Fun fact: if you’re a trans masculine person taking testosterone as part of your transition, you might be growing prostate tissue. Look under your seats. You get a prostate! You get a prostate! You get a prostate!
There’s a lot I’ve learned about taking testosterone in my eight months taking it. The risks, I learned things like high blood pressure, male pattern baldness, acne, and fertility changes from doctors. But the fun facts? I’ve learned those from offhand remarks made by fellow trans men smoking outside gay bars. Like the fact that trans mascs on T actually grow “innumerable miniature prostates.”
Trans people and medical professionals have a lot to learn from each other. Luckily, there are people who are both, including James Lauren, a nurse practitioner specializing in queer and trans health. Lauren (he/they) practices at Westside Family Medicine in New York City and was a fellow in the Keith Haring Nurse Practitioner Postgraduate Fellowship in LGBTQ+ Health at Callen-Lorde Community Health Center. He’s also currently enrolled in the Hunter College Doctor of Nursing Practice program – all that is to say, if there was ever an ideal trans person to ask about this stuff, it’s James Lauren. I spoke to him about growing prostate tissue and the other side effects of T we don’t get told about.
What Do I Mean by “Risks” and “Side Effects?”
There’s a clarification I have to make before we start talking about prostates. Before writing this, I had been referring to all effects of testosterone as “side effects,” but as Lauren has taught me, effects and side effects are not perfect synonyms. So what’s the difference?
“I would say the ‘effects’ vs ‘side effects’ of gender affirming testosterone depend on what someone is looking for!” said Lauren. For example, “facial hair might be a desired effect in someone where that is their main goal, and then bottom growth is a tolerable ‘side effect.’”
As for risks, Lauren refers me to a chart from the World Professional Association for Transgender Health (WPATH) Standards of Care. They point out, “note where it says things like ‘possible increased risk with the presence of additional risk factors’ or ‘increased risk,’ not ‘this will definitely happen to everyone.’”
So is HRT “risky” overall? No. It just has side effects to be aware of, as does every medication. As Lauren puts it, “every single person is walking around with hormones in their body, either a system which is dominated by estrogen or one that is dominated by testosterone. We are shifting that balance, not adding a completely foreign concept to a body.”
Now, back to your regularly scheduled prostate content.
You Can Grow “Innumerable Miniature Prostates”
When a friend first told me, “you know we get a free prostate on T, right?” I didn’t believe him. Then, I found medical studies confirming this and did believe him. Except it’s not “a” prostate. In the words of Zinnia Jones of Gender Analysis, who broke down several of these medical studies, we grow “innumerable miniature prostate glands” in the vaginal canal.
These mini-prostates have been found in intersex patients, too, so if you’re intersex and have a vagina, congrats! You might have got a few prostates for free. This phenomenon is called “prostatic metaplasia,” and it’s completely health-neutral. According to Gender Analysis, “no patients experienced the growth of cancers or masses in the area at a followup time of up to 156 months.”
It’s worth noting that one of the medical studies behind this had a sample size of only 21 patients, and all of them had been on T for at least a year. And for all this (limited) research, not a single study mentions how this feels, or if we can feel it at all. If we really have innumerable small prostates, would that be noticeable during sex? Once again, I’m left with nothing but anecdotal and personal evidence.
Personally, I would say I’ve noticed a difference (in a good way). But is it just because I know they’re there? Have other people noticed? I spoke with several of the trans mascs in my life, and the consensus seems to be yes, but… most people weren’t aware that the miniature prostates were even there.
Out of six people who agreed to answer questions on the record, only two had ever heard about prostatic metaplasia, and both had some confusions – one person thought it only applied to people who have had reconstruction surgery, and the other had “heard about it but trans medicine is so underfunded and under researched I wasn’t sure if it was factual or a rumor.” And that’s exactly the problem. Because of a lack of research, I’m not learning about my own prostate(s) from a medical professional. I learned from a fellow T-boy and some Googling.
Emotional Changes Aren’t One Size Fits All
When I asked Lauren what lesser-known effects of testosterone he thought people should know about, he said emotional changes are “important to be aware of. I think that a lot of people are looking for the physical changes, so they may be caught off guard by how they ‘feel’ different. This is not necessarily a ‘bad’ thing. In fact, many people feel great once they start testosterone, but it is something to be aware of, and one of the many reasons I recommend (but do not require!) things like therapy and support groups.”
Are those different feelings only anger and chaos, like we get told to expect by some cis doctors? No. Lauren’s own emotional experience on T was “surpis[ing], but in a positive way. I found that I just generally felt better on it than prior to starting and during the period when I came off for personal reasons.”
My emotional experience was similar. Being on T didn’t make me irritable – it gave me energy and made me happy and excited to be alive. I’ve experienced a greater change in irritability from a concussion than I have from HRT.
Even medical providers have misconceptions about emotional changes on T. Lauren tells me he’s heard a provider say, “my teenage boy is a nightmare, I can’t prescribe something that is going to make someone so angry and difficult.”
In response to that, Lauren says, “I am sorry her teenage boy is being difficult but this is not relevant to transmasculine experience! In my experience, the mental and emotional changes on testosterone for trans guys is far more often a positive change than a negative one.”
Low Dose T Still Has the Same Effects as High Dose, but Slower
Some trans mascs may opt to take a lower dose of testosterone. If you’re on low dose T, it will cause a slower transition, which might be more comfortable for you – there is no “right” timeline to transition. But if you’re considering a lower dose to avoid certain effects, that’s not how testosterone works.
