I saw 3 patients this week for follow up on trying to treat their dysphoria without HRT. two failures and one success. I think people should be offered a choice they are not currently being offered.

Yeah I think the whole thing that makes being trans hard is that the world is built to validate all your fears and that's what most of us spend our pre-transition life working up the courage to fight. Because people have so many fears and it's so easy to continue repressing, I'm skeptical of anyone who feels their dysphoria is "cured". I mean could be, but I would only believe it if I heard them still saying it on their deathbed at the ripe age of 97. There are way too many stories of people bottling that shit back up in the closet for 20 more years.

Opting in is very important. If someone isn't opted in to transition, it's going to be hard to navigate the obstacles that inevitably come with transitioning and create positive experiences like you have experienced. Not saying it isn't possible, but not being fully in on it makes it easy to sabotage or not even seek out potential positive paths.

Also, I think you got lucky. I ended up being fired on day 1 of my first flight instructor job out of flight school cause they thought my transition meds made me a liability in the cockpit. And then with the timing of the pandemic, plus the health impacts from that, I basically got fucked out of that career path completely, and now I'm chronically unemployed. I know people who have been divorced by their spouse due to their transition. Several in fact. It's incredibly common. And of course losing family is also incredibly common, and for people in certain situations (for example if someone is living with family) that can be utterly devastating.

Having opt in to transition is important for dealing with those challenges too of course. It goes both ways. But I think assuming that everyone's family, home, and work life will improve with transition just cause it happened to you is just a wrong assumption.

I think it's fine if someone decides that they're not willing to deal with the fallout of transition and would rather try other treatments instead.

You can "what if" about pretty much any life decisions. There are potential positive and negative things down every path. There's definitely a "hindsight is 20/20" bias in how you're looking at it. Not saying you took the wrong path. Any decision you chose of your own volition rather than being forced/pressured into it by someone else is a good choice. But saying this is how it should go for everyone is short sighted.

Or aiming a rocket ship towards the moon from earth without a steering wheel or guidance computer.

This is even funnier for anyone who's ever played Kerbal Space Program or otherwise knows how orbital trajectories work, cause aiming at the moon doesn't get you to the moon.

Kate gives a better answer than I will, but to add to her's, the most common thing that I see especially in young, early, gender dysphoric AFABs pre-T is various forms of hyperandrogenism.

You can't just check the testosterone and the DHEA-s

At this point when someone really wants to know, I run this incredibly detailed androgen panel that basically hits all of the metabolites. Or at least the vast majority of them.

I timed the lab draw for approximately 7 to 10 days after the last day of bleeding to try and catch the androgenic peak. I see how high it goes.

A lot of times, those that have hyperandrogenism simply respond to blockade. Giving them something as simple as Bicalutamide makes the dysphoria go away.

What's truly bizarre though is that sometimes, it makes it infinitely worse.

Separating the two groups into as I usually classify them, Tinkerbell's and helgas. AKA Type 1 or type 2 FTM In my theory, the skinny tiny elvish ones respond best to Bicalutamide and the heavy, large, dwarven barmaid body type tends to feel worse on it.

Is also seems to apply to lesbians experiencing a shift in their sexual orientation on the drug. The pixies shift towards attraction to males whereas it does not seem to have any impact on the helgas.

Now that is an over generalization, and I use those terms sort of jokingly but also sort of not. Because literally, this is what they look like when they show up.

The tiny, pixie-like lesbian that says that they want to take testosterone almost always inverts and becomes a gay transgender man.

The ones that are built like a linebacker when they show up, identify as a lesbian, but then decide to transition, they almost always remain attracted to women and have never experienced any change in their orientation through the process.

Exactly why that is? I'm still trying to understand it. But it's a pattern that I cannot ignore. It's glaringly obvious.

I had a patient explode at me once, as I was warning them about the possible change in their sexual orientation. They were a Tinkerbell, and basically, I told them, hey, I know you have a girlfriend and you're a lesbian, but this may change your sexual orientation because I've seen it happen many times.

The patient was super offended and basically flipped out at me and nearly ended the appointment. They basically said if I brought it up again, they were done. Told me that it was absolutely revolting that I would suggest that they might become into men.

