Binders Full of Women (Consultant Journal Guides)

Consultant in Cardiovascular Diseases and Internal Medicine. Bernard Gersh covers general cardiology for the European Heart Journal and particularly his core research interests i. Recipient of the Friedrich Goetz Award.

Treasurer of the European Association of Cardiovascular Prevention. Ulf Landmesser focuses on prevention, lipids, stem cells and basic science for the European Heart Journal. As head of Translational Medicine and non-invasive clinical cardiologist at the University Hospital Zurich, he relates experimental research mouse models of atherothrombosis to clinical studies in patients with ACS. William Wijns covers acute coronary syndromes, coronary artery disease and interventional cardiology for the European Heart Journal. Oxford University Press is a department of the University of Oxford.

It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Gersh Bernard Gersh, M. In transgender males, testosterone will result in clitoromegaly, temporary or permanent decreased fertility, deepening of the voice, cessation of menses usually , and a significant increase in body hair, particularly on the face, chest, and abdomen.

Cessation of menses may occur within a few months with testosterone treatment alone, although high doses of testosterone may be required. If uterine bleeding continues, clinicians may consider the addition of a progestational agent or endometrial ablation Clinicians may also administer GnRH analogs or depot medroxyprogesterone to stop menses prior to testosterone treatment. The hormone regimen for transgender females is more complex than the transgender male regimen Appendix B. Treatment with physiologic doses of estrogen alone is insufficient to suppress testosterone levels into the normal range for females Most published clinical studies report the need for adjunctive therapy to achieve testosterone levels in the female range 21 , , , — , , Multiple adjunctive medications are available, such as progestins with antiandrogen activity and GnRH agonists Spironolactone works by directly blocking androgens during their interaction with the androgen receptor , , It may also have estrogenic activity Cyproterone acetate, a progestational compound with antiandrogenic properties , , , is widely used in Europe.

Leuprolide and transdermal estrogen were as effective as cyproterone and transdermal estrogen in a comparative retrospective study Among estrogen options, the increased risk of thromboembolic events associated with estrogens in general seems most concerning with ethinyl estradiol specifically , , , which is why we specifically suggest that it not be used in any transgender treatment plan. Injectable estrogen and sublingual estrogen may benefit from avoiding the first pass effect, but they can result in more rapid peaks with greater overall periodicity and thus are more difficult to monitor , However, there are no data demonstrating that increased periodicity is harmful otherwise.

Clinicians can use serum estradiol levels to monitor oral, transdermal, and intramuscular estradiol. Blood tests cannot monitor conjugated estrogens or synthetic estrogen use. The transdermal preparations and injectable estradiol cypionate or valerate preparations may confer an advantage in older transgender females who may be at higher risk for thromboembolic disease Our recommendation to maintain levels of gender-affirming hormones in the normal adult range places a high value on the avoidance of the long-term complications of pharmacologic doses.

Those patients receiving endocrine treatment who have relative contraindications to hormones should have an in-depth discussion with their physician to balance the risks and benefits of therapy. Clinicians should inform all endocrine-treated individuals of all risks and benefits of gender-affirming hormones prior to initiating therapy. Clinicians should strongly encourage tobacco use cessation in transgender females to avoid increased risk of VTE and cardiovascular complications. We strongly discourage the unsupervised use of hormone therapy Tailoring current protocols to the individual may be done within the context of accepted safety guidelines using a multidisciplinary approach including mental health.

No evidence-based protocols are available for these groups We need prospective studies to better understand treatment options for these persons. Physical changes that are expected to occur during the first 1 to 6 months of testosterone therapy include cessation of menses, increased sexual desire, increased facial and body hair, increased oiliness of skin, increased muscle, and redistribution of fat mass. Changes that occur within the first year of testosterone therapy include deepening of the voice , , clitoromegaly, and male pattern hair loss in some cases , , , Table Estimates represent clinical observations: Physical changes that may occur in transgender females in the first 3 to 12 months of estrogen and antiandrogen therapy include decreased sexual desire, decreased spontaneous erections, decreased facial and body hair usually mild , decreased oiliness of skin, increased breast tissue growth, and redistribution of fat mass , , , , , Table Breast development is generally maximal at 2 years after initiating hormones , , , Over a long period of time, the prostate gland and testicles will undergo atrophy.

