If you've ever seen a video with audio that is ever so slightly out of sync, so slightly that you couldn't even figure out that that was the problem at first, you'll have some slight notion of how I felt without HRT. All day. Every day. Everything was off. Everything. In some fundamental way that was key to how I existed in the world at all, how I interacted with anyone and anything, everything just felt awful, but I also had no way of knowing it could be any better than awful. I am honestly amazed I managed to avoid killing myself. In the year since I've been on Hormone Replacement Therapy (HRT), I've noticed a lot of changes. Many of them are the kinds everyone can see. But the most important ones are invisible.
I'd read about the effects of HRT, always in terms of the physical; breast development usually in line with cisgender women of one's family, finer hair texture, softer skin, and so on. I'd also read that some girls saw very little or no visible outward impact. I saw one girl's pictures of herself after more than two years of HRT, and she showed no visible breast development in any of them. Shortly before my endocrinology appointment, I realized that I'd have to come to terms with the fact that I just couldn't predict exactly what would happen, so I'd need to be okay with anything. Or nothing.
At the time, flush with the revelation of my previously misunderstood gender, that wasn't very hard. I was just so absolutely relieved to able to experience a full range of emotions, to get up and go out for the day feeling like good things would happen, to be pleased with how I looked. The things that upset me, even big things, just didn't upset me that much. And the happy things, they were brilliant flashes of ecstatic joy that left afterimages superimposed over everything else for hours or days.
When I was younger, as soon as puberty began, I developed an immediate and almost pathological aversion to body hair of any kind. I didn't think much of this at the time, but as it coincided with the onset of a deep depression that lasted roughly 30 years, I think now that this was another level of me understanding but also not understanding the problem. In the same way that I'd never liked my old name, but couldn't think of any other boy's names that felt any less wrong, I didn't like the kind of body hair I was developing, and I especially did not like it growing on my face, but since I felt like it was supposed to go that way, I just thought of it as a dislike, an opinion. I did not think to consider a girl's name in the same way I did not think to consider any way to prevent the growth from happening. It just never occurred to me that I could do either. Guys in my school who had started to have facial hair come in grew as much as they could, while I futilely hoped that mine would never come.
I made it to my appointment and was in and out with a prescription quickly and easily. I remember being a little bit annoyed that even though my name had been legally changed, and my gender legally corrected, my prescription bottles still had my old name on them, because that information had not propagated through the VA Medical system at that time. But mostly, I remember being relieved that no precluding conditions had been revealed. Their biggest concern seemed to be whether I was a tobacco user or not, and I was told anecdotally about a trans woman who found out she had to quit smoking before they'd put her on estradiol, since the combined risk of blood clots was too high to be considered acceptable. From what I understand, she found the will to quit rather quickly, and permanently. I've never been a tobacco user, so I was fine.
The first week on HRT was challenging. It wasn't exactly bad, but it was definitely difficult. I was experiencing emotions with an intensity I'd never even been able to conceive of before. While part of me actually found this satisfying, because I had starved myself of any emotion of any kind for so long, I also worried that my mood would be permanently volatile. Even when facing the possibility of that, I understood that I'd be much happier overall than I'd been before. When the first week ended and the volatility started to die down, I remembered having a new worry. I worried that whenever my doses were changed, I might be just as moody again.
When I'd been on Effexor XR, an antidepressant, in the past, and that dosage was shifted up or down by any amount over any period of time, I was completely exhausted for a fairly predictable term, usually about two weeks. I would be awake for maybe 6-8 hours a day, max. After my body had adjusted to the new dose, that went away, but it happened every time the dose was altered, whether increased or decreased. Since that was being done on a monthly basis for awhile, it felt like half my life was erased. I was afraid that I'd have a solid week of volatile moodiness every time my HRT doses were adjusted. This fear proved unfounded.
With HRT, while I remember seeing some mild breast development fairly quickly, I noticed much more than that how tremendously, after the first week, my overall mood and sense of well-being gelled and stabilized into something fairly consistent and reliable. And positive. I was already happy, having finally figured out what the problem had always been, and knowing how completely true and right that felt, to have a real core truth of self that had always been missing. Or hidden, I should say. If realizing I had been incorrectly designated male at birth was the eruption of a volcano, HRT has been the myriad intangible environmental factors that solidified it into a mountain.
Before long, a clear cycle emerged. I experience regular monthly (more or less) symptoms of PMS, but as I have no uterus, they are almost entirely emotional. Every fourth week or so, I'll have about three days of mildly increased irritability, and greatly increased emotional volatility. Self-awareness helps the most with all of it; just knowing what it is makes it easy to discount things that I think or feel that seem distorted in any way. It's never very hard for me to enjoy the giddy happy parts, and to feel and fully experience the more deeply sad or upset parts without having them linger or take over after they'd run their course.
