Download Community Hormone Access Project (CHAP)

WELCOME TO THE COMMUNITY HORMONE
ACCESS PROJECT (CHAP) PROTOCOLS
In this document, we have gathered together best practices from an international array of clinics specializing in
transgender healthcare. These protocols are based on our belief that excellent healthcare for transgender and gender
non-conforming people includes access to hormone treatments in a non-judgmental clinical setting which supports them
in making informed decisions about their healthcare. These protocols were developed over many months of work with
the Trans Youth Support Network and include input from trans activists and patients, community clinics, mental health
professionals and providers working in a wide variety of healthcare settings. We hope you find them useful as you begin
the process of adding hormone monitoring and/or prescribing to your practice.
The Community Hormone Access Project is here to help you as you start this important process. We are happy to act as
a resource for further information, particularly around ongoing training and helping you find mentorship from providers
who have expertise in hormone provision, as well as creating a network of providers who are working to add this critical
element to their practice.
While hormone access is one of the major healthcare issues for trans people, it is only one component of ensuring that
you are providing excellent, accessible, respectful care to your trans and gender non-conforming patients. Please see the
information on page 4 in this document about becoming a member of the Trans Youth Support Network and gaining
direct access to feedback from trans and gender non-conforming young people about how to continue to make your
practice more responsive to their needs.
We are thrilled you are considering this step. Please let us know what else you need from us along the way!
Sincerely,
The Community Hormone Access Project
Katie Burgess
Executive Director, TYSN
[email protected]
(612)363-7574
Roxanne Anderson
Executive Director, Minnesota Transgender Health Coalition
[email protected]
612-823-1152
Elizabeth Goodney, Katie Spencer, Erin Wilkins, Morgan Anderson, Megan Holm
VISION, PHILOSPHY, AND METHOLOGY OF
COMMUNITY HORMONE ACCESS PROJECT (CHAP)
Trans Youth Support Network Healthcare Subcommittee
The Community Hormone Access Project (CHAP) was founded out of the Trans youth Support Network’s (TYSN)
mission to promote racial, social, and economic justice for trans youth with the freedom to self-identify gender identity
and expression. In order to fulfill this mission, the TYSN Network Collaborative Healthcare Subcommittee developed the
Community Hormone Access Project (CHAP) to promote equitable medical healthcare services for trans and gender nonconforming youth in sliding scale, community based clinics. Our vision of equitable medical healthcare services for trans
and gender non-conforming youth include the affordable prescription and monitoring of Hormone Replacement
Therapy without unnecessary psychological intervention. In order to achieve our mission, we provide consultation,
evaluation, and researched protocol to medical healthcare providers. Simultaneously, TYSN provides trans and gender
non-conforming youth the opportunity to consult and evaluate medical healthcare providers and the clinics they
operate out of. We seek to build these relationships into a community of accountable and culturally sensitive medical
healthcare services for trans and gender non-conforming youth.
CHAP is a dedicated group comprised of medical and mental health providers, community based clinic workers, and
trans activists. Utilizing informed consent models from several leading clinics across the United States and Canada,
CHAP has created comprehensive protocols based on a best practices approach to the provision and maintenance of
hormone therapy. CHAP’s recommended approach is consistent with the latest version of the World Professional
Association for Transgender Health’s Standards of Care, published in September 2011 and utilizes major medical
treatment protocols, including the Endocrine Society of North America.
Our informed consent protocols prescribe that patients who are requesting hormones have the cognitive ability to make
such a decision and comprehensive information about hormones and their effects. In other words, this means that
patients must show that they can understand the potential risks and benefits of Hormone Replacement Therapy and
that they are able to anticipate how that choice may impact them now and in the future.
The philosophy framing the development of CHAP’s recommended protocols includes an understanding of the fluidity of
gender and respect for individuals’ respective journeys. CHAP believes each individual has a right to express their gender
and modify their body to be congruent with their individual needs.
CHAP believes all transgender people have a right to empowering, embodying, empathic healthcare. Transgender
people consistently and historically have experienced patronizing and pathologizing treatment at the hands of medical
professionals. According to the 2011 report issued by the National Center for Transgender Equality in coalition with the
National Gay and Lesbian Task Force on the National Transgender Discrimination Survey, 19% of transgender individuals
are refused healthcare and 28% are verbally harassed in medical settings. TYSN Youth Members often report choosing
to access unsafe hormones (on the street and over the internet) due to negative experiences at clinics and with medical
providers that have made them feel unsafe, disrespected, patronized, and offended. CHAP believes an informed
consent model can be a positive and empowering medical experience, which can have a profound impact on
transgender patients’ health and well-being. Informed consent gives patients the power to advocate for themselves in
medical settings and facilitates a sense of body ownership, which is often a barrier to transgender patients accessing
medical care as well as feeling at home in their own bodies.
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WHAT IS THE NETWORK COLLABORATIVE?
The TYSN Network Collaborative is a place where social service organizations, community groups, and young
people can come together to work on making systems, services, and institutions better for our community.
The Network Collaborative’s mission is to promote racial, social, and economic justice for trans youth with the
freedom to self-define gender identity and expression. Network Members commit to changing what they do
so that our mission can come true.
Healthcare Agency Members
TYSN partners with a variety of community based healthcare clinics and other agencies in Minnesota to
decrease the barriers trans youth face in accessing healthcare services. The main strategy behind building
these relationships is increasing confidential and constructive feedback from young trans patients and
potential patients to the agency. The secondary strategy is to develop relationships between agency
representatives to share best-practice guidelines for working with trans youth. Most often, the results of this
process are improved policies, procedures, and paperwork – such as reforming intake practices to be more
inclusive of trans and LGBTQ patients or creating gender inclusive bathrooms.
Individual Medical Practitioner Members
TYSN strives to develop relationships with individual practitioners in Minnesota as well as agencies. Similarly,
the main strategy behind building these relationships is increasing confidential and constructive feedback
from young trans patients and potential patients to the practitioners. The secondary strategy is to develop
relationships between practitioners to share best-practice guidelines for working with trans youth. This
process has the potential to result in improved culturally sensitivity on the part of the practitioner and more
accessible healthcare services for trans youth in Minnesota.
Please log on to www.transyouthsupportnetwork.org/network.html and download the New Member
Handbook for more information.
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ASSESSING READINESS FOR HORMONES
Informed consent requires a detailed discussion with the patient covering the risks and benefits of
treatment. See pages 19-25 for sample forms. All treatment for minors requires parental/guardian consent,
usually from both parents, unless the minor falls under the definition of a legally emancipated minor.