“I do get a decent amount of patients who seem to think that a ‘low dose’ means they will only get certain changes and not all of them, but unfortunately at this time you can’t pick and choose what will change and what won’t,” said Lauren. “I have to tell people if there are any possible effects of testosterone that are a real deal-breaker for you, you should consider that it may not be the right path for you, as we can’t predict the exact timeline of what will change and when for each person. Even a ‘low dose’ will cause the same effects as a ‘high dose,’ it will just take a longer time to get there.”
Unbalanced Levels of Testosterone Can Convert to Estrogen
It’s easy to think “more testosterone = more effects faster,” and as someone with the shittiest whitest facial hair at 8 months in, I get the urge to rush. But it turns out taking more than your medically recommended dose of testosterone can be counter-intuitive. If your body has too much, it may begin to convert T to E.
How the testosterone gets converted is a multi-step process. As explained by the High Therapy Clinic in Miami, it’s “a series of enzyme conversions that begins with cholesterol and ends with estradiol” and that conversion is facilitated by an enzyme called aromatase. No matter your assigned sex at birth, your body needs a balance of hormones to function. If it senses too strong of an imbalance, this process is meant to protect you, since estrogen is necessary for things like brain function and bone density.
Lauren confirms this: “One of the handful of good reasons that we don’t encourage just taking the highest dose of testosterone that is available is that it will at some point aromatize to estrogen and become counterproductive.”
As they also note, this is “not really a ‘side effect’ because it doesn’t cause some sort of direct effect of the medication on your body. It’s [more of] an interesting biochemical process.”
So, how fast does this biochemical process happen and at what testosterone levels? Say it with me now: we don’t know! More accurately, it varies greatly from person to person, and this effect has been studied more in cis men than trans men (shocker). If you stick to your assigned T dose and get your hormone levels checked often, you likely don’t need to worry about this.
Changes in Susceptibility to STIs/UTIs
This is another “I heard it from a friend” that I wanted to check in with a medical professional, since I had seen a 2019 University of Washington study that showed that trans men on T may be more susceptible to STIs and UTIs. The study states that “compared to cisgender women, the vaginal floras of transgender men were less likely to have Lactobacillus as their primary genus.” Lactobacillus is a probiotic that protects you from certain infections. But, crucially, this study notes that “to the author’s knowledge, there are no clinical studies evaluating the influence that testosterone administration has on the vaginal microbiome.” That’s right, NO clinical studies. As much as I hate reading the phrase “vaginal flora,” this is yet another hole (no pun intended) in the medical system’s knowledge of trans men on HRT.
I told Lauren that I’ve heard of changes to UTI/STI susceptibility on T. I asked what they know about this and what precautions we can take. To pull a single quote from his answer would take away important information and context, so here it is in full:
“The lack of natural estrogen in the genital area that can happen after being on gender affirming testosterone can lead to the tissue being more delicate, in a sense, and easier to bleed or be more painful. This can lead to more UTIs as well. It is called vaginal atrophy (or whatever word someone prefers to use for the anatomy), and is also common in post-menopausal cis women. It is important for them to know this before starting T so that they can be aware that it is a possible effect, especially since it is quite easily treatable.
Some people are uncomfortable discussing these things and wind up suffering needlessly. If someone is having sex that puts them at risk for STI acquisition, they should make sure they are being appropriately screened and offered the right interventions such as PrEP and doxy-PEP. They should also be comfortable discussing genital symptoms with their medical provider, so they may be treated and avoid unnecessary suffering.”
Why Don’t We Know More About T?
If there’s one thing I’ve learned about the effects of testosterone, it’s that we aren’t studying the effects enough. Almost every study I found while writing this has a small sample size, or hasn’t been repeated as often as more mainstream medical studies are in order to have their findings confirmed.
That comes from the fact that medical professionals simply aren’t educated enough about trans people. When I asked Lauren whether medical institutions should be teaching more about trans medicine, he requested to print his YES in all caps and size-40 font (and I, in smaller font, agree). As someone with firsthand experience in the medical school system, he said, “it is barely being taught at all. We are in NYC and my own education was exceedingly minimal. The fellowship I did at Callen-Lorde is necessary right now because there is no standardized required education for this area of medicine, so medical providers are completely unprepared.”
Hearing that there’s no standardized education on trans medicine is jarring, but not surprising. As Lauren tells other providers, “if you can manage hypertension, asthma, diabetes, all these other complicated medical conditions, then gender affirming medical care should be a breeze!”
He’s right. Trans medicine isn’t any more medically complex than any other field. So why is studying it so fraught?
“Without training, people are afraid. Charitably, at best, it is because they are being cautious and do not want to cause harm. At worst, it is because they do not believe that this population deserves care. If it was taught in school, it would normalize the treatment more, familiarize people with what to expect and how to take care of the population, and maybe even move the needle on someone who’s only information is coming from what they read in the news. Some places are probably doing a great job, and some places are doing nothing. It should be standardized.”
When I reached out to Lauren for this interview, even he had never heard the “innumerable small prostates” thing. I asked his thoughts on this – both the fun fact itself, and the fact that he didn’t know.
“It is exciting that there is always new research being done now on trans health, and there should be new information rolling in all the time,” Lauren said. “I have to say to my patients sometimes, when discussing possible side effects, that unfortunately there is not nearly as much research on transgender medicine as things like erectile dysfunction or male pattern baldness due to the stakeholders, but it is wonderful to see that this is changing!”
And maybe, just maybe, that change starts by asking your doctor if they’ve ever heard of growing innumerable miniature prostates in the vaginal canal.
Feature image by wagnerokasaki via Getty Images