Hairy Situations

Hair loss, hair regrowth, and transition

When I was thirteen, after surviving the worst night of my life, I stood in front of a bathroom mirror. I already couldn’t really recognize my reflection anymore; testosterone had begun its grim work on my skull, work which wouldn’t be undone for another twenty-four years. On an impulse, I swept my hair backwards, and for a single, beautiful moment, that shattered reflection was suddenly me again.

I started growing my hair out immediately. My parents, who might before have hesitated at having an apparently-teenage-boy with long hair in the late-90’s, let me do whatever I wanted as long as it wasn’t obviously self-harming in those tender days.

I wore it long, unchanged, in that same swept-back ponytail, until I hatched, twenty-two years later. And, because men in my family have pretty significant hair loss, the glory of my hair slowly turned into this over the next twenty years.

Before I hatched, most of my dysphoria was an incoherent screaming, a doomed sense of disquiet and wrongness, that I couldn’t make sense of. Two, and only two, signals came through clearly. I longed for feminine community. And, just as urgently, I despaired at the disintegration of my hair. Years before I hatched, I went from salon to salon, hoping for advice to help. They all told me to just shave off what little I had left. I fled each on the verge of tears.

When I finally did transition, I knew that I had to do anything I possibly could to regain any amount of hair I could. Feminine hair was the first gender-affirming thing I ever did for myself, and I knew that I’d never achieve my modest transition goal—seeing myself in the mirror, no prosthetics or cosmetics—if I couldn’t.

Two and a half years and a lot of work later, this is what my hair looks like.

In this respect, my whole universe has changed. Yours can too.

The right follicles in the right places

Hair is a tricky thing in transition because it’s one of the most important, and most visible, parts of being gendered right consistently. Transfeminine people endure laser and electrolysis at enormous cost to exorcise the exact same facial hair that transmasculine people celebrate with tender hearts and dewy eyes as it comes in, follicle by precious follicle. It’s so important that one of my favorite trans jokes is that, no matter what your gender is, 90% of transition boils down to getting fat and hair in the right spots.

In my quest to recover my hairline, I did a lot of research, and I tried everything in the book there was to try. I’m going to be frank: I wasted a lot of money on long-shot hopes that ultimately did nothing for me—and that I didn’t even need, in the end, if I’d had patience and trusted the best science, like I damn well should’ve.

This is going to be a frank guide for what we do and don’t know about hair loss and restoration, what our best bets are for regrowing hair you’ve lost, keeping the hair you’ve got (especially if you’re transmasculine and going on testosterone), and on coaching hair to show up in the right places.

What we (think we) know about hair loss

The science of hair loss is an extremely lucrative field of medical research because there’s enormous demand for hair growth cures from people of all genders. Androgenic Alopecia (AGA), sometimes very erroneously called male-pattern baldness, is responsible for over 95% of all hair loss and hair thinning, not only in men, but women as well, affecting at least “80 percent of males and 50% females.”

First, the basics: hair does not grow continuously. Every hair follicle goes through three phases of growth, which repeat in a cycle. Anagen, the main growth cycle, lasts for between 2-6 years per follicle. During this time, the follicle continuously produces between one and four hairs per follicle. At the end of anagen, there is a short phase called the catagen phase, where the follicle releases any growth factor attached to and supplying hairs growing out of it. Finally, in telogen, the hair follicle rests for a few months, producing nothing and healing itself. During this phase, existing hair can fall out, and if it doesn’t, when new hair begins to grow in the next anagen phase, the existing hair will be pushed out and shed.

This, for reference, is why you shouldn’t worry when hair comes out in your hairbrush. You’re just tugging out strands that’ve been released already in the telogen phase.

The current understanding of how AGA occurs is pretty simple: testosterone, which all human bodies require for our survival, is converted into dihydrotestosterone (DHT) by an enzyme called 5alpha-reductase (yes, 5alpha is meant to have no space or hyphen). All androgens (both T and DHT), it is thought, eventually cause hair follicles to permanently minimize by binding with DHT receptors on follicles. Once a follicle has minimized—and it is crucial to note here that the follicle does not die, it just stops producing the kinf of hair we generally want—it is understood that it can never again be coaxed into growing hair again. DHT is the key here; evidence shows it has a far, far larger role in hair follicle miniaturization than testosterone.

