Gender Identity Disorder of Adulthood Hormonal Treatments

Cross-sex hormonal treatments play an important role in the psychological and anatomic gender transition process for properly selected adult patients with GID. Internationally recognized Standards of Care indicate that such treatments are "medically necessary" for rehabilitation in the new gender and that they improve quality of life and limit psychiatric comorbidities which may accompany lack of treatment (Levine et al. 1998). Others have also noted that these treatments should no longer be considered experimental and are now a component of accepted medical practice for GID (Cole et al. 1994; Schaefer and Wheeler 1995). These treatments have been used for more than three decades and appear to be generally safe when administered to carefully evaluated and monitored patients (Table 70-10).

Ideally, the psychotherapist should be sufficiently familiar with the Standards of Care (Levine et al. 1998) and should explain to the patient the need for patient and therapist to work together for a sufficient period of time before the therapist can make an official recommendation to an endocrinologist, urologist, or family physician (Steiner 1985; Levine et al. 1998). Some psychiatrists also provide hormonal monitoring and treatment as part of their overall management of GID. Although hormone treatment should be provided and monitored by a responsible and appropriate physician, it is not uncommon for patients to come to psychotherapy having already begun hormones either on their own (obtained through Internet sources without a prescription or via "black market" sources) or as prescribed for years by other physicians. Consequently, the psychotherapist should exercise good judgment in considering the patient's hormone experience but should ensure that the patient's understanding of hormone treatment and its side effects is thorough. A patient's long-term use of hormones does not necessarily imply that the patient has accurate or adequate knowledge for making appropriate decisions regarding hormonal treatment.

Hormone treatment may have the benefit of being both diagnostic and therapeutic. Sometimes patients find that the effects and side effects of cross-sex hormonal treatments are not what they anticipated, and they end their experiment with these medications. The role of fantasy and inflated expectations about the physical and psychic effects of hormones cannot be overemphasized in this regard. Psychotherapists need to understand that many patients will appear indecisive in their efforts and will make many attempts to begin and then abandon their interest in or use of hormones before they reach a comfort level in their decision with this treatment option; indeed, many patients change their view of this treatment option throughout their lifetime.

The first detailed reports of endocrine treatment of transsexuals were provided by Harry Benjamin (1964c, 1969). There have been reports detailing treatment that describe what may now be considered supraphysiological dosages of hormonal therapy (Benjamin 1969; Futterweit 1980; Hamburger 1969; W. J. Meyer et al. 1981). The tendency to use relatively large dosages of estrogens or androgens has occasionally led to serious medical complications. One cannot stress strongly enough the necessity of carefully monitoring hormonal therapy, with the intent of using the smallest dosage of hormone necessary to achieve both a restriction of endogenous hormonal effects and the induction of characteristics of the anatomically other sex.