Page 1 of 35. Transpeople, hormones and health risks: a Lao study
Postprint copy of article appearing in International Journal of Sexual Health, 21: pp35-48, 2009
Transpeople, hormones and health risks in Southeast Asia: a Lao study.
Sam Winter, B.Sci., P.G.D.E., M.Ed., Ph.D.
Associate Professor,
Division of Learning, Development and Diversity,
Faculty of Education,
University of Hong Kong.
Hong Kong,
China
Serge Doussantousse, M.P.H.,
Independent Researcher,
Vientiane,
Lao People’s Democratic Republic
Acknowledgements: to the staff of the Lao Youth Aid Project, without whose help this research would not have been possible.
Funding: University of Hong Kong Small Project Funding: Project No: 200507176179
Key words: transgenderism, hormones, Laos, transwomen
Abstract
Cross-sex hormones, while often effective in producing some of the bodily changes desired by transpeople, may also involve harmful side effect risks, especially when used against contraindications and precautions, and in the wrong dosages. Same-sex hormones blockers (interrupting the person’s own sex hormone production) may also have potential side effects. Yet there is evidence from Southeast Asia that transpeople commonly use hormones of both types without any medical supervision, often unaware of the risks at which they put themselves. This report, employing a sample of Lao transwomen, examines the degree to which participants using hormones also make use of medical supervision, as well as examining participants’ knowledge and experience of hormone effects and side effects. The results suggest that large numbers of Lao transwomen use hormones without at any time consulting a medical professional, experience various minor (undesirable) side effects as well as (desirable) effects from hormone use, but are apparently unaware of many of the more major risks associated with these hormones. The implications for health services are discussed.
Transpeople, hormones and health risks: a Lao study
Abstract
Cross-sex hormones, while often effective in producing some of the bodily changes desired by transpeople, may also involve harmful side effect risks, especially when used against contraindications and precautions, and in the wrong dosages. Same-sex hormones blockers (interrupting the person’s own sex hormone production) may also have potential side effects. Yet there is evidence from Southeast Asia that transpeople commonly use hormones of both types without any medical supervision, often unaware of the risks at which they put themselves. This report, employing a sample of Lao transwomen, examines the degree to which participants using hormones also make use of medical supervision, as well as examining participants’ knowledge and experience of hormone effects and side effects. The results suggest that large numbers of Lao transwomen use hormones without at any time consulting a medical professional, experience various minor (undesirable) side effects as well as (desirable) effects from hormone use, but are apparently unaware of many of the more major risks associated with these hormones. The implications for health services are discussed.
Key words: transgenderism, hormones, Laos, transwomen
Introduction
Cross-sex hormones are commonly used by transpeople to induce some of the bodily changes that they desire. Among late adolescent and adult transwomen two groups of cross-sex hormones are commonly used; oestrogens and (less commonly) progestagens (with androgen suppressors, sometimes called male hormone blockers or anti-androgens, also used quite widely. This report, employing a sample of Lao transwomen, examines the degree to which participants using hormones also make use of medical supervision, as well as examining participants’ knowledge and experience of hormone effects and side effects. Our research questions were as follows. Among transwomen who have taken cross-sex hormones, ( a ) how many take them without accessing medical advice?; ( b ) how many report beneficial hormone effects; and ( c ) how much do they know about undesirable side effects? Among transwomen who cease hormone use, ( d ) how many cite undesirable side effects as a reason; and ( e) what sort of side effects do they cite?. Among transwomen who continue hormone use, ( f) what sort do they take, and in what dosages?
Effects of hormones
Accounts of the effects of hormones are available in e.g. Ashbee and Goldberg (2006; Gooren & Delemarre-van de Waal (2007); Meyer et al. (2001); Tom Waddell Health Center Transgender Team (2006). Ashbee and Goldberg (2006) provide a readable summary, noting that oestrogens and anti-androgens have similar effects upon the body. Both classes of hormone are often found to reduce sex drive, reduce the frequency of spontaneous erections or erections during sex, reduce sperm production and ejaculatory fluid, increase nipple and breast growth, decelerate growth of facial and body hair, reduce baldness. In addition, oestrogen softens the skin, decreases muscle mass and increases body fat (producing a more stereotypically female form), and reduces testicular size. Cognitive and affective effects have also been noted; for example a sense of emotional well-being and emotional sensitivity, and improved impulse control (Tom Waddell Health Center Transgender Team, 2006). Cohen-Kettenis and Pfafflin (2003) note evidence that MtF hormone regimens can reduce aggression. They also remark on anecdotal evidence of increased emotional calm. The effects of progestagens appear less clearly known. Ashbee and Goldberg (2006) note a ‘lack of clear evidence that they are important in “feminization”’(p.4), and may simply lead to ‘enhanced estrogen feminization effects’ (Tom Waddell Health Center Transgender Team, 2006, p14).
