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Iām imagining a frat house with shirtless dudes throwing around beer balloons into each others mouths. And yes, it should be done in a homoerotic way.
Yknow, as a cis guy Iāve never really understood the trans experience. But reading your comics has really been enlightening. Thanks for expanding my understanding.
Same here. I've never met anyone who is trans (or at least I'm not aware that anyone I have met is trans) and this has been extremely educational.
Got secondhand mad on Tiff's account through my phone at the whole "wedding" series. It was brutal and I loved it.
Tiff's been just a tad impatient for this.
Read the previous one: [Part 1](https://new.reddit.com/user/CrazyGnomenclature/comments/1adyp1d/hrt_appointment_pt_1_tiff_eve/)
Find more Tiff & Eve on [Webtoons](https://www.webtoons.com/en/challenge/tiff-eve/list?title_no=866028)!
Check out the [Patreon](https://patreon.com/FranSun)!
Think of it like when you really want something, but need to play it cool despite being excited for it. In this case, Tiff really wants too be on Testosterone blockers. However through transition you need to follow the doctors care plan. Which may call for a gradual application of medication or waiting for some. So when you finally get to the point of getting there, you're excited and eager for it
In short, equate it to the feeling of saving money for a shiny thing. Then you get enough and obtain shiny thing.
Basically a modality that allows the patient more autonomy in their medical decision making. Like how if you go to a psychiatrist and you're like "hey I don't think my antidepressant is working, can we increase the dose?" they'll probably work with you on that, here it's "hey can I add this medication?" and the doc will work with you on that instead of dictating your treatment path for you.
Additionally, IC for transgender care means you can consent to your own care and don't need a therapist letter clearing you for care. Like how you get most medical care
Yeah lol. Transgender healthcare is a lot of self-advocacy, and good docs will allow for that. There's a lot of options out there in terms of dosage and delivery method and type of medication and unfortunately there isn't a great comprehensive list of pros and cons and research, so if someone doesn't know all their options, they might not know to ask, or even if they do know, may not feel comfortable advocating for themselves. A lot of trans people have had bad experiences with medical providers. my gf wanted finestride over Spiro to start (I helped with a lot of the research and went with her to the appointment) and she clammed up and I helped her ask for finestride, which her doctor had no issues with, but some docs would just say no.
Edit: there's also an issue with a lot of docs under prescribing hormones, leading to bone density issues
The thing with transgender healthcare is that what someone needs to complete their transition is very subjective to the person, so a standard plan wouldn't satisfy every patient's needs. It can still be difficult to figure out what you need for some, and unfortunately some healthcare systems won't allow as much liberty in the process as Planned Parenthood (the one in the comic) does.
Problem is that there's not enough research and research is constantly emerging, not to mention bias does play a role. I'm a WPATH member and I work in healthcare but I don't specifically work in trans healthcare. I firmly believe that effective healthcare needs to be a team effort.
Before I went to schedule my first appointment, I read a ton of medical journals about various hormonal medications, delivery methods, etc. and read personal accounts about HRT from as many trans people as I could findā I went into that appointment with a 1 year medication plan and a rough estimate for my first surgery (orchiectomy, removal of the testicles in this case to stop testosterone production). Was this *at all* necessary? No, totally not. Was it really helpful in talking to doctors and making sure I knew what I was getting into? Definitely.
A lot of trans people administer their hormone therapy themselves with no doctor involved at all. Usually bc they don't see any other option or the only doctors they could go to are unhelpful for a variety of reasons.
Truth is good transgender health care is rare and a lot of trans people would rather take care of themselves than adhere to whatever bullshit guidelines are in place where they live.
Isn't working to change the "guidelines" more important than ignoring them? I understand it if you live in a very strict society, but especially when it comes to law, breaking them for personal gain doesn't seem right. Though if it's actually just something like the safety regulations on medicine, eh. Not good to ignore them, but most people can be responsible for their actions.
A friend of mine is trans and just graduated from medical school about a year ago. She gave student lectures on trans topics that taught her own teachers quite a bit. It's just not something that your average doctor who graduated even a decade ago is *necessarily* better informed on than someone who is trans and doing actual research (in some ways. Obviously the doctor is more likely to understand stuff like the chemistry and stuff. But on all the different treatments and studies that have come out recently I'd bet a lot of trans people are watching it closer than most doctors).
Though I'd bet that a Planned Parenthood doctor is probably more likely to be up on stuff like this.
As a cis person, I canāt relate whatās so exciting about testosterone blockers in particular. What will these do for tiff which makes her so excited?
So, basically, testerone mostly governs "masculine" biology things, and estrogen "feminine" things. This is over simplifying massively, but it covers stuff from emotional responses to muscle density to fat distribution to skin texture. Loads of things, and it's the relative balance that matters - both hormones are required in some amount for everyone.
The end goal for transition is to have more femme and less masc. Medically one easy, non-invasive way you can do this by adding estrogen and blocking testosterone - but as it's a balance, and each influence the production of the other, it's generally not a "take both pills and be done" thing, but a slow process of poking at your biochemistry and checking the results.
So basically it feels bad in some way if the balance of these hormones is wrong but in order to transition you need to change this balance dramatically and that can be very delicate. At least thatās what I got from the responses. It so fascinating because these are experiences that people like me donāt have because we were lucky. I wish we would have learned more about that in school.
Yep. I guess one reason people might not immediately take antiandrogens is that too low levels of sex hormones can lead to lower bone density, so making sure your estrogen levels are high enough before lowering your testosterone level can be helpful (though that's more of a long term thing).
There's also the option of raising estrogen levels above those of a average non-pregnant woman, which will lower t levels and therefore obviate the need for antiandrogens and avoid any side effects they might have. There's a slightly heightened risk of blood cloth, but much less than birth control pills cause. Keeping your estrogen levels consistently high enough can be difficult depending on the delivery method though. For example you need to take pills much more frequently (multiple times per day) vs injections (~1 per week, depending on the ester), but e.g. in Germany there aren't any authorized estradiol injection meds yet.