Put in more practical terms, AGA is a process in which the anagen phase becomes shorter and shorter and the telogen phase becomes longer and longer, until the hair follicle remains in telogen permanently. The permanently here is really important, because this understanding means that there are no treatments for hair loss that even attempt to coax minimized follicles back into producing hair. Most minimized follicles still produce hair—just not the thick, pigmented hair most people care about, known as terminal hair.

Based on this model, we do have a bunch of treatment that try to either stop this process from progressing—AGA is a gradual thing, and can definitely be interrupted—or cause new hair growth where there wasn’t any before.

But there are some really, really big problems with our current understanding, and the field is only barely beginning to face those problems.

…But it’s pretty significantly wrong

Why are there problems? Three massive pieces of proof, which boil down to one incredibly inconvenient piece of evidence.

Trans women regrow hair

The first piece of data that our current understanding of AGA simply cannot cope with is the fact that transfems on feminizing HRT almost universally regrow hair that they’ve lost to AGA. Now, when transfeminine people start on HRT, we’re told very firmly that we won’t get any hair regrowth. All of us. And then, we turn to each other and talk, and those of us who’ve been in transition for longer periods of time laugh and explain that that’s simply not true.

Our current model of AGA allows for no possible routes for revitalizing miniaturized hair follicles; according to every significant in-use model, once AGA has completed its work on a follicle, that follicle is done for. This is why transfems are told we won’t experience hair regrowth.

But now we have undeniable evidence of exactly that happening, in the scholarly literature, with no possible intervention from any other hair restoration treatments. And the AGA research field has absolutely no idea what to do about this fact.

Cis women without PCOS have a later onset of AGA than cis men

Anyone with significant testosterone in their systems can see AGA start up pretty early on in life; the early stages of AGA are regularly observed in teenage boys, who’ve only had significant testosterone and DHT levels for a couple of years. Meanwhile, AGA doesn’t typically begin in cis women until much later, often not until the beginning of perimenopause.

If you're not familiar with perimenopause, it's the beginning stages of the menopause transition, where cis womens’ bodies end their reproductive cycles completely. As part of this transition, their estrogen levels drop significantly. This drop, coincidentally,, is why older cis women are at much higher risk for osteoporosis than the general public is.

Oh, and PCOS? That asterisk? One of the main symptoms of PCOS is highter testosterone and DHT levels.

Testosterone is essential in hair virilization

This is going to take a smidge of explanation.

If you look at your arm, you’ll see lots of those thin, white “baby hairs.” Those are called vellus hairs, and they grow all over your body—believe it or not, they’re one of the main ways that your body regulates heat. The hair follicles that make vellus hairs are exactly the same as the ones that produce the much more substantial hair you’ll see on your head, with one exception: they have not been virilized.

Once a hair follicle has been exposed to enough testosterone, its anagen phase will permanently transform in subtle and important ways, building much more substantial hairs and flooding those hairs with pigment. Hair that has been virilized is called terminal hair.

Why is this a problem? “DHT is a more potent form of testosterone and [testosterone and DHT] are expected to convert hair follicles from vellus to terminal[,] not the other way around, [so] this inference gives rise to a paradox.” Our entire understanding of how hair growth and loss functions, in short, is circular. The same chemicals which cause hair follicles to grow terminal hair also, somehow, cause those same follicles to stop growing terminal hair.

Biological systems don’t really work that way. When supplied with the same input, except for a few very specific exceptions, they’ll keep on producing the same output.

Estrogen: the inconvenient part of AGA research

Again and again and again, in all types of hair loss situations, introducing estrogen has caused hair to regrow, either from nothing or at an increased rate. HRT in postmenopausal cis women is associated with lower rates of AGA and improved hair growth. And despite the fact that a small group of researchers continue to ring the bell about the importance of estrogen to AGA research, it has been almost entirely ignored by mainstream research, which focuses on hair treatment for cisgender men who don’t want all of the other effects that come with estrogen.

The main competing model of AGA is much more complicated than the common one. To oversimplify this model by a lot, it argues that calcium is essential to the hair growth cycle (which we know), and that DHT doesn’t actually cause hair loss—rather, it fixes calcium in the hair follicle, calcifying it, and the calcification causes scarring and that (in combination with skin tension and roughness) keeps the hair follicle in telogen forever.

