Endocrine Society Guidelines

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The Endocrine Society Guidelines page contains a summary of tables contained in the journal article: "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline".

We have transcribed them into wiki code and optimized for mobile devices to facilitate their transclusion into other articles where they need to be referenced.

Common Effects of Hormone Therapy

Feminizing Effects in Transgender Females[1][2][3]

Effect

Onset

Max

Change in body fat distribution

3–6 mo

2–3 y

Decrease in muscle mass and strength

3–6 mo

1–2 y

Softening of skin / decreased oiliness

3–6 mo

Unknown

Decreased sexual desire

1–3 mo

3–6 mo

Decreased spontaneous erections

1–3 mo

3–6 mo

Male sexual dysfunction

Variable

Variable

Breast growth

3–6 mo

2–3 y

Decreased testicular volume

3–6 mo

2–3 y

Decreased sperm production

Unknown

>3 y

Decreased terminal hair growth

6–12 mo

>3 y a

Scalp hair

Variable

b

Voice changes

None

c


a Complete removal of male sexual hair requires electrolysis or laser treatment or both.
b Familial scalp hair loss may occur if estrogens are stopped.
c Treatment by speech pathologists for voice training is most effective

Abbreviations: Unk, Unknown.

Masculinizing Effects in Transgender Males[1][2][3][4]

Effect

Onset

Max

Skin oiliness/acne

1–6 mo

1–2 y

Facial/body hair growth

6–12 mo

4–5 y

Scalp hair loss

6–12 mo

a

Increased muscle mass/strength

6–12 mo

2–5 y

Change in body fat distribution

1–6 mo

2–5 y

Cessation of menses

1–6 mo

b

Clitoral enlargement

1–6 mo

1–2 y

Vaginal atrophy

1–6 mo

1–2 y

Deepening of voice

6–12 mo

1–2 y


aPrevention and treatment as recommended for biological men.
bMenorrhagia requires diagnosis and treatment by a gynecologist.

Preformatted Letters Useful for Informed Consent

About Informed Consent

The ICATH model reflects the basic human right to self-actualization. ICATH is not an institution, an agency or an organization: the use of Informed Consent is a trans-affirmative Standard of Care that is acknowledged and honored by medical providers around the world.

When giving informed consent, no therapist or letter is required, the patient is informed by the medical provider what a medication's effects (reversible, and irreversible) will be when administered. The patient, once informed, gives their consent to receive such treatment under the care of the provider.

ICATH promotes a departure from the system that uses Gender Identity Disorder Diagnosis and Gender Dysphoria as a means for accessing gender-confirming health care, and follows the Standard of Care already established for non-trans people accessing gender affirming healthcare.


Introduce Informed Consent to Your Medical Provider Using This Letter[5]

Dear Provider:
Thank you for working with me. As my provider you are in the position to offer me medical care that can support me to express my gender physically. I am writing this letter to request that you follow the standards of care outlined for this medication or procedure and allow us to use informed consent. I am aware of the following in regards to this gender affirming care and expect to discuss this with you in our appointment:

  • Potential social consequences
  • Potential occupational consequences
  • Potential effects on familial relationships
  • Potential financial costs
  • Potential impacts on mental and physical health

I am informed on the psychosocial impacts of this medical procedure and/or medication and am able to make an informed decision.

Sincerely, _______

Writing a letter with a Mental Health Counselor [6]

NOTE: Replace all Red Font with your details

DATE

PROVIDER NAME
ADDRESS
ADDRESS
PHONE/FAX

Dear PROVIDER NAME:

PATIENT NAME has met with a therapist/advocate regarding hormone use.

PATIENT PRONOUN has discussed the following in regards to beginning hormone use:

  • Potential social consequences
  • Potential occupational consequences
  • Potential effects on familial relationships
  • Potential financial costs
  • Potential impacts on mental and physical health

PATIENT NAME is informed on the psychosocial impacts of hormone use and is able to make an informed decision.

Sincerely,

THERAPIST NAME, CREDENTIAL
Therapist/Advocate

I, PATIENT NAME, have explored the potential psychosocial impacts of hormone use and am able to make an informed decision.

Sincerely,

PATIENT NAME

PARENT NAME

Patient

Parent/Guardian

Diagnostic Criteria and Treatment Eligibility Guidelines

Diagnostic Criteria

DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults[7]

  1. A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:
    1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
    2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
    3. A strong desire for the primary and/or secondary sex characteristics of the other gender
    4. A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
    5. A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)
    6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)
  2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  3. Specify if:
    1. The condition exists with a disorder of sex development.
    2. The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).

ICD-10 Criteria for Transsexualism

NOTE: This is considered an outdated definition and it's revision is being discussed for future editions.[8] [footnote 1]

Transsexualism (F64.0) has three criteria
  1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments.
  2. The transsexual identity has been present persistently for at least 2 y.
  3. The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality.