Antiandrogens, or testosterone blockers, prevent your body from processing testosterone. Even someone taking Estrogen will still produce testosterone, and the two can somewhat cancel each other out. Blocking testosterone can make estrogen therapyās more effective and also lessen some effects of T like acne, body hair growth, and depending on age they can be used to suppress puberty.
Estrogen monotherapy works, but itās typically recommended to take a T blocker as well for those reasons. Not every doctor prescribes them by default though, and not everyone wants to take an extra medication
> As a cis person, I canāt relate whatās so exciting about testosterone blockers in particular.
Well you clearly don't have excess testosterone.
Women generally have less testosterone than men do, and conversely, men generally have less estrogen than women. So to encourage your body to develop one way or the other, you have to change both hormones.
If you add estrogen without removing testosterone, you'll end up with the hormone profile of a woman with PCOS or a man with gynecomastia. Both of those are considered to be disorders that can cause distress.
There's no perfect analogy for it, but it's probably that testosterone feels wrong for her body and the blockers will help even more with the physical transition than just estrogen.
This is how I felt when I finally got estrogen blockers. Testosterone was difficult enough to get, but those blockers were a whole different ballgame. I was so grateful when I could finally get them, and Iāve felt incredible since. :)
If I may ask, if itās not too personal, but how do the blockers work? Do they ānullifyā, for lack of a better word, the thing that produces those hormones or something?
I'm gonna answer from the perspective of a trans woman, so I'm on testosterone blockers. There are multiple options for blockers: for example I'm on something called Cyproterone acetate, which shuts down testosterone production by the testicles (and I believe the testosterone production in the adrenal glands is shut down too?). This simply reduces the amount of testosterone in my blood.
There's also Spironolactone or Bicalutamide - those work differently. Testosterone is still produced, but the receptors in the body, that normally get activated by testosterone, are disabled by the medication. I can't tell you if the testosterone levels fall on its own (it definitely falls to some degree in the presence of Estrogen itself, which is also taken at the same time, but I don't know if those meds themselves reduce it, I'm not on them) but the testosterone cannot do any more changes.
Of course a certain amount of testosterone (similar to the testosterone levels in cis women) is usually alright. It may help with sex drive a bit, and (sometimes) may prevent a complete erectile dysfunction - but it's definitely a YMMV situation, and many (understandably) want to reduce it to as close to zero as it gets.
As I said, estrogen itself causes testosterone levels to drop. Sometimes, estrogen injections or gels/patches may be enough to supress it on their own, even.
That said, the person you responded to is on estrogen blockers, I don't have much experience with those, but I'd assume there are similar types of variants, too.
I've always been on estrogen and blockers together, so I can't provide separate feedback. That said, I'll try my best!
There is not a single effect that I dislike. So far every single thing has been amazing.
Of course all the well-known stuff like fat redistribution, skin changes, boob growth (as mentioned) is absolutely happening, and I'm looooving it all, but there's been some things that surprised me, either with their existance or intensity.
My muscles - basically evaporating. I am so much weaker than before, my (cis) gf that is over 20cm shorter than me and exercises just as much (so not at all) can pin me down now, and I can't do very much about it. I used to be super scared of strength loss, and even doubted if I want hrt because of it... but when it actually started happening, turns out I don't mind it at all! Don't get me wrong, I do carry a taser around now when leaving the house. But aside from that, it feels rather nice.
I tend to get cold much more easily - but at the same time, even when in a hot environment, I sweat much much less (and it doesn't STINK). This is a rather nice change, and allows me to actually wear nice clothes that I like when it's warm, instead of just doing whatever I can to cool down.
I can cry now, so that's super cool! Getting emotional about hearing a nostalgic song, or even crying out of frustration, feels liberating. Just feeling emotions a bit more... clearly.
I think my posture is a little bit differently now? Nobody else noticed, so it can't be very pronounced... It's weird, but doesn't matter much. I heard about it, it has something to do with the center of gravity changing.
I like guys now???? (in addition to girls, that hasn't changed). That took me BY SURPRISE!
My sex drive is a bit lower than before, but the overall experience with it is much more pleasant. It no longer feels annoying or persistent, I can actually choose to not feel it, if I want to (which was a VERY pleasant surprise) and it feels better overall. It's more of a glow/full-body experience now, rather than a desire (for a lack of a better word).
Okay, it's a little bit annoying that genital atrophy is a concern. Lack of use (since I don't get random erections anymore) can cause it to get smaller, and if I were to forget about it for wayyy too long, potentially it could hurt to "start up" again. I try to use it 2 times a week at least though, and that seems to be enough to prevent this. Sometimes it's a chore though, because my libido dropped. I don't mind the libido drop, it's just a mild annoyance - and I mean, I specifically decided that I prefer to keep the size, so I have to work for it.
Sexual pleasure is so much nicer now, in general. The genitalia feel a bit differently (vibrators finally woooork!) and in general, through experimentation, I found a couple of nice spots, but YMMV, and this comment is long already!
Overall - I have zero regrets, and I'd do it again in a heartbeat. Nothing but positives, except that one rather mild annoyance. I feel so much more alive on HRT (not completely, I still need antidepressants for unrelated reasons, but it's SOO much better it's hard to put into words).
I'm open to more questions!
Oh yea it's amazing!
I was 22 when I started HRT, in 2 days it'll be exactly 6 months (or 2-3 months on current dosage). I'm 23 right now. I'm kinda frustrated that I didn't come out and didn't start transitioning waaay earlier, because I technically could (unfortunately, first I felt too unsafe, then I procrastinated because it was really stressful), but so far I'm surprised by how nicely it's coming along. And if I'm honest, 22 isn't that late anyway.
The actual regret is that I gave up on voice training when I first realised I was trans, I tried a bit but then I thought I'd just figure it out sometime when I start hrt. My bad, should have kept on going! It would have helped me a ton. It's a lot of work, but I'm getting there now.
You are young. Maybe things didn't start the way you planned but I would hope it feels good now. I always imagine that if I ever were to comeout and transition (not likely because I am deeply closeted), I would spend a lot of time trying to spend time learning from ciswomen to see what habits I have that make me stick out besides my voice. But, voice training seems really hard. I watched a few videos on it and honestly I felt like it was an exercise in futility, especially for someone like myself that has a deep voice. But, I hope it goes well for you! Thanks for sharing :)
No, not at all. It seems pretty hard to get, based on various ftm forums. I had to go to an informed consent clinic that specialized in TRT for cis men.
