The Psychology of Transgender Issues
Culturally-Sensitive Transgender Health Care
Rachael St. Claire, PsyD, Licensed Psychologist
(Disclaimer: The following information is provided to educate you
and your health care providers in culturally sensitive health care for
persons with transgender issues. Specific medical information is
also gleaned from the transgender medical literature and the common
practice of physicians I work with. This information should not be
used in determining your own medical care. Your medical care should
be determined by your physician in collaboration with you. I recommend
that your physician become familiar with the readings listed in the
bibliography at the end of this article. I also recommend that you
and your physician obtain a copy of the Harry Benjamin International
Gender Dysphoria Association Standards of Care at their website http://www.hbigda.org/.)
Transgender persons have specific health care
needs, and are seeking health care from primary care providers in
increasing numbers. The primary health care provider’s lack of training in
basic transgender healthcare and the social stigmatization of transgender
persons within health care settings are significant barriers to accessing
medically necessary healthcare for transgender persons. Health-care professionals are not
knowledgeable in the specific medical care transgender patients need, and
are unaware of how to provide an excellent health care experience to
transgender persons. Transgender persons may avoid seeking health-care
because of the fear of stigmatization and shame, the belief that
transgender sensitive health-care is not available, and the assumption
that medical care for transgender health issues is not a covered benefit
in the health plan.
Transgender persons face numerous complex
medical, psychological, and social issues. The transgender person’s
process of understanding his or her gender identity and sexual issues can
take many years, complicated by societal stigmatization, shame, numerous
forms of discrimination, and the lack of access to competent health care.
Years of clinical experience with transgender persons since the 1950’s
have shown that cross-gender behavior and identity issues cannot be
ameliorated by psychotherapeutic approaches. However, transgender affirmative
medical and psychological care can play a vital role in assisting
transgender people in the healing process and in establishing healthy and
functional lives.
The use of cross-sex hormones and genital
surgery to complement full time transition from one gender to the other is
established as an effective intervention for gender dysphoria. Transgender persons who undergo
such medically supervised interventions experience significant benefit to
their quality of life. Cases
of regret following cross-sex hormone administration and genital surgery
are rare but do occur.
I.
Who is the
transgender person?
Transgender people experience varying levels
of incongruence between their natal sex and the gender roles society
expects them to fulfill.
With age this incongruence creates increasing gender dysphoria and
often depression, as they begin to understand that they identify with the
opposite natal sex. Any
combination of gender identity and sexual orientation is possible. The incongruence between natal
sex, gender roles, and gender identity can be lessened and often
eliminated through bio-psych-social interventions, including living
part-time or full-time in their self-identified gender, hormonally
inducing the secondary sex characteristics congruent with self-identified
gender, and facial plastic surgery and genital surgery consistent with
self-identified gender.
A. Important
terms related to gender and sexuality.
1. Natal or biological sex.
Biological maleness or femaleness, including
the sex determining genes, the sex chromosomes, the gonads, the sex
hormones, internal reproductive structures and external genitalia.
2. Sexual orientation.
An emotional, erotic, and sexual relationship
between persons of either the same (homosexual) or different
(heterosexual) sex or both (bi-sexual). Transgender persons may not
self-identify with the stereotypical definitions of lesbian, gay, or
bisexual. Transgender and
non-transgender persons may experience specific erotic attraction to
transgender men and women.
For example, a transsexual woman in a relationship with a natal
woman may not self-identify with the category “lesbian” and neither may
her partner.
3.
Secondary sex characteristics.
Genetically
transmitted anatomical, physiological, or behavioral characteristics, such
as voice quality, abundance of facial and body hair, bone structure,
subcutaneous fat distribution, or breast development, that first appear in
humans at puberty and differentiate between the sexes without having a
direct reproductive function.
4. Gender roles:
Gender roles are behaviors, attitudes, or
personality characteristics that a culture in a specific historical period
designates as masculine or feminine.
