Based on medical papers, testosterone consumption for women comes with many negative physical side effects beyond the expected effects of facial hair growth, voice deepening, and fat redistribution. These effects include:

Potential infertility with some studies finding poor ovarian health (Cheng et al., 2019)
Cardiovascular disease (Dutra et al., 2019; Wierckx et al., 2012)

Risk of myocardial infarction for women on testosterone is elevated by 4 times relative to control females and >2 times relative to control males (Alzahrani et al., 2019)

Weight gain/obesity (Dutra et al., 2019)
Hypertension (Dutra et al., 2019)
Insulin resistance (Dutra et al., 2019)
Hypertriglyceridemia (Dutra et al., 2019)
Erythrocytosis/polycythemia – increase in red blood cells (Madsen et al., 2021)

Erythrocytosis developed in 11% of women on testosterone. Factors appearing to influence one’s risk include increasing time on testosterone, injecting testosterone instead of using a transdermal method, BMI, age of starting testosterone, and tobacco use (Madsen et al., 2021)
Increased hemoglobin (Olson-Kennedy et al., 2018b)

Vaginal atrophy (Baldassarre et al., 2013)

Thinner epithelium and loss of intermediate and superficial layers, but the basal and parabasal layers seemed unaffected. Lower doses of testosterone may reduce risk (Baldassarre et al., 2013)

Depletion of vaginal glycogen (Baldassarre et al., 2013)

In theory, this would raise the vagina’s pH and leave women on testosterone vulnerable to fungal and bacterial infections, but no studies had reported on this and it’s possible that this risk could be balanced out by not having vaginal sex (Baldassarre et al., 2013)

Abnormal blood lipid levels (Dutra et al., 2019; Olson-Kennedy et al., 2018b)
Lowered prolactin (Olson-Kennedy et al., 2018b)

Women who have taken testosterone also report mental changes:

Loss of ability to cry (Bell, 2021)
Lowered anxiety and confidence boost (Dutra et al., 2019; Pressly, 2020; Purkis & Lawson 2021; Shrier, 2020)
Increased dislike of the female form, including lesbians losing interest in women (Bell, 2021; Pressly, 2021)
Reduced short-term memory (Shrier, 2020)
Irritability/aggression (Joyce, 2021; Kuklin, 2014; Shrier, 2020)
Increased sex drive (Kuklin, 2014; Shrier, 2020)

In addition to these mental shifts, testosterone appears to increase a trans-identified woman’s desire for a double mastectomy. In a 2018 study headed by Dr. Johanna Olson-Kennedy titled “Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults,” a “chest dysphoria scale” ranging from 0 to 51 was devised. Two groups of women were given a questionnaire that would then be scored to determine their score on the “chest dysphoria scale.” The first study group consisted of women between the ages of 13 and 23 (average 17) who were on testosterone but had not undergone a double mastectomy. The second study group consisted of women between the ages of 14 and 25 (average 19) who had taken testosterone and undergone a double mastectomy. The age at which the women in the second group had undergone a double mastectomy ranged from 13 to 24 with 17.5 being the average age at the time of surgery.

For young women on testosterone who had not undergone a double mastectomy, “chest dysphoria” increased by 0.33 points for each month spent on testosterone. Of the young women who had not undergone surgery, 70% said that “having chest surgery” was “one of the most important things for [them] right now” and 25% said that it was “very important.” The average “chest dysphoria” score from this cohort was 29.6.

“Whatever it is, the way you tell your story online can make all the difference.”

— Marcia

Of young women whose breasts had been surgically removed, their average “chest dysphoria” score was 3.3. Based on the improvement of “chest dysphoria,” the research paper recommends “chest surgery” be provided based on “individual need” and that age restrictions on the surgery be removed.

While the drop in “chest dysphoria” scores may seem impressive, there are some major issues with this conclusion. For starters, the young women recruited were existing patients or recent patients at the Center for Transyouth Health and Development – it seems probable that women experiencing regret about testosterone or surgeries would be more likely to distance themselves from the center. Moreover, considering that the scale included items like “I get gendered as female because of my chest” and “I sleep with a binder on at night,” it’s not a surprise that the scores would have a notable drop – some items measured physical logistics of having breasts that just wouldn’t apply to women who had their breasts cut off. There were some questions that measured mental well-being like comfort with bathing and making life plans, but without a group of women attempting to desist, this study can’t prove that a surgery is the best way to improve the lives of women struggling to accept their sex. Additionally, the scale having questions focused on physical aspects of breast development only limits the scale’s ability to compare the non-surgical cohort to the post-surgical cohort – the scale’s inclusion of physical items means it can still find trends within the non-surgical cohort like the correlation between time on testosterone and desire for a double mastectomy.

