Hormone therapy has become one of the cornerstones of modern treatment for transsexualism. It is even incorporated into the diagnostic process, with the International Classification of Diseases, 10th Edition (ICD-10) acknowledging its importance: "Transsexualism is the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone therapy."

Medical Support

Medical doctors with specialist experience in hormone disorders and treatments are called Endocrinologists and play an important part in the treatment process. Initially their input is vital in terms of assessing and managing any underlying hormonal problems that may present with gender confusion. These may include intersex conditions or endocrine disorders, but these are extremely rare. Their main role is the careful planning, initiation and supervision of hormone treatment for those transsexuals seeking permanent transition.

Aims of Hormone Treatment

The main aim of hormone treatment is to enable a safe gender transition with the associated desired positive changes, both physical changes and emotional ones. It is usually a careful step in a 3-stage process that includes the Real Life Experience (RLE), hormone therapy and gender reassignment surgery (in that order).

Monitoring and treatment go hand-in-hand and must occur simultaneously. There are significant risks associated with hormone therapy. There must be strategies in place to minimise side effects, manage any complications and modify the treatment regime to meet the needs of the individual.

Hormone treatment regimes can be divided into hormonal therapy for Male to Female transsexuals (MTFs) and hormonal therapy for Female to Male transsexuals (FTMs). Each treatment regime can be subdivided into different stages: Initiation therapy, Preoperative therapy and Postoperative therapy.

Starting Hormone Treatment

Hormone therapy is an important component of the overall treatment for transsexualism but its initiation must be carefully timed. The 3 main phases of treatment, described above, must be carefully navigated and advanced through in sequence. As treatment progresses, the resultant changes become increasingly permanent and therefore more and more likely to be irreversible. Therefore close monitoring is key to its success, with careful supervision by both the endocrinologists and the psychiatrists, throughout the whole process. Individuals should never be tempted to take hormones that are not medically supervised.

Standards of Care and Hormone Treatment

The Standards of Care underpin the 3-step process of treatment: the RLE, hormone therapy and surgery (in that order). Hormone treatment can be started following the recommendation of one mental health professional, usually a consultant psychiatrist with specialist experience in gender identity disorders, but the Standards of Care recommend the need of the RLE. The time for the RLE is open to interpretation, but it is usually a minimum of 3-6 months or with the addition of 3 months of psychotherapy before initiation.

Specialist services, however, feel that hormone treatment should be delayed until the individual has demonstrated a positive RLE in terms of psychological and social stability, and any issues addressed during the transition. Therefore the RLE varies from person to person, but it is generally accepted that a period of 2 years is appropriate.

Any underlying physical health problems need to be addressed, the individual must be prepared to take medication regularly and appropriately and must be over the age of 18 years old. As with any medication, there are a number of risks and side effects as well as the benefits. These need to be explored in detail before starting treatment so that an informed decision can be made.

The gold standard in terms of scientifically measuring how effective treatments are, is through randomised-controlled clinical trials. Unfortunately, as yet, they have been very few clinical trials looking at the different treatments for transsexuals. However, treatments have evolved over the last 50 years and specialist services now have robust, safe and very reliable treatment protocols.

Male to Female (MTF) Transsexuals

The mainstay hormone treatment for MTF transsexuals is the use of the feminizing hormone Oestrogen, usually in its synthetic from, Ethinyloestradiol. Its effects are achieved by the suppression of natural testosterone production in preoperative transsexuals. These effects are dose-dependent, the higher the dose, the greater the suppression. Unfortunately, so are its side effects. The main danger is an increased risk of developing blood clots. Therefore, the minimum dose possible needs to be used and will require careful monitoring to adjust the dose. The hormone treatment can be given as tablets or sometimes through skin patches.

Anti-androgen therapy, either by using Cyproterone Acetate or Finasteride, can also be used. Their side effects can include depression or abnormalities of liver function.

More recently, "chemical castration" agents, medicines called Gonadotrophin Releasing Hormone Analogues (GnRH) have been used. These suppress natural testosterone production within weeks, although there is often an initial burst in testosterone (and therefore masculinizing effects for a few weeks), but are generally very well tolerated. This treatment can only be given by regular injection, so this can be off-putting for some.

Post-operatively, the doses of Oestrogen can be significantly reduced. However there is still a need for long-term maintenance treatment to preserve bone density and good physical and emotional well-being.

Female to Male (FTM) Transsexuals

Masculinization, sometimes known as virilisation, of FTM transsexuals is via the administration of testosterone. This is usually given as a regular injection, fortnightly or monthly. Testosterone achieves masculinization by suppressing the ovaries in pre-operative transsexuals and is very effective in the vast majority of individuals.

Effects can be very rapid. Periods cease within the first few months and the facial and bodily changes occur gradually over time. Monitoring is required throughout and the dose adjusted accordingly. Although the treatment for FTM transsexuals is perhaps a more simple process, there are a number of dose-related side effects so longer term superversion is necessary to limit the adverse effects.

Benefits versus Risks

Hormone treatment carries a certain degree of risk and certainly is not for everyone. Find out more in the Help and Advice for Taking Hormones section where you will find a list of the common side effects and associated risks.

More information can be found about the different hormones prescribed for Male to Female (MTF) transsexuals and Female to Male (FTM) transsexuals on the MTF and FTM pages.

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