5. Gender identity.
A person’s identification with maleness or
femaleness. Biological sex is
typically assigned at birth and the felt sense of maleness or femaleness,
and self-identification as male or female is congruent. Gender identity may be incongruent
with the person’s natal sex.
Some transgender persons self-identify as transgender, a third
category of gender identity distinct from man or woman.
6. Gender dysphoria.
A state of emotional distress associated with
the incongruence between one’s natal sex and gender identity. The intensity of the emotional
distress can vary greatly from mild and transient to intense and
persistent. Persons with
intense gender dysphoria often desire to change their secondary sex
characteristics through sex hormones, and may desire a gender transition,
and genital surgery. Intense
gender dysphoria can place some individuals at higher risk for clinical
depression, suicidal risk, and significant psychological dysfunction. However, not all transgender
persons subjectively experience intense gender dysphoria.
7. Transgender:
Transgender is a non-pathologizing umbrella
term coined by the transgender community to include all persons with
diverse gender behaviors and identifications, including cross-dressing,
transsexual, transgenderist, androgyne, and intersex persons. Transgender may be used to
describe an individual or a community. It is not a diagnostic medical
term. Transgender identity
refers to a person who self-identifies as belonging to the transgender
community. This term is an
acceptable transgender sensitive term that is considered by most to be
respectful; however, some individuals may associate it with stigmatization
and pathologizing intent.
Some individuals who alter their secondary sex characteristics may
not self-identify as transgender at all, and may do so for social,
political, and aesthetic motivations.
B. The spectrum of transgender Identity.
1. Cross-dresser or Transvestite.
Cross-dressers are persons who dress in the
clothing of the opposite sex for erotic pleasure, emotional satisfaction,
or both. Transvestite was
originally a clinical term and it is falling out of usage in favor of the
term cross-dresser. Partial
cross-dressing may progress to complete cross-dressing. Cross-dressing is a behavior that
is necessary to exploring diverse gender roles in various social
contexts. Persons who
eventually self-identify as transgenderist or transsexual may initially
self-identify as a cross-dresser in the initial stages of gender
exploration.
Transgenderist or Bi-gendered.
Transgenderist persons live in the gender role
of the opposite sex full-time.
Bi-gendered persons identify with maleness and femaleness, and may
live part-time as a man and part-time as a woman. There may be interest in
cross-sex hormones and aesthetic cosmetic surgery, but genital surgery is
not desired.
2. Transsexual.
A person who identifies with the gender of the other sex, who undergoes hormonal modification of secondary sex characteristics and genital surgery in order to live permanently in the gender role of the other sex. Some individuals self-identify as transgender or transsexual men or women, while others do not consider themselves transsexual any longer after full time transition and genital surgery.
3. Inter-sexed or Hermaphrodite.
An anomaly of one or more characteristics of
biological sex which may have been surgically altered at birth.
II. What is the psychiatric perspective on transgender persons?
A. The
American Psychiatric Association DSM-IV.
The Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (DSM-IV),
considers transgender persons to be afflicted by a disturbance in
sexuality (Transvestic Fetishism) or gender identity (Gender Identity
Disorder). The persistent
desire to live as the gender of the opposite natal sex is described as a
“disturbance”. However, the
diagnosis of Gender Identity Disorder is only made for persons with
clinically significant distress or functional impairment. This requirement is often
overlooked by health care professionals in documenting assessment and
treatment services.
B. Diagnostic
Nomenclature.
The term “transsexual” was
introduced in the 1950’s to designate a person who aspired to or actually
lived in the gender role of the opposite natal sex. The diagnostic category
“Transsexualism” was introduced into the DSM-III in 1980, and in 1994 it
was replaced with “Gender Identity Disorder”. There is an alternative diagnosis
“Gender Identity Disorder Not Otherwise Specified.”
C. Objections to
Psychiatric Classification.
