I’m not a doctor or a scientist. What I am is a trans man whose own transition experiences have made me curious about how it all works. Recently, nothing has captured my fascination more than my switch from topical gel testosterone to subcutaneous injectable testosterone. Specifically, I’m taken with the fact that the T is… suddenly actually working? This is great news for me, but why?
Which form of T is most effective? I can’t definitively give an answer to that. To be able to make such a sweeping statement with confidence, I’d need some serious scientific data to back it up, and unsurprisingly, that research barely exists yet for trans men.
Like so many other times in my transition, I’ve found myself in a position where relevant studies aren’t there yet and Google can’t help me unless I add “Reddit” to the end of my search. The best I can do is interview people who have switched forms of testosterone, and talk to a medical professional who would know— namely, Helena Turner (she/her), a nurse practitioner who’s worked in primary care for nine years. Though Turner herself is not trans, she is one of the (seemingly rare) medical professionals who knows what’s up. “Most of my clinical practice has been as a primary care provider working with and for LGBTQIA+ folks who believe in compassionate, non-judgmental, full-scope primary care — which includes providing gender affirming medicine,” says Turner.
Is One Form of Testosterone More Effective Than Another?
“In broad and general terms, no,” Turner says. “No matter how the medication is delivered, it is acting systemically. Individual differences in absorption can change the ‘effective dose,’ aka amount of medication reaching target receptors, but assuming that dose is the same, testosterone is testosterone is testosterone in terms of how quickly an effect will occur. Generally speaking, injectable medications have higher bioavailability” — meaning the T in your system is more easily used by your body — “than medications delivered in other manners because injecting a med bypasses the skin, through which topical meds need to be absorbed to have an effect.”
Absorption is an important factor, but it comes down to finding the right dose for you. “Every person’s response will be individual, [and] if the dose is sufficient — and if we assume that the effective dose is the same, a big assumption — then changes will occur at the same rate,” Turner adds.
If there is such a thing as an Official Answer™ about testosterone effectiveness, it would come from The World Professional Association for Transgender Health. According to WPATH, “there is evidence that transdermal and intramuscular testosterone achieve similar masculinizing results, although the timeframe may be somewhat slower with transdermal preparations.” This particular quote cites a 2005 study I was unable to find myself, despite my (and JSTOR’s) best efforts, so some science is out there, but it’s almost 20 years old, and not the most readily accessible to your average trans Googler. My personal experience certainly aligns with this study: Masculinizing results went slower on gel.
Speed of Changes: Anecdotal Evidence
I spoke with seven trans people who have been on multiple forms of testosterone. I naively expected people’s testosterone timelines to be as straightforward as mine was — start on one form, have qualms with it, switch to another — but six out of seven interviewees had switched back and forth between gel and shots. Some were even on forms of T I was unfamiliar with, such as auto-injectors like Xyosted or slow-release testosterone. I thought slow-release meant pellets, but it is actually testosterone undecanoate, an option I’d never heard of before. The interviewee using it, Warren (he/him), describes it as “an intramuscular injection, as a sort of serum that releases the T over a long period of time, so you’re not doing shots super frequently. It’s more like three month intervals instead of three week intervals.”
Regardless of people’s testosterone timelines, there was a clear trend as to which form was fastest: five out of seven interviewees brought up changes feeling faster on injectable testosterone.
One interviewee, Prior (they/he), says that when they switched, they “[couldn’t] really categorize any of the changes as positive or negative, but here’s what I noticed was different: T dick started growing faster; voice deepening sped up; attraction to women WAY increased; more body hair, seemed to get thicker too; way more acne on [my] face, especially [around the] chin and jawline.”
I’ve noticed all of these changes in myself since switching, too, except for changes in my attraction to women, which went from high to high.
“The effects were much more pronounced with the shots,” another interviewee, Chris (he/they), says. “My mental health was better, I was hairier, I smelled grosser (positive), I got balder, and my period stopped.” Mav (he/him) shares that he “felt immense relief and gratification when I started injections and almost immediately started experiencing faster changes.”
“Faster” is not synonymous with “better.” In some cases, a more gradual change can be a good thing — as Ren (they/he) puts it, their slower experience on gel “wasn’t positive or negative for me. Being a singer, the slow changes gave me more time to adjust to my voice and keep it flexible as the vocal cords thicken.”
There is no “better” form of testosterone. If we define “more effective” as “faster,” this very small sample of anecdotal evidence points to shots yielding faster changes. But as Turner says, testosterone is testosterone, so if by “effective” we simply mean “causes effects at all,” both forms get the job done.
Why Choose Testosterone Gel, Then?
Testosterone gel is not without its own unique benefits: mainly, not having to poke yourself with a needle, and less hormone level fluctuation.
