Transgender hormone therapy

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    • Transgender hormone therapy, also called hormone replacement therapy (HRT) or gender-affirming hormone therapy (GAHT), is a form of

    masculinization or feminization
    :

    Eligibility for transgender hormone therapy may be concluded by assessing a patient for gender dysphoria or persistent gender incongruence, though many medical institutions now used an informed consent model. This model ensures patients are informed of the procedure process, including possible benefits and risks, while removing many of the historical barriers needed to start hormone therapy. Treatment guidelines for therapy have been developed by several medical associations.

    Some

    Non-binary people may also engage in hormone therapy in order to achieve a desired balance of sex hormones or to help align their bodies with their gender identities.[1] Many transgender people obtain hormone therapy from a licensed health care provider and others obtain and self-administer hormones
    .

    Requirements

    The formal requirements to begin gender-affirming hormone therapy vary widely depending on geographic location and specific institution. Gender affirming hormones can be prescribed by a wide range of medical providers including, but not limited to, primary care physicians, endocrinologists, and obstetrician-gynecologists.[2]

    Historically, many health centers required a psychiatric evaluation and/or a letter from a therapist before beginning therapy. Many centers now use an

    Howard Brown Health Center[4] and Planned Parenthood[5]
    ) advocate for this type of informed consent model.

    The World Professional Association for Transgender Health (WPATH) Standards of Care, 7th edition, note that both of these approaches to care are appropriate.[2]

    Gender dysphoria

    Many international guidelines and institutions require persistent, well-documented gender dysphoria as a pre-requisite to starting gender-affirmation therapy.

    gender nonconforming individuals experience gender dysphoria.[8]

    Treatment options

    Guidelines

    For transgender youth, the Dutch protocol existed as among the earlier guidelines for hormone therapy by delaying puberty until age 16.[9][10] The World Professional Association for Transgender Health (WPATH) and the Endocrine Society later formulated guidelines that created a foundation for health care providers to care for transgender patients.[11][12] UCSF guidelines are also sometimes used.[3] There is no generally agreed-upon set of guidelines, however.[13]

    Delaying puberty in adolescents

    Main article: Puberty blocker
    Tanner Stages for Female Sexual Characteristics
    Tanner Stages for Male Sexual Characteristics

    Adolescents experiencing gender dysphoria may opt to undergo puberty-suppressing hormone therapy at the onset of puberty. The Standards of Care set forth by

    WPATH classifies puberty-suppressing hormone therapy as a "fully reversible" intervention. Delaying puberty allows individuals more time to explore their gender identity before deciding on more permanent interventions and prevents the physical changes associated with puberty.[6]

    The preferred puberty-suppressing agent for both individuals assigned male at birth and individuals assigned female at birth is a

    GnRH Analogue.[6] This approach temporarily shuts down the Hypothalamic-Pituitary-Gonadal (HPG) Axis, which is responsible for the production of hormones (estrogen, testosterone) that cause the development of secondary sexual characteristics in puberty.[15]

    Feminizing hormone therapy

    Main article: Feminizing hormone therapy

    demasculinization and promotion of feminization and breast development. Estrogens are administered in various modalities including injection, transdermal patch, and oral tablets.[18]

    The desired effects of feminizing hormone therapy focus on the development of feminine secondary sex characteristics. These desired effects include: breast tissue development, redistribution of body fat, decreased body hair, reduction of muscle mass, and more.[18] The table below summarizes some of the effects of feminizing hormone therapy in transgender women:

    Effects of feminizing hormone therapy
    Effect Time to expected
    onset of effect[a]    		 Time to expected
    maximum effect[a][b]     		Permanency if hormone
    therapy is stopped
    Breast development and nipple/areolar enlargement 2–6 months 1–5 years Permanent
    Thinning/slowed
    growth of facial/body hair
    		 4–12 months >3 years[c] Reversible
    Cessation/reversal of
    male-pattern scalp hair loss
    		 1–3 months 1–2 years[d] Reversible
    Softening of
    oiliness and acne
    		 3–6 months Unknown Reversible
    Redistribution of body fat in a feminine pattern 3–6 months 2–5 years Reversible
    Decreased muscle mass/strength 3–6 months 1–2 years[e] Reversible
    Widening and rounding of the pelvis[f]
    		 Unspecified Unspecified Permanent
    Changes in mood, emotionality, and behavior Unspecified Unspecified Reversible
    Decreased
    sex drive
    		 1–3 months Temporary[19] Reversible
    Decreased
    morning erections
    		 1–3 months 3–6 months Reversible
    decreased ejaculate volume
    		 1–3 months Variable Reversible
    Decreased
    fertility
    		 Unknown >3 years Reversible or permanent[g]
    Decreased testicle size 3–6 months 2–3 years Unknown
    Decreased penis size None[h] Not applicable Not applicable
    Decreased
    prostate gland
    size    		 Unspecified Unspecified Unspecified
    Voice changes None[i] Not applicable Not applicable
    Footnotes and sources
    Footnotes:
    1. ^ a b Estimates represent published and unpublished clinical observations.
    2. gonad removal. Generally, older individuals with intact gonads may have less feminization
      overall.
    3. ^ Complete removal of male facial and body hair requires electrolysis, laser hair removal, or both. Temporary hair removal can be achieved with shaving, epilating, waxing, and other methods.
    4. Familial scalp hair loss
      may occur if estrogens are stopped.
    5. physical exercise
      .
    6. epiphyseal closure
      .
    7. sperm quality is likely and sperm preservation
      options should be counseled on and considered before initiation of therapy.
    8. ^ Conflicting reports, with none reported observed in transgender women but significant albeit minor reduction of penis size reported in men with prostate cancer on androgen deprivation therapy.[20][21][22][23]
    9. voice training
      is effective.
    Sources: Guidelines:[24][6][25] Reviews/book chapters: [26][27][28][29] Studies:[30][31]