Transgender activists
oppose the pathologizing of transgender identity that leads to
stigmatization and the medicalization of modifying markers of biological
sex. Many transsexual persons
are arbitrarily denied access to needed health care. Transgender activists assert that
transgender identity is not pathological and is a normal variation of
human sexuality, as is lesbian, gay, and bisexual identity. While some transgender activist
groups object to the medical provider’s gate-keeping role in controlling
access to hormones and genital surgery, most transsexual persons recognize
the value of knowledgeable medical and psychological care.
III. Diagnostic criteria for Gender Identity
Disorder.
D. A strong and persistent
cross gender identification (not merely a desire for any perceived
cultural advantages of being the other sex).
In children, the
disturbance is manifested by four (or more) of the following:
1.
in boys, preference for cross dressing or simulating female attire;
in girls, insistence on wearing only stereotypical masculine clothing
2.
strong and persistent preferences for cross sex roles in make
believe play or persistent fantasies of being the other sex
3.
intense desire to participate in the stereotypical games and
pastimes of the other sex
4.
strong preference for play mates of the other sex
In adolescence and adults,
the disturbance is manifested by symptoms such as stated desire to be the
other sex, frequent passing as the other sex, desire to live or be treated
as the other sex, or the conviction that he or she has the typical
feelings and reactions of the other sex.
E. Persistent discomfort with
his or her sex or sense of inappropriateness in the gender role of that
sex.
In children, the
disturbance is manifested by any of the following: in boys, assertion that
his penis or testes are disgusting or will disappear or assertion that it
would be better not to have a penis, or aversion toward rough-and-tumble
play and rejection of male stereotypical toys, games, and activities; in
girls, rejection of urinating in a sitting position, assertion that she
has or will grow a penis, or assertion that she does not want to grow
breasts or menstruate, or marked aversion toward normative feminine
clothing.
In adolescents and adults,
the disturbance is manifested by symptoms such as preoccupation with
getting rid of primary and secondary sex characteristics (e.g., request
for hormones, surgery, or other procedures to physically alter sexual
characteristics to simulate the other sex) or belief that he or she was
born the wrong sex.
C. The disturbance is not
concurrent with a physical intersex condition.
D. The disturbance causes
clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
Note: Gender Identity Disorder may be further
specified as sexually attracted to males, females, both, or neither.
III. What is transgender-sensitive health care?
A. Proper Names and Pronouns.
The transgender person adopts a second name other than their legal name with which they may prefer to be addressed. If making a permanent transition, the birth name is legally changed with a court order. Always ask for their preference. Convey respect by addressing the transgender person using pronouns appropriate to their gendered presentation. If uncertain as to their preference, ask. Some states allow for the sex designation on the driver’s license to be changes prior to genital surgery.
B. Rapport.
Sensitivity to transgender issues will enhance the health care experience. Be sensitive to the likelihood your patient has experienced some form of stigmatization and discrimination with health care professionals. Your patient may experience anxiety and shame over their body, and should not be unnecessarily made to disrobe. If mistakes in names and pronouns occur, recognize the error, and offer an apology. Maintain a comfortable degree of eye contact. Guard against making assumptions with regard to marital status, sexual orientation, parenthood and employment. Express your concern about their general well-being. Be aware of the reactions of other health care personnel who come into contact with your patient. If discriminatory behavior is observed, educate and provide guidance.
C. Health care provider attitudes and beliefs.
Unacknowledged negative
attitudes can be unwittingly conveyed to transgender patients, and this
can create a barrier to health care.
Some surveys of medical professionals show a minority hold a
negative view toward transgender persons. Examples of negative attitudes and
beliefs include:
1.
Living as the other sex is
sexually perverted, psychologically disturbed, socially depraved, morally
corrupt, or religiously sinful,
2.
Gender transition is motivated by erotic or sexual
desires,
3.
Gender dysphoria is a
psychological disturbance that does not warrant medical intervention,
4.
Medical intervention with an anatomically healthy body is
unethical.
The degree of a person’s stereotypical maleness or femaleness is not an indication of the degree of gender dysphoria. Prior to seeking medical help with transition, transgender men and women may display a stereotypical physical appearance in an attempt to deny a cross-sex gender identity. For example, gender dysphoric natal females may have had breast implants and present an overtly feminine appearance prior to seeking masculinizing hormones. Gender dysphoric natal males are not necessarily overtly feminine in their appearance or behavior prior to seeking care.
