When I read the CBS News headline this morning, I almost burst out laughing:
Testosterone gel no fountain of youth, study finds
After almost 9 years on a variety of testosterone gels and creams designed to simulate the hormone production that cisgender men enjoy naturally, if that were really true then I'd be an infant by now!
The news report is quick to point out that the study only dealt with men over 65 with low testosterone levels. They rubbed either hormone-containing gel or placebo gel on their skin for a year, filled out a questionnaire and walked on a treadmill for 6 minutes. At best, the study concluded, there may be a mild correlation between increased testosterone levels and improvement in sex life, walking and mood, but they didn't see any correlation between hormones and other health benefits or risks because the study was too narrow, small and short-term. This is considered the "gold standard" of research at this point.
It turns out that, despite a host of commercials pitching testosterone gel for men with "low T" in recent years, very little is known about the effects of giving additional testosterone to men of any age. Unsurprisingly, even less is known about its impacts on transgender people.
If you ask me, supplemental testosterone is less a fountain of youth and more a fountain of hair and body odor, but even after all this time that's still the main thing I could tell you. There are, of course, expected changes that any trans support group member can name: some parts grow, some parts shrink, you'll eat nonstop for awhile and at some point you stop looking and sounding 12... but information on what exactly testosterone means to our health in the short- and long-term is hard to come by because we lack even the most basic studies on the physical impact of transition.
Trans people are hard to study for a lot of reasons. First, we're a fairly small and hidden portion of the population. We're so small and difficult to trace that there aren't even reliable numbers about how many trans-identified people there are in the US or worldwide. There are even fewer studies that show how many people in the US live as a gender other than the one they were assigned at birth; many people in this category do not identify themselves as transgender on studies for a variety of reasons, ranging from safety to politics to poorly-worded questions.
Second, trans people have historically been un- or under-insured, which complicates health-related studies. Coupled with astronomical rates of un- and under-employment , which also contributes to poor health, and doctors who do not know how to treat trans people for unrelated problems, we're often not in the best health to begin with. Other medical issues are often at least a complicating factor, at most a disqualifying one, for research and studies. How can we tell if trans men are more likely to have heart problems than our cisgendered peers if trans men are also more likely to be overweight and uninsured? How do we measure mental health and mood of people on supplemental "cross-gender" hormones when trans people have much higher levels of depression and poverty?
Third, it's always difficult to determine what if any group might be a suitable control against trans people. People with the same identity? With the same hormone levels? With the same starting secondary sex characteristics? And when a 30-year-old transgender man has the hormone levels of a 17-year-old cisgender boy, what age would you choose for a control group? Unlike the study of men over 65, there was no harm done to the men who used gel that did not contain testosterone, and the same is true of studies done on women taking hormone replacements after menopause; at most, one group may experience slight benefits compared to the other. For a study of transgender people, the idea that half would be placed on placebo hormones would make it an absolute non-starter, both among individual participants and among the community as a whole. As virtually all modern medical or scientific studies require a control, this creates an additional level of difficulty in creating an effective study.
Fourth, hormones never have immediate effects. At best they change things slowly over time. Even for trans people starting hormone therapy for the first time and noticing every single minute change, there is very little to report over the first weeks, months and year. Longitudinal studies would prove more useful, but by definition those take time. And unlike studies regarding mental health, in which a person can report that they perceive they are less depressed than they were six months ago, the average person cannot report fluctuations in cholesterol levels, heart rate or even overall energy in retrospect.
Despite these difficulties, however, we need these studies.
We need to know to what extent testosterone increases the risk of heart attacks rather than simply saying "it could happen" as we prescribe high-dose injections to 16-year-olds.
We need to know whether the increase in breast cancer risk that is seen in some cisgender women who take estrogen is the same or less in trans women.
We need to know what risks "cross-gender" hormone therapy has and if those risks can be mitigated in any way, including by altering doses, frequency or delivery method. Do hormone pills cause more liver damage than injections? Are lower doses more often better or worse for the body?
Ordinarily I would complain here that, under the American medical system, where the impetus for research and innovation is wholly held by large pharmaceutical companies searching for the next money-making pill. However, all major studies done thus far on supplemental testosterone in men 65 and older have been funded by the government and conducted at universities such as UPenn and UCLA.
So what we need isn't attention from a multinational conglomerate who would scoff at our relatively small numbers. We need doctors and researchers who realize that these are questions of enormous importance. We need government officials who recognize that trans people are worth grant money. And we need answers.
Our lives depend on them.
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