Hormone Therapy.
See also: www.spanglefish.com/transnews/index.asp?pageid=222686
This document is prepared with Male-Female Transsexuals in mind. This is where my experience and knowledge lies; I have little experience with Female-Male Transsexuals hormonal needs. It would be wrong for me to try to comment or advise on their regimes. There is plenty of information on the internet on F-M hormones and groups specifically for the F-M Transsexuals.
Hormones: are one of the body’s great communication networks (the others are the nervous and immune systems). A hormone molecule, released by one of about a dozen glands, travels through the blood until it reaches a cell with a receptor that it fits. Then, like a key in a lock, the molecule attaches to the receptor and sends a signal inside the cell. The signal may tell the cell to produce a certain protein or to multiply.
Hormones are involved in just about every biological process: immune function, reproduction, growth, even controlling other hormones. Endocrine hormones are released by the thyroid, parathyroid, adrenal and other glands, under the general direction of the pituitary gland. After SRS (castration) the adrenal gland still continues to produce Testosterone, albeit comparable to the lower level of a female.
Sex hormones are responsible for some of the most dramatic changes that occur in the body. They control puberty, egg and sperm production, pregnancy, birth and lactation (breastfeeding).
M-F feminising hormones: The manufacturers of oestrogen and progesterone products specify them for medical use in females and do not acknowledge their use for M-F transsexuals, so there is little clinical data available regarding this usage. There has been little research carried out and any real information available is from the users and of course that is anecdotal. However, this is probably better than the assumed knowledge that our ‘specialists’ rely on. If asked, many tend to quote from the manufacturers data sheets. They certainly do not listen to us.
There are many hormones produced by the body but the ones that interest us most are the sex hormones; Oestrogen, Progesterone, Prolactin, Testosterone, in the main. These four hormones are found in males and females. In the males, Testosterone is the main sex hormones and the other three at low levels and females Oestrogen, Progesterone, Prolactin are the main sex hormones and Testosterone at a low level. What we do is to change that balance using cross sex hormones.
Hormone Therapy: An important part of Transitioning is cross sex Hormone Therapy. M-F Transsexuals take Oestrogen and some will take Progesterone as well, F-M Transsexuals take Testosterone. M-F Transsexuals will usually take an anti-androgen to block Testosterone production and help make the Oestrogen/ Progesterone work more effectively.
How much hormone: This is a very contentious issue. This depends on the individual. How you feel on those levels and the results of blood tests.
The World Professional Association for Transgender Health (WPATH), formerly known as the (Harry Benjamin International Gender Dysphoria Association1998 Edition states “the administration of hormones is not to be lightly undertaken because of their perceived medical and social dangers.”
Three criteria exist (WPATH SOC Ver. 6 and earlier): 1. Aged 18 years, 2. demonstrable knowledge of what hormones medically can and cannot do and 3. their social benefits and risks.
In the private treatment of Transsexuals there needs to be a flexibility of approach rather than an adherence to rigid gender clinic policies, albeit based on the WPATH guidelines.
New Version of WPATH (World Professional Association for Transgender Health), Standards of Care, Version 7, International Guidelines.
Some key revisions:
• Psychotherapy is no longer a requirement to receive hormones and surgery, although it is suggested.
"It used to be a minimum amount of psychotherapy was needed. An assessment is still required but that can be done by the prescribing hormone provider,"
"The SOC are flexible clinical guidelines; they allow for tailoring of interventions to the needs of the individual receiving services and for tailoring of protocols to the approach and setting in which these services are provided,"
Standards of Care: The decision to recommend hormonal and surgical treatment is based on the conclusion reached through the diagnostic assessment that the person’s gender problems cannot be resolved with counselling or therapy and the only reasonable expectation is that the person will benefit from hormones and sexual reassignment surgery.
Care should be patient centred: The Specialist has a responsibility to ensure that the patient understands the criteria for the administration of the hormone regime, the risks, side effects and effects, long and short term before prescribing but generally the patient should normally be prescribed after three months of counselling, after the initial diagnosis. The patient should also be involved in the discussions on their regime. This does not happen. The patient’s opinion seems to be irrelevant and generally ignored.