The only absolute medical contra indication to initiating or maintaining estrogen or testosterone therapy is an
estrogen- or testosterone-sensitive cancer. Other conditions such as obesity, cardiovascular disease,
dyslipidemas, or other conditions should not preclude treatment in the setting of informed consent. While in
the past, history of venous thromboembolism was a contraindication to estrogen hormone replacement,
recent data shows that safer estrogen preparations, such as transdermal, do not preclude this.
If prescribing masculinizing or feminizing hormones for a patient who has not used them before, assess for
pre-existing health conditions to aid in determining which preparation and dosage to prescribe (see Hormone
Administration on page 7). It is the clinician's responsibility to monitor the effects of masculinizing and
feminizing hormones.
Checklist for Assessing Readiness
This can be accomplished in one (or more) visits
1.
2.
3.
4.
Determine if patient is in need of bridging hormone treatment (see page 11 on bridging)
Conduct initial medical evaluation and initial laboratory tests
Determine that there are no contraindications for hormone therapy
Review informed consent of medical risks of hormone therapy with patient (see pages 19-25)
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University of California, San
Francisco, Department of Family and Community Medicine, April 2011
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BASELINE LABORATORY TESTS
Essentials for Trans Women
Fasting lipid panel (if on oral estrogen). If taking spironolactone, then include potassium and creatinine). Use F
reference values for trans women taking estrogens. Creatinine clearance should be a clinical judgment based
on muscle mass and body fat distribution.
There is no current clinical evidence for checking liver function in trans women using estrogen. The standard
of testing liver function in trans women is based on older studies with methodological flaws, using
formulations no longer prescribed (ethinyl estradiol), and not controlling for conditions that cause elevated
liver function including alcohol and hepatitis B. Transient elevations with no clinical significance were included
in the evidence that estrogen causes liver abnormalities. Current publications make no mention of liver
function abnormalities in relation to estrogen use. However, it may be useful to check transaminases if patient
is taking oral estrogen. (Grade A, B)
Essentials for Trans Men
Hemoglobin, LDL/HDL. Use M reference values for transmen taking testosterone. (Grade C)
Considerations with Respect to Laboratory Tests
Family history and/or other possibly relevant risk factors.
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University
of California, San Francisco, Department of Family and Community Medicine, April 2011
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HORMONE ADMINISTRATION
The use of masculinizing and feminizing hormones to balance gender (induce or maintain the physical and
psychological characteristics of the sex that matches the patient's gender identity) is increasing around the
world. Masculinizing and feminizing hormone administration is currently an off-label use of both estrogens
and androgens; however, over 50 years of clinical experience have shown that this practice is effective in
treating gender dysphoria. (See Hembree, et al (2009) and Gooren, et al (2008) in References.) It is important
that the ability to understand and monitor this treatment becomes a part of primary care practice. This
protocol is intended to aid in that process.
Not all transgender patients will want to take masculinizing and feminizing hormones, but if a transgender
patient does need to express a gender different from their assigned birth sex on a consistent basis,
masculinizing and feminizing hormones are the most common body modification that transgender patients
can access for self-actualization, bringing the endocrine and psychological systems into balance.
An individual may already be receiving masculinizing and feminizing hormones when they become the
physician's patient. Review the current regimen in combination with a thorough assessment of the patient's
general health to determine whether to recommend changes in dosage or preparation.
Most medical problems that arise in the transgender patient are not secondary to masculinizing and
feminizing hormone use.
Discuss fertility issues with all patients considering hormone therapy. (See section Fertility Issues)
Note: Hormone therapy does not necessarily prevent pregnancy. Testosterone is not a contraceptive
substance; transmen having unprotected sex (where semen may enter the vaginal canal) are at risk for
pregnancy if they have not had a hysterectomy.
If prescribing masculinizing and feminizing hormones for a patient who has not used them before, assess for
pre-existing conditions, to aid in determining which preparation and dosage to prescribe (see
recommendations below). It is the clinician's responsibility to monitor the effects of hormones. (See Assessing
Readiness for Hormones on page 5)
Hormonal therapy for trans women may include anti-androgen therapy as well as estrogen therapy. Non-oral
estrogens, including sublingual, transdermal, and injectable hormones are preferable. These have the
advantage of avoiding first pass through liver metabolism. (Grade B)
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University
of California, San Francisco, Department of Family and Community Medicine, April 2011
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EVIDENCE BASED TRANSGENDER MEDICINE
"Published transgender-specific level 1 evidence is essentially non-existent. [...] Long-term,
prospective studies for most transgender-specific health issues are lacking, thus resulting
in variable preventive care recommendations based primarily on expert opinion. However,
by utilizing an increasing body of peer-reviewed, scientific research on transgender health,
along with relevant data from the general population, one can develop an evidence-based
approach to preventive care for patients who are transgendered or transsexual."
-- Jamie Feldman, M.D. (Feldman, J [2007])
Many thousands of transgender and transsexual people have been treated with masculinizing and
feminizing hormones (see http://www.transhealth.ucsf.edu/trans?page=protocol-hormones) and surgical
procedures for over 70 years in Western Europe and over 60 years in the US. Yet because of the stigma of
gender-variance and sex reassignment (also called sex affirmation, or gender confirmation) which discourages
funding for research, and because of the difficulty of conducting randomized trials involving masculinizing and
feminizing treatments, very little specific information about treatment actually exists beyond case reports and
small scale studies on specific clinical issues.
To address the health care needs of their transgender and transsexual patients, clinicians have extrapolated
from studies based on non-transgender populations, and adapted findings from the few long-term
masculinizing and feminizing hormonal assessments done in the Netherlands by Gooren, et al., combined with
their own clinical experience, to support clinical judgments regarding basic health care with general
success.(Gooren, LJ [2008])
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University
of California, San Francisco, Department of Family and Community Medicine, April 2011
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MENTAL HEALTH
As with all patients, the primary care medical provider should screen for psychiatric conditions, including
substance abuse. Depression is common, and providers should ask about persistent depressed mood,
anhedonia, and suicidal ideation, and treat or refer those with clinical depression. Trans people, especially the
urban poor, may have suffered harassment or physical trauma. Patients who have experienced trauma should
be asked about symptoms of post-traumatic stress disorder, as well as other anxiety disorders. Substance use
may occur as avoidance coping in patients with gender dysphoria and/or stressful environments. Referral for
psychiatric illness and substance abuse treatment should be to a mental health provider with an
understanding of trans care issues.