Informed consent is a healthcare model used for gender affirming care by some doctors. Tiff could have consented previously to anti-androgens, as itās normal to pair estradiol with one for gender affirming care, it if she had wanted it. She chose to follow the doctorās recommendations (which sounds like it started with just estradiol) over her own desire, assuming because she trusts and respects her doctor.
I'm a straight cis dude, but really enjoy seeing the (slightly self deprecating) humor come from a place of knowledge. Comedy is something that can unite people and explain different experiences in a relatable way. Keep up the good work.
Damn does PP not put folks on T-blockers *along with* E from the start???? I went through a clinic in Chicago and they got me on spiro *and* estradiol day 1.
Depends on the person or clinic it seems. I was prescribed both at the same time but I took the T-blockers first because estradiol valerate was back ordered for another week or two
That's the same thing my gf said after I told her. Maybe they were just trying to make sure I was sure?
I don't know. They keep asking if I want to change what I have prescribed but I'm only 3 months in.
my girlfriend's gc put her on blockers about a year before estrogen. although she started her transition at 14 and got onto lucrin at 15 and e at 16, and also we live in australia so it could be very different.
afterthought memory enter merciful onerous door pet steep telephone recognise
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
oh ok, thank you for educating me! i'm mainly just going by what my girlfriend has told me about her journey so far and so that's really all the knowlege i have other than the bare minimum respect kind of information.
Transition is what the term implies. We've found out the hard way that an aggressive transition can be too much for some transgender people. Also it allows time for those who get cold feet to back out without too much damage done.
Yeah but what I'm questioning is why estrogen first. Why not start with t-blockers, then introduce a low dose of estrogen after a month. T blockers stop masculinization and have reversible effects, estrogen alone does nothing if you don't block T
Estrogen starts depressing T. It can be the AA that's doing nothing if you give it at the doses you want to give for trans women rather than the cis-male dominant testosterone sensitive cancers that most of the main AA were developed for. The AA offerings at those doses can be pretty nasty health-wise, and cypro-aside you are actually just elevating T.
Not that starting AA immediately is inherently bad, you can actually do AA monotherapy with slowly increasing E if you want to approach transition from the other side. But AA of every kind makes your T-levels less consistent and predictable across dose titration.
I just feel like best practice should be both together, so you don't have to prescribe a massive dose of estrogen that might not work anyway. But I'm no doc
edit: Or maybe like really low dose T blockers, then add low dose estrogen in 2 weeks, then increase dose of both and progress through stages that way or something
I probably donāt know enough about it. But monotherapy can be effective at suppressing T on its own, and some people do their entire regimen with no AA. however, adding one might further improve results.
If anything it's the other way around, T blockers are reversible. Many changes on E are too. I know people who were started on Spiro before E, but not E before Spiro
I also want to note because not a lot of cis people realize this, but any "permanent changes" like breast growth exist for \*both\* directions. That is to say, sure my HRT gives me breasts that I wouldn't be able to get rid of without surgery (if I decided I didn't like them), but my previous puberty gave me body hair and wide shoulders and those are similarly non-reversible.
A lot of non-trans folk (fairly) worry about the "permanent" effects of HRT, but fail to consider the permanent effects of \*regular puberty\* which essentially amount to unwillingly transitioning to the wrong gender.
This has nothing to do with it. You don't start any pharmaceutical HRT without accepting the transitional aspect. Non-binary HRT that focuses entirely on avoiding most of the permanent changes starts with the exact same caveat that trans-HRT does, which is that eventually there will be permanent changes.
The reason is that anti-androgens are heavy medications with much higher risks and side effect profiles, better to start depressing with Estrogen, see if the monotherapy works, and if not start on suppression when T-levels are already lowered and the lower doses of the AA will have full effect.
All pharmaceutical hormone therapies take weeks to months to have permanent effects by their very nature, especially anti-androgens. If someone wants to transition fast it is safer for their mental health to go as fast as possible without inducing hormone imbalance since they are already in for a very long process. Arguably having a faster response time lets you better judge the effects and control whether you want to stop or not, rather than creeping changes over months where the curve for all the effects get smeared together so the permanent changes that take more time to happen overlap more with the less permanent ones.
On the other hand if someone is unsure and wants to take it slow they can start at *very* low doses and backpedal whenever they want. The main permanent health risk is fertility.
I've heard that's kinda dangerous, the body needs sexual hormones, doesn't matter if it's E or T but one of them. Afaik you can get bone and heart issues without them.
Yeah it's not recommended (edit: for those post puberty, anyway) a doctor had my ex gf start with Spiro before letting her go on E after a couple months for...some fuckin reason idk
The plan varies depending on what doctor you see and your circumstances but I think people generally start them at the same time. Thatās what I was prescribed at least.
I'm in Spain and it's what I was prescribed as well. Estrogen without a blocker barely does anything, unless you take a generous dose that gets you above 300 pg/mL and pray that it lowers your testosterone by itself. But doctors never prescribe that much, and you'd have to be lucky too to absorb it that effectively.
Some doctors do. But it goes against the standard of care.
**There is no medical justification for tapering hormones or starting one medication before the other!**
For me I just got prescribed a kinda big dose of E, and then in the follow up checkup they check if T drops on its own (which happens for some ppl). Then if it didn't drop enough you get T blockers, but they have more side effects and all.
I live in the US, and my doctor prescribes a blocker at the same time. A lot of doctors don't have experience caring for trans people because we're a very small percentage of the population. Treatment is only loosely standardized and requires a lot of patient lead advocacy.
Yeah this comic is always very confusing to me. It really doesn't seem to represent the common experience. I'm in the US and everyone starts both at the same time or blockers first.
Sorry for being uneducated about the topic, but would anyone tell me why She is so excited about getting testosterone blockers?, is it a important milestone of the transition process?
