Transgender hormone therapy

Transgender hormone therapy, also sometimes called cross-sex hormone therapy, is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender nonconforming individuals for the purpose of more closely aligning their secondary sexual characteristics with their gender identity. This form of hormone therapy is given as one of two types, based on whether the goal of treatment is feminization or masculinization:

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Some intersex people may also undergo hormone therapy, either starting in childhood to confirm the sex they were assigned at birth, or later in order to align their sex with their gender identity. Non-binary people may also undergo hormone therapy in order to achieve a desired balance of sex hormones or to pass as a desired gender. [1]

Requirements

The formal requirements for hormone therapy vary widely.

Historically, many health centers required a psychiatric evaluation and/or a letter from a therapist before beginning therapy. Many centers now use an informed consent model that does not require any routine formal psychiatric evaluation but instead focuses on reducing barriers to care by ensuring a person can understand the risks, benefits, alternatives, unknowns, limitations, and risks of no treatment.[2] Some LGBT health organizations (notably Chicago's Howard Brown Health Center[3] and Planned Parenthood[4]) advocate for this type of informed consent model.

The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) require that the patient be referred by a mental health professional who has diagnosed the patient with persistent gender dysphoria. The Standards also require that the patient give informed consent, in other words, that they consent to the treatment after being fully informed of the risks involved.[5]

The World Professional Association for Transgender Health (WPATH) Standards of Care, 7th edition, note that both of these approaches to care are appropriate.[6]

Treatment options

Guidelines

The World Professional Association for Transgender Health (WPATH) and the Endocrine Society formulated guidelines that created a foundation for health care providers to care for transgender patients.[7]

Feminizing hormone therapy
See also: Transgender hormone therapy (male-to-female)

Feminizing hormone therapy usually includes medication to suppress testosterone production and induce feminization. Types of medications include estrogens, antiandrogens (testosterone blockers), and progestogens.[8] Most commonly, an estrogen is combined with an antiandrogen to suppress and block testosterone. This allows for demasculinization and promotion of feminization and breast development.

Masculinizing hormone therapy
See also: Transgender hormone therapy (female-to-male)

Masculinizing hormone therapy usually includes testosterone to produce masculinization and suppress the production of estrogen.[9] Treatment options include oral, parenteral, subcutaneous implant, and transdermal (patches, gels). Dosing is patient-specific and is discussed with the physician.[10] The most commonly prescribed methods are intramuscular and subcutaneous injections. This dosing can be weekly or biweekly depending on the individual patient.

Safety

Hormone therapy for transgender individuals has been shown in medical literature to be generally safe, when supervised by a qualified medical professional.[11] There are potential risks with hormone treatment that will be monitored through screenings and lab tests such as blood count (hemoglobin), kidney and liver function, blood sugar, potassium, and cholesterol.[10][8] Taking more medication than directed may lead to health problems such as increased risk of cancer, heart attack from thickening of the blood, blood clots, and elevated cholesterol.[10][12]

Fertility consideration

Transgender hormone therapy may limit fertility potential.[13] Should a transgender individual choose to undergo sex reassignment surgery, their fertility potential is lost completely.[14] Before starting any treatment, individuals may consider fertility issues and fertility preservation. Options include semen cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation.[13][14]

A study due to be presented at ENDO 2019 (the Endocrine Society's conference) reportedly shows that even after one year of treatment with testosterone, a transgender man can preserve his fertility potential.[15]

Treatment eligibility

Eligibility is determined using major diagnostic tools such as ICD-10 or the Diagnostic and Statistical Manual of Mental Disorders (DSM). Psychiatric conditions can commonly accompany or present similar to gender incongruence and gender dysphoria. For this reason, patients are assessed using DSM-5 criteria or ICD-10 criteria in addition to screening for psychiatric disorders. The Endocrine Society requires physicians that diagnose gender dysphoria and gender incongruence to be trained in psychiatric disorders with competency in ICD-10 and DSM-5. The healthcare provider should also obtain a thorough assessment of the patient's mental health and identify potential psychosocial factors that can affect therapy.[16]

ICD-10

The ICD-10 system requires that patients have a diagnosis of either transsexualism or gender identity disorder of childhood. The criteria for transsexualism include:[17]

  • A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex
  • A wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex

Individuals cannot be diagnosed with transsexualism if their symptoms are believed to be a result of another mental disorder, or of a genetic or chromosomal abnormality.

