Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects

Abstract

Cross-sex hormone treatment is an important component in medical treatment of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Endocrinologists are often faced with designing treatment recommendations. Although guidelines from organizations, such as the Harry Benjamin International Gender Dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
Association, have been helpful, management remains complex and experience guided. We discuss the range of treatment used by transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people, the rationale behind these, and the expectation from such treatment. Recommendations from seven clinical research centers treating transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people are discussed. In addition, self-reported hormonal regimens from 25 male-to-female transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people and five female-to-male transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people are reported. Finally, the potential adverse effects of cross-sex hormone treatment of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people are reviewed. In light of the complexity of managing treatment goals and adverse effects, the active involvement of a medical doctor experienced in cross-sex hormonal therapy is vital to ensure the safety of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people.

Authors – Eva Moore, Amy Wisniewski and Adrian Dobs.

Introduction

Endocrinologists are consulted in the management of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Cross-sex hormonal treatment is desired by such patients to successfully live as a member of their identified gender• However gender is far more complicated. It is the complex interrelationship between an individual’s sex (gender biology), one’s internal sense of self as male, female, both or neither (gender identity) as well as one’s outward presentations and behaviours (gender expression) related to that perception, including their gender role. Together, the intersection of these three dimensions produces one’s authentic sense of gender, both in how people experience their own gender as well as how others perceive it.
• Gender is expressed in terms of masculinity and femininity. It is largely culturally determined and is assigned at birth based on the sex of the individual. It affects how people perceive themselves and how they expect others to behave.
• Socially and culturally constructed roles, behaviours, expressions and identities of girls, women, boys, men, and trans people.
. Endocrine treatment provides some relief from the dichotomy between body habitus and gender identity• One’s innermost concept of self as male or female or both or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different than the sex assigned at birth. Individuals are conscious of this between the ages 18 months and 3 years. Most people develop a gender identity that matches their biological sex. For some, however, their gender identity is different from their biological or assigned sex. Some of these individuals choose to socially, hormonally and/or surgically change their sex to more fully match their gender identity.
• The gender to which one feels one belongs.
• Internal and psychological sense of oneself as a woman, a man, both, in between, or neither.
(1). Ideally, this transition• The social, psychological, emotional and economic processes that a trans person undergoes to move from their assigned gender role into their chosen or acquired gender. The time this takes is variable and depends on the individual’s ability to embrace significant change in their life. If requiring genital surgery the individual will have to undergo a so called Real Life Test, i.e. living in their acquired gender role for a minimum of 1 year.
• Refers to the process during which trans people may change their gender expression and/or bodies to reflect their gender, including changes in physical appearance (hairstyle, clothing), behaviour (mannerisms, voice, gender roles), identification (name, pronoun, legal details), and/or medical interventions (hormone therapy, gender-affirming surgery).
should be quick and complete. However, the medical risks of sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. steroids are real; thus, medical providers are confronted with the difficult dilemma of balancing medical risks and psychological needs of patients.

The prevalence of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people has been determined to be as high as 1 in 11,900 males and 1 in 30,400 females (2). Standards of care for the psychological, endocrinological, and surgical management of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people have been proposed by the Harry Benjamin International Gender Dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
Association, Inc. (3, 4). Specific management of hormonal regimens and long-term management, however, remain difficult to navigate. As a result, most physicians depend on observational and anecdotal reports to guide endocrine treatment.

This review will discuss the endocrinological treatment of male-to-female (M->F) and female-to-male (F->M) transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. We present the specificities of cross-sex hormone treatment and the reasonable expected effects of those treatments, followed by a brief discussion of the range of treatments used by transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Our intent is to provide a rationale to guide the endocrinological care of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people.