The Specialist decides when, what and how much and most rely, ‘a one size fits all’. But does it? We are all different and our needs are different; body mass, build; including height and weight and receptiveness to the hormones. There has been no research on cross sex hormones, so there is no one body that can really give any advice. Specialists therefore tend to err on the safe side and manufacturers data sheet and not for our benefit.
Given the chance feminisation will closely follow the female puberty and will last at least as long. Most clinics reduce your hormones after about two years or post op. to a maintenance dose; feminisation will cease and be incomplete. Why would our feminisation be that much shorter than the female puberty? This makes no sense whatsoever.
The hormone regime should be adequate, well balanced, consisting of an anti-androgen, Oestrogen and Progesterone and long term. Once post op. the hormones, certainly Oestrogen and progesterone should be maintained at the same level for at least for an equal time to the female puberty. Why would you need to change? The hormones that you have been taking would have already chemically castrated you so the surgery would make little difference.
Some also say that it is age related, the older the less effect the hormones have. However, taking control of my own hormone regime, I have shown by my own Transitioning, that this is not necessarily true. My development has been very effective. More likely is that the clinics prescribe insufficient levels of hormones to the older patients, being over cautious; no wonder the hormones have less effect. 100mcg patches, twice a week, that they regularly prescribe is woefully inadequate. I believe that we need a similar level to other Transsexuals, irrespective of age. However, we need to assume that there could be a small increase in risk.
Should we, or shouldn’t we self-medicate? This is a decision that the individual must make for him/ herself. I would not advise for or against. It worked well for me but I self-medicated after much time spent researching; I knew what I wanted and what I felt I needed. It is not a decision that should be taken lightly. Self medicating can be safe but it is important to choose your regime carefully, ensure that the Pharmacy you use is reliable and only supplies hormones of the best quality. Most medicines will be generic copies, possibly manufactured in India. If you do decide to go ahead and self medicate, then I would strongly advise that you see your GP, to monitor your health and blood levels, as soon as possible. I saw my GP after about 6 weeks of self medicating; the hormones were already affecting me both physically and emotionally.
The pros and cons of self-medicating.
Pros: You have control over your regime. You can start on your hormone regime, earlier. You decide on what hormones you take and how much. If you are going through the NHS you can reduce the period it takes to progress to your surgery, dependent on when you start your Real Life Experience. The positive action of self medicating will often help control the stress and depression that you are likely to be suffering.
Cons: Risk of poor quality or contaminated medication if buying on the internet, unless you go to one of the more used sites. Greater risk to health if you have some pre-existing condition that you are unaware of. These risks can be minimised by getting the support of your GP as soon as possible. Usually quite expensive.
Disclaimer: The pros and cons are not exhaustive and I am not suggesting that this is your best way forward but if you decide to then you must research the options thoroughly before embarking on any self medication. This is a decision that only you should make for yourself. Involve your GP as soon as possible.
So again the question ‘How much hormone’? Mostly, those that get help from Gender Clinics will probably be prescribed Progynova, a bio-identical Oestrodiol and an anti-androgen, to block the natural Testosterone. A maximum of 4mg Oestrogen seems to be the norm, or 100mcg patches, changed twice a week.
These levels are often reduced, post op. or after about 2 years to a maintenance dose. Progesterone is rarely prescribed. Feminisation would cease, breasts in most cases will be immature and not fully developed.
About Progesterone: A well known ‘Gender Specialist’ who is also a GP and should know better quotes: ‘As progesterone does not exist in genetic girls until age 14, it is clear that progesterone cannot possibly have any effect on breast development in the genetic female. To be clear, there is no direct involvement of progesterone in determining the size of breasts. Oestrogen is the primary enabler of breast growth. And there is no reason to suppose that the development of the breast in trans women is different.’ How can he be so specific as age 14? Girls start their puberty at various ages; some as young as 10 or 11 and others much later?
