April 21, 2022 • 37 mins
Garrison is joined by Dr. Victoria Grieve to discuss HRT gender affirming care for Trans people.
https://twitter.com/VixenVVitch
Victoria.grieve@pitt.edu
https://diyhrt.github.io/
https://hrt.cafe/
https://diytrans.wiki/Main_Page
https://www.them.us/story/informed-consent-hrt-map-trans-healthcare
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Greetings listeners in the podcast verse, This is it could
happen here the podcast about things falling apart and sometimes
how we can put stuff back together. I'm Garrison Davis
are Resident Gender mess In the past few weeks, we've
been talking a lot here on the show about the
(00:25):
escalating war on trans people and queer folks in general.
There's been a wave of bills making any gender affirming
healthcare of felony for people under the age of eighteen,
which forcibly detransitions teenagers and multiple states, and we've had
a lot of banning trans people from participating in sports
and trying to ban books and discussion in schools about
(00:47):
the just the existence of queer people at all. But
today we're not really going to be talking about that.
We've talked about that plenty for the past few weeks.
It's good to have a little little bit of a break,
but we'll still be talking about stuff around trans people.
Because with all the discussion around gender affirming healthcare, I
thought it would be a good idea to put something
together talking about what HRT or hormone replacement therapy actually is,
(01:11):
as since it's the most common form of trans healthcare
and since many states are trying to or already have
criminalized it, perhaps I can use the POD to point
people towards alternative means of receiving care, you know, in
the vein of the putting stuff back together side of
the show. Now, I want to clarify upfront that we're
(01:32):
not giving anyone medical advice, obviously. I'm just making observations
and talking about things as they exist, um and talking
about things that many trans people have been doing for
a long time, and that includes d I Y HRT.
My doctorate program is in parapsychology, not medical science, so
just keep that in mind. First, I will quickly clarify
(01:54):
what HRT or hormone replacement therapy actually is for specifically
non CIS gender individuals, because HRT as a term is
also used for CIS women to describe similar but different treatment.
So HRT as a form of gender affirming treatment is
when someone receives sex hormone medication that produces a number
(02:17):
of desired secondary sex characteristics. There are two broad types
of hormone therapy that one would receive, depending on what
direction you want to go in gender of wise, there's
feminizing hormones and masculinizing hormones. Feminizing hormones produce more typically
feminine traits, right, big big shocker there. Uh. It usually
(02:40):
consists of a form of estrogen, usually called estradial. There's
different types of estradial, and also it can include anti
androgen's aka a testosterone blockers. Masculinization therapy consists of taking
to sasterone or androgen's and then also less commonly anti strogens,
but usually just tinking to toss your own will suffice. Now,
(03:05):
I'm no expert in hormones despite my weekly shot, but
lucky enough I was able to sit down with an
actual expert on hormones and talk over zoom. So what
follows is segments from our conversation. I guess first, do
you want to introduce yourself? Sure? I am the Reverend
Dr Victoria Luna B. Grieve. I am an assistant professor
(03:27):
at the University of Pittsburgh School of Pharmacy. My primary
clinical focuses on gender affirming hormone therapy, other kind of advocacy,
work in queer healthcare, and I do a lot of
other stuff on the side. Heatigo g Ludac, instructional design,
game design, just anything that strikes my fancy really fun
fun stuff in with within kind of our our coverage
(03:50):
of trend stuff the past few weeks and months, it's
been mostly on like the bills and like the politics
side of things. I definitely had some people like reach
out and be like, okay, but how like why why treads? Gender?
Why why hormones? Like why are hormones actually important? Like
could you actually explain like what, like you know, with
all of these all these states banding hormones, let's I
(04:13):
would like to kind of explain why it's such a
big deal and like how much these things actually are
like life saving medication for so many people. Yeah, so
why are hormones? I love it because it's a question
that as like a species, we've been we have known
the answer to for like five thousand years. It's it's
(04:35):
very funny, but um, hormones are. Okay. A big part
of this requires to like acknowledge something that is very
wrong in in like the medical literature. There's a lot
of elements of healthcare that are coordinated between like male
and female, and there's a kind of like obviously is
(04:56):
a little so there's a lot of I mean like
from like from people's I know, when trans people talking
about interacting with the medical system, it's always like, oh, yes,
we're gonna be doing this bullshit, Yes of course. Yeah, well,
but it even goes to it like a really deep level,
like if you're in the hospital and you get a
CBC count, there's a male profile and a female profile
of what your hematocrit should be on, like what the
(05:18):
level of red blood cells are, and and the general
understanding and like the health industry is that there's a
biological anatomical difference between them. And for the longest time,
certainly in this country, trans women would have would be
compared against the male profiles. But but it's nonsense. It's
actually should be thought of in form of hormone dominance,
because the vast majority of medical differences are not anatomical,
(05:42):
they're hormonal, and and that right there should should give
the game away, which is really funny, which is why
it's why I kind of hate the term biological woman
whenever people start using that, because that's not really how
biology works. Yeah, I mean that Oak is my my
nesting partner. My fiancee wishes that she could be a robot,
(06:03):
and then if she were to do that and upload
her brain into an immortal robot body. She would no
longer be a biological woman, but she would still be
a woman. It's just cybernetic. Um. I hate that. It's
like organic. Organic just means it has carbon in it. Like,
give me a break. Yes, so yeah, hormones, what's what's
(06:23):
what's the deal do they? Because I know all of
people will be like, well, all of these trends, people
sure do seem sad. I want that's how how how
can we make things better? Does this thing actually work? Uh? Well,
so it's somewhat multifactorial. I have a friend who does
um sell imaging, and her like working theory, which I'm
(06:44):
a little dubious of, is that like the brains of
trans people like have receptors for hormones that the body
doesn't make, and we should think of being transgender is
having like a form of hypogonadism. Yeah, there's there's a
lot of different trains of thought there in terms of
the different theories of why trends people exist and how
it's like you know, the girl's brain, boys body, blah
(07:04):
blah blah blah blah, which all, if you dig deep enough,
goes back to eugenic. So it's all, yeah, I've always
not liked that model. I've always it's always I've always
found it to be a little bit uncomfortable because I
take hormones because I want to, And I don't think
it's because my my my brain is like secretly looking
for girl receptors or something like, right, I totally agree,
(07:29):
Like it also requires a certain like extremely binary understanding
of gender, which I also do not ascribe to. So
it's a very like odd thought. But putting aside all
of that, if you just wanted to look at the
like why people want hormones, Because when a person who
wants hormones gets the hormones they want, their suicidality goes down,
(07:49):
their anxiety, depression goes down, gender dysphoria, if we wanted to,
you know, talk about the problems with that, essentially like
goes away, uh, and they get this to get treated
like the way they want to be treated in society.
So from the if if you want to look at it,
not from like the causes, but from the results, giving
gender affirming hormone therapy to a person who is requesting
(08:12):
gender afforming hormone therapy has a success rate. The rate
of regret from starting hormones is one percent or less,
which is unbelievable in the health care field, like like
having a child, like biologically giving birth has a seven
percent regret rate, Like the idea of any therapy having
(08:35):
that high of a rate of preventing death, anxiety, depression, bullying,
like all of the different effects. Being that successful should
be like a miracle. It should be looked at as
the thing we in healthcare are like should do absolutely ethically.
Uh and it it is is so much more complicated
(08:57):
than that. So like hormones from the results obviously makes sense.