Tanner Stages of Breast Development and Male External Genitalia[9]

The description of Tanner stages for breast development:

  1. Prepubertal
  2. Breast and papilla elevated as small mound; areolar diameter increased
  3. Breast and areola enlarged, no contour separation
  4. Areola and papilla form secondary mound
  5. Mature; nipple projects, areola part of general breast contour

For penis and testes:

  1. Prepubertal, testicular volume, 4 mL
  2. Slight enlargement of penis; enlarged scrotum, pink, texture altered, testes 4–6 mL
  3. Penis longer, testes larger (8–12 mL)
  4. Penis and glans larger, including increase in breadth; testes larger (12–15 mL), scrotum dark
  5. Penis adult size; testicular volume . 15 ml


Treatment Eligibility

Criteria for Gender-Affirming Hormone Therapy for Adolescents[10]

Adolescents are eligible for GnRH agonist treatment if:

  1. A qualified MHP has confirmed that:
    • the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),
    • gender dysphoria worsened with the onset of puberty,
    • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,
    • the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,
  2. And the adolescent:
    • has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,
    • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending onb applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,
  3. And a pediatric endocrinologist or other clinician experienced in pubertal assessment
    • agrees with the indication for GnRH agonist treatment,
    • has confirmed that puberty has started in the adolescent (Tanner stage G2/B2),
    • has confirmed that there are no medical contraindications to GnRH agonist treatment.

Adolescents are eligible for subsequent sex hormone treatment if:

  1. A qualified MHP has confirmed:
    • the persistence of gender dysphoria,
    • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,
    • the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,
  2. And the adolescent:
    • has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility),
    • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,
  3. And a pediatric endocrinologist or other clinician experienced in pubertal induction:
    • agrees with the indication for sex hormone treatment,
    • has confirmed that there are no medical contraindications to sex hormone treatment.

Criteria for Gender-Affirming Hormone Therapy for Adults[10]

  1. Persistent, well-documented gender dysphoria/gender incongruence
  2. The capacity to make a fully informed decision and to consent for treatment
  3. The age of majority in a given country (if younger, follow the criteria for adolescents)
  4. Mental health concerns, if present, must be reasonably well controlled

Mental health professionals in the WPATH SOC model[10]

Competency of Mental Health Professionals Working with Children or Adolescents with Gender Dysphoria

The following are recommended minimum credentials for mental health professionals who assess, refer, and offer therapy to children and adolescents presenting with gender dysphoria:

  1. Meet the competency requirements for mental health professionals working with adults, as outlined in "Qualified Mental Health Proffessionals"
  2. Trained in childhood and adolescent developmental psychopathology;
  3. Competent in diagnosing and treating the ordinary problems of children and adolescents.

Competency of Mental Health Professionals Working with Adults Who Present with Gender Dysphoria[10]

  1. A master’s degree or its equivalent in a clinical behavioral science field. This degree or a more advanced one should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country.
  2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes.
  3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria.
  4. Documented supervised training and competence in psychotherapy or counseling.
  5. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
  6. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

Psychosocial Assessment[10]

  1. Assess gender dysphoria[footnote 2]
  2. Provide information regarding options for gender identity and expression and possible medical interventions[footnote 3]
  3. Assess, diagnose, and discuss treatment options for co-existing mental health concerns[footnote 4]
  4. If applicable, assess eligibility, prepare, and refer for hormone therapy[footnote 5]


HRT referral letter overview:
  1. The client’s general identifying characteristics;
  2. Results of the client’s psychosocial assessment, including any diagnoses;
  3. The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
  4. An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;
  5. A statement about the fact that informed consent has been obtained from the patient;
  6. A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

Prescribed Medications and Dosage Guidelines

Protocol Induction of Puberty[11]

Induction of female puberty with oral 17b-estradiol, increasing the dose every 6 mo
5 μg/kg/d
10 μg/kg/d
15 μg/kg/d
20 μg/kg/d
Adult dose = 2–6 mg/d
In postpubertal transgender female adolescents, the dose of 17b-estradiol can be increased more rapidly:
1 mg/d for 6 mo
2 mg/d
Induction of female puberty with transdermal 17b-estradiol, increasing the dose every 6 mo (new patch is placed every 3.5 d)
6.25–12.5 μg/24 h (cut 25-μg patch into quarters, then halves)
25 μg/24 h
37.5 μg/24 h
Adult dose 5 50–200 μg/24 h


Induction of male puberty with testosterone esters increasing the dose every 6 mo (IM or SC)
25 mg/m2/2 wk (or alternatively, half this dose weekly, or double the dose every 4 wk)
50 mg/m2/2 wk
75 mg/m2/2 wk
100 mg/m2/2 wk
Adult dose = 100–200 mg every 2 wk
In postpubertal transgender male adolescents the dose of testosterone esters can be increased more rapidly:
75 mg/2 wk for 6 mo
125 mg/2 wk


Abbreviations: IM, intramuscularly; SC, subcutaneously.

Hormone Regimens in Transgender Persons

Transgender females a
Estrogen
Oral
Estradiol
2.0 – 6.0 mg/d
Transdermal
Estradiol transdermal patch
0.025 – 0.2 mg/d
(New patch placed every 3 – 5 d)
Parenteral
Estradiol valerate or cypionate
5 – 30 mg IM every 2 wk
2 – 10 mg IM every week
Anti-androgens
Spironolactone
100 – 300 mg/d
Cyproterone acetate b
25 – 50 mg/d
GnRH agonist
3.75 mg SQ (SC) monthly
11.25 mg SQ (SC) 3-monthly
Transgender males
Testosterone
Parenteral testosterone
Testosterone enanthate or cypionate
100–200 mg SQ (IM) every 2 wk or SQ (SC) 50% per week
Testosterone undecanoate c
1000 mg every 12 wk
Transdermal testosterone
Testosterone gel 1.6% d
50 – 100 mg/d
Testosterone transdermal patch
2.5 – 7.5 mg/d

Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously.

aEstrogens used with or without antiandrogens or GnRH agonist.
bNot available in the United States

cOne thousand milligrams initially followed by an injection at 6 wk then at 12-wk intervals.
dAvoid cutaneous transfer to other individuals.

