What is the most effective treatment for a transgender patient with needle phobia (fear of needles) requiring testosterone therapy?

Testosterone Therapy for Needle-Phobic Transgender Patients

For transgender patients with needle phobia requiring testosterone therapy, transdermal testosterone gel (1.62%) applied to the upper arms and shoulders is the most effective non-injectable option, with a starting dose of 40.5 mg daily (2 pump actuations), targeting serum testosterone levels of 300-1,000 ng/dL. 1, 2, 3

Primary Recommendation: Transdermal Testosterone Gel

Transdermal testosterone formulations (gels and patches) are the preferred alternatives to injectable testosterone for patients who cannot tolerate needles. 1, 2 These formulations avoid the need for intramuscular or subcutaneous injections while still achieving appropriate masculinization and testosterone levels in the cisgender male range. 4

Specific Dosing Protocol

• Start with testosterone gel 1.62% at 40.5 mg daily (2 pump actuations) applied once daily in the morning to clean, dry, intact skin of the upper arms and shoulders 3
• The dose can be adjusted between 20.25 mg (1 pump) and 81 mg (4 pumps) based on serum testosterone levels 3
• Target trough testosterone levels of 300-1,000 ng/dL, measured in the morning before the next application 2, 4

Monitoring and Dose Adjustment

• Check testosterone levels at 14 days and 28 days after starting treatment, then periodically thereafter 3
• If testosterone is >750 ng/dL: decrease by 20.25 mg 3
• If testosterone is 350-750 ng/dL: continue current dose 3
• If testosterone is <350 ng/dL: increase by 20.25 mg 3

Expected Physical Effects and Timeline

Transdermal testosterone produces the same masculinizing effects as injectable formulations, though the timeline may vary slightly:

• Voice deepening occurs due to thickened vocal cords 1, 2
• Facial and body hair growth develops progressively 1, 2
• Menstrual suppression typically occurs within several months 2, 5
• Increased muscle mass and strength, with decreased fat mass 1, 2, 5
• Clitoral enlargement and increased libido are common effects 2, 5
• Improvements in gender dysphoria, anxiety, and depression are documented benefits 5

Critical Safety Monitoring

Hematologic Monitoring

A key advantage of transdermal testosterone is a lower risk of erythrocytosis compared to injectable formulations. 1, 2 However, monitoring remains essential:

• Check hemoglobin and hematocrit at baseline and regularly during treatment 2
• Hemoglobin will increase to male reference range within 3 months 2
• If hematocrit rises above normal male range, consider dose reduction or temporary withholding 2

Cardiovascular and Metabolic Monitoring

• Monitor lipid profiles regularly, as testosterone may increase LDL and triglycerides while decreasing HDL 2, 6, 5
• Check blood pressure, as testosterone may cause increases 2
• Monitor liver function tests periodically 2

Bone Health Considerations

Inadequate testosterone dosing can negatively impact bone density, making appropriate dosing and monitoring essential 1, 4

Application Instructions and Safety Precautions

Proper Application Technique

• Apply to upper arms and shoulders only—do not apply to abdomen, genitals, chest, armpits, or knees 3
• Limit application area to what would be covered by a short-sleeve t-shirt 3
• Wash hands immediately with soap and water after application 3
• Cover application sites with clothing once gel has dried 3
• Avoid swimming, showering, or washing application site for minimum 2 hours after application 3

Critical Safety Warning: Secondary Exposure Prevention

Children and women must avoid contact with unwashed or unclothed application sites, as secondary exposure can cause virilization 3. This is particularly important given documented cases of virilization in children exposed to testosterone gel products. 3

• Wash application sites thoroughly with soap and water before any anticipated skin-to-skin contact 3
• If unintended contact occurs, the exposed person should wash the contact area with soap and water immediately 3

Alternative Non-Injectable Option: Testosterone Patches

While the evidence focuses primarily on gels, testosterone patches (50-100 μg/24 hours) are another transdermal option that may be considered for needle-phobic patients, though specific dosing protocols are less well-defined in the transgender medicine literature. 1

Why Not Testosterone Undecanoate?

Testosterone undecanoate (long-acting injectable) should be avoided despite its less frequent dosing schedule because it raises concerns for pulmonary oil microembolism and anaphylaxis, and is subject to risk evaluation and mitigation strategies. 1, 4 This makes it inappropriate for routine use, particularly in needle-phobic patients who would still require injections.

Common Pitfalls to Avoid

• Do not use supraphysiologic dosing—this increases adverse effects without additional benefit 2
• Do not apply gel to areas other than upper arms and shoulders—absorption and safety profiles differ by application site 3
• Do not neglect monitoring for erythrocytosis, even with transdermal formulations 2, 4
• Ensure adequate dosing to prevent negative bone health impacts 1, 4

Quality of Life and Mental Health Benefits

Gender-affirming hormone therapy with testosterone is medically necessary for many transgender individuals, with strong evidence showing improvements in quality of life and relief of psychological distress associated with gender dysphoria. 1 The transdermal route allows needle-phobic patients to access these critical benefits without compromising treatment efficacy.