For a child to be diagnosed with gender identity disorder of childhood under ICD-10 criteria, they must be pre-pubescent and have intense and persistent distress about being the opposite sex. The distress must be present for at least six months. The child must either:

  • Have a preoccupation with stereotypical activities of the opposite sex – as shown by cross-dressing, simulating attire of the opposite sex, or an intense desire to join in the games and pastimes of the opposite sex – and reject stereotypical games and pastimes of the same sex, or
  • Have persistent denial relating to their anatomy. This can be shown through a belief that they will grow up to be the opposite sex, that their genitals are disgusting or will disappear, or that it would be better not to have their genitals.

DSM

The DSM-5 states that at least two of the following criteria must be experienced for at least six months' duration for a diagnosis of gender dysphoria:[18]

  • A strong desire to be of a gender other than one's assigned gender
  • A strong desire to be treated as a gender other than one's assigned gender
  • A significant incongruence between one's experienced or expressed gender and one's sexual characteristics
  • A strong desire for the sexual characteristics of a gender other than one's assigned gender
  • A strong desire to be rid of one's sexual characteristics due to incongruence with one's experienced or expressed gender
  • A strong conviction that one has the typical reactions and feelings of a gender other than one's assigned gender

In addition, the condition must be associated with clinically significant distress or impairment.[18]

Readiness
See also: Real-life experience (transgender)

Some organizations – but fewer than in the past – require that patients spend a certain period of time living in their desired gender role before starting hormone therapy. This period is sometimes called real-life experience (RLE). The Endocrine Society stated in 2009 that individuals should either have a documented three months of RLE or undergo psychotherapy for a period of time specified by their mental health provider, usually a minimum of three months.[19]

Transgender and gender non-conforming activists, such as Kate Bornstein, have asserted that RLE is psychologically harmful and is a form of "gatekeeping", effectively barring individuals from transitioning for as long as possible, if not permanently.[20]

Accessibility

Gender-affirming care is health care that affirms people to live authentically in their genders, no matter the gender they were assigned at birth or the path their gender affirmation (or transition) takes. It allows each person to seek only the changes or medical interventions they desire to affirm their own gender identity, and hormone therapy (“HRT” or gender-affirming hormone therapy) may be a part of that. [21]

Some transgender people choose to self-administer hormone replacement medications, often because doctors have too little experience in this area, or because no doctor is available. Others self-administer because their doctor will not prescribe hormones without a letter from a psychotherapist stating that the patient meets the diagnostic criteria and is making an informed decision to transition. Many therapists require at least three months of continuous psychotherapy and/or real-life experience before they will write such a letter. Because many individuals must pay for evaluation and care out-of-pocket, costs can be prohibitive.

Access to medication can be poor even where health care is provided free. In a patient survey conducted by the United Kingdom's National Health Service in 2008, 5% of respondents acknowledged resorting to self-medication, and 46% were dissatisfied with the amount of time it took to receive hormone therapy. The report concluded in part: "The NHS must provide a service that is easy to access so that vulnerable patients do not feel forced to turn to DIY remedies such as buying drugs online with all the risks that entails. Patients must be able to access professional help and advice so that they can make informed decisions about their care, whether they wish to take the NHS or private route without putting their health and indeed their lives in danger."[22] Self-administration of hormone replacement medications may have untoward health effects and risks.[23]

A number of private companies have attempted to increase accessibility for hormone replacement medications and help transgender people navigate the complexities of access to treatment. Plume is building a healthcare service specifically for the transgender community.[24] In September of 2020, Plume partnered[25] with Solace to expand accessibility and awareness of Gender-Affirming Hormone Therapy (GAHT). Solace is a not-for-profit mobile application focused on providing access to credible, relevant transition information and allowing users to create a custom transition roadmaps and goals.[26]

