December 09, 2018 7 min read

We see many transgender and non-binary patients at MSH. These are the principles that apply when we offer gender affirming hormone treatment… We hope you find them helpful and that we see you at one of our practices shortly! 1. Leaving gender dysphoria untreated is harmful to most people and is associated with a much higher suicide risk than the general population. GAHT (gender affirming hormone treatment) does not necessarily bring the suicide risk down to that of the general population, but it does significantly decrease it. 2. There are risks involved in undergoing gender affirming hormone treatment, but with access to sound medical care and the best hormones, the risk is absolutely minimal, and the benefits will most likely outweigh the risks. Your doctor will inform you about the applicable hormones with the lowest risks in your case. It is your responsibility to attend regular follow-ups, have your blood tests done and maintain a very healthy lifestyle. The importance of exercise, a good diet and the avoidance of harmful substances like smoking, excessive alcohol and recreational drugs cannot be over emphasised. 3. We do follow WPATH guidelines, but also look at current literature from all over the world to inform our decision making around the management of our patient’s Gender Affirming Hormone Treatment. We do not have a “one-size-fits-all” approach to patients. Each patient is treated individually. 4. We follow a very conservative approach with very small amounts of hormones initially. We believe this to be much safer and that our patients have time to adapt to the changes much more effectively. If a patient wants to, we do go to absolutely optimal levels of hormones eventually, once we have established that it is safe and tolerated well. Again, we emphasise the individual approach in treating each patient. 5. Being transgender/non-binary is challenging in itself. Transitioning can be very challenging. We highly recommend patients to see a therapist on a regular basis. Not because we believe you have a psychiatric condition or that you can’t cope, we purely want all our patients to be supported throughout the process. 6. Future fertility is an extremely important factor to consider. We recommend egg or sperm freezing for all our patients. We acknowledge that people find themselves in different life-phases and that this might not be feasible or applicable to all, but this will be discussed with you during the consultation and should also be discussed at length with your therapist. We recommend the following service providers:

If you decide not to preserve your fertility, you will need to send us a letter in which you state in writing that you do not wish to do so, in order for it to be saved on your file prior to the commencement of hormone treatment (this can be emailed directly to your doctor). 7. Contraception: Please be aware that gender affirming hormone treatment can cause infertility, although you may remain fertile, even if you are on high dosages of hormones. We also always encourage the use of condoms to protect you against sexually transmitted infections. Please do discuss contraception with your doctor if there is any possibility of conception in you or your partner, especially trans men who are having receptive vaginal sex. Remember: even when your partner just ejaculates on the outside, you can still fall pregnant! 8. Irreversible changes: Due to our very gradual approach with the introduction of hormones, most changes will be very subtle initially and if there is anything you don’t like, we could just stop the hormones and things can go back to more or less what it was before you started treatment. The following changes will be irreversible:

For masculinising hormones: - Deepening of the voice (may be partially surgically corrected in some cases) - Changing of facial features (would soften again if hormones are stopped) - Additional hair growth (would need to be removed with laser or electrolysis) - Male pattern boldness (may be partially reversed with medical treatment like minoxidil, fillers and PRP) - Enlargement of the clitoris/phallus (it will get smaller if hormones are stopped, but probably not to its original size) - Loss of fertility (may be regained with the right medical treatment, but there are no guarantees)

For feminising hormones: - Breast growth (may be surgically corrected) - Changing of facial features and body fat distribution (would harden again if hormones are stopped) - Loss of fertility (may be regained with the right medical treatment, but there are no guarantees)

The extent to which changes will be reversable depend on how long the hormones have been taken, what dosages you were using and how responsive your body is to the effect of hormones. 9. The following effects can be expected from the hormones: (the first time-frame concerns when you can expect to start seeing effects and the second is when the effects evolve to their greatest effect. It all depends on your body’s responsiveness to hormones and the levels you can tolerate).