Guidelines for Monitoring Hormonal Therapy Patients

Suppression and Induction of Puberty

Baseline and Follow-Up Protocol During Suppression of Puberty[11]

NOTE:"Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs [12]. If the gonadal axis is not completely suppressed—as evidenced by (for example) menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased. During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. The following table illustrates a suggested clinical protocol."[11] [footnote 6]

Every 3–6 mo
Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
Every 6–12 mo
Laboratory: LH, FSH, E2/T, 25OH vitamin D
Every 1–2 y
Bone density using DXA
Bone age on X-ray of the left hand (if clinically indicated)


Abbreviations: DXA, dual-energy X-ray absorptiometry; E2, estradiol; FSH, follicle stimulating hormone; LH, luteinizing hormone; T, testosterone;


Baseline and Follow-up Protocol During Induction of Puberty[11]

Every 3–6 mo
  • Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
Every 6–12 mo
  • In transgender males: hemoglobin/hematocrit, lipids, testosterone, 25OH vitamin D
  • In transgender females: prolactin, estradiol, 25OH vitamin D
Every 1–2 y
  • BMD using DXA
  • Bone age on X-ray of the left hand (if clinically indicated)

BMD should be monitored into adulthood (until the age of 25–30 y or until peak bone mass has been reached). For recommendations on monitoring once pubertal induction has been completed, see Tables 14 and 15.

Abbreviation: DXA, dual-energy X-ray absorptiometry

Continued Monitoring of Hormone Therapy

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy:

Transgender Male

  1. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions.
  2. Measure serum testosterone every 3 mo until levels are in the normal physiologic male range:[13] [14]
    1. For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. The target level is 400–700 ng/dL to 400 ng/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range.
    2. For parenteral testosterone undecanoate, testosterone should be measured just before the following injection. If the level is, 400 ng/dL, adjust dosing interval.
    3. For transdermal testosterone, the testosterone level can be measured no sooner than after 1 wk of daily application (at least 2 h after application).
  3. Measure hematocrit or hemoglobin at baseline and every 3 mo for the first year and then one to two times a year. Monitor weight, blood pressure, and lipids at regular intervals.
  4. Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss.
  5. If cervical tissue is present, monitoring as recommended by the American College of Obstetricians and Gynecologists.
  6. Ovariectomy can be considered after completion of hormone transition.
  7. Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society.



Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy:

Transgender Female

  1. . Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of feminization and for development of adverse reactions.
    1. Serum testosterone levels should be ,50 ng/dL.
    2. Serum estradiol should not exceed the peak physiologic range: 100–200 pg/mL.
  2. For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter.
  3. Routine cancer screening is recommended, as in nontransgender individuals (all tissues present).
  4. . Consider BMD testing at baseline (160). In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.


Medical Risks Associated With Sex Hormone Therapy

Transgender female: estrogen

Very high risk of adverse outcomes
  • Thromboembolic disease
Moderate risk of adverse outcomes
  • Macroprolactinoma
  • Breast cancer
  • Coronary artery disease
  • Cerebrovascular disease
  • Cholelithiasis
  • Hypertriglyceridemia

Transgender male: testosterone

Very high risk of adverse outcomes
  • Erythrocytosis (hematocrit . 50%)
  • Severe liver dysfunction (transaminases . threefold upper limit of normal)
  • Coronary artery disease
  • Cerebrovascular disease
  • Hypertension
  • Breast or uterine cancer