D.
Confidentiality.
E. The social stigma attached
to cross-dressing leads transgender persons to go to great lengths to
conceal their transgender status.
Patients may concerned about what clinical information and
diagnosis will be placed in their paper or electronic medical charts, and
who will have access to that information. Health care providers should
discuss the following with their patients:
1.
What diagnostic and clinical information will be included in
written and electronic medical charts.
2.
Who will have access to this medical information
3.
How to resolve concerns about confidentiality.
IV. What is the Harry Benjamin International Gender Dysphoria Association (HBIGDA) ?
HBIGDA’s stated purpose is to provide a
multi-disciplinary professional society, representing the specialties of
medicine, psychology, social sciences, and the law, for the purpose of
furthering research and treatment of gender dysphoria, including
transsexualism. HBIGDA
publishes a set of clinical guidelines, The Standards of Care, derived from the empirical research and
clinical experience of experts in gender dysphoria. Only recently has HBIGDA included
transgender medical professionals on its Board and professional
committees.
A. The Standards of Care for Gender Identity Disorders.
The Standards of Care (SOC), introduced in 1979 and
updated regularly, represents HBIGDA’s multidisciplinary consensus on
clinical guidelines for recommending cross-sex hormones and genital
surgery. The SOC were developed in order to
minimize potential regrets following administration of sex hormones and/or
genital surgery, and to codify expert clinical knowledge in defense of
these procedures against attacks by psychiatrist critics. Specialists in transgender health
care widely follow the SOC
when making
treatment decisions for sex hormones and genital surgery. Some transgender persons
consider the SOC a paternalistic
infringement on personal liberty, and resent the medical provider’s role
as a “gate-keeper”. Providers
working with transgender patients should obtain a copy of the SOC from the HBIGDA , be
familiar with the clinical guidelines, and discuss with the patient any
“gatekeeping” concerns.
B. The three stages of gender transition.
The process of transition
from living as one gender to the other typically involves three stages,
and can take numerous years from the time professional consultation is
first sought. Psychotherapy
is helpful in exploring gender issues, making choices about how to best
resolve gender dysphoria, and managing the complex emotional and
interpersonal tasks of gender transition. Some individuals resolve gender
dysphoria without full-time transition to the other sex, sex hormones
and/or genital surgery.
1. The Real Life Experience (RLE).
a)
The RLE is full time living in the gender role consistent with the
cross-sex gender identity. Prior to the RLE, the transgender person
changes their legal name, and carefully plans for gender transition with
key people, such as family, friends, employer and co-workers. Gendered
physical appearance, style of dress, deportment, and voice, all evolve
with experience during the RLE. The long held hopes and dreams for gender
transition are now subject to the realities of lived daily experiences.
This period can be highly stressful with increased needs for support and
guidance.
b)
Transgender persons usually begin cross-sex hormones prior to
beginning the RLE because the induced feminizing or masculinizing effects
support a more realistic feminine or masculine appearance.
c)
Prior to embarking on a RLE, the consequences of full time gender
transition to family relationships, interpersonal functioning, education
and employment, and financial stability are carefully considered.
d)
RLE can result in disturbance to family relationships, loss of
important social relationships, employment discrimination and job loss,
stigmatization, and social disability.
e)
An extended full time RLE of at least one year is required by the
SOC prior to genital surgery in
order to determine whether full time and permanent gender transition will
substantially increase both psychological and social adaptation.
2. Hormonal therapy.
a) Therapeutic Aim.
The purpose of cross-sex hormone administration is the acquisition of the secondary sex characteristics of the other sex, in transsexual patients to the fullest extent possible. The SOC state that cross-sex hormones are medically necessary for rehabilitation in the new gender. The physical and psychological changes assist in feeling and appearing more like the desired sex. Hormones promote the aligning of physical appearance with gender identity and body image, and assist in passing into society in the new gender. As such, hormones limit psychiatric morbidity, and increase quality of life, although hormones are associated with specific health risks.
b) Risk associated with delayed or denied access to cross-sex hormones.
