Category Archives: Hormones

Review of: Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report

This is a fairly straightforward case study of a Turkish trans man (born female) with anorexia. In order to avoid menstruating, he dieted excessively and induced vomiting. He also wished to avoid looking female. This went on for 21 years, beginning when he was 19.

Once he was on hormones and menstruation stopped, the disordered eating ended. It has not returned after two years. He says he is no longer concerned with his weight since he is living as a man.

It is important to remember that this is just a case study. This is only one individual; the relationship between eating disorders and gender dysphoria is complicated. We can only come to limited conclusions from any one person’s story.

In fact, there are six other case studies where physical transition did not cure an eating disorder. Two trans women with eating disorders were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. One trans woman believed that transition had cured her, but she was severely underweight, even more so than she had been before transition.

There are three case studies where surgery seems to have caused or triggered disordered eating. This trans man began binging and purging for the first time after having his breasts, uterus, and ovaries removed. One of the trans women in this study had an eating disorder in adolescence; her symptoms returned after sex reassignment surgery 20 years later. Finally, this adolescent trans man recovered from an eating disorder and transitioned; after his mastectomy, he began to relapse and ten months later he returned to the clinic for eating disorders.

In addition, there are a number of case studies where factors other than gender dysphoria played a role in an eating disorder. The most striking is this case of identical twins; both twins had anorexia, but only one had gender dysphoria. The twins shared genes and an abusive father, but one grew up to be a feminine gay man while the other was a trans woman.

Back to this case study. It is clearly different from typical cases of anorexia:

The rejection of femininity was the primary underlying motivation for loss of weight, and not the wish to look slim. She stated that her primary motive for purging was to stop menstruation and her second motivation was to get rid of female body shape; the latter motivation was so strong that she expressed that if she could look like a man if she put on weight she would eagerly try to put on some weight. Thus with this definite statement she was to be separated from the primary cognition of AN which is an intense fear of gaining weight. Her eating disorder symptoms were greatly alleviated after sex reassignment.”

More importantly, in this case, taking testosterone stopped the disordered eating.

The trans man in this story also had a sex reassignment surgery, although the study does not say what the surgery was (mastectomy, genital surgery, or hysterectomy with removal of the ovaries). He changed his name and is living as a man.

It is likely that transitioning cured him of anorexia. However, it is also possible that the testosterone itself played a role. Low testosterone is linked to eating disorders in both men and women. There is a study underway to see if taking testosterone can help women with eating disorders, but we will not know the results for a few more months.

A few other things of note:

The patient did not seek help for his eating disorder, even when he saw a psychiatrist for depression. His eating disorder only came out when he applied to change his sex on his identity card and was referred to a psychiatry clinic.

In order to be able to take hormones, the patient stopped vomiting. However, he continued to restrict his calories until he was actually on hormones.

Before treatment, the trans man ate more when he was depressed.

He had problems with his teeth due to vomiting eroding the enamel.

After finishing college, he had a serious suicide attempt.

The patient’s gender dysphoria began in childhood:

“In her early childhood A.T, felt strongly that she belonged to the male sex. She played boys’ toys and games, preferred boys for playmates, and she was interested in football. When she reached puberty the growth of her breasts and the onset of menstruation caused her to have severe stress, in order to hide her breasts she was wearing extra large size clothes and she was pretending a kyphosis-like posture. During the first year of her university education she had severe depressive symptoms connected with her gender dysphoria; she was spending the greater part of her time at home as she was uneager to dress and live like a woman.”

Original Source:

Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report by Şenol Turan, Cana Aksoy Poyraz, Alaattin Duran in Eat Behav. 2015 Aug;18:54-6.

Study of the effect of estradiol on gonadotrophin levels in untreated male-to-female transsexuals – Brief Review

This is just a quick review of an old study.

This study found that trans women (born male) and control males responded to estradiol in the same way.  Specifically, they looked at how taking estradiol affected the levels of other hormones: testosterone, estradiol, lutenizing hormone, and follicle stimulating hormone.