It aligns your bodies shape and like fat fat deposits
and the way that you feel, the way that you
relate to your emotions. It all goes back to the
way that hormones work on your body. And there's there's
like the old saying that like assis person would never
(09:18):
want to try gender forming homerone therapy, So like, if
you have the in if you want to try it,
you should be allowed to try it. I mean, like
you're you're kind of a good example right here, Like yeah,
but I'm sitting Yeah, if you're sitting around a bar
with a bunch of like CIS guys and you're like, hey,
who wants some estrogen? They would all like shrink away
from it, Like no, absolutely, because yeah, it's definitely a thing.
(09:42):
Like I'm not the most dysphoric person, but I'm like, sure,
I'll take estrogen. That sounds fun. That's like, it's like that,
that sounds like a thing that I could enjoy watching
my body change. And I'm you know, it's it's I'm
happy that we're moving more towards that and not having
to deal with, oh, I'm so dysphoric, i want to die,
(10:02):
which is obviously they're a big thing for a lot
of people. I'm not I'm not minimizing that right um.
But also a lot of trans people have had more
kind of complicated feelings on gender, whether they're like gender queer,
non binary. Having the past had made it more difficult
to get gender firm in care because they don't fit
into those specific like male female boxes as easily. M Well,
(10:23):
and what you're talking about is really something that's relatively recent.
The idea of gender euphoria, like the idea that people
want to take because it gives them joy to like
dress or act or feel a certain way, and that
I mean, health care is all about, at least up
until well, the reality of health care is that it
(10:44):
is all about finding problems to solve and not really
looking at like your life just better in general. Yeah, exactly.
So you know, I know plenty of people who started
hormones of any type just because they felt it would
make them happier, and they were correct, And that gender
euphoria is just as good of a reason to take
it as the dysphoria. The problem ends up in how
(11:06):
the medical industry treats it, because dysphoria quote unquote is
something that's long. Oh my gosh, I could go into
the whole history of that if you wanted, but I'm
sure we could talk about the ds M four and
five for a long time. Oh it's so frustrating. I
spend I spend a two hour session in my Queer
healthcare class, specifically just dunking on the ds M five
definition of gender dysphoria. Um. But the real problem is,
(11:29):
like this focus on this negative quality and how that
actually damages a lot of the conversations around uh, gender
firming hormone therapy and trans people in general. Like, instead
of seeing it as like this manifestation of people like
truly taking control of their lives to become authentic in
like the truest way, Like you have never met a
(11:52):
more truly well uh self made man than a transman
who gets hormones. Like it's I mean it's and it's
still something where even we're not quite at the at
the gender utopia, I mean obviously because of all of
the anti tran stuff, but even even on like just
purely purely the medical side, like I even for for
(12:12):
informed consent, um, I still needed to get diagnosed with
gender dysphoria at the informed Consent clinic in order to
get hormones, which is in part like an insurance thing,
and you know it has has all of these all
of these bullshit reasons. Um, but that is that is
something we're still we're still definitely dealing with, Oh my goodness. Yeah.
And the better informed care clinics are the ones that
(12:33):
they realize it's just like an effort in box ticking.
So they're just like, Yep, sounds good. You came here
to this clinic and you asked about hormones. Sounds like
gender dysphoria to me, Like we'll sell your insurance whatever.
We gotta say. Yes, eventually we'll go into like hormone
(12:56):
blockers as well. UM. But I want to talk about
there's a lot of this. There's a lot of rhetoric
that's been we're growing for a long long time about
the extremely damaging, irreversible effects of of hormone replacement therapy um,
and how they're gonna permanently alter your biology. If you
give these two children and there's five year olds taking
(13:17):
testosterone and it's gonna like you're like, You're like, really
that sounds very scary. UM. So that's something I would
like to discuss. It's like because a lot of people
when we when we do we talk talk about hormones,
they think of it as this like big, extremely life
altering thing um that has like these you know, irreversible
effects on your your your bones are gonna get weak
(13:40):
and trivel to never and never get big again, and
all of all of this very scary stuff. Um. What's
up with that? I think a lot of it goes
back to that biological essentialism, because hormones, even for the
people who give them, are considered partially like reversible. Because
the mid majority of the things that happen one take
(14:02):
a long ass time, like you will know whether or not.
This is a good idea for the majority of people
well before the physical manifestations occur. Uh. And and considering
like one of the biggest problems we have with certain formulations,
like in the once a week or once every other
week injectable version of estrogen, By the time you get
to right before your next dose, your estrogen is so
(14:25):
low you're feeling it and it's starting to like reverse
some of those So like, if you're feeling it after
two weeks, how irreversible could it be? Uh? And some
of it depends on like eight timing, because if we're
talking about a person who has say, already gone through
a testosterone mediated puberty, then some of the things are
(14:47):
just not going to be affected. You can't change like
bone size, height or anything like that. There's some interesting
things about like hip uh, like flexation and and and
and pivoting and yeah actually yeah and and and even
like shoe sizes can can change because of the way
the ligaments work on hormones. But like the bones aren't
going to change once they're done growing. But that's sort
(15:09):
of where the puberty blockers come in that we can
we'll talk about later. Um. But for the for the
majority of people, if you are going through if you
have gone through a puberty that you did not want,
you can take hormones to go through puberty you do
want and get the effects that you do want. And
some of the elements sure, like you know, growing breasts
uh guna coomastia as we would call it, an assist man,
(15:32):
which is another whole nonsense. Um, is not irreversible, Like
you can have them removed if you decided that you
needed to, like de transition, which is a whole another story.
But even then it takes like five years to see
their final breast size. Like if you if you're on
hormones for five years and you're worried about the irreversible
(15:55):
quote unquote effects, like what are we doing here? I mean?
And even I've heard from a lot of my elder
trans friends that whenever they go off hormones sometimes their
breasts just kind of go away because they're not massive
to begin with. Like if it's generally generally generally you
don't get the massive, massive honkers immediately. Um. I know,
(16:17):
I know we're trying, um, but a lot of a
lot a lot of even the you know, that was
one of the big things that informed content thing was like,
you know, a lot of these changes are reversible except
for breasts. These are these are these are these are
permanent change. Be careful and all my transferends are like
a little bit. But I like, your nipples won't shrink,
(16:39):
Like your nipples will definitely be bigger, and that that
won't change. But a lot of like the size actually
does fluctuate, and I can even tell that on like
depending on if I like missidos or something, being like
oh yeah, like there is a lot of a lot
of fluctuation even like on like you know, like temperature
and stuff. How cold will determine how how how how
(16:59):
how my chest looks it is? It is, uh, it's
pretty fun. I mean, I am I just like the
bio hacking thing in general. It is like the cyberpunk
and me um. But yeah, I guess I guess we
could talk about hormone hormone blockers as well, because this
is the other kind of thing you hear a lot
about when conservatives are very scared about transpeople. The idea
(17:20):
of hormone blockers like making people infertile or making permanent
changes to children's health or something. Blah blah blah blah blah. Gosh.
That's the thing that is like really really frustrating for me,
specifically because puberty blockers, the ganada trope in the g
(17:42):
n r H antagonist and agonists, which have been around
for like long time, but like ever for for I
want to say it was like a hundred years, but
I might be misquoting something that I'm half remembering, but
they've been around for like a really long time to
the point where we have generics and in the in
the pharmaceutical industry, that means that it's been like decades
at the very least, something that had rigorous testing that
(18:05):
has an indication with the FDA for precocious puberty, which
just means a person who is usually SIS who for
whatever reason, has puberty at a very young age. With
some of the some of the specific cases that I've
seen that I've that I've looked into, um involved giving
puberty blockers to like a three or four year old
because their body is trying to undergo puberty. So even
(18:28):
the idea of like, oh, well, I don't know this
twelve year old being on a puberty blocker for three years.
