Alternative medicine

Natural transition

Can herbal hormone therapy help the transgender community?
Alternative medicine

Natural transition

Can herbal hormone therapy help the transgender community?

I remember when someone first told me about Black Cohosh. It’ll help with your cramps, they said, and it regulates hormones. (That someone may have been the internet.)

I was a young transsexual not on any pharmaceutical hormones, and my immediate response was, “Great! Something I can do on my own without going to a scary doctor and having my gender scrutinized!”

With no further discussion, I drank this disgusting tea every day for a month or two, hoping it would quickly put an end to my body’s female functioning and I would grow facial hair and, I don’t know, suddenly be very strong and have a low voice or something.

That didn’t happen (not a bit), but Rae Swersey, a trans herbalist in Asheville, North Carolina, says the story is familiar. “People come to me often and ask to talk about hormones. The main question people ask me is, ‘oh, can I just take plants instead of pharmaceuticals?’” The answer is a bit more complex than a simple yes or no.

Access to prescription hormones for trans folks has gotten easier, but depending on your health insurance and what part of the country you live in, it can still be tough to find a competent doctor.

Most endocrinologists, or specialists who focus on hormones, report having limited knowledge of transgender bodies. In a recent survey, a majority identified themselves as not competent to treat trans patients and 30 percent said they wouldn’t treat a trans patient at all.

Rae Swersey in the office of Take Care Herbals in Asheville, North Carolina.

Rae Swersey in the office of Take Care Herbals in Asheville, North Carolina.

There’s also a dearth of research on transgender people and hormones. Even though trans people have been accessing pharmaceutical hormones for at least 50 years (albeit not always easily), the effects of hormones on our bodies — especially long term — are not well understood. Bone health, cardiovascular outcome, and cancer risk for trans people taking hormones all need more study, said Dr. Eric Klett, an Assistant Professor of Medicine and Nutrition at University of North Carolina, who works with trans patients as an endocrinologist. “The biggest gap is the long-term effects,” he said. “Most of the data is extrapolated from the cisgender population.”

Most endocrinologists, or specialists who focus on hormones, report having limited knowledge of transgender bodies.

Taking pharmaceutical hormones, prescribed by a doctor for those with a “gender identity disorder” diagnosis, can lead to significant, sometimes permanent body changes. Even for people who really want those changes, it’s an unsettling proposition in an environment where data and expertise are scarce, so it isn’t surprising that some trans people would seek out alternatives. In the forums for My Evanesce, a website for feminizing herbal extracts, anonymous users identified themselves as being from a wide range of ages and at varying states of transition and shared their stories of trying to navigate their medical care.

“I recently had a meet and greet with my new md a woman dr and we were discussing my med history,” one user wrote. “When I posed a question as to hormone levels she pretty much shooed the the question as if the levels were not important.” “Sadly that is an attitude I have come to know from my personal physicians too,” another answered.

It’s impossible to know how many trans people are turning to herbs, but it’s easy to see how some would take to the internet and search things like “herbal testosterone” and “herbal estrogen” which turn up questionable results such as “Proven Herbs for Boosting Testosterone Levels” and “Herbs that Raise Estrogen Levels.” The prices for a so-called “herbal transition” aren’t necessarily lower; costs for both herbal remedies and medical treatment vary widely, and both can easily exceed $100 a month. But the temptation for trans people to indulge this little cottage industry is real. And as a woodsy transsexual myself, I’m tempted to believe.

Rae Swersey is one of a growing number of herbalists specializing in herbal support for transgender people.

Swersey, wearing black jeans and a leather jacket, met me in a shabby office building by the highway that serves as the headquarters of Take Care Herbals. Swersey, who goes by they and them pronouns, is self-deprecating and warm — like me, a 30-something genderqueer former punk who’s gone kinda crunchy but still hates hippies. “I really wanted a skill when the apocalypse happened, and I knew that I didn’t have any,” they said, so they came to the Appalachians to study herbs at the Chestnut School for Herbal Medicine. “I just kind of fell in love with the woods and couldn’t think of my life without being in these mountains.”

