Hormone Therapy for Non-Binary People

Hormone therapy is not a one-size-fits-all journey. For non-binary people—those whose gender identity does not fall exclusively within the categories of man or woman—the goal of hormone therapy can be very different from full masculinization or feminization. It might mean seeking a middle ground, achieving specific physical changes, or simply reducing the dysphoria tied to certain aspects of one’s body.

This is a rapidly evolving area of medicine. The WPATH Standards of Care Version 8 (2022) recognize explicitly and in detail, for the first time, that non-binary and gender-diverse people can benefit from hormone therapy using customized protocols [1]. The Endocrine Society, in its 2017 clinical guidelines, had already opened the door to non-standard dosages for those desiring partial masculinization or feminization [2]. The field is expanding, and with it, the awareness that there is no single “correct” way to live in one’s body.

This article explores the available options: from microdosing to selective protocols, from expected effects to the practical challenges of access. The information is based on existing scientific literature and does not replace the advice of an experienced endocrinologist.

Beyond Binary Transition

For a long time, medicine treated gender transition as a journey with only two destinations: male-to-female or female-to-male. Protocols were built around this binary framework, aiming to bring hormone levels and secondary sex characteristics as close as possible to the typical range of the gender opposite to the one assigned at birth [2].

This approach has helped—and continues to help—millions of binary trans people. But it does not reflect everyone’s experience. An increasing number of people identify outside the gender binary: the Trevor Project, in its 2023 survey of over 28,000 LGBTQ+ youth in the United States, found that 41% of participants identified as non-binary or genderqueer [7]. The American Psychological Association has recognized for years that gender identity exists along a spectrum and that non-binary identities are authentic and valid expressions of the human experience [6].

For these individuals, standard hormone therapy—designed for a complete transition to the opposite pole—might not align with their goals. Some AFAB (assigned female at birth) people desire a slight deepening of the voice but not a full beard. Some AMAB (assigned male at birth) people want softer skin and a reduction in body hair but no breast development. Still others seek more pronounced changes but not a total transition.

The WPATH SOC8 clearly states that “non-binary people may request hormone therapies aiming for partial masculinization or feminization” and that “protocols must be tailored to the individual’s goals” [1]. This is not an exception or a concession: it is an acknowledgment that medical care must serve the person, not an abstract model.

Microdosing: What It Is and How It Works

Hormone microdosing involves taking doses of sex hormones (testosterone or estrogen) that are lower than those used in standard transition protocols. The goal is not to reach the typical hormone levels of the opposite gender, but to induce changes that are more gradual, slower, and potentially less pronounced [3].

The term “microdosing” is predominantly used in trans and non-binary communities; in medical settings, it is more often referred to as “low-dose hormone therapy” or “customized protocols.” Regardless of the name, the principle is the same: start with reduced dosages, carefully monitor the effects, and adjust the treatment based on the body’s response and the person’s goals.

It is crucial to clarify one point: microdosing does not allow you to pre-select which changes will occur and which won’t. Hormones act on all tissues that possess the relevant receptors. Testosterone, even at a low dose, affects the larynx, skin, hair follicles, adipose tissue, and muscles. Estrogen, even at a low dose, affects breast tissue, skin, fat distribution, and sexual function. What microdosing does allow is slowing down the pace of these changes and, in some cases, achieving a less pronounced final result—giving the person more time to evaluate if the changes align with what they desire [5].

Some preliminary studies suggest that low-dose protocols can be effective in reducing gender dysphoria in non-binary people, with a high satisfaction profile [3]. However, specific research on microdosing is still limited, and large-scale, long-term studies are lacking.

Low-Dose Testosterone

Low-dose testosterone is the most common option for non-binary AFAB people who desire partial masculinization. Typical dosages are about half of standard ones: for example, 25-50 mg per week of injectable testosterone enanthate (compared to the standard 50-100 mg), or half a dose of transdermal gel [2][3].

Expected Effects

The changes induced by low-dose testosterone are the same as those from standard therapy, but they manifest more slowly and may reach a lesser extent:

• Voice: Voice deepening generally begins after 2-6 months, but progression is more gradual. Some people achieve an intermediate vocal register—neither distinctly feminine nor distinctly masculine—which may match their goal. This change is irreversible: even if therapy is stopped, the voice does not return to its previous register.

• Body and facial hair: Hair growth increases, but at a low dose, facial hair develops more slowly and may remain sparser. This is also an irreversible or only partially reversible change.

