Department of Endocrinology and Gynaecology (G.TS., R.R., P.D.S.), University Hospital, Gent 9000 Belgium; and Department of Andrology (L.G.), Free University Hospital, Postbus 7057-1007 MB Amsterdam, The Netherlands
Address correspondence to: Guy TSjoen, M.D., University Gent, 9K12 IE Endocrinology, De Pintelaan 185, Gent, 9000 Belgium. E-mail: guy.tsjoen{at}ugent.be.
To the editor:
The Clinical Review by Moore et al. (1) on endocrine treatment in transsexual people in the August issue of JCEM is timely. We wish to offer some nuances to the recommendations made by Moore et al. (1).
The authors state that transition should be rapid and complete. However, cross-sex hormonal effects are, to an extent, irreversible. In our view, hormonal treatment should be embedded in the so-called "real-life test". The real-life test is an extended period of full-time living as a member of the desired sex. The real-life test allows the subject and the attending professional to monitor the experience in the new sex status as she/he habituates her/his responses to other people. Without this test of how others react and how she/he reacts to others, the subject knows only her/his private convictions and fantasies of being a member of the opposite sex. The subject should have lived at least 2 yr full-time in the new sex before irreversible surgical reassignment is considered. The real-life test may be prolonged if too many hurdles present themselves during the test period. It is our belief that a slow transition phase of usually 2 yr, rather than a quick one, may be more advisable. Arguments include psychosocial reasons and, furthermore, a more gradual adaptation of the body to a changing hormonal milieu. In this regard, the dual-phase hormonal schedules may be recommendable. The first largely reversible phase includes antiandrogens (e.g. cyproterone acetate 50100 mg daily) in male-to-female transsexuals and progestins (e.g. lynestrenol 5 mg daily) in female-to-male transsexuals. This is an important phase of the real-life test, during which sex-specific features of the natal sex such as erections/ejaculations or menstrual bleeding are suppressed. This allows assessment of whether loss of characteristics of the natal sex alleviates the suffering of the candidate and whether induction of characteristics of the desired sex will further enhance well-being. If so, this is to be followed by administration of cross-sex hormones, with largely irreversible feminization and masculinization. Pharmacological ablation of endogenous sex steroid production before the initiation of exogenous cross-sex steroid treatment may allow a lower dosage of cross-sex hormones and reduce the risks of side effects and thus morbidity. This is worthy of research, but preliminary results in patients treated following this hormonal regimen, published in abstract form, indicate relatively few and minor morbidities that are mostly reversible with appropriate treatment (2). Unlike Moore et al. (1), we would no longer advise ethinylestradiol in the high dosage of 100 µg anymore because it is associated with an unacceptably high thrombotic risk (3). Moreover, we would like to argue that transdermal estrogens also can be advised under the age of 40, especially in smokers.
Moore et al. (1) argue that the Amsterdam group (4) reported a high incidence of depressive mood changes, hyperprolactinemia, and thromboembolic events, compared with a normal population. It is not unreasonable to assume that side effects are related to the dosage of administered hormones. Whether depression in transsexual people is due to hormonal changes is debatable. Transsexuals go through important life events during transition, both before and after sex reassignment surgery (SRS), with gains and losses. So, the question is not whether depression scores are worse in transsexual people than in a control group, but whether the score has improved after gender reassignment. Preliminary results of our follow-up study show that suicidal attempts had significantly diminished after SRS (5). Improved and consistent general well-being is one of the important reasons why we consider both hormonal treatment and SRS to be parts of a rehabilitation process wherein, gradually, bodily features are adjusted to gender identity.
Usually, after 2 yr of cross-sex hormonal treatment, SRS is performed. Moore et al. (5) state in their recommendation table that endometrial ultrasounds should be performed every 2 yr in female-to-male transsexuals. In Europe, female-to-male transsexuals usually undergo hysterectomy and ovariectomy after approximately 2 yr of androgen administration. Long-term androgen administration induces polycystic changes of the ovaries indistinguishable from polycystic ovaries (6). Polycystic ovaries are more at risk of malignant development.
Finally, we feel that recommendations for the initial visit should include clinical examination assessing general health, hormonal status, and complication risk and karyotyping to diagnose intersex conditions.
Received October 6, 2003.
References
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