See also

References
  1. Ferguson, Joshua M. (November 30, 2017). "What It Means to Transition When You're Non-Binary". Teen Vogue.
  2. UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at transcare.ucsf.edu/guidelines.
  3. Schreiber, Leslie. "Howard Brown Health Center Establishes Transgender Hormone Protocol". www.howardbrown.org. Howard Brown. Archived from the original on 2011-10-08. Retrieved 2011-08-25.
  4. "What Health Care & Services Do Transgender People Require?". www.plannedparenthood.org. Retrieved 2019-10-16.
  5. Coleman, Eli; et al. (August 2012). "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7". International Journal of Transgenderism. 13 (4): 165–232. doi:10.1080/15532739.2011.700873. S2CID 39664779.
  6. Deutsch MB, Feldman JL. Updated recommendations from the world professional association for transgender health standards of care. Am Fam Physician. 2013 Jan 15;87(2):89-93.
  7. Unger, Cécile A. (December 2016). "Hormone therapy for transgender patients". Translational Andrology and Urology. 5 (6): 877–884. doi:10.21037/tau.2016.09.04. ISSN 2223-4691. PMC 5182227. PMID 28078219.
  8. "Information on Estrogen Hormone Therapy | Transgender Care". transcare.ucsf.edu. Retrieved 2019-08-07.
  9. "Masculinizing hormone therapy - Mayo Clinic". www.mayoclinic.org. Retrieved 2019-08-02.
  10. "Information on Testosterone Hormone Therapy | Transgender Care". transcare.ucsf.edu. Retrieved 2019-08-07.
  11. Weinand, J. D.; Safer, J. D. (June 2015). "Weinand J, Safer J. Feb 2015. "Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals." Journal of Clinical & Translational Endocrinology (2015)". Journal of Clinical & Translational Endocrinology. 2 (2): 55–60. doi:10.1016/j.jcte.2015.02.003. PMC 5226129. PMID 28090436.
  12. Task Force on Oral Contraceptives; Koetsawang, Suporn; Mandlekar, A.V.; Krishna, Usha R.; Purandare, V.N.; Deshpande, C.K.; Chew, S.C.; Fong, Rosilind; Ratnam, S.S.; Kovacs, L.; Zalanyi, S. (May 1980). "A randomized, double-blind study of two combined oral contraceptives containing the same progestogen, but different estrogens". Contraception. 21 (5): 445–459. doi:10.1016/0010-7824(80)90010-4. ISSN 0010-7824. PMID 7428356.
  13. TʼSjoen, Guy; Van Caenegem, Eva; Wierckx, Katrien (2013). "Transgenderism and reproduction". Current Opinion in Endocrinology, Diabetes and Obesity. 20 (6): 575–579. doi:10.1097/01.med.0000436184.42554.b7. ISSN 1752-2978. PMID 24468761. S2CID 205398449.
  14. De Sutter, P. (2001). "Gender reassignment and assisted reproduction: present and future reproductive options for transsexual people". Human Reproduction (Oxford, England). 16 (4): 612–614. doi:10.1093/humrep/16.4.612. ISSN 0268-1161. PMID 11278204.
  15. "Ovary function is preserved in transgender men at one year of testosterone therapy | Endocrine Society". www.endocrine.org. Retrieved 2019-03-25.
  16. "CORRIGENDUM FOR "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline"". The Journal of Clinical Endocrinology & Metabolism. 103 (7): 2758–2759. 2018-07-01. doi:10.1210/jc.2018-01268. ISSN 0021-972X. PMID 29905821.
  17. "ICD-10 Diagnostic Codes". ICD-10:Version 2010. Retrieved 2014-06-08.
  18. American Psychiatry Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed.). Washington, DC and London: American Psychiatric Publishing. pp. 451–460. ISBN 978-0-89042-555-8.
  19. Hembree, Wylie, C; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette; Gooren, Louis; Meyer III, Walter; Spack, Norman; Tangpricha, Vin; Montori, Victor (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline" (PDF). The Journal of Clinical Endocrinology & Metabolism. 94 (9): 3132–54. doi:10.1210/jc.2009-0345. PMID 19509099. Archived from the original (PDF) on 2014-03-13. Retrieved 2014-06-07.
  20. Bornstein, Kate (2013). My Gender Workbook, Updated : How to Become a Real Man, a Real Woman, the Real You, or Something Else Entirely (2nd ed.). New York: Routledge. ISBN 978-0415538657.
  21. https://getplume.co/blog/plume-day-campaign/. Missing or empty |title= (help)
  22. "Survey of Patient Satisfaction with Transgender Services" (PDF). Archived from the original (PDF) on 2016-03-04. Retrieved 2016-01-08.
  23. Becerra Fernández A, de Luis Román DA, Piédrola Maroto G (October 1999). "Morbilidad en pacientes transexuales con autotratamiento hormonal para cambio de sexo" [Morbidity in transsexual patients with cross-gender hormone self-treatment] (PDF). Med Clin (Barc) (in Spanish). 113 (13): 484–7. ISSN 0025-7753. PMID 10604171.
  24. "Plume is building a healthcare service specifically for the transgender community". TechCrunch. Retrieved 2020-10-29.
  25. Plume. "Two Fastest-Growing Trans Tech Companies, Plume and Solace, Partner to Provide Gender-Affirming Hormone Therapy to App Users". www.prnewswire.com. Retrieved 2020-10-29.
  26. "Solace Is an App That Helps Trans People Transition". www.vice.com. Retrieved 2020-10-29.
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