• Fat redistribution: Fat gradually shifts from the hips and thighs toward the abdomen, producing a more android body profile. This change is reversible upon stopping therapy.

• Muscle mass: A slight increase in lean mass and strength. Reversible change.

• Skin: Becomes oilier, with possible onset of acne. The severity is generally lower than with standard dosages. Reversible change.

• Menstrual cycle: At a low dose, the cycle may take longer to stop completely—up to 6-12 months, compared to the 2-6 months typical of standard dosages. In some cases, at very low dosages, the cycle does not stop entirely, although it becomes irregular.

• Clitoral growth: A moderate increase in size, with heightened sensitivity. Irreversible or partially irreversible change.

What to Keep in Mind

The crucial point is that irreversible changes (voice, hair, clitoris) can occur even at low dosages—they just happen more slowly. There is no dose of testosterone that guarantees “only a deeper voice without the beard” or vice versa. Testosterone affects the entire body [2].

Some people choose a time-limited approach: taking testosterone for long enough to achieve desired irreversible changes (e.g., voice deepening) and then stopping, maintaining those changes while the reversible ones (fat redistribution, muscle mass) gradually regress. This strategy requires an open and ongoing dialogue with your endocrinologist.

Low-Dose Estrogen

Low-dose estrogen is an option for non-binary AMAB people seeking partial feminization. Typical dosages are lower than standard ones: for example, 1-2 mg of oral estradiol per day (compared to the standard 2-6 mg), or reduced-dose patches or gels [2][5].

Expected Effects

As with testosterone, the effects are the same as standard therapy but more gradual:

• Skin: Becomes softer and less oily. This is often one of the first perceived changes and one of the most appreciated by non-binary people. Reversible change.

• Breast development: Even at a low dose, estrogen can stimulate breast tissue growth. The extent is variable and strongly influenced by genetics. In some cases, development remains minimal; in others, it may be more noticeable than desired. This change is irreversible without surgery.

• Fat redistribution: Fat accumulates more on the hips, thighs, and buttocks, softening body contours. Reversible change.

• Reduction in body hair: Body hair becomes finer and less noticeable. The effect is gradual and does not completely eliminate existing hair. Partially reversible change.

• Muscle mass: A reduction in muscle mass and strength. Reversible change.

• Sexual function: Possible reduction in libido and spontaneous erections. At low dosages, these effects are generally less pronounced. Reversible change.

What to Keep in Mind

The primary irreversible effect of estrogen is breast development. For a non-binary person who desires skin feminization and fat redistribution but not breast growth, this is a vital consideration. It is not possible to take estrogen and selectively exclude the effect on breast tissue [5].

Some people choose to proceed with low-dose estrogen, accepting the possibility of slight breast development as an acceptable compromise for the other benefits. Others explore alternative options, such as antiandrogens without estrogen or SERMs, which we will discuss in the following sections.

Antiandrogens Without Estrogen

For non-binary AMAB people who wish to reduce the effects of testosterone without inducing feminization, taking an antiandrogen alone—without estrogen—is an option discussed in clinical settings, though less studied than standard protocols [1][3].

How It Works

Antiandrogens (such as spironolactone, cyproterone acetate, or bicalutamide) reduce testosterone activity by blocking androgen receptors or suppressing the hormone’s production. Without the addition of estrogen, the result is a reduction in androgenic effects—less body hair, less oily skin, possible slowing of male pattern baldness—without the appearance of feminine characteristics like breast development.

Possible Effects

• Reduction in sebum production and improvement in acne
• Slowing of body hair growth
• Possible slowing of androgenetic alopecia (male pattern baldness)
• Reduction in libido
• Possible changes in mood and energy levels

Risks and Limitations

This approach has a major limitation: it leaves the body without a dominant sex hormone. Both testosterone and estrogen play essential roles in bone, cardiovascular, metabolic, and cognitive health. Prolonged hormone deficiency can lead to [5]:

• Loss of bone density (osteoporosis)
• Chronic fatigue
• Depression
• Sexual dysfunction
• Hot flashes and night sweats (similar to those in menopause)
• Increased long-term cardiovascular risk

For this reason, therapy with an antiandrogen alone is generally considered viable only in the short-to-medium term or with particularly careful monitoring of bone and metabolic health. Some clinicians prescribe a very low dose of estrogen alongside the antiandrogen—enough to protect the bones and cardiovascular system, but not enough to cause significant feminization. It’s a delicate balance that requires an experienced endocrinologist [2].

