Hormone replacement therapy (transgender)
||Parts of this article (those related to the Standards of Care) need to be updated. (February 2017)|
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Hormone replacement therapy for transgender or gender variant individuals, also sometimes called cross-sex hormone therapy, is a form of hormone replacement therapy (HRT) in which sex hormones and other hormonal medications are administered to transgender or gender variant individuals for the purpose of synchronizing their secondary sexual characteristics with their gender identity. This form of HRT is given as one of two types, based on whether the goal of treatment is feminization or masculinization:
- Hormone replacement therapy (male-to-female) – for transgender women; consists of estrogens and antiandrogens
- Hormone replacement therapy (female-to-male) – for transgender men; consists of androgens like testosterone
The formal requirements for hormone replacement therapy vary widely.
The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) require psychological counseling and for the patient to live a period of a time in the desired gender role, in order to assure that they can psychologically function in that gender role. This period is sometimes called the real-life experience (RLE). While this standard was widely followed in the 20th century, a growing number of physicians refuse to follow the Standards of Care, insisting that they are too restrictive and that inhibiting patient access to hormone therapy does more harm than good.
Some LGBT health organizations (notably Chicago's Howard Brown Health Center) advocate for an informed consent model where the patient must only prove that they understand the risk and consent to the procedure in order to access hormone therapy.
Some individuals choose to self-administer their medication ("do-it-yourself") because they do not have access to adequate medical care (either the available doctors do not have the necessary experience or the patient cannot afford care since transition-related procedures are prohibitively expensive and rarely covered by health insurance). However, self-administration of hormones is potentially dangerous. Individuals seeking physicians who are knowledgeable and willing to treat transgender patients may wish to consult transgender support groups or a directory of LGBT-friendly doctors.
The World Professional Association for Transgender Health (WPATH) recommends that individuals satisfy two sets of criteria – eligibility and readiness – to undertake any stage of transition, including hormone replacement therapy.
Eligibility is determined using a major diagnostic tool, such as ICD-10 or the Diagnostic and Statistical Manual of Mental Disorders (DSM).
- A transsexual identity for over two years
- A strong and persistent desire to live as a member of the opposite sex, usually accompanied by a desire to make one's body as congruent as possible with the preferred sex through surgery and hormone treatments
For a child to be diagnosed with gender identity disorder of childhood under ICD-10 criteria, they must be pre-pubescent and have intense and persistent distress about being the opposite sex. The distress must be present for at least six months. The child must either:
- Have a preoccupation with stereotypical activities of the opposite sex – as shown by cross-dressing, simulating attire of the opposite sex, or an intense desire to join in the games and pastimes of the opposite sex – and reject stereotypical games and pastimes of the same sex, or
- Have persistent denial relating to their anatomy. This can be shown through a belief that they will grow up to be the opposite sex, that their genitals are disgusting or will disappear, or that it would be better not to have their genitals.
- Strong and persistent cross-gender identity: Adolescents and adults must display a persistent desire to be the other sex, frequent pass as the other sex, desire to live or be treated as the other sex, or believe that they have the typical feelings and reactions of the other sex. In children, cross-gender identity may be demonstrated by meeting the following criteria:
- An insistence that one is or desires to be the other sex.
- Children who seek a male-to-female transition must display a preference for cross-dressing or simulating female attire, and those who seek a female-to-male transition must persistently wear stereotypical male clothing.
- Persistent fantasies of being the other sex, or a strong and persistent preference for cross-sex roles in make-believe play.
- Intense desire to participate in stereotypical games of the other sex.
- Persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex. In children, this may involve disgust with the penis or testes, or a belief that they will disappear. In adults and adolescents, it may manifest as a preoccupation with removing primary or secondary sex characteristics through surgery or hormone replacement therapy.
- The disturbance must not be concurrent with a physical intersex condition.
- The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The DSM-V replaced the term gender identity disorder with gender dysphoria to avoid the implication that gender nonconformity is in itself a mental disorder, but kept the entry so that individuals could still seek treatment. The DSM-V, unlike the DSM-IV and ICD-10, separates gender dysphoria from sexual paraphilias and diagnoses it on the basis of a strong conviction that one has feelings typical of the other sex, or a strong desire to be treated as the other sex or be rid of one's sex characteristics.
The second requirement for undertaking hormone replacement therapy is readiness. This means that the patient is likely to take hormones in a responsible manner; has made progress in addressing other identified problems, leading to improved or stable mental health; and has consolidated gender identity through psychotherapy or by life experience in their desired gender role.
Some organizations – but fewer than in the past – require, based on guidelines such as the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, that patients spend a certain period of time living in their desired gender role before starting hormone replacement therapy. This period is sometimes called real-life experience (RLE). The Endocrine Society stated in 2009 that individuals should either have a documented three months of RLE or undergo psychotherapy for a period of time specified by their mental health provider, usually a minimum of three months.
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.
Some transgender people choose to self-administer hormone replacement medications, often because doctors have too little experience in this area, or because no doctor is available. Others self-administer because their doctor will not prescribe hormones without a letter from a psychotherapist stating that the patient meets the diagnostic criteria and is making an informed decision to transition. Many therapists require at least three months of continuous psychotherapy and/or real-life experience before they will write such a letter. Because many individuals must pay for evaluation and care out-of-pocket, costs can be prohibitive.
Access to medication can be poor even where health care is provided free. In a patient survey conducted by the United Kingdom's National Health Service in 2008, 5% of respondents acknowledged resorting to self-medication, and 46% were dissatisfied with the amount of time it took to receive hormone therapy. The report concluded in part: "The NHS must provide a service that is easy to access so that vulnerable patients do not feel forced to turn to DIY remedies such as buying drugs online with all the risks that entails. Patients must be able to access professional help and advice so that they can make informed decisions about their care, whether they wish to take the NHS or private route without putting their health and indeed their lives in danger." Self-administration of hormone replacement medications may have untoward health effects and risks.
- "The Harry Benjamin International Gender Dysphoria Association's Standards Of Care For Gender Identity Disorders, Sixth Version" (PDF). February 2001. Retrieved 2011-12-14.
- Schreiber, Leslie. "Howard Brown Health Center Establishes Transgender Hormone Protocol". www.howardbrown.org. Howard Brown. Retrieved 2011-08-25.
- "THInCing About Hormones?: Hormone FAQs" (PDF). Retrieved 2011-12-14.
- "ICD-10 Diagnostic Codes". ICD-10:Version 2010. Retrieved 2014-06-08.
- "DSM-V Fact Sheet" (PDF). Retrieved 2014-06-08.
- Hembree, Wylie, C; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette; Gooren, Louis; Meyer III, Walter; Spack, Norman; Tangpricha, Vin; Montori, Victor (September 2009). "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline" (PDF). Clinical Endocrinology & Metabolism. 94 (9): 11. doi:10.1210/jc.2009-0345. PMID 19509099. Retrieved 2014-06-07.
- Bornstein, Kate (2013). My Gender Workbook, Updated : How to Become a Real Man, a Real Woman, the Real You, or Something Else Entirely. (2nd ed.). New York: Routledge. ISBN 978-0415538657.
- "Survey of Patient Satisfaction with Transgender Services" (PDF). Retrieved 2016-01-08.
- Becerra Fernández A, de Luis Román DA, Piédrola Maroto G (October 1999). "Morbilidad en pacientes transexuales con autotratamiento hormonal para cambio de sexo" [Morbidity in transsexual patients with cross-gender hormone self-treatment]. Medicina Clínica (in Spanish). 113 (13): 484–7. PMID 10604171.