Profile of Transfeminine Care in the TCM Clinic

Count the number of transgender people you are knowingly familiar with in your daily life. Now, count how many transgender patients you knowingly have in your practice. Bonus points if you got past the fingers on one hand! Many Traditional Chinese Medicine practitioners have little to no experience treating trans people, or coordinating gender-affirming care with other medical professionals. Moreover, there is a significant lack of research about transgender experience in general, and certainly in the realm of allopathic transgender medical care. Fortunately, a number of organizations have endeavored to bridge this gap with relevant data, evidence-based practice, and education. The University of California San Francisco’s Center of Excellence for Transgender Health offers an authoritative guide for transgender primary and gender-affirming care. That being said, compared to allopathic medicine, the scarcity of information on transgender care in Chinese medicine is even greater.

Without offering an entire course in Trans 101, what you need to know is that gender is a constellation, and that transgender people do not neatly fall into a binary of female-male, or simply into trans woman (MTF), or trans man (FTM). Some trans people identify that way, but not all. So always ask for clarification, either in your intake forms or directly as it is appropriate. In this article, we will offer some broad strokes of experience for supporting transgender people - specifically trans feminine people or people assigned male at birth who are taking feminizing hormones - in their personal journeys towards gender affirmation.

From my perspective as a transgender person and Chinese medicine practitioner, I want to equally affirm a patient’s identity and transition path, and also clearly communicate that a chosen path does not come without positive and negative consequences. Affirming one’s identity medically comes with the price of certain side effects. I would argue that no one understands this trade-off greater than transgender people. Transgender people know that being yourself in a society that is averse to and oppressive of your experience comes at a cost. Supporting and affirming your patients within your clinic and beyond makes a significant impact.

In fact, you may be one of the few people in their life that does so.

Before getting into common Western medical treatment as well as examples of specific signs, symptoms, and treatment options in Chinese medicine, we should always remember that in Traditional Chinese Medicine we treat a pattern of imbalance, not only symptoms. Though there may be some shared similarities that transfeminine people undergoing medical transition collectively have, a patient’s Individual experience must always be taken into account alongside a thorough diagnosis; including a health history, the pulse, and observing changes in the tongue. Moreover, even in the realm of medical transition pathways, there is no one-size-fits-all template. Each patient chooses their personal medical transition journey, within the framework of their individual history and constitution. This is especially true with patients who access gender-affirming treatment on a consent-based model where there is even greater variation.

Take a mid-30s trans feminine patient of mine, D, for instance. She followed the “traditional” or the most commonly prescribed route for feminizing, Hormone Replacement Therapy (HRT). This began with the medication spirolactone/aldactone for one year to suppress testosterone, followed by on-going exogenous estrogen. She previously worked with a Chinese Medical professional before, but this was the first time she was seeking care for issues related to transition in the clinic.

“I’m tired and cold all the time now,” she says, having started medical transition about 1 year before she showed up in my office. “Also, I get leg cramps really easily. It never used to be like that.” Having been an athlete prior to transition, she laments that "I can't run like I used to and get winded faster." “What’s even weirder is that when I started HRT, I felt nauseous, almost like I was having morning sickness. Oh, and before I quit spirolactone, I was never horny anymore. But that came back once I got off it and started estrogen.” Many of D’s symptoms were most prominent when her testosterone and estrogen were both low (colder body temperature, low libido, fatigue/reduced stamina). Some, like the nausea, had started after she and her doctor introduced estrogen.

As was true with D, transfeminine people undergoing testosterone suppression with concurrent estrogen supplementation frequently show the following: thinner and weaker pulses overall, and deeper pulses in the chi positions. This usually indicates Qi and Yang deficiency. Testosterone, it can be argued, is Yang with estrogen considered to be Yin. Ultimately a relative excess of Yin damages the Yang even if the introduction of a Yin “substance” is intentional. In D’s case, her goal was ultimately to more deeply embody Yin in spite of her assigned sex and physical constitution at birth (not the same as her identity). Transfeminine patients undergoing medical transition can also exhibit slippery or thin pulses alongside thicker tongue coatings indicating the presence of Dampness. In the case of my patient, she exhibited Damp symptoms and signs such as a sensation of heaviness and fatigue, as well as nausea, but her weight remained the same, even though her muscle to fat ratio significantly changed over time. Again, these are expected and intentional effects of her gender affirmation treatment, but nevertheless nothing comes without cost. These constitutional changes can be seen as a soft constant for people undergoing this style of HRT regimen.