SERMs and Selective Approaches

SERMs (Selective Estrogen Receptor Modulators) are medications that act on estrogen receptors in a tissue-specific manner: they can have an estrogenic effect in some tissues and an anti-estrogenic effect in others. Drugs like raloxifene and tamoxifen, originally developed for the treatment of osteoporosis and breast cancer, are being discussed within the medical community as potential tools for non-binary hormone therapy.

The Principle

The idea is to use a SERM to achieve the protective effects of estrogen on bone and cardiovascular health while simultaneously blocking the estrogenic effect on breast tissue. In theory, this could allow a non-binary AMAB person to take an antiandrogen (to reduce testosterone effects) with a SERM (to protect health without inducing breast growth).

The Reality

Research on the use of SERMs in non-binary and transgender people is extremely limited. There are no specific clinical trials evaluating their efficacy and safety in this context. The available data comes from studies on cisgender women undergoing menopause or oncological therapy, and is not directly transferable.

Furthermore, SERMs are not without side effects: they can cause hot flashes, leg cramps, and, in some cases, an increased risk of thromboembolism. Their use in non-binary hormone therapy remains experimental and off-label [5].

Another discussed approach is the use of 5-alpha-reductase inhibitors (such as finasteride or dutasteride) for AMAB individuals. These drugs block the conversion of testosterone into dihydrotestosterone (DHT), the metabolite responsible for specific androgenic effects like baldness and some beard growth. They do not reduce the effects of testosterone on muscle mass or voice. They are sometimes used to complement other treatments.

All these selective approaches share the same limitation: the scientific evidence base is still insufficient to make definitive recommendations. They are options to be discussed with an experienced endocrinologist, fully aware that you are navigating territory largely unexplored by formal research.

Access in Italy

Accessing hormone therapy for non-binary people in Italy presents specific challenges that go beyond those already faced by binary trans people. The Italian healthcare system, while having made significant progress—such as SSN (National Health Service) coverage for gender-affirming hormonal drugs since 2020—remains largely built around a binary transition model [4].

How the Process Works

The formal pathway to access hormone therapy in Italy generally involves a psychological evaluation at a specialized center (such as SAIFIP in Rome, CIDIGEM in Turin, Careggi in Florence, or other regional centers), followed by endocrinological intake. The Italian ONIG guidelines, updated in recent years, have begun to include non-binary identities in their protocols, but practical application varies enormously from center to center.

Specific Difficulties

The main problem for non-binary people is that many professionals—psychologists, psychiatrists, endocrinologists—are unfamiliar with customized and low-dose protocols. A study published in the International Journal of Transgender Health (2021) documented that non-binary people face significant barriers in accessing care: a lack of knowledge among healthcare professionals, rigidly binary protocols, and the need to “prove” an identity that doesn’t fit expected categories [4].

In practice, this can translate into:

• Pressure to conform to a binary pathway: Some centers may agree to start hormone therapy only if the person presents themselves as a “trans man” or “trans woman,” discouraging requests for partial masculinization or feminization.
• Lack of low-dose protocols: Not all endocrinologists know about or are willing to prescribe microdosing protocols, preferring to stick to standard dosages.
• Longer wait times: Non-binary people may encounter resistance or skepticism that lengthens the evaluation process.

Which Centers Are More Open

There is no official list of “non-binary friendly” centers in Italy, but some practical pointers can help:

• Centers that have updated their protocols to WPATH SOC8 tend to be more open to non-binary identities and customized protocols.
• Private endocrinologists with experience in gender medicine may be more flexible in adapting dosages to individual goals.
• Local LGBTQ+ associations (such as Arcigay, MIT, Libellula, and many grassroots organizations) often maintain updated lists of professionals experienced in working with non-binary people.
• Forums and online groups dedicated to non-binary people in Italy are an invaluable resource for peer-to-peer recommendations.

The WPATH SOC8 is clear: non-binary people have the right to the same level of care and respect as binary trans people, and their therapeutic goals are equally valid [1]. When a professional is unable or unwilling to offer this type of care, seeking an alternative is a right, not a whim.

The Challenges

Non-binary people seeking customized hormone therapy face challenges that go beyond strictly medical issues.

