This form refers to the use of testosterone by persons who wish to become more masculinized as part of a gender transitioning process.

You are being asked to initial the various statements on this form to indicate that the risks as well as the changes which may occur as a result of the use of testosterone have been explained to you and that you understand them. If you have any questions or concerns about the information below, we encourage you to take all the time you need to: ask questions, read, research , talk with clinic staff and think about these important aspects of your treatment.

Please initial and date.

Patient Provider Date

1. ______ ______ ___/___/___ I have been informed that masculinizing effects of testosterone may take several months to become noticeable, up to five years to be complete. Some of these changes will be permanent, including:
   
   
   • Hair loss, especially at my temples and crown of my head and, possibly, becoming completely bald
   • Beard and mustache growth
   • Deepening of my voice
   • Increased hair growth on my arms, legs, chest, back, and abdomen
   • Enlargement of my clitoris
   
   
   These additional changes will not be permanent if I stop testosterone:
   
   
   • Decrease of fat in my breasts, buttocks and thighs
   • Increase of fat in my abdomen
   • More muscle development
   • More red blood cells in my blood
   • Behavioral changes, similar to those experienced at puberty, and increased sex drive
   • Acne, which may become severe and may cause permanent scarring if not treated
   
   
   
2. ______ ______ ___/___/___ I understand that it is not known exactly what the effects of testosterone are on fertility. I have been informed that, if I stop taking testosterone, I may or may not be able to become pregnant in the future.
   
   
3. ______ ______ ___/___/___ I understand that there are brain structures which are affected by testosterone and estrogen, and that current medical science does not understand these adequately. I understand that taking a hormone may have long-term effects on the functioning of my brain which are impossible to predict. These effects may be beneficial, damaging, or both.
   
   
4. ______ ______ ___/___/___ I understand that everyone’s body is different and that there is no way to predict what will be my response to hormones. There is a very complex interaction in each person between all the different hormones. I understand that the right dosage for me may not be the same as for someone else.
   
   
5. ______ ______ ___/___/___ I will have physical examinations and blood tests periodically to make sure I am not having a bad reaction to the hormones. I understand this is required to continue testosterone therapy through this clinic.
   
   
6. ______ ______ ___/___/___ I have been informed that using testosterone may increase my risk of developing diabetes in the future because of changes in my ovaries.
   
   
7. ______ ______ ___/___/___ I understand that the endometrium (the lining of my uterus) is able to turn testosterone into estrogen and so increase my risk of cancer of the endometrium. I have been informed that not having my period for prolonged times may increases this risk. In order to reduce this risk, another hormone may be recommended to induce a menstrual period (shed the endometrium) several times a year.
   
   
8. ______ ______ ___/___/___ I understand that through an interaction in the blood, my taking testosterone may actually increase the effectiveness of the estrogen in my body. The results of this are not known.
   
   
9. ______ ______ ___/___/___ I have been informed that if my periods stop while I am taking testosterone I probably will not be able to become pregnant. I understand that testosterone should not be used to prevent pregnancy. Even if I have stopped having periods I should still use birth control (preferably barrier methods) if I am having sex where semen could enter my vagina or uterus.
   
   
10. ______ ______ ___/___/___ I understand the effects of testosterone will not protect me from sexually transmitted diseases or from HIV.
    
    
11. ______ ______ ___/___/___ I understand that the effects of testosterone will not protect me from cervical cancer or breast cancer. It is important to continue to be alert to the health care needs of my body. I understand that annual breast exams and monthly self-breast exams are recommended, even after chest reconstruction. My provider may also recommend periodic pap smears.
    
    
12. ______ ______ ___/___/___ I understand that fatty tissue in my breasts is able to turn testosterone into estrogen, which may increase my risk of breast cancer in the future.
    
    
13. ______ ______ ___/___/___ I have been informed that testosterone puts a stress on the liver which may lead to liver inflammation. I will be monitored for liver problems before starting testosterone and periodically during therapy
    
    
14. ______ ______ ___/___/___ I have been informed that if I take testosterone my good cholesterol (HDL) will probably go down and my bad cholesterol (LDL) will probably go up. This will likely increase my risk of a heart attack or stroke in the future. The rates of risks for FTMs on testosterone are similar to the risks that are found in non-transgender men.
    
    
15. ______ ______ ___/___/___ I understand that there are emotional changes I will likely experience as a result of testosterone therapy, and that clinic staff can assist me in finding resources to explore these changes.
    
    
16. ______ ______ ___/___/___ I understand that once injected, if I have any adverse reactions to testosterone I must wait for them to wear off.
    
    
17. ______ ______ ___/___/___ I agree to tell my medical provider about any non-clinic hormones, dietary supplements, herbs, recreational drugs or medications I might be taking. I understand that being honest with my provider is crucial to developing a trusting relationship. Sharing this information will help my provider to prevent potentially harmful interactions. I have been informed that clinic staff will continue to provide me with medical care, regardless of what information I share with them.
    
    
18. ______ ______ ___/___/___ I agree to take hormones as prescribed and to inform my provider of any problems or dissatisfactions I may have with the treatment. I’ve been informed that if I take too much testosterone that my body may convert it into estrogen. This may slow or stop the desired effects of the hormone.
    
    
19. ______ ______ ___/___/___ I understand that there are medical conditions that could make taking testosterone either dangerous or damaging. I agree that if clinic staff suspect I may have one of these conditions, I will be evaluated for it before the decision to start or continue testosterone therapy is made.
    
    
20. ______ ______ ___/___/___ I understand that I can choose to stop taking testosterone at any time. I also understand that my provider can discontinue treatment for clinical reasons.

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Patient Signature Date

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Parent/Guardian Signature Date