In the latest version of the WPATH Standards of Care, Version 7, Section V111, page 49, Progestins. ‘Because progestins play a role in the mammary development on a cellular level, some clinicians believe that these agents are necessary for full breast development’
So should progesterone be prescribed? I would say an emphatic ‘yes’, of course it should, if that is what the patient wants for her balanced regime.
So what is an adequate and well balanced regime? In my opinion and as a result of my research and talking to many M-F Transsexuals; pre op. 8mg of Oestrogen, 200mg Progesterone both bio-identical to the female hormones and in my case, 200mg Spironolactone as an anti-androgen (Spironolactone tablets belong to a group of medicines called potassium-sparing diuretics [water tablets], which help you lose excess fluid from your body). Spironolactone has a mild anti-androgenic effect. There is a quite wide range of anti-androgens available.
Also Finasteride, Proscar is a medicine which is used in benign prostatic hyperplasia. Finasteride has a useful side effect in stopping MPB (male pattern baldness). Finasteride belongs to a group of medicines called 5 alpha reductase inhibitors. 1mg would be more than adequate for this purpose.
This regime suited me but you need to find the best balance to suit yourself.
Post op. the anti-androgen and Finasteride can be stopped as they are no longer necessary.
Transsexuals will take cross-sex hormones throughout their lives and most will undergo high risk and intrusive surgeries to change their bodies. Both the hormones and the surgeries can have specific health effects that need to be acknowledged and monitored to maintain the good health of the Transsexual. This is why the support of your GP is so important.
You can greatly reduce that risk by not smoking, drinking and eating more healthily and taking up gentle exercise; walking, swimming and cycling.
It is claimed that hormones increase the risk of DVT and breast cancer. Yes, certainly the earlier female hormones in use, Ethinyl Estradiol, a synthetic estrogen and Premarin, a conjugated oestrogen (an extract of pregnant mares urine) did increase the risk of DVT but the Bio-identical, such as 17β-Estradiol used pose a much lower risk. ‘Professor Louis Gooren of Amsterdam did a survey of over 3000 transsexuals using bio-identical female hormones against a similar cross section of males not on any medication and the results showed no significant differences'. Instances of breast cancer are not known but thought to be low, probably not much higher than that of males’. **However, it must be recognised that if you have a history or if there has been a history of heart problems, DVT, diabetes, etc. in your family then the hormones may increase that risk. That is why medical support is so important.
I do still honestly believe that the cross sex hormones that transsexuals take are very safe, subject to**, certainly safer than some medications that we can freely buy over the counter such as Paracetomol and much safer than smoking, drinking and too much junk food.
Summary: Hormone therapy is a very important part of transitioning.
The majority of gender clinics under prescribe and for too short a period. They appear to be blinkered against the vast amount of knowledge and experience amongst those Transsexuals who have completed their transitioning and been able to take control of their regime. Still, what do we know?
A proper well balanced, long term regime is very important to achieve full Feminisation and in line with the Female puberty.
WPATH SOC, Version 7: "The SOC are flexible clinical guidelines; they allow for tailoring of interventions to the needs of the individual receiving services and for tailoring of protocols to the approach and setting in which these services are provided,"
How soon will the Gender Clinics start to use the new guidelines? The NHS bought out guidelines for those that self medicate http://gires.org.uk/assets/DOH-Assets/pdf/doh-hormone-therapy.pdf Pages 17and 18. They feel that this carries a risk and to reduce that risk their guidelines recommend that your Doctor should take over that prescribing. These were bought out several years ago and I have heard of no instances where these guidelines have been followed.
I have concerns that the WPATH SOC, Version 7 guidelines will not be followed and nothing will improve in the care of Transsexuals. Previous versions, they have rarely followed the guidelines to our disadvantage but use them when it suits them. I had better explain: Dr Russell Reid occasionally ignored guidelines but to the patients advantage. Some NHS Psychiatrists, from a well known NHS Gender Clinic reported him to the GMC, in an attempt to get him struck off. They found against Russell but said he could continue to practice but under supervision. He retired and as a consequence we lost probably the best and most experienced Specialist we have ever had. http://en.wikipedia.org/wiki/Russell_Reid
WPATH Standards of Care, Version 7,
International Guidelines.
