Transsexualism: Clinical guide to gender identity disorder

• 71% for Axis I disorders (primarily mood and anxiety disorders)
  
• 42% for comorbid personality disorders, primarily a cluster B diagnosis
  
• 45% for substance-related disorders
  
• 6.5% for psychotic disorders
  
• 3.2% for eating disorders.⁹
  

Persons with GID transgress the traditional binary gender system and as a consequence experience discrimination in employment, social services and housing.¹⁰ Jones and Hill¹¹ have proposed that these experiences result in vulnerability to Axis I disorders.

TREATING PATIENTS WITH GID

Psychotherapy. GID treatment decisions are made without clear prospective data. Standards of care are determined by the World Professional Association for Transgender Health (WPATH).¹² Psychotherapy is often given before SRS but is not required. The therapist is left to determine the treatment terms and goals.

Your role in treating patients with GID goes beyond making an accurate diagnosis, identifying comorbid psychopathology, and instituting a treatment plan. Other tasks include:

• counseling the patient about the range of treatment options and their implications
  
• engaging in psychotherapy
  
• ascertaining eligibility and readiness for hormones and surgical therapy
  
• making formal recommendations to medical and surgical colleagues
  
• documenting the patient’s relevant history in a letter of recommendation
  
• educating support systems
  
• being available for follow-up.
  

Because these tasks may be daunting for one clinician, you might consider referring the patient to a gender disorder clinic (see Related resources).

Candidates for triadic therapy. For appropriately screened adults with severe GID, the therapeutic approach relies on triadic therapy:

• a 3-phase approach centered around real-life experience in the desired role
  
• hormones of the desired gender
  
• and surgery to change the genitalia and secondary sex characteristics.
  

HORMONE THERAPY

WPATH has established eligibility and readiness criteria for HRT in patients with GID (Table 3). Administering cross-sex hormones (testosterone in women; estrogens in men) brings about important physical changes as well as psychological relief. The prescribing physician need not be an endocrinologist but should become well-versed in relevant data.

Table 3

WPATH criteria for hormone replacement therapy*

Eligibility criteria 3 criteria exist	Patient is at least age 18 Patient understands what hormones medically can and cannot do and their social benefits and risks Patients has had either: Providing hormones to patients who have not fulfilled criterion 3 can be acceptable in selected circumstances, such as to facilitate monitored therapy using hormones of known quality as an alternative to black-market or unsupervised hormone use
Readiness criteria All 3 must exist	Patient has had further consolidation of gender identity during the real-life experience or psychotherapy Patient has made some progress mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, and suicidality Patient is likely to take hormones in a responsible manner
Source: World Professional Association for Transgender Health (WPATH)

Options include oral, injectable, and transdermal formulations (Table 4); physician discretion and patient preference determine the formulation used.

Table 4

Sample hormonal regimens for transsexual patients*

	Medication	Starting dose	Subsequent dose	When to change doses
Female to male	Testosterone enanthanate or testosterone cypionate	200 mg IM every 2 weeks	100 to 150 mg IM every 2 weeks	After masculinization complete and/or oophorectomy/hysterectomy
	Transdermal testosterone	5 mg to skin every day	Usually stays the same	Little data exist on efficacy; effective for maintenance, and may be less efficacious during transition
Male to female	Conjugated estrogens	1.25 mg/d (or 0.625 mg/d for smokers)	2.5 mg/d (Do not increase in smokers)	To obtain best clinical results, or if testosterone is not suppressed After sexual reassignment surgery, dose may be decreased without losing secondary sexual characteristics
	OR oral estradiol	1 mg/d	2 mg/d
	OR transdermal estradiol	0.1 mg patch/week	Two 0.1 mg patches/week
	Spironolactone	200 mg/d	May discontinue	After sexual assignment surgery
	Medroxyprogesterone†	10 mg/d	May increase to 20 to 40 mg/d (usually not needed)	If testosterone is not suppressed and patient/doctor does not want to increase estrogen
	OR micronized progesterone	100 mg bid	May discontinue after breast development is complete	Micronized progesterone is more costly but may lessen side effects of anxiety, as compared with medroxyprogesterone
* Professional consensus does not exist regarding the most efficacious and safest dosing regimens for gender transition. This table reflects reasonable starting and maintenance doses that are supported in the (admittedly less than optimal) medical literature, and reflect the author’s opinion and practice. This table is not meant to include all possible hormone regimens, only several of the most commonly used medications.
† Professional consensus does not exist regarding progesterone’s role in MTF transition.
Adapted and reprinted with permission from Table VII in Oriel KA. Medical care of transsexual patients. J Gay Lesbian Med Asso 2000;4(4):193.

IM testosterone therapy (standard dose 200 to 250 mg/2 weeks) is complicated by fluctuating serum testosterone levels. Fatigue or irritability can occur when serum testosterone levels are low (on days 10 to 17). Oral testosterone suppresses the menstrual cycle in only 50% of FTMs.