This form refers to the use of estrogen by persons who wish to become more feminized as part of a gender transitioning process.

You are being asked to initial the various statements on this form to indicate that the risks as well as the changes which may occur as a result of the use of estrogen have been explained to you and that you understand them. If you have any questions or concerns about the information below, we encourage you to take all the time you need to: ask questions, read, research , talk with clinic staff and think about these important aspects of your treatment.

Please initial and date.

Patient Provider Date

1. ______ ______ ___/___/___ I have been informed that the feminizing effects of estrogen can take several month to become noticeable. Some of these changes will be permanent. Permanent changes include:



1. ______ ______ ___/___/___ I will probably develop breasts. These may take several years to develop to their full size. (There is extreme variation in the size of breasts I may expect. Some of this is predictable based on the size breasts my mother and sisters have, but not completely.) If I stop taking estrogen they may shrink somewhat but not completely.



2. ______ ______ ___/___/___ I understand that there are brain structures that are affected by testosterone and estrogen, and that current medical science does not understand these structures adequately. I understand that taking a hormone which will likely affect a part of my brain whose function is not clear may have long-term effects on the functioning of my brain which are impossible to predict. These effects may be beneficial, damaging, or both.


2. _____ ______ ___/___/___ These additional changes will not be permanent and should go away if I stop taking estrogen:



• Acne I might have will probably decrease
• If I am going bald, it will probably slow down. It will probably not stop completely
• My skin may become softer
• Hair growth on my body may become less noticeable; however, it will not go away
• My beard may become less prominent; however, it will not go away.
• The way my body smells, especially the sweat from my armpits, will probably become less noticeable and may change in quality
• The fat on my abdomen may decrease
• The fat on my buttocks and thighs may increase in a more feminine pattern


3. ______ ______ ___/___/___ I have been informed estrogen may cause, or contribute to, depression. If I have a history of depression, I will discuss this with clinic staff to explore what treatment options are available to me.



4. ______ ______ ___/___/___ Estrogen will decrease two brain hormones that support size and function of my testicles, which may then effect my overall sexual function. These effects should go away if I stop taking estrogen. These effects include:



1. ______ ______ ___/___/___ Up to about 40% shrinkage in the size of my testicles. I understand that, even while I am on estrogen, monthly testicular exams are still recommended.



2. ______ ______ ___/___/___ Decrease in the testosterone production from my testicles.



3. ______ ______ ___/___/___ The amount and quality of my ejaculation may decrease, or it may stop entirely. My sperm will still be present in my testicles but will probably stop maturing, so I may become infertile. I have been informed that I may still be able to make someone pregnant. I have been informed that, if I am having sex with someone who can become pregnant, some form of birth control should be used.



4. ______ ______ ___/___/___ I have been informed that, if I stop taking estrogen, my ability to make sperm normally may or may not ever come back.



5. ______ ______ ___/___/___ My erections when aroused may no longer be hard enough for intercourse.



6. ______ ______ ___/___/___ Decrease or loss of morning and spontaneous erections.



7. ______ ______ ___/___/___ My sex drive may decrease.


5. ______ ______ ___/___/___ I understand the effects of estrogen will not protect me from sexually transmitted diseases or from HIV.



6. ______ ______ ___/___/___ If I have experienced significant breast development from hormonal therapy, I understand that it is recommended that I do a breast self-examination on a monthly basis, and have an annual breast exam.
   


7. ______ ______ ___/___/___ I have been informed that taking estrogen can increase my risk of blood clots, which can result in:



1. ______ ______ ___/___/___ chronic leg vein problems,



2. ______ ______ ___/___/___ a pulmonary embolism (blood clot to the lung) which may cause permanent lung damage or death.



3. ______ ______ ___/___/___ a stroke which might result in permanent brain damage, such as being paralyzed or unable to talk or death.


8. ______ ______ ___/___/___ I have been informed the risk of blood clots is much worse if I smoke tobacco, especially if I am over 35. I understand that the danger is so high I have been advised that I should stop smoking tobacco completely if I start taking estrogen. My provider can give me referral to smoking cessation resources.



9. ______ ______ ___/___/___ I have been advised estrogen can cause increased blood pressure. If I have high blood pressure, I may be able to take estrogen if my blood pressure is controlled with medications and/or diet and/or lifestyle changes. Clinic staff will help me address this problem.



10. ______ ______ ___/___/___ I have been informed that estrogen puts a stress on the liver which may lead to liver inflammation or a back-up of liver products in the bile ducts (the liver's "plumbing system"). I will be monitored for liver problems before starting estrogen and periodically during therapy. I have also been informed that there is a slight risk of long-term estrogen use causing liver cancer.



11. ______ ______ ___/___/___ I have been informed estrogen may increase migraine headaches and this may be a reason to choose to stop taking estrogen.



12. ______ ______ ___/___/___ I have been informed estrogen may cause nausea and vomiting, similar to morning sickness in a pregnant woman. If nausea and vomiting are severe or prolonged, I understand that is recommended that I talk with my health care provider.



13. ______ ______ ___/___/___ I understand I am more likely to have dangerous side effects from estrogen if I smoke, am overweight, am over 40, have a history of blood clots, high blood pressure, or prior estrogen-dependent cancers.



14. ______ ______ ___/___/___ I understand estrogen may cause changes in my cholesterol. My HDL (good cholesterol) may go up and my bad cholesterol (LDL) may go down. This will probably decrease my risk of heart attacks and strokes in the future



15. ______ ______ ___/___/___ I understand taking estrogen should prevent prostate problems. There is a slight chance that taking estrogen will cause overgrowth of the prostate. An annual prostate exam is recommended for people over 50 and older.



16. ______ ______ ___/___/___ I agree to tell my medical provider about any non-clinic hormones, dietary supplements, herbs, recreational drugs or medications I might be taking. I understand that being honest with my provider is crucial to developing a trusting relationship. Sharing this information will help my provider to prevent potentially harmful interactions. I have been informed that clinic staff will continue to provide me with medical care, regardless of what information I share with them.



17. ______ ______ ___/___/___ I understand that everyone’s body is different and that there is no way to predict what will be my response to hormones. I understand that the right dosage for me may not be the same as for someone else.



18. ______ ______ ___/___/___ I agree to take hormones as prescribed and to inform my provider of any problems or dissatisfactions I may have with the treatment. I’ve been informed that, if I take too much estrogen, my body may convert it into testosterone. This may slow or stop the desired effects of the hormone.



19. ______ ______ ___/___/___ I will have physical examinations and blood tests periodically to make sure I am not having a bad reaction to the hormones. I understand this is required to continue hormone therapy through this clinic.



20. ______ ______ ___/___/___ I understand that there are medical conditions that could make taking estrogen either dangerous or damaging. I agree that if clinic staff suspect I may have one of these conditions, I will be evaluated for it before the decision to start or continue estrogen therapy is made.



21. ______ ______ ___/___/___ I understand that I can choose to stop taking estrogen at any time. I also understand that my provider can discontinue treatment for clinical reasons.

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Patient Signature Date

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Medical Provider Signature Date

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Parent/Guardian Signature Date