Continued Reading

Footnotes

  1. The Working Group has recommended reconceptualizing the ICD‐10 category F64.0 Transsexualism as Gender incongruence of adolescence and adulthood and the ICD‐10 category F64.2 Gender identity disorder of childhood as Gender incongruence of childhood.
  2. Mental health professionals assess clients’ gender dysphoria in the context of an evaluation of their psychosocial adjustment (Bockting et al., 2006; Lev, 2004, 2009). The evaluation includes, at a minimum, assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender nonconformity on mental health, and the availability of support from family, friends, and peers (for example, in person or online contact with other transsexual, transgender, or gender nonconforming individuals or groups). The evaluation may result in no diagnosis, in a formal diagnosis related to gender dysphoria, and/or in other diagnoses that describe aspects of the client’s health and psychosocial adjustment. The role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to or better accounted for by other diagnoses. Mental health professionals with the competencies described above (hereafter called “a qualified mental health professional”) are best prepared to conduct this assessment of gender dysphoria. However, this task may instead be conducted by another type of health professional who has appropriate training in behavioral health and is competent in the assessment of gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy. This professional may be the prescribing hormone therapy provider or a member of that provider’s health care team.
  3. An important task of mental health professionals is to educate clients regarding the diversity of gender identities and expressions and the various options available to alleviate gender dysphoria. Mental health professionals then may facilitate a process (or refer elsewhere) in which clients explore these various options, with the goals of finding a comfortable gender role and expression and becoming prepared to make a fully informed decision about available medical interventions, if needed. This process may include referral for individual, family, and group therapy and/or to community resources and avenues for peer support. The professional and the client discuss the implications, both short- and long-term, of any changes in gender role and use of medical interventions. These implications can be psychological, social, physical, sexual, occupational, financial, and legal (Bockting et al., 2006; Lev, 2004). This task is also best conducted by a qualified mental health professional, but may be conducted by another health professional with appropriate training in behavioral health and with sufficient knowledge about gender nonconforming identities and expressions and about possible medical interventions for gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy.
  4. Clients presenting with gender dysphoria may struggle with a range of mental health concerns (Gómez-Gil, Trilla, Salamero, Godás, & Valdés, 2009; Murad et al., 2010) whether related or unrelated to what is often a long history of gender dysphoria and/or chronic minority stress. Possible concerns include anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders (Bockting et al., 2006; Nuttbrock et al., 2010; Robinow, 2009). Mental health professionals should screen for these and other mental health concerns and incorporate the identified concerns into the overall treatment plan. These concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender dysphoria (Bockting et al., 2006; Fraser, 2009a; Lev, 2009). Addressing these concerns can greatly facilitate the resolution of gender dysphoria, possible changes in gender role, the making of informed decisions about medical interventions, and improvements in quality of life. Some clients may benefit from psychotropic medications to alleviate symptoms or treat coexisting mental health concerns. Mental health professionals are expected to recognize this and either provide pharmacotherapy or refer to a colleague who is qualified to do so. The presence of co-existing mental health concerns does not necessarily preclude possible changes in gender role or access to feminizing/masculinizing hormones or surgery; rather, these concerns need to be optimally managed prior to or concurrent with treatment of gender dysphoria. In addition clients should be assessed for their ability to provide educated and informed consent for medical treatments. Qualified mental health professionals are specifically trained to assess, diagnose, and treat (or refer to treatment for) these co-existing mental health concerns. Other health professionals with appropriate training in behavioral health, particularly when functioning as part of a multidisciplinary specialty team providing access to feminizing/masculinizing hormone therapy, may also screen for mental health concerns and, if indicated, provide referral for comprehensive assessment and treatment by a qualified mental health professional.
  5. The SOC provide criteria to guide decisions regarding feminizing/masculinizing hormone therapy (outlined in section VIII and Appendix C). Mental health professionals can help clients who are considering hormone therapy to be both psychologically prepared (for example, has made a fully informed decision with clear and realistic expectations; is ready to receive the service in line with the overall treatment plan; has included family and community as appropriate) and practically prepared (for example, has been evaluated by a physician to rule out or address medical contraindications to hormone use; has considered the psychosocial implications). If clients are of childbearing age, reproductive options (section IX) should be explored before initiating hormone therapy. It is important for mental health professionals to recognize that decisions about hormones are first and foremost the client’s decisions – as are all decisions regarding healthcare. However, mental health professionals have a responsibility to encourage, guide, and assist clients with making fully informed decisions and becoming adequately prepared. To best support their clients’ decisions, mental health professionals need to have functioning working relationships with their clients and sufficient information about them. Clients should receive prompt and attentive evaluation, with the goal of alleviating their gender dysphoria and providing them with appropriate medical services.
  6. (Pg 15) Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs (88). If the gonadal axis is not completely suppressed—as evidenced by (for example) menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased. During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. The following table illustrates a suggested clinical protocol.

References

  1. 1.0 1.1 Price TM, Blauer KL, Hansen M, Stanczyk F, Lobo R, Bates GW. Single-dose pharmacokinetics of sublingual versus oral administration of micronized 17b-estradiol. Obstet Gynecol. 1997;89(3): 340–345.
  2. 2.0 2.1 Asscheman H, Gooren LJ, Assies J, Smits JP, de Slegte R. Prolactin levels and pituitary enlargement in hormone-treated male-to-female transsexuals. Clin Endocrinol (Oxf). 1988;28(6):583–588.
  3. 3.0 3.1 Gooren LJ, Harmsen-Louman W, van Kessel H. Follow-up of prolactin levels in long-term oestrogen-treated male-to-female transsexuals with regard to prolactinoma induction. Clin Endocrinol (Oxf). 1985;22(2):201–207.
  4. Wierckx K, Van Caenegem E, Schreiner T, Haraldsen I, Fisher AD, Toye K, Kaufman JM, T’Sjoen G. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence. J Sex Med. 2014;11(8):1999–2011.
  5. https://icath.info/2016/08/31/write-a-letter-to-your-medical-provider/ | Introduce Informed Consent to Your Medical Provider Using This Letter
  6. https://icath.info/2016/08/31/writing-a-letter-with-a-mental-health-counselor/ | Writing a letter with a Mental Health Counselor
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association Publishing.
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5032510/ | Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerations
  9. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299–315.
  10. 10.0 10.1 10.2 10.3 10.4 World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. Available at: http://www.wpath.org .
  11. 11.0 11.1 11.2 11.3 Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM; Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–3154.
  12. Carel JC, Eugster EA, Rogol A, Ghizzoni L, Palmert MR, Antoniazzi F, Berenbaum S, Bourguignon JP, Chrousos GP, Coste J, Deal S, de Vries L, Foster C, Heger S, Holland J, Jahnukainen K, Juul A, Kaplowitz P, Lahlou N, Lee MM, Lee P, Merke DP, Neely EK, Oostdijk W, Phillip M, Rosenfield RL, Shulman D, Styne D, Tauber M, Wit JM; ESPE-LWPES GnRH Analogs Consensus Conference Group. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics. 2009;123(4):e752–e762.
  13. Lapauw B, Taes Y, Simoens S, Van Caenegem E, Weyers S, Goemaere S, Toye K, Kaufman J-M, T’Sjoen GG. Body composition, volumetric and areal bone parameters in male-to-female transsexual persons. Bone. 2008;43(6):1016–1021.
  14. >Ott J, Kaufmann U, Bentz EK, Huber JC, Tempfer CB. Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Fertil Steril. 2010;93(4):1267–1272.