I dropped it, and said okay, no problem. I could not believe how hostile they were about it. Super offended.

I was supposed to see them 3 months later for follow up, but they showed up 6 weeks later. Chief complaint was "private"

I walk into the room, and the patient is there, and says that they need to go on prep.

Ask why, and they say rather bluntly, "Because I fucked six dudes in the past 6 weeks and I don't want to have to hear from you how you were right. So just give me what I need so that I can stay safe".

And I did. And that was pretty much the conversation. I didn't shame them about it, but just looking at their face and body, I knew that it was highly likely that this would happen simply by starting testosterone. I'd seen it happen hundreds of times before.

I see so many people, I do so many transitions that the pattern, it becomes more and more evident. I start to see the same subtypes of transgender people. And how they respond to certain drugs and how it affects their sexuality and various aspects of their behavior and so on.

I hope that gives at least a peak into some of it, but it's a lot more complicated than I've described here. This is an oversimplification.

Checkout the list on the FAQ for an overview . Everyone is unique and even saying what is most common is hard to say at this point. For example many places will cite that 21-OHD is the most common nonclassic CAH, but in certain locations of the world something else is more common so if your family comes from that location then it isn't rare. A percentage, but not all of those with EDS have gender dysphoria. Even for ERa activation there appears to be two very different groups. One with very little and one with a lot so that isn't universal and dealing with it only applies to a subset.

One thing that has a detailed paper backing it up is that those with gender dysphoria have on average lower vitamin D levels. Maybe it is unrelated to sex hormones, but still having very low levels isn't good.

There does seem to be many patterns that are worth further investigation such as folate issues and b vitamin deficiencies, low zinc levels, etc. For most it is a combination of a number of things and not a single genetic variant. For those that I chat with, lab work, looking up genetics, family history, etc all help figure out what to investigate first. More often than not there are medical conditions that are associated and once they get a better idea of the underlying cause they can improve their treatment and health.

Helping everyone with gender dysphoria figure out what is going on in their body and helping them have better autonomy is my personal goal.

For the exception it’s a good idea to keep track of this individual if possible, because it’s very much possible that for this person will have Gender Dysphoria reemerge a few years or decades from now. Playing devils advocate you could say internalised transphobia could explain why this individual is seemingly content with not transitioning. If this was the case maybe it’s something that could be best explored with a therapist

You have to understand. This is occurred more than just once. There's like 20 to 30 of these people now. Some of them, told me that they felt this way all on their own, by treating some other problem that they had.

So while I understand that you feel this way, I can't produce you years of data because I don't have it. But I'm certainly going to pay attention to it over time.

Regardless, it needs to be remarked on at least publicly, because the idea that such a thing is impossible is also not scientifically justified. Nobody really knows. There hasn't been studies of the opposition trying to fix things and then seeing if you can, and then following those people. Nobody knows what's going to happen. But ultimately, I'm going to give people this choice. Because it's their choice. I'm not forcing it on to anyone.

Yeah but what's the alternative? Try and railroad the person into transition?

It's up to the person to figure out as time goes on, professional support for many of us is key to that. It might be that you are right, but that person might be in a better place in acceptance, or you might be wrong and they might live perfectly happily.

Anecdotally for myself I take a zinc+copper, but it depends on the person what they need. I am also nearly a decade on HRT. The reduction/resolving of gender dysphoria appears with Zinc appears to occur if you take the Zinc pre-hrt and not post-hrt. After hrt it simply helps with your overall health and a lot is associated. Basic stuff like resolving eczema, hair thinning, etc that can be caused caused by low zinc.

Zinc is near the top of my list of things I keep researching because of how many different ways it is used in the body. I see it *over and over* from the community and like vitamin D having very low zinc has no big redeeming qualities that I can tell.

I mean if your goal is body feminization with the absence of breast development, you can always try and block it with SERMs But that is only a little effective. It reduces the breast size but doesn't eliminate it.

Definitively, the best way to do this, is to go see this guy named Dr Daniel Medalie.