Although the time course of breast development in transgender females has been studied , precise information about other changes induced by sex hormones is lacking There is a great deal of variability among individuals, as evidenced during pubertal development. We all know that a major concern for transgender females is breast development. If we work with estrogens, the result will be often not what the transgender female expects. Alternatively, there are transgender females who report an anecdotal improved breast development, mood, or sexual desire with the use of progestogens.

However, there have been no well-designed studies of the role of progestogens in feminizing hormone regimens, so the question is still open. Our knowledge concerning the natural history and effects of different cross-sex hormone therapies on breast development in transgender females is extremely sparse and based on the low quality of evidence. Current evidence does not indicate that progestogens enhance breast development in transgender females, nor does evidence prove the absence of such an effect.

This prevents us from drawing any firm conclusion at this moment and demonstrates the need for further research to clarify these important clinical questions Transgender persons have very high expectations regarding the physical changes of hormone treatment and are aware that body changes can be enhanced by surgical procedures e. Clear expectations for the extent and timing of sex hormone—induced changes may prevent the potential harm and expense of unnecessary procedures.

Hormone therapy for transgender males and females confers many of the same risks associated with sex hormone replacement therapy in nontransgender persons. The risks arise from and are worsened by inadvertent or intentional use of supraphysiologic doses of sex hormones, as well as use of inadequate doses of sex hormones to maintain normal physiology , Pretreatment screening and appropriate regular medical monitoring are recommended for both transgender males and females during the endocrine transition and periodically thereafter 26 , Table 14 contains a standard monitoring plan for transgender males on testosterone therapy , Key issues include maintaining testosterone levels in the physiologic normal male range and avoiding adverse events resulting from excess testosterone therapy, particularly erythrocytosis, sleep apnea, hypertension, excessive weight gain, salt retention, lipid changes, and excessive or cystic acne Adapted from Lapauw et al.

Because oral alkylated testosterone is not recommended, serious hepatic toxicity is not anticipated with parenteral or transdermal testosterone use , Past concerns regarding liver toxicity with testosterone have been alleviated with subsequent reports that indicate the risk of serious liver disease is minimal , , Table 15 contains a standard monitoring plan for transgender females on estrogens, gonadotropin suppression, or antiandrogens Key issues include avoiding supraphysiologic doses or blood levels of estrogen that may lead to increased risk for thromboembolic disease, liver dysfunction, and hypertension.

Clinicians should monitor serum estradiol levels using laboratories participating in external quality control, as measurements of estradiol in blood can be very challenging VTE may be a serious complication. A study reported a fold increase in venous thromboembolic disease in a large cohort of Dutch transgender subjects This increase may have been associated with the use of the synthetic estrogen, ethinyl estradiol The incidence decreased when clinicians stopped administering ethinyl estradiol Thus, the use of synthetic estrogens and conjugated estrogens is undesirable because of the inability to regulate doses by measuring serum levels and the risk of thromboembolic disease.

In a German gender clinic, deep vein thrombosis occurred in 1 of 60 of transgender females treated with a GnRH analog and oral estradiol The patient who developed a deep vein thrombosis was found to have a homozygous C T mutation in the methylenetetrahydrofolate reductase gene. In an Austrian gender clinic, administering gender-affirming hormones to transgender females and 89 transgender males was not associated with VTE, despite an 8. A more recent multinational study reported only 10 cases of VTE from a cohort of subjects Thrombophilia screening of transgender persons initiating hormone treatment should be restricted to those with a personal or family history of VTE Monitoring D -dimer levels during treatment is not recommended Estrogen therapy can increase the growth of pituitary lactrotroph cells.

