Hormonal Treatment of Transsexual Adults: State of the Art

Practice guidelines for the treatment of transsexual persons have been published by the Endocrine Society. Among their conclusions is that transsexual persons deserve and require hormone levels needed to safely achieve and maintain the sexual characteristics of their desired gender.¹

The psychic trauma of feeling trapped in the wrong body has been recorded throughout history. The word “transsexual” was first used in 1923.

The availability of diethylstilbestrol and testosterone in the 1930s allowed the first effective treatment of transsexuals. In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4), the term gender identity disorder was used.¹ To remove the stigma associated with the word “disorder,” DSM-5 changed the diagnostic term to gender dysphoria.²

“Transsexualism is not about sex. It is all about gender. A certain amount of uncertainty is common in childhood. But for some people, the physical changes of puberty cause severe and lasting dysphoria,” said Matthew Leinung, MD, chief of endocrinology at Albany Medical Center in Albany, New York.

Incidence, Etiology and Diagnosis

“We don’t have any hard data on incidence. It may be about three people out of 1,000. Male-to- female transsexuals may be twice as common as female-to-male. The etiology is probably biologic but no one knows ‘the cause’ at this time,” said Joshua D. Safer, MD, director of the endocrinology fellowship training program at Boston Medical Center.

The World Professional Association for Transgender Health (WPATH), founded in 1979, has established criteria for diagnosing gender dysphoria. Because gender dysphoria may be confused with or accompanied by psychological or psychiatric conditions, both WPATH and the Endocrine Society recommend that a mental health professional make the initial diagnosis.¹ According to DSM-IV-TR diagnostic criteria include:

• A strong and persistent cross-gender identification
• Persistent discomfort with gender
• Absence of a physical intersex condition
• Severe distress that interferes with work or social life

Treatment Basics

WPATH and the Endocrine Society require that a person considered for hormone treatment be both eligible and ready. Most children outgrow gender confusion by adolescence, so treatment is not recommended before early puberty.¹ “It is becoming more common to see gender dysphoria at younger ages. Life transition periods are stressful. Most of our patients present at college age,” said Dr. Safer.

Hormone treatment in adults may be recommended if:¹

• Diagnostic criteria have been met
• Psychiatric comorbidity has been treated or ruled out
• Outcomes, risks and benefits of treatment are understood
• At least 3 months of psychotherapy or real life experience living as the desired gender confirms the desire for change
• Stable mental health is probable and the person is able to take hormone treatment responsibly