The patient presenting for initiation of masculinizing and feminizing hormonal therapy for gender transition
may require particular attention. While transition itself often provides great relief from gender dysphoria, it
may be a time of heightened environmental stress, presenting challenges with the patient's family, partner,
school, and/or place of employment. Referral to a psychotherapist experienced in working with trans people is
helpful for many.
The World Professional Association for Transgender Health (WPATH) publishes Standards of Care (SOC) which
are periodically updated. These protocols may be reviewed at www.wpath.org. The SOC recommend a mental
health evaluation for those starting masculinizing and feminizing hormonal therapy. CHAP advocates that
primary care providers can initiate masculinizing and feminizing hormonal therapy for transition based on
their own assessment, with referral to mental health only when determined to be necessary. The primary care
provider should assess every patient initiating masculinizing and feminizing hormonal therapy for ability to
understand the risks and benefits of treatment, discuss these with the patient, and consider obtaining a signed
consent of this understanding. (See Sample Consent Forms on pages 19-25)
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University
of California, San Francisco, Department of Family and Community Medicine, April 2011
Mental health can be a complicated topic for providers working with transgender populations as the field of
mental health has been in the past a site of tremendous oppression and trauma for many transgender
individuals. The history of “gate-keeping” models of care and the existence of gender identity disorder as a
psychiatric diagnosis had created barriers to transgender patients accessing care. The landscape of
transgender health care has shifted tremendously from its origins, and there is no longer a requirement for
transgender patients to complete a course of psychotherapy.
Transgender people face stigma, lack of social support, and other specific challenges in accessing healthcare.
Additionally, the trauma of living in a transphobic culture and the multiple forces of systemic oppressions can
impact a transgender person’s mental health when accessing services. As a provider, it is important to be
aware of the impact of stigma on mental and physical health and to conceptualize provision of trans
supportive and competent medical care as an intervention in combating the deleterious effects of stigma in
individuals lives.
It is important that providers refer patients for mental health services appropriately, and keep in mind their
own socialization around gender and sexuality which may lead them to be overly critical or pathologizing of
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transgender clients. This is to say, gender non conformity in itself is NOT pathological, and does not indicate a
referral for mental health services. A thorough mental health assessment of current psychological functioning
is recommended as part of treatment, but as long as mental health symptoms are well controlled, the
existence of mental health concerns does not preclude initiation of hormone therapies. Keep in mind these
recommendations from the WPATH SOC:
Psychotherapy is not an absolute requirement for hormone therapy and surgery. A mental
health screening and/or assessment as outlined above is needed for referral to hormonal and
surgical treatments for gender dysphoria. In contrast, psychotherapy – although highly
recommended – is not a requirement.
The SOC do not recommend a minimum number of psychotherapy sessions prior to hormone therapy or
surgery. The reasons for this are multifaceted (Lev, 2009). First, a minimum number of sessions tends to be
construed as a hurdle, which discourages the genuine opportunity for personal growth. Second, mental health
professionals can offer important support to clients throughout all phases of exploration of gender identity,
gender expression, and possible transition – not just prior to any possible medical interventions. Third, clients
differ in their abilities to attain similar goals in a specified time period.
When faced with a client who is unable to access services, referral to available peer support resources (offline
and online) is recommended. Finally, harm reduction approaches might be indicated to assist clients with
making healthy decisions to improve their lives.
CHAP recommends providers comply with the accepted guidelines for initiating hormone therapy as described
by the most recent stands of care published by WPATH. These include:
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI);
4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.
Again, providers should be aware that a mental health diagnosis does not preclude initiation of hormone
therapy.
As noted in section VII of the SOC, the presence of co-existing mental health concerns does not necessarily
preclude access to feminizing/masculinizing hormones; rather, these concerns need to be managed prior to or
concurrent with treatment of gender dysphoria.
In selected circumstances, it can be acceptable practice to provide hormones to patients who have not fulfilled
these criteria. Examples include facilitating the provision of monitored therapy using hormones of known
quality as an alternative to illicit or unsupervised hormone use or to patients who have already established
themselves in their affirmed gender and who have a history of prior hormone use. It is unethical to deny
availability or eligibility for hormone therapy solely on the basis of blood seropositivity for blood-borne
infections such as HIV or hepatitis B or C.
In rare cases, hormone therapy may be contraindicated due to serious individual health conditions.
Health professionals should assist these patients with accessing non-hormonal interventions for gender
dysphoria. A qualified mental health professional familiar with the patient is an excellent resource in these
circumstances.
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HARM REDUCTION, BRIDGING, AND
CONTINUING TREATMENT
Some patients may already have been using masculinizing and feminizing hormones; they may have had
them prescribed by a physician (and may be seeking a new physician for whatever reason), or they may have
obtained hormones through overseas, "street," or Internet sources, without any prior physician evaluation. In
this latter instance, the WPATH SOC has provisions for physicians to continue the medical treatment of
patients who have independently initiated masculinizing and feminizing hormone therapy, regardless of the
patient's ability or desire to receive gender-related psychiatric/psychological evaluation. Physicians may
provide treatment based upon the principle of Harm Reduction. When patients have demonstrated their
determination to continue using medication(s) without physician oversight, then it is usually advisable to
assume their medical care and prescribe appropriate hormones. Denying them care will only result in their
continued independent treatment, possibly to their detriment.
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University
of California, San Francisco, Department of Family and Community Medicine, April 2011
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NON-FDA APPROVED MEDICATION THAT MAY
BE SEEN IN SELF-MEDICATING PATIENTS
There is an anti-androgen that may be seen in use amongst self-medicating patients that is not FDA
approved. The name of the anti-androgen is cyproterone acetate. This is occasionally imported by patients
from Canada or from other nations in which it has gained approval. The side effects information and other
possibly relevant details on the drug are fairly long so iti s best to refer to the included documents from Bayer
Canada or the British regulatory agency, the MHRA. The information on dosing based on the Canadian
Sherbourne protocols suggests the following:
Starting does between 25-50mg/day oral
Maximum dose 100mg/day oral
Physician info: See pages 3 to 12 on Androcur Bayer Physician Information Sheet
Consumer info: See pages 27 to 30 of Androcur Bayer Physician Information Sheet
Patient should be given an opportunity to read the consumer information segment so that they are aware of
the risks and benefits of the medication. The injectable version is unlikely to be seen in patients who are selfmedicating as oral is typically preferred by patients in that context. Keep in mind that much of the
documentation is geared towards use for prostate cancer so certain elements of the documentation will be
irrelevant to the treatment of trans women.