    Masculinizing hormone therapy

    Main article: Masculinizing hormone therapy

    subcutaneous injections. This dosing can be weekly or biweekly depending on the individual patient.[citation needed
    ]

    Unlike feminizing hormone therapy, individuals undergoing masculinizing hormone therapy do not usually require additional hormone suppression such as estrogen suppression. Therapeutic doses of testosterone are usually sufficient to inhibit the production of estrogen to desired physiologic levels.[15]

    The desired effects of masculinizing hormone therapy focus on the development of masculine secondary sex characteristics. These desired effects include: increased muscle mass, development of facial hair, voice deepening, increase and thickening of body hair, and more.[34]

    Effects of masculinizing hormone therapy[3][6]
    Reversible Changes Irreversible Changes
    Increased libido Deepening of voice
    Redistribution of body fat Growth of facial/body hair
    Cessation of ovulation/menstruation Male-pattern baldness
    Increased muscle mass Enlargement of clitoris
    Increased perspiration Growth spurt/closure of growth plates
    Acne Breast atrophy
    Increased RBC count

    Safety

    Hormone therapy for transgender individuals has been shown in medical literature to be generally safe, when supervised by a qualified medical professional.[35] 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.[33][17] 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.[33][36]

    Feminizing hormone therapy

    The Standards of Care published by the World Professional Association for Transgender Health (WPATH) summarize many of the risks associated with feminizing hormone therapy (outlined below).[6] For more in-depth information on the safety profile of estrogen-based feminizing hormone therapy visit the feminizing hormone therapy page.

    Summary of Risks of Estrogen Therapy[37]
    Likely Increased Risk Possible Increased Risk Inconclusive/No Increased Risk
    Venous thromboembolic disease
    		 Type 2 diabetes Breast cancer
    Cardiovascular disease Hypertension Prostate cancer
    Hypertriglyceridemia Hyperprolactinaemia
    Gallstones Osteoporosis
    Hyperkalemia
    Cerebrovascular disease
    Polyuria (or dehydration)[a]
    Meningioma[b]
    1. ^ Only present in individuals taking spironolactone
    2. ^ Only present in individuals taking cyproterone

    Masculinizing hormone therapy

    The Standards of Care published by the World Professional Association for Transgender Health (WPATH) summarize many of the risks associated with masculinizing hormone therapy (outlined below).[6] For more in-depth information on the safety profile of testosterone-based masculinizing hormone therapy visit the masculinizing hormone therapy page.

    Summary of Risks of Testosterone Therapy[37]
    Likely Increased Risk Possible Increased Risk Inconclusive/No Increased Risk
    Polycythemia Type 2 diabetes Osteoporosis
    Weight gain Breast cancer
    Acne Ovarian cancer
    Pattern hair loss Uterine cancer
    Hypertension Cervical cancer
    Sleep apnea
    Decreased HDL cholesterol
    Decreased LDL cholesterol
    Cardiovascular disease
    Hypertriglyceridemia

    Fertility consideration

    Transgender hormone therapy may limit fertility potential.

    sex reassignment surgery, their fertility potential is lost completely.[39] Before starting any treatment, individuals may consider fertility issues and fertility preservation. Options include semen cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation.[38][39]

    A study presented at ENDO 2019 (the Endocrine Society's conference) shows that even after one year of treatment with testosterone, a transgender man can preserve his fertility potential.[40]

    Treatment eligibility

    Many providers use informed consent, whereby someone seeking hormone therapy can sign a statement of informed consent and begin treatment without much gatekeeping. For other providers, eligibility is determined using major diagnostic tools such as ICD-11 or the Diagnostic and Statistical Manual of Mental Disorders (DSM) to classify a patient with gender dysphoria. 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-11 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-11 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.[41]

    WPATH Standards of Care

    The WPATH Standards of Care, most recently published in 2022, outlines a series of guidelines which should be met before a patient should be allowed transgender hormone replacement therapy:[37]

    • Gender incongruence is marked and sustained
    • Patient meets diagnostic criteria for gender incongruence prior to gender-affirming hormone treatment in regions where a diagnosis is necessary to access health care
    • Patient has capacity to consent to hormone therapy treatment
    • Other possible causes of apparent gender incongruence have been identified and excluded
    • Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed
    • Understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options

    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).

