Transdermal testosterone is an option for biologic females who are leery of injections.13 Patches result in stable testosterone levels in the male range but may cause skin irritation in >50% of patients. Use transdermal estrogen in males with clotting abnormalities or who are age >40.
Medical workup. Basic medical monitoring includes serial physical examinations, vital signs, weight measurements, laboratory assessment, and screening for pelvic malignancies.
For biologic males receiving estrogen, pretreatment laboratory assessment includes free testosterone, fasting glucose, liver function tests, and complete blood count, with reassessment at 6 and 12 months and annually thereafter. Obtain pretreatment prolactin levels and repeat annually. If hyperprolactinemia fails to develop within 3 years, no further measurements are necessary. Monitor for breast and prostate cancer, and instruct patients to perform self-breast exams. Following orchiectomy, estrogen doses can be reduced by one-third to one-half.
For biologic women receiving androgen, obtain pretreatment liver function tests and complete blood count, then reassess at 6 months, 12 months, and annually thereafter. Do yearly liver palpation examinations.
Physiologic changes. Biologic males treated with estrogens can expect breast growth, redistribution of fat in keeping with female habitus, decreased upper body strength, decreased body hair, retardation of male pattern balding, diminished testicular size, and decrease in erection firmness and frequency. MTF transsexuals require electrolysis to remove facial hair, as HRT does not do this.
Biologic females treated with testosterone can expect deepening of the voice, clitoral enlargement, mild breast atrophy, increased facial and body hair and male-pattern baldness, increased upper body strength, weight gain, and decreased hip fat.
With effective and continuous dosages, most changes begin in 2 to 4 months, start becoming irreversible in 6 to 12 months, start to level off in 2 years, and are mostly complete in 5 years. Men with insufficient breast growth following HRT may pursue breast augmentation surgery.
Voice changes. Hormone therapy generally is presumed to “masculinize” the voice of FTM transsexuals. In one series, after initiation of hormone therapy, 12 of 16 (75%) FTM transsexuals believed they had a voice that always would be considered masculine.14,15
For MTF transsexuals, no surgical technique of pitch elevation is satisfactorily safe and effective. The most widely used—cricothyroid approximation—may not be long-lasting and can decrease range, loudness, and vocal quality.13
HRT COMPLICATIONS
Medical complications. Biologic males treated with estrogens and progestins may be at increased risk for blood clotting, benign pituitary prolactinomas, infertility, weight gain, liver disease, gallstones, somnolence, hypertension, and diabetes mellitus.
Biologic females treated with testosterone may be at increased risk for acne, cardiovascular disease from shifts of lipid profiles to male patterns, benign and malignant liver tumors, and hepatic dysfunction.
Psychiatric issues. Physical masculinization occurs much more rapidly and results in a more convincing opposite sex appearance in FTMs than feminization does in MTFs.16,17 Behaving masculine may be more socially acceptable for women and therefore easier than it is for men to behave convincingly feminine without being characterized.
Cross-sex hormones contribute to the expression of sex-dimorphic behaviors in adulthood.18,19 Estrogen appears to influence affect intensity, whereas androgens influence aggression and sexual motivation. Earlier studies established that untreated MTFs and FTMs do not differ in sex hormone levels from their biologic counterparts.20,21
After 3 months of HRT, transsexuals’ sex hormones are in the range of their identified sex. FTMs treated with androgens become more prone to aggression and exhibit increased sexual motivation and arousability associated with an overall dampened affect. MTFs treated with estrogen show decreased irritability and sexual arousability.22
SEX REASSIGNMENT SURGERY
The cost of SRS often is prohibitive. Patients may turn to the Internet or foreign venues for hormone therapy and surgical procedures. Thailand is a popular overseas destination, where the average cost for MTF surgery is approximately $6,000 to $9,000. In the United States the cost of counseling, hormones, electrolysis, and surgeries is typically $30,000 to $40,000.23
Surgical options are not limited to genital reassignment but include mammoplasty (breast augmentation for MTF), chest reduction surgery (FTM), trachea shave surgery, forehead/brow ridge contouring, chin and jaw contouring, scalp advancement surgery, cheek implant surgery, alarplasty (nasal base resection to narrow a nose), and chin contouring.
Some insurance companies assert that transsexual procedures are not medically necessary and are declining coverage. WPATH contends that sex reassignment is effective and medically indicated in severe GID.
Postsurgical outcomes. Patients who are emotionally healthy, have adequate social support, and attain reasonable cosmetic results are most satisfied with life after SRS.24 In studies of GID patients, the best predictor of postoperative psychopathology was poor surgical results.25
FTMs are transformed through the use of hormones and generally are not perceived as visibly different from other men. Genital surgery is often seen as a final step in completing the transition to the identified gender.