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HORMONE ACCESS AND YOUNGER YOUTH
Youth who are younger than 18 are increasingly seeking out services, including medical transition options.
Endocrinological interventions for adolescents fall into two categories:
1. Fully reversible interventions. These involve the use of GnRH analogues to suppress estrogen or testosterone
production and consequently delay the physical changes of puberty. Alternative treatment options include
progestins (most commonly medroxyprogesterone) or other medications (such as spironolactone) that decrease
the effects of androgens secreted by the testicles of adolescents who are not receiving GnRH analogues.
Continuous oral contraceptives (or depot medroxyprogesterone) may be used to suppress menses.
2. Partially reversible interventions. These include hormone therapy to masculinize or feminize the body. Some
hormone-induced changes may need reconstructive surgery to reverse the effect (e.g., gynaecomastia caused by
estrogens), while other changes are not reversible (e.g., deepening of the voice caused by testosterone).
From the WPATH Standards of Care Version VII (2011)
Adolescents may be eligible for puberty suppressing hormones as soon as pubertal changes have begun.
In order for adolescents and their parents to make an informed decision about pubertal delay, it is
recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. Some
children may arrive at this stage at very young ages (e.g., 9 years of age). Studies evaluating this
approach only included children who were at least 12 years of age (Cohen-Kettenis,Schagen, Steensma,
de Vries, & Delemarre-van de Waal, 2011; de Vries, Steensma et al., 2010;Delemarre-van de Waal, van
Weissenbruch, & Cohen Kettenis, 2004; Delemarre-van de Waal &Cohen-Kettenis, 2006).
Two goals justify intervention with puberty suppressing hormones: (i) their use gives adolescents more
time to explore their gender nonconformity and other developmental issues; and (ii) their use may
facilitate transition by preventing the development of sex characteristics that are difficult or impossible
to reverse if adolescents continue on to pursue sex reassignment.
Puberty suppression may continue for a few years, at which time a decision is made to either discontinue
all hormone therapy or transition to a feminizing/masculinizing hormone regimen.
Pubertal suppression does not inevitably lead to social transition or to sex reassignment.
Adolescents may be eligible to begin feminizing/masculinizing hormone therapy, preferably with
parental consent. In many countries, 16-year-olds are legal adults for medical decision-making and do
not require parental consent. Ideally, treatment decisions should be made among the adolescent, the
family, and the treatment team.
Regimens for hormone therapy in gender dysphoric adolescents differ substantially from those used in
adults (Hembree et al., 2009). The hormone regimens for youth are adapted to account for the somatic,
emotional, and mental development that occurs throughout adolescence (Hembree et al., 2009).
Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to
an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is
strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al.,2010),
withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a
neutral option for adolescents.
CHAP encourages providers to treat adolescents with care and respect and to assist them in accessing appropriate care.
There are several providers in the Minneapolis-St. Paul area that specialize in working with adolescents and are
knowledgeable about puberty suppression and hormone administration during adolescence. CHAP encourages providers
to either refer to these providers, or work closely with these providers when working with adolescents.
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SUGGESTED DOSAGES OF FEMINIZING /
MASCULINIZING HORMONES
Feminizing
Dosage
Estrogen
Oral: estradiol
Transdermal: estradiol patch
2.0–6.0 mg/d
0.1– 0.4 mg twice weekly
Parenteral: estradiol
valerate or cypionate
5–20 mg im every 2 wk
2–10 mg im every week
Antiandrogens
Spironolactone
Cyproterone acetateb
100–200 mg/d
50–100 mg/d
3.75 mg sc monthly
GnRH agonist
160–240 mg/d
Masculinizing
Dosage
Testosterone
Oral: testosterone
undecanoateb
Parenteral
Testosterone enanthate
or cypionate
Testosterone
undecanoate b,c
Transdermal
Testosterone gel 1%
Testosterone patch
100–200 mg im every
2 wk or 50% weekly
1000 mg every 12 wk
2.5–10 g/d
2.5–7.5 mg/d
a Estrogens used with or without antiandrogens or GnRH agonist.
b Not available in the United States.
c 1000 mg initially, followed by an injection at 6 wk, then at 12-wk intervals
**Tables taken from The Endocrine Society’s Clinical guidelines for Endocrine Treatment of Transsexual Persons
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MONITORING OF MTF TRANSSEXUAL
PERSONS ON CROSS-HORMONE THERAPY
1. Evaluate patient every 2–3 months in the first year and then 1–2 times per year to monitor for appropriate signs
of feminization and for development of adverse reactions.
2. Measure serum testosterone and estradiol every 3 months.
a. Serum testosterone levels should be <55 ng/dl.
b. Serum estradiol should not exceed the peak physiologic range for young healthy females, with ideal levels,
200 pg/ml. c. Doses of estrogen should be adjusted according to the serum levels of estradiol.
3. For individuals on spironolactone, serum electrolytes particularly potassium should be monitored every 2–3
months initially in the first year, 2 weeks after a dose change, and yearly when stable.
4. Routine cancer screening recommended in non-transsexual individuals (breasts, colon, prostate).
5. Consider BMD testing at baseline if risk factors for osteoporotic fracture are present (e.g., previous fracture,
family history, glucocorticoid use, prolonged hypogonadism). In individuals at low risk, screening for osteoporosis
should be conducted at age 60 or in those who are not compliant with hormone therapy.
**Tables taken from The Endocrine Society’s Clinical guidelines for Endocrine Treatment of Transsexual Persons
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MONITORING OF FTM TRANSSEXUAL
PERSONS ON CROSS-HORMONE THERAPY
1. Evaluate patient every 2–3 months in the first year and then 1–2 times per year to monitor for appropriate signs of
virilization and for development of adverse reactions.
2. Measure serum testosterone every 2–3 months until levels are in the normal physiologic male range or optimal
effects are reached regardless of level (as long as it’s not too high):
a. For testosterone enanthate/cypionate injections, the testosterone level should be measured mid-way
b.
c.
d.
e.
between injections. If the level is >700 ng/dl or <350 ng/dl, adjust dose accordingly.
For parenteral testosterone undecanoate, testosterone should be measured just before the following
injection.
For transdermal testosterone, the testosterone level can be measured at any time after 1 week.
For oral testosterone undecanoate, the testosterone level should be measured 3–5 hours after ingestion.
Note: During the first 3–9 months of testosterone treatment, total testosterone levels may be high although
free testosterone levels are normal due to high sex hormone binding globulin levels in some biological
women.
3. Measure estradiol levels during the first 6 months of testosterone treatment or until there has been no uterine
bleeding for 6 months. Estradiol levels should be <50 pg/ml.