There have been several reports of prolactinomas occurring after long-term, high-dose estrogen therapy — In most cases, the serum prolactin levels will return to the normal range with a reduction or discontinuation of the estrogen therapy or discontinuation of cyproterone acetate , , The onset and time course of hyperprolactinemia during estrogen treatment are not known. Clinicians should measure prolactin levels at baseline and then at least annually during the transition period and every 2 years thereafter.

Given that only a few case studies reported prolactinomas, and prolactinomas were not reported in large cohorts of estrogen-treated persons, the risk is likely to be very low. Because the major presenting findings of microprolactinomas hypogonadism and sometimes gynecomastia are not apparent in transgender females, clinicians may perform radiologic examinations of the pituitary in those patients whose prolactin levels persistently increase despite stable or reduced estrogen levels.

Some transgender individuals receive psychotropic medications that can increase prolactin levels Administering testosterone to transgender males results in a more atherogenic lipid profile with lowered high-density lipoprotein cholesterol and higher triglyceride and low-density lipoprotein cholesterol values — Studies of the effect of testosterone on insulin sensitivity have mixed results , A randomized, open-label uncontrolled safety study of transgender males treated with testosterone undecanoate demonstrated no insulin resistance after 1 year , Numerous studies have demonstrated the effects of sex hormone treatment on the cardiovascular system , , , Long-term studies from The Netherlands found no increased risk for cardiovascular mortality Likewise, a meta-analysis of 19 randomized trials in nontransgender males on testosterone replacement showed no increased incidence of cardiovascular events A systematic review of the literature found that data were insufficient due to very low—quality evidence to allow a meaningful assessment of patient-important outcomes, such as death, stroke, myocardial infarction, or VTE in transgender males Future research is needed to ascertain the potential harm of hormonal therapies Clinicians should manage cardiovascular risk factors as they emerge according to established guidelines A prospective study of transgender females found favorable changes in lipid parameters with increased high-density lipoprotein and decreased low-density lipoprotein concentrations However, increased weight, blood pressure, and markers of insulin resistance attenuated these favorable lipid changes.

Thus, there is limited evidence to determine whether estrogen is protective or detrimental on lipid and glucose metabolism in transgender females With aging, there is usually an increase of body weight. Therefore, as with nontransgender individuals, clinicians should monitor and manage glucose and lipid metabolism and blood pressure regularly according to established guidelines We recommend that clinicians obtain BMD measurements when risk factors for osteoporosis exist, specifically in those who stop sex hormone therapy after gonadectomy.

Baseline bone mineral measurements in transgender males are generally in the expected range for their pretreatment gender However, adequate dosing of testosterone is important to maintain bone mass in transgender males , In one study , serum LH levels were inversely related to BMD, suggesting that low levels of sex hormones were associated with bone loss.

Thus, LH levels in the normal range may serve as an indicator of the adequacy of sex steroid administration to preserve bone mass. The protective effect of testosterone may be mediated by peripheral conversion to estradiol, both systemically and locally in the bone. In aging males, studies suggest that serum estradiol more positively correlates with BMD than does testosterone , and is more important for peak bone mass Estrogen preserves BMD in transgender females who continue on estrogen and antiandrogen therapies , , , , Fracture data in transgender males and females are not available.

Transgender persons who have undergone gonadectomy may choose not to continue consistent sex steroid treatment after hormonal and surgical sex reassignment, thereby becoming at risk for bone loss. There have been no studies to determine whether clinicians should use the sex assigned at birth or affirmed gender for assessing osteoporosis e.

Although some researchers use the sex assigned at birth with the assumption that bone mass has usually peaked for transgender people who initiate hormones in early adulthood , this should be assessed on a case-by-case basis until there are more data available. This assumption will be further complicated by the increasing prevalence of transgender people who undergo hormonal transition at a pubertal age or soon after puberty.

