Hormone Therapy for Gender Affirmation

With the recognition of gender identity as a fundamental human right, people are recognized as active subjects of law, especially in relation to personal decisions, such as gender self-perception and bodily modifications.

Transgender (trans) people require specific particularities regarding their health care. That is why it is important to know and understand these needs in order to provide them with adequate and quality health care.

Gender identity

By gender identity we mean the identifications that a subject assumes in a gender (female/male/other) beyond the materiality of their body in anatomical-aesthetic terms. It is generally linked to practices, behaviors or attitudes that are expressed both in general patterns of social interaction and specifically sexual. It also involves the strategies, symbols, modes, styles, and practices that a person adopts to communicate their choice or gender to others.

A trans person is that who identify with, feel and express a gender different from the one assigned at birth. Trans people, to achieve that felt gender expression, may partially modify their bodies through cosmetic surgeries, hormone therapies, breast implants, mastectomy, etc.

Considerations for health personnel

When consulting with a doctor for advice or starting treatment for the adequacy of self-perceived gender identity, it is important that the health professional meets the following requirements:

• It is essential to emphasize that everything spoken is strictly confidential and protected by doctor-patient privilege.
• Provide adequate information so that the person can make informed decisions.
• Ask what their pronouns are and refer to them as indicated.
• Remember to address the person you consult in accessible language. If technical and scientific terms are used, the person might leave without having understood some important things.
• Be open, accessible and encourage the patient to ask all questions they might have.
• Ask directly what the reason for the consultation is since it is sometimes assumed that any medical consultation of a trans person only relates to issues associated with their gender identity (implants, hormones, etc.).
• Do not assume the sexual orientation of the person who consults but ask if it is relevant to what is being discussed.
• If the person arrives at the consultation accompanied, ask if they prefer to be attended alone or with their companion.

Informed consent

It is important to explain correctly and clearly what hormone therapy consists of. Information should be provided on:

• Hormones used and how they are administered.
• How will these affect the patient’s body.
• The psychological effect this therapy might have on the patient.
• Adverse effects.
• The alternatives of possible therapies.
• It is also important to have time to reflect on the decision and that it is with autonomy.

Fertility

It is essential to report that hormone therapies are not contraceptive.

• Fertile trans women can impregnate, even if they are taking hormones if they don't use contraceptive methods properly, such as condoms.
• Trans men who use male hormones can become pregnant as testosterone is not an effective method of contraception.

What is a hormone?

It is a chemical substance, secreted mostly by sexual organs, ovaries and testicles, which in addition to being related to reproduction are responsible for secondary sexual characteristics, such as the development of the breasts, distribution of body fat, increase in the size of the penis and scrotum, thickening of the skin, changes in the tone of the voice or the appearance of body hair. These are the reasons why a trans person resorts to this method to modify their body and adapt it to their gender identity.

In some cases, hormone therapies, in addition to physical changes, can cause emotional changes, mood, euphoria, sensitivity, etc. It is important to warn the person about this and discuss it during follow-up.

THERAPY FOR FEMINIZATION

For this purpose, hormones are divided into two groups:

• Female hormones (mainly estrogens)
• Antiandrogens (block male hormones)

• Depending on the drug administered, it can be oral, transdermal (through patches and gels) and the dosage can be daily, or biweekly.
• Results can begin to be observed within approximately 3 months and the objective achieved within 2 to 3 years. That is, they are progressive effects, patients should always be warned in order to avoid false expectations to be generated. The extent of these will also depend on factors including age, physical characteristics, and genetics.

Expected results (not all are the same in each person):

• Redistribution of body fat
• Decreased muscle mass
• Smoother, less oily skin
• Breast enlargement
• Decreased testicular volume
• Decreased body hair
• Decreased spontaneous erections, semen production
• Erectile dysfunction.

Adverse effects of estrogens and anti-androgens (adverse effects do not necessarily happen. That is why it is important to have periodical medical checks and not self-medicate.)