4. Measure CBC and liver function tests at baseline and every 3 months for the first year and then 1–2 times a year.
Monitor weight, blood pressure, lipids, fasting blood sugar (if family history of diabetes) and hemoglobin A1c (if
diabetic) at regular visits.
5. Consider BMD testing at baseline if risk factors for osteoporotic fracture are present (e.g., previous fracture, family
history, glucocorticoid use, prolonged hypogonadism). In individuals at low risk, screening for osteoporosis should be
conducted at age 60 or in those who are not compliant with hormone therapy.
6. If cervical tissue is present, a pap smear every 1-3 years for patients over 21 years old is recommended by the
American College of Obstetricians and Gynecologists.
7. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society.
**Tables taken from The Endocrine Society’s Clinical guidelines for Endocrine Treatment of Transsexual Persons
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RECOMMENDATIONS
Over 35/smokers: Oral estrogens confer an increased risk of thromboembolic disease. (Grade B)
After gonadectomy: Lower doses are recommended: 50-100mcg transdermal, 1-2mg sublingual estradiol, 1-2
sprays/day Evamist®. Titrate to effect, considering patient tolerance. (Grade C)
Progesterone: The risks and benefits of progesterone are not well-characterized. Some providers have found it to have
positive effects on the nipple areola and libido. Mood effects may be positive or negative. Different progesterone
regimens include daily 5 to 10mg medroxyprogesterone orally, 100-200mg prometrium at bedtime of oral or
compounded micronized progesterone, or Depo-Provera 150mg IM every 3 months, for 2-3 years. There is a risk of
significant weight gain and depression in some individuals.
As per other studies using oral progesterone in post-menopausal women (e.g., the Women's Health Initiative [WHI]
study), the use of medroxyprogesterone orally may increase the risk of coronary vascular disease whereas IM injections
(i.e., Depo-Provera) may minimize this additional risk. (Grade B and C)
Anti-androgens: Initial dose of spironolactone is 100mg daily in a single or divided dose, with titration up by 50mg
weekly to a typical dose of 200mg daily (with occasional patients -- especially larger or younger -- requiring as much as
400mg daily. Dose may be divided bid or may be taken all at once in the A.M. (all at once in A.M. is advised against due
to diuretic effects interrupting sleep). Check potassium. Progesterone may have some anti-androgenic activity, and
may be an alternative if spironolactone is contraindicated.
If patients have significant hair loss issues, finasteride may be added as an adjunct (even initially). Generally 1 - 5mg
daily. If patients pay out of pocket, they may buy the 5mg tabs and divide them in half or quarters.
Testosterone therapy is not withheld for hyperlipidemia.
Allergy Alert: Testosterone cypionate is suspended in cottonseed oil. Testosterone enanthate is suspended in sesame
oil; Sustanon® (available in Europe) is suspended in peanut oil. Some patients experience skin reactions to the adhesive
in Androderm® (transdermal patch). Compounding pharmacies may be able to provide testosterone cypionate in
sesame oil.
Use of transdermal preparations (e.g., Androderm® or Androgel® 1%/Testim®) may be recommended if slower
progress is desired, or for ongoing maintenance after desired virilization has been accomplished with intramuscular
injection.
Rarely, use a progestin to stop periods if patient only wants a low dose of testosterone, or is having difficulty stopping
menses.
For male-pattern baldness (MPB): finasteride or minoxidil. Caution patients that finasteride will likely slow or decrease
secondary hair growth, and may slow or decrease clitoromegaly.
For patients with concerns about too heavy secondary hair growth (e.g., male relatives are excessively hirsute):
finasteride, dutasteride.
For patients with too significantly increased sexual interest: low dose SSRIs.
For patients who desire greater clitoromegaly: topical testosterone on clitoris (must be subtracted from total dose and
patients must be warned that this may hasten Male Pattern Baldness).
This protocol is based on a critical review of the medical literature that exists on transgender health care, and on the physicians' many combined
years of clinical practice. In evaluating their recommendations, the MAB members employed the Strength-of-Recommendation Taxonomy (SORT)
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used by the American Academy of Family Physicians. We applied this taxonomy to transgender-related practice using the following grade
definitions and notation to indicate strength of recommendations and the basis on which the recommendations are made.
GRADE DEFINITIONS
A
Relatively low quality transgender-specific retrospective or observational study data
B
Inconsistent, or limited-quality patient oriented evidence obtained from other disciplines that the experts have
adapted to transgender contexts
C
Expert opinion, derived from clinical experience, study of prior publications, and consensus among the providers
serving on the Medical Advisory Board
This protocol emphasizes the areas of special consideration in which transgender-related medical treatments may have
an impact on a patient's well-being.
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FURTHER RECOMMENDATIONS
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Anti-transgender bias in the medical profession and U.S. health care system has catastrophic
consequences for transgender and gender non-conforming people. This study is a call to action for the
medical profession;
The medical establishment must fully integrate transgender-sensitive care into its professional
standards, and this must be part of a broader commitment to cultural competency around race, class,
and age;
Doctors and other health care providers who harass, assault, or discriminate against transgender and
gender non-conforming patients should be disciplined and held accountable according to the standards
of their professions.
Public and private insurance systems must cover transgender-related care; it is urgently needed and is
essential to basic health care for transgender people.
Ending violence against transgender people must be a public health priority, because of the direct and
indirect negative effect it has on both victims and on the health care system that must treat them.
Medical providers and policy makers should never base equal and respectful treatment and the
attainment of government-issued identity documents on:
Whether an individual has obtained surgery, given that surgeries are financially inaccessible for large
majorities of transgender people because they are rarely covered by either public or private insurance;
Whether an individual is able to afford or attain proof of citizenship or legal residency.
Rates of HIV infection, attempted suicide, drug and alcohol abuse, and smoking among transgender
and gender non-conforming people speak to the overwhelming need for:
Transgender-sensitive health education, health care, and recovery programs;
Transgender-specific prevention programs.
Additional data about the health outcomes of transgender and gender non-conforming people is
urgently needed;
Health studies and other surveys need to include transgender as a demographic category;
Information about health risks, outcomes and needs must be sought specifically about transgender
populations;
Transgender people should not be put in categories such as “men who have sex with men” (MSM) as
transgender women consistently are and transgender men sometimes are. Separate categories should
be created for transgender women and transgender men so HIV rates and other sexual health issues
can be accurately tracked and researched.