Sex for comparison within risk assessment tools may be based on the age at which hormones were initiated and the length of exposure to hormones. In some cases, it may be reasonable to assess risk using both the male and female calculators and using an intermediate value. Because all subjects underwent normal pubertal development, with known effects on bone size, reference values for birth sex were used for all participants We suggest that transgender females with no known increased risk of breast cancer follow breast-screening guidelines recommended for those designated female at birth.

Studies have reported a few cases of breast cancer in transgender females — A Dutch study of transgender females followed for a mean of 15 years range of 1 30 years found one case of breast cancer. In transgender males, a large retrospective study conducted at the U. Veterans Affairs medical health system identified seven breast cancers The authors reported that this was not above the expected rate of breast cancers in cisgender females in this cohort. Furthermore, they did report one breast cancer that developed in a transgender male patient after mastectomy, supporting the fact that breast cancer can occur even after mastectomy.

Indeed, there have been case reports of breast cancer developing in subareolar tissue in transgender males, which occurred after mastectomy , Women with primary hypogonadism Turner syndrome treated with estrogen replacement exhibited a significantly decreased incidence of breast cancer as compared with national standardized incidence ratios , We need long-term studies to determine the actual risk, as well as the role of screening mammograms.

Regular examinations and gynecologic advice should determine monitoring for breast cancer. Prostate cancer is very rare before the age of 40, especially with androgen deprivation therapy Childhood or pubertal castration results in regression of the prostate and adult castration reverses benign prostate hypertrophy Although van Kesteren et al. Studies have also reported a few cases of prostate carcinoma in transgender females — Transgender females may feel uncomfortable scheduling regular prostate examinations.

Gynecologists are not trained to screen for prostate cancer or to monitor prostate growth. Thus, it may be reasonable for transgender females who transitioned after age 20 years to have annual screening digital rectal examinations after age 50 years and prostate-specific antigen tests consistent with U. Preventive Services Task Force Guidelines Although aromatization of testosterone to estradiol in transgender males has been suggested as a risk factor for endometrial cancer , no cases have been reported.

When transgender males undergo hysterectomy, the uterus is small and there is endometrial atrophy , Studies have reported cases of ovarian cancer , Although there is limited evidence for increased risk of reproductive tract cancers in transgender males, health care providers should determine the medical necessity of a laparoscopic total hysterectomy as part of a gender-affirming surgery to prevent reproductive tract cancer Given the discomfort that transgender males experience accessing gynecologic care, our recommendation for the medical necessity of total hysterectomy and oophorectomy places a high value on eliminating the risks of female reproductive tract disease and cancer and a lower value on avoiding the risks of these surgical procedures related to the surgery and to the potential undesirable health consequences of oophorectomy and their associated costs.

The sexual orientation and type of sexual practices will determine the need and types of gynecologic care required following transition. Additionally, in certain countries, the approval required to change the sex in a birth certificate for transgender males may be dependent on having a complete hysterectomy. Clinicians should help patients research nonmedical administrative criteria and provide counseling. If individuals decide not to undergo hysterectomy, screening for cervical cancer is the same as all other females.

For many transgender adults, genital gender-affirming surgery may be the necessary step toward achieving their ultimate goal of living successfully in their desired gender role. The type of surgery falls into two main categories: Those that change fertility previously called sex reassignment surgery include genital surgery to remove the penis and gonads in the male and removal of the uterus and gonads in the female.

The surgeries that effect fertility are often governed by the legal system of the state or country in which they are performed. Other gender-conforming surgeries that do not directly affect fertility are not so tightly governed. Gender-affirming surgical techniques have improved markedly during the past 10 years. Reconstructive genital surgery that preserves neurologic sensation is now the standard. The satisfaction rate with surgical reassignment of sex is now very high Additionally, the mental health of the individual seems to be improved by participating in a treatment program that defines a pathway of gender-affirming treatment that includes hormones and surgery , Table Surgery that affects fertility is irreversible.