My biggest issue with the study is not the missing control group or rigged scale – it’s the researchers’ reaction to their data. They fail to question why testosterone is being given to girls and young women as a treatment for gender dysphoria if time spent on testosterone correlates with worsening dysphoria surrounding breast development. They do not question why this correlation and potential causation would exist. Does more time spent trying to live as a boy make the physical logistics of having breasts more challenging? Does more time spent trying to live as a boy make any reminder of their femaleness a greater source of distress? Does more time spent envisioning a future as a different sex increase feelings that life is on hold until their bodies are drastically changed? There’s no realization that maybe a girl wouldn’t feel such a strong need to have her breasts cut off if she just hadn't been given testosterone in the first place.

This failure to consider not prescribing testosterone to girls seems to stem from a larger pattern in gender research of ignoring the possibility of desistance. This results in researchers like Olson-Kennedy merely asking “does a double mastectomy reduce ‘chest dysphoria’ based on this scale I designed” instead of raising questions like “what is the healthiest way for a young woman to navigate distress surrounding breast development and alienation from one’s sex?” There was no group in the study where girls tried to accept their breasts while not on testosterone or with therapy instead of surgery. Olson-Kennedy’s shortcomings about big picture health become even more apparent considering a talk she delivered roughly two months after publishing the “chest reconstruction” paper: “And here’s the other thing about ‘chest surgery,’ if you want breasts at a later point in your life, you can go and get them” (Is This Appropriate Treatment, 2018). The head researcher on this study published in JAMA Pediatrics either believes or is willing to pretend that silicone is an adequate replacement for natural tissues, nerves, and milk ducts.

I’m not a gender doctor or researcher. But when the experts of a field produce sub-par research and make statements detached from reality, being an outsider seems all right. In the following paragraphs, I’ll be presenting a few theories as to why the use of testosterone would correlate with an increased hatred of one’s breasts.

Before outlining the theories, I want to acknowledge that my theories suggest a causational relation between testosterone use and worsening dysphoria about breasts even though the original data only shows a correlation. It is possible that this is a spurious correlation or that there are lurking variables. Perhaps the correlation is driven by girls who are more desperate for a double mastectomy staying on testosterone for longer rather than the testosterone causing their level of desire to change. Perhaps the women in this study who had been on testosterone longer had larger breasts, making the physical logistics more salient. However, from the stories of detransitioners and my own observations of women currently transitioning, I suspect that this correlation is at least partially driven by testosterone use causing an increased desire for a double mastectomy.

One potential reason why testosterone might increase a woman’s hatred of her breasts can be seen in the story of Kiera Bell. A combination of testosterone and binding caused her breasts to become misshapen, and this made her hate them even more (Bell, 2020). While Bell was the only girl who I found explicitly discussing altered breast development, it seems plausible that breasts becoming misshapen due to testosterone would make other young women begin hating them or hate them even more.

Kiera Bell has also said that her double mastectomy was partially motivated by a desire to align her face and torso (2020). Her bearded face and deepened voice allowed her to pass as a man, and her breasts didn’t match her new look. Transitioning made her breasts feel even more out of place. A similar struggle can be seen in the story a detransitioner named Bianca shared in Gender Dysphoria. After taking puberty blockers, testosterone, and undergoing a double mastectomy, she began wanting genital surgery in hopes that she could go all the way with another woman without that woman realizing Bianca was female¹ (Evans & Evans, 2020). Because she was living a lifestyle where she passed herself off as male thanks to her prior medical procedures, having female genitals became a problem for her. Even though Bianca’s story is focused on genital surgery while the Olson-Kennedy study focused on double mastectomies, Bianca’s story still demonstrates the general concept of how changing some sex-characteristics leads to a greater desire to change additional sex-characteristics. The mismatch between the natural body and the medical alterations deepens difficulties with accepting the natural body. If the natural body had been left alone, then sex-characteristics like breasts or a vagina would fit in with the rest of the body. If support was given to help women like them desist, then the natural body could be accepted.

A final reason why testosterone use may cause an increased desire for a double mastectomy could be displaced meaning. Displaced meaning is a coping mechanism where people address the gap between their ideal life and current life by telling themselves that their life will be ideal once they make a particular purchase. This potential purchase becomes a symbol for their idealized life. The meaning is displaced because the purchase will not actually bring a perfect life. Should the person make their purchase, they will be thrilled initially only to later realize their life hasn’t been fixed. Once they are confronted again with the gap between their ideal and real life, they will likely find a new purchase onto which they can place undue meaning.

To clarify, a man who purchases a house so he’ll have a dry place to sleep is not an example of displaced meaning. A roof will keep him dry – his expectation is something that the house can directly provide and using physical means to solve a physical problem is not indicative of symbolic thinking. He may have thoughts that sleeping in a dry place will bring comfort, but this expectation is still closely tied to what a house can realistically provide and doesn’t turn the house into a symbol for a perfect life. On the other hand, a single man struggling with loneliness who purchases a rose covered cottage with dreams of a sweet romantic house bringing about the perfect marriage is guilty of displaced meaning. Rose covered cottages don’t come with a free wife and kids. A house can’t directly cure loneliness. His desire for the house is based on how it symbolizes a more socially fulfilling life. As he begins to notice that his purchase didn’t actually fix his life, the excitement from the purchase will wear off and his loneliness will return. Instead of confronting his inability to attract a wife head-on, perhaps he’ll start telling himself that his love life will fall into place once he installs a fire pit surrounded by string lights.

