented bleeding every month when I saw absolutely no use for having a uterus and ovaries, but this was long before I realized I was trans, and I did not remotely consider surgery as a viable option.
After a number of years on the pill, I wanted to give my body a break from hormones. I had been using condoms during “PIV” sex anyway, as a safer sex practice since I was (and still am) polyamorous. After going off the pill, I found that my periods were somewhat less erratic than they had been in the past.
I still had irregularities, however, and at some point in my thirties I was prescribed an ultrasound. Despite having access to a modern medical office in the 2000s, I was required to drink four eight-ounce glasses of water an hour before the appointment, so that my uncomfortably full bladder would push the necessary organs into view.
I was diagnosed with polycystic ovarian syndrome (PCOS), and told the condition might go away on its own if I lost some weight. At the time I was near my highest adult weight, 173 pounds, which for a 5' 4" woman was considered borderline obese. I did lose weight, and my periods did become more regular. I realize that not everyone with PCOS has this experience or outcome, however.
I eventually looked into going back on birth control when I learned there was a possibility to have a normal-length period only once every three months, by taking a pill every day for that period of time, instead of stopping for one week out of each month. Some women had figured this out a long time ago, but more doctors were now openly supporting this practice.
I started taking the pill again, looking forward to a future of fewer periods. But after two months, I saw blood. I panicked, as I was having unprotected intercourse with my spouse and primary partner, Ziggy, at that time. Getting pregnant was unthinkable to me.
The doctor said that my body apparently could not “hold” my period for that long. Though this explanation seemed unlikely given my history, I decided to just go off the pill completely, and use condoms full-time. As a relatively healthy individual, I’d sometimes gone over a year without visiting a pharmacy, so without good reason to do so I’d prefer to avoid picking up prescriptions and taking regular medication.
Now in my forties, I was learning a lot more about gender and sexuality, and questioning everything. After a lot of reading, dialogue, and introspection, I came to realize that I was not a woman at all. My disconnect with my female-assigned reproductive system had reached a critical point. I was simply not meant to live in a body that was dominated by estrogen.
I could not wait for menopause; I needed to start testosterone therapy, and end my periods once and for all. Fortunately, I didn’t have too many roadblocks to obtaining the needed hormones, which was a relief. The timing was good, as my spouse’s insurance didn’t start covering trans health care until the year after I announced my new name and non-binary gender in 2013.
I went back to seeing a therapist that I had previously consulted for depression, and got a diagnosis of gender dysphoria. My doctor referred me to a nurse practitioner who had more experience with trans patients than he did. She asked me some questions, but did not require me to lie about my agender identity in order to obtain treatment.
Though I was pursuing a legal transition to male and wished to be listed as male for medical purposes, I made it clear that I was neither a man nor a woman. I sought the physical attributes typical of cisgender males, but that had no bearing on my clothing, hobbies, beliefs, or mannerisms. Testosterone therapy would, hopefully, make me more comfortable with my body, but it would not actually change my (lack of) gender.
The NP did ask more than once if I were pregnant, and warned me numerous times that it was still possible to get pregnant while on testosterone therapy. I assured her that I was not pregnant and would never be (unless, goodness forbid, I got raped), having stopped engaging in PIV sex some time ago. While I had eventually overcome the pain of receptive intercourse and had many enjoyable experiences, I no longer wanted anyone to interact with my vulva or vagina in any way unless it was medically necessary to do so.
In January 2014, with Ziggy at my side, I got my first injection of what he jokingly and affectionately referred to as “boy juice”: Testosterone cypionate. From the elation I felt, I immediately knew I’d made the right choice. Though ending menstruation was only one of many reasons I wanted to undergo a hormonal transition, I could not wait for my hated periods to end.