Gender-affirming genital surgeries for transgender females that affect fertility include gonadectomy, penectomy, and creation of a neovagina , Surgeons often invert the skin of the penis to form the wall of the vagina, and several literatures reviews have reported on outcomes Sometimes there is inadequate tissue to form a full neovagina, so clinicians have revisited using intestine and found it to be successful 87 , , Some newer vaginoplasty techniques may involve autologuous oral epithelial cells , The scrotum becomes the labia majora.

Surgeons use reconstructive surgery to fashion the clitoris and its hood, preserving the neurovascular bundle at the tip of the penis as the neurosensory supply to the clitoris. Some surgeons are also creating a sensate pedicled-spot adding a G spot to the neovagina to increase sensation Most recently, plastic surgeons have developed techniques to fashion labia minora. To further complete the feminization, uterine transplants have been proposed and even attempted Neovaginal prolapse, rectovaginal fistula, delayed healing, vaginal stenosis, and other complications do sometimes occur , Clinicians should strongly remind the transgender person to use their dilators to maintain the depth and width of the vagina throughout the postoperative period.

Genital sexual responsivity and other aspects of sexual function are usually preserved following genital gender-affirming surgery , Ancillary surgeries for more feminine or masculine appearance are not within the scope of this guideline. Voice therapy by a speech language pathologist is available to transform speech patterns to the affirmed gender Spontaneous voice deepening occurs during testosterone treatment of transgender males , No studies have compared the effectiveness of speech therapy, laryngeal surgery, or combined treatment.

Breast surgery is a good example of gender-confirming surgery that does not affect fertility. In all females, breast size exhibits a very broad spectrum. For transgender females to make the best informed decision, clinicians should delay breast augmentation surgery until the patient has completed at least 2 years of estrogen therapy, because the breasts continue to grow during that time , Another major procedure is the removal of facial and masculine-appearing body hair using either electrolysis or laser treatments.

Other feminizing surgeries, such as that to feminize the face, are now becoming more popular — In transgender males, clinicians usually delay gender-affirming genital surgeries until after a few years of androgen therapy. Those surgeries that affect fertility in this group include oophorectomy, vaginectomy, and complete hysterectomy. Surgeons can safely perform them vaginally with laparoscopy.

These are sometimes done in conjunction with the creation of a neopenis. The cosmetic appearance of a neopenis is now very good, but the surgery is multistage and very expensive , Radial forearm flap seems to be the most satisfactory procedure , Other flaps also exist Surgeons can make neopenile erections possible by reinervation of the flap and subsequent contraction of the muscle, leading to stiffening of the neopenis , , but results are inconsistent Surgeons can also stiffen the penis by imbedding some mechanical device e.

Because of these limitations, the creation of a neopenis has often been less than satisfactory. Recently, penis transplants are being proposed In fact, most transgender males do not have any external genital surgery because of the lack of access, high cost, and significant potential complications.

Some choose a metaoidioplasty that brings forward the clitoris, thereby allowing them to void in a standing position without wetting themselves , Surgeons can create the scrotum from the labia majora with good cosmetic effect and can implant testicular prostheses The most important masculinizing surgery for the transgender male is mastectomy, and it does not affect fertility. Breast size only partially regresses with androgen therapy In adults, discussions about mastectomy usually take place after androgen therapy has started. Because some transgender male adolescents present after significant breast development has occurred, they may also consider mastectomy 2 years after they begin androgen therapy and before age 18 years.

Clinicians should individualize treatment based on the physical and mental health status of the individual. There are now newer approaches to mastectomy with better outcomes , These often involve chest contouring Mastectomy is often necessary for living comfortably in the new gender Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult.