Common Effects of Hormone Therapy

Feminizing Effects in Transgender Females[1][2][3]

Effect

Onset

Max

Change in body fat distribution

3–6 mo

2–3 y

Decrease in muscle mass and strength

3–6 mo

1–2 y

Softening of skin / decreased oiliness

3–6 mo

Unknown

Decreased sexual desire

1–3 mo

3–6 mo

Decreased spontaneous erections

1–3 mo

3–6 mo

Male sexual dysfunction

Variable

Variable

Breast growth

3–6 mo

2–3 y

Decreased testicular volume

3–6 mo

2–3 y

Decreased sperm production

Unknown

>3 y

Decreased terminal hair growth

6–12 mo

>3 y a

Scalp hair

Variable

b

Voice changes

None

c


a Complete removal of male sexual hair requires electrolysis or laser treatment or both.
b Familial scalp hair loss may occur if estrogens are stopped.
c Treatment by speech pathologists for voice training is most effective

Abbreviations: Unk, Unknown.


Masculinizing Effects in Transgender Males[1][2][3][4]

Effect

Onset

Max

Skin oiliness/acne

1–6 mo

1–2 y

Facial/body hair growth

6–12 mo

4–5 y

Scalp hair loss

6–12 mo

a

Increased muscle mass/strength

6–12 mo

2–5 y

Change in body fat distribution

1–6 mo

2–5 y

Cessation of menses

1–6 mo

b

Clitoral enlargement

1–6 mo

1–2 y

Vaginal atrophy

1–6 mo

1–2 y

Deepening of voice

6–12 mo

1–2 y


aPrevention and treatment as recommended for biological men.
bMenorrhagia requires diagnosis and treatment by a gynecologist.

Preformatted Letters Useful for Informed Consent

About Informed Consent

The ICATH model reflects the basic human right to self-actualization. ICATH is not an institution, an agency or an organization: the use of Informed Consent is a trans-affirmative Standard of Care that is acknowledged and honored by medical providers around the world.

When giving informed consent, no therapist or letter is required, the patient is informed by the medical provider what a medication's effects (reversible, and irreversible) will be when administered. The patient, once informed, gives their consent to receive such treatment under the care of the provider.

ICATH promotes a departure from the system that uses Gender Identity Disorder Diagnosis and Gender Dysphoria as a means for accessing gender-confirming health care, and follows the Standard of Care already established for non-trans people accessing gender affirming healthcare.

Introduce Informed Consent to Your Medical Provider Using This Letter[5]

Dear Provider:
Thank you for working with me. As my provider you are in the position to offer me medical care that can support me to express my gender physically. I am writing this letter to request that you follow the standards of care outlined for this medication or procedure and allow us to use informed consent. I am aware of the following in regards to this gender affirming care and expect to discuss this with you in our appointment:

  • Potential social consequences
  • Potential occupational consequences
  • Potential effects on familial relationships
  • Potential financial costs
  • Potential impacts on mental and physical health

I am informed on the psychosocial impacts of this medical procedure and/or medication and am able to make an informed decision.

Sincerely, _______

Writing a letter with a Mental Health Counselor [6]

NOTE: Replace all Red Font with your details

DATE

PROVIDER NAME
ADDRESS
ADDRESS
PHONE/FAX

Dear PROVIDER NAME:

PATIENT NAME has met with a therapist/advocate regarding hormone use.

PATIENT PRONOUN has discussed the following in regards to beginning hormone use:

  • Potential social consequences
  • Potential occupational consequences
  • Potential effects on familial relationships
  • Potential financial costs
  • Potential impacts on mental and physical health

PATIENT NAME is informed on the psychosocial impacts of hormone use and is able to make an informed decision.

Sincerely,

THERAPIST NAME, CREDENTIAL
Therapist/Advocate

I, PATIENT NAME, have explored the potential psychosocial impacts of hormone use and am able to make an informed decision.

Sincerely,

PATIENT NAME

PARENT NAME

Patient

Parent/Guardian

Diagnostic Criteria and Treatment Eligibility Guidelines

Diagnostic Criteria

DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults[7]

  1. A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:
    1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
    2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
    3. A strong desire for the primary and/or secondary sex characteristics of the other gender
    4. A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
    5. A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)
    6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)
  2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  3. Specify if:
    1. The condition exists with a disorder of sex development.
    2. The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).

ICD-10 Criteria for Transsexualism

NOTE: This is considered an outdated definition and it's revision is being discussed for future editions.[8] [footnote 1]

Transsexualism (F64.0) has three criteria
  1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments.
  2. The transsexual identity has been present persistently for at least 2 y.
  3. The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality.

Tanner Stages of Breast Development and Male External Genitalia[9]

The description of Tanner stages for breast development:

  1. Prepubertal
  2. Breast and papilla elevated as small mound; areolar diameter increased
  3. Breast and areola enlarged, no contour separation
  4. Areola and papilla form secondary mound
  5. Mature; nipple projects, areola part of general breast contour

For penis and testes:

  1. Prepubertal, testicular volume, 4 mL
  2. Slight enlargement of penis; enlarged scrotum, pink, texture altered, testes 4–6 mL
  3. Penis longer, testes larger (8–12 mL)
  4. Penis and glans larger, including increase in breadth; testes larger (12–15 mL), scrotum dark
  5. Penis adult size; testicular volume . 15 ml

Treatment Eligibility

Criteria for Gender-Affirming Hormone Therapy for Adolescents[10]

Adolescents are eligible for GnRH agonist treatment if:

  1. A qualified MHP has confirmed that:
    • the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),
    • gender dysphoria worsened with the onset of puberty,
    • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,
    • the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,
  2. And the adolescent:
    • has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,
    • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending onb applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,
  3. And a pediatric endocrinologist or other clinician experienced in pubertal assessment
    • agrees with the indication for GnRH agonist treatment,
    • has confirmed that puberty has started in the adolescent (Tanner stage G2/B2),
    • has confirmed that there are no medical contraindications to GnRH agonist treatment.