Unfortunately, I did have to wait. Six months went by, and I was still bleeding. As I had decided to use men’s restrooms exclusively (unless gender-neutral restrooms were available) starting the day of my first shot, this was particularly intolerable; I did not want to be changing tampons in the men’s room. And as my face and body “virilized”, I didn’t want to be seen shopping for sanitary products either — though Ziggy, who is male-assigned but genderqueer, was happy to buy them for me if needed.
The NP agreed to increase my testosterone dosage, as she had started me on a pretty low dose. In July 2014, I had what I thought would be my final period.
Injections at first were pretty straightforward. Ziggy and I were both trained to do them, but I felt confident enough to handle them on my own. After several injections at the office, I was released to do them at home, which I did, every other week, for the first two years.
At this point, I started becoming more and more anxious as the day of my shot neared. While I could still lay out all of the supplies and fill the syringe, it was taking me longer and longer to get up the nerve to actually plunge that needle into my thigh. I tried a number of tricks: Deep breathing, singing, even removing the clock from the wall so I didn’t have to hear the annoying ticking sound.
One morning, after half an hour of sitting on the toilet seat with the needle poised inches above my thigh, unable to commit, I screamed in frustration. I sent Ziggy a frantic text asking he could do my injection when he got home from work late that night; he readily agreed.
Ziggy took over doing my shots for the next several months, but I wasn’t happy with this situation. Though I’d read intramuscular injection was the most effective and affordable form of testosterone delivery currently available in the U.S., I needed to investigate alternatives. I was particularly interested in pellets that could be injected by a doctor into the buttocks muscle, dissolving slowly over a period of three to five months.
I was fortunate to find a doctor in San Francisco who offered this procedure, and after some wrangling our insurance agreed to cover most of the cost. I had the pellets inserted in the summer of 2017, very glad to be done with needles for the forseeable future.
Though the implantation was an outpatient procedure (I walked home soon afterward), it was minor surgery, and I knew I’d be in pain for a few days after the lidocaine wore off. But I wasn’t expecting that pain to last for weeks. I took more ibuprofen that month than I had in the previous entire year. (I avoid painkillers unless I’m in significant distress.)
The doctor said this level of pain wasn’t typical. I said I understood, but unless he could guarantee this wouldn’t happen again (which I knew he could not), there was no way I would get another implant. As nice as it was to not have to deal with home injections any more, I simply could not face the risk having my life disrupted by pain for several weeks every few months.
There was another problem too; my testosterone levels were too high. They had been registering on the high side, compared with cis males my age, since soon after I started hormones, but now they were off-the-charts high, to the point that some aromatized to estrogen (which was the last thing I wanted). Trying to control my hormone levels would be much more difficult with implants done only three-four times a year. I really didn’t want to go back to the shots, but I had to try something else.
I knew that topical gel was an option, but one I’d been avoiding, as it had to be applied every day and tended to be very expensive. But our insurance agreed to cover most of the cost, which was a good thing as the retail price was a staggering $700 per month for a three-ounce container, which at my starting dose was a one-month supply. I don’t know many people who could easily afford the out-of-pocket cost of this medication, which, like other forms of testosterone, is primarily prescribed and marketed to cisgender men.
The gel was described as colorless and odorless, but I could definitely smell it; perhaps my nose had become more sensitive as I had been using unscented personal care products. It also left a flaky white residue when it dried. I was cautioned to avoid open flame (including cigarettes, though thankfully I’ve never smoked) until it did, as it was highly flammable. Oh, and no showering for at least a couple of hours after applying either. If I’d had a day job or been exercising regularly, timing the spreading of this glop on my chest every day would have been even more of a pain.
But at least the application wasn’t physically painful, and was something I could do myself, which I did beginning in the fall of 2017 for several months. I had my testosterone levels checked again, and was pleased to see they now fell within the normal range.
Then one day in March of 2018, bam — blood on the toilet paper. I couldn’t believe it. Four years I had been free of this menace, only for my dreaded periods to return. Why now?? My pellets should have worn off months ago; if the gel weren’t working, why did it take so long for it to become apparent that I’d been spreading an expensive placebo on my chest and shoulders all this time?