Subjects and methods

Literature review

A computerized search of the published literature was performed through PubMed, a search engine that matches keywords to medically related articles, abstracts, and bibliographies. Keywords used for the search included transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body., transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people, transgender• Sometimes used as an umbrella to describe anyone whose identity or behaviour falls outside of stereotypical gender norms. More narrowly defined, it refers to an individual whose gender identity does not match their assigned birth gender. Being transgender does not imply any specific sexual orientation (attraction to people of a specific gender). Therefore, transgender people may additionally identify with a variety of other sexual identities as well.
• An umbrella term used to include transsexual people, transvestites and cross-dressers, as in “the transgender community.”
• This is an umbrella term that applies to anyone who does not feel that their gender identity (e.g., identifying as male, female, or other) matches their anatomical/bio- logical sex.
• An umbrella term for people whose gender identity and/or expression differs from that of their sex assigned at birth. Transgender people may or may not alter their bodies to better fit with their gender identity through means such as hormones or surgery. Some intersex people identify as transgender but the two are not the same. Identities such as transsexual or transvestite are distinct sub-categories of transgender and should not be used as synonyms. Should only be used as an adjective e.g. ‘transgender people’. The word “Transgendered” is used by some people but its use is discouraged.
, transgendered, cross-sex, phytoestrogen, gynecomastia, spironolactone, cyproterone, tamoxifen, and testosterone. Articles in peer reviewed medical journals that suggested the use of sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. steroid hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people were retrieved and reviewed for content, and their references were used to identify other literature of interest. Articles that reported clear dosing information for cross-sex hormonal treatment were evaluated. Drug information was obtained from Micromedex, a database of pharmacological agents, and PubMed to obtain generic names when trade names or European brands were reported. A total of 61 articles fit our criteria for review in this manuscript.

Subjects

In addition to reviewing the literature, we present information on transgender• Sometimes used as an umbrella to describe anyone whose identity or behaviour falls outside of stereotypical gender norms. More narrowly defined, it refers to an individual whose gender identity does not match their assigned birth gender. Being transgender does not imply any specific sexual orientation (attraction to people of a specific gender). Therefore, transgender people may additionally identify with a variety of other sexual identities as well.
• An umbrella term used to include transsexual people, transvestites and cross-dressers, as in “the transgender community.”
• This is an umbrella term that applies to anyone who does not feel that their gender identity (e.g., identifying as male, female, or other) matches their anatomical/bio- logical sex.
• An umbrella term for people whose gender identity and/or expression differs from that of their sex assigned at birth. Transgender people may or may not alter their bodies to better fit with their gender identity through means such as hormones or surgery. Some intersex people identify as transgender but the two are not the same. Identities such as transsexual or transvestite are distinct sub-categories of transgender and should not be used as synonyms. Should only be used as an adjective e.g. ‘transgender people’. The word “Transgendered” is used by some people but its use is discouraged.
individuals seen in the Johns Hopkins Endocrine Clinic. We report on consecutive patients seen in consultation from 1999Б─⌠2000. On presentation, patients were asked to report the hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. they were currently taking. The generic name was recorded for brand names that were reported by subjects. Occasionally, the term used by a subject was too broad to fit a single generic drug, and our best judgment was used to interpret the dose and formulation used.

Results

Feminizing endocrine treatment regimens of M->F transsexual people

Six clinical centers reported dosing information in medical journals for endocrinological treatment of M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people (). Treatment regimens included various forms of estrogen, progestins, and/or antiandrogens. No randomized trials were found.

TABLE 1. Hormonal regimens in presurgical transsexual people

Oestrogens

Estrogen is the cornerstone for feminization of M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Typical transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. estrogens were two to three times as high as the recommended doses for hormone replacement therapy (HRT) in postmenopausal women. HRT includes ethinyl estradiol 20Б─⌠50 µg/d, (17) conjugated equine estrogen 0.625 mg/d (18), or transdermal 17ß-estradiol 5 mg/d (19).

Oral delivery was used by most centers. The exception was transdermal 17ß-estradiol in M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people over age 40 yr. TranssexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people in The Netherlands were given transdermal estradiol once patients reached 40 yr of age due to an association of thromboembolic events in older transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people (6, 20). This policy was supported by a decrease in cardiovascular events after standardizing this regimen in their clinic (6). Of note, im formulations were rarely reported. Avoidance of im dosing was rationalized by the prolonged time to reach steady state and the potential for abuse of this method (21). Additionally, there was no reported sublingual administration of 17ß-estradiol. Pharmacokinetic studies indicate that this route may allow a higher boost of plasma estradiol levels with a greater ratio of estradiol to estrone in comparison to other administrations (22). The safety of this route has not yet been determined.