For transgender males, the outcomes are less certain. However, the problems are now better understood Several postoperative studies report significant long-term psychological and psychiatric pathology — One study showed satisfaction with breasts, genitals, and femininity increased significantly and showed the importance of surgical treatment as a key therapeutic option for transgender females Another analysis demonstrated that, despite the young average age at death following surgery and the relatively larger number of individuals with somatic morbidity, the study does not allow for determination of causal relationships between, for example, specific types of hormonal or surgical treatment received and somatic morbidity and mortality Reversal surgery in regretful male-to-female transsexuals after sexual reassignment surgery represents a complex, multistage procedure with satisfactory outcomes.

Further insight into the characteristics of persons who regret their decision postoperatively would facilitate better future selection of applicants eligible for sexual reassignment surgery. We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment. When a transgender individual decides to have gender-affirming surgery, both the hormone prescribing clinician and the MHP must certify that the patient satisfies criteria for gender-affirming surgery Table There is some concern that estrogen therapy may cause an increased risk for venous thrombosis during or following surgery For this reason, the surgeon and the hormone-prescribing clinician should collaborate in making a decision about the use of hormones before and following surgery.

One study suggests that preoperative factors such as compliance are less important for patient satisfaction than are the physical postoperative results However, other studies and clinical experience dictate that individuals who do not follow medical instructions and do not work with their physicians toward a common goal do not achieve treatment goals and experience higher rates of postoperative infections and other complications , It is also important that the person requesting surgery feels comfortable with the anatomical changes that have occurred during hormone therapy. Dissatisfaction with social and physical outcomes during the hormone transition may be a contraindication to surgery An endocrinologist or experienced medical provider should monitor transgender individuals after surgery.

Those who undergo gonadectomy will require hormone replacement therapy, surveillance, or both to prevent adverse effects of chronic hormone deficiency. Mayo Clinic, Evidence-based Practice Center, significant financial interest or leadership position: AbbVie consultant , National Institutes of Health grantee , significant financial interest or leadership position: Pediatric Endocrine Society immediate past president.

Cystic Fibrosis Foundation grantee , National Institutes of Health grantee , significant financial interest or leadership position, Elsevier Journal of Clinical and Translational Endocrinology editor. Disclosures prior to this time period are archived.

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Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. Changes Since the Previous Guideline. Biological Determinants of Gender Identity Development. A correction has been published: Biological sex, biological male or female: These terms refer to physical aspects of maleness and femaleness. As these may not be in line with each other e.

This means not transgender. This is the distress and unease experienced if gender identity and designated gender are not completely congruent see Table 2. Typically, transgender people seek to make their gender expression align with their gender identity, rather than their designated gender. For transgender people, their gender identity does not match their sex designated at birth. Most people have a gender identity of man or woman or boy or girl.

For some people, their gender identity does not fit neatly into one of those two choices. Unlike gender expression see below , gender identity is not visible to others. Gender incongruence is also the proposed name of the gender identity—related diagnoses in ICD Not all individuals with gender incongruence have gender dysphoria or seek treatment. This is also called gender-confirming or gender-affirming treatment.

Sex designated at birth: This refers to sex assigned at birth, usually based on genital anatomy. This refers to attributes that characterize biological maleness or femaleness. The best known attributes include the sex-determining genes, the sex chromosomes, the H-Y antigen, the gonads, sex hormones, internal and external genitalia, and secondary sex characteristics. Gender identity and sexual orientation are not the same. Irrespective of their gender identity, transgender people may be attracted to women gynephilic , attracted to men androphilic , bisexual, asexual, or queer.

Not all transgender individuals seek treatment. This refers to individuals assigned female at birth but who identify and live as men. This refers to individuals assigned male at birth but who identify and live as women. Prepubertal children may choose to transition socially. This is an older term that originated in the medical and psychological communities to refer to individuals who have permanently transitioned through medical interventions or desired to do so.

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. The condition exists with a disorder of sex development. The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender with or without legalization of gender change and has undergone or is preparing to have at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender e.