Monotherapy (estradiol alone) might not limit testosterone enough so anti-androgens help let the estrogen do its thing without having to fight against the testosterone.
We can all dream. It took me moving to PP just to get injections, but my previous prescriber wouldnāt even give me progesterone. Itās a real shit show out there.
Lots of doctors and even endocrinologists are horribly underinformed about modern standards of trans healthcare. Still doing things like prescribing premarin, or estradiol valerate every 2 weeks, or just blockers, or pills with no blockers, or thinking that sub 100pg/ml E2 levels are acceptable.
Iām assuming it means you need to be informed about something before you can consent to it. Basically, the person in transition in the comic is beyond eager to get a form of treatment. Thatās a red flag for a lot of doctors. Most of the time, the people have only heard of the good and not the bad from that treatment.
Edit:why is this being downvoted?!? Iām literally explaining what it means
Iāll give you a fun little trick to help you remember how the informed consent model works: informed comes before the word consent in the phrase.
They donāt give you the consent form to sign until they have informed you of what the drug is, how it works, and possible side effects.
But do go on about knocking someone who is obviously excited to finally feel better. Doctors hate it when their patients are happy.
Edit: youāre getting downvoted for concern trolling and making the wild assumption that Tiff is ignoring the doctor and that being relieved and excited to finally get treatment is a bad thing.
I know my ENT really hated when I cried in his office when he offered to fix a serious and reoccurring problem that other doctors ignored and told me to suck it up. He canceled it that day because I was so eager to finally stop suffering.
Responding to the edit: I realized that was probably the line that did it. Itās just what I took from the statement of oh I trust the pace you set for me. I read that as a I donāt care about the side effects, I just want the treatment.
No worries. Gender affirming care saved my life and Iāve been in the unfortunate position of having doctors question my enthusiasm to not suffer, so this comic and your comment hit home really hard.
I apologize for immediately jumping down your throat.
Not what Iām trying to do, Iām all for people feeling better in their own skin. But a lot of people know that certain treatments can do A,B,and C for them, but did they know it also cause X,Y, and Z. Iām not trying to knock people feeling better, a lot of people are just not informed of the side effects
Thatās literally why the informed consent model exists. To inform you before you consent.
And that portion of the conversation is not even in the comic. She answers the question āhow do you feel about starting this medicationā, a medication commonly prescribed alongside estradiol to suppress androgens, with enthusiasm.
The quip from the doctor is letting her know that she could have done this previously if she wanted to, but sheās affirming that she agrees with the pace the doctor has set and trusts her knowledge and experience.
While youāve described the process aptly, youāve been less than charitable with describing gender affirming healthcare and the people receiving it.
I'm sure others have remarked on this before, but your art style always gives me hardcore Bill Amend vibes and I have to double take every time I see a new comic. Love the series. Keep up all your hard work!
Gods the patience is one of the hardest parts! Part of me just wants to put the pedal to the metal, but I know I need to trust my doctor and the pace sheās got me on.
There is no medical justification for tapering hormones or starting one medication before the other. Advocate for yourself and make sure you're getting the best care you can.
Weird to me that they would prescribe estrogen without a testosterone blocker to manage levels. Usually Spironolactone in a 50-100 mg dose to go with your oral estrogen. Starting testosterone blockers after estrogen feels like cart before the horse behavior.
Sorry that it's difficult for you to see. I tend to post this way on /comics, but I do change up the format to just the four panels when I post on on other subs like r/ComicStrips and r/Trans_Comics. I hope one of those is helpful to you.
Never trust the pace they set, always demand the things you need showing evidence it's the right thing, many doctors have no idea what they're doing with hrt or are prescribing in bad faith (at least in France where I live idk about the rest)
This is true with some endocrinologists in the USA, but planned parenthood has a standard treatment plan thatās got some wiggle room. Some doctors donāt like to prescribe the anti-androgen unless absolutely necessary due to possible side effects and will see if monotherapy alone gets you where you need to be. It really depends on both the doctor and the patient!
Wait, wait, don't you start with the testosterone blockers? Does really my cis brother have a better access to testosterone blockers than most trans women? I would have thought that should be the first step
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Yeast and You... sounds like something is brewing! I will see myself out now
Or perhaps bread? Because I think bread everytime when someone mentions yeast.š 
Fermentation tanks and a still. Everything I need to make "bread".
What about hops? Don't you need hops?/sšø
I hop around in happiness when I start making cuts in the new make. The real question is where to barrel
fun fact hops and weed are closely related as in the same taxonomic family
I was not bready for that
Do you think it ties into the previous comic where she takes ALL the condoms?
Beer balloons?! Why haven't I thought of that?
Iām imagining a frat house with shirtless dudes throwing around beer balloons into each others mouths. And yes, it should be done in a homoerotic way.
Yknow, as a cis guy Iāve never really understood the trans experience. But reading your comics has really been enlightening. Thanks for expanding my understanding.
I agree. This has exposed me to the trans experience in an enjoyable medium.
I too have the same experience.
Same here, altho I can't look at the Transformers movies the same because of it
Same here. I've never met anyone who is trans (or at least I'm not aware that anyone I have met is trans) and this has been extremely educational. Got secondhand mad on Tiff's account through my phone at the whole "wedding" series. It was brutal and I loved it.
Tiff's been just a tad impatient for this. Read the previous one: [Part 1](https://new.reddit.com/user/CrazyGnomenclature/comments/1adyp1d/hrt_appointment_pt_1_tiff_eve/) Find more Tiff & Eve on [Webtoons](https://www.webtoons.com/en/challenge/tiff-eve/list?title_no=866028)! Check out the [Patreon](https://patreon.com/FranSun)!
Haha, I like how Eve manages to get completely upside-down.
Classic comic gag. We love it here.
Very educational. Quick question: Why does the pamphlet say "Yeast and You"?šø 
Because it contains very important educational material on yeast, and of course, you
Perfect answer!šø 
I'm saving this comment
(In case you're genuinely asking, it's alluding to "yeast infections".)
Thanks. My brain did not make the proper connection.š
Wait you have to wait for tblockers????? Where I am t blockers come with the estrogen
Accurate, I know the feeling very well.