• Short term (there are usually no serious side effects): the most common are usually weight gain, decreased sex drive, mood changes, breast pain, headache, hot flashes.
• Long term: the appearance of varicose veins, venous thrombosis, increased cholesterol levels, increased prolactin, cardiovascular disease (stroke, heart attacks) and infertility can be observed. Control is also important to prevent breast and prostate cancer.

Medical consultation in trans women:

Medical follow-up is suggested at four weeks, three and six months, and every 6-12 months thereafter (most often if problems arise). Attention should be directed primarily to blood pressure, side effects, emotional changes, sexuality, weight, quality of life, and counseling on sexually transmitted infections (STIs), problematic substance use, and fertility.

 Medical Tests:

• Blood tests for measurement of hormonal values and particular controls.
• Mammography
• Rectal examination / prostate antigen

THERAPY FOR MASCULINIZATION

For this purpose, hormonal treatment consists of the application of testosterone.

• Depending on the drug administered, it can be intramuscular (injected), transdermal (through patches and gels) and the dosage can be daily, biweekly or quarterly.
• Results can begin to be observed within approximately 3 months and the objective can be achieved within 2 to 5 years. Once again, patient should be properly informed on the length of the process. The extent of the results will also depend on factors including age, physical characteristics, and genetics.

Expected results (not all are the same in each person):

• Changes in the tone of the voice, which becomes deeper.
• Changes in the skin, which sometimes becomes oilier.
• Changes in perspiration.
• Decreased breasts.
• Hair growth on the face and body.
• The absence of menstruation becomes more noticeable in the first months of therapy (secondary amenorrhea), as well as the increase in size or hypertrophy of the clitoris.
• Body fat in the hips and thighs decreases and increases in the back.

Adverse effects of testosterone (Adverse effects do not necessarily appear. That is why it is important to have medical control and not self-medicate.)

• Short-term: adverse effects are usually mild, the most frequent are weight gain, instability in the voice, increased sexual desire, emotional fluctuations (increased aggressiveness) or decreased emotions, pain in the clitoris and acne.
• Long-term: there may be an increased risk of developing diabetes, alterations in the liver (although it is rare), alterations in cholesterol levels, increased hematocrit, worsening of sleep apnea, polycystic ovaries and decreased fertility. It is important to continue monitoring for breasts (even after mastectomy), ovaries, and endometrium to prevent cancers.

Medical consultation in trans men:

Medical follow-up is suggested at four weeks, three and six months, and every 6-12 months thereafter (most often if problems arise). Attention should be directed primarily to blood pressure, side effects, emotional changes, sexuality, weight, quality of life, menstruation assessment and counseling on sexually transmitted infections (STIs), problematic substance use, and fertility.

Medical Tests:

• Blood tests for measurement of hormonal values and particular controls.
• Annual mammogram from 40-50 years, depending on risk factors, family history, presence of breast tissue, regardless of whether mastectomy or breast reduction was performed.
• Biannual pelvic examination for tumor exploration.
• Cervical smear every two to three years based on current recommendations.
• Pelvic ultrasound when necessary and evaluate if needed post-hysterectomy and/or oophorectomy.
• Bone density five to ten years after starting testosterone treatment and then periodically.

Contraindications for both treatments

• The only absolute medical contraindication to initiating or maintaining estrogen or testosterone therapy is an estrogen- or testosterone-sensitive cancer.
• Conditions such as obesity, cardiovascular disease or dyslipidemia should not prevent treatment but most be closely monitored.

Considerations for starting or continuing hormone therapy in people over the age of 40:

• There is no set maximum age limit for hormone therapy.
• Trans men who begin treatment after age 40 will usually take longer to get to the desired results.
• Osteoporosis has been reported in both older trans men and women and is often associated with low adherence to the hormonal regimen.

Important considerations:

• Never self-medicate.
• Always consult with your doctor if you are taking any medication to make sure the therapy won’t alter their effects.
• Always perform the treatment with medical advice.

Hope you found this helpful.

Love,

Dr Merkel