ESOTERICA: On Medical Transition

June 14, 2018



In Justice Calling (now available as an eBook on Amazon!), Sheriff Penny Lux undergoes medical transition through the application of a patch to her chest; when the patch is damaged, her body slowly starts to revert to its former state. I wrote this into the story without considering the science behind it too thoroughly, but since this is Pride Month, I figured it would be worth diving in a little deeper. In this edition of Esoterica, we'll be talking about the science behind medical transition as it currently exists, as it could exist in the near future, and as it seems to exist on Klea thanks to the Followers of the Flame. We'll also take a brief look at the medical transition tech of the Federation at large.


Before we dive in, then, a few content notes: this article focuses solely on medical aspects of transition, which are only a part of the overall experience, and one that not all trans folk engage in, so this should not be taken as representative of all trans folk's experiences. Be advised that we'll be digging in with a lot of detail, talking about genitals, reproduction, infertility, and DNA. Also, while I will do my best to be inclusive of enbies and trans men, I am a trans woman myself, and so the perspective may seem a little skewed. 


That said, let's begin!


A primary tool of contemporary medical transition is hormones. Many transgender folk also elect to pursue surgical and dermal options (such as breast reduction, hair removal, and GRS), while many others choose not to seek, cannot afford, or are barred access to medical options entirely. For those who are willing and able to access medical options, though, the most dramatic and fundamental changes to a trans person's day-to-day appearance often come from hormone treatments.

Hormone treatments, commonly referred to as HRT or "Hormone Replacement Therapy," are incredibly complex. Bloodwork and labs are needed to ensure that the levels of both the hormones themselves and other important biological indicators are maintained at proper levels. This is at least partially because hormones affect the person taking them on a cellular level, causing those cells to activate certain genes and "switch off" certain others through the science of
gene regulation. Sexual hormones, in particular, including androgens (such as testosterone) and estrogens (such as estradiol), are lipid-based hormones, which allows them to pass through the phospholipid bilayer of the cell membrane in order to activate steady, long-burning changes via nuclear receptors.


As a result, hormone treatment is able to change many key features of a human body related to gene transcription in differentiated cells. Much like the natural emergence of higher concentrations of sexual hormones during puberty, HRT "switches on" genes in cells that relate to secondary sexual characteristics. For example, testosterone causes the activation of genes which help convert fat into muscle, along with thickening the vocal cords to lower the pitch of the voice; estradiol, on the other hand, induces the development of breast tissue and helps redistribute fat in the body. Additionally, HRT can also feature hormone "blockers" in order to counter the hormones being produced by the body. By countering those hormones, some of the genes which are not desired can be "switched off;" for instance, in trans women, the use of spironolactone can partially undo the "body hair growth" gene effects of testosterone. (It's worth noting here that virtually all bodies produce both estrogens and androgens naturally, but in very different amounts; all bodies will start growing more body hair during puberty, but the rate relates directly to the levels of testosterone in the blood.)


For all that our current HRT may seem like magic, though, it's far from perfect. It cannot reverse all of the changes that a typical puberty will cause, nor can it perfectly mimic all of the effects of a typical puberty, particularly when started later. As an example, a trans woman whose voice has dropped (such as Penny Lux in Justice Calling) cannot have her voice raised by taking hormones. Other limitations exist based on what pieces of anatomy are available. While the levels of various hormones in utero can and do influence the differentiation of fetal cells between sexual configurations - like whether gonads will develop into testes or ovaries - once those cells have differentiated, hormones alone cannot reverse or alter this process. HRT can't turn one reproductive set into another; instead, it can drastically reduce fertility. With current medical technology, surgery is required to mimic the effects of an alternate sexual differentiation, and generally renders the person receiving the surgery incapable of conception. (AMAB trans folk generally have their testicles removed during genital surgery, while AFAB trans folk can have their uterusi removed; since HRT can't generate new anatomy, that leaves no options for conception.)