That sounds very dangerous when we have a person over
here who was on it for fifteen years with no
ill effects, like like no long lasting ill effects. Um
that the idea of anybody describing it as like experimental
is absolutely a historic outside of the realm of reality. Yeah,
(18:52):
there's it's it's basic anti anti intellectualism, because yeah, we've
been giving sis children hormone blockers for a long time
for early onset puberty, and it turns out they work
and they're pretty safe. So yeah, maybe we should give
those two trans kids too if they want them. Uh,
it seems like something we could at least try and
see if it improves mental health. And then it's it's
(19:13):
not even a matter that we have to try it.
We've been doing it for like almost ten years. Like
the it was first I think it was like two
thousand thirteen. There's a there's a ted talk I use
in my class of a of a physician who like
pioneered the use of puberty blockers in trans kids and
showed that any trans kid who got puberty blockers and
then was allowed to undergo the puberty that they desired
(19:35):
at an appropriate age, which is actually like fourteen fifteen
at the same time as their peers. UM. But even
if they had to wait till eighteen, the psychological effects
of having an in appropriate puberty are essentially nullified. They
are otherwise psychologically and physically like identical to their their
CIS gender peers. So it's like we have actual evidence
(19:58):
that it is extre really beneficial and extremely worthwhile. And
like the one kind of long term side effect is
you might be up to an inch shorter than you
otherwise be, which is a wildly like problematic like study
that was done because like we don't have time machines
to know whether or not that work, Like what would
your control group be? UM, And it's just wild. It's
(20:21):
very bothersome to me because a lot of the gender
affirming hormone therapy, the evidence is all over the place
for a variety of political reasons and and historical reasons.
But for hormone blockers, or for puberty blockers specifically, the
evidence is like really solid, really strong. And this is
(20:42):
the question I actually have because I'm actually unfamiliar with
this specific thing. But yeah, if you give like um,
hormone blockers to like a kid who's tend they still
kind of like grow at the same rate as a
lot of as a lot of their peers. And then
is that it just it's it's this specifically like the
secondary sex characteristic changes that get put on pause. Um,
(21:08):
but there's just so much Yeah, there's just so much
fear around the whole. Even even just the hormone blocker
thing right when we're getting you know, just like prescribing
hormone blockers being like a felony offense in multiple states.
Now you're like, it's like, it's it is just an
extreme degree of anti anti intellectualism, just like just like
(21:29):
purposeful like ignorance, um and just extreme hatred and uh bigotry,
and it's it is uh, I mean yeah, it's a
I'm kind of speaking to the choir here, but but
but but that's the trick. And and even like the
purity blocker thing, like you were saying, your body will
(21:49):
still make human growth hormone, you will still grow, it's
just that the modulation of that with say testosterone, which
would increase the overall growth like just doesn't there. And
people say make a lot of you know, talk a
lot about the idea of um bone mineral density because
you don't have testosterone or estrogen, which are both necessary
(22:12):
one or the other necessary for your like bone mineral
density to not like have like easily fractured bones, but
like you don't even have that until you go through puberty.
If you're just like preventing one puberty, the endogenous puberty,
and then providing the hormones for an exogenous puberty, they're fine,
Like they have the hormones they need, their bones are happy.
(22:32):
Uh So, yeah, I look to talk about I guess
kind of access to hormones and in like the like
the different models of of obviously we're not giving up
(22:54):
medical advice, but like this access to hormones and the
different ways that people can go about that now through doctors,
through informed consent um and all of all and all
of that jazz. Yeah. So the informed consent model is
a much more recent option, and it's not available everywhere.
(23:14):
I have a friend in Texas we had to find
a clinic that was like two hours away to get
her hormones. But here where I live, we actually have
to informed consent clinics. So it's pretty convenient, but it
varies wildly by by region. Uh And the informed carre
clinics are great. It means you come in, they say,
this is what's going to happen. Do you still want
to do it? You say yes, They take some blood,
they run some tests, you come back in two weeks,
(23:35):
and they go here. You go like that. That's they
work really well, depending on the clinic, I guess. And uh,
but the more traditional quote unquote standard model would be
going to your PCP or or whoever and saying that
you want to do this, which makes most of them
very concerned because most physicians, pharmacist, nurses, they don't get
(23:56):
taught anything about trans people, are caring for trans people,
are gender affirming hormon therapy in their school like, so
they have nothing to fall back on. Uh. So that
makes them very nervous to do it. And then UH,
if you if you look at gosh, I really want
to tell you about the guideline stuff at some point
here because it is bucked wild um as to why
(24:18):
that would be a concern. But another part of it
is is also the insurance. You know, America's original sin
in our healthcare dystopia, if you will. Uh, the insurances
historically have required and and part of this is also
from antiquated guidelines that has been somewhat like just grandfathered
in to excuse the term. Uh, this idea of like
we you have to go to a therapist. You can
(24:40):
go to a psychologist and they have to say that
you have gender dystoria, that's why it's in the d
s M. And then after you do that, some places
require you to socially transition before getting hormones or anything,
which can be extremely problematic for some individuals. That just
increases like visibility and bullying and and such in a
way that it makes drive people. It's it's sort of
(25:02):
was intentionally required back in the day to drive people
to not want hormones anymore. And it's all of these
gate keeping steps. And it's even worse if you wanted
to get a surgery later on, where you have to
have been on hormones for a certain length of time,
you have to have two different generally like susgender right.
(25:22):
Health care practitioners who don't necessarily understand like the full
like everything that's going on, write you letters before. The
most insurances up until recently wouldn't even cover it. So
it's just gate keeping step after gate keeping step. Because
even the Big Guidelines, which is w PATH, which is
about to put out their so gate guidelines. Um, there's
a guidelines out of San Francisco, and the Endocrine Society
(25:44):
has guidelines from two seventeen that are but all of
those are made by cisgender people, usually with the intent
to gate keep this care because it's either they're uncomfortable
with it, because they're unfamiliar with it, they have some
kind of ideological reasons to be against it, or whatever
whatever else. There's a survey that I often quote to
(26:05):
my students in class that, Um, they surveyed a whole
bunch of trans individuals trying to get care from their physicians,
and it was nearly a quarter of them said that
they avoided healthcare because of discrimination, and half of them
reported having to teach their health care practitioner how to
(26:25):
care for them, which is wild. Like, imagine going to
the hospital with like heart failure and having to like
talk your physician through how to care for you. Can
you can you live for two years with heart failure? First?
Before we go, Oh my gosh, could you imagine if
we treated other things this way? I'd be like, well,
are you sure that you have diabetes? Are you sure
(26:48):
that you're like, well, we can't treat your diabetes you're
too fat. Well your b m I is too high,
so we can't give you the insulin. Like, give me
a break. What is happening? Uh it seems like Uh,
basically what you're saying is that we've got a good system.
We gotta oh, we gotta figure it out. Absolutely no
notes dent perfect in every way. Well that doesn't for
(27:12):
us today here. Uh well, specifically if I could, Um,
it's really interesting from like the healthcare perspective, because from
you know, the practitioner's perspective, because there's essentially two kinds
of like treatment. There's guideline based medicine and evidence based medicine,
and a lot of schools, like my school teaches a
lot of guideline based medicine, which is for something like
(27:35):
hypertension or diabetes, is put out by like large organizations
with a ton of evidence. It is actually like pretty reasonable.