Swersey had promised to take me on a plant walk in the forest, which was glowing with autumn mountain brightness. They were in their element, quickly hopping down to a squat to show me turkey tail mushrooms growing off a rotting log. The little fungi were soft to the touch. As they showed me plants that might be used to make herbal tinctures — turkey tail for immunity tonics, usnea for healing infections — I asked the big question: Herbal transition. “That’s not real, right?”

You can hear sound from the woods and Rae Swersey's songs about herbs on our daily podcast, The Outline World Dispatch. Subscribe on Apple Podcasts or wherever you listen.

Swersey — along with every herbalist I talked to for this story — cautioned against any belief that popping an herbal androgen or “feminizing” herb for a few weeks or months will help trans people suddenly see all the results they might want from pharmaceuticals. “Plants don’t act like pharmaceutical hormones because they’re not pharmaceuticals,” they said. “Can certain characteristics change over time? Yes. Are certain results guaranteed? No.”

Swersey’s approach with trans clients is to try to find out exactly what people mean when they say “herbal transition.” For example, are they looking to change their voice or muscle mass, or reduce the stress associated with not passing as the gender they identify with? Some requests are more treatable with herbs than others, they said, and every treatment depends on the person. Some people might be looking for support around secondary sex characteristics, while others might need help with emotional regulation. “Gender dysphoria and how it shows up in every person is actually really vast and different,” they said.

But in all cases, Swersey discusses the likely outcome based on personal anecdotes, not on scientific study. They frequently formulate individualized tinctures they say address both physical and emotional aspects of what their clients are looking for. If you want to grow a beard or breasts, though, they generally tell you to go see a medical doctor.

Hormones, which are often described as “chemical messengers,” are produced by glands in various parts of our bodies and deliver messages to our cells via the bloodstream. Testosterone and estrogen, which regulate most secondary sex characteristics, are produced in the gonads (the testes or ovaries). As we go through puberty and grow older, sex hormones help regulate growth, bone and muscle mass, hair growth and loss, sex drive, our voices, our moods, and how tough and porous our skin is, among other things.

Bodies produce varying amounts of sex hormones based on sex at birth (male, female, or intersex) as well as our lifestyles, diets, medications, and stress levels. And, how hormones affect us is also influenced by how our cells receive them: Hormones send targeted messages, and these signals are picked up only by cells with the right receptors. All in all, the endocrine system is dynamic, with no two bodies producing and receiving exactly the same amount of hormones in exactly the same way, and there’s a lot that scientists still don’t understand.

Studies published in peer-reviewed journals have shown associations between plants and hormonal effects. Soy, for example, is a well-known “estrogenic” plant that has been studied for its (potentially harmful effects on cisgender women’s bodies. Some pine pollens have been shown to be androgenic, meaning they contain testosterone and other male hormones, albeit in much smaller doses than the human body. One study found pine can cause sex changes in fish exposed to lots of pollen from milling operations in rivers. This research is far from what would be needed to confirm that these supplements have a measurable effect on human hormone levels, however.

Herbs can stimulate hormone receptors, or they can stimulate hormone production, said Vilde Chaya, a computer programmer-turned-herbalist with StoneFruit Community Herbalists in Pittsburgh. Soy and vitex or chasteberry is thought to affect estrogen receptors; ashwaganda is among many plants that have been used to stimulate testosterone in male-assigned bodies. She says there are also herbs that seem to affect hormones somehow, but the mechanism is unclear: licorice, peony, and spearmint all fall into that category. In all of these cases, however, no scientific studies have been conducted to demonstrate that the herbs produce clear, consistent hormonal effects in human bodies. And evidence of herb-hormone interactions for trans people is entirely anecdotal.

When transgender people are prescribed pharmaceutical hormones, they are taking bioidentical hormones that work just like the hormones our bodies produce. Transmasculine people typically take synthetic testosterone, and transfeminine people typically take some bioidentical form of estrogen, plus an androgen blocker to slow the production or reception of testosterone. The dosages are standardized, and can act on people’s bodies fairly quickly. Herbs simply aren’t going have the intense effects these bioidentical pharmaceuticals can at full doses. “A lot of herbs can be really great and they can definitely have some hormonal effects. But I don’t know anyone who’s taken herbs who feels like that was equivalent to taking hormones,” Chaya said. “Herbs are different.”

