What To Expect When You Start Taking Testosterone

Photographed by Rachel Cabitt.
For many trans-masculine people, testosterone (also called T) is a big part of their transition. The hormone helps to shape their body into a version of themselves that matches their true gender. But, while many people know that testosterone can help someone grow facial hair and may deepen their voice, there are plenty of other ways the hormone affects a trans man's body.
So, what actually happens when someone starts taking T? We spoke with Nathan Levitt, NP, a family nurse practitioner and coordinator with NYU Langone Health’s transgender program, to explain what someone interested in testosterone can expect — from the first doctor's visit to exactly how their body will change.
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Step 1: Talking it out.

There's a lot to talk about before someone actually starts taking hormones, Levitt says. At NYU Langone, patients typically come in for a meeting with Levitt and his colleagues before they get a prescription for testosterone. The first question he asks is what transition looks like for them. Even though most people think of transition as when someone starts taking hormones and later has gender confirming surgeries, not everyone who transitions wants to take either or both of those steps.

"Some people might just be interested in changing their name, their pronouns, the way they dress, and coming out to their families and friends," Levitt says. Not everyone needs medical help to present the way they want.

For those who do want to medically transition, Levitt asks about their goals and makes sure they understand the risks and benefits of taking hormones. Sometimes, he says, people have unrealistic expectations. "I've had patients tell me they want to start testosterone and they expect that a week later they'll have facial hair, a deep voice, and be accepted by everyone in their lives," he says. That's not going to happen right away. The bodily changes that come along with testosterone usually take one to six months to show up, but can take up to a year depending on the individual.

Levitt also talks about reproductive options, because a person's ability to carry a healthy pregnancy will change when they're on testosterone. Transgender men can and do become pregnant, but they have to stop taking testosterone while they're carrying, which can be a deal breaker for some people.
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Step 2: Going over medical history.

While most people who want to take hormones will be able to, there are a few reasons Levitt wouldn't prescribe testosterone: if someone is currently pregnant, if they have a hormone-dependent cancer like uterine, endometrial, or ovarian cancer, or if they have uncontrolled heart disease or liver damage. Levitt would also avoid prescribing testosterone if it seemed as if someone couldn't legally consent to hormone therapy, and he might enlist the help of mental health practitioners in those cases.
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Step 3: Choosing how you'll take your testosterone.

Patients then have to decided how they want to administer the hormones. There are a few different options: Some people choose injections they can administer themselves in either the leg or the stomach every one to two weeks, some decide on pellet implants that have to be administered in a hospital and last for three to four months, and some choose a daily gel that they can rub on their shoulders. Levitt suggests the gel for people who are squeamish about injecting themselves with needles.

Usually, he starts with a low dosage to see how the patient's body reacts, and then will increase the dose as the patient wants.
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Step 4: Seeing changes.

Once someone starts taking testosterone, there are several bodily changes they can expect, Levitt says. These can include: facial hair growth, body hair growth, increased muscle mass, a deeper voice, shifts in body fat from the hips and thighs to the abdomen, an increased sex drive, an enlarged clitoris, acne, and male pattern baldness. Testosterone will also cause the patient's menstrual cycle to stop eventually.

Testosterone can also cause a few side effects that a patient's primary care physician and gynecologist should be aware of, such as increased blood pressure and cholesterol, as well as vaginal dryness.

All of these effects vary person to person. "Some people are on testosterone for years and their voice doesn't change much," Levitt says. The amount of muscle someone gains, where their body hair grows, how big their clitoris grows (it's usually between 1 to 3 centimeters), and whether or not they get male pattern baldness depends on the dosage of testosterone they're on, their specific body, and their family history (if your dad is balding, chances are you will, too).

When the effects start also varies. Patients can usually expect to see changes within the first six months, Levitt says, but some can be on testosterone for a whole year before they notice a difference in their body and patients at heavier weights might not see changes as quickly as others.

A few of the effects are irreversible, so Levitt makes sure a patient knows that before they start taking testosterone. The facial and body hair growth, the enlarged clitoris, the baldness, and the deeper voice won't go away if someone decides to stop taking their hormones. Other effects, like the muscle gain, would diminish if someone were to stop taking testosterone, so many people take hormones for the rest of their lives after transition, according to Carleton College's Gender and Sexuality Center.
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Step 5: Following up.

Conversations with their health care team don't end once someone has started taking testosterone. They'll have to check in with their primary care provider for lab tests every few months for the first year, and then every six months for every subsequent year, according to Carleton College. Doctors monitor patients' blood pressure, weight, and liver enzymes, and administer blood tests, pregnancy tests, and HIV tests depending on whether someone is having sex that could lead to pregnancy or having unprotected sex that could cause STIs.

With the boosted libido they feel on testosterone, transgender men sometimes have sex way more frequently than they did previously, Levitt says. But they don't always have the right information to protect themselves. Some people believe that testosterone acts like birth control, because it causes the menstrual cycle to stop. That's not true, Levitt says. It's possible to get pregnant while taking T, so they'll still need to use protection during penetrative penis-in-vagina sex.

Because of the increased sex drive, Levitt suggests trans men who have partners bring their partners into the doctor's office with them to talk about expectations, since their boosted libido can have a big effect on their partners' lives, too. Just remember that it's totally okay if your sex drive doesn't match your partner's. (Masturbation is a great way to make sure everyone is satisfied).
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Step 6: Surgeries (if you want them).

Trans men who are interested in gender confirming surgeries will have to stop taking their hormones at least two weeks before surgery, Levitt says. "With any surgery, but specifically chest surgery, they can develop pockets of blood or fluid when on testosterone," he says. It's important for patients in those situations to know that stopping the hormones could cause a change in mood and make them sad or depressed, because their body is used to the testosterone boost.

Still, Levitt says that being able to take hormones and have gender confirming surgeries if they want them makes transgender people healthier and happier in the long-run. "Trans people who can safely change their bodies, tend to take better care of their bodies," he says. "When patients who are treated well and with respect, other parts of their health are taken better care of, too."
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