In transgender care, there can be some side effects from medications that are often used “off label” to facilitate specific results. For example, aldactone, a diuretic traditionally used for hypertension and congestive heart failure, has the “side effect” of suppressing testosterone by blocking androgen receptors. This would be problematic in someone who did not want to experience lower testosterone levels—such as a male-identified person who might then experience low libido or gynecomastia as a result. But for transfeminine people, this is a goal. That being said, suppressing testosterone does not come without consequences. D experienced this in the form of lower energy and endurance overall, running colder, and having less libido. Common TCM treatment principles for treating a patient like D include tonifying Qi and Yang, draining Dampness, and calming Shen, especially given the psychological stress that trans people experience on a regular basis.

The fact that trans feminine patients do not ovulate simplifies the picture to a degree, but be aware that some HRT regimens are timed to mimic various stages of a female cycle. Trans patients with stable healthcare access who are taking HRT usually find and commit to an on-going medication regimen. For transfeminine patients this is often after two years, beyond which estrogen does not have significantly new effects. Patients may also alter the forms of hormones they take along the way, such as switching from pills or patches to injections. Each change in their gender affirmation pathway requires a reevaluation from a Chinese medical standpoint. They may also experience other medical events such as surgeries that require other approaches beyond compensating for the side effects of medication. As practitioners of Chinese Medicine, we are trained to evaluate how a patient’s condition, constitution, and patterns manifest in each moment, and we treat them with the present, the past, and potential futures in mind.

Other symptoms that transgender patients often experience and that are treatable in the clinic include: anxiety, depression, insomnia, PTSD, breast tenderness, and others. Some of this can be related to their Western medical treatment, while much of it is a result of living as a trans person in the world. Regardless of the etiology, we as practitioners with understanding and humility have the opportunity to holistically treat their physical-mental-emotional-spiritual axis concurrently. Always care for your patient as an individual, and intimately understand their gender affirmation pathway and respond accordingly.

Common Needs and Treatments for Transfeminine Patients:

The following are some general recommendations from my own clinical experience. They should only be applied in accordance with the TCM diagnosis and treatment principle for that patient:

1. Surgical Recovery: pain and trauma from common gender affirmation surgeries inevitably result in Qi and Blood stasis. Patients can implement a proactive regimen of a Tian qi-based formula, taken by mouth in capsules just before, and during immediate surgical recovery to facilitate healing and pain relief. The capsule ingredients can also be combined with clean water to form a paste, applied as a salve to wounds and sutures. A Tian qi-based formula would be contraindicated with a current or past history of elevated liver enzymes, liver disease, or kidney damage. Acupuncture protocols could include “Circle the Dragon,” distal points along relevant meridians, Hua Tou Jia Ji points adjacent to spinal segment level that corresponds to relevant dermatomes for the surgical area, alongside bilateral LI-4, with 1-2 hertz continuous wave electro-stimulation.
2. Breast Enhancement and Minimizing Estradiol Doses: There are some herbs with phyto estrogenic properties that can be helpful, depending on the pattern presentation, such as herbs: Dang gui, She chuang zi, Jue ming zi, Hong hua, and Sha yuan zi.
3. Prevention of side effects from estradiols: Estradiol medications can have a proliferative effect on specific tissues of the body. If a patient’s family medical history is of concern, it can be prudent to include herbs such as Lingzhi within your herbal formula.
4. Low Energy/Fatigue: Qi and Yang tonic formulas such as Bu Zhong Yi Qi Tang may be appropriate, depending on the presentation.
5. Decreased Libido: Yin yang huo, Tu si zi, Gou qi zi, Bai shao (monitor patient’s testosterone levels in concert with their PCP so as not to inadvertently spike their levels), micronized progesterone.
6. Digestive disharmony: Qi regulating herbs such as Dang shen, Gan cao, Hou po, Zi su geng may be appropriate, along with acupuncture at PC-6, ST-21, Ren-12.

Supporting and treating the tremendous diversity in the trans and gender non-conforming community is an exciting opportunity. Patients can experience a significant amount of adversity and often medical gatekeeping, which can be confusing to navigate. By working with them respectfully and enthusiastically, you will benefit their quality of life and enhance their transition experience profoundly.

Resources

• Chen, J. (2005, October 1). Estrogen and herbs. Acupuncture Today. Retrieved March 19, 2022, from https://www.acupuncturetoday.com/mpacms/at/article.php?id=30213
• University of California San Francisco’s Center of Excellence for Transgender Health https://transcare.ucsf.edu/guidelines

About the Author

Avery Grace (they/she) is a queer, transfeminine L.Ac. and DAOM candidate, and originally served trans and queer people in private practice in San Francisco. She is a former adjunct faculty member at the American College of Traditional Chinese Medicine/California Institute of Integral Studies, and has since practiced in Phoenix, AZ and New Orleans, LA, and soon in Oregon. Avery currently lives on the unceded territories of the Confederated Tribes of Warm Springs, otherwise known as Bend, OR. When not practicing medicine, Avery is an emerging playwright and co-parent of three.