Abstract
Purpose: Chronic gender-affirming hormone therapy (GAHT) with sublingual estradiol (SLE) has not been studied. We aimed to compare GAHT with SLE only, to combined oral (CO) estradiol and cyproterone acetate, in treatment-naive trans women.
Methods: Twenty-two trans women enrolled into either the CO arm or the SLE-only arm (0.5 mg four times daily) in this 6-month prospective study. Anthropometric and laboratory variables were collected at baseline and 3 and 6 months. At the study beginning and end, body composition was measured by dual-energy X-ray absorptiometry and bioelectrical impedance, and gender dysphoria, sexual desire, and function were assessed by validated questionnaires.
Results: Subjects in the SLE were older, 26.3±5.8 years versus 20.1±2.3 years, p=0.006. All anthropometric, body composition, and laboratory variables were identical at baseline. Although dysphoria appeared greater, and sexual function lower at baseline in the CO group, this canceled out after age adjustment. Both treatments induced similar biochemical and hormonal changes. Creatinine, hemoglobin and cholesterol decreased significantly, while testosterone was suppressed to the same level in both groups: 3.22 [1.47-5.0] nmol/L in the SLE group and 2.41 [0.55-8.5] nmol/L in the CO, p=0.65. Significant changes in body composition toward a more feminine body were noted in both groups. Dysphoria did not significantly improve in either group, while sexual desire and function decreased at six months in both, p<0.001.
Conclusions: Both treatments achieved similar clinical changes. At this stage, SLE, which repeatedly induces alarming excursions of serum estradiol throughout the day, appears to offer no advantage over the CO approach.
Why the skull?
Sexual desire & function decreasing is commonly seen as a negative thing, and dysphoria not improving is clearly negative - so I am attempting a kind of sympathetic humor at the unfortunate irony of a treatment being unsuccessful. It makes me sound monstrous, now that I have to explain it.
Thank you for explaining.
Personally we do not think desire decreases completely, but in our own experience it has changed and made us wish for different functioning. Perhaps we always had that to some degree but the problem is that medical science is not really a place for many of us to feel congruent in our desires and functioning, that is why it is a problem for many trans femmes, we believe.
As for functioning without the medical science currently able to provide us what we require, this can be true somewhat. However, it can be mitigated by alternative practices.
Personally, my desire pretty much disappeared… sometimes it super bothers me, especially since I know things need to stay engaged down there if I ever opt for certain surgeries. It’s not bothersome enough that I’ve seriously brought it up with my doctor, but I did ask to be prescribed progesterone to help as I’ve seen many anecdotes about it increasing sex drive and desire…zero change so far. I’d say it’s pretty nice for the most part as there’s this edge which is no longer there, buuuut I do sometimes miss actually feeling that type of desire. I have read that it just randomly returns eventually, so just doing my best to enjoy whatever this is for now 🤭
Progesterone can make desire or horniness return. However, in our experience and this might just be us it can bring with it a certain amount of dysmorphia.
Estrogen increased desire significantly for me, but I personally wish it had decreased desire and functioning. I like the atrophy (esp. when I started to think of myself in normative terms as a woman), and I would prefer a much lower libido, I think I would (selfishly) be happy with no libido.
Part of the problem with this study is that it has such a small sample size, dysphoria clearly decreases for many trans people when they take HRT and there are many, much larger and better studies showing this.
I don’t really follow what you mean about medical science and congruence with desire and function, or what you mean by alternative practices.
We mean that medical science cannot give us certain body parts that would increase sexual functioning such a clitoris, certain glands nor ovaries, a womb etc (yet) and by alternative practises we mean kink or possibly certain cultural practises like tantra etc.
A vaginoplasty absolutely can provide you with some of the anatomy like a clitoris and vagina … ovaries and a womb might be necessary for reproduction, but HRT substitutes for the ovaries and I don’t see how a womb necessarily increases sexual function in the sense that the researchers meant (which is the ability for arousal and orgasm).
I hear you about the womb, though - it’s painful to me in ways I don’t understand that I can never become pregnant. This is a bizarre change for me, since I have been very clear about not wanting children my whole life, and I felt the biological urge to reproduce only after taking estrogen. I completely understand why Lily Elbe tried (and tragically failed) to have a uterus surgically implanted.
Well, yes to a certain degree, however, most endogenic clitorises are inside the body and look like a wishbone in a way that no surgery or other medical procedures etc can currently do which is what we want, plus we believe ones created by vaginoplasty surgery don’t have the same number of nerve endings as endogenic ones. This is what we meant about sexual functioning as we want to be able to do all the things people who have them endogenically can do which isn’t possible sadly, we just feel empty and might still if we did have such surgeries.
Vaginas are similar in that we believe no current procedures can make them fully feel or function like endogenic ones inside, so we are hesitant about having surgery, it might help us, it might not.
Okay, fair about them only being needed for reproduction but we would very much like to be pregnant and would solve this situation we have gotten ourselves into where there’s probably no chance of having bio children any other way.
Yeah, we have seen that awful film about Lily Elbe, plus looked into it and it is possible but it would mean somebody with an endogenic womb dying currently as it is massive surgery and not sure whether the recipient would survive either. Given what happened to Lily Elbe, who knows. Guessing it would require some kind of crispr modification currently to be anywhere close to successful, even though that technology is nowhere near ready for that kind of modification.
We guess what we mean basically is that for us sexual functioning is tied very much to having certain body parts in an endogenic way because every time we think about any kind of sexual stuff currently we just get dysphoric and dysmorphic in a way that we aren’t sure would be solved by surgery completely.
We’re very glad if this doesn’t happen to other trans femmes though, because either it doesn’t or they don’t talk about it or they aren’t allowed to lest they get some transmisic somewhere to say some bullshit, for us though it hurts a lot and we’re glad if no others are going through this.
You might feel empty still, but you might also feel a massive improvement. A vaginoplasty is a known effective treatment for the feelings you are having, and it honestly sounds to me like you are sacrificing the potential and known good because you can’t have the perfect.
When I was in denial before my egg cracked, I often rationalized that I shouldn’t transition because as you mention I can never be a woman for a million reasons - that even with estrogen and surgeries I would never experience a woman’s orgasm, I even had the same thought as you about the number of nerve endings in the clit vs a penis.
But I can tell you I definitely have what would be characterized as powerful female orgasms now despite the supposed deficiencies of my genitals. I underestimated how it would feel on the other side.
What I have heard about neo-vaginas is that they are not distinguishable from natal vaginas, in they way they look, feel, or function. We can nitpick and find minor differences, and we can certainly focus on those differences to fuel dysphoria and insecurities, but choosing to do nothing makes less sense to me since the outcome is obviously worse (genitals that won’t ever or in any way work).
All this to say, I share your fears and capacity for rationalizing myself out of difficult choices like this, but I have gotten to the point where I feel more pragmatic and I am willing to trust that there is potential for a vaginoplasty to improve my situation.
Of course I am terrified of how I might feel, how my perfectionism and dysphoria might respond and reject my artificial genitals, but it is a leap of faith, and one that I feel is justified by extensive research that over and over confirms that this procedure improves the kinds of suffering we are experiencing. Hopefully it improves things, but worst case scenario I think it will still have been a rational choice to take that risk given the alternative.
We will get back to this more fully soon. However, we appreciate you actully engaging with us about the negative stuff. We find much of the time the rest of the trans community doesn’t want to engage with this kind of stuff and a lot of the time it feels like they’re saying “shut up, we only want positivity.”
It helps to work through this stuff where we’re not being told to shut up, condescended to, demeaned or being told to be happy with what we have or might get which is what happens all too often for some reason.