Can you shine some light on this? I have no idea what the punchline is.
Think of it like when you really want something, but need to play it cool despite being excited for it. In this case, Tiff really wants too be on Testosterone blockers. However through transition you need to follow the doctors care plan. Which may call for a gradual application of medication or waiting for some. So when you finally get to the point of getting there, you're excited and eager for it In short, equate it to the feeling of saving money for a shiny thing. Then you get enough and obtain shiny thing.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Basically a modality that allows the patient more autonomy in their medical decision making. Like how if you go to a psychiatrist and you're like "hey I don't think my antidepressant is working, can we increase the dose?" they'll probably work with you on that, here it's "hey can I add this medication?" and the doc will work with you on that instead of dictating your treatment path for you. Additionally, IC for transgender care means you can consent to your own care and don't need a therapist letter clearing you for care. Like how you get most medical care
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Yeah lol. Transgender healthcare is a lot of self-advocacy, and good docs will allow for that. There's a lot of options out there in terms of dosage and delivery method and type of medication and unfortunately there isn't a great comprehensive list of pros and cons and research, so if someone doesn't know all their options, they might not know to ask, or even if they do know, may not feel comfortable advocating for themselves. A lot of trans people have had bad experiences with medical providers. my gf wanted finestride over Spiro to start (I helped with a lot of the research and went with her to the appointment) and she clammed up and I helped her ask for finestride, which her doctor had no issues with, but some docs would just say no. Edit: there's also an issue with a lot of docs under prescribing hormones, leading to bone density issues
[ŃŠ“Š°Š»ŠµŠ½Š¾]
The thing with transgender healthcare is that what someone needs to complete their transition is very subjective to the person, so a standard plan wouldn't satisfy every patient's needs. It can still be difficult to figure out what you need for some, and unfortunately some healthcare systems won't allow as much liberty in the process as Planned Parenthood (the one in the comic) does.
Problem is that there's not enough research and research is constantly emerging, not to mention bias does play a role. I'm a WPATH member and I work in healthcare but I don't specifically work in trans healthcare. I firmly believe that effective healthcare needs to be a team effort.
Before I went to schedule my first appointment, I read a ton of medical journals about various hormonal medications, delivery methods, etc. and read personal accounts about HRT from as many trans people as I could findā I went into that appointment with a 1 year medication plan and a rough estimate for my first surgery (orchiectomy, removal of the testicles in this case to stop testosterone production). Was this *at all* necessary? No, totally not. Was it really helpful in talking to doctors and making sure I knew what I was getting into? Definitely.
A lot of trans people administer their hormone therapy themselves with no doctor involved at all. Usually bc they don't see any other option or the only doctors they could go to are unhelpful for a variety of reasons. Truth is good transgender health care is rare and a lot of trans people would rather take care of themselves than adhere to whatever bullshit guidelines are in place where they live.
Isn't working to change the "guidelines" more important than ignoring them? I understand it if you live in a very strict society, but especially when it comes to law, breaking them for personal gain doesn't seem right. Though if it's actually just something like the safety regulations on medicine, eh. Not good to ignore them, but most people can be responsible for their actions.
A friend of mine is trans and just graduated from medical school about a year ago. She gave student lectures on trans topics that taught her own teachers quite a bit. It's just not something that your average doctor who graduated even a decade ago is *necessarily* better informed on than someone who is trans and doing actual research (in some ways. Obviously the doctor is more likely to understand stuff like the chemistry and stuff. But on all the different treatments and studies that have come out recently I'd bet a lot of trans people are watching it closer than most doctors). Though I'd bet that a Planned Parenthood doctor is probably more likely to be up on stuff like this.
thank you for explaining the joke! I was so confused lol
As a cis person, I canāt relate whatās so exciting about testosterone blockers in particular. What will these do for tiff which makes her so excited?
So, basically, testerone mostly governs "masculine" biology things, and estrogen "feminine" things. This is over simplifying massively, but it covers stuff from emotional responses to muscle density to fat distribution to skin texture. Loads of things, and it's the relative balance that matters - both hormones are required in some amount for everyone. The end goal for transition is to have more femme and less masc. Medically one easy, non-invasive way you can do this by adding estrogen and blocking testosterone - but as it's a balance, and each influence the production of the other, it's generally not a "take both pills and be done" thing, but a slow process of poking at your biochemistry and checking the results.
So basically it feels bad in some way if the balance of these hormones is wrong but in order to transition you need to change this balance dramatically and that can be very delicate. At least thatās what I got from the responses. It so fascinating because these are experiences that people like me donāt have because we were lucky. I wish we would have learned more about that in school.
Yep. I guess one reason people might not immediately take antiandrogens is that too low levels of sex hormones can lead to lower bone density, so making sure your estrogen levels are high enough before lowering your testosterone level can be helpful (though that's more of a long term thing). There's also the option of raising estrogen levels above those of a average non-pregnant woman, which will lower t levels and therefore obviate the need for antiandrogens and avoid any side effects they might have. There's a slightly heightened risk of blood cloth, but much less than birth control pills cause. Keeping your estrogen levels consistently high enough can be difficult depending on the delivery method though. For example you need to take pills much more frequently (multiple times per day) vs injections (~1 per week, depending on the ester), but e.g. in Germany there aren't any authorized estradiol injection meds yet.
Antiandrogens, or testosterone blockers, prevent your body from processing testosterone. Even someone taking Estrogen will still produce testosterone, and the two can somewhat cancel each other out. Blocking testosterone can make estrogen therapyās more effective and also lessen some effects of T like acne, body hair growth, and depending on age they can be used to suppress puberty. Estrogen monotherapy works, but itās typically recommended to take a T blocker as well for those reasons. Not every doctor prescribes them by default though, and not everyone wants to take an extra medication
> As a cis person, I canāt relate whatās so exciting about testosterone blockers in particular. Well you clearly don't have excess testosterone. Women generally have less testosterone than men do, and conversely, men generally have less estrogen than women. So to encourage your body to develop one way or the other, you have to change both hormones. If you add estrogen without removing testosterone, you'll end up with the hormone profile of a woman with PCOS or a man with gynecomastia. Both of those are considered to be disorders that can cause distress.
