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For more than three years, Devon Jones gave himself weekly shots of testosterone to align his body with the feeling that he was male. The shots worked. Jones' voice dropped, body fat shifted from his thighs and breasts into his neck and stomach, and he sprouted facial hair.
But then last year, Jones, a 27-year-old author who lives in Dorchester, stopped taking the hormone.
"I realized that wasn't the look I was ultimately going for," Jones said. "I wanted to still have breasts that had substance to them, they’d really shrunk and I wanted that back."
And Jones wants the option of getting pregnant and having a child, something he could not do while testosterone overpowered estrogen in his body. It's not clear if he will be able to get pregnant now.
"I'll only know that when I try," he said.
Jones still use male pronouns. The changes to his voice are permanent. But as estrogen again becomes the dominant hormone in Jones' body, the hair on his face doesn't grow as quickly and his body fat has shifted back.
"I have a more curvy feminine shape. I’m more comfortable now with people being confused. So it’s an evolving process. It’s weird to be in the middle of it right now actually, and talking about it," Jones said, his voice trailing off.
Jones is part of a growing group of young adults who are genderfluid and are using hormone therapy and surgery to create bodies that matches this identity.
"It’s molding my body to fit my mind, physically changing myself so that I feel more comfortable as a person."Dale Jackson
"It’s molding my body to fit my mind, physically changing myself so that I feel more comfortable as a person," said Dale Jackson, a 33-year-old author who lives in Atlanta. Jackson takes a low dose of testosterone for two reasons. First, because he's worried that a full dose would exacerbate his anxiety. And second, because a half dose helps him moderate the effects.
"I like the idea of being in the middle," Jackson said. "This allows me to explore my masculine side, but I don’t want to push it too far." Jackson does not want a big bushy beard or arms so hairy "that gorillas were looking at me like, is that our cousin?"
Both Jones and Jackson are under the care of physicians who are helping them pursue a more gender neutral body. But there are no guidelines. So far, in the emerging world of transgender medicine, protocols assume that patients want to end up on one end of the spectrum or the other, male or female, says Dr. Tim Cavanaugh, who runs the transgender health program at Fenway Health.
"[The guidelines] really don’t address this idea of gender spectrum or gender fluidity, but we we see it a lot," Cavanaugh said.
An estimated 100 to 150 of Fenways Health's 1,500 transgender patients are genderfluid. Most of the genderfluid patients are transitioning from female towards male. So how do doctors know how much testosterone will produce the effects these patients are looking for?
"To a certain extent we’re making it up, but I’d like to think of it more as finessing the regimens that we have based on the individual person’s desires and needs," Cavanaugh said. "[It's difficult], especially with testosterone. Testosterone is very potent and even when we try to prescribe low doses, every person responds in a different way."
Some doctors are uncomfortable with the idea of using medicine to experiment with changing social norms.
"To a certain extent we’re making it up, but I’d like to think of it more as finessing the regimens that we have based on the individual person’s desires and needs."Dr. Tim Cavanaugh
"But from the point of view of the Medical Society, this represents a population that is underserved," said Dr. Marian Craighill, who chairs the committee on lesbian, gay, bisexual and transgender matters at the Massachusetts Medical Society. "We are definitely looking for more and more places where patients can go to get good and appropriate medical care."
Doctors have lots of questions about transgender health, says Dr. Lachlan Forrow, director of ethics at Beth Israel Deaconess Medical Center. "But the fundamental driving factor has to be asking those questions as a way of compassionately and professionally helping this person in front of me."
Some providers are guided by Catholic or other religious teachings that frown on any biological manipulation that changes the body. Father James Bretzke, who teaches moral theology at Boston College, says there’s a vigorous debate underway about gender theory that is testing that teaching.
"There is a line that would say there are only two genders and they are tied physically to the female and male genitalia," Bretzke said. "Whereas many other theologians would argue that, at least to some extent, gender is a product of social construction."
If gender is a product of social construction, then using medicine to fix every patient's discomfort may not be the best long term solution, Cavanaugh says.
"I hope we are headed to a place where we recognize that gender is not one thing or the other, not male or female, and that culturally we can become more comfortable with that idea," Cavanaugh said. "Hormones and surgery are always going to be options for people, but I really hope that we won’t feel compelled to use them as much as we do now."
But for now, some genderfluid patients say they can not find peace without medical intervention.
"I had an incredible amount of dysphoria around my chest, it was consuming. I got to the point where in order for me to thrive and to do the work I wanted to be able to do and just live my life, I needed to have surgery," said Taan Shapiro, a 33-year-old a teacher and parent in Boston who had surgery to create a flatter, more masculine looking chest.
Shapiro, who uses the pronouns they and them, says some strangers assume they are a teenage boy, others that Shapiro is female. Shapiro is not planning any more surgery or hormone therapy.
"Where I am is where I’m at and I feel good about myself," Shapiro said, "[in a place] somewhere between male and female."
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