Higher doses of estrogens and/or im formulations were used in specific conditions for short periods of time. One group applied im 17ß-estradiol 80-100 mg for the initial 6-12 months of treatment (12). Indications include an inability to lower serum testosterone to 50 б╣g/dl (1.74 SI) with no coexisting medical condition or psychiatric clearance for a more rapid feminization (10). Nevertheless, higher doses of estrogens may not lead to more rapid or dramatic clinical changes. Ethinyl estradiol doses of 500 µg demonstrated the same degree of testosterone suppression as 100 µg in a small, observational case-controlled study of M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people (14). However, breast growth was enhanced with higher estrogen levels (14). Estrogen doses were lowered in patients with cardiac or other comorbidities (9) or when adverse effects occurred (8, 9, 12, 15, 20). High doses were avoided to minimize adverse effects. After gonadectomy, all centers maintained estrogen therapy. Two centers recommended lowering the dose of estrogens to half the presurgical levels, for example to 50 µg of ethinyl estradiol (6, 9). Alternatively, another center applied a constant hormonal dose both before and after surgery (8). The rationale for continuing estrogen included maintenance of femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). features and bone mineral density (7, 10).

Antiandrogens and progestins

Concurrent administration of hormonal modulators may potentiate the effects of estrogen. Antiandrogens are theorized to lower serum levels of testosterone or to block its bindingCompressing one’s chest to create a more androgynous or masculine appearance. to the androgen receptor, thereby decreasing masculineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with boys and men. secondary sexual characteristics. Indeed, several studies reported lowering of testosterone with cyproterone acetate 100 µg/d (5, 23). A synergistic effect with estrogen on the physical and emotional changes was also observed by one group with spironolactone (11). This can be particularly helpful in patients with comorbidities that prohibit high levels of estrogen. Cyproterone acetate is not approved for use by the Food and Drug Administration in the United States.

GH-releasing hormone agonists have been considered by some to increase estrogen effects when risk factors limit the dose of estrogen (7).

Addition of progesterone for M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people is advocated by some (8, 9, 11). Reasons included enhanced breast growth (9, 11) or to decrease irritability and breast sensitivity (8). However, the clinical effect of progestins was not evident in small observational studies (15). In light of the Womens Health Initiative study (24), progestin therapy should be approached with caution. Combined estrogen and progestin therapy increase the risk of coronary heart disease, strokes, pulmonary embolism, and invasive breast cancers in postmenopausal women on HRT. Possible comparable adverse effects in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people may preclude the empirical use of a progestin for sustained periods of time.

Effects of sexual hormonal treatment in M->F transsexual people

Adverse effects of sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. steroid therapy are real and apparent. Retrospective morbidity and mortality data have been reported from the Division of Endocrinology and Andrology at the Free University Hospital in Amsterdam. Of greatest concern is a reported 20-fold increase in venous thrombosis, (6) a decrease from 45-fold in an earlier report (20). Another common phenomenon is an increase in prolactin levels (6, 25) with a possible association with accelerated growth of prolactinomas with feminizing therapy (8, 26, 27). Visual fields and prolactin levels can help assess this risk in patients. Depression is increased in comparison to the general population (20). This is an important reminder that gender reassignmentThe process by which an individual reassigns their gendered appearance., although effective in relieving the gender dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
, should not be considered a cure. Contraindications to therapy have been published and should be considered before initiation of cross-sex hormone therapy (27). Positive and negative effects are reported (Table 2).

Table 2. Side effects of hormonal treatment of transsexual people

Risks to M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people are likely correlated to dose. Estrogen administration to reproductive age women for contraception has demonstrated dose-dependent relationships to venous thromboembolytic disease, pulmonary embolism, myocardial infarction, stroke (43), and adverse liver effects (44, 45). A synergistic risk was seen in women who smoke, are over 35 yr of age, or have other risk factors for cardiovascular disease (46, 47). It is likely that these effects are also present in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Smoking cessation, weight reduction, exercise, and appropriate diet are critical elements for preventive health in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Minimizing the dose of estrogens, especially in older patients and those with comorbidities, is critical.

Johns Hopkins Clinic self-reported use of feminizing hormones in M->F transsexual people

Description of the Hopkins population

Thirty transgender• Sometimes used as an umbrella to describe anyone whose identity or behaviour falls outside of stereotypical gender norms. More narrowly defined, it refers to an individual whose gender identity does not match their assigned birth gender. Being transgender does not imply any specific sexual orientation (attraction to people of a specific gender). Therefore, transgender people may additionally identify with a variety of other sexual identities as well.
• An umbrella term used to include transsexual people, transvestites and cross-dressers, as in “the transgender community.”
• This is an umbrella term that applies to anyone who does not feel that their gender identity (e.g., identifying as male, female, or other) matches their anatomical/bio- logical sex.
• An umbrella term for people whose gender identity and/or expression differs from that of their sex assigned at birth. Transgender people may or may not alter their bodies to better fit with their gender identity through means such as hormones or surgery. Some intersex people identify as transgender but the two are not the same. Identities such as transsexual or transvestite are distinct sub-categories of transgender and should not be used as synonyms. Should only be used as an adjective e.g. ‘transgender people’. The word “Transgendered” is used by some people but its use is discouraged.
individuals (97% Caucasian) are reported, including 18 presurgical M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people (age, 46.5 yr; range, 39–61 yr), seven postsurgical M->F subjects (age, 49.3 yr; range, 35–68 yr), and five F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people (age, 40.2 yr; range, 31–51 yr). The average level of education beyond high school was 3.75 yr. The hormone use presented is that used by the individual upon presentation to the clinic.