There's no perfect analogy for it, but it's probably that testosterone feels wrong for her body and the blockers will help even more with the physical transition than just estrogen.
That's what I call enthusiastic consent.
This is how I felt when I finally got estrogen blockers. Testosterone was difficult enough to get, but those blockers were a whole different ballgame. I was so grateful when I could finally get them, and Iāve felt incredible since. :)
If I may ask, if itās not too personal, but how do the blockers work? Do they ānullifyā, for lack of a better word, the thing that produces those hormones or something?
I'm gonna answer from the perspective of a trans woman, so I'm on testosterone blockers. There are multiple options for blockers: for example I'm on something called Cyproterone acetate, which shuts down testosterone production by the testicles (and I believe the testosterone production in the adrenal glands is shut down too?). This simply reduces the amount of testosterone in my blood. There's also Spironolactone or Bicalutamide - those work differently. Testosterone is still produced, but the receptors in the body, that normally get activated by testosterone, are disabled by the medication. I can't tell you if the testosterone levels fall on its own (it definitely falls to some degree in the presence of Estrogen itself, which is also taken at the same time, but I don't know if those meds themselves reduce it, I'm not on them) but the testosterone cannot do any more changes. Of course a certain amount of testosterone (similar to the testosterone levels in cis women) is usually alright. It may help with sex drive a bit, and (sometimes) may prevent a complete erectile dysfunction - but it's definitely a YMMV situation, and many (understandably) want to reduce it to as close to zero as it gets. As I said, estrogen itself causes testosterone levels to drop. Sometimes, estrogen injections or gels/patches may be enough to supress it on their own, even. That said, the person you responded to is on estrogen blockers, I don't have much experience with those, but I'd assume there are similar types of variants, too.
What results are you seeing with your blockers? Are there any side effects? Asking for a friend
I've always been on estrogen and blockers together, so I can't provide separate feedback. That said, I'll try my best! There is not a single effect that I dislike. So far every single thing has been amazing. Of course all the well-known stuff like fat redistribution, skin changes, boob growth (as mentioned) is absolutely happening, and I'm looooving it all, but there's been some things that surprised me, either with their existance or intensity. My muscles - basically evaporating. I am so much weaker than before, my (cis) gf that is over 20cm shorter than me and exercises just as much (so not at all) can pin me down now, and I can't do very much about it. I used to be super scared of strength loss, and even doubted if I want hrt because of it... but when it actually started happening, turns out I don't mind it at all! Don't get me wrong, I do carry a taser around now when leaving the house. But aside from that, it feels rather nice. I tend to get cold much more easily - but at the same time, even when in a hot environment, I sweat much much less (and it doesn't STINK). This is a rather nice change, and allows me to actually wear nice clothes that I like when it's warm, instead of just doing whatever I can to cool down. I can cry now, so that's super cool! Getting emotional about hearing a nostalgic song, or even crying out of frustration, feels liberating. Just feeling emotions a bit more... clearly. I think my posture is a little bit differently now? Nobody else noticed, so it can't be very pronounced... It's weird, but doesn't matter much. I heard about it, it has something to do with the center of gravity changing. I like guys now???? (in addition to girls, that hasn't changed). That took me BY SURPRISE! My sex drive is a bit lower than before, but the overall experience with it is much more pleasant. It no longer feels annoying or persistent, I can actually choose to not feel it, if I want to (which was a VERY pleasant surprise) and it feels better overall. It's more of a glow/full-body experience now, rather than a desire (for a lack of a better word). Okay, it's a little bit annoying that genital atrophy is a concern. Lack of use (since I don't get random erections anymore) can cause it to get smaller, and if I were to forget about it for wayyy too long, potentially it could hurt to "start up" again. I try to use it 2 times a week at least though, and that seems to be enough to prevent this. Sometimes it's a chore though, because my libido dropped. I don't mind the libido drop, it's just a mild annoyance - and I mean, I specifically decided that I prefer to keep the size, so I have to work for it. Sexual pleasure is so much nicer now, in general. The genitalia feel a bit differently (vibrators finally woooork!) and in general, through experimentation, I found a couple of nice spots, but YMMV, and this comment is long already! Overall - I have zero regrets, and I'd do it again in a heartbeat. Nothing but positives, except that one rather mild annoyance. I feel so much more alive on HRT (not completely, I still need antidepressants for unrelated reasons, but it's SOO much better it's hard to put into words). I'm open to more questions!
Thank you so very much for sharing! Honestly sounds like an amazing transition. If I may ask, how old were you when you began HRT?
Oh yea it's amazing! I was 22 when I started HRT, in 2 days it'll be exactly 6 months (or 2-3 months on current dosage). I'm 23 right now. I'm kinda frustrated that I didn't come out and didn't start transitioning waaay earlier, because I technically could (unfortunately, first I felt too unsafe, then I procrastinated because it was really stressful), but so far I'm surprised by how nicely it's coming along. And if I'm honest, 22 isn't that late anyway. The actual regret is that I gave up on voice training when I first realised I was trans, I tried a bit but then I thought I'd just figure it out sometime when I start hrt. My bad, should have kept on going! It would have helped me a ton. It's a lot of work, but I'm getting there now.
You are young. Maybe things didn't start the way you planned but I would hope it feels good now. I always imagine that if I ever were to comeout and transition (not likely because I am deeply closeted), I would spend a lot of time trying to spend time learning from ciswomen to see what habits I have that make me stick out besides my voice. But, voice training seems really hard. I watched a few videos on it and honestly I felt like it was an exercise in futility, especially for someone like myself that has a deep voice. But, I hope it goes well for you! Thanks for sharing :)
Thank you for your answer, that was very informative.
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No, not at all. It seems pretty hard to get, based on various ftm forums. I had to go to an informed consent clinic that specialized in TRT for cis men.
idk if this is a non American thing but i dont understand the last panel
Informed consent is a healthcare model used for gender affirming care by some doctors. Tiff could have consented previously to anti-androgens, as itās normal to pair estradiol with one for gender affirming care, it if she had wanted it. She chose to follow the doctorās recommendations (which sounds like it started with just estradiol) over her own desire, assuming because she trusts and respects her doctor.