Adolescents are eligible for subsequent sex hormone treatment if:

  1. A qualified MHP has confirmed:
    • the persistence of gender dysphoria,
    • any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,
    • the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,
  2. And the adolescent:
    • has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility),
    • has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,
  3. And a pediatric endocrinologist or other clinician experienced in pubertal induction:
    • agrees with the indication for sex hormone treatment,
    • has confirmed that there are no medical contraindications to sex hormone treatment.

Criteria for Gender-Affirming Hormone Therapy for Adults[10]

  1. Persistent, well-documented gender dysphoria/gender incongruence
  2. The capacity to make a fully informed decision and to consent for treatment
  3. The age of majority in a given country (if younger, follow the criteria for adolescents)
  4. Mental health concerns, if present, must be reasonably well controlled

Mental health professionals in the WPATH SOC model[10]

Competency of Mental Health Professionals Working with Children or Adolescents with Gender Dysphoria

The following are recommended minimum credentials for mental health professionals who assess, refer, and offer therapy to children and adolescents presenting with gender dysphoria:

  1. Meet the competency requirements for mental health professionals working with adults, as outlined in "Qualified Mental Health Proffessionals"
  2. Trained in childhood and adolescent developmental psychopathology;
  3. Competent in diagnosing and treating the ordinary problems of children and adolescents.

Competency of Mental Health Professionals Working with Adults Who Present with Gender Dysphoria[10]

  1. A master’s degree or its equivalent in a clinical behavioral science field. This degree or a more advanced one should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country.
  2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes.
  3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria.
  4. Documented supervised training and competence in psychotherapy or counseling.
  5. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
  6. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

Psychosocial Assessment[10]

  1. Assess gender dysphoria[footnote 2]
  2. Provide information regarding options for gender identity and expression and possible medical interventions[footnote 3]
  3. Assess, diagnose, and discuss treatment options for co-existing mental health concerns[footnote 4]
  4. If applicable, assess eligibility, prepare, and refer for hormone therapy[footnote 5]


HRT referral letter overview:
  1. The client’s general identifying characteristics;
  2. Results of the client’s psychosocial assessment, including any diagnoses;
  3. The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
  4. An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;
  5. A statement about the fact that informed consent has been obtained from the patient;
  6. A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

Prescribed Medications and Dosage Guidelines

Protocol Induction of Puberty[11]

Induction of female puberty with oral 17b-estradiol, increasing the dose every 6 mo
5 μg/kg/d
10 μg/kg/d
15 μg/kg/d
20 μg/kg/d
Adult dose = 2–6 mg/d
In postpubertal transgender female adolescents, the dose of 17b-estradiol can be increased more rapidly:
1 mg/d for 6 mo
2 mg/d
Induction of female puberty with transdermal 17b-estradiol, increasing the dose every 6 mo (new patch is placed every 3.5 d)
6.25–12.5 μg/24 h (cut 25-μg patch into quarters, then halves)
25 μg/24 h
37.5 μg/24 h
Adult dose 5 50–200 μg/24 h


Induction of male puberty with testosterone esters increasing the dose every 6 mo (IM or SC)
25 mg/m2/2 wk (or alternatively, half this dose weekly, or double the dose every 4 wk)
50 mg/m2/2 wk
75 mg/m2/2 wk
100 mg/m2/2 wk
Adult dose = 100–200 mg every 2 wk
In postpubertal transgender male adolescents the dose of testosterone esters can be increased more rapidly:
75 mg/2 wk for 6 mo
125 mg/2 wk


Abbreviations: IM, intramuscularly; SC, subcutaneously.

Hormone Regimens in Transgender Persons

Transgender females a

Estrogen
Oral
Estradiol
2.0 – 6.0 mg/d
Transdermal
Estradiol transdermal patch

(New patch placed every 3 – 5 d)
0.025 – 0.2 mg/d
Parenteral
Estradiol valerate or cypionate
5 – 30 mg IM every 2 wk
2 – 10 mg IM every week
Anti-androgens
Spironolactone
100 – 300 mg/d
Cyproterone acetate b
25 – 50 mg/d
GnRH agonist
monthly
3.75 mg SQ (SC)
3-monthly
11.25 mg SQ (SC)


Transgender males

Testosterone
Parenteral testosterone
Testosterone enanthate or cypionate
100–200 mg SQ (IM) every 2 wk or SQ (SC) 50% per week
Testosterone undecanoate c
1000 mg every 12 wk
Transdermal testosterone
Testosterone gel 1.6% d
50 – 100 mg/d
Testosterone transdermal patch
2.5 – 7.5 mg/d

Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously.



aEstrogens used with or without antiandrogens or GnRH agonist.

bNot available in the United States

cOne thousand milligrams initially followed by an injection at 6 wk then at 12-wk intervals.
dAvoid cutaneous transfer to other individuals.