Perhaps the hardest part to explain to anyone is how I am happy even with the saddest parts, even when they are at their worst. Experiencing PMS, even without the raging uterus throwing out everything it's spent the last month building, is affirming in a way. It's not exactly pleasant, per se, but in a meta sense, the fact that it's the kind of unpleasantness my brain feels like it has always been expecting feels good in that it feels right. It feels right in the same way that before, without HRT, everything felt wrong. Some fundamental level below consciousness, where reality lives. This is what I mean when I try to explain to my cis female friends that if there was a way for me to have an actual uterus and ovaries and everything, I'd absolutely do it, cramps and all, even if I can't possibly imagine how bad they could get. Because they'd be the right kind of bad, the kind of bad that is a simple fact of life for most women.
Spontaneous erections, that fact of life for most men, died off, and I don't remember when. I've had a few in the past year, but they're incredibly rare, now, though they remain just as random as before. The first time it happened after having not happened for a long time, I remember being absolutely mortified. I was at school, so I wasn't able to go hide anywhere or anything. But by the time I realized that there was nothing I could do, it subsided, and that was that. It also occurred to me one day that while I knew there had been a last time that I'd masturbated, I couldn't remember when it was or anything else about it at all. I'm not getting into any details here, and I can of course only speak for myself, but under the influence of estrogen and not testosterone, my penis behaves very differently than it did with testosterone and not estrogen.
When I was in my initial endocrinology consult, I'd been told that my libido would go off a cliff. Every "warning" they gave me to make sure I knew what I was signing myself up for sounded wonderful. No more rapacious sex drive making me absolutely miserable because I hated sex exactly as much as I felt compelled to seek it out? Sign me up.
But my libido didn't go off a cliff. It didn't even get any smaller, really. It just changed shape. Have you ever heard the thing about the elephant's foot and the point of a stiletto heel? The idea is that the pressure beneath the stiletto heel under the weight of an average person is greater than the pressure under the elephant's foot, because the pressure is focused more narrowly. That was what my testosterone-driven sex drive felt like. I perceived it as sharp and demanding, here and then gone, disruptive and distracting.
Once I started HRT, my libido started changing shape. Rather than my previous state of being very binary about sex — either absolutely not thinking about it at all, or absolutely unable to think about anything else — I moved into a more stable, oceanic state. Things can shift and change and heat and cool, but everything happens gradually, now, and this, too, feels ineffably natural. Especially in contrast with what I'd had going on before. Now, instead of being 0%, no sex, or 100%, yes sex, I'm kind of 85% sex all the time, except when I'm actually having sex, and it's amazing. I don't know how to explain that any better. It's not "sex" in the sense of the actual act, it's more like... being in touch with that thing that makes all life possible, which expresses itself, in most adult humans, sexually. My physicality in any space, the things I say and the way I say them... it's all become this celebration of life, of being alive.
When I do have sex, it feels very natural and right, but having never previously experienced anything like what I have now, I'd never known what "natural" or "right" truly felt like. I could feel physically sated before, but never really actually satisfied in the way that I've discovered really great sex can make me feel. Connecting on any deeper level with my partner was exceedingly rare, even within the context of a single long-term monogamous relationship. There's a Weezer song that goes, "I'm sorry for what I did, I did what my body told me to, I didn't mean to do you harm," and that is probably the best way to sum up my relationship with my own body without HRT, and how I felt about what my partners must have thought, even when they pointedly reassured me that they did not. Life was an awful, high-anxiety scramble to seek out sex, have sex, and not really enjoy the sex or anything else about the whole situation, forever.
The jagged, brittle obsidian of my former sex drive was softened and polished into something beautiful. The world has a color now that it did not have before. It's not the old metaphor of black-and-white vs. color. It's more like the earliest color movies vs. the most modern ones. Before, the world had a subtle unreality to it. It did not look like the world, it looked like a poor representation of the world. Now, it's cinematic and beautiful. Things that used to challenge me in Buddhist books I'd read, like being completely present while looking at a leaf, have become almost frighteningly easy, when I remember to even try to do them.
At my three-month checkup, the doctor seemed surprised at how much breast tissue I'd developed on such a low dose over such a short period. I remember feeling very self-satisfied, like this was some kind of sign that my body was pleased to finally have a medium in which it could exist as it was meant to. My doses were adjusted slightly, doubling the estradiol and spironolactone to 2mg and 100mg per day, respectively. The medroxyprogesterone dose did not change, and it never has. It's been 5mg per day since the beginning. The patient name on the bottles of the second set of meds was correct. It was a small change but it mattered a lot to me. It didn't feel like anyone was trying to imply that I was medicating Jason into oblivion, anymore. It felt like Sera had her girly pills, and that was it.
