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From Dimensions at the Castro-Mission Health Center in San Francisco
reprinted with permission
Dimensions Treatment Guidelines for FTM Transition
Philosophy of Care:
Since the inception of the Harry Benjamin guidelines, there have been changes in the definition of "gender", both socially and generationally. Gender expression no longer needs to be divided along rigid masculine/feminine lines in American society. Transgender and questioning youth appear to range on a spectrum of gender identity never addressed by the Harry Benjamin guidelines. We recognize the right of each patient to define their own gender identity independent of our preconceptions. We do not discriminate or withhold hormones on the basis of gender identity definition.
A transgender identity is not a psychiatric illness. Many youth do have mental health needs, regardless of gender identity. If we do not define a trangsendered person as mentally ill, it would be discriminatory on the basis of diagnosis to force such clients to undergo evaluation and/or treatment by mental health personnel. However, if anyone in the Dimension team feels that a mental health evaluation is needed, hormonal treatment may be postponed until this evaluation is done and any mental health issues are resolved. We do not withhold general medical services from patients who refuse to see a therapist or psychiatrist. All youth at Dimensions are routinely offered appropriate mental health services and/or referrals.
The Dimensions team cares for our patients as a team. The team will make decisions on appropriate care for each transgender patient, with adequate input from medical, nursing, mental health and social services staff. If a conflict exists among the team regarding appropriate care for an individual, then further evaluation will be pursued to resolve this conflict.
Discussion of patient goals and expectations. Assess desire and readiness for gender transition. Asses connection with transgender community and exposure to persons who have completed transition.
Complete physical, HCM. Dimensions does not require routine pelvic exams and pap smears for FTMs, but will recommend them where indicated by the patients history.
Labs ordered for:
Hormonal studies indicated by findings in history and physical
Asses individual medical issues
Discussion and signing of Informed Consent.
Testosterone. Be aware of drug interactions: increases anticoagulant effect of warfarin, increases clearance of propranol, increases the hypoglycemic effects of sulfonylureas. Available forms:
Testosterone enanthate or cypionate 50 mg IM q 2 wks x 6-8 weeks. Increase by 25- 50 mg q 2 weeks as needed up to max of 200mg q 2 weeks. (Check for allergy to sesame or cottonseed oil)
Transdermal testosterone is expensive therefore not immediately recommended. It can cause skin irritation in some patients. It is beneficial for patients who are emotionally sensitive to fluctuations in testosterone level, since it provides a consistent dose. It is available as Androderm or Testoderm TTS 2.5 – 10.0 mg patch qd.
Oral preparations of testosterone are not used due to dangerous side effects.
Testosterone Gel. New on the market.
Monitor labs 3 months after start of testosterone then every 6-12 months
ALT or Liver panel
Testosterone level study 100 mg q 2 weeks.
Review medication use and dosage
Monitor mood cycles and adjust medication as indicated
Complete forms for name/gender change, if desired.
After menses have stopped, do provera challenge within 3 to 6 months. (It is very important to explain to the patient that this may cause a menstrual period.) If bleeding occurs, repeat cycling every 2-3 months until none occurs.
Asses vaginal dryness and problems with sex. Consider topical estrogens if desired.
Review CAD risk factors
Continue routine HCM (including breast exam, STD screening, pap smears, mammograms after age 40)