But that means that if you're going along with what
they say, that means that you believe that they read
those studies correctly and that their interpretation is in no
way compromised by like sources of their income, say, and
(27:58):
that those guideline is actually match your patients. So it's
a lot of assumptions that you're making, which can be
extremely problematic. And evidence based is where you dive into
literature and you figured it out yourself, which is very
time consuming and requires an awful lot of like professional uh,
like you know, criticism in a way. Uh, but when
you look at it for for trans care, for for
(28:19):
gender affirming hormone therapy, those guidelines are unbelievably compromised. To
give you an example, a hotly contested issue in feminizing
therapy is the use of micronized progesterone in feminizing care. Uh.
It's kind of like all over the place. There's a
long history of it, of of this controversy. In the
(28:40):
upcoming w path socate guidelines that I had like a
preliminary copy to to provide notes on there, there's a
single statement that just says that there's a controversy that
exists and you should not use micronized progesterone and transfeminine care.
And they list a study. Okay, if you pull up
(29:01):
that study, the title of it is progesterone is important
for transgender women's therapy. Applying evidence for the benefits of
progesterone insists women, and it is like a pretty long
document that concludes that it is like an ethical imperative
to offer it. So the idea that the people who
(29:21):
are writing the w path guidelines read this article, read
this this like meta analysis and went, yeah, I don't
really agree with any of that. I'm just gonna say no,
is just so infuriating. Again, that seems like we've got
a good system going here. Yeah, no, notes, I guess
on that note, let's I want to discuss some of
the some things that are talking about as much as
(29:42):
like um antiandrogen's, uh, progesterone, spiro and what all kind
of those do and how they can kind of supplement
a regular estradial regiment regiment. Yes, that sounds that sounds fancy. Sure, sure,
So generally speaking, if you're maybe you give a baseline
for for folks who are unaware. The way that we
(30:03):
do feminizing therapy is we offer estra dial, which is
a bioequivalent version of E two, because there's like three
different versions of estro of estrogen UM and an antiandrogen
because testosterone tends to be somewhat of an overriding hormone.
The presence of testosterone will override the effects of estrogen
to a certain extent depending on doses and stuff like that,
(30:23):
which is for the transmasculine individuals, why we just give testosterone.
It just does the job. You don't need to block
the estrogen. Uh So there's a you know, there's a
lot of history in just those hormones as well that
we could talk about, like conjugated estrogens versus estra dial
and and all the different other stuff. But for the
(30:43):
antiandrogens that we give historically in this country, we give
spiron lactone, which is a mineral corticoid. It's a potassium
sparing diuretic, and it's just really good. At higher levels.
We usually use it in like cardio issues like it
can be used for like hypertensions and other things. Um,
I believe it makes you pee a lot, So it's
(31:05):
a diuretic meaning that it makes you urinate and awful lot.
And it's a potassium sparing because it prevents your body
from eliminating potassium. So uh well, so that is that's
the thing that I think is really really wild because
you're using these high levels of it, it is preventing
your production of your endogenous production of testosterone and making
(31:28):
you pee all of the time, which spoilers estradial also
makes you pay more often, So like that's a real
fun combination. But then physicians, if they don't know what
the heck they're doing, they might say something like, well,
you can't eat any bananas, and like, historically the people
who are on feminizing therapy are healthy enough that their
body just accommodates for it. And if you have hyper keelmo,
(31:51):
which is like too much potassium, you're gonna know, like
your muscles are gonna ache and there's gonna be a
lot of like telltale side effects. Usually it's only a
problem if you are like only consuming a like salt
alternative that has potassium instead of sodium, which is not
super common not super common, or if you have some
(32:12):
other reason why your body is like holding onto potassium. Um,
So it's not usually an issue. Uh, it's an inspiral
actrone isn't sufficient for everyone. There's plenty of people who
have like refractory testosterone after some time, and there's some
other options. Uh, there's kind of a weird controversy about
it that is sort of heralded by the San Francisco Guidelines.
(32:33):
I mentioned earlier that spironal actone uh leads to Okay, well,
I want to make sure I get the wording right.
It's leads to premature fusing of the breast bud uh
and overall smaller breast size, which the document that they
cite for that is a real weird retrospective study from
like a bunch of years ago on the rate of
(32:54):
trans women getting breast augmentation, and it found that the
vast majority of trans women who are on spironal act
tone got breast agmented getting breast But the problem is,
like of their sample group of like to people, almost
all of the moron spur on a lactone. Like there's
like a sampling error, Like it's not it's very silly. Um.
(33:16):
And also even like that premature fusing in the breastbed,
I have never been able to find anything that suggests
that that's a thing or even like a way to
explain what that statement even means. But the San Francisco guidelines,
to go back to the my guideline thing actually says
has some like maybe don't use spar on lactone even
(33:37):
though it's something we've been using since literally like the
fifties or sixties for this purpose. In other countries, you'll
use what's called cyprotorone, which is a synthetic progesterone, but
it's not actually approved in the States because it has
a like there is actually some evidence that it causes
increase in certain specific cancers, but it's like a pretty
limited overall risk, Like it's not like something like you know,
(34:00):
going outside increases your risk of cancer. It's it's not
like a huge deal, but it was enough that they
don't it's not approved in the States, but in a
lot of other countries you'll you might get syprotarone, which
there's a lot of you know, controversy around that too
for those reasons. UM Here, the other option that we
usually see is finasteride, which is a five alpha reductation
(34:20):
inhibitor that essentially is preventing testosterone from being turned into
dihydro testosterone, which we use normally for UM to prevent
quote unquote male pattern boldness and in higher doses for
prostate cancer because it's real good at because it like
reverses some of the feedback loops just reducing product testosterone production. UM,
(34:43):
so it's just fine, like that one has like very
limited side effects, but it might not have as substantial
of a UM reduction of testosterone that spiral lactone does. UH.
And then the kind of third one that we really
we don't see our often, but there's a lot of
interesting evidence about is called by cooludamide. It's also a
(35:05):
prostate cancer medication. It actually blocks all of the receptors
of testosterone in your body while not reducing the production
of it. So you'll see a person who has like
you know, they have like seven hundred their their testosterone
comes back is like seven six D whatever, but they're
entirely feminized because none of it has anywhere to work. UM.
But the problem with that is by colutamide being an
(35:26):
anti cancer med UH primarily is ridiculously expensive. I think
it's like fifty bucks a dose or something like here,
it's so great, uh, I will say, And and for
my genderqueers out there or anyone anyone else. So we
can also just take estrogen without any without any blockers UM,
and you still get results as I can, as I
(35:48):
can confirm UM, and for a subset of the population,
just taking estrogen at sufficient dosages will also reduce your
levels of progester of testosterone, like, it's your body knows
what it's doing. Is it is? It is? It is
pretty cool. How but you can just change things up
(36:09):
in your body is like, oh, we're doing this now, Okay,
got it great? I have all these mechanisms. It's wonderful.
And with that, that wraps up part one of our
little two part series of episodes talking about hormone replacement therapy. Tomorrow,
I'll talk more about access to gender affirming treatment and
touch on d I y h R T special thanks
(36:31):
to Dr Victoria Luna Brennan Grieve for chatting with me
about gender affirming hormonal treatment. You'll get to hear more
of my discussion with her tomorrow as well, including a
brief tangent about the Scythian priestesses, which I was it
was very, very very excited to talk about, but that
doesn't for us today. You can follow this show at
(36:51):
Happen to Hear pod and Cool Zone Media on Twitter
and Instagram, and you can look at my late night
gender tweets at Hungry about Ie on or dot com.