Medical Gatekeeping

Gatekeeping—the control of access to care by healthcare professionals—is a known problem for all trans people, but it intensifies for non-binary individuals. When the system is designed to evaluate whether a person is “trans enough” to access therapy, identities that don’t fit the binary model are often marginalized [4]. A person who says, “I want a slightly deeper voice, but not a beard,” may meet with confusion, skepticism, or outright refusal from professionals accustomed to full transition pathways.

The Lack of Standardized Protocols

Research on microdosing and non-binary protocols is still in its infancy [3]. There are no detailed guidelines on dosages, timelines, and specific monitoring for non-binary people. This means that every pathway is, to some extent, experimental—which can be a source of anxiety for both the individual and the doctor.

A Binary Healthcare System

From hospital admission forms to “M/F” options on documents, the healthcare system is built around the gender binary. Non-binary people may feel invisible or forced to oversimplify their identity to navigate a system that does not accommodate them. In Italy, where there is not yet legal recognition of non-binary gender, this institutional invisibility compounds the practical challenges of accessing care [4].

Mental Health

The Trevor Project found that non-binary people have significantly high rates of suicidal ideation and psychological distress, often higher than those of binary trans people [7]. The causes are multiple: less social recognition, invisibility, difficulty accessing care, and the stress of living in a world that constantly demands they check one of two boxes. This makes it all the more urgent to ensure equitable and respectful access to hormone therapy for those who desire it.

Medical Monitoring

Regardless of the dosage—standard or reduced—medical monitoring is essential. Some people make the mistake of thinking that microdosing, being “low dose,” does not require the same level of medical oversight as standard therapy. This is not true [2][5].

Recommended Tests

The Endocrine Society guidelines (2017) and WPATH SOC8 (2022) recommend the following schedule, which is also applicable to low-dose protocols [1][2]:

First year: every 3 months

• Serum testosterone and estradiol levels
• Complete blood count (CBC) (paying attention to hematocrit for those taking testosterone)
• Liver function (AST, ALT)
• Lipid panel
• Fasting blood glucose
• Prolactin (for those taking antiandrogens like cyproterone acetate)
• Electrolytes, particularly potassium (for those taking spironolactone)

Subsequent years: every 6-12 months

• The same tests at a reduced frequency, once stable levels are reached
• Periodic bone densitometry (DEXA scan), especially for those taking antiandrogens without estrogen

Why Monitoring Is Crucial Even at Low Dosages

The risks of hormone therapy don’t disappear at lower doses: they are reduced, but not eliminated. Testosterone, even in small amounts, can increase hematocrit. Estrogen, even at a low dose, carries a thromboembolic risk (especially when taken orally). Antiandrogens always require liver function monitoring and, depending on the drug, potassium or prolactin checks [2].

Furthermore, monitoring hormone levels is the only way to know if the dosage is actually producing the expected changes. Some people respond to low doses more strongly than anticipated; others might not achieve significant changes with the initial dosage. Only blood tests allow for precise calibration of the treatment.

An often underestimated aspect: regular monitoring is also an opportunity to discuss with your doctor how you are feeling, whether the changes meet your expectations, and if you wish to adjust your pathway. Non-binary hormone therapy is by definition an ongoing process of customization, and dialogue with your healthcare provider is an integral part of the treatment.

Conclusion

Non-binary people exist, their identities are valid, and their right to customized medical care is enshrined in the most authoritative international guidelines [1][6][8]. Hormone therapy is not a pathway tailored solely for those seeking a complete transition: it can be modulated, adapted, and dosed according to each individual’s unique goals.

Microdosing, antiandrogens, time-limited protocols, and selective approaches offer options that did not exist in the medical vocabulary twenty years ago. Research is still in its early stages—we need more studies, more data, and more dedicated protocols [3]. But the direction is clear: medicine is moving toward a model of care that centers the person, not the diagnostic category.

Significant challenges remain, especially in Italy: the healthcare system is still largely binary, many professionals are unfamiliar with customized protocols, and access can be difficult [4]. But things are changing, driven by scientific research, international guidelines, and the voices of non-binary people themselves, who rightfully demand to be heard and treated with the same competence and respect given to anyone else.

If you are a non-binary person considering hormone therapy, know that you have the right to seek a pathway that aligns with who you are—not who the system expects you to be. Talk to an experienced endocrinologist, educate yourself, connect with the community, and remember that your body is yours. The decisions on how to live in it belong to you.