He's a plastic surgeon with a Cleveland Clinic and is the best top surgeon in the world in my opinion. I have seen this dude do top surgery on trans men and you couldn't even tell it was done. He did a double incision surgery on someone and the surgical line where the incision was done was so fine that it looked like a cat scratch.

This guy didn't have the traditional underscars. It was done so well, literally it was basically invisible.

When people ask me who the best top surgeon to go to is, unequivocally, it's this doctor. He's incredibly skilled. The best. Never seen anyone better.

But, if you go see him, have top surgery done now, before things get big, that's it. You can feminize the rest of your body all you want, but you will never grow breasts. They will stay flat.

I have a few people that have done this or who are in the process of doing this now. It's not that uncommon. Maybe 10 to 20 times I've done it.

I'm similar. I don't really mind my breasts now that I have them, but I don't really "embrace" them as confirming my eunuch identity. I have the methylation defects, and take methylated B vitamins. My eunuch nature is "neither" sex, mostly, though I'm fine being basically male. I look and sound mostly male.

The breasts are limiting in some male spaces, of course. I can't go swimming topless, for example. So I wear a compression shirt under a swimming shirt. I've had melanoma too, so if anyone ever asks I'll just say I'm being careful about sun exposure. My celtic/scandinavian redhead-light complexion makes that pretty believable!

You want to go down a real deep rabbit hole?

A lot of times, the patients that present to me with asexuality as their listed sexuality have some sort of endocrinological dysfunction, or, have gender dysphoria. Treatment of said things often results in a complete change in their asexuality.

Something as simple as starting birth control on an asexual AFAB with acne and dysmenorrhea has resulted in the development of libido. Obviously, a lot of my FTM asexuals are not asexual post T.

Asks a lot of questions about what asexuality actually is. Is it an orientation? Is it a disease state? Can it be fixed or should it be fixed?

Whenever I talk about it I always get in trouble, but I've seen a lot of really interesting things happen to asexual patients. In both directions. Sometimes the development of asexuality is quite dysphoric for someone who has a sexuality, and vice versa. As I've absolutely seen people become asexual once starting HRT who previously were not.

I would agree that it's small, but it's probably the largest sample size that anybody has anywhere else in the world.

We have about 3,000 registered transgender patients in our practice, with 4,000 total patients.

Because I'm openly admitting to doing this, and I'm pretty sure I'm the only person that is, I'm getting more and more of them every day. They are sort of coming out of the woodwork in a way that would make you stunned to see how many of them they're really are. So many people with gender dysphoria who don't want to transition, and would do anything to not have to feel the dysphoria anymore aside from transition.

I'm the only actual doctor at the practice, but we have two mid-levels. I don't know of any particular practice anywhere else that has more trans people. I'm sure there are centers that have more, like UCSF or Fenway, but not by one single human that sees them all.

That being said the variability of it is absolutely 100% on point. Each single time that I do it, it's completely unique to that person. There are various times that I see the same thing work in different people, but it's not like one panacea fits everyone.

It's much the same way that I have to approach post-finasteride syndrome. I more or less poke it with a stick repeatedly until I find out what works and what doesn't for that specific human. As I get more talented, I get better at selecting which stick to use, but ultimately, I'm still just poking it with sticks until I figure out which one is the sharpest for that person's issue.

Sometimes, none of them are sharp enough. That's a very bitter pill that I'm trying to swallow right now on many patients because it's very frustrating to fail when I see others succeed and don't know why.

Kate already answered this. But this is basically our entire theory. Meyer-Powers syndrome is the explanation for the connection between hypermobility and gender dysphoria.

As well as the multitude of other things that you describe there. It's all in the list. It's all genetically linked.

We're still flushing out the theory, testing things and looking at stuff, but it gets more refined by the day. I'm getting better and better at treating it as well.

Hypermobility is associated with gender dysphoria. See the EDS section on the wiki. Classic like EDS (the most common form) also results in 21-OHD variant called CAH-X which influence sex hormone production and can result in atypical levels. Combine with some of the other genetic variants and then gender dysphoria appears in higher numbers it seems. See the main FAQ page for a list of conditions you probably recognize.

Clomipramine and therapy.