    In Sweden, for instance, patients seeking to access gender affirming healthcare must first undergo extended evaluations with psychiatric professionals, during which they must - without any form of medical transition - successfully live for one full year as their desired gender in all professional, social, and personal matters. Gender clinics are recommended to provide patients with wigs and breast prostheses for the endeavor. The evaluation additionally involves, if possible, meetings with family members and/or other individuals close to the patient. Patients may be denied care for any number of "psychosocial dimensions", including their choice of job or their marital status.[42][43]

    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.[44]

    In September 2022, the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transgender and Gender Diverse People (SOC) Version 8 were released and removed the requirement of RLE for all gender-affirming treatments, including gender-affirming surgery.[45]

    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.[46]

    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 an approval letter from a psychotherapist. Many therapists require extended periods 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.[citation needed
    ]

    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."[47] Self-administration of hormone replacement medications without medical supervision may have untoward health effects and risks.[48]

    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.[citation needed]

    See also

    References

    1. ^ Ferguson JM (November 30, 2017). "What It Means to Transition When You're Non-Binary". Teen Vogue.
    2. ^
      PMID 23317072
      .
    3. ^ a b c Deutsch MB, ed. (June 2016). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People (2nd ed.). San Francisco, CA: UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco.
    4. ^ Schreiber L. "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.
    5. ^ "What Health Care & Services Do Transgender People Require?". www.plannedparenthood.org. Retrieved 2019-10-16.
    6. ^
      S2CID 39664779
      .
    7. ^ "Gender dysphoria". nhs.uk. 2017-10-23. Retrieved 2021-11-15.
    8. PMID 26825472
      .
    9. PMID 25403246
      .
    10. ISSN 0804-4643
      .
    11. ISSN 0021-972X
      .
    12. PMID 28078219
      .
    13. PMID 29844850
      .
    14. PMID 29262142
      . Retrieved 2021-11-12.
    15. ^
      S2CID 197664792
      .
    16. ^ "Hormone Use for Non-Binary People". GenderGP. Retrieved 2020-10-18.
    17. ^ a b "Information on Estrogen Hormone Therapy". Transgender Care. transcare.ucsf.edu. Retrieved 2019-08-07.
    18. ^ a b c "Overview of feminizing hormone therapy". Gender Affirming Health Program. transcare.ucsf.edu. Retrieved 2021-11-12.
    19. PMID 32008926
      .
    20. PMID 20626600
      .
    21. PMID 12667885
      .
    22. PMID 23008326
      .
    23. ISBN 978-3-662-04491-9
      .
    24. S2CID 3726467
      .
    25. ^ Bourns A (2015). "Guidelines and Protocols for Comprehensive Primary Care for Trans Clients" (PDF). Sherbourne Health Centre. Retrieved 15 August 2018.
    26. S2CID 207503049
      .
    27. PMID 12915619
      .
    28. S2CID 144580633
      .
    29. S2CID 24493388
      .
    30. ISSN 1479-6848
      .
    31. S2CID 3716975
      .
    32. ^ "Masculinizing hormone therapy - Mayo Clinic". www.mayoclinic.org. Retrieved 2019-08-02.
    33. ^ a b c "Information on Testosterone Hormone Therapy". Transgender Care. transcare.ucsf.edu. Retrieved 2019-08-07.
    34. ^ Deutsch MB (17 June 2016). "Overview of masculinizing hormone therapy". UCSF Gender Affirming Health Program. San Francisco, CA: The University of California. Retrieved 2021-11-12.
    35. PMID 28090436
      .
    36. PMID 7428356
      .
    37. ^
      PMID 36238954
      .
    38. ^
      S2CID 205398449
      .
    39. ^
      PMID 11278204
      .
    40. ^ "Ovary function is preserved in transgender men at one year of testosterone therapy". Endocrine Society. 23 March 2019. Retrieved 25 March 2019.
    41. PMID 29905821
      .
    42. S2CID 256073192
      .
    43. ^ "God vård av vuxna med könsdysfori" (PDF).
    44. ISBN 978-0415538657
      .
    45. PMID 36238954
      .
    46. ^ "Gender-Affirming Hormone Therapy 101: Introducing the #HRTSavesLives Campaign". 10 August 2020.
    47. ^ "Survey of Patient Satisfaction with Transgender Services" (PDF). The Audit Information & Analysis Unit. National Health Service. Archived from the original (PDF) on 2016-03-04. Retrieved 2016-01-08.
    48. PMID 10604171. Archived from the original
      (PDF) on 2017-12-08. Retrieved 2018-11-11.
    Retrieved from "https://en.wikipedia.org/w/index.php?title=Transgender_hormone_therapy&oldid=1217899969"