This model fits the evidence we’ve seen about estrogen in hair regrowth because estrogen plays an important role in calcium transport through cell membranes in many other areas of the body, as well as better binding in bones. It also thins and softens skin, relaxing scalp tension. An estrogen-inclusive model of hair loss and regrowth would, in short, explain all data points pretty neatly.

Whatever, nerd. How can I get my hair back?

The good news is that there are a lot of good options for either restoring hair that you’ve lost and to keep yourself from losing what you have, especially if you’re transmasculine and going on T. I’ll only be covering stuff that we’ve got peer-reviewed evidence to support, and I’ll be going from most effective to least effective option. There’s other options out there, but you need to assume they’re snake oil without decent research evidence to back them up.

People get desperate about their hair. I know that one from personal experience. Because of this, shady folks are all too willing to take advantage of that desperation.

One last note, as a disclaimer: as with anything medical, every body is different. What works for most people might not work for you, and vice versa.

Hair transplants

Hair transplants are the last word in hair restoration, and while most people who get hair transplants are men, plenty of women—yes, cis women—get them too. There’s a lot of prejudice and misinformation about hair transplantation—that someone will never get a good hairline this way, that people can always tell, that the hair grafts fall out over time, blah blah blah.

The fact of the matter is that the standard hair transplantation technique, follicular unit transplant (FUT), has a follicle survival rate of over 99%. That means if you get a 3,000 follicle graft—and that’s a massive graft—all but about 30 follicles will survive and start growing hair.

3,000 follicles, for reference, is enough to do almost the entire top of a person’s head.

If you’ve got all-over hair thinning, rather than a bald spot or a receding hairline, you might want to get follicular unit extraction (FUE) transplants instead. The main advantage here is that there won’t be a scar from the transplant area—which is almost never a problem with FUT, because the area is usually completely covered with hair—but it comes with a significant bump in cost and a slightly lower follicle survival rate of only 97%.

Finally, research your doctors. Choose carefully. I know someone who got absolutely screwed at a national chain franchise, which promised her one thing and didn’t tell her the truth until she was in the chair for the transplant. The best doctors almost always strike out on their own from national chains, so do your due diligence!

Cost: $4-5/follicle, on average. Top doctors will charge more. Dr. Gabel, who literally wrote the book on hair transplantation for trans women, charges $8/follicle. I’ve seen his results firsthand. If you need serious work, he’s worth every penny.

Time to full effect: 12 months.

Feminizing HRT

Not to beat a dead horse, but nothing chemical regrows hair lost to androgenic alopecia like starting feminizing HRT.

Cost: $5-15/month.

Time to full effect: Several years.

Minoxidil

Short of surgery and estrogen, minoxidil is the only thing out there that’s going to reliably give you hair where you’ve already lost it. You’ve probably heard of this stuff by its brand name, Rogaine, but minoxidil was originally developed as an oral blood pressure pill—it’s actually more effective as a pill than as the foam or liquid you put on your scalp, and cheaper too!

There are three big downsides for minoxidil:

1. If you ever stop taking it, the hair you grow with it will fall out. This one’s for life, folks.

2. The topical version is pretty toxic to cats. If you have kissy kitties, you’ll want strictly oral.

3. The pill version is systemic, meaning it’ll boost terminal hair growth everywhere on your body. I’m on oral, and mostly it just means that my facial hair has been a smidge more stubborn. It really isn’t bad. It’s all upside for trans men, though!

Note for transmascs: If you’re impatient for your facial hair to get going, minoxidil can coax things along for the first couple of years. A lot of trans guys like to use the foam on their beard areas early on, to get some early beard growth.

Cost: $7/month (oral), or $30/month (topical)

Time to full effect: 9 months.

Finasteride/Dutasteride

Regardless of esterogen’s role in hair, too much DHT is bad for scalp hair. Finasteride and Dutasteride are 5alpha-reductase inhibitors, which will reduce DHT, stopping hair loss. They’re generally considered to be quite safe, and are very widely prescribed, but there are some concerns about it, mostly in terms of reduced erectile function in men. That may not be a worry for transfems, and definitely won’t be for transmascs.