**National Center for Transgender Equality Discrimination Survey
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SAMPLE CONSENT FORM FOR PATIENT
CONSIDERING FEMINIZING HORMONES
* Adapted from: Primary Care Protocol for Transgender Patient Care, Center of Excellence for
Transgender Health, University of California, San Fran cisco, Department of Family and
Community Medicine, April 2011
_________________________________________________________________________
You are considering taking feminizing hormones, so you should learn about some of the risks, expectations,
and long term considerations, associated with taking feminizing hormones.
It is very important to remember that everyone is different, and that the extent of, and rate at which your
changes take place depend on many factors. These factors include your genetics, the age at which you start
taking hormones, and your overall state of health.
It is also important to remember that because everyone is different, your medicines or dosages may vary
widely from those of your friends, or what you may have read in books or online. Many people are eager for
changes to take place rapidly: Please remember that you are going through a second puberty, and puberty
normally takes several years for the full effects to be seen. Taking higher doses of hormones will not
necessarily make things move more quickly; it may, however, endanger your health.
There are four areas where you can expect changes to occur as your hormone therapy progresses.
1) Physical
The first changes you will probably notice are that your skin will become a bit drier and thinner. Your pores
will become smaller, and there will be less oil production. You may become more prone to bruising or cuts.
You may notice that you perceive pain or temperature differently, or that things just “feel different” when you
touch them. You will probably notice skin changes within a few weeks. In these first few weeks you will notice
that the odors of your sweat and urine will change, and that you may sweat less overall.
You will also notice small “buds” developing beneath your nipples within a few weeks of starting your
treatment. These may be slightly painful (especially to the touch) and uneven between the right and left side.
This is normal, and is the normal course of breast development. The pain will diminish somewhat over the
course of several months. Breast development is quite variable from person to person. Not everyone develops
at the same rate, and most transgender women can only expect to develop an “A” cup or perhaps a small “B”
cup, sometimes only after many years of hormone therapy. Like non-transgender women, the breasts of
transgender women vary in shape and size, and are sometimes different sizes or shapes between the right and
the left.
Weight will begin to redistribute around your body. Fat will begin to collect around your hips and thighs, and
the fat under your skin throughout your body will become a bit thicker, giving your arms and legs less muscle
definition and a smoother appearance. Hormones will not have a significant effect on the fat in your abdomen
(otherwise known as your “gut”. Your muscle mass will decrease significantly, as will your strength (thought
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you should continue to exercise to maintain your muscle tone as well as your general health). Depending on
your diet, lifestyle, genetics, and starting weight and muscle mass, you may gain or lose weight once you begin
HRT.
The fat under the skin in your face will increase and shift around to give your eyes and face in general a more
female appearance. Please note that your bone structure (including your hips, arms, hands, legs and feet) will
not change. The facial changes can take up to 2 years or more to see the final result; it is usually a good idea to
wait at least 2 years after beginning HRT before considering any drastic facial feminization procedures.
The hair on your body, such as your chest, back and arms will decrease in thickness and will grow at a slower
rate. It may not all go away, however, and some people may need electrolysis or laser to help reduce
unwanted body hair. Your beard may thin a bit and grow a bit slower; however, it will rarely go away
completely without electrolysis or laser treatments. If you have had any scalp balding, this should slow or stop,
though the amount that will grow back is variable.
Some people may notice minor changes in shoe size or height. This is not due to bony changes, but due to
changes in the ligaments and muscles of your feet.
2) Emotional
Your overall emotional state may or may not change, this varies from person to person. Puberty is a roller
coaster of emotions, and the second puberty that you will experience during your transition is no exception.
You may find that you have access to a wider range of emotions or feelings, or have different interests, tastes
or pastimes, or behave differently in relationships with other people. While psychotherapy is not for everyone,
most people would benefit from a course of supportive psychotherapy while in transition to help you explore
these new thoughts and feelings, and get to know your new self.
3) Sexual
Soon after beginning hormone treatment, you will notice a decrease the number of erections that you have.
When you do have an erection, it will be less firm and will not last as long. You may lose the ability to
penetrate. You will still have erotic sensation, and will still be able to orgasm. However, when you do orgasm,
it may be “dry”. You may find that there are different sex acts or different parts of your body that bring you
pleasure.
Your testicles will shrink to less than half their original size, or less. In nearly all cases, this does not affect the
amount of scrotal skin available for future genital surgery.
4) Reproductive
You must assume that within a few months of beginning hormone therapy, you will become permanently and
irreversibly sterile. While some people may be able to maintain a sperm count on hormone therapy, or have
their sperm count return after stopping hormone therapy, you must assume that this will not be the case for
you. If you think that there might be any chance that you may in the future want to plan a pregnancy using
your own sperm, you should speak to the doctor about preserving your sperm in a sperm bank. This process
generally takes 2-4 weeks and costs between roughly $2,000-$3,000. You should store your sperm before
beginning any hormone therapy.
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Also, if you are on hormones but remaining sexually active with a person who is able to become pregnant, you
should always continue to use a birth control method to prevent unwanted pregnancy.
Many of the effects of hormone therapy are reversible, if you stop taking them. The degree to which they can
be reversed depend on how long you have been taking them. Breast growth, and possibly sterility are not
reversible. If you have an orchiectomy (which is removal of the testicles) or genital reassignment surgery, you
will be able to take a lower dose of hormones. However, it is important to remain on at least a low dose of
hormones post-op until at least age 50 years old, to prevent a weakening of the bones, otherwise known as
osteoporosis.
Feminizing hormone therapy for transwomen may include three different kinds of medicines: Estrogen,
testosterone blockers, and progesterones.
1) Estrogen
Estrogen is the hormone responsible for most female characteristics. It causes the physical changes of
transition, as well as many of the emotional changes. Estrogen may be given as a pill, by injection, or by a
number of preparations applied to the skin, such as a cream, a gel, a spray or a patch.
Pills are convenient, cheap and effective, but they are hard on your liver and are less safe after age 35 or if you
smoke. Patches can be very effective and safe, they may cost a little more than pills, and they require that you
wear them at all times. Sometimes, they may irritate your skin. Creams, sprays and gels are very effective and
safe, and absorb quickly into your skin. These do tend to be a bit more expensive, and may not work as well
for people who still have testicles.
Risks associated with estrogen include high blood pressure, blood clots, liver problems, stroke, and perhaps
diabetes. Also, there are potential unknown risks since we have not done a lot of research on the use of
estrogen in transwomen. It is possible that in the future we may learn about more risks or side effects,
particularly when using estrogen for many years. Contrary to what many may believe, a very small amount of
estrogen is needed to deliver the maximum effect. Taking very high doses of estrogen does not necessarily
make changes happen more quickly, but it can be dangerous and harmful to your health.
