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SubQ vs IM Injections for Testosterone

Jude Samson with everything you need to know about testosterone injections for those who are starting HRT.

Disclaimer: I will not be going into dose amounts nor will I discuss specific gauges as they vary from person to person and should be gone over with your doctor. Additionally, I am not advocating for one technique over another, this is for informational purposes only and for you to bring questions to your clinician.

There are various means of taking testosterone, which include transdermal or surgically implanted pellets. Transdermals are an option for some depending on what’s available in their particular area or what they (and/or their doctor) feel is most ideal. The difficulty with them is that they’re either gels, patches, or roll-ons like a deodorant and there’s a potential issue that there’s no way to get a very specific amount guaranteed to be absorbed through the skin, it can be messy, and it also means you cannot touch cis women or even female dogs for many hours after application. Some trans men I’ve spoken with via Facebook groups swear by this method and love the non-invasiveness of the gels. The surgical pellets route is a lesser-known option that implants a series of pellets into the buttocks below the skin to allow for continual release without the need for frequent injections. This is a good process for those who cannot or will not inject, but it does require a minor procedure. There have been instances where the pellets do not operate appropriately (releasing too much or too little or nothing at all).

The most popular options are typically injections because a specific measured amount can be pulled and injected into the body. Even with this method, there are two different approaches – subcutaneous (SubQ) or Intramuscular (IM). First, let’s have a quick understanding of what each term means and what it means to us as trans men.

Self-Injecting: Some people, for one reason or another, need to go to a doctor’s office to receive their injections. Others will self-inject. This means doing your own injections at home with your own supplies and not utilizing the assistance of a medical office or staff.

IM: This requires a larger needle as you are, literally, injecting into the muscle. In most cases, especially for the guys who are self-injecting this often means the thighs as it’s the easiest area for us to reach.

SUBQ: This means ‘under the skin’ and the most common shot in this manner are those who have to handle their insulin. Since you do not have to puncture as far or through tougher material like a muscle the needles can be smaller. We will typically do this in our belly although thighs and upper arms are also options.

NEEDLES: Some syringes come with needles permanently affixed while others come with needle hubs that can be twisted off and replaced. While the ones that cannot be changed afford a slightly better chance of not losing a single drop, the ones you can change allow you to use a larger needle to draw your dose with and then change to a brand new and smaller needle for the actual injection. The more times you poke a needle the duller it gets so starting with a fresh needle is always ideal, but if you’re doing just one poke for a draw and one poke to inject you may not even feel a difference.

Ryan Sallans has been an invaluable resource to the trans community with his speaking engagements, book, and ongoing YouTube videos. Among those videos, Ryan discusses changing over to subQ shots after years taking his HRT by IM injections and it’s definitely worth a watch, especially since it’s under 5 minutes. If you want to watch another quick (less than 5 minutes) video from Ryan regarding IM injections and how to do so with as little pain as possible then you can check out this video as well. (Before anyone worries about safety practices, be sure to review his response video).

"The big question is – which one is most effective?"

The big question is – which one is most effective? There’s no clear-cut answer because each person is different and responds to HRT in a different way. Initially many medical professionals swore by IM only and most of the testosterone vials you may get will say for **Intramuscular Use Only** although the science behind delivery methods has rarely been studied. Until now. Endocrinologist Norman P. Spack spearheaded research to determine if there was a difference in efficacy based on the method of injection and determined that, not only was there little difference as far as how the body absorbed the testosterone but that a subQ method had many benefits over the more traditional IM methods. Those benefits are primarily comfort-based as the patient can now use smaller needles, less risk of sciatic injury (for those receiving injections from another person), and less accumulation of scar tissue from large needles given that trans men will be using HRT for the rest of their lives.

Additionally, many who do IM injections will inject every 10 or 14 days which may require a larger dose per injection. This method could create spikes and drops and some may be prone to “rage spikes.” This, along with a fear of the larger needle, is one of the primary reasons I opted for subQ injections right from the start back in 2014. Doing weekly subQ meant a smaller dose and a smaller break in between shots so that I inject every 7 days instead. This, for me personally, allowed me to avoid potential spikes and drops or rages and I felt that I afforded me a smoother mental and physical transition from week to week. Some have argued that the body won’t absorb as much using this method and that too much of the medication would just be wasted in the body. Again, my personal experience differs from these claims as I had a reasonable dose and yet my body was processing testosterone at an excessively high level – higher than the top male levels. My doctor and I discussed these levels and obviously brought my dose down to main a more appropriate level.

The idea to flood your system with testosterone may sound appealing, especially when you’re incredibly anxious to get started, but I do want to offer some words of caution. First, too much testosterone can wind up being converted to estrogen and that will just wind up being entirely counterproductive to the entire process. Secondly, testosterone increases red blood cell production, which means the body (specifically the heart) has to work a little harder to push your blood around. If you or your family members have any cardiac history, it’s imperative you tell your doctor so you can be monitored. Do not avoid telling your doctor because you think they won’t put you on HRT. My family and I have a significant cardiac history, and I am on HRT, so I am safely monitored by my endocrinologist and my cardiologist. And, as I mentioned, rage. Flooding your body with unsafe doses of testosterone can cause immense rage that’s just bound to get you in trouble and perhaps even hurt you or those around you. Start slow and low and let your doctor ease you into higher doses as needed.

The science behind injections and the body absorbing the medication is interesting but can be overwhelming for those newer to injections. Ultimately, it is up to each person to select the delivery method that they are most comfortable with, including not using injections at all. Regardless of method, it’s imperative that you have a detailed conversation with your doctors before changing anything. The most important thing is to make sure you have the right information, and don’t be afraid to give your doctor new information. Many physicians are on the learning curve with the trans population and will need us to help guide them with new information. While you shouldn’t be telling your doctor how to do their job, you shouldn’t be afraid of your doctor either. Make sure you have an open line of communication. It’s going to be a long journey; you will need them in your corner and up-to-date.

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