Good Stuff Happens in 1:1 Meetings: Why you need them and how to do them well
Transgender pp
1. Testosterone Therapy
• Injection of testosterone cypionate (Depo-testosterone) and
testosterone enanthate—every two to four weeks,
• and testosterone propionate—once or twice a week.
• Androdermpatch—one or two patches a day.
• Androgel, rub directly on skin. May rub off on partner.
• Testosterone ointment (cream), applied to the face and clitoral area.
Requires large areas of skin for application.
• Methyl/testosterone and oxandrolone pills are generally avoided due to
their side effect profile (potential liver complica
2. Progesterone Therapy
• Provera (medroxyprogesterone) is usually
avoided. There is no clinical evidence suggesting
that it helps feminization, and it may cause a
higher incidence of breast cancer, cardiovascular
disease, high blood pressure, cholesterol
increase, weight gain, depression, and varicose
veins.
• Natural progesterone (Prometrium) does not
have the adverse effects of Provera on blood
cholesterol or blood pressure.
3. Anti-androgen Therapy
• Pills include spironolactone and finasteride. Spironolactone (brand names
Aldactone, Novo-Spiroton, Spiractin, Spirotone, Verospiron, and Berlactone) is the
treatment of choice due to safety and availability. It is a potassium-sparing
diuretic. Finasteride (Propecia 1 mg or Proscar 5 mg) may be used alone or in
combination with spironolactone. It reduces the size of the prostate and improves
male pattern baldness. There are debates about its value and expense.
• Other anti-androgen drugs include Androcur (cyproterone acetate) and Eulexin
(flutamide). They are unfavorable because of their toxicity profile and lack of
availability.
• GnRNagonists (gonadotropin-releasing hormone) include nafarelin
acetate, goserelin acetate, and leuprorelin acetate. They are generally fully
reversible in adolescents and do not carry risk of thromboembolic disease (due to
blood clots). They are available by pill, injection, or nasal spray.
• Bilateral orchiectomy is removal of the testicles. This eliminates 90% of
testosterone production and helps reduce the estrogen dose used for therapy, but
may shrink the amount of skin available to create a vagina, should that surgery be
pursued.
4. Estrogen Therapy
• Oral estrogens include the conjugated estrogen Premarin (purported to cause more mood swings);
the synthetic, plant-based version of Premarin, Cenestin; and the estradiolvalerate tablets Estradiol
and Estrace. Oral estrogrens stress the liver more than transdermal and injectable estrogens do.
• Sublingual forms of estrogren (dissolving under the tongue) absorb better and avoid passing
through the liver, which reduces the risk of blood clots. Premarin is removed in urine and there is a
limit to what can be absorbed, so taking more in one dose is not helpful.
• Transdermalestrogens include the
– skin patches Estroderm, Climara, Alora, and Vivelle
– creams Premarin and Estrace,
– and the gel Estrasorb. Patches may cause irritation and people could be allergic to the adhesion used.
Creams require frequent use on large areas of skin.
• Estrogen injections include estradiolvalerate (Delestrogen) and estradiolcypionate (Depo-Estradiol).
One vial can last up to six months. The hormone preparation is thick and requires a 3 cc or 3 ml
syringe, an 18 or 20 gauge needle to draw up, and a 21 or 22 guage needle to inject. Length should
be 1 to 1-½ inch. Because of the large sizes required, the puncture wound is bigger; watch for
infection at the injection site. In Illinois, people over the age of 18 can buy up to 20 syringes
without a prescription at a pharmacy (not always without a hassle). Bulk purchases where available
can save money; for example, a pack of 10 syringes may cost $12 while 100 may cost $25. Check
also syringe exchanges, such as the one at TPAN, for free supplies.
Transgender has been defined in many different ways and the definition is evolving. Although there isn’t one accepted definition of transgender, it is generally viewed as an umbrella term thatcomprises anyone who does not conform to traditional gender norms. This includes: Those who identify and/or express their gender as opposite their birth sex (often referred to as transsexuals, particularly after undergoing medical and hormonal treatment). For example, a person born with female anatomy may feel his true gender identity is male. This person might refer to himself as a man, may take on male mannerisms and style of dress, and may medically and/or surgically alter his body to affirm his male gender identity. There is a wide array of terms that have been used to describe people within this group, including MTF, FTM, transwoman, transman, transsexual, gender-affirmed female, gender-affirmed male, and gender affirmed person. Surgical intervention is not a requirement for an individual to fall within this group.2) Those who define their gender as outside the binary construct of just male or just female. This includes those who identify with a fluid or changeable gender; those who prefer not to define themselves by any gender; those who feel their gender comprises both male and female elements; and those who feel gender cannot be restricted to just the two categories of male and female. Some people will use different labels for this, like genderqueer, queer, or gender fluid.3) Those who for various reasons reflect the outward manifestations of different gender roles and cross-dress to varying extents. That is, people who wear clothing, jewelry, and/or make-up not traditionally associated with their anatomical sex, and who generally have no intention or desire to change their sex. Cross-dressing is more often associated with men, and is usually done on an occasional basis. Cross-dressing may be engaged in for numerous reasons, including a need to express a feminine/masculine side, artistic expression, or erotic enjoyment. “Cross-dresser” should be used instead of the term “transvestite” (which is considered pejorative). Some, but not all transsexuals go through a “cross-dressing” period as they sort out their feelings. Cross-dressing can provide them temporary emotional (as opposed to sexual) relief from their feelings of being in the wrong anatomical body. Indeed, it might be said that some of these people aren’t cross-dressing at all because when they exhibit a gender expression that is opposite their birth sex, their gender identity and gender expression are then aligned.
Deciding what surgeries are needed is often very difficult for patients, not only because of financial considerations. Some patients might decide they don’t need any surgery. Others may be encouraged by some health practitioners and/or trans support groups to have some or a lot of surgery in order to better pass or to achieve a desired look. The primary care physician can help the patient sort through the competing factors/pressures and reach a realistic assessment of both the patient’s needs and the results to be expected from such surgeries. Transpeople are no different from non-transpeople in having to navigate the social pressures associated with the culture’s current physical attraction standards. Many MTFs assimilate into society without any facial or vocal feminizing surgeries.Patients who have vaginoplasty and mammoplasty surgeries should still have routine mammograms and gynecological exams. MTFs will still require periodic prostate screenings even if they have had some form of genital surgery.
See Handout 7-A for a list of multiple resources. See 7-B for references.