There is not much scientific evidence about the risks of cancer in transgender women.
We believe that your risk of prostate cancer will go down, but we are not sure, and therefore you will still
need to be tested for that cancer when appropriate. Your risk of breast cancer may increase slightly, though it
will still be less than a non-transgender female. Breast cancer screening with mammograms is recommended
to begin between ages 40 and 50, for people who have been on hormones for more than 2-3 years.
Many transwomen are interested in taking estrogen injections. Estrogen injections may be appropriate for
some people in some cases. When you take estrogen injections, you will have the same amount of estrogen as
a pregnant woman. This can make you nauseous, tired, or cause you to gain weight or have mood swings. In
people who smoke, or people over 35-40 years old, this high level of estrogen can be dangerous and increase
your risk of stroke, blood clots, diabetes, or other disorders. If the doctor does start you on estrogen
injections, you should expect to stop them after 1-2 years, since the body is not designed to be constantly
exposed to such high levels of estrogen. When you stop the injections and switch to another form of estrogen,
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you may feel sick for a while, with mood swings, anxiety, and other symptoms as your body re-adjusts to the
lower and healthier levels of estrogen.
After you have had genital surgery or orchiectomy (removal of the testicles), your estrogen dose will be
lowered, and estrogen injections will be stopped. Once you have had your testicles removed, you need very
little estrogen to maintain your feminine characteristics.
Estrogen can make your liver work too hard, causing damage. Your doctor will periodically check your liver
functions, cholesterol, and perform a diabetes screening test to monitor your health while on testosterone
therapy.
2) Testosterone blockers
There are a number of medicines which can be used to block testosterone. Some of these drugs block the
action of testosterone in your body, and some of them also prevent the production of testosterone. Most of
the testosterone blockers are very safe. The one most commonly used, spironolactone, does have some side
effects. It can make you urinate excessively, especially when you first start taking it, which can make you feel
dizzy or lightheaded. It is important to drink plenty of fluids when taking this medicine. Also, spironolactone
can interact with some blood pressure medicines and can be dangerous in people with kidney problems. It is
important to share your full medical history and medication list with the doctor so that they can be sure there
will be no interactions. People taking spironolactone must have their potassium levels checked periodically, as
it can rarely get dangerously high, which can cause your heart to stop.
3) Progesterone
Progesterone is a source of constant debate among both people seeking hormones and providers.
Progesterone has a number of reported benefits, such as improved mood, energy or libido, better breast
development, or better body fat redistribution and “curves”. There is very little scientific evidence to support
these claims. However, some people do prefer to take progesterone and have seen some of these benefits.
When you take a natural form of progesterone, your risk of things like blood clots, stroke, or cancer are
minimized, but still may be increased; There simply is not enough research in this area to make an accurate
prediction of you risk.
Progesterone may be given by a pill or by a cream. The pill is easy and relatively safe, the cream is also quite
easy and safe. Both are about the same price.
I understand the foregoing information about feminizing hormone usage, and I hereby consent to the
prescription use of feminizing hormones.
Patient________________________________________ Date_____________________
Physician______________________________________ Date_____________________
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SAMPLE CONSENT FORM FOR PATIENT
CONSIDERING MASCULINIZING HORMONES
* Adapted from: Primary Care Protocol for Transgender Patient Care, Center of Excellence for
Transgender Health, University of California, San Francisco, Department of Family and
Community Medicine, April 2011
______________________________________________________________
You are considering taking testosterone, so you should learn about some of the risks, expectations, long term
considerations, and medications associated with transition from female to male.
It is very important to remember that everyone is different, and that the extent of, and rate at which your changes take
place depend on many factors. These factors include your genetics, the age at which you start taking hormones, and
your overall state of health.
It is also important to remember that because everyone is different, your medicines or dosages may vary widely from
those of your friends, or what you may have read in books or online. Many people are eager for changes to take place
rapidly; please remember that you are going through a second puberty, and puberty normally takes several years for the
full effects to be seen. Taking higher doses of hormones will not necessarily make things move more quickly—it may,
however, endanger your health.
There are four areas where you can expect changes to occur as your hormone therapy progresses.
1) Physical
The first changes you will probably notice are that your skin will become a bit thicker and more oily. Your pores will
become larger, and there will be more oil production. You may develop acne, which in some cases can be bothersome or
severe. Acne can be managed with good skin care technique as well as typical acne treatments such as lotions. You may
notice that you perceive pain or temperature differently, or that things just “feel different” when you touch them. You
will probably notice skin changes within a few weeks. In these first few weeks you will notice that the odors of your
sweat and urine will change, and that you may sweat more overall.
Your breasts will not change much during transition, though you may notice some breast pain, or a slight decrease in
size. For this reason, many breast surgeons recommend waiting for at least six months after beginning testosterone
therapy before having chest reconstruction surgery.
Weight will begin to redistribute around your body. Fat will diminish somewhat around your hips and thighs, and the fat
under your skin throughout your body will become a bit thinner, giving your arms and legs more muscle definition and a
slightly rougher appearance. Testosterone may cause you to gain fat around your abdomen (otherwise known as your
“gut”). Your muscle mass will increase significantly, as will your strength. However, in order to maximize your
development and maintain your health you should exercise 4-5 times a week with 30 minutes/day of cardio/aerobics, as
well as at least mild weight training. Depending on your diet, lifestyle, genetics, and starting weight and muscle mass,
you may gain or lose weight once you begin HRT.
The fat under the skin in your face will decrease and shift around to give your eyes and face in general a more angular,
male appearance. Please note that your bone structure will likely not change, though some people in their late teens or
early twenties may see some subtle bone changes. The facial changes can take up to 2 years or more to see the final
result.
The hair on your body, such as your chest, back and arms will increase in thickness, become darker and will grow at a
faster rate. You may expect to develop a pattern of body hair similar to other men in your family. However, again please
remember that everyone is different, and that it can take up to 5 years or longer to see the final results. Most transmen
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notice some degree of frontal scalp balding, mostly in the area of your temples. Depending on your age and family
history, you may develop thinning or even complete hair loss in a male pattern baldness pattern.
Beards vary from person to person. Some people develop a thick beard quite rapidly, others make take several years to
do so, while others may never develop a full and thick beard. This is a result of genetics and the age at which you start
testosterone therapy. You might notice that non-transgender men also have a varying degree of facial hair thickness,
and a varying age at which their beard fully developed.