The authors were attempting to test Dorner’s theory that gender dysphoria in trans women is caused by a defect in a normal imprinting mechanism of testicular testosterone on the hypothalmus. In other words, it might be that testosterone affects the hypothalmus prenatally, but something goes wrong with the process in trans women.

They conclude that if there is such a defect, it does not affect the levels of these hormones or the way they response to estrogen.

The study does not, of course, prove Dorner’s theory.

What I found interesting was that both trans women and control men responded to taking estrogen in the same way.

Original Study:

Study of the effect of estradiol on gonadotrophin levels in untreated male-to-female transsexuals by Goodman RE, Anderson DC, Bu’lock DE, Sheffield B, Lynch SS, Butt WR in Arch Sex Behav. 1985 Apr;14(2):141-6.

Effects of cross-sex hormone treatment on cortical thickness in transsexual individuals – Review of Abstract

This is an interesting study that found that taking cross-sex hormones changed the thickness of the cortex in the brain.

I have only been able to see the abstract; the study was published in May 2014 and I do not have access to it.

The study looked at 15 trans men (born female) before and after they took testosterone for at least six months. They also looked at 14 trans women (born male) before and after they took androgen blockers and estrogens for at least six months.

They found that :

“After testosterone treatment, FtMs (trans men) showed increases of CTh bilaterally in the postcentral gyrus and unilaterally in the inferior parietal, lingual, pericalcarine, and supramarginal areas of the left hemisphere and the rostral middle frontal and the cuneus region of the right hemisphere. There was a significant positive correlation between the serum testosterone and free testosterone index changes and CTh changes in parieto-temporo-occipital regions. In contrast, MtFs (trans women), after estrogens and antiandrogens treatment, showed a general decrease in CTh and subcortical volumetric measures and an increase in the volume of the ventricles.”

In other words, taking testosterone makes certain areas of your brain thicker and more testosterone changes your brain more.

Blocking testosterone and taking estrogens makes certain areas of your brain shrink. According to the abstract, this makes the ventricles get bigger – the ventricles are a network of cavities in the brain that contain cerebrospinal fluid.

We already know that there are sex differences in the thickness of the brain’s cortex, although we don’t know exactly what they mean. (You can read more about cortical thickness and what it might mean here.)

Thus study suggests that some of the sex differences we observe in the brain are related to the hormones in our bodies. Our brains are not set in stone by pre-natal exposure to hormones.

For transgender people this study shows that hormone therapy will change your brain.

It does not tell us what that will means in terms of changes in thoughts, feelings, or behaviors.

It’s also not clear if the changes in the trans women’s brains are caused by reducing the testosterone level or adding estrogen or both.

The abstract does not discuss whether the changes caused by the cross-sex hormones make the brain more “masculine” or “feminine” or neither.

It looks like this study is a follow-up to an earlier study, Cortical Thickness in Untreated Transsexuals. The earlier study found that before hormone therapy there were differences between transsexuals and control groups.

The differences the authors found in their earlier study were fairly complicated:

“We would suggest that transsexuals do not show a simple masculinization (FtMs) or feminization (MtFs) of their brains—rather, they present a complex picture in their process of sexual differentiation depending on the brain region studied and the kind of measurements taken.”

In other words, there were some ways in which trans men have brains like cis men’s and some ways in which their brains are like cis women’s while trans women have brains that are like cis women’s in some ways and like cis men’s in others.

One caveat to the pre-hormone part of the study – the authors only included people who were “erotically attracted to subjects with the same anatomical sex.” Thus, it is possible that the brain differences they observed were caused by sexual orientation, not gender identity.

Many studies of gender identity and the brain make this mistake. For example, they will compare a group of trans men who are attracted to women to a group of cis men who are attracted to women and a group of cis women who are attracted to men. It makes it impossible to be sure if any differences between the brains of trans men and cis women are due to gender identity or sexual orientation.

Studies of gender identity and the brain should include control groups of lesbians and gay men as well as straight people.

In any case, the current study shows that taking cross-sex hormones will further change the brain.