Testosterone gel works by getting rubbed directly into your skin, typically daily. I can’t speak for anyone else’s gel experience, but I’d say the texture of mine was like slightly thicker/stickier hand sanitizer. Multiple interviewees mentioned finding the daily application annoying to keep up with, as well as disliking the texture of the gel — but obviously, unlike injections, it’s totally painless, and that’s a huge plus. Ren, who is now on subcutaneous injections, has a “condition called complex regional pain syndrome that affects my legs and makes the [intramuscular] injection into my thigh more painful.” Everyone has their own medical history that changes their relationship to injections; even if you have no problem with shots, a needle is a needle.
Also, because you’re applying gel daily, your hormone levels may be more stable than if you were injecting weekly. According to WPATH, “because intramuscular testosterone [is] often administered every 2–4 weeks, some patients may notice cyclic variation in effects (e.g., fatigue and irritability at the end of the injection cycle, aggression or expansive mood at the beginning of the injection cycle)… This may be mitigated by using a lower but more frequent dosage schedule or by using a daily transdermal preparation,” aka gel.
Some interviewees mention wanting to switch to avoid migraines specifically. Chris says they were “initially afraid to do the switch to shots because of the potential to cause migraines from hormone fluctuations.” Ren switched from injections to gel at one point because their doctor thought it would ease the migraines they developed.
I asked Helena Turner about this. “A number of symptoms could be attributed to peaks and troughs — this is definitely possible, though it’s not something that I’ve had patients on T relate to injection schedules that I can recall,” she says. “In general, migraines can absolutely be associated with hormonal fluctuations; I have usually seen reference to these in the setting of menstrual cycles — ‘catamenial migraines’ are migraines caused by a pre-menstrual drop in estrogen. It makes sense to me that a dosing schedule which allows for more stable levels could reduce frequency of migraines.”
Testosterone and Absorption
Why did gel go slower for me? My number one suspect is absorption. The real answer is likely a combination of reasons, but one of them may be that gel has more variables affecting absorption than shots do. Turner says that getting more visible results from testosterone “is mostly going to have to do with how reliably the med is delivered to target receptors. If someone has more visible effects from one form of T versus another, it’s probably because they are getting a more appropriate effective dose.”
I think the difference in variables plays out for me like this: On shots, I inject my testosterone subcutaneously (into the fat). Boom, my dose of testosterone is in me. But on topical testosterone, there’s more time for things to go awry between applying the gel and the T reaching its target receptors.
According to Folx Health, after you apply your T gel, you should “let it fully dry before putting on clothing and going about the day. This is important because while it is still wet, it could run off onto the clothing which decreases the amount that is absorbed, and therefore decreases the dose absorbed by the body. Even when it is dry, the gel continues to be absorbed through the skin for up to 5-6 hours, meaning application time should be taken into consideration when planning to shower, apply lotion/moisturizer, swim, exercise, or just generally get sweaty.”
I was careful about shower timing while I was on gel, but was I too sweaty for it to work at its best? Was I changing shirts in a way that was affecting it? I don’t know, but there was likely some element of user error at play, even if it was small.
Turner echoes Folx Health’s tips on gel. “There are a lot of particularities about gel application that can affect absorption — let it dry before putting a shirt on, don’t shower soon after putting it on, etc. Applying moisturizer or sunscreen over the T gel application site one hour later can increase absorption.”
Yes, that is a real tip backed up by science. According to AndroGel’s prescribing information, “Application of moisturizing lotion increased mean testosterone Cavg [average serum concentration over 24 hours] and Cmax [peak serum concentration] by 14% and 17%, respectively, compared to AndroGel 1.62% administered alone. Application of sunscreen increased mean testosterone Cavg and Cmax by 8% and 13%, respectively, compared to AndroGel 1.62% applied alone.” So if you’re already putting one form of goop on your arm, it turns out other goops can help.
Injectable Testosterone Allergies
Another reason someone might opt for gel over shots is that you can be allergic to injectable testosterone — specifically, testosterone cypionate, which is formulated in cottonseed oil. The allergy is to the cottonseed oil, not the testosterone, so even if you have this allergy, there are still forms of T you can take. Testosterone enanthate is another injectable form that’s formulated in sesame oil instead. If you’re allergic to sesame, you’ll be allergic to that one, too, but a serious allergic reaction to testosterone enanthate is rare.
I asked Turner what happens if someone who’s unknowingly allergic injects. She says that “reactions are generally local — itchiness, swelling — like a bad bug bite, and with continued exposure can worsen, like more intense or longer lasting irritation and symptoms with subsequent injections. Reactions may not appear with the first few injections, and importantly, as far as I know or have seen, it is not a first exposure/injection to immediate anaphylaxis kind of a thing.”