So see you all on the other side.
Greetings listeners in the podcast verse, This is it could
happen here the podcast about things falling apart and sometimes
how we can put stuff back together. I'm Garrison Davis
are Resident Gender mess In the past few weeks, we've
been talking a lot here on the show about the
(00:25):
escalating war on trans people and queer folks in general.
There's been a wave of bills making any gender affirming
healthcare of felony for people under the age of eighteen,
which forcibly detransitions teenagers and multiple states, and we've had
a lot of banning trans people from participating in sports
and trying to ban books and discussion in schools about
(00:47):
the just the existence of queer people at all. But
today we're not really going to be talking about that.
We've talked about that plenty for the past few weeks.
It's good to have a little little bit of a break,
but we'll still be talking about stuff around trans people.
Because with all the discussion around gender affirming healthcare, I
thought it would be a good idea to put something
together talking about what HRT or hormone replacement therapy actually is,
(01:11):
as since it's the most common form of trans healthcare
and since many states are trying to or already have
criminalized it, perhaps I can use the POD to point
people towards alternative means of receiving care, you know, in
the vein of the putting stuff back together side of
the show. Now, I want to clarify upfront that we're
(01:32):
not giving anyone medical advice, obviously. I'm just making observations
and talking about things as they exist, um and talking
about things that many trans people have been doing for
a long time, and that includes d I Y HRT.
My doctorate program is in parapsychology, not medical science, so
just keep that in mind. First, I will quickly clarify
(01:54):
what HRT or hormone replacement therapy actually is for specifically
non CIS gender individuals, because HRT as a term is
also used for CIS women to describe similar but different treatment.
So HRT as a form of gender affirming treatment is
when someone receives sex hormone medication that produces a number
(02:17):
of desired secondary sex characteristics. There are two broad types
of hormone therapy that one would receive, depending on what
direction you want to go in gender of wise, there's
feminizing hormones and masculinizing hormones. Feminizing hormones produce more typically
feminine traits, right, big big shocker there. Uh. It usually
(02:40):
consists of a form of estrogen, usually called estradial. There's
different types of estradial, and also it can include anti
androgen's aka a testosterone blockers. Masculinization therapy consists of taking
to sasterone or androgen's and then also less commonly anti strogens,
but usually just tinking to toss your own will suffice. Now,
(03:05):
I'm no expert in hormones despite my weekly shot, but
lucky enough I was able to sit down with an
actual expert on hormones and talk over zoom. So what
follows is segments from our conversation. I guess first, do
you want to introduce yourself? Sure? I am the Reverend
Dr Victoria Luna B. Grieve. I am an assistant professor
(03:27):
at the University of Pittsburgh School of Pharmacy. My primary
clinical focuses on gender affirming hormone therapy, other kind of advocacy,
work in queer healthcare, and I do a lot of
other stuff on the side. Heatigo g Ludac, instructional design,
game design, just anything that strikes my fancy really fun
fun stuff in with within kind of our our coverage
(03:50):
of trend stuff the past few weeks and months, it's
been mostly on like the bills and like the politics
side of things. I definitely had some people like reach
out and be like, okay, but how like why why treads? Gender?
Why why hormones? Like why are hormones actually important? Like
could you actually explain like what, like you know, with
all of these all these states banding hormones, let's I
(04:13):
would like to kind of explain why it's such a
big deal and like how much these things actually are
like life saving medication for so many people. Yeah, so
why are hormones? I love it because it's a question
that as like a species, we've been we have known
the answer to for like five thousand years. It's it's
(04:35):
very funny, but um, hormones are. Okay. A big part
of this requires to like acknowledge something that is very
wrong in in like the medical literature. There's a lot
of elements of healthcare that are coordinated between like male
and female, and there's a kind of like obviously is
(04:56):
a little so there's a lot of I mean like
from like from people's I know, when trans people talking
about interacting with the medical system, it's always like, oh, yes,
we're gonna be doing this bullshit, Yes of course. Yeah, well,
but it even goes to it like a really deep level,
like if you're in the hospital and you get a
CBC count, there's a male profile and a female profile
of what your hematocrit should be on, like what the
(05:18):
level of red blood cells are, and and the general
understanding and like the health industry is that there's a
biological anatomical difference between them. And for the longest time,
certainly in this country, trans women would have would be
compared against the male profiles. But but it's nonsense. It's
actually should be thought of in form of hormone dominance,
because the vast majority of medical differences are not anatomical,
(05:42):
they're hormonal, and and that right there should should give
the game away, which is really funny, which is why
it's why I kind of hate the term biological woman
whenever people start using that, because that's not really how
biology works. Yeah, I mean that Oak is my my
nesting partner. My fiancee wishes that she could be a robot,
(06:03):
and then if she were to do that and upload
her brain into an immortal robot body. She would no
longer be a biological woman, but she would still be
a woman. It's just cybernetic. Um. I hate that. It's
like organic. Organic just means it has carbon in it. Like,
give me a break. Yes, so yeah, hormones, what's what's
(06:23):
what's the deal do they? Because I know all of
people will be like, well, all of these trends, people
sure do seem sad. I want that's how how how
can we make things better? Does this thing actually work? Uh? Well,
so it's somewhat multifactorial. I have a friend who does
um sell imaging, and her like working theory, which I'm
(06:44):
a little dubious of, is that like the brains of
trans people like have receptors for hormones that the body
doesn't make, and we should think of being transgender is
having like a form of hypogonadism. Yeah, there's there's a
lot of different trains of thought there in terms of
the different theories of why trends people exist and how
it's like you know, the girl's brain, boys body, blah
(07:04):
blah blah blah blah, which all, if you dig deep enough,
goes back to eugenic. So it's all, yeah, I've always
not liked that model. I've always it's always I've always
found it to be a little bit uncomfortable because I
take hormones because I want to, And I don't think
it's because my my my brain is like secretly looking
for girl receptors or something like, right, I totally agree,
(07:29):
Like it also requires a certain like extremely binary understanding
of gender, which I also do not ascribe to. So
it's a very like odd thought. But putting aside all
of that, if you just wanted to look at the
like why people want hormones, Because when a person who
wants hormones gets the hormones they want, their suicidality goes down,
(07:49):
their anxiety, depression goes down, gender dysphoria, if we wanted to,
you know, talk about the problems with that, essentially like
goes away, uh, and they get this to get treated
like the way they want to be treated in society.
So from the if if you want to look at it,
not from like the causes, but from the results, giving
gender affirming hormone therapy to a person who is requesting
(08:12):
gender afforming hormone therapy has a success rate. The rate
of regret from starting hormones is one percent or less,
which is unbelievable in the health care field, like like
having a child, like biologically giving birth has a seven
percent regret rate, Like the idea of any therapy having
(08:35):
that high of a rate of preventing death, anxiety, depression, bullying,
like all of the different effects. Being that successful should
be like a miracle. It should be looked at as
the thing we in healthcare are like should do absolutely ethically.
Uh and it it is is so much more complicated
(08:57):
than that. So like hormones from the results obviously makes sense.
