This post is part of Outward, Slate’s home for coverage of LGBTQ life, thought, and culture. Read more here.
Spironolactone is the most commonly prescribed anti-androgen (male hormone suppressant) for transgender women as part of their hormone therapy in the United States and Canada. It suppresses testosterone and helps create more opportunity for estrogen levels to rise, which in turn enables a lot of positive physical effects, from softening the skin to improving body odor to reducing hair growth.
But, as transgender researcher and peer coach Beverly Cosgrove pointed out in a well-circulated article earlier this year, spironolactone also has many other effects, including fatigue, fogginess, muscular atrophy, and weight gain, among others. One of its most profound effects does actually exactly what the drug is designed to do: kill your boner. Historically, the “goal” of hormone therapy was the total transformation of one’s genitals—that’s how the first doctors in the field of transsexualism imagined it, and that goal motivated the establishment of this treatment regimen of de facto castration.
For a lot of trans women, having their penises effectively switched off is desirable. But for others who have been prescribed spironolactone, this and other effects are part of a larger suite of quality-of-life concerns that don’t often occur to doctors when it comes to treating women. This disconnect illuminates how often transition-related care fails to account for the ways in which trans women seek to live full and varied lives.
Spiro comes with a lot of baggage, much of which is well known. And while its inexpensiveness partially accounts for its wide usage, the drug is not much different in price from other, less-disruptive anti-androgens. Nevertheless, spironolactone enjoys a privileged status in transition-related care. Why?
Spironolactone is valued for its ability to “feminize” patients in a way that matches the assumptions of a predominately cisgender, male, white, and heterosexual medical community: by deflating your muscles, softening your dick, stunting your hair growth, and shrinking your balls. In the eyes of cisgender medical providers, right back to Harry Benjamin (who first proposed the term transsexualism in the 1950s), a trans woman meant someone who wanted to perfectly embody the traditional gender roles of a woman. It would have never occurred to these practitioners that their patients might want to eschew traditional gender roles; that view has remained largely consistent up until today.
Most doctors working with transgender patients typically have a set regimen in mind, geared toward adjusting their patients’ testosterone and estrogen levels to within certain set parameters. The idea is pretty straightforward: If you want to achieve “feminization,” you need to get your T low and your E high. The standard starting dosage of spironolactone is between 100 mg and 200 mg, administered daily.
My endocrinologist is somewhat unique in that, as I’ve changed my doses over the past year, he’s pretty much rolled with it. He provides me with all the information I need to make smart choices and gives me options when it comes to doses and drugs that will help me achieve my goals. This kind of specialized care has been hugely beneficial. This way, I can make executive decisions about my body that align with my personal goals and feelings, and I’m able to defer to his insight in order to ensure I’m moving safely and stably ahead.
Not every doctor defers to their patients in this way, instead trusting (often outdated) research that fails to recognize the agency or specificity of individual transgender patients. Many doctors rely heavily on increasingly high doses of steroid medication as an essential component of their treatment protocols. Several of my friends describe a protocol of 200 mg of spironolactone for three months before estrogen as a way of pushing their T all the way down. Others have estrogen doses of 2 mg and take 400 mg of spironolactone, with physicians ratcheting the numbers up and up after each blood test.
In some cases, though, doctors forgo blood tests. Many clinical settings emphasize accessibility to care over the quality of care—often as a result of poor funding, high demand, and limited resources. That means that these underresourced clinics end up providing a one-size-fits-all approach, when specialized care is essential.
My friend Daniela (who declined to include her surname) was prescribed 200 mg of spironolactone at a clinic offering accessible transition-related care, but she got her prescription without doing any bloodwork. In the first few months on this dosage, she experienced a number of unpleasant side effects, ranging from a plummeting sex drive to painful headaches, memory loss, dietary disruptions, and such difficulty focusing that she found it hard to read. “I wouldn’t be able to remember things I had just heard,” said Daniela, who works as an English teacher. “For a while I had thought that this was just what HRT was like—that I’m not going to be able to read anymore, and I’m not going to have a sex drive. I was resigned to being in zombie mode.”
