On Meds

Late 2023 saw me pass one milestone and approach another. As of that October, I’d been taking estrogen for ten years. Two months later, I would be turning sixty. Both milestones boggled my mind a little when I thought about them, and the juxtaposition of the two—the thought that I’d waited a half century to pursue physical congruence—made me sad. Only one of them made any public splash, however. I decided in summer 2022 to mark my sixtieth birthday by dyeing my hair pink. The idea excited me (I’d never done anything like it), and I shared my intention in the following months with my mom and siblings, and some of my friends, returned to it periodically over the next year, and posted photos on social media the night of my visit to the salon. By contrast, though such anniversaries are commonly shared in the trans community, I let the start of my second decade on estrogen pass with little to no fanfare.

The reason these two observances differed so much wasn’t the sadness I felt about my late blooming, at least not mainly. My dominant emotions where hormone therapy was concerned were positive: the joy of congruence, and pride at overcoming decades of transphobic programming to take this step at all. I remember the first time I swam in water over my head when I was a child. It was a sunny summer morning, I was with my family on a multi-day cruise of the eastern Maine coast, and we were anchored in a favorite harbor near where we lived. Our boat had a short wooden ladder that we kept lashed to the top of the cabin while sailing, but could suspend from one side of the hull for swimming or loading and unloading people and supplies. I’d climbed down this ladder until I was half submerged, but refused to surrender the final rung and push off. Despite my parents’ assurances, I was convinced I would sink if I did. I remember experiencing something like euphoria when I finally fell back and kicked out a few feet from the boat, then darted back and found my head still above water and my lungs full of air. Starting on hormones, and coming out in general, were similar if more protracted experiences. Stopping my ears to the tired chorus of self-recriminations and doubts, I let go and fell over backwards into the arms of a world I’d always feared. 

The main reason I didn’t publicly celebrate ten years on hormones was that I’d always felt ambivalent about meds.

This ambivalence was wrapped up in my complex early feelings about the girl inside me. From a young age, I was torn between self-affirmation and self-loathing, between my recognition that she was me and my desire to snuff her out. Faced with these conflicting drives, the best way forward I could come up with was to reimagine her as only a part of myself, and to try to partition her off from the rest of me and the murderous world outside. This arrangement was more of an ongoing deadlocked conflict than a settled compromise. The part of me who hated her (myself) accepted her imprisonment as a minimal concession, but continued to push for her (my) annihilation. The part of me who embraced her rationalized her placement in ad seg as a way of keeping her safe and, importantly, unsullied: the unborn me who, this part of me hoped, would emerge someday. (Trans inmates are often isolated today to protect them from their fellow prisoners, in particular if, as is frequently the case, they’ve been sent to prisons meant for people of a different gender.)

But if I, the core me, she, were to be locked away indefinitely, then who was “I”—the outward facing persona, the shell me? At least, who would this persona or shell be in the interim? My dominant desire to conceal the girl inside me made shell me exceedingly cautious. I became a fortress in both spirit and body, allowing in only those things I trusted would neither sully her nor betray her presence. This included medical interventions of any sort. No drugs, no surgeries, unless I was seriously hurt or sick. Any more lax stance, I was sure, would kickstart my slide into the thing I feared more than I wanted—transitioning, congruence, a thing I had no honoring language for then. This resolution neatly dovetailed with a narrative about transitioning that I long cherished: that (if and) when it happened, it would be “natural,” that is to say, would come without medical assistance to the extent that was practicable. I wanted to experience coming out as a belated birth, the completion of a process that had been interrupted the first time. The prohibition on drugs extended to the illicit ones. Though I was curious about hallucinogens, I worried what I might reveal about myself in an impaired state. I made an exception for alcohol. All of the adults in my family drank, so its effects were familiar to me, and seemed manageable. I justified this decision with a distinction that had the advantage of toeing my parents’ line about such things: beer, wine, and liquor were (natural) foodstuffs, not (manufactured/artificial) “drugs.”