It aligns your bodies shape and like fat fat deposits
and the way that you feel, the way that you
relate to your emotions. It all goes back to the
way that hormones work on your body. And there's there's
like the old saying that like assis person would never
(09:18):
want to try gender forming homerone therapy, So like, if
you have the in if you want to try it,
you should be allowed to try it. I mean, like
you're you're kind of a good example right here, Like yeah,
but I'm sitting Yeah, if you're sitting around a bar
with a bunch of like CIS guys and you're like, hey,
who wants some estrogen? They would all like shrink away
from it, Like no, absolutely, because yeah, it's definitely a thing.
(09:42):
Like I'm not the most dysphoric person, but I'm like, sure,
I'll take estrogen. That sounds fun. That's like, it's like that,
that sounds like a thing that I could enjoy watching
my body change. And I'm you know, it's it's I'm
happy that we're moving more towards that and not having
to deal with, oh, I'm so dysphoric, i want to die,
(10:02):
which is obviously they're a big thing for a lot
of people. I'm not I'm not minimizing that right um.
But also a lot of trans people have had more
kind of complicated feelings on gender, whether they're like gender queer,
non binary. Having the past had made it more difficult
to get gender firm in care because they don't fit
into those specific like male female boxes as easily. M Well,
(10:23):
and what you're talking about is really something that's relatively recent.
The idea of gender euphoria, like the idea that people
want to take because it gives them joy to like
dress or act or feel a certain way, and that
I mean, health care is all about, at least up
until well, the reality of health care is that it
(10:44):
is all about finding problems to solve and not really
looking at like your life just better in general. Yeah, exactly.
So you know, I know plenty of people who started
hormones of any type just because they felt it would
make them happier, and they were correct, And that gender
euphoria is just as good of a reason to take
it as the dysphoria. The problem ends up in how
(11:06):
the medical industry treats it, because dysphoria quote unquote is
something that's long. Oh my gosh, I could go into
the whole history of that if you wanted, but I'm
sure we could talk about the ds M four and
five for a long time. Oh it's so frustrating. I
spend I spend a two hour session in my Queer
healthcare class, specifically just dunking on the ds M five
definition of gender dysphoria. Um. But the real problem is,
(11:29):
like this focus on this negative quality and how that
actually damages a lot of the conversations around uh, gender
firming hormone therapy and trans people in general. Like, instead
of seeing it as like this manifestation of people like
truly taking control of their lives to become authentic in
like the truest way, Like you have never met a
(11:52):
more truly well uh self made man than a transman
who gets hormones. Like it's I mean it's and it's
still something where even we're not quite at the at
the gender utopia, I mean obviously because of all of
the anti tran stuff, but even even on like just
purely purely the medical side, like I even for for
(12:12):
informed consent, um, I still needed to get diagnosed with
gender dysphoria at the informed Consent clinic in order to
get hormones, which is in part like an insurance thing,
and you know it has has all of these all
of these bullshit reasons. Um, but that is that is
something we're still we're still definitely dealing with, Oh my goodness. Yeah.
And the better informed care clinics are the ones that
(12:33):
they realize it's just like an effort in box ticking.
So they're just like, Yep, sounds good. You came here
to this clinic and you asked about hormones. Sounds like
gender dysphoria to me, Like we'll sell your insurance whatever.
We gotta say. Yes, eventually we'll go into like hormone
(12:56):
blockers as well. UM. But I want to talk about
there's a lot of this. There's a lot of rhetoric
that's been we're growing for a long long time about
the extremely damaging, irreversible effects of of hormone replacement therapy um,
and how they're gonna permanently alter your biology. If you
give these two children and there's five year olds taking
(13:17):
testosterone and it's gonna like you're like, You're like, really
that sounds very scary. UM. So that's something I would
like to discuss. It's like because a lot of people
when we when we do we talk talk about hormones,
they think of it as this like big, extremely life
altering thing um that has like these you know, irreversible
effects on your your your bones are gonna get weak
(13:40):
and trivel to never and never get big again, and
all of all of this very scary stuff. Um. What's
up with that? I think a lot of it goes
back to that biological essentialism, because hormones, even for the
people who give them, are considered partially like reversible. Because
the mid majority of the things that happen one take
(14:02):
a long ass time, like you will know whether or not.
This is a good idea for the majority of people
well before the physical manifestations occur. Uh. And and considering
like one of the biggest problems we have with certain formulations,
like in the once a week or once every other
week injectable version of estrogen, By the time you get
to right before your next dose, your estrogen is so
(14:25):
low you're feeling it and it's starting to like reverse
some of those So like, if you're feeling it after
two weeks, how irreversible could it be? Uh? And some
of it depends on like eight timing, because if we're
talking about a person who has say, already gone through
a testosterone mediated puberty, then some of the things are
(14:47):
just not going to be affected. You can't change like
bone size, height or anything like that. There's some interesting
things about like hip uh, like flexation and and and
and pivoting and yeah actually yeah and and and even
like shoe sizes can can change because of the way
the ligaments work on hormones. But like the bones aren't
going to change once they're done growing. But that's sort
(15:09):
of where the puberty blockers come in that we can
we'll talk about later. Um. But for the for the
majority of people, if you are going through if you
have gone through a puberty that you did not want,
you can take hormones to go through puberty you do
want and get the effects that you do want. And
some of the elements sure, like you know, growing breasts
uh guna coomastia as we would call it, an assist man,
(15:32):
which is another whole nonsense. Um, is not irreversible, Like
you can have them removed if you decided that you
needed to, like de transition, which is a whole another story.
But even then it takes like five years to see
their final breast size. Like if you if you're on
hormones for five years and you're worried about the irreversible
(15:55):
quote unquote effects, like what are we doing here? I mean?
And even I've heard from a lot of my elder
trans friends that whenever they go off hormones sometimes their
breasts just kind of go away because they're not massive
to begin with. Like if it's generally generally generally you
don't get the massive, massive honkers immediately. Um. I know,
(16:17):
I know we're trying, um, but a lot of a
lot a lot of even the you know, that was
one of the big things that informed content thing was like,
you know, a lot of these changes are reversible except
for breasts. These are these are these are these are
permanent change. Be careful and all my transferends are like
a little bit. But I like, your nipples won't shrink,
(16:39):
Like your nipples will definitely be bigger, and that that
won't change. But a lot of like the size actually
does fluctuate, and I can even tell that on like
depending on if I like missidos or something, being like
oh yeah, like there is a lot of a lot
of fluctuation even like on like you know, like temperature
and stuff. How cold will determine how how how how
(16:59):
how my chest looks it is? It is, uh, it's
pretty fun. I mean, I am I just like the
bio hacking thing in general. It is like the cyberpunk
and me um. But yeah, I guess I guess we
could talk about hormone hormone blockers as well, because this
is the other kind of thing you hear a lot
about when conservatives are very scared about transpeople. The idea
(17:20):
of hormone blockers like making people infertile or making permanent
changes to children's health or something. Blah blah blah blah blah. Gosh.
That's the thing that is like really really frustrating for me,
specifically because puberty blockers, the ganada trope in the g
(17:42):
n r H antagonist and agonists, which have been around
for like long time, but like ever for for I
want to say it was like a hundred years, but
I might be misquoting something that I'm half remembering, but
they've been around for like a really long time to
the point where we have generics and in the in
the pharmaceutical industry, that means that it's been like decades
at the very least, something that had rigorous testing that
(18:05):
has an indication with the FDA for precocious puberty, which
just means a person who is usually SIS who for
whatever reason, has puberty at a very young age. With
some of the some of the specific cases that I've
seen that I've that I've looked into, um involved giving
puberty blockers to like a three or four year old
because their body is trying to undergo puberty. So even
(18:28):
the idea of like, oh, well, I don't know this
twelve year old being on a puberty blocker for three years.