Original Article (Abstract):

Effects of cross-sex hormone treatment on cortical thickness in transsexual individuals by Zubiaurre-Elorza L, Junque C, Gómez-Gil E, Guillamon A in J Sex Med. 2014 May;11(5):1248-61.

Related blog post – Increased Cortical Thickness in Male-to-Female Transsexualism – A Review and a Hypothesis.

Bilateral Non-arteritic Ischemic Optic Neuropathy in a Transsexual Woman Using Excessive Estrogen Dosage – Review

This is a study of a trans woman who went blind, probably because she gave herself an overdose of estrogen which caused her to have a stroke. In addition to losing her sight, she is no longer able to take any estrogen.

The main conclusion from this study is follow your doctor’s advice when it comes to taking hormones.

The article goes into a detailed discussion of the individual case and their diagnosis and treatment of the trans woman. The patient was in her early 50s and had been diagnosed with gender dysphoria. Her doctor had already started her on androgen blockers.

The trans woman had a history of type 2 diabetes, hypertension, obesity, and smoking. She was taking metformine 850 mg BID, glimepride 3 mg OD, and insulin therapy (NPH 12 Units OD.

These factors suggested that hormone therapy would be risky for her. The doctors put her on a low dose of transdermal estrogens and encouraged her to adopt a more healthy lifestyle.

The patient was doing well at losing weight and quitting smoking. Her hypertension persisted and she was given lisinopril 20 mg OD for it.

However, she was not doing well emotionally and was admitted to the Department of Psychiatry for several months for depression and “personality problems.” (I’m not sure what that last bit means.) The patient had been diagnosed previously with “mixed personality disorder with mainly cluster B traits” in addition to her gender dysphoria.

After 10 months of hormone therapy, the patient lost sight in one eye; six months later she lost some of her vision in the other eye. At this time they discovered that her estrogen levels were very high. The patient admitted that she had overdosed herself because she was impatient for feminization.

The authors conclude:

Both oral contraceptives in premenopausal and hormone replacement therapy in postmenopausal women are known to increase the risk for cardiovascular diseases, including cerebrovascular diseases (Sare, Gray, & Bath, 2008). Other cardiovascular risk factors, such as smoking, hypercholesterolemia, hypertension, and type 2 diabetes, play an even more important role (Lindenstrøm, Boysen, & Nyboe, 1993). It is advised that cardiovascular risk factors should be monitored and treated in transsexual persons before initiation of cross-sex hormone treatment (Hembree et al.,2009); however, no recommendations are available on a dosage reduction in sex hormone treatment in patients with cardiovascular risk factors.

In conclusion, we presented a case of bilateral non-arteretic anterior ischemic optic neuropathy possible associated to excessive estrogen therapy in a transsexual woman with co-morbidities. It is highly likely that these high estradiol levels were related to the cerebrovascular thrombosis and also played a role in development of the bilateral sequential NA-ION.

The authors suggest that cardiovascular risk factors should be monitored and treated before starting cross-sex hormone therapy. This is, of course, good advice.

However, the problem here was that the patient went against her doctor’s orders and overdosed on hormones. I would add a few conclusions to theirs:

1. Patients should follow their doctors orders when it comes to hormone doses.

2. Doctors should be aware that some patients may be extremely distressed and behave irrationally. They should clearly explain how long feminization takes and just as importantly, provide supportive therapy throughout the process.

3. Doctors and patients must work together as a team. Both doctors and patients have a role to play in creating that team. Patients must cooperate and be honest; doctors must earn the trust of patients.

4. We need more research on the safety of hormones and dosages for people who are older and/or in bad health.

5. We need more research on how to help someone with gender dysphoria who is unable to take hormones or who must take them at a low dosage.

Bold added by George Davis.

Orignal Article:

Bilateral Non-arteritic Ischemic Optic Neuropathy in a Transsexual Woman Using Excessive Estrogen Dosage by Wierckx K, De Zaeytijd J, Elaut E, Heylens G, T’Sjoen G. in Arch Sex Behav. 2014 Feb;43(2):407-9. doi: 10.1007/s10508-013-0187-9. Epub 2013 Sep 21.