(1)
Cross-sex hormone administration can be effectively managed within
the primary care setting; however, primary care providers who are unsure
of how to manage cross-sex hormones, may feel compelled to refer patients
requesting hormones to endocrinology specialists.
(2)
Hormones and related medical care may be denied when confusion
exists about what treatment is covered in the health plan benefit.
(3)
Unnecessary delay or denial of access to hormone administration is
a risk factor for psychological impairment and self-administered treatment
with hormones obtained on the black market or from international
suppliers. Self-treatment
results in higher levels of medical complications compared to medically
supervised hormone administration, including hyperprolactinemia, elevated
liver enzymes, and an increase in cardiovascular risk factors (i.e.,
thromboembolism, elevated LDL-cholesterol and triglycerides).
c) Requirements for hormonal therapy.
One letter of recommendation from a qualified mental health professional to the provider responsible for managing the hormone regimen is required. This letter should document that the patient has fulfilled the eligibility and readiness criteria listed below. Hormones should not be prescribed without such consultation from mental health professionals.
(1) Eligibility Criteria.
(a)
Age 18 years.
(b)
Demonstrable knowledge of what hormones medically can and cannot do
and their social benefits and risks.
(c)
Either a documented real life experience should e undertaken for at
least three months prior to the administration of hormones, or
(d)
A period of psychotherapy of a duration specified by the mental
health professional after the initial evaluation (usually a minimum of
three months) should be undertaken.
(e)
Under no circumstances should a person be provided hormones who has
neither fulfilled the RLE or psychotherapy criteria. .
(2) Readiness criteria.
(a)
The patient has had further consolidation of gender identity during
the real-life-experience or psychotherapy.
(b)
The patient has made some progress in mastering other identified
problems to improving or continuing stable mental health.
(c)
Hormones are likely to be taken in a responsible manner
3. Genital and breast surgery.
a) Male to Female Surgeries include:
(1) Breast augmentation.
(2) Thyroid cartilage reduction (“tracheal chave”).
(3) Orchidectomy.
(4) Vaginoplasty..
(5) Facial feminization surgery.
b) Female-to-Male surgeries include:
(1) Chest reconstruction.
(2) Metiodioplasty- surgical freeing or unhooding of the clitoris.
(3) Oophorectomy
(4) Hysterectomy.
(5) Phalloplasty.
c) Requirements for Genital Reconstructive and Breast Surgery.
Two letters of recommendation are required: the first is an extensive report from the primary therapist, and the second is an evaluation of readiness by an independent provider. Both letters should document that the patient has fulfilled the eligibility and readiness criteria listed below.
(1) Eligibility Criteria.
(a)
Legal age of majority in the patient’s nation.
(b)
12 months of continuous hormonal therapy for those without a
medical contraindication
(c)
12 months of successful continuous full time
real-life-experience. Periods
of returning to the original gender may indicate ambivalence about
proceeding and should not be used to fulfill this criterion
(d)
if required by the mental health professional, regular responsible
participation in psychotherapy throughout the real-life-experience at a
frequency determined by the mental health professional. Psychotherapy per se is not an
absolute eligibility criterion for surgery
(e)
demonstrable knowledge of the cost, required hospitalizations,
likely complications, and post surgical rehabilitation requirements of
various surgical approaches
(f)
awareness of different competent surgeons
(2) Readiness Criteria.
(a)
Demonstrable progress in consolidating the evolving gender
identity
(b)
Demonstrable progress in dealing with work, family, and
interpersonal issues resulting in a significantly better state of mental
health
C. The Health Law Standards of Care for Transsexualism.
These alternative
“standards of care” were developed by transgender activists and attorneys
at the International Conference on Transgender Law and Employment
Policy. Some patients may ask
about them, so it is important to show your awareness of their
existence. These standards
assert the right of access to cross-sex hormones and genital and other
surgeries, without a mandatory period of real-life-experience in the
gender role opposite to natal sex and without the recommendation of a
mental health professional, as long as there are no medical
contra-indications to these procedures.