Launch of New Version of WPATH (World Professional Association for Transgender Health), [Formerly known as the Harry Benjamin International Gender Dysphoria Association], Standards of Care, Version 7, International Guidelines.
Some key revisions:
• Psychotherapy is no longer a requirement to receive hormones and surgery, although it is suggested.
"It used to be a minimum amount of psychotherapy was needed. An assessment is still required but that can be done by the prescribing hormone provider," Bockting explained.
• A number of community health centres in the U.S. have developed protocols for providing hormone therapy based an approach known as the Informed Consent Model. These protocols are consistent with version 7 revisions of WPATH's standards of care.
"The SOC are flexible clinical guidelines; they allow for tailoring of interventions to the needs of the individual receiving services and for tailoring of protocols to the approach and setting in which these services are provided," Coleman explained.
"Access is more open and acknowledges transgender care is being provided in community health centres. This certainly makes it easier to access hormones," Bockting added.
• There are now different standards for surgery, as well. For example, a transgender man who wants a hysterectomy no longer has to live one year as a male in order to receive the surgery. Likewise, a transgender woman who wants her testicles removed does not have to live one year as a female.
For people who want genital reconstructive surgery, however, the standards of care recommend living a year in the role of the gender they are transitioning.
• Another major change, Bockting explained, is that the standards "allow for a broader spectrum of identities – they are no longer so binary."
"There is no one way of being transgender and it doesn't have to mirror the idea of a change of their sex," Bockting explained.
"These standards allow for a gender queer person to have breasts removed without ever taking hormones," he said.
The WPATH conference in Atlanta, along with the Southern Comfort Conference and the conference of the Gay & Lesbian Medical Association, was a joint effort to show the world what is being done in the area of LGBT health.
But, Bockting added, the new WPATH standards of care also show the tremendous effort that transgender people themselves are doing to ensure their access to healthcare.
"Often times the standards of care were perceived as a barrier even though they were meant as access to care for hormone therapy and surgery,"
"The new standards showcase the important role [transsexual, transgender, and gender nonconforming people] have played in changing the landscape of transgender health in the U.S.," Bockting added.
Other Positive Changes:
The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include:
• Concise and more cogent criteria for access to hormonal and surgical transition care.
• Relaxation of the age 18 restriction for access to hormonal transition care.
• Removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.
• Clarification that “the presence of co-existing mental health concerns does not necessarily preclude access to feminising/ masculinising hormones .”
• Removal of barriers to surgical care because of family intolerance or interpersonal issues.
• An expanded role for medical health professionals in granting access to hormonal therapies.
• Acknowledgement of informed consent model protocols, developed at community health centers worldwide for hormonal transition care.
• Emphasis of cultural competence and sensitivity for care providers.
• Expanded and clarified information on puberty delaying treatment for gender dysphoric adolescents.
• Clarification on the role of the SOC as flexible clinical guidelines that may be tailored for individual needs and local cultures.
Issues for Future Revisions: Although the 7th Version of the SOC is significantly improved over previous versions, there remain issues of concern to trans communities and their allies. One issue is promotion of a widely held myth that Gender Dysphoria in children will persist in only a small minority by adolescence, in other words, that gender identity in children is malleable and impersistent.
Full version of latest WPATH SOC version 7 guidelines. www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf
From the GIRES website: WPATH – Standards of Care: Now in its seventh edition, the standards of care are based on the best available science and expert professional consensus. The new edition reflects the current attitude that transgender people are not inherently disordered.
One of the British gender identity clinics has stated in response to a Freedom of Information request: “Specifically, our Care Pathway follows the stages laid down within The Harry Benjamin International Standards of Care (this differs from the WPATH guidance), as we believe that hormone treatment is best undertaken after real life experience has begun”. The clinic is using an out of date document to justify its questionable practice. WPATH has therefore made it clear in a recent letter that the new Standards of Care take precedence over all earlier versions.