Another friend, M Zavos, is a transsexual woman and an artist based in Arizona. She also found spiro’s sexual effects to be disruptive, along with what she called “brain fog”—a persistent sense of fatigue, haziness, and confusion. M’s experience with spiro was so unpleasant that she leapt at the opportunity to get an orchiectomy (testicle removal), eliminating the need for testosterone suppressant altogether. The change was like a breath of fresh air. According to M, many trans women she talks to are hesitant to look into an orchiectomy because they want to continue using their penises during sex. But what they don’t always understand is how much of their problems can be chalked up to the specific effects of spironolactone, as opposed to their transitions in general.
“When I was on spiro, my dick wasn’t working,” said M. “Once I got an orchiectomy and was no longer on spiro, I started topping my boyfriend.” She adds that even though something like surgery is often characterized as “drastic” or “dramatic,” one moment of intervention can produce much better results than a lifetime of medication—especially one as complex and far-reaching in its effects as spironolactone.
For both Daniela and M, the issue comes down to an underfunded model of health care that sees patients primarily as income units or consumers, with little room for adequate communication between practitioners, or specialized attention to the needs and wants of individual patients. It’s an unfortunate fact of transgender health care (especially in the United States) that marginalized communities and women are often forced to take whatever treatment they can, and the providers working with them are generally unable to devote the necessary time and energy to helping them determine the right treatments for their goals and lifestyles.
“It’s not full care, in the full sense of the word. It’s like throwing a prescription at me—which I was very happy to take, but still,” Daniela says, trailing off. “Free clinics are so amazing and essential, but there should really be better resources.”
Daniela is now based in Spain, where spiro is not commercially available; she’s since switched to Androcur. She’s a lot more comfortable on it and hasn’t experienced headaches or memory problems, though she does acknowledge that spiro’s strength produced “feminizing” benefits. Androcur isn’t available in the United States. Though it is available in Canada, it isn’t widely prescribed. There are other anti-androgens on the market as well, including nonsteroidal options like bicalutamide and nilutamide. Nevertheless, spironolactone is still the drug of choice, for reasons that remain a bit of a mystery.
It would be easy to chalk the situation up to a binary-focused, traditional model of transition-related care. But the issues are deeper than that. Sure, one of the problems with spiro is that the “feminization” it achieves speaks only to a narrow definition of the term. (Indeed, that is one of the reasons that nonbinary or gender-nonconforming transfeminine people generally dislike it.) But both Daniela and M identify as “binary” transsexual women, and their transition goals lean toward what might be considered a normative or mainstream view of femininity. Their issues with spiro weren’t to do with its incompatibility with their transition goals, but the way it disrupted the rhythms of their daily lives and made it hard to do the simple things that they enjoyed doing—like having sex, eating food, reading, making art, and seeing friends.
Often, when we discuss how transition-related care affects those who use it, we focus only on its capacity to achieve transition-related results. But it’s just as important to think about how different treatments and programs affect the quality of our lives, no matter how we identify.
Spironolactone works well for some people in achieving some of their goals. But it’s not right for everyone, and it shouldn’t be prescribed that way. Transgender patients require specialized, ongoing care that respects their individual needs and bodies. Unfortunately, that’s not an option in our current prevailing medical system, where there are incentives on even the most high-minded of practitioners to treat individual patients as problems to solve and boxes to check rather than as complete and complex human beings with unique desires and goals.
Because there is no incentive, financial or social, for cisgender practitioners to understand transgender health care as complex, evolving, and individualized, it is easy for them to continue prescribing a drug that only does half the job that trans women need it to do. The issue is systemic. Until our capitalist medical system changes, trans women will continue to get substandard care.