V. What are the mental health issues?
A. The role of the behavioral health professional.
1. Assessment and diagnosis.
a) Gender identity and sexual identity.
b) Coping resources.
c) Mood disorders.
d) Substance use disorders.
e) Suicide Potential and prevention.
f) Family and relationship disruptions.
2. Psychotherapy.
a) Validation and support.
b) Exploring options for resolving gender identity issues.
c) Exploring issues of internalized transphobia, homophobia, stigmatization, shame, and, guilt.
d) Problem-solving transition issues.
e) Specific treatment for mental health problems.
(1) Depression and anxiety.
(2) Suicidal ideation..
(3) Acute crisis situations.
3. Referral to health care professionals for specialty medical care.
a) Referral to a local transgender support group.
b) Referral for cross-sex hormones.
c) Referral for genital surgery.
B. Stress associated with being transgender.
1. Stigmatization
2. Discrimination
3. Financial costs.
C. Psychological issues.
1. Coming out.
2. Shame and guilt.
3. Grief and loss.
4. Isolation.
VI.
Administration of cross-sex hormones.
A. Desired outcomes.
1. Elimination to the greatest degree possible, the secondary sex characteristics of the natal sex.
2. Induction to the greatest degree possible, the secondary sex characteristics of the other sex.
a) Desired estrogenic feminization.
(1) Breast development with full maturation in 2 to 6 years (lesser hemi-circumference than in female family members is expected); enlargement of the areola; tenderness and transitory pain may occur within the first 1 to 2 years.
(2) Smoother, softer, less oily skin.
(3) Increase in subcutaneous fat.
(4) Re-distribution of fat onto lower abdomen, thighs, and buttocks.
(5) Diminished body hair on the abdomen and pubic area.
(6) Slowing or cessation of scalp hair loss.
b) Desired androgenic masculinization.
(1) Cessation of menstrual bleeding (in approximately 3 to 6 months).
(2) A male pattern of facial and body hair similar in degree and pattern found in males of the immediate family. This may include male pattern baldness.
(3) Deepening of the voice, beginning in 6 to 10 weeks, which is irreversible.
(4) Reduction of subcutaneous fat (but increase in abdominal fat).
(5) Increased muscle mass.
(6) Thickening of skin.
(7) Clitoral enlargement.
3. Prevention of the deleterious health effects associated with the elimination of natal sex hormones
a) Osteoporosis may be a risk in transsexual men and women who have had gonads surgically removed. In order to prevent bone density loss after gonad removal, cross-sex hormones must be continually taken (at lower dosages).
4. Minimization and management of potential complications associated with exogenous cross-sex hormones.
B. Cross-sex hormone management.
1. The initial primary care visit.
a) Discuss goals and expectations for cross-sex hormones, including future transition and surgery goals.
b) Assess SOC eligibility and readiness criteria, including mental health professional letter of recommendation. Assess whether mental health needs are being addressed.
c) Obtain sex history and assess HIV/STD risk.
d) Inform about benefits and risks of cross-sex hormone use.
e) General exam and systems review.
f) Teach and encourage breast self-exam.
g) Obtain informed consent.
h) Order screening laboratory studies.
(1) Male-to-female: CBC, liver enzymes, lipid profile, renal panel, fasting glucose, testosterone level, prolactin level.
(2) Female-to-male: CBC, liver enzymes, lipid profile, renal panel, fasting glucose.
2. Follow up visits: 3 months after starting cross-sex hormones, and every 6 to 12 months thereafter.
a) Assess changes in secondary sex characteristics.
b) Review compliance with hormone regimen.
c) Assess for hormone related mood changes.
d) Education about HIV/STD prevention.
e) Assess psychological and social impact of gender transition, if in RLE.
f) If needed, complete forms for name and gender change documentation.
g) Laboratory monitoring.