Black cohosh is used to treat symptoms of menopause. Some trans herbalists believe it can stimulate the production of estrogen.

Black cohosh is used to treat symptoms of menopause. Some trans herbalists believe it can stimulate the production of estrogen.

Dong Quai is used to treat menstrual cramps. Some believe it stimulates estrogen.

Dong Quai is used to treat menstrual cramps. Some believe it stimulates estrogen.

Black cohosh is used to treat symptoms of menopause. Some trans herbalists believe it can stimulate the production of estrogen.

Dong Quai is used to treat menstrual cramps. Some believe it stimulates estrogen.

Most herbal supplements designed to change hormone levels aren’t marketed to — or tested on — transgender people. They’re marketed to cisgender people for issues like menopause, sex drive, and erectile dysfunction — again, without much backing by peer-reviewed studies. You can get red ginseng for $22.99 a bottle, ashwaganda for $18.99, or herbal mixes promoting “menopausal hormone balance” for $30 a month, sold at places like GNC and Whole Foods.

The science behind these treatments is murky. The FDA doesn’t approve herbal supplements or tinctures, nor can they be patented. The lack of patents means large companies with resources don’t have an incentive to fund research into plant-based remedies. Herbal remedies are rarely researched in controlled studies of the type pharmaceutical drugs are subject to, and as a result, there is no real consensus about what works. The research is even sparser when it comes to trans people and herbs.

Dr. Eric Klett, who works with trans patients as an endocrinologist in North Carolina, says his patients sometimes ask about natural transition options.

“I have one patient that swears that [black cohosh] improves their overall well-being, and I say, well that’s fine, but I don’t think that it’s really doing anything from a hormonal perspective,” he says. He discourages using herbs this way. “I don’t know what’s in them, and I don’t know how they’re metabolized.”

As I walked in the Appalachian woods with Rae Swersey looking at pines and chewing on leaves, I experienced a familiar feeling — the sweetness that comes from a private conversation with another trans person, someone who knows what it’s like to move through a world that might not see yourself and your body as you do.

Hawthorn is another tree Swersey loves to touch and talk about. We stand underneath one on our way out of the woods, Swersey taking pictures of me while I take pictures of the hawthorn. “Thorns are just modified leaves for protection,” they explain, pointing at its knobs and tough thorns. Their business card is a hawthorn coming up out of a combat boot.

Like most trans people, I have never had this kind of safe-feeling interaction in medical care, or even in more mundane situations — at work, at the gym, in interviews. For a lot of us, cisgender people are potentially unsafe. At best, they don’t see our bodies the way we see our own; at worst, they are liable to mock, berate, or assault us. These fears are all the more real in medical situations, particularly for transfeminine people and people of color, who are the most likely to experience outright violence.

Most herbal hormone supplements are marketed to cisgender people for issues like menopause, sex drive, and erectile dysfunction.

Behind Swersey’s work, and that of the other herbalists I talk to, there’s a goal that goes beyond giving people some herbs that might help them. Swersey is creating a space where their trans clients, whatever they’re seeking, can have an affirming experience talking to someone about their body, which is rare — and potentially healing in its own right.

Perhaps more fundamentally, Swersey and other trans herbalists are also pushing the idea of holistic-ness itself — looking at all bodies as more than just their separate, individual functions and parts. Trans herbalists, the few that there are, attempt to fill a gap in how trans bodies are treated writ large, even without the science to “prove” their work is valid.

Swersey’s boots are crunching in the leaves as we head back to the car, breathing in the fall air. “We are far from being seen as whole people, and far from getting our needs met.”

Lewis Wallace is the state politics editor for Scalawag and a freelance journalist. He last wrote for The Outline about how the U.S. is tracking a record number of immigrants with ankle monitors.