Transgender Cross Sex Hormones

What are hormones?

Hormones are chemical messengers that deliver instructions to various tissues and organs in the body. All bodies produce numerous different hormones in differing amounts.

At puberty, bodies with testes start to produce higher levels of testosterone.  This causes the development of masculine secondary sex characteristics: a deeper voice, facial hair, increased body hair, more muscle mass, and so forth.  And at puberty, bodies with ovaries start to produce higher levels of estrogen, which causes the development of feminine secondary sex characteristics such as breast development and a curved body shape with increased fat on the hips, buttocks, and thighs.

What is “cross-sex” hormone therapy?

Some transgender people choose to take “cross-sex” hormones; that is, hormones that align with their gender identity rather than the sex they were assigned at birth.  “Cross-sex” hormones can be used to make the body more masculine or more feminine so that it is more closely aligned with the person’s inner sense of self. 

Who is a candidate for cross-sex hormone therapy?

In order to receive cross-sex hormone therapy through our clinic, an adult must:

  1. Have a persistent, serious desire to modify their body by taking hormones that align with their gender identity rather than their sex assigned at birth
  2. Be able to understand hormone therapy including risks and be able to give consent for treatment
  3. Be able to take medications correctly and be willing to follow up as recommended
  4. Be 19 years of age or older
  5. Have any medical or mental health conditions reasonably well controlled

Requirements are slightly different for people under 19 years of age.  People under age 19 need the consent of a parent or guardian and a relationship with a therapist.

Do you require a letter from a therapist in order to start hormone therapy?

For adults (age 19 or older in Nebraska), a letter from a therapist is not required of every patient.  If a patient has a therapist, a letter from that person is very helpful and much appreciated since it helps us assess the patient’s readiness for hormone therapy.

Prospective patients who do not have a therapist will have a gender assessment by our providers.  If we are concerned about a person’s readiness for hormone therapy, we will recommend establishing a relationship with a therapist before hormones can be prescribed.

We encourage all of our patients to consider participating in therapy during the gender transition process.  Transitioning is a stressful experience as a person negotiates relationships with family members, significant others, and coworkers and learns to live in the world as their affirmed gender.  Support during this process is important for everyone and a therapist who specializes in gender is highly recommended.  We can suggest qualified therapists.

What is the follow-up after starting hormone therapy?

In general, most patients have a clinic visit every 3 months during the first year of treatment.  At this clinic visit, we check their vital signs, talk with them about the changes they are experiencing and any concerns, and draw some blood to check their hormone levels.  Based on the patients’ response to their treatment and their lab results, we make adjustments in their medications.

After the first year, most patients are seen every 6 months for the same evaluation.  In the third year and beyond, most patients are seen on an annual basis. These are general guidelines. An individual patient’s follow-up would be tailored to their needs.

How long does a person continue hormone therapy?

The decision to continue or discontinue hormones is entirely up to the individual.  The physical transition process, during which hormones alter the physical characteristics of the body, can take up to five years.  After that, many people choose to continue taking hormones in order to maintain the changes that have already occurred.  The goal of hormone therapy is to keep the hormones within the normal, physiologic ranges.  Around age 50-60 years, hormone levels naturally decline in healthy people and some individuals might discontinue them then or reduce them to a very low dose. 

If a person has surgery to remove the testes (orchiectomy), the body would no longer produce testosterone.  A testosterone blocker would no longer be needed but estrogen would still be needed to maintain feminine characteristics.

If a person has surgery to remove the ovaries (oophorectomy), the body would no longer produce estrogen.  However, testosterone would still be needed to maintain masculine characteristics.

Each person’s body is different!

The changes that an individual will experience ― and whether the changes will be pronounced or subtle ― will depend on many factors including:

  • Age when a person starts hormone therapy: younger people tend to have more noticeable changes than those who start hormones at an older age
  • Body type and characteristics before starting hormones: people who do not appear highly masculine or highly feminine (sometimes called “androgynous” appearance) tend to have more noticeable changes than those who have a very recognizable gender expression
  • Family characteristics: for example, the family tendency to go bald or to have a heavy beard can influence the changes in a person’s hair pattern

Body changes are variable and somewhat unpredictable.  It is not possible to tailor a hormone regimen to produce some changes and not others, or to minimize some changes and maximize others.