Medical regimens used

In contrast to medical recommendations, M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people presenting to Johns Hopkins were on much higher doses of sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. steroids. Treatment that exceeded recommended estrogen dosages in M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people was reported by eight subjects (45%), and five subjects (28%) reported three or more times the recommended dosage. For example, one subject reported taking conjugated equine estrogens 13 mg/d, in addition to a weekly estradiol injection and daily oral medroxyprogesterone. This individual’s dose of conjugated estrogens alone is 21 times the dose recommended for HRT in postmenopausal women. Furthermore, the patients reported using multiple formulations of hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. concurrently. For example, eight subjects (44%) reported taking three or more hormonal medications, and two of those reported five or six different daily medications. Additionally, despite the hesitancy of providers to distribute injectable hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. to M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people, 28% reported their use. In light of the older age of subjects, these high doses and complex regimens were particularly concerning for increased risk of adverse effects. It was not asked how the patients obtained these high doses of hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones., but multiple sources were presumed.

Unique to self-reported hormonal regimes, four subjects (22%) reported the use of one or more herbal supplements containing phytoestrogens, although this was not specifically asked. Some studies have demonstrated mild effects of soy isoflavones on maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). testosterone and estrone levels, although other similar studies have shown no significant change (48). Synergistic possibilities, adverse effects, and drug-herbal interactions are mostly unknown. Phytoestrogens are readily available from the internet and health food stores.

Patients presenting to the endocrine clinic after surgical treatment reported more reasonable hormonal doses. More patients reported hormone dosages similar to those used in hypogonadal women. However, individuals still reported high doses. One reported ethinyl estradiol 0.9 mg/d, oral estradiol 1.25 mg/d, and spironolactone. In comparison, the ethinyl estradiol dose alone is 30 times the dose used in HRT in postmenopausal women. Due to the study design, it is unknown how these estrogen doses compared with previous values in the same individual.

Masculinizing endocrine treatment of F->M transsexual people

Testosterone is the key hormone in F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people for the development of secondary sexual characteristics of the desired gender• However gender is far more complicated. It is the complex interrelationship between an individual’s sex (gender biology), one’s internal sense of self as male, female, both or neither (gender identity) as well as one’s outward presentations and behaviours (gender expression) related to that perception, including their gender role. Together, the intersection of these three dimensions produces one’s authentic sense of gender, both in how people experience their own gender as well as how others perceive it.
• Gender is expressed in terms of masculinity and femininity. It is largely culturally determined and is assigned at birth based on the sex of the individual. It affects how people perceive themselves and how they expect others to behave.
• Socially and culturally constructed roles, behaviours, expressions and identities of girls, women, boys, men, and trans people.
. Injectable testosterone was often used alone, both before and after oophorectomyA surgery to remove the ovaries; a gender-affirming, masculinizing lower surgery. (Table 1). Oral testosterone undecanoate, available outside of the United States, has been associated with more consistent but lower serum testosterone levels (49). It may not adequately suppress menstruation without the addition of a progestin (12, 20). GH-releasing hormone agonists have been used in adolescent transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people to delay puberty, to allow cross-sex hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. to be postponed until adulthood with less psychological stress to the individual (50). Transdermal applications approximated physiological testosterone better than the other delivery methods (51).

Effectiveness was assessed with clinical change, because 17ß-estradiol decreases only minimally (37). Cessation of menses occurred within several months (15). Other effects are reported (Table 2). The appropriate dose of testosterone may vary from patient to patient, but blood levels should be close to the normal mid-male value of 500 µg/dl (17.35 SI). Dosing every 2 wk is recommended to maintain a blood level within physiological range (52).