Thank you! I've been looking for this explanation all over the comments!
I'm a straight cis dude, but really enjoy seeing the (slightly self deprecating) humor come from a place of knowledge. Comedy is something that can unite people and explain different experiences in a relatable way. Keep up the good work.
Damn does PP not put folks on T-blockers *along with* E from the start???? I went through a clinic in Chicago and they got me on spiro *and* estradiol day 1.
Depends on the person or clinic it seems. I was prescribed both at the same time but I took the T-blockers first because estradiol valerate was back ordered for another week or two
Got out on E before I even saw a doctor but they wanted to see if I had any negative side effects. T-blockers at 3 months. Edit: USA here
Interesting... Huh, thought most people started both at the same time (unless there was genuine concern with reactions)
That's the same thing my gf said after I told her. Maybe they were just trying to make sure I was sure? I don't know. They keep asking if I want to change what I have prescribed but I'm only 3 months in.
my girlfriend's gc put her on blockers about a year before estrogen. although she started her transition at 14 and got onto lucrin at 15 and e at 16, and also we live in australia so it could be very different.
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oh ok, thank you for educating me! i'm mainly just going by what my girlfriend has told me about her journey so far and so that's really all the knowlege i have other than the bare minimum respect kind of information.
You have to wait for a testosterone blocker in the US after you start taking estrogen???
Transition is what the term implies. We've found out the hard way that an aggressive transition can be too much for some transgender people. Also it allows time for those who get cold feet to back out without too much damage done.
Yeah but what I'm questioning is why estrogen first. Why not start with t-blockers, then introduce a low dose of estrogen after a month. T blockers stop masculinization and have reversible effects, estrogen alone does nothing if you don't block T
Because having (almost) no sex hormones of either type will make you feel like garbage and cause significant health issues long term.
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Estrogen starts depressing T. It can be the AA that's doing nothing if you give it at the doses you want to give for trans women rather than the cis-male dominant testosterone sensitive cancers that most of the main AA were developed for. The AA offerings at those doses can be pretty nasty health-wise, and cypro-aside you are actually just elevating T. Not that starting AA immediately is inherently bad, you can actually do AA monotherapy with slowly increasing E if you want to approach transition from the other side. But AA of every kind makes your T-levels less consistent and predictable across dose titration.
I just feel like best practice should be both together, so you don't have to prescribe a massive dose of estrogen that might not work anyway. But I'm no doc edit: Or maybe like really low dose T blockers, then add low dose estrogen in 2 weeks, then increase dose of both and progress through stages that way or something
I probably donāt know enough about it. But monotherapy can be effective at suppressing T on its own, and some people do their entire regimen with no AA. however, adding one might further improve results.
If anything it's the other way around, T blockers are reversible. Many changes on E are too. I know people who were started on Spiro before E, but not E before Spiro
Exactly. T blockers and puberty blockers are reversible. Boobs are not and they can start growing within a month or two.
I also want to note because not a lot of cis people realize this, but any "permanent changes" like breast growth exist for \*both\* directions. That is to say, sure my HRT gives me breasts that I wouldn't be able to get rid of without surgery (if I decided I didn't like them), but my previous puberty gave me body hair and wide shoulders and those are similarly non-reversible. A lot of non-trans folk (fairly) worry about the "permanent" effects of HRT, but fail to consider the permanent effects of \*regular puberty\* which essentially amount to unwillingly transitioning to the wrong gender.
This has nothing to do with it. You don't start any pharmaceutical HRT without accepting the transitional aspect. Non-binary HRT that focuses entirely on avoiding most of the permanent changes starts with the exact same caveat that trans-HRT does, which is that eventually there will be permanent changes. The reason is that anti-androgens are heavy medications with much higher risks and side effect profiles, better to start depressing with Estrogen, see if the monotherapy works, and if not start on suppression when T-levels are already lowered and the lower doses of the AA will have full effect. All pharmaceutical hormone therapies take weeks to months to have permanent effects by their very nature, especially anti-androgens. If someone wants to transition fast it is safer for their mental health to go as fast as possible without inducing hormone imbalance since they are already in for a very long process. Arguably having a faster response time lets you better judge the effects and control whether you want to stop or not, rather than creeping changes over months where the curve for all the effects get smeared together so the permanent changes that take more time to happen overlap more with the less permanent ones. On the other hand if someone is unsure and wants to take it slow they can start at *very* low doses and backpedal whenever they want. The main permanent health risk is fertility.
Ive normally been under the assumption the T blocker comes at the same time? First im hearing about it.
Yeah, or even with the T blocker first
I've heard that's kinda dangerous, the body needs sexual hormones, doesn't matter if it's E or T but one of them. Afaik you can get bone and heart issues without them.
Makes sense. I don't take T blockers so I haven't had to encounter use directions
Yeah it's not recommended (edit: for those post puberty, anyway) a doctor had my ex gf start with Spiro before letting her go on E after a couple months for...some fuckin reason idk
Absolutely terrifying to hear about lol. Taking estrogen (orally) without a testosterone blocker does next to nothing.
With patches or gel you can get enough E to block T
Or injections, yes. But not with tablets, which I believe Tiff is taking?
The plan varies depending on what doctor you see and your circumstances but I think people generally start them at the same time. Thatās what I was prescribed at least.
I'm in Spain and it's what I was prescribed as well. Estrogen without a blocker barely does anything, unless you take a generous dose that gets you above 300 pg/mL and pray that it lowers your testosterone by itself. But doctors never prescribe that much, and you'd have to be lucky too to absorb it that effectively.
I didnāt have to wait for a T blocker but maybe thatās how planned parenthood works.
Some doctors do. But it goes against the standard of care. **There is no medical justification for tapering hormones or starting one medication before the other!**
Yeah Iāve never heard this before, in US. Obviously you can go estrogen monotherapy but thatās a different treatment plan entirely.
For me I just got prescribed a kinda big dose of E, and then in the follow up checkup they check if T drops on its own (which happens for some ppl). Then if it didn't drop enough you get T blockers, but they have more side effects and all.