The most powerful thing was me basically telling the patient to their face, hey, listen, this sounds a lot like OCD. You are describing OCD.

The patient told me over and over again how they didn't want to be transgender but they felt like they had the transition because they have to. It was this like weird obsessive compulsive aspect to the thing.

It would be like someone telling you that they really don't want to burn their hand by sticking it in the fire but they feel like they have to stick it in the fire and all day long, they have thoughts about sticking their hand in the fire.

That person logically, doesn't want to stick their hand in the fire. Cognitively, they know that's a bad idea. But their brain just keeps screaming at them to stick their hand in the fire all day long.

That drug really helps interrupt that cycle. But also recognizing that cycle for what it is, a feedback loop of anxiety that feeds on itself and grows ever stronger as you feed it, allows you to finally break it.

Once the patient was able to recognize that it was exactly this. OCD, was given a drug that helped tone down the invasive thoughts, and did some therapy, they made a full recovery.

I've seen this play out a few different times. The story above could apply to about four or five different patients. It's sort of an amalgamation of all of them. Another one did well on olanzapine when clomipramine wasn't on the money.

I always feel a little bad when I tell stories of this nature online because it's like I'm fibbing a little bit. But in a way, I'm trying to combine multiple different patients that have the same story and get the useful bits of data out of each one out there because it might be helpful to someone. I hope that makes sense.

Basically, the above patient is like five different patients Who recovered from the gender dysphoria because it was actually OCD and not really dysphoria. It just happened to be the thing that they obsessed over.

This is the sort of thing that I would urge you to speak to a specialist about. Someone educated about gender issues but also OCD.

Sometimes it's really hard to tell these things apart, and with the assistance of somebody who knows what they're doing, the problem can get solved. One way or another.

Really though, what really matters is that you end up happy in the body that you're in. However that body ends up looking. That's ultimately, your choice, and your life to live.

Actually the patient that had the low T and the high E felt better upon correction.

I've actually had that patient like no less than 10 times. And most of the time, they actually feel better with correction. But they are the outlier.

Mostly because I would expect someone with aromatase excess to be highly masculinized in the first place. It's unusual to see someone with those levels present with gender dysphoria because of the masculinizing effect of estrogen in utero.

The past year I have learned that those who are transitioning/transitioned were the most hostile to me even asking questions let along the idea that underlying causes could be found. It has been the pre-hrt folks that have been the most curious to work with me to learn about their specific situation. In both cases I have helped with a lot of health conditions, but as far as “law of diffusion of innovation” there is nothing going on, mostly simply don't care, there is no funding, etc. It will probably be a slow word of mouth type of thing. Research papers will take years to get out etc, all slow and boring.

Well, yes, but I've also treated 18 to 22-year-olds who told me that the choice to transition was a catastrophic mistake. So what should I do? It's not my decision to make.

Are you willing to sacrifice those people who made a catastrophic mistake in the reverse direction in order to prevent it for those kids?

Ethically to me, the correct answer is to give the choice to the patient. It's not my decision to make.

I appreciate the support in regards to my rhetoric.

I'm trying very hard to write in a way that is going to be read the way that I want it to be read as opposed to just extremely cold, logical, and autistic as fuck.

I know what I think in my mind, but I'm not always great at putting it down into words such that it is interpreted the way that I want it to be. It is something I'm actively working on. So I appreciate you noticing. That means a lot. It's very encouraging.

1. Most of the time, though there are certainly cases that are entirely psychiatric. Both biological and psychiatric dysphoria can both be treated a multitude of different ways.

2. All the time. Though unfortunately, I don't really have a lot of support in it. Overwhelmingly the answer when anyone ever has any sort of gender dysphoria is to rubber stamp them for hormones. I understand how we've gotten to this point, but it doesn't necessarily mean that it's the right choice for everyone.

3. The choice of what treatment to pursue, should always, 100% of the time, be in the hands of the patient. The most critical part of the whole thing is that a person has autonomy over their own life and their own body. It is not wrong to offer them a choice, but it is 100% wrong to deny them a choice, if one exists. They must always be allowed to space to change their mind at any time and treatment plan at any time. It's the only ethical way to handle it that I can see.