Adverse effects of masculinizing treatments in F->M transsexual people

Thorough evaluation of the risks of androgen administration to F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people has been limited because a small population has presented at treatment centers (6). Retrospective data from 293 patients report no change in mortality, but the population may not be large enough to assess more subtle differences in morbidity and mortality (6).

Adverse effects of androgen administration in F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people were observed in two retrospective studies from the Division of Endocrinology and Andrology at the Free University Hospital in Amsterdam. Effects of testosterone administration observed from biological males should be remembered such as polycythemia as a rare complication (53, 54). Contraindications to therapy have been published and should be considered before initiation of cross-sex therapy (55).

Serious adverse risks may be underestimated. The worrisome combination of increased weight, decreased insulin sensitivity, poor lipid profile, and an increase in hematocrit have raised the concern for cardiac and thromboembolytic events. In fact, case reports of cerebral vascular accidents have been reported for individuals with supraphysiological levels of testosterone (56, 57). Polycystic ovarian disease is a risk factor for endometrial cancer (56), and polycystic ovarian morphology of the ovary has been seen in greater numbers in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people before androgen therapy than in the general population (57, 58). Mild endometrial hyperplasia has been appreciated on removal of the uterus (39). A case report detailed two transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people with ovarian cancer in F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people and raised the question of an association (42). Total hysterectomyA surgical procedure to remove all or part of the uterus, and sometimes the ovaries and/or fallopian tubes; a gender-affirming, masculinizing lower surgery. after 2 yr of therapy, followed by 50% reduction in testosterone, may be a way to avoid these potential risks, and some experienced clinicians advocated for this procedure (8, 10).

Johns Hopkins Clinic self-reported testosterone use in F->M transsexual people

Five of five F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people seen at Johns Hopkins reported testosterone regimens in agreement with published values. Testosterone doses ranged from 150–400 mg/month im. This was similar to the typical dose used in HRT for hypogonadal men [50–400 mg every 2–4 wk (Ref. 59)]. The exact formulations of testosterone used were not clear in most cases, but were likely testosterone enanthate (depot-testosterone) because this is the more readily available testosterone formulation in the United States and the reported doses were consistent with its packaging. Only one subject reported the addition of the antiestrogen, tamoxifen. This subject had a history of breast cancer. The single postsurgical subject reported using a transdermal testosterone patch at 5 mg/d.

Limitations of this review

Limitations to the review of literature include failure to identify articles by the search keywords. Likewise, articles not obviously likely to report hormonal treatment from their titles or abstracts may have been missed. The rationale of hormonal treatments may be more complex than reported in the literature, and tailoring to individual patients may be underreported. The data from surveyed transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people might not be an adequate sample of other populations of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. The results may not be representative of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people of other ages, races, education level, locations, or availability of the internet. Reported medications and doses by transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. subjects may differ from what is actually taken by subjects. Herbal medications, food choices, and other supplements may have been underreported. The F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. group in particular may have been too small to adequately represent treatment issues in the general population of F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people.

Important comment

Our results show variation among treatment centers with published endocrinological guidelines for the treatment of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. This is particularly apparent in regard to estrogen dose in people of older ages and the addition of a progestin and/or antiandrogen to the treatment regimen. Results from our survey of M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people demonstrated markedly elevated hormone doses and even greater complexity in their treatment regimens. Estrogen doses were often at alarming levels, and multiple formulations were used. This phenomenon has also been observed by other experienced physicians (6, 21, 26, 28, 60, 61). Doses reported by transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people were presumed to reflect their personal understanding or experience of what is necessary for their desired physical change. However, to our knowledge no study has evaluated the degree of desired effects seen with these extreme hormonal levels. Modest increases in cross-sex hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. did not show greater efficacy in the few studies available. Instead, other means for more desirable feminineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with girls and women. characteristics were advocated by experienced clinicians such as surgery, electrolysis, and/or speech therapy.

Masculinizing therapy for F->M transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people was simpler in comparison, with fewer variations between patients and providers. Nevertheless, appropriate dosing was more subjective because clinical markers were better indications of adequate therapy than hormonal levels. Experience has been limited by the small amount of patients that present to treatment centers.

Congruent expectations of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people and providers are crucial to minimize adverse effects. Health risks associated with low-dose sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. steroid administration have been reported by the Woman’s Health Initiative (24). Our review suggested that morbidity and mortality associated with cross-sex hormone administration in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people may be associated with much higher risks. Further studies of the long-term implications of cross-sex hormonal administration in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people are needed. Education and close medical monitoring of patients are important aspects of treating transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people.