Dutasteride is much more powerful than finasteride, but more power isn’t always better here. It’s generally best to start with finasteride and only go up in power if you’re still losing hair.

Note for transmascs: If keeping a full head of hair is important to you, get on finasteride when you start HRT. It won’t interfere with your transition.

Cost: $12-15/month

Time to full effect: 3-4 months.

Microneedling

Here’s a fun one.

Jabbing your hairline once a week with dozens of tiny, 2.5mm needles can apparently help get hair growth going. The reasons why this works aren’t super clear, but it seems to work best when combined with topical minoxidil; the best theory here is that minoxidil works by dilating blood vessels, and microneedling kinda ram-jams it into your scalp right next to the hair follicles you’re trying to treat. It does certainly seem to work—it did for me, before I switched to oral minoxidil—but it’s kind of weird.

Important note: You’ll do this at home, and that means you need to sanitize your microneedle stamp with rubbing alcohol before and after each use, or you’ll eventually give yourself an infection.

Cost: $25 for a microneedling pen

Time to full effect: 6-12 months.

Platelet-rich plasma injections

PRP is just blood plasma that’s heavy with platelets, and to do PRP injections, a nurse will take a vial or two of your blood, spin it in a centrifuge to separate the plasma, and then reinject it into your scalp. Some studies have shown that doing this three or four times can improve hair density decently, but the quality of that evidence is not very high.

However, the cost for this treatment definitely can be quite high; a series of PRP treatments can run you about 1/3 the cost of a hair transplant. Consider your finances carefully before doing this. Since the average cost of a 1500-follicle hair graft is around $6000, a round of PRP injections will run you around 25% the cost of that, for far less certain results.

These effects are also not permanent, even in the best-case scenarios.

Cost: $1500+ for a series of 3-4 treatments

Time to full effect: 6 months.

Low-level laser

There are a few studies that have shown that low-intensity laser shining on your scalp can improve hair density. In a nutshell, you get a helmet, and you sit around wearing it once a day for a half hour, and it shines laser light on your scalp. However, the quality of the research is very low, lacking any statistical significance, and garbage imitation devices abound to the point that they interfere with even medical research into this therapy.

While I have done my best to not editorialize, I really would recommend against trying a LLL device. The costs are high and the certainty extremely low.

Cost: $500-1000 for a device, plus a pittance for electricity to run it.

Time to full effect(?): 3-6 months.

Hair Care 101

Maybe the single most important thing you can do to get better hair is sit down with a good hair stylist, pay them for their time, and have them talk you through what kind of hair you have and what it means. Different hair requires different care. If you have Type 2a hair—fine and lightly wavy—like mine, washing or even conditioning your hair every day will absolutely wreck it, while a daily spritz of dry shampoo four or five days out of every seven instead will give it body and life like you’ve never seen before. Shower caps exist for a reason.

You may or may not have also heard that sulfates and sulfides in shampoos and conditioners—and they’re in most of them—can be bad for your hair. Most people won’t need to worry about this, because if you’ve got average hair types and thicknesses, your hair is the kind of hair mainstream shampoo was designed for. If you’ve got fine or dry hair (Type 2a is the poster child for this), though, sulfates and sulfides are going to be strong enough that they’ll make your hair break and shatter by stripping away too much oil, so it’ll be worth it to buy the expensive sulfate- and sulfide-free shampoos and conditioners. Don’t worry—since you won’t be washing as often, a bottle will last you for ages. I buy like two a year, tops.

Finally, if you want to grow longer, stronger hair, it’s a good idea to take a biotin supplement. You can’t really overdose on biotin. Like, seriously, just about the only way you could die from taking too much of it is to drown in a pool of liquid biotin; your body will just pee it out. Joking aside, the only real risk of a biotin overdose is dehydration from peeing too much, so drink your water while you’re on it—and stop taking it at least four days before your hormone levels test, or it’ll mess up your estrogen level results!

Be patient

All of these therapies require time. That wait—especially for estrogenic HRT to do its thing, if you’re on it—is pretty crappy. Almost all of the best stuff takes a year or more to see real results, and when you’re scrambling to get your body in order after a lifetime of it hurting you, that wait can be completely intolerable.

But it’s worth it.