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Endocrine Treatment of Transsexual Persons

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Below is the Abstract and Summary of Recommendations from a lengthy peer-reviewed literature review and consensus statement.

Full text via Journal of Clinical Endocrinology & Metabolism

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Abstract

Objective: The aim was to formulate practice guidelines for endocrine treatment oftranssexual persons.

Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.

Consensus Process: Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines.

Conclusions: Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person’s genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person’s desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.

Summary of Recommendations

1.0 Diagnostic procedure
1.1 We recommend that the diagnosis of gender identity disorder (GID) be made by a mental health professional (MHP). For children and adolescents, the MHP should also have training in child and adolescent developmental psychopathology. (1 ⊕⊕○○)

1.2 Given the high rate of remission of GID after the onset of puberty, we recommend against a complete social role change and hormone treatment in prepubertal children with GID. (1 ⊕⊕○○)

1.3 We recommend that physicians evaluate and ensure that applicants understand the reversible and irreversible effects of hormone suppression (e.g. GnRH analog treatment) and cross-sex hormone treatment before they start hormone treatment.

1.4 We recommend that all transsexual individuals be informed and counseled regarding options for fertility prior to initiation of puberty suppression in adolescents and prior to treatment with sex hormones of the desired sex in both adolescents and adults.

2.0 Treatment of adolescents
2.1. We recommend that adolescents who fulfill eligibility and readiness criteria for gender reassignment initially undergo treatment to suppress pubertal development. (1 ⊕○○○)

2.2. We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty (confirmed by pubertal levels of estradiol and testosterone, respectively), but no earlier than Tanner stages 2–3. (1 ⊕⊕○○)

2.3. We recommend that GnRH analogs be used to achieve suppression of pubertal hormones. (1 ⊕⊕○○)

2.4. We suggest that pubertal development of the desired opposite sex be initiated at about the age of 16 yr, using a gradually increasing dose schedule of cross-sex steroids. (2 ⊕○○○)

2.5. We recommend referring hormone-treated adolescents for surgery when 1) the real-life experience (RLE) has resulted in a satisfactory social role change; 2) the individual is satisfied about the hormonal effects; and 3) the individual desires definitive surgical changes. (1 ⊕○○○)

2.6 We suggest deferring surgery until the individual is at least 18 yr old. (2 ⊕○○○)

3.0 Hormonal therapy for transsexual adults
3.1 We recommend that treating endocrinologists confirm the diagnostic criteria of GID or transsexualism and the eligibility and readiness criteria for the endocrine phase of gender transition. (1 ⊕⊕⊕○)

3.2 We recommend that medical conditions that can be exacerbated by hormone depletion and cross-sex hormone treatment be evaluated and addressed prior to initiation of treatment (see Table 11⇓: Medical conditions that can be exacerbated by cross-sex hormone therapy). (1 ⊕⊕⊕○)

3.3 We suggest that cross-sex hormone levels be maintained in the normal physiological range for the desired gender. (2 ⊕⊕○○)

3.4 We suggest that endocrinologists review the onset and time course of physical changes induced by cross-sex hormone treatment. (2 ⊕⊕○○)

4.0 Adverse outcome prevention and long-term care
4.1 We suggest regular clinical and laboratory monitoring every 3 months during the first year and then once or twice yearly. (2 ⊕⊕○○)

4.2 We suggest monitoring prolactin levels in male-to-female (MTF) transsexual persons treated with estrogens. (2 ⊕⊕○○)

4.3 We suggest that transsexual persons treated with hormones be evaluated for cardiovascular risk factors. (2 ⊕⊕○○)

4.4 We suggest that bone mineral density (BMD) measurements be obtained if risk factors for osteoporosis exist, specifically in those who stop hormone therapy after gonadectomy. (2 ⊕⊕⊕○)

4.5 We suggest that MTF transsexual persons who have no known increased risk of breast cancer follow breast screening guidelines recommended for biological women. (2 ⊕⊕○○)

4.6 We suggest that MTF transsexual persons treated with estrogens follow screening guidelines for prostatic disease and prostate cancer recommended for biological men. (2 ⊕○○○)

4.7 We suggest that female-to-male (FTM) transsexual persons evaluate the risks and benefits of including total hysterectomy and oophorectomy as part of sex reassignment surgery. (2 ⊕○○○)

5.0 Surgery for sex reassignment
5.1 We recommend that transsexual persons consider genital sex reassignment surgery only after both the physician responsible for endocrine transition therapy and the MHP find surgery advisable. (1 ⊕○○○)

5.2 We recommend that genital sex reassignment surgery be recommended only after completion of at least 1 yr of consistent and compliant hormone treatment. (1 ⊕○○○)

5.3 We recommend that the physician responsible for endocrine treatment medically clear transsexual individuals for sex reassignment surgery and collaborate with the surgeon regarding hormone use during and after surgery. (1 ⊕○○○)