The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments. The transsexual identity has been present persistently for at least 2 y. The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality.

Mental health concerns, if present, must be reasonably well controlled.

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Adolescents are eligible for GnRH agonist treatment if: A qualified MHP has confirmed that: Adolescents are eligible for subsequent sex hormone treatment if: A qualified MHP has confirmed: And a pediatric endocrinologist or other clinician experienced in pubertal induction: The description of Tanner stages for breast development: Adjust maintenance dose to mimic physiological estradiol levels see Table Induction of male puberty with testosterone esters increasing the dose every 6 mo IM or SC: Adjust maintenance dose to mimic physiological testosterone levels see Table IM, intramuscularly; SC, subcutaneously.

For recommendations on monitoring once pubertal induction has been completed, see Tables 14 and DXA, dual-energy X-ray absorptiometry. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions. Measure serum testosterone every 3 mo until levels are in the normal physiologic male range: Alternatively, measure peak and trough levels to ensure levels remain in the normal male range. For parenteral testosterone undecanoate, testosterone should be measured just before the following injection.

For transdermal testosterone, the testosterone level can be measured no sooner than after 1 wk of daily application at least 2 h after application. Measure hematocrit or hemoglobin at baseline and every 3 mo for the first year and then one to two times a year. Monitor weight, blood pressure, and lipids at regular intervals. Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss. If cervical tissue is present, monitoring as recommended by the American College of Obstetricians and Gynecologists.

Ovariectomy can be considered after completion of hormone transition. Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of feminization and for development of adverse reactions. Measure serum testosterone and estradiol every 3 mo.

Serum estradiol should not exceed the peak physiologic range: For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter. Routine cancer screening is recommended, as in nontransgender individuals all tissues present. Consider BMD testing at baseline In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.

This table presents strong recommendations and does not include lower level recommendations. Demonstrable knowledge of all practical aspects of surgery e. A case for clarity, consistency, and helpfulness: A History of Transsexuality in the United States. Was muss das Volk vom Dritten Geschlecht wissen. Verlag Max Spohr, Leipzig; Gender dysphoria syndrome—the conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multi-dimensional rehabilitative regimen.

Transgender experience and identity. Handbook of Identity Theory and Research. Challenging Assumptions About Gender and Sexuality. Gender identity disorder outside the binary: Accessed 26 August World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people.

Accessed 1 September A European network for the investigation of gender incongruence: Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. Gender development in women with congenital adrenal hyperplasia as a function of disorder severity. Gender role behavior, sexuality, and psychosocial adaptation in women with congenital adrenal hyperplasia due to CYP21A2 deficiency. Prenatal androgenization affects gender-related behavior but not gender identity in 5—year-old girls with congenital adrenal hyperplasia.

Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth. Gender identity outcome in female-raised 46,XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation. The heritability of gender identity disorder in a child and adolescent twin sample.

Binders Full of Women – a book

Gender identity disorder in twins: Androgen receptor repeat length polymorphism associated with male-to-female transsexualism. Association study of gender identity disorder and sex hormone-related genes. Desisting and persisting gender dysphoria after childhood: Factors associated with desistence and persistence of childhood gender dysphoria: Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: Children and adolescents with gender identity disorder referred to a pediatric medical center.

Autism spectrum disorder risk factors and autistic traits in gender dysphoric children. Gender role reversal among postoperative transsexuals.

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Regret after sex reassignment surgery in a male-to-female transsexual: Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Children and adolescents referred to a specialist gender identity development service: Accessed 20 July Surgical treatment of gender dysphoria in adults and adolescents: Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: Young adult psychological outcome after puberty suppression and gender reassignment.

Puberty suppression in a gender-dysphoric adolescent: Desire for amputation of a limb: Final height, gonadal function and bone mineral density of adolescent males with central precocious puberty after therapy with gonadotropin-releasing hormone analogues. Efficacy and safety of recombinant human follicle stimulating hormone Gonal-F with urinary human chorionic gonadotrophin for induction of spermatogenesis and fertility in gonadotrophin-deficient men.