Guidelines for Monitoring Hormonal Therapy Patients

Suppression and Induction of Puberty

Baseline and Follow-Up Protocol During Suppression of Puberty[11]

NOTE:"Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs [12]. If the gonadal axis is not completely suppressed—as evidenced by (for example) menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased. During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. The following table illustrates a suggested clinical protocol."[11] [footnote 6]

Every 3–6 mo
Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
Every 6–12 mo
Laboratory: LH, FSH, E2/T, 25OH vitamin D
Every 1–2 y
Bone density using DXA
Bone age on X-ray of the left hand (if clinically indicated)


Abbreviations: DXA, dual-energy X-ray absorptiometry; E2, estradiol; FSH, follicle stimulating hormone; LH, luteinizing hormone; T, testosterone;

Baseline and Follow-up Protocol During Induction of Puberty[11]

Every 3–6 mo
  • Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
Every 6–12 mo
  • In transgender males: hemoglobin/hematocrit, lipids, testosterone, 25OH vitamin D
  • In transgender females: prolactin, estradiol, 25OH vitamin D
Every 1–2 y
  • BMD using DXA
  • Bone age on X-ray of the left hand (if clinically indicated)

BMD should be monitored into adulthood (until the age of 25–30 y or until peak bone mass has been reached). For recommendations on monitoring once pubertal induction has been completed, see Tables 14 and 15.

Abbreviation: DXA, dual-energy X-ray absorptiometry


Continued Monitoring of Hormone Therapy

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Male

  1. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions.
  2. Measure serum testosterone every 3 mo until levels are in the normal physiologic male range:[13][14]
    1. For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. The target level is 400–700 ng/dL to 400 ng/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range.
    2. For parenteral testosterone undecanoate, testosterone should be measured just before the following injection. If the level is, 400 ng/dL, adjust dosing interval.
    3. For transdermal testosterone, the testosterone level can be measured no sooner than after 1 wk of daily application (at least 2 h after application).
  3. Measure hematocrit or hemoglobin at baseline and every 3 mo for the first year and then one to two times a year. Monitor weight, blood pressure, and lipids at regular intervals.
  4. Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss.
  5. If cervical tissue is present, monitoring as recommended by the American College of Obstetricians and Gynecologists.
  6. Ovariectomy can be considered after completion of hormone transition.
  7. Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society.

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female

  1. . Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of feminization and for development of adverse reactions.
    1. Serum testosterone levels should be ,50 ng/dL.
    2. Serum estradiol should not exceed the peak physiologic range: 100–200 pg/mL.
  2. For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter.
  3. Routine cancer screening is recommended, as in nontransgender individuals (all tissues present).
  4. . Consider BMD testing at baseline (160). In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.

Medical Risks Associated With Sex Hormone Therapy

Transgender female: estrogen

Very high risk of adverse outcomes
  • Thromboembolic disease
Moderate risk of adverse outcomes
  • Macroprolactinoma
  • Breast cancer
  • Coronary artery disease
  • Cerebrovascular disease
  • Cholelithiasis
  • Hypertriglyceridemia

Transgender male: testosterone

Very high risk of adverse outcomes
  • Erythrocytosis (hematocrit . 50%)
  • Severe liver dysfunction (transaminases . threefold upper limit of normal)
  • Coronary artery disease
  • Cerebrovascular disease
  • Hypertension
  • Breast or uterine cancer