Some of the effects listed above in this paragraph are more easily reversible than others. The breast growth and sterility may be permanent (Ashbee and Goldberg, 2006). Some effects can also be jeopardized by imprudent use. For example a transperson taking high levels of oestrogen may find that the extra oestrogen is actually converted to testosterone; the effect being to retard the progress of feminisation (see Ashbee and Goldberg, 2006, p6). A transperson using oestrogen alongside other drugs; for example, tobacco-based nicotine, is liable to undermine the effects of the oestrogen. She is also likely to exaggerate the risk of cardio-vascular disease into which the use of hormones already places her. This leads us to a discussion of side effects.
Side effects of hormones
The drugs discussed above are either documented or feared to have a range of side effects, some of which are major. Ashbee & Goldberg (2006) note that oestrogen may ( a ) increase blood pressure, prompting a range of cardio-vascular problems, including heart attack and brain damage; ( b ) increase the risk of blood clots, in turn leading to permanent lung or brain damage, heart attack, and/or chronic deep vein problems; ( c ) increase deep fat deposits around vital organs, leading to diabetes and heart disease; ( d ) increase the risk of gall stones and a blocked gallbladder. They add that it may cause nausea, vomiting, headaches and migraines, milky discharge from the breasts and possible prolactinoma, damaged vision and headaches. Turning their attention to anti-androgens, they note that spironolactone alters the water/salt balance in the kidneys and can lead to low blood pressure or high levels of potassium in the blood, leading to potentially life-threatening changes in heart rhythm. They add that it can also cause skin-rash. Finally, they note that all hormones, (oestrogen-based, anti-androgen and the less commonly used progestagens) can put a strain on the liver, possibly leading to liver disease (see Ashbee and Goldberg, 2006, p15).
In addition to the above, the literature cites a range of other side effect risks of varying degrees of severity (see Tom Waddell Health Center Transgender Team, 2006; Meyer et al., 2001; Cohen-Kettenis and Pfafflin, 2003; Feldman, 2007; and Gooren and Delemarre-van der Waal, 2007). These risks include: pancreatitis; hepatitis; fluid retention (oedema); muscular and skeletal pain, retracted (and painful) testicles, decreased libido, impotence and permanent infertility, fatigue and drowsiness, emotional lability and mood disorders (including depression, irritability, crying and indirect expressions of anger), reduced assertiveness, a darkening of the skin, dry skin or brittle nails, contact dermatitis, acne, unwanted weight gain, facial and body hair growth and coarsening (particularly where a person has ingested too much oestrogen), increased excretion of sodium, calcium and chlorides, and increased urination (as well as increased dribbling after urination). Finally, there are suspicions regarding effects on the risk of breast cancer (Feldman, 2007; Tom Waddell Health Center Transgender Team, 2006) .
Actual risks may depend on many factors. Some may be associated with a particular form of hormone administration (for example contact dermatitis in the case of transdermal administration) or the specific chemical form of the hormone involved. Others may be heightened where hormones are used against contraindications and in violation of precautions (for example, cigarette smoking or concurrent use of contra-indicated drugs, wrong dosages, advanced age, retinopathy, seizure disorder and certain endocrine abnormalities, as well as any pre-existing history of some of the conditions that the hormones risk promoting (Meyer et al., 2001; Tom Waddell Health Center Transgender Team, 2006).
Unsupervised use of hormones in Southeast Asia
In view of the side effects risks cited above, most medical texts (e.g. Eyler, 2007), guidelines for professionals (e.g. Tom Waddell Health Center Transgender Team, 2006; Meyer et al., 2001) and guides for transpeople (e.g. Ashbee and Goldberg, 2006; Curtis et al, 2008) stress the importance of medical supervision for transpeople using hormones. However, across much of the developing world this ideal is inevitably undermined by the scarcity of medical personnel, negative attitudes towards transpeople on the part of health workers, and low income levels in the transgender community, which together lessen the likelihood of being able to visit a doctor for any reason at all, let alone on matters relating to hormones. But beyond this, medical supervision for hormone use is likely undermined by limited knowledge (within the transgender population) about hormone health risks, limited training (among practitioners) in transgender health issues, and the easy availability and low cost of hormones in some countries (over-the-counter at pharmacies, and/or through family planning centres in others).