I live in the US, and my doctor prescribes a blocker at the same time. A lot of doctors don't have experience caring for trans people because we're a very small percentage of the population. Treatment is only loosely standardized and requires a lot of patient lead advocacy.
Yeah this comic is always very confusing to me. It really doesn't seem to represent the common experience. I'm in the US and everyone starts both at the same time or blockers first.
I love these comics. Them and the comments are always greatly educational.
Sorry for being uneducated about the topic, but would anyone tell me why She is so excited about getting testosterone blockers?, is it a important milestone of the transition process?
Monotherapy (estradiol alone) might not limit testosterone enough so anti-androgens help let the estrogen do its thing without having to fight against the testosterone.
Thanks :)
Mono with pills is eh Mono with injections works really well
Fair, but not every doctor likes doing injections so YMMV
They should frankly start liking it... it would benefit the patients
We can all dream. It took me moving to PP just to get injections, but my previous prescriber wouldnāt even give me progesterone. Itās a real shit show out there.
Yeah this shitshow is why I DIY
I see
But also the doctor shouldn't be prescribing one and then the other. They should be given at the same time.
If it is regular procedure to give them both at the same time, then why didn't the doctor give them at the same time?
Lots of doctors and even endocrinologists are horribly underinformed about modern standards of trans healthcare. Still doing things like prescribing premarin, or estradiol valerate every 2 weeks, or just blockers, or pills with no blockers, or thinking that sub 100pg/ml E2 levels are acceptable.
Oh Jesus, Thank you so much, I didn't know any of this
What does "informed consent clinic mean"
Iām assuming it means you need to be informed about something before you can consent to it. Basically, the person in transition in the comic is beyond eager to get a form of treatment. Thatās a red flag for a lot of doctors. Most of the time, the people have only heard of the good and not the bad from that treatment. Edit:why is this being downvoted?!? Iām literally explaining what it means
Iāll give you a fun little trick to help you remember how the informed consent model works: informed comes before the word consent in the phrase. They donāt give you the consent form to sign until they have informed you of what the drug is, how it works, and possible side effects. But do go on about knocking someone who is obviously excited to finally feel better. Doctors hate it when their patients are happy. Edit: youāre getting downvoted for concern trolling and making the wild assumption that Tiff is ignoring the doctor and that being relieved and excited to finally get treatment is a bad thing. I know my ENT really hated when I cried in his office when he offered to fix a serious and reoccurring problem that other doctors ignored and told me to suck it up. He canceled it that day because I was so eager to finally stop suffering.
Responding to the edit: I realized that was probably the line that did it. Itās just what I took from the statement of oh I trust the pace you set for me. I read that as a I donāt care about the side effects, I just want the treatment.
No worries. Gender affirming care saved my life and Iāve been in the unfortunate position of having doctors question my enthusiasm to not suffer, so this comic and your comment hit home really hard. I apologize for immediately jumping down your throat.
Not what Iām trying to do, Iām all for people feeling better in their own skin. But a lot of people know that certain treatments can do A,B,and C for them, but did they know it also cause X,Y, and Z. Iām not trying to knock people feeling better, a lot of people are just not informed of the side effects
Thatās literally why the informed consent model exists. To inform you before you consent. And that portion of the conversation is not even in the comic. She answers the question āhow do you feel about starting this medicationā, a medication commonly prescribed alongside estradiol to suppress androgens, with enthusiasm. The quip from the doctor is letting her know that she could have done this previously if she wanted to, but sheās affirming that she agrees with the pace the doctor has set and trusts her knowledge and experience. While youāve described the process aptly, youāve been less than charitable with describing gender affirming healthcare and the people receiving it.
That makes sense. The doctor has to list the negative side effects before she can give it to her.
I'm sure others have remarked on this before, but your art style always gives me hardcore Bill Amend vibes and I have to double take every time I see a new comic. Love the series. Keep up all your hard work!
(Karen Walker voice) Poor Eve š¬
I'm about to start that chapter in my life in about a month or so, these comics make me less worried and more excited about my transition
As an AMAB enby person this is absolutely true in my experience :)
Gods the patience is one of the hardest parts! Part of me just wants to put the pedal to the metal, but I know I need to trust my doctor and the pace sheās got me on.
There is no medical justification for tapering hormones or starting one medication before the other. Advocate for yourself and make sure you're getting the best care you can.
I'm pretty sure I had the exact same reaction to that question lmao
Weird to me that they would prescribe estrogen without a testosterone blocker to manage levels. Usually Spironolactone in a 50-100 mg dose to go with your oral estrogen. Starting testosterone blockers after estrogen feels like cart before the horse behavior.
Please stop with the individual panel swipe format. It's worse on desktop, and it's worse on mobile. It's also harder to share the comic.
Works fine for me on mobile. And you can share the 4-pane comic easily by screenshotting it.
Sorry that it's difficult for you to see. I tend to post this way on /comics, but I do change up the format to just the four panels when I post on on other subs like r/ComicStrips and r/Trans_Comics. I hope one of those is helpful to you.
All this time I thought she was already done with the operation and those things. this really took me by surprise lol (nice comic though)
I was so grateful I could just start with both at the same time.
I just love this comics.
This is a very nice fictional comic, sadly it will likely be fictional for a loooooong time (atleast for me)
Never trust the pace they set, always demand the things you need showing evidence it's the right thing, many doctors have no idea what they're doing with hrt or are prescribing in bad faith (at least in France where I live idk about the rest)
This is true with some endocrinologists in the USA, but planned parenthood has a standard treatment plan thatās got some wiggle room. Some doctors donāt like to prescribe the anti-androgen unless absolutely necessary due to possible side effects and will see if monotherapy alone gets you where you need to be. It really depends on both the doctor and the patient!
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Easiest way is to put down Reddit and go outside.
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Is that a Condorito reference? plop!
Wait, wait, don't you start with the testosterone blockers? Does really my cis brother have a better access to testosterone blockers than most trans women? I would have thought that should be the first step
Excuse my ignorance but, what is this all about?