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Informed Consent vs. the Gatekeeper

Traditionally, practitioners have required a written letter from a health care professional "clearing" a patient for hormone transition therapy.  This policy may certainly still be appropriate for some aspects of transgender care, such as transgender surgery.  It is gradually fading away, however, when it comes to initiating hormone therapy.  It is important for health care providers managing hormone therapy to understand their patients enough to know if therapy is appropriate.  Providers must also adequately discuss the risks and benefits of therapy so that patients can provide their own well-informed consent.  More and more minors are seeking to transition, so this informed consent extends to their guardians.  I believe that health care professionals are still crucial, and I prefer that all of my patients follow up with a health care professional who has experience working with transgender people, because of the significant personal and social challenges that accompany transitioning.  

A Little Bit About Hormone  Therapy

The mainstay of hormone treatment for the male-to-female patient is estrogen.  There are different forms of estrogen, and estradiol is the most prominent, which is why almost all forms of pharmaceutical estrogen come as estradiol. Estradiol comes in a pill, a patch, a compounded cream, and an injectable oil.  Which formulation we use has to do with both a patient's age and medical history, a patient's preference, and with what works best for an individual.  Almost all patients are also on some form of anti-androgen (androgen means testosterone).  This has typically been spironolactone, which is a blood pressure pill.  Other anti-androgen agents have been used as well.  Progesterone has been used a lot in the treatment of male-to-female patients, because it is thought to help with breast development (although this has not yet been proven).  The physical changes to anticipate include softening of the skin, a decrease in facial and body hair, breast development, and later the development of female body contours.  The voice does not change with hormone therapy.  

The mainstay of hormone treatment for the female-to-male patient is testosterone.  Rarely is any other medication needed.  Testosterone cannot be taken as a pill, because it stresses out the liver.  It is taken as either a gel that's rubbed on the skin or a an injection given once weekly or every two weeks. The gel is typically difficult to get covered these days and is expensive.  Almost all of my patients are on injections.  Physical changes we see include facial and body hair growth, deepening of the voice, loss of female contours, and enlargement of the clitoris.  

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