* * *

Starting on hormones in 2013 was the first affirming step I took from which there would be no turning back—at least not after a certain point. I was assured by both friends in the community and my medical providers that I would soon know if this step was right for me. How? I just would. To someone who had structured her life up until then around elaborate rationalizations enforced by a strong will, this assurance seemed flimsy at best. I expressed my initial doubts in the journal I started keeping in January of that year:

Does one come out the other (or another) side, or does one stay in the rabbit hole? Or is this simply another rabbit hole to explore? Or have I been in this rabbit hole all my life, ε̩̍  am now taking a different “Drink Me”? Or am I finally emerging from the rabbit hole into the open air?…At different times, each of these feels apt. (Entry between 1/15-1/25)

A bit anxious before bed Th or F night, lay in bed doing a qigong breathing exercise → for whatever reason, my mind put me in a place where I was almost drowning, ε̩̍ had a small airspace that I had to conserve—I found myself struggling not to panic, ε̩̍  to keep my breathing steady. (Entry between 2/5-2/12)

By mid-March, though, I was ready, and filled my first prescriptions of estradiol (2 mg daily) and spironolactone. The latter drug is used in the treatment of a number of conditions, including heart failure and high blood pressure, because it prevents the body from absorbing excessive amounts of the adrenal hormone aldosterone. It similarly inhibits the body’s testosterone receptors, an effect that medical reference sources not devoted to trans health rarely if ever mention. (The NIH’s National Library of Medicine site MedlinePlus, for example, lists breast enlargement and erectile dysfunction as potential side effects, but otherwise demurs on the subject: “This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.”¹) The relief I felt after being on spiro for only a short period was patent. As I told friends at the time, it was like a radio inside me that had been playing loud static since the onset of puberty had been turned off.

My reaction to estradiol was quite different, however. Within forty-eight hours of starting on it, I experienced migraine with aura for the first time. The aura—shimmering arcs of light at the periphery of my vision—spooked me, and I informed my doctor’s office that morning of my symptoms. My primary care provider responded via email soon after with news that knocked me flat:

A migraine with aura…can significantly increase your risk for a stroke…We can still use testosterone blockers safely in this situation, but I do not think that any dose of estrogen would be considered safe.

My journal entries in the following days document the trauma this email triggered:

To some extent, my body will remain monstrous to me.

I have fantasized about shaving my head, but suspect I would regret it.

I feel like I am in mourning—like I have been informed not only that my child was stillborn, but also that I am barren.

Hope is a dangerous drug.

I wept in my counselor’s office during my next appointment. 

Soon enough, though, it became clear that my PCP, despite working for a clinic that served many trans clients, didn’t know what she was talking about. I arranged to start again on a lower dosage and work my way up to 2 mg, an approach that a close friend had taken recently. I put off doing so for some months, though, to treat a non-trans-related condition, since I’d been advised that the drug for it wouldn’t mix well with estradiol.

This delay had the benefit of easing me into hormone therapy without producing more than mild physical changes. By the time things started to pop that fall after I went back on estradiol, I was eager for what was to come. One evening a month or so into the full regimen, I bent my head to pull off my turtleneck, then looked at my bare chest, first to the left, then to the right, straightened up again, and danced around my bedroom pumping my arms in the air and shouting to myself “I have tits!!” One morning sitting at my desk early the following year, I started rubbing my belly, and in a moment became present to how soft my skin had grown, and caressed it obsessively for days after, absorbing the wonder of it.