Anaphylaxis is possible, though rare, and if you really want to put your mind at ease, you can get checked for cottonseed and sesame allergies first. And don’t freak out if your injection site itches just a teeny tiny bit immediately afterward — that’s most likely normal.
Turner agrees about allergy testing and says that in an ideal world, this would “be double checked by [your] provider before [your] first injection regardless of allergy history.” “Ideal world” is doing a lot of lifting here. Turner is a medical professional who’s well-versed in queer and trans medicine, but not all medical professionals are. Which leads me to unmask the real Scooby Doo villain of transitioning…
Which Form of Testosterone Is Easier To Get With Insurance?
It’s not just testosterone’s effects that have been different since I switched from gel to shots. The difficulty of actually acquiring the prescription has changed, too, in my case for the better. Ryan (he/him)’s experience was most similar to mine: “So far, injectable testosterone has by far been the easiest method to obtain from pharmacies and with my insurance. The gel was much more expensive to fill and so were the patches.”
When I was looking to start gel, I was delayed an extra three months by trying to find a pharmacy that had it in stock. I cried in five Walgreens/CVSes in two different states when they’d tell me my prescription was ready, then out of stock, then they had no idea of when it would even possibly be in stock. Of the 14 months I was on gel, insurance only automatically covered it about half the time, and for the other half, I was either fighting with insurance agents or pharmacists to get that fixed, or couldn’t get it fixed and had to pay out of pocket. I easily spent hundreds of dollars on gel. Meanwhile, on shots, all I’ve had to pay for out of pocket was around $50 for my initial injection supplies, which will last me over a year.
Overall, interviewees were split on whether gel or shots were easier to obtain and get covered by insurance. Some people had no problems with either form, and some people had problems with both.
“Luckily, I haven’t had any issues with pharmacies or insurance,” Ren says. “Gel tends to take longer to get in stock at the pharmacy and luckily between my student health insurance plan and my parent’s health insurance plan, all my testosterone has been fully covered under insurance.”
Tyler (they/them), who is on auto-injectors, says that “auto injectors [were the easiest to get covered] by far since insurance approval seemed like just a week or so… I get a few months of supply and I never have any issues of delay or prior authorization, both of which I had with IM and gel.”
Chris, unfortunately, has had a harder time, no matter the form of T. “The gel was harder to find. Only one pharmacy in a three hour radius would fill my prescription. The shots were also bad but because there was a needle shortage. I would go weeks without medication solely because my prescription was considered cosmetic and I wasn’t medically important enough to be on the waitlist for needles.”
Mav’s situation was somewhere in the middle. “Financially, injections have been much easier. I was paying out-of-pocket for my gel, now I’m paying a much smaller co-pay for testosterone, syringes, and needles. Injections have been harder to get consistently for a couple of reasons; My testosterone refill request takes longer to process than gel ever did. Since testosterone is a controlled substance, I have a narrow window between requesting my refill too early and getting denied, and requesting too late and running out of my medication. So far, I’ve gone 2-3 weeks without testosterone between each refill, because I haven’t found the right timing yet and my doctor is notoriously difficult to get in contact with.”
Mav makes an important point: Even with an easier time with insurance, there’s still a big hurdle to clear to get T, which is dealing with the medical system as a whole.
Wait, You Mean The (Lack Of) Trans Healthcare Was the Villain All Along?
Yep. I’m lucky that my reason for switching was purely based on what I wanted to get from my transition. Multiple interviewees have stories about the medical system preventing them from accessing testosterone in ways that were out of their control.
In Chris’s case, he was on gel and “wanted to go back to the shots but covid hit and I could not get an appointment. The doctors stopped refilling my prescription because I couldn’t come in for blood tests… I couldn’t get the blood tests because I couldn’t get an appointment. So I was dropped. I moved out of state to an area with no trans healthcare because it was what we could afford at the time. Haven’t had the opportunity to start back up.”
I know the US healthcare system is bad, because I live in it. In what I’m considering an equality win, I’ve had almost as much trouble with my medication for Crohn’s disease as I have with testosterone, but getting T prescriptions filled still takes that cake. A 2021 study confirms the obvious: “transgender people experience significant difficulties with insurance, cost of care, and overall health.”
It’s not just the US healthcare system, either. Warren mentions an “unfortunate clerical error which resulted in me coming off T unexpectedly for eight months.” In what world should our access to life-saving care be at the whims of clerical errors?
Warren is now on slow-release T, but switching to that was an uphill battle. “It took a bit of persuading my gender doctor that I felt that would be the right choice, and then a waiting game of admin time, waiting for the letter to by typed and then waiting on the wonderful postal system for my letter to reach my GP and for them to agree to what’s known in the UK as a shared-care agreement… Overall, I waited about three-ish months.”