Continued Reading

Footnotes

  1. The Working Group has recommended reconceptualizing the ICD‐10 category F64.0 Transsexualism as Gender incongruence of adolescence and adulthood and the ICD‐10 category F64.2 Gender identity disorder of childhood as Gender incongruence of childhood.
  2. Mental health professionals assess clients’ gender dysphoria in the context of an evaluation of their psychosocial adjustment (Bockting et al., 2006; Lev, 2004, 2009). The evaluation includes, at a minimum, assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender nonconformity on mental health, and the availability of support from family, friends, and peers (for example, in person or online contact with other transsexual, transgender, or gender nonconforming individuals or groups). The evaluation may result in no diagnosis, in a formal diagnosis related to gender dysphoria, and/or in other diagnoses that describe aspects of the client’s health and psychosocial adjustment. The role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to or better accounted for by other diagnoses. Mental health professionals with the competencies described above (hereafter called “a qualified mental health professional”) are best prepared to conduct this assessment of gender dysphoria. However, this task may instead be conducted by another type of health professional who has appropriate training in behavioral health and is competent in the assessment of gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy. This professional may be the prescribing hormone therapy provider or a member of that provider’s health care team.
  3. An important task of mental health professionals is to educate clients regarding the diversity of gender identities and expressions and the various options available to alleviate gender dysphoria. Mental health professionals then may facilitate a process (or refer elsewhere) in which clients explore these various options, with the goals of finding a comfortable gender role and expression and becoming prepared to make a fully informed decision about available medical interventions, if needed. This process may include referral for individual, family, and group therapy and/or to community resources and avenues for peer support. The professional and the client discuss the implications, both short- and long-term, of any changes in gender role and use of medical interventions. These implications can be psychological, social, physical, sexual, occupational, financial, and legal (Bockting et al., 2006; Lev, 2004). This task is also best conducted by a qualified mental health professional, but may be conducted by another health professional with appropriate training in behavioral health and with sufficient knowledge about gender nonconforming identities and expressions and about possible medical interventions for gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy.
  4. Clients presenting with gender dysphoria may struggle with a range of mental health concerns (Gómez-Gil, Trilla, Salamero, Godás, & Valdés, 2009; Murad et al., 2010) whether related or unrelated to what is often a long history of gender dysphoria and/or chronic minority stress. Possible concerns include anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders (Bockting et al., 2006; Nuttbrock et al., 2010; Robinow, 2009). Mental health professionals should screen for these and other mental health concerns and incorporate the identified concerns into the overall treatment plan. These concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender dysphoria (Bockting et al., 2006; Fraser, 2009a; Lev, 2009). Addressing these concerns can greatly facilitate the resolution of gender dysphoria, possible changes in gender role, the making of informed decisions about medical interventions, and improvements in quality of life. Some clients may benefit from psychotropic medications to alleviate symptoms or treat coexisting mental health concerns. Mental health professionals are expected to recognize this and either provide pharmacotherapy or refer to a colleague who is qualified to do so. The presence of co-existing mental health concerns does not necessarily preclude possible changes in gender role or access to feminizing/masculinizing hormones or surgery; rather, these concerns need to be optimally managed prior to or concurrent with treatment of gender dysphoria. In addition clients should be assessed for their ability to provide educated and informed consent for medical treatments. Qualified mental health professionals are specifically trained to assess, diagnose, and treat (or refer to treatment for) these co-existing mental health concerns. Other health professionals with appropriate training in behavioral health, particularly when functioning as part of a multidisciplinary specialty team providing access to feminizing/masculinizing hormone therapy, may also screen for mental health concerns and, if indicated, provide referral for comprehensive assessment and treatment by a qualified mental health professional.
  5. The SOC provide criteria to guide decisions regarding feminizing/masculinizing hormone therapy (outlined in section VIII and Appendix C). Mental health professionals can help clients who are considering hormone therapy to be both psychologically prepared (for example, has made a fully informed decision with clear and realistic expectations; is ready to receive the service in line with the overall treatment plan; has included family and community as appropriate) and practically prepared (for example, has been evaluated by a physician to rule out or address medical contraindications to hormone use; has considered the psychosocial implications). If clients are of childbearing age, reproductive options (section IX) should be explored before initiating hormone therapy. It is important for mental health professionals to recognize that decisions about hormones are first and foremost the client’s decisions – as are all decisions regarding healthcare. However, mental health professionals have a responsibility to encourage, guide, and assist clients with making fully informed decisions and becoming adequately prepared. To best support their clients’ decisions, mental health professionals need to have functioning working relationships with their clients and sufficient information about them. Clients should receive prompt and attentive evaluation, with the goal of alleviating their gender dysphoria and providing them with appropriate medical services.
  6. (Pg 15) Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs (88). If the gonadal axis is not completely suppressed—as evidenced by (for example) menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased. During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. The following table illustrates a suggested clinical protocol.

References

  1. 1.0 1.1 Price TM, Blauer KL, Hansen M, Stanczyk F, Lobo R, Bates GW. Single-dose pharmacokinetics of sublingual versus oral administration of micronized 17b-estradiol. Obstet Gynecol. 1997;89(3): 340–345.
  2. 2.0 2.1 Asscheman H, Gooren LJ, Assies J, Smits JP, de Slegte R. Prolactin levels and pituitary enlargement in hormone-treated male-to-female transsexuals. Clin Endocrinol (Oxf). 1988;28(6):583–588.
  3. 3.0 3.1 Gooren LJ, Harmsen-Louman W, van Kessel H. Follow-up of prolactin levels in long-term oestrogen-treated male-to-female transsexuals with regard to prolactinoma induction. Clin Endocrinol (Oxf). 1985;22(2):201–207.
  4. Wierckx K, Van Caenegem E, Schreiner T, Haraldsen I, Fisher AD, Toye K, Kaufman JM, T’Sjoen G. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence. J Sex Med. 2014;11(8):1999–2011.
  5. https://icath.info/2016/08/31/write-a-letter-to-your-medical-provider/ | Introduce Informed Consent to Your Medical Provider Using This Letter
  6. https://icath.info/2016/08/31/writing-a-letter-with-a-mental-health-counselor/ | Writing a letter with a Mental Health Counselor
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association Publishing.
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5032510/ | Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerations
  9. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299–315.
  10. 10.0 10.1 10.2 10.3 10.4 World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. Available at: http://www.wpath. org/site_page.cfm?pk_association_webpage_menu51351&pk_ association_webpage53926.
  11. 11.0 11.1 11.2 11.3 Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM; Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–3154.
  12. Carel JC, Eugster EA, Rogol A, Ghizzoni L, Palmert MR, Antoniazzi F, Berenbaum S, Bourguignon JP, Chrousos GP, Coste J, Deal S, de Vries L, Foster C, Heger S, Holland J, Jahnukainen K, Juul A, Kaplowitz P, Lahlou N, Lee MM, Lee P, Merke DP, Neely EK, Oostdijk W, Phillip M, Rosenfield RL, Shulman D, Styne D, Tauber M, Wit JM; ESPE-LWPES GnRH Analogs Consensus Conference Group. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics. 2009;123(4):e752–e762.
  13. Lapauw B, Taes Y, Simoens S, Van Caenegem E, Weyers S, Goemaere S, Toye K, Kaufman J-M, T’Sjoen GG. Body composition, volumetric and areal bone parameters in male-to-female transsexual persons. Bone. 2008;43(6):1016–1021.
  14. Ott J, Kaufmann U, Bentz EK, Huber JC, Tempfer CB. Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Fertil Steril. 2010;93(4):1267–1272.