That sounds very dangerous when we have a person over
here who was on it for fifteen years with no
ill effects, like like no long lasting ill effects. Um
that the idea of anybody describing it as like experimental
is absolutely a historic outside of the realm of reality. Yeah,
(18:52):
there's it's it's basic anti anti intellectualism, because yeah, we've
been giving sis children hormone blockers for a long time
for early onset puberty, and it turns out they work
and they're pretty safe. So yeah, maybe we should give
those two trans kids too if they want them. Uh,
it seems like something we could at least try and
see if it improves mental health. And then it's it's
(19:13):
not even a matter that we have to try it.
We've been doing it for like almost ten years. Like
the it was first I think it was like two
thousand thirteen. There's a there's a ted talk I use
in my class of a of a physician who like
pioneered the use of puberty blockers in trans kids and
showed that any trans kid who got puberty blockers and
then was allowed to undergo the puberty that they desired
(19:35):
at an appropriate age, which is actually like fourteen fifteen
at the same time as their peers. UM. But even
if they had to wait till eighteen, the psychological effects
of having an in appropriate puberty are essentially nullified. They
are otherwise psychologically and physically like identical to their their
CIS gender peers. So it's like we have actual evidence
(19:58):
that it is extre really beneficial and extremely worthwhile. And
like the one kind of long term side effect is
you might be up to an inch shorter than you
otherwise be, which is a wildly like problematic like study
that was done because like we don't have time machines
to know whether or not that work, Like what would
your control group be? UM, And it's just wild. It's
(20:21):
very bothersome to me because a lot of the gender
affirming hormone therapy, the evidence is all over the place
for a variety of political reasons and and historical reasons.
But for hormone blockers, or for puberty blockers specifically, the
evidence is like really solid, really strong. And this is
(20:42):
the question I actually have because I'm actually unfamiliar with
this specific thing. But yeah, if you give like um,
hormone blockers to like a kid who's tend they still
kind of like grow at the same rate as a
lot of as a lot of their peers. And then
is that it just it's it's this specifically like the
secondary sex characteristic changes that get put on pause. Um,
(21:08):
but there's just so much Yeah, there's just so much
fear around the whole. Even even just the hormone blocker
thing right when we're getting you know, just like prescribing
hormone blockers being like a felony offense in multiple states.
Now you're like, it's like, it's it is just an
extreme degree of anti anti intellectualism, just like just like
(21:29):
purposeful like ignorance, um and just extreme hatred and uh bigotry,
and it's it is uh, I mean yeah, it's a
I'm kind of speaking to the choir here, but but
but but that's the trick. And and even like the
purity blocker thing, like you were saying, your body will
(21:49):
still make human growth hormone, you will still grow, it's
just that the modulation of that with say testosterone, which
would increase the overall growth like just doesn't there. And
people say make a lot of you know, talk a
lot about the idea of um bone mineral density because
you don't have testosterone or estrogen, which are both necessary
(22:12):
one or the other necessary for your like bone mineral
density to not like have like easily fractured bones, but
like you don't even have that until you go through puberty.
If you're just like preventing one puberty, the endogenous puberty,
and then providing the hormones for an exogenous puberty, they're fine,
Like they have the hormones they need, their bones are happy.
(22:32):
Uh So, yeah, I look to talk about I guess
kind of access to hormones and in like the like
the different models of of obviously we're not giving up
(22:54):
medical advice, but like this access to hormones and the
different ways that people can go about that now through doctors,
through informed consent um and all of all and all
of that jazz. Yeah. So the informed consent model is
a much more recent option, and it's not available everywhere.
(23:14):
I have a friend in Texas we had to find
a clinic that was like two hours away to get
her hormones. But here where I live, we actually have
to informed consent clinics. So it's pretty convenient, but it
varies wildly by by region. Uh And the informed carre
clinics are great. It means you come in, they say,
this is what's going to happen. Do you still want
to do it? You say yes, They take some blood,
they run some tests, you come back in two weeks,
(23:35):
and they go here. You go like that. That's they
work really well, depending on the clinic, I guess. And uh,
but the more traditional quote unquote standard model would be
going to your PCP or or whoever and saying that
you want to do this, which makes most of them
very concerned because most physicians, pharmacist, nurses, they don't get
(23:56):
taught anything about trans people, are caring for trans people,
are gender affirming hormon therapy in their school like, so
they have nothing to fall back on. Uh. So that
makes them very nervous to do it. And then UH,
if you if you look at gosh, I really want
to tell you about the guideline stuff at some point
here because it is bucked wild um as to why
(24:18):
that would be a concern. But another part of it
is is also the insurance. You know, America's original sin
in our healthcare dystopia, if you will. Uh, the insurances
historically have required and and part of this is also
from antiquated guidelines that has been somewhat like just grandfathered
in to excuse the term. Uh, this idea of like
we you have to go to a therapist. You can
(24:40):
go to a psychologist and they have to say that
you have gender dystoria, that's why it's in the d
s M. And then after you do that, some places
require you to socially transition before getting hormones or anything,
which can be extremely problematic for some individuals. That just
increases like visibility and bullying and and such in a
way that it makes drive people. It's it's sort of
(25:02):
was intentionally required back in the day to drive people
to not want hormones anymore. And it's all of these
gate keeping steps. And it's even worse if you wanted
to get a surgery later on, where you have to
have been on hormones for a certain length of time,
you have to have two different generally like susgender right.
(25:22):
Health care practitioners who don't necessarily understand like the full
like everything that's going on, write you letters before. The
most insurances up until recently wouldn't even cover it. So
it's just gate keeping step after gate keeping step. Because
even the Big Guidelines, which is w PATH, which is
about to put out their so gate guidelines. Um, there's
a guidelines out of San Francisco, and the Endocrine Society
(25:44):
has guidelines from two seventeen that are but all of
those are made by cisgender people, usually with the intent
to gate keep this care because it's either they're uncomfortable
with it, because they're unfamiliar with it, they have some
kind of ideological reasons to be against it, or whatever
whatever else. There's a survey that I often quote to
(26:05):
my students in class that, Um, they surveyed a whole
bunch of trans individuals trying to get care from their physicians,
and it was nearly a quarter of them said that
they avoided healthcare because of discrimination, and half of them
reported having to teach their health care practitioner how to
(26:25):
care for them, which is wild. Like, imagine going to
the hospital with like heart failure and having to like
talk your physician through how to care for you. Can
you can you live for two years with heart failure? First?
Before we go, Oh my gosh, could you imagine if
we treated other things this way? I'd be like, well,
are you sure that you have diabetes? Are you sure
(26:48):
that you're like, well, we can't treat your diabetes you're
too fat. Well your b m I is too high,
so we can't give you the insulin. Like, give me
a break. What is happening? Uh it seems like Uh,
basically what you're saying is that we've got a good system.
We gotta oh, we gotta figure it out. Absolutely no
notes dent perfect in every way. Well that doesn't for
(27:12):
us today here. Uh well, specifically if I could, Um,
it's really interesting from like the healthcare perspective, because from
you know, the practitioner's perspective, because there's essentially two kinds
of like treatment. There's guideline based medicine and evidence based medicine,
and a lot of schools, like my school teaches a
lot of guideline based medicine, which is for something like
(27:35):
hypertension or diabetes, is put out by like large organizations
with a ton of evidence. It is actually like pretty reasonable.
