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.
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.
I was worried you might feel I was somehow dismissing your needs, so hopefully my response did not feel dismissive. I was just hoping to show that how even if those are your needs, that satisficing might still make sense here. It probably helps that I have some similar feelings as you, it is painful to me that I will never be a cis woman. For years I dismissed the possibility of transition because I could never be a cis woman, but I still affirm my transition - life is better for it.
I hope not to be demeaning, condescending, etc. but I admit I can sometimes mess up or not see how something I say comes across - hopefully you will grant me grace in those moments if they do occur. Also, I am sorry that you feel alienated this way in the community, but it is my experience that the trans community is filled with negative emotions and especially accounts of dysphoria as you just gave. At the very least, you are hardly alone in your “negativity”. :-)