2) Emotional
Your overall emotional state may or may not change, this varies from person to person. Puberty is a roller coaster of
emotions, and the second puberty that you will experience during your transition is no exception. You may find that you
have access to a narrower range of emotions or feelings, or have different interests, tastes or pastimes, or behave
differently in relationships with other people. While psychotherapy is not for everyone, most people would benefit from
a course of supportive psychotherapy while in transition to help you explore these new thoughts and feelings, and get to
know your new self.
3) Sexual
Soon after beginning hormone treatment, you will likely notice a change in your libido. Quite rapidly, your clitoris will
begin to grow, and will become larger when you are aroused. You may find that there are different sex acts or different
parts of your body that bring you erotic pleasure. Your orgasms will feel different, with perhaps more peak intensity, and
more focused on your genitals, as opposed to a whole body experience. It is recommended that you explore and
experiment with your new sexuality through masturbation, using sex toys, and involve your sexual partner.
4) Reproductive
You may notice at first that your periods become lighter, arrive later, or are shorter in duration than previously. Some
people will actually notice heavier or longer lasting periods for a few cycles before they stop altogether.
Testosterone greatly reduces your ability to become pregnant. However, it does not eliminate the risk of pregnancy
completely. If you are on testosterone and remaining sexually active with a non-transgender man, you should always
continue to use a birth control method to prevent unwanted pregnancy.
It is possible for transgender men to become pregnant while on testosterone. If you suspect you may be pregnant, have
a pregnancy test as soon as possible, so that your doctor can stop your testosterone treatment, which may be
dangerous to the fetus. If you want to become pregnant, you must first stop your testosterone treatment and wait until
your doctor tells you that it is okay to begin trying to conceive. Your doctor may check your testosterone levels before
clearing you to begin efforts of conception.
Testosterone therapy may change the shape of your ovaries and make it more difficult for them to release eggs. If this
happens, you may need to use fertility drugs, or use techniques such as in vitro fertilization in order to become
pregnant. It is possible that after taking testosterone, you may completely lose the ability to become pregnant.
“Freezing” eggs is not yet a realistic alternative for preserving your fertility.
After being on testosterone for some time, you may experience a small amount of spotting or bleeding. This may occur if
you miss a dose, or change your dosage. You should report any bleeding or spotting to the doctor; in some cases, it must
be followed up with an ultrasound to be sure that you do not have a precancerous condition called “hyperplasia”.
The risk of developing hyperplasia while taking testosterone is not clear. It is usually recommended that as long as you
have a uterus, you are screened for hyperplasia once every two years, even if you have not had any bleeding. There are
two ways to do this. One is to have an ultrasound performed. Another way is to take a hormone called progesterone for
10 days, after which you will have small period. This helps to “reset” your uterus and help prevent hyperplasia. If you
take 10 days of progesterone and do not have a period, you will need an ultrasound as this may indicate that hyperplasia
has developed.
Your risk of cervical cancer relates to your past and current sexual practices. Please note that even people who have
never had a penis in contact with their genitals may still contract HPV infections. The HPV vaccine (Gardasil) can greatly
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reduce your risk of cervical cancer, depending on the age at which you get the vaccine, and how many sexual partners
you have had before receiving the vaccine. Pap smears are generally recommended every two years; more or less
frequent pap smears may be recommended by the doctor, depending on your sexual history and the results of your
prior pap smears.
The risk of cancer of the ovaries may be slightly increased while on testosterone treatment. Ovarian cancer is difficult to
screen for, and most cases of ovarian cancer are discovered after it is too late to be treated. A pelvic examination, where
your doctor uses a gloved hand to examine your vagina, uterus and ovaries is recommended every 1-2 years to help
detect this condition. Many experts recommend a full hysterectomy and bilateral salpingo-oopherectomy (removal of
the uterus, ovaries, and fallopian tubes) within 5-10 years of beginning testosterone treatment in order to minimize your
cancer risk.
The risk of breast cancer while on testosterone treatment is not significantly increased. However, there has not been
enough research on this topic to be certain of the actual risk. It is still important to receive periodic mammograms or
other screening procedures as recommended by your doctor. After breast removal surgery, there is still a small amount
of breast tissue left behind. It may be difficult to screen this small amount of tissue for breast cancer, though there are
almost no cases of breast cancer in transgender men after chest reconstruction surgery.
Testosterone will change your overall health risk profile to that of a man. Your risk of heart disease, diabetes, high blood
pressure, and high cholesterol may go up, though these risks may be less than a non-transgender man’s risks. Since men
on average live about 5 years less than women, you may be shortening your lifespan by several years by taking
testosterone. Since you do not have a prostate, you have no risk of prostate cancer and there is no need to screen for
this condition.
Testsosterone can make your blood become too thick, which can cause a stroke, heart attack or other conditions.
Testosterone can cause your liver to work too hard, causing damage. Your doctor will perform periodic tests of your
blood count, cholesterol, kidney functions, and liver functions, and a diabetes screening test in order to closely monitor
your therapy. Testosterone levels do not need to be routinely checked as they are expensive; however, your doctor may
choose to check them for a variety of reasons.
Some of the effects of hormone therapy are reversible if you stop taking testosterone. The degree to which the effects
can be reversed depends on how long you have been taking the testosterone. Clitoral growth, facial hair growth, and
male-pattern baldness are not reversible.
If you have had your ovaries removed, it is important to remain on at least a low dose of hormones post-op until at least
age 50 years old (and perhaps beyond), to prevent a weakening of the bones, otherwise known as osteoporosis.
Testosterone comes in several forms. Most transgender men begin using an injectible form of testosterone, which is
safe and effective. Some men chose to begin on a lower dose and increase slowly, while others chose to begin at a
standard dose. Both approaches have their pros and cons, and you can discuss this with the doctor. Testosterone levels
tend to be most even when the injections are given weekly. There are also trandermal forms (patches, gels, and creams)
available. Most men will need to start with injections in order to see significant changes, some may then change to one
of the transdermal forms.
Taking more testosterone will not make your changes progress more quickly and can be unsafe. Excess testosterone can
be converted to estrogen, which can then increase your risks of hyperplasia or cancer, as well as make you feel anxious
or agitated, can harm your liver, and can cause your cholesterol or blood count to get too high. It is important to be
patient and remember that puberty can take years to develop all of its changes.
I understand the foregoing information about testosterone usage, and I hereby consent to the prescription use of
testosterone.
Patient________________________________________ Date_____________________
Physician______________________________________ Date_____________________
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