While few use the term “displaced meaning,” the concept and its connection to transitioning has been observed by third-parties like Abigail Shrier: “A funny thing about wanting body modifications – small changes, like a tattoo, or more invasive ones, like a nose job, liposuction, or even a double mastectomy: we’re often sure that if we just had that thing, we’d be a lot happier” (2020, 108). The concept and connection have also been described by people like Rene Jax and Bianca (respectively) who have first hand experience of cross-sex hormones and surgeries:

The main milestone was finding a doctor who would give me the hormones. If I get… female cross-sex hormones my life will be perfect. And then you think, “Well, if I can only get my voice – get my male voice up here – then that’ll make me, you know, just happy.” And then you think, “The next thing is, well if I can get breast implants that’s all I need.” It’s never enough. And finally, if you’ve gone through the therapy and you can convince a doctor to start cutting on you, you go and you have a sex change. [...] I had my sex change in 1990 and in the back of my mind I didn’t think… I thought it might be like all the other stuff I had done, but I was hoping, just hoping that that would make me feel complete. […] The sex change didn’t solve my discomfort. The doctors who are honest will say that the gender dysphoria is always there and it’s because the confusion… starts out being about your anatomy, but really… it’s you don’t like yourself (Vorobey, 2018). - Rene Jax

That [“everything would be OK if only you could stop your development as a girl and transition to be a boy”] was the message throughout the whole process, including some of the professionals who seemed to encourage the idea that transitioning was a solution to my problems [family issues, difficulties making female friends, low self-esteem, disgust over menstruation] (Evans & Evans, 2020, 42). - Bianca

Assuming some of the girls partaking in Olson-Kennedy’s study had displaced meaning associated with testosterone consumption, it should be expected that time on testosterone would lead to an increased desire for a double mastectomy. More time on testosterone would be more time to notice that it hadn’t fixed their complicated life issues. Since the girls would have gotten used to placing unrealistic meaning onto a transition-related purchase, double mastectomies are an obvious next candidate and the surgery becomes a new symbol for an idealized life.

The possibility of displaced meaning as a motive for transitioning reveals another major limit of the Oson-Kennedy study. While they explore how the post-mastectomy group had improved “chest dysphoria,” they fail to investigate whether the dysphoria had actually been alleviated or if it had just been refocused on a new body part. After a double mastectomy, some women go on to pursue hysterectomies, hip shaves, Adam’s apple implants, metoidioplasties, and phalloplasties. Assuming some of the post-mastectomy girls Olson-Kennedy studied had displaced meaning into the mastectomy, it would seem likely that their desire for other surgeries would have increased after the mastectomy, but such questions were not asked in the original study. This is also where having a study group pursuing desisting instead of medical transitioning could come in handy – desisting would likely encourage learning to use healthier coping mechanisms than displacing meaning into transitioning. Comparing those who tried desisting, girls on testosterone, and post-surgery girls also on testosterone would have allowed for a much bigger picture on what a healthy approach to distress about puberty and feelings of alienation from one’s sex looks like.

While the Olson-Kennedy study had some severe limits, it does at least provide evidence of a correlation between time on testosterone and increased “chest dysphoria,” which then feeds into girls feeling like they need a double mastectomy. Based on the three theories I’ve explored, I suspect this correlation is at least partially caused by testosterone use. Increased hatred of one’s breasts and an increased desire for a double mastectomy seem to be additional side effects of testosterone use for trans-identifying girls. If testosterone use results in dysphoria being transferred elsewhere rather than relieved, then it doesn’t make sense as a treatment for dysphoria, especially considering the other physical and mental side effects of testosterone. A lack of regret in young women who transition with no control group isn’t the best metric to determine if the hormonal and surgical intervention were the optimal approach; young women in Gender Dysphoria were confident they wanted to transition and probably would have been happy to begin the medical route, but they still desisted, finding peace with their bodies and avoiding medical side effects. It’s worth investigating if people have the potential to live a satisfactory life without the mental and physical repercussions inherent to fighting their sex. It’s time for researchers to look into desisting, hold their field to higher standards, and reconsider how they define ‘healthy.’ Maybe then they’ll get better pieces than Olson-Kennedy’s.

Notes

While my discussion in the article focuses on how trying to pass as a man in sexual contexts hurt Bianca by pushing her towards more extreme surgeries, I still want to specify that lying about one’s sex to a potential sexual partner is highly immoral because of the impacts on one’s potential partner. It can’t be informed consent if the other party isn’t informed. What Bianca was doing to the women she dated was wrong, and undergoing genital surgery to further disguise her sex would not have made her actions any more moral.

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