Three months is already agonizing, but waiting for gender-affirming care in the UK is unfortunately nothing new. Last year, the BBC reported that “transgender people in England have faced waits of up to seven years for an initial NHS assessment.” That’s longer than most of my trans friends have been on HRT at all.
We Have To Be Our Own Advocates
I asked interviewees what advice they’d give to anyone considering switching, and the overwhelmingly most popular advice was to be your own medical advocate.
Warren summarizes it well: “Backing yourself up with research and knowledge is always a good plan. Advocating for yourself can be scary, but you have every right to do so, and if you feel you would benefit from a different testosterone then you should go into it with some fight in you.”
Chris agrees. “Doctors aren’t always the most informed in HRT options and reactions, [so] do your own research, too. Sometimes there will be obstacles that might make you have to stop cold turkey that cannot be planned for. Don’t worry, everything doesn’t come undone when you stop.”
Tyler adds: “If you live somewhere progressive like I do, always go that extra step for a gender affirming center or doctor team. I would’ve had so much less [trouble] if I had these nice people just talking to me like a person.”
I’m lucky enough to have a medical professional handling my HRT that not only understands trans medicine, but is trans themselves. It took a lot of self-advocacy to get me here, especially when my first HRT prescriber was a doctor whose online practice straight up disappeared with no warning, and when I told my current GP the gel dose she had me on, his response was a slack-jawed “you’re on HOW MUCH?!”
There Is No One Way To Take Testosterone
Like I started with, I am not a doctor. I am not a scientist. I am just one guy begging both of those groups of people to look more into trans experiences so there will be better information out there than this, which is one man’s experience and his attempt to describe the experiences of others. This isn’t about convincing people to switch forms of T. Transition is highly individual, and if what you’re doing works for you, that’s perfect. The point is that if you’re already considering switching, there’s not a lot of information on making the switch, and trans people deserve to make informed health decisions just like anyone else.
I went into this wanting to find out if gel or shots are more effective. What I learned instead expands far beyond just the science of how testosterone works: There is no one way to take T. Shots and gel aren’t the only options, and even two people on the exact same dose of the exact same method will take it differently. Some will take breaks, some won’t; some will have relatively easy access to T, some will have to work harder for it; some will experience completely different physical effects than others, which doesn’t even account for how they view those effects through the filter of their own transness.
It sounds obvious, but every transition is unique. Turner says that a person’s body’s reaction to testosterone gel/injections is “as individual as the response to any hormone or combination of hormones in a body, which is to say — very! Think about how different the impacts of first puberty are from person to person.”
The emotional impacts vary, too. “I don’t consider myself a trans guy, so my whole experience with testosterone has been filled with uncertainty,” Prior says. “I think I had hoped that taking T would make me feel certain, one way or the other (as there are famously only two ways), of what I am. But it’s honestly been a lot of back and forth. Not very much euphoria or dysphoria, just a hungrier, hornier, hairier life.”
Ryan took a pause from T for a while because of medical complications and “on a personal level, I felt as though I needed to pump the brakes a bit on the HRT part of my transition.” He’s back on T now, with the understanding that “it’s pointless to compare yourself to other people because everyone’s body is different and HRT impacts everyone differently. The people I know that have had good experiences with gel have different transition goals than me, and that’s okay. It’s really about what kinds of changes you want to get from HRT.”
Everyone gets something different out of transition. Everyone wants something different out of transition. How effective T is for you is not just a matter of gel or injections: It’s your pre-existing conditions, your self-perception, your access to trans resources and healthcare. The person who gets the most ideal effects out of T isn’t the person on shots or gel. It’s the person with the best insurance and most clear sense of what “ideal effects” means to them.
What If You’re Interested In Switching Forms Of Testosterone?
Turner’s advice for anyone considering switching is to “speak with their medical team and peers to see what other options might be available.” What medical teams or peers are available to any given trans person vary wildly, but the good news is that if you’re medically cleared to take testosterone in the first place, there’s no harm in switching what kind you’re on or taking extended breaks if you feel like it. Turner says that “provided the dose and formulation someone is using is safe in the first place, [there is] no harm in changing between safe methods, nor in taking a break and re-starting if or when that feels necessary.”
It comes down to whether you’re happy with how your transition is going, what new things you’re willing to try, and what medical resources you can access.
Ren puts it best: “The best decision I made during my transition was to let myself experiment. It doesn’t have to be that deep if you don’t want it to be. You can start hormones, try it out, stop if you don’t like it. You’re allowed to play around.”
Super appreciate this article and how informative it is!!