For masculinising hormones: - Skin oiliness/acne 1-6 months (1-2 years) - Facial/body hair growth 3-6 months (3-5 years) - Scalp hair loss >12 months - Increased muscle mass/strength 6-12 months (2-5 years) - Body fat redistribution 3-6 months (2-5 years) - Cessation of menses 2-6 months - Clitoral enlargement 3-6 months (1-2 years) - Vaginal atrophy 3-6 months (1-2 years) - Deepened voice 3-12 months (1-2 years)

For feminising hormones: - Body fat redistribution 3-6 months (2-5 years) - Decreased muscle mass/ strength 3-6 months (1-2 years) - Softening of skin/decreased oiliness 3-6 months - Decreased libido 1-3 months (1-2 years) - Decreased spontaneous erections 1-3 months (3-6 months) - Breast growth 3-6 months (2-3 years) - Decreased testicular volume 3-6 months (2-3 years) - Decreased sperm production variable - Thinning and slowed growth of body and facial hair 6-12 months (> 3 years)

10. According to the latest research and the knowledge that we have at our disposal at the moment, this is what we know about the risks involved in gender affirming hormones:

For masculinising hormones:

Likely increased risk:

Polycythemia (blood becoming too much and therefor too thick – we manage this by donating blood or decreasing your hormone levels); Weight gain; Acne; Androgenic alopecia (balding); Sleep apnoea

Possible increased risk if there are additional risk factors:

Elevated liver enzymes; High Cholesterol; Destabilization of certain psychiatric disorders; Cardiovascular disease; Hypertension; Type 2 diabetes

No increased risk or inconclusive:

Loss of bone density; Breast cancer; Cervical cancer; Ovarian cancer; Uterine cancer

For feminising hormones:

Likely increased risk:

Blood Clots; Gallstones; Elevated liver enzymes; Weight gain; Hypertriglyceridemia (cholesterol)

Likely increased risk with additional risk factors:

Cardiovascular disease

Possible increased risk with additional risk factors:

Hypertension, Hyperprolactinemia, Type 2 Diabetes

No increased risk or inconclusive:

Breast cancer

11. It is your responsibility to report any side-effects to your doctor. 12. It is your responsibility to stick to screening programmes:

- If you still have a cervix: Pap smear within two years of first penetrative sex or after the age of 25 and then every 1 to 5 years after that, depending on your risk and previous results (should be discussed with your doctor). - If you have not had top surgery: Mammograms from the age of 40 or earlier, depending on your family history (should also be discussed with your doctor). - Monthly testicular self-examination if you have testicles. - Prostate physical exams and PSA testing from the age of 45 or earlier if you have a family history and still have a prostate (discuss this with your doctor). - Colonoscopy from the age of 50, every 10 years.

13. It is your responsibility to disclose your full medical history to your doctor, especially the following:

- Family history of heart disease or blood clots - Your psychiatric history - Your current mental state (untreated depression and anxiety can make the transitioning period much more difficult) - Known medical conditions - Medication - Any other concerns regarding your health - Surgeries - Your smoking, drinking, drug-taking, eating and exercise habits

It is extremely important to inform your doctor if there are any changes in your health. 14. We do not expect you to fit into a certain box in order to take hormones. You do not have to dress or act in a certain way or desire a full transition with surgery in order to qualify for hormones. We are here to assist you to reach your own goals, whatever they might be. We only play an advisory role in the process and will attempt to act in your best interest at all times. We do need your cooperation in looking after your health and sharing all information with us. 15. We strongly advocate the multidisciplinary team approach and prefer to keep in touch with all other healthcare providers you see. We would generally give you the report directly and ask you to share it with them, if you are comfortable to do so. In some cases, we will, with your consent, communicate with them directly. All the healthcare professionals you see are more than welcome to contact us in case they have any comments, questions or concerns. 16. You will have medical appointments suggested at certain intervals by your doctor. If you however need to see your doctor inbetween these appointments, please contact reception to arrange an appointment. You can see us as often as you like! If your doctor is not available, there are other doctors on the MSH team that will be able to assist you. Please note, that as per our terms and conditions, we do not offer emergency services at MSH. If it is after hours or there is no appointment available, you will have to see your GP or go to the emergency department. 17. You may bring any person along to the consultation. Please be aware that some of the things we discuss during the consultation may be of a very sensitive nature. Please inform your guest that they will have to leave the room at any point if you are uncomfortable. We hope that you find this information valuable and that we will be seeing you at one of our clinics soon!
Dr Elna Rudolph
Written by Dr Elna Rudolph – Clinical Head of My Sexual Health 011 568 4800
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