The inability to become pregnant is one of the current limitations of HRT/medical transition in general that many AMAB trans folk (myself included) truly lament - I can only assume that similar can be said of AFAB trans folk around the ability to impregnate. The very forefront of scientific research as of writing this article seems to suggest that for trans women and AMAB enbies, however, it may soon be possible to become pregnant.
A 2017 article suggested that trans women could be the recipients of womb transplants, several of which had been successfully performed on cis women at the time. But, significant complications would arise for trans women, including a narrower birth canal virtually requiring a c-section. A trans woman's body would also lack a native endometrium, corpus luteum, or ovaries, meaning that all of the hormonal changes that typically occur due to the interaction of these components would need to be stimulated with further applied hormonal treatments. Moreover, the pregnancy would require an already fertilized embryo; in most cases, that would mean none of the pregnant parent's DNA would be involved (because, again, most trans women are rendered sterile during genital surgery, which would most likely precede a womb implantation). 

For Justice Calling, I imagined a bit of a wish-fulfillment scenario, where in place of all of these limitations and complications was a single, simple piece of technology that could seamlessly combine and improve on all of these notions. The Followers of the Flame who visit Klea have access to extremely advanced technology: not only has human science progressed by approximately 450 years at the time of this story, but it has benefited tremendously from the patronage of Federation science. Accordingly, even though the FoF use less tech than their counterparts in the Federation proper, their transition technology is  almost magical in comparison to our current standards. The FoF "transition patch" (a literal patch strapped to the chest) fully reverses all aspects of sexual development.


Well, how?


I imagine the patch as an extremely sophisticated chemical computer. It draws energy from the heat of its user's skin and the kinetic energy of blood flow in the chest, using microneedles to tap into the bloodstream. From there, it samples the predominant hormones in the blood and sends out chemical assays that can determine the current extent and typology of sexual development. Then, using nanomachinery, it formulates a cocktail of biochemicals from the user's own bloodstream. These biochemicals will induce or reverse every necessary function by following specific markers in the body and aggressively altering DNA gene "switches" or even copying or reordering genes to better accommodate the necessary functions (as DNA sometimes does). After all, the DNA in an ovary is virtually the same as the DNA in a testis, barring the presence of an extra X chromosome instead of a Y (usually), so there is no theoretical reason that one couldn't be induced to function as the other. Therefore, with the FoF patch, rather than a foreign source of hormones fighting with what the body is producing on its own, the body is reprogrammed to make the desired hormones (or gametes, or tissues, etc.) on its own. 


The development of genitalia, the thickening of vocal cords in AMABs, and the widening of the birth canal are also processes this patch can reverse, though it takes much longer. Tagged signals race to unneeded tissue and initiate apoptosis - programmed cell death - gradually removing excess material, while other signals encourage growth elsewhere as needed. This process likely relies heavily on viral vectors and other gene therapies that, as stated above, reprogram the body at the level of its DNA to behave differently than before. Over time, this reprogramming allows the body to completely reverse its shape. Depending on the type of patch, this process could also be altered to remove all sexual characteristics or to encourage the development of a mixture. 


When Penny's patch is damaged, however, it ceases to function properly as a regulatory agent. The gene-altering chemicals it produces stop being produced, and gradually, the body filters through its existing supply and recycles them into the basic components from which they were originally formed. The genes slowly start to revert, and in some cases even experience a sort of "genetic slingshot" effect, temporarily increasing hormone levels beyond their former baseline. In Penny's example, this is most notable with her voice, which begins to deepen all over again after her patch breaks. Poor Penny :(

If this feels a little sad, don't fret too much - the Followers are not the only source of transition tech, and in fact, they may be the worst in the Federation due to their tendency to avoid "unnecessary" technological interventions. While the specific technologies for medical transition most likely vary quite a bit throughout the Federation, human-specific ones are generally centered in HomeSol (i.e. our current solar system), where the Crisilans took charge of spearheading transition technology during the few decades prior to first contact with the Federation. Crisilans, having no natural sense of gender as distinct from sex (a subject of some discussion in Culture Shock, the pre-series-to-be to The Aeon Immortal), immediately latched on to transition as a fascinating opportunity for cultural exchange and threw the full force of their medical research into it. At the time of The Abadon Relic, the tech is immaculate and ubiquitous, completely and permanently restructuring a human body from the DNA-out in a matter of a few intensive days. It is also easily reversible, giving rise to a much more fluid notion of what "bodies" are.


Hm, I should probably slate that in for further exploration in Culture Shock, as well!


For now, though, I'll just say it again: happy pride 2018, everyone. :D

And, one final shout out for this really cool video, where I got the cover photo for this post:


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