At the six month checkup, I had been directed to immediately double the spironolactone dose to a total of 200mg per day, and to gradually increase the estradiol to 3mg and then ultimately 4mg. I was instructed to stay at 2mg estradiol daily until two weeks at 200mg spironolactone had passed, then bump to 3mg for another two weeks before finally settling at 4mg by May 2015.
Physical changes started becoming suddenly noticeable, and I'm reminded of when I was a kid. We had a puppy named Cubby, and whenever I'd stay the weekend at a friend's house and return, Cubby always seemed like he'd grown enormously since I'd seen him last, just a couple days before. Registering the physical changes felt a lot like that. In May 2015, with the stabilized new normal regimen of HRT, my figure appeared to change dramatically. I'm sure that what really happened was that it had been slowly and surely filling in, and that I just actually noticed it, finally, but the physical changes seemed to all work more or less like this. One day, I'd notice that I had hips. Another day, I'd notice that what little body hair I had was indeed much finer in texture and thickness than before. I would try on a strapless dress that hadn't been able to stay up before, and it would sit just right because I had finally developed enough of a bust.
Around this time, I heard about the #FreeTheNipple campaign on social media, and I started to wonder whether I'd be taken down or left up if I posted a topless picture of myself. I figured, if they take me down, that's Instagram weighing in on my gender, saying "this one's a girl." And if they left me up, I'd be out there with my bare breasts and free nipples, a victory of a different sort. But I worried about potentially opening myself up to violence, and thought it was probably a bad idea.
Anyway, I put the picture up, and it took Instagram all of an hour to take it down, with their standard message about how I had violated their community guidelines. I posted a follow-up picture, with my pajama top back on, mildly grateful to them for acknowledging that I was a woman, at least. My body was being censored, just like any other girl's. The whole trilogy is a roller-coaster ride from start to finish, and if you want to see my bare breasts, this is probably gonna be the only way for awhile.
I felt fine, overall. Nothing seemed unusual or bad in any way. But at the nine month checkup, my doctor seemed surprised to learn that I hadn't been feeling physically ill or in any undue pain — because my estrogen levels were about three times an average cis woman's levels. Through raised eyebrows and constant head-shaking, she reduced my estradiol dosage immediately back down to 2mg per day. I guess it worked, because I still haven't died.
Somewhere along the line, I experienced a craving for dark chocolate. I mean an actual craving. I had previously thought I'd had cravings for things now and then, but once I felt this craving, I realized that everything I'd previously thought to be a craving was really just a gentle suggestion of the faintest whisper of desire. I felt like I was going to literally die if I did not get a ton of chocolate. Fortunately, my landlord responded to my text begging for chocolate, and brought me a bar or two and some chocolate ice cream with chocolate pieces in it, which were probably covered in some other kind of chocolate. I don't remember, I just devoured most of it, and then felt much better. I assumed at the time that this would just be a monthly thing, so I stocked up on a wide variety of chocolates. It hasn't happened since.
Yesterday, I had my one-year checkup. While in the waiting area, a woman asked if I was going to a Halloween party. She asked, I imagine, because I had about four days' worth of facial hair growth, since I had electrolysis yesterday, as well. I smiled at her, said "no," and then gave her one of my cards. She flipped it over a few times to take it all in, then put the card away with her things and thanked me for giving it to her. We talked for a little while about other things, like our shared Japanese heritage.
In the actual appointment itself, I met the actual endocrinologist for the first time, rather than a resident, and she was fantastic. She's very trans-services-positive, and argues the evidence every time she has an opportunity; these services vastly improve and save lives. We talked briefly about how the VA seems to be coming along with more and better transition service coverage, and I expressed my belief that the VA would cover most or all major transition services within five years. She seemed to find this belief reasonable. I gave her one of my cards, and she thanked me, jotting down a few notes on it for later. When it was over, the plan going forward was for me to manage refills on my own for longer periods without checkups in between, and for me to wait on a phone call from urology to schedule the consult for my orchiectomy.
I don't know where I'd be without HRT. I really can't even imagine. I like to think I'd be nearly as happy overall, still, that I'd finally realized who I really was all along. I don't want to be so hyperbolic as to suggest it's as valuable as the air I breathe. But perhaps there's a good metaphor there. Being on HRT is like having clean air, instead of smog so thick you can physically feel it when you walk through it. It's like having a healthy, balanced diet, instead of nothing but frozen microwave pizzas and Pepsi every day. Being on HRT feels good, like relieving a headache. It's as if all my life I'd been constantly struggling just to be able to have the basic capacity to even try to build towards happiness and productivity, and now I rest naturally at that starting point, at the worst.