(1) Male-to-female: CBC, liver enzymes, lipid profile, renal panel (if using spironolactone), testosterone level (if feminization is unsuccessful with maximum estrogen dosing), prolactin level (for first three years; elevations may occur with estrogen noncompliance).
(2) Female-to-male: CBC, liver enzymes, lipid profile, testosterone level, vaginal bleeding should be evaluated (EMBx).
h) Continue routine health care maintenance:
(1) Male-to female: breast self-exam, mammography, prostate screening, PAP smear
(2) Female-to-male: breast self-exam, mammography, PAP smear.
C. Contra-indications to cross-sex hormones.
1. Sex steroids in general.
a) Serious cardiovascular disease.
b) Cerebrovasular disease.
c) Thromboembolic disease.
d) Marked obesity.
e) Poorly controlled diabetus mellitus.
f) Serious liver disease.
2. Estrogens.
a) Strong family history of breast cancer.
b) Prolactin-producing pituitary tumor.
3. Testesterone.
a) Severe lipid disorders with cardiovascular complications.
4. Prior to elective surgery.
Sex hormones should be stopped 3 to 4 weeks
prior to elective surgery because of the increased thromboembolic risk
associated with immobization which may be increased by sex steroids .
D. Typical hormone regimens prior to genital surgery.
1. Male to Female cross-sex hormone management.
a) General Considerations.
(1)
Estrogen is primarily responsible for inducing female sex
characteristics in biological males, and reducing gonadotropin output and
androgen production.
(2)
Total mortality for exogenous estrogen use is not higher than in
the general population.
(3)
No specific estrogen preparation has been demonstrated more
efficacious then others.
Optimal dosages have not been established.
(4)
The choice of hormone regimen
will depend upon health risks, side effects, availability, cost,
route of delivery, geographical preferences, and transgender folk
tradition.
(5)
Large doses of estrogen alone may not be sufficient to
significantly increase estrogen blood levels and to completely suppress
testosterone in biological males.
(6)
An androgen-suppressing agent in addition to estrogen is more
effective in suppressing testosterone to within normal female levels;
then, lower dosages of estrogens may be needed to achieve normal
biological female estrogen levels.
(7)
The same dosages of estrogens and anti-androgens have widely
varying effects on estrogen and testosterone levels in different
patients.
(8)
Estrogen and testosterone blood levels have nor been shown to
correlate with degree of feminization or maculinization.
(9)
A small percentage of biological males may not show significant
feminization even with estrogen and testosterone levels within the normal
female range.
(10)
A combined intramuscular and oral estrogen regimen may be most
reliable in producing estrogen levels at or above the normal female range,
and suppressing testosterone levels to normal female range.
(11)
Estrogen decreases adrenal androgens. In post-operative transsexual
women, low levels of adrenal androgens may further contribute to decreased
libido.
b)
Delivery route: oral, intramuscular, or transdermal?
(1)
Oral.
(a)
Easy daily use
(b)
Inexpensive.
(c)
Greater clotting potential then intramuscular and transdermal.
(2)
Intramuscular
(a)
Less expensive.
(b)
Daily dosing not required.
(c)
Lesser clotting potential than oral delivery.
(d)
Higher potential for overdose with self-administration.
(e)
Some patients have difficulty with self-injection.
(f)
High levels of circulating estrogens.
(g)
Problematic syringe disposal.
(3)
Transdermal.
(a)
Easy application without daily dosing.
(b)
Less potent then
c)
Estrogens.
(1)
Estradiol.
(a)
oral (Estrace): 4 mg+
per day.
(b)
intramuscular
(estradiol valerate) 40 mg per month or 20mg every two weeks.
(c)
transdermal (Estraderm 50-100 mg two patches per week).
(d)
Low heptic toxicity
(e)
Blood levels can be easily compared with normal female reference
range.
(2)
Ethinyl Estradiol.
(a)
administered orally (Estynil) 0.1-0.5 mg per day have been
reported. One study found
breast growth the same for 0.1 mg/d and 0.5mg/d of ethinyl estradiol.