Long-term observation of 87 girls with idiopathic central precocious puberty treated with gonadotropin-releasing hormone analogs: The efficacy and safety of gonadotropin-releasing hormone analog treatment in childhood and adolescence: Association between polycystic ovary syndrome and female-to-male transsexuality.

The effects of long term testosterone administration on pulsatile luteinizing hormone secretion and on ovarian histology in eugonadal female to male transsexual subjects. Distinctive features of female-to-male transsexualism and prevalence of gender identity disorder in Japan. Excessive androgen exposure in female-to-male transsexual persons of reproductive age induces hyperplasia of the ovarian cortex and stroma but not polycystic ovary morphology. Transgender men who experienced pregnancy after female-to-male gender transitioning.

Donor inseminations in partners of female-to-male transsexuals: Luteinizing hormone and follicle stimulating hormone secretion patterns in boys throughout puberty measured using highly sensitive immunoradiometric assays. Clinical management of gender identity disorder in adolescents: Puberty suppression in adolescents with gender identity disorder: Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Antagonistic and agonistic GnRH analogue treatment of precocious puberty: Therapeutic potential of GnRH antagonists in the treatment of precocious puberty.

Efficacy and safety of gonadotropin-releasing hormone agonist treatment to suppress puberty in gender dysphoric adolescents. Resumption of puberty after long term luteinizing hormone-releasing hormone agonist treatment of central precocious puberty. Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria.

A longitudinal evaluation of bone mineral density in adult men with histories of delayed puberty. Normal volumetric bone mineral density and bone turnover in young men with histories of constitutional delay of puberty. Bone loss following hypogonadism in men with prostate cancer treated with GnRH analogs.

Reduction of bone density: Effect of central precocious puberty and gonadotropin-releasing hormone analogue treatment on peak bone mass and final height in females. Review of outcomes after cessation of gonadotropin-releasing hormone agonist treatment of girls with precocious puberty. Bone mineral density and body composition in short children born SGA during growth hormone and gonadotropin releasing hormone analog treatment. Bone mass at final height in precocious puberty after gonadotropin-releasing hormone agonist with and without calcium supplementation.

Hypertension during therapy with triptorelin in a girl with precocious puberty. Arterial hypertension during treatment with triptorelin in a child with Williams-Beuren syndrome. Puberty suppression and executive functioning: Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Endocrine treatment of transsexual people: Retrospective study of the management of childhood and adolescent gender identity disorder using medroxyprogesterone acetate.

Consecutive lynestrenol and cross-sex hormone treatment in biological female adolescents with gender dysphoria: Endocrine treatment of transsexual persons: Adolescent consent in health care decision-making and the adolescent brain. Accessed 25 June Prescribing of cross-sex hormones as part of the gender identity development service for children and adolescents. Accessed 14 June Physiological estrogen replacement therapy for puberty induction in girls: Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: Pharmacokinetics of testosterone and estradiol gel preparations in healthy young men.

Effects of oestradiol on gonadotrophin levels in normal and castrated men. Money J, Ehrhardt A. Effects of different steps in gender reassignment therapy on psychopathology: Review of studies of androgen treatment of female-to-male transsexuals: Endocrine care of transpeople part I. A review of cross-sex hormonal treatments, outcomes and adverse effects in transmen. Testosterone therapy in adult men with androgen deficiency syndromes: Effects of three different testosterone formulations in female-to-male transsexual persons. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: Long-term treatment of transsexuals with cross-sex hormones: Spironolactone with physiological female steroids for presurgical therapy of male-to-female transsexualism.

Endocrine treatment of male-to-female transsexuals using gonadotropin-releasing hormone agonist. Sexual desire in trans persons: An observational retrospective evaluation of 79 young men with long-term adverse effects after use of finasteride against androgenetic alopecia.