But that means that if you're going along with what
they say, that means that you believe that they read
those studies correctly and that their interpretation is in no
way compromised by like sources of their income, say, and
(27:58):
that those guideline is actually match your patients. So it's
a lot of assumptions that you're making, which can be
extremely problematic. And evidence based is where you dive into
literature and you figured it out yourself, which is very
time consuming and requires an awful lot of like professional uh,
like you know, criticism in a way. Uh, but when
you look at it for for trans care, for for
(28:19):
gender affirming hormone therapy, those guidelines are unbelievably compromised. To
give you an example, a hotly contested issue in feminizing
therapy is the use of micronized progesterone in feminizing care. Uh.
It's kind of like all over the place. There's a
long history of it, of of this controversy. In the
(28:40):
upcoming w path socate guidelines that I had like a
preliminary copy to to provide notes on there, there's a
single statement that just says that there's a controversy that
exists and you should not use micronized progesterone and transfeminine care.
And they list a study. Okay, if you pull up
(29:01):
that study, the title of it is progesterone is important
for transgender women's therapy. Applying evidence for the benefits of
progesterone insists women, and it is like a pretty long
document that concludes that it is like an ethical imperative
to offer it. So the idea that the people who
(29:21):
are writing the w path guidelines read this article, read
this this like meta analysis and went, yeah, I don't
really agree with any of that. I'm just gonna say no,
is just so infuriating. Again, that seems like we've got
a good system going here. Yeah, no, notes, I guess
on that note, let's I want to discuss some of
the some things that are talking about as much as
(29:42):
like um antiandrogen's, uh, progesterone, spiro and what all kind
of those do and how they can kind of supplement
a regular estradial regiment regiment. Yes, that sounds that sounds fancy. Sure, sure,
So generally speaking, if you're maybe you give a baseline
for for folks who are unaware. The way that we
(30:03):
do feminizing therapy is we offer estra dial, which is
a bioequivalent version of E two, because there's like three
different versions of estro of estrogen UM and an antiandrogen
because testosterone tends to be somewhat of an overriding hormone.
The presence of testosterone will override the effects of estrogen
to a certain extent depending on doses and stuff like that,
(30:23):
which is for the transmasculine individuals, why we just give testosterone.
It just does the job. You don't need to block
the estrogen. Uh So there's a you know, there's a
lot of history in just those hormones as well that
we could talk about, like conjugated estrogens versus estra dial
and and all the different other stuff. But for the
(30:43):
antiandrogens that we give historically in this country, we give
spiron lactone, which is a mineral corticoid. It's a potassium
sparing diuretic, and it's just really good. At higher levels.
We usually use it in like cardio issues like it
can be used for like hypertensions and other things. Um,
I believe it makes you pee a lot, So it's
(31:05):
a diuretic meaning that it makes you urinate and awful lot.
And it's a potassium sparing because it prevents your body
from eliminating potassium. So uh well, so that is that's
the thing that I think is really really wild because
you're using these high levels of it, it is preventing
your production of your endogenous production of testosterone and making
(31:28):
you pee all of the time, which spoilers estradial also
makes you pay more often, So like that's a real
fun combination. But then physicians, if they don't know what
the heck they're doing, they might say something like, well,
you can't eat any bananas, and like, historically the people
who are on feminizing therapy are healthy enough that their
body just accommodates for it. And if you have hyper keelmo,
(31:51):
which is like too much potassium, you're gonna know, like
your muscles are gonna ache and there's gonna be a
lot of like telltale side effects. Usually it's only a
problem if you are like only consuming a like salt
alternative that has potassium instead of sodium, which is not
super common not super common, or if you have some
(32:12):
other reason why your body is like holding onto potassium. Um,
So it's not usually an issue. Uh, it's an inspiral
actrone isn't sufficient for everyone. There's plenty of people who
have like refractory testosterone after some time, and there's some
other options. Uh, there's kind of a weird controversy about
it that is sort of heralded by the San Francisco Guidelines.
(32:33):
I mentioned earlier that spironal actone uh leads to Okay, well,
I want to make sure I get the wording right.
It's leads to premature fusing of the breast bud uh
and overall smaller breast size, which the document that they
cite for that is a real weird retrospective study from
like a bunch of years ago on the rate of
(32:54):
trans women getting breast augmentation, and it found that the
vast majority of trans women who are on spironal act
tone got breast agmented getting breast But the problem is,
like of their sample group of like to people, almost
all of the moron spur on a lactone. Like there's
like a sampling error, Like it's not it's very silly. Um.
(33:16):
And also even like that premature fusing in the breastbed,
I have never been able to find anything that suggests
that that's a thing or even like a way to
explain what that statement even means. But the San Francisco guidelines,
to go back to the my guideline thing actually says
has some like maybe don't use spar on lactone even
(33:37):
though it's something we've been using since literally like the
fifties or sixties for this purpose. In other countries, you'll
use what's called cyprotorone, which is a synthetic progesterone, but
it's not actually approved in the States because it has
a like there is actually some evidence that it causes
increase in certain specific cancers, but it's like a pretty
limited overall risk, Like it's not like something like you know,
(34:00):
going outside increases your risk of cancer. It's it's not
like a huge deal, but it was enough that they
don't it's not approved in the States, but in a
lot of other countries you'll you might get syprotarone, which
there's a lot of you know, controversy around that too
for those reasons. UM Here, the other option that we
usually see is finasteride, which is a five alpha reductation
(34:20):
inhibitor that essentially is preventing testosterone from being turned into
dihydro testosterone, which we use normally for UM to prevent
quote unquote male pattern boldness and in higher doses for
prostate cancer because it's real good at because it like
reverses some of the feedback loops just reducing product testosterone production. UM,
(34:43):
so it's just fine, like that one has like very
limited side effects, but it might not have as substantial
of a UM reduction of testosterone that spiral lactone does. UH.
And then the kind of third one that we really
we don't see our often, but there's a lot of
interesting evidence about is called by cooludamide. It's also a
(35:05):
prostate cancer medication. It actually blocks all of the receptors
of testosterone in your body while not reducing the production
of it. So you'll see a person who has like
you know, they have like seven hundred their their testosterone
comes back is like seven six D whatever, but they're
entirely feminized because none of it has anywhere to work. UM.
But the problem with that is by colutamide being an
(35:26):
anti cancer med UH primarily is ridiculously expensive. I think
it's like fifty bucks a dose or something like here,
it's so great, uh, I will say, And and for
my genderqueers out there or anyone anyone else. So we
can also just take estrogen without any without any blockers UM,
and you still get results as I can, as I
(35:48):
can confirm UM, and for a subset of the population,
just taking estrogen at sufficient dosages will also reduce your
levels of progester of testosterone, like, it's your body knows
what it's doing. Is it is? It is? It is
pretty cool. How but you can just change things up
(36:09):
in your body is like, oh, we're doing this now, Okay,
got it great? I have all these mechanisms. It's wonderful.
And with that, that wraps up part one of our
little two part series of episodes talking about hormone replacement therapy. Tomorrow,
I'll talk more about access to gender affirming treatment and
touch on d I y h R T special thanks
(36:31):
to Dr Victoria Luna Brennan Grieve for chatting with me
about gender affirming hormonal treatment. You'll get to hear more
of my discussion with her tomorrow as well, including a
brief tangent about the Scythian priestesses, which I was it
was very, very very excited to talk about, but that
doesn't for us today. You can follow this show at
(36:51):
Happen to Hear pod and Cool Zone Media on Twitter
and Instagram, and you can look at my late night
gender tweets at Hungry about Ie on or dot com.
So see you all on the other side.
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