* * *

My experience with my PCP was broadly of a piece with the trans community’s fraught historical relationship with the Western medical establishment. From the time queerness started being pathologized in the latter half of the nineteenth century, trans folks entered medical literature as antagonists. Early sexologists forced us into other queer identities to preserve cis- and heteronormative theoretical models of gender and sexuality that our existence threatened. The main exception was the German physician Magnus Hirschfeld, but his pioneering work in affirming medical care was brutally terminated by the Nazis in the early 1930s. (Many of the books being burned in a famous 1933 photograph were from the library of Hirschfeld’s Institut für Sexualwissenschaft.²) Research in this field continued on the Continent after World War II, but the medical establishment in the U.S. didn’t begin to come to terms with us until the 1950s after the media frenzy surrounding Christine Jorgenson in 1952-53 stirred popular interest in us. (Jorgenson traveled to Denmark to receive affirming care.) It took another three decades for the psychiatric profession to officially recognize the trans condition, when it entered the 1980 third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as a “sexual disorder.” (DSM-I appeared in 1952.) Transness didn’t shed this stigmatizing and erroneous classification until the fifth edition (DSM-V), published in 2013—the year I started hormone therapy.

In that half century-plus, access to affirming medical care in the U.S., when it wasn’t denied outright, was long used to conform us as much as possible to the old cis- and heteronormative models. Trans women, for example, needed to be “passable” (look like cis women) and at least had to profess to be straight (attracted to men) in order to receive care. This gatekeeping role formally gave way to an “informed consent” model in 2012 with the publication of the seventh edition of the World Professional Association for Transgender Health’s Standards of Care (SOC 7). Under this new model, providers would facilitate our access to care on the presumption that we knew who we were and had the right to bodily and mental autonomy. Though a general consensus now exists among the governing bodies of the medical field about the benefits of affirming care for trans folks, the new standard of care is far from universally employed. In part, this lingering reticence is a product of the fierce backlash from regressive forces on the right, whose sadistic legislative trolling and extra-legal intimidation tactics are putting a chill on care in many places. It’s also the case, though, that the older normative thinking about gender is still prominent in the medical community. While providing trans folks with hormone therapy remains controversial for many providers, for example, it’s readily accessible to post-menopausal cis women, and to cis men and women with other hormone imbalances (e.g., gynecomastia and erectile dysfunction in men). Moreover, whereas those of us desiring affirming surgeries still too often confront roadblocks to obtaining them, members of the intersex community continue to be subjected to surgeries in infancy meant to align their genitals with binary male/female norms. In each case, the presumption being made is that the individual’s gender identity is coequal with their genitalia—in the case of many intersex folks, the side of the binary that their genitals more strongly suggest—a belief that negates the very existence of transness.³

* * *

Even after I embraced the positive effects of hormone therapy, my reticence about meds and medical interventions more generally lingered, though its focus narrowed and grew more nuanced. In conversations I had with other trans folks soon after I came out, I was struck by how many of them talked about hormones and surgeries as if they weren’t choices, but dicta indelibly printed on the fabric of the space-time continuum. In retrospect, I suspect this approach helped them make the more daunting aspects of transitioning feel manageable. Still, surrendering your agency to external standards like this seemed uncomfortably similar to the old gatekeeping, and to the cisnormative stuff we had all internalized for so long. I also recognized in the checklist approach the potential for falling down a rabbit hole in pursuit of an illusory ideal of perfection, one procedure leading to another with results that would always disappoint.

These concerns raised a basic question: just what was gender congruence? I knew in general terms that the goal of transitioning wasn’t to look like a model, or even necessarily to pass as cis (though passing has benefits independent of self-image, notably safety). That congruence was a feeling that inside and outside were in sync, that you recognized yourself when you looked in the mirror or moved through the world. That as such, it was necessarily different for each individual. It soon became clear that congruence wasn’t something you achieved once and for all at some point, like reaching the summit of a mountain. Even the most content and self-aware among us were ambushed by dysphoria, had days (weeks, months . . .) when we were dogged by sadness and doubt. More basically, the idea of a “self” whose boundaries were settled and absolute was also an illusion. We were not fortresses, but networks of symbiosis constantly shaped by and inflecting in turn a multitude of external influences, from the benign bacteria inhabiting our digestive tract to the negative cultural messaging infusing our every sinew and synapse before we were aware of it.