After thorough review of the literature, our recommendations for endocrine treatment and monitoring are reported (Table 3). Feminizing regimens include estrogens used in doses double to those used in hypogonadal women with the goal to suppress testosterone and maintain estrogen at feminineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with girls and women. levels. Antiandrogens can be added if testosterone is difficult to suppress with this estrogen dose alone. Some have benefit with the addition of a progestin. Likewise, masculinizing regimens should be similar to that used in hypogonadal men with the goal to keep testosterone in the mid-male range. After gonadectomy, these doses can be substantially decreased while maintaining the above serum levels. Serious adverse effects are apparent in M->F transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. F->M may also experience serious adverse effects, including cardiovascular and gynecological risks. Monitoring of the endometrium by yearly ultrasound is indicated. Any vaginal bleeding after prolonged therapy warrants an endometrial biopsy. Newer, transdermal applications should be considered because they may provide a more consistent hormone level and may decrease severe adverse effects. Close monitoring and yearly reevaluation of treatment are also important to minimize the adverse effects while maximizing the benefits. Age appropriate screening and preventive care for the biological sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. of patients is also essential. Randomized clinical trials are needed to build on the years of clinical contributions to this field.

Table 3. Recommended hormonal treatment regimes and follow-up for transsexual people

Acknowledgements

We thank Terry Prendiville, a recipient of a Provost Award from the Johns Hopkins University, for her thoughtful work on this project, as well as Donald E. Moore, M.D., for his help in review of the manuscript.

Footnotes

This work was supported by a Provost Award from Johns Hopkins University.

Abbreviations: F->M, female-to-male; HRT, hormone replacement therapy; M->F, male-to-female.

Received December 13, 2002.

Accepted April 25, 2003.

© Eva Moore, Amy Wisniewski and Adrian Dobs (2003) The Journal of Clinical Endocrinology & Metabolism Vol. 88, No. 8 3467-3473.

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• Kanhai R, Hage J, Asscheman H, Mulder J 1999 Augmentation mammaplasty in male-to-female transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Plast Reconstr Surg 104:542-549
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• Giltay E, Gooren L 2000 Effects of sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. steroid deprivation/administration on hair growth and skin sebum production in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. males and females. J Clin Endocrinol Metab 85:2913-2921
• Futterweit W 1980 Endocrine management of transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body.: hormonal profiles of serum prolactin, testosterone, and estradiol. N Y State J Med 80:1260-1264
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• Futterweit W, Schwartz I 1988 Histopathology of the breasts of 12 women receiving long-term exogenous androgen therapy. Mt Sinai J Med 55:309-312
• Elbers J, Asscheman H, Seidell J, Frolich M, Meinders E, Gooren L 1997 Reversal of the sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. difference in serum leptin levels upon cross-sex hormone administration in transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. J Clin Endocrinol Metab 82:3267-3270
• Elbers J, Asscheman H, Seidell J, Megens J, Gooren L 1997 Long-term testosterone administration increases visceral fat in femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). to maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. J Clin Endocrinol Metab 82:2044-2047
• Futterweit W, Deligdisch L 1986 Histopathological effects of exogenously administered testosterone in 19 femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). to maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. J Clin Endocrinol Metab 62:16-21
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• Futterweit W 1984 Clinical features of polycystic ovarian disease. In: Polycystic ovarian disease. New York: Springer-Verlag; 83-95
• Futterweit W, Weiss R, Fagerstrom R 1986 Endocrine evaluation of forty female-to-male transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people: increased frequency of polycystic ovarian disease in femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
  • When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
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• Cooper M 1983 Hormone treatment clinic for transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. people. Hawaii Med J 43:142-146
• Schaefer L, Wheeler C, Futterweit W 1995 Gender identity• One’s innermost concept of self as male or female or both or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different than the sex assigned at birth. Individuals are conscious of this between the ages 18 months and 3 years. Most people develop a gender identity that matches their biological sex. For some, however, their gender identity is different from their biological or assigned sex. Some of these individuals choose to socially, hormonally and/or surgically change their sex to more fully match their gender identity.
  • The gender to which one feels one belongs.
  • Internal and psychological sense of oneself as a woman, a man, both, in between, or neither.
  disorders (transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
  • When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
  ). In: Gabbard G, ed. Treatments of psychiatric disorders. 2nd ed. Washington, DC: Am Psych Press; 2015-2079