Across much of Southeast Asia the conditions described above apply. Most recent figures available on the WHO on-line statistical data base illustrate the point. In the poorest seven countries in the region (Myanmar, Thailand, Laos, Vietnam, Cambodia, Indonesia and the Philippines) the average per capita gross income (unweighted) is US$2900 per annum. Average government expenditure on health per annum (unweighted) is US$54.6. The average number of physicians (again unweighted) per 10,000 population is 4.71. In Thailand and other places pharmacies sell a wide range of oestrogen-based oral contraceptives, as well as cross-hormone injectables, over the counter and at reasonable cost. Androgen suppressants such as Androcur are also available, though less widely. In the Philippines, free contraceptives (normally made available to natal women) are often available through local health centres.
Not surprisingly then, I have found in my work with transwomen in Thailand and the Philippines large numbers of individuals using cross-sex hormones and hormone-blockers without any medical supervision at all, taking hormones recommended by their transgender friends, and against contraindications and precautions (the most common one perhaps being heavy smoking). Irregular and high dosages are common. Transwomen often seem to adopt a ‘more is better’ attitude, ingesting large doses of hormones when available (with the intention of accelerating or enhancing changes), and sometimes going for periods without (when they cannot afford hormones).
The issue of self-medication by transpeople is so widespread across Southeast (and South) Asia that it has merited mention in a recent regional report on transpeople’s welfare (South and Southeast Asia Resource Centre on Sexuality, 2008). Scattered research of a more formal sort sheds more light on the issue. From Thailand there are the studies of Cameron (2006) and Luhmann (2006). Cameron (2006), in a detailed report on sexual health, remarked on the widespread unsupervised use of hormones (p31). Luhmann (2006), in a study of 67 transwomen in Thailand, found that only 50% of his sample had ever discussed hormone treatment with a medical doctor. With regard to their last hormone dose, only 27.5% had consulted a doctor, though rather more (41.2%) had consulted other health personnel.
From Malaysia, Teh (2002) reports that 63% of a sample of around 500 transwomen, were taking hormones. Participants overwhelmingly found out whatever they knew about hormones from their transgender friends, with few consulting medical personnel about hormone use. Around two thirds confessed they did not know how much they should be consuming each day, and around half were apparently unaware of the potential side effects of hormone use. Many of the participants complained of health problems after taking the hormones, though less than half had gone to consult a doctor about their problems, preferring instead to self-medicate (p64-65) From the Philippines, Winter, Rogando-Sasot and King (2007) report that, among a sample of 147 Filipina transwomen, around 70% of whom reported hormone use, nearly 90% had used them without medical supervision.
Two recently completed studies (in Thailand, with Chaiyada Lertraksakun, and the Philippines, with Brenda Alegre (both reports in preparation)) have looked in greater depth at transwomen’s hormone use, and the associated side effects. In each study the sample consisted of 150 transwomen. In Thailand 139 (93% of the sample) reported ever taking hormones (mean age of initial use 16.7 years). While the vast majority of those taking hormones had sought advice before doing so (87%), relatively few 33.08% of those seeking advice, 30.94% of those taking hormones) had sought advice from a medically qualified professional (doctor or nurse). Advice from medical professionals was hardly more frequent later on, during hormone use. Though 81% sought advice of some sort while taking hormones, only 69 (that is 56.56% of those seeking advice, 49.64% of those taking hormones) sought it from a doctor or nurse. This widespread absence of medical consultation was surprising in view of the fact that the vast majority of the sample reported undesirable side effects (128, or 92.1% of those taking hormones). Not surprisingly, in view of the profusion of side effects, a substantial number of study participants (29) had stopped taking hormones. At the time of our study only 73.33% of entire sample (79.1% of those who had taken hormones at some time in their lives) were still taking them. Almost all who had stopped cited actual unwanted side effects ( most commonly headaches, giddiness and nausea, tiredness and lethargy, mood changes and fat accumulation). Nineteen cited fears about possible future ill effects on health – especially cancer, kidney and liver problems, together with bone decay. Many participants who still took hormones reported taking variable quantities, often peaking well above the recommended daily dosage.