My regular doctor (who I’d returned to) increased my dose, but my previously sky-high T levels were now at the low end of the normal range. And our insurance was now charging me twice the cost for even less product, making the gel even less appealing as a long-term solution. (They also sent me a belated bill, charging more for the pellet implants than originally planned.)
Concerned, my doctor referred me to a radiologist for an ultrasound. I was less than thrilled to see that technology had only advanced to the point that I had to drink three full glasses of water instead of four before my appointment. Thankfully, I was allowed to pee before the transvaginal portion of the exam began. My doctor had specifically instructed that the exam should not be done transvaginally without my explicit permission, which I appreciated, but I did allow it when asked.
Having not been penetrated in several years, the procedure was very uncomfortable, despite the technician’s best efforts. But I was treated with the utmost respect and never misgendered. No abnormalities were found, just a couple of small, insignificant cysts.
I got another period the following month, with cramps bad enough that I was literally doubled over with pain. I had to sing as a featured soloist in a rare (for me) paid concert appearance while bleeding and doped up on ibuprofen. Of course, many, many people have accomplished more demanding tasks while suffering from far worse pain. But I wasn’t accustomed to this, and it simply didn’t seem fair considering I’d been applying the hormone gel every day without fail.
My doctor was still concerned, but he was also going on sabbatical, so referred me to another, more trans-experienced doctor in the practice. After some consultation, we agreed that I should go back to biweekly injections. I could not face doing them again myself, and didn’t want Ziggy to either. We determined that I could get them done on a drop-in basis at the doctor’s office for an affordable (to us) price.
May 2018, I put the gel away and headed to the doctor’s office with my vial of testosterone. My new doctor had put me back on my low, initial dosage; I expressed concern that this wouldn’t be enough to stop my periods, but she said that bodies change over time.
The lab technician was friendly, even bubbly. “We LOVE doing injections! We do this all day!” I was pleased to have this option, especially when one of their offices was actually open on Memorial Day so I didn’t have to delay getting my shot that week.
Sadly, a few weeks later I got another period, with intensely painful cramps. My doctor increased my dose slightly, and is now working on referring me to a specialist. Surgery might be a consideration at this point, but I’m very concerned about risks and complications so I consider that to be a last resort, especially as I grow ever closer to menopause.
If surgery were risk- and cost-free, I seriously would have liked my uterus and ovaries removed back in my early 20s. I have never had any use for these organs. They have caused me nothing but grief.
Now, all this being said, I must emphasize that despite being queer, trans, black, and in a same-sex marriage, I enjoy a number of privileges. I have been covered by health insurance continuously since I was a teenager. I have been financially and emotionally supported by my spouse for the last several years. I live in a rent-controlled apartment in San Francisco, one of the most queer- and trans-friendly cities in the country. I go to a doctor’s office where all of the employees are trained to respect gender and sexual diversity and welcome patients from the LGBT+ community.
And yet, I cannot take it for granted that I will always enjoy these privileges. I am concerned that under the current presidential administration, my health and very life are in jeopardy. Especially as Ziggy’s insurance only started covering trans health care when they were forced to do so by the state of California, I fear that if I wait to long to decide whether or not to have surgery, it might no longer be an affordable option for us. Even hormone injections could become prohibitively expensive or difficult if our insurance dropped coverage for them, or if pharmacists started refusing to dispense them to me under the guise of “religious freedom”.
For now, I will continue to work with the medical establishment on getting my hormone levels under control, while I still have the means and access to the tools to do so. I do not want to see blood coming from between my legs ever again, but I realize I don’t have ultimate control in this area. I just know that I was not meant to live in a body that was capable of incubating another human being. Rectifying that mistake has been a lengthy, difficult process, and one that I hope does not dominate the rest of my life.