And yet: all that was in no way to say that we couldn’t know ourselves—the I at the center of our own symbiotic networks—well enough to recognize ourselves when we saw ourselves. Nor was it to say that we didn’t know how to pursue that sense of recognition. In 2013, after a half-century of denial, I started hormone therapy because yes, I just knew it was the step I needed to take. And this decision was soon confirmed by the way it made me feel: the magical growth of my breasts and softening of my skin, yes, but also the expulsion of long buried trauma, the dispersion of the inner static—the general sense of buoyancy. And with these feelings came a deeper sense of rightness. I began to recognize all the ways in which I’d always been the person—the girl, the woman—I was, not as some idle fantasy or wished-for ideal, but as an experiential reality. Everything in my life up to that point told me that despite how dramatic the break felt in the moment, there must be substantial continuity between my pre- and post-transition life, between shell me and me. How else could I have survived all those years? That conviction was soon firmed up. Long repressed memories of dreams, emotions, the way I reacted in certain situations, resonated with who I saw and felt myself becoming. Diving into my writings from my late teens and 20s, I saw even more striking evidence of an unsevered if frayed line between past and present.

Along with this sense of continuity, I recognized a more general truth about our relationship to our gender identity: that while gender inflects everything we do, feel, say, etc., we don’t spend our lives thinking about it unless we’re living in fear. In my own case, the perpetual state of self-consciousness I felt before coming out was a product of my anxiety around presenting myself as something I wasn’t—male. Because my shell-me schtick was so ingrained, I generally experienced that anxiety as little more than a gray sense of malaise. It was only when a situation confronted me with the choice of asserting myself in some grossly incongruent “male” way, or tempted me to an overt expression of femininity, that I seized up. After coming out, the more confident I grew presenting as myself, the less aware I was of doing so. Thanks to feminism’s historical gains during my lifetime, I didn’t have to justify my passion for things like record collecting and sports, though my relationship to each, in particular sports, changed after I realized how much those passions had been tied up with passing as male. Nor did I have to explain my apartment’s lack of conventionally feminine décor and amenities, and its perpetual need of a good dusting. What mattered was that it was the right space for an eccentric intellectual who had slept with her fair share of monsters.

I was similarly freed up where my appearance and presentation were concerned. I studied cis women after I started on estrogen, and realized that if 5’11” was tall for a woman, and my right hand was larger than the average woman’s, neither was a significant outlier. I remember sitting in the bleachers at a Pirates game staring at the hands of the young mother sitting in the row below me, absorbing the fact that mine were the same size as hers. Hormone therapy had no effect on my height, and little effect on my hand size: puberty baked in my bone structure, and my hands became only marginally more slender due to the general loss of muscle mass brought on by estrogen. Hormones didn’t turn me into the person I wanted to be, in other words. They helped midwife the belated birth of the person I was, which gave me more confidence occupying a perch towards the outer edge of the bell curve.

Mimicry is one of the defining characteristics of our social species. Expressed in our instinct to herd, it’s the source of some of our worst tendencies, as the present political climate is bearing out all too well. With a little courage and generosity, though, our sociality can also foster some of our greatest traits. I’ve learned to feel more and more comfortable in my own skin in no small part from my interactions with and observations of other women, cis and trans. I wonder at what point that benefit started to be mutual for the cis women in my circles, or if it always was? I wonder what impact my self-comfort has on others I come in contact with? Did that young mother hate her hands as much as I loved them? How did seeing my hands (if she did) make her feel about hers? How many cis women my height feel self-conscious in line at the grocery store? Does seeing me set them at ease? How many cis people see trans folks as mirrors of their own aspirations? How many want to smash those mirrors? For how much longer?

¹ https://medlineplus.gov/druginfo/meds/a682627.html (accessed January 19, 2024)
² https://www.hmd.org.uk/resource/6-may-1933-looting-of-the-institute-of-sexology/ (accessed 2/14/2024)
³ The trans community has a long, complicated relationship with the intersex community in the history of American medicine. Julian Gill-Peterson documents this relationship in detail in Histories of the Transgender Child (U Minnesota P, 2018).