(b)
is superior to conjugated estrogens in suppression of testosterone
and gonadotropins but equal in promoting breast tissue growth.
(c)
is associated with higher levels of liver function abnormalities
than conjugated estrogens.
(3)
Conjugated estrogens. (Premarin) 5 mg per day oral.
d) Progesterones
(1)
Medroxyprogesterone (Provera) 2.5-10 mg/d.
e) Anti-androgens
(1)
Spironolactone (a diuretic with antiandrogenic effects) 100-300
mg/d.
(2)
Cyproterone 100 mg/d.
2. Female to Male cross-sex hormone management.
a) General considerations.
(1)
Testosterone is primarily responsible for inducing male secondary
sex characteristics, and is the single exogenous hormone administered to
transsexual men.
(2)
Exogenous testosterone is primarily administered by intramuscular
injections that can be taught to the patient.
(3)
No significant morbidity has been observed in studies of androgen
administration in transsexual men, and total mortality is not greater than
in the general population.
(4)
Due to potential for increased cardiac disease risk factors,
tobacco use should be discouraged, and exercise and low fat diet should be
encouraged.
b) Delivery route.
(1)
Intramuscular recommended.
(2)
Transdermal is available but little insufficient clinical
experience.
(3)
Oral doses not recommended because the high dosages required result
in elevated liver enzymes and high blood pressure.
c)
Androgens.
(1)
Testosterone cypionate (cotton seed oil suspension) 200 mg every
two weeks. Lower doses do not
adequately suppress gonadatropins; higher doses do not further increase
clitoral length or suppress gonadotropins. Maximal cliteral length 6cm.
(2)
Testosterone enanthate (sesame seed oil suspension).
E. Potential health risks of high dose oral estrogens.
1.
In general, estrogen administration is considered to be an
acceptably safe practice when managed by knowledgeable medical
professionals.
2.
Documented: elevated liver enzymes, increased production of
coagulation factors, elevated triglycerides, and rennin, benign pituitary
prolactinoma, weight gain.
3.
Venous/ thrombosis/thromboembolism is observed with oral estrogens
(2-6%), most often in patients over 40 years (12%) in the first year of
estrogen use. Transdermal delivery is associated with relatively reduced
clotting potential compared to oral estrogens, and is recommended in
patients over 40 years old. Regimen aspirin is recommended for patients
over 40 years old to reduce risk of clotting.
4.
Breast carcinoma is documented in the medical literature in two
cases.
5.
Prostate carcinoma is documented in three cases but may be
independent of estrogen use.
6.
Depressive mood changes.
F. Potential health risks associated with exogenous androgens.
1.
Androgen administration is generally considered to pose fewer
health risks than estrogen.
2.
Changes in lipid profile such as increased cholesterol, and lower HDL. Risk
for cardiac disease is higher in natal males, and transsexual men taking
androgens may be at higher risk also.
3.
Hypertension.
4.
Elevated liver enzymes and hepatotoxicity.
5.
Weight increases
greater than 10 percent (17.2% in one sample).
6.
Acne (50 to 60%) on face or back; more severe cases (12%) may
require dermatological treatment.
7.
Migraine headaches in the first 3 to 6 months that may be
alleviated by dosing change.
8.
Unknown effects on breast, cervical, endometrial, and ovarian
tissues. After many years of
testosterone use, intrauterine complications may develop, such as
endometriosis, fibroid ovarian cysts, fibrous scar tissue of the
reproductive organs.
Oophorectomy and/or hysterectomy may be recommended in transsexual
men treated with testosterone after successful transition.
9.
Mood changes, including depression and irritability.
G. Potential health risks of progesterones.
1.
Thromboembolism.
2.
Breast carcinoma.
3.
Elevated liver enzymes.
4.
Hypertension.
5.
Cardiac disease.
H. Potential health risks of anti-androgens.
1.
Weakness, fatigue, decreased appetite, weight gain, headache,
excessive thirst or urination.
VII.
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