Position statement on the hormonal management of adult transgender and gender diverse individuals

Abstract

Introduction Rising demand for gender‐affirming hormone therapy mandates a need for more formalised care of transgender and gender diverse (TGD) individuals in Australia. Estimates suggest that 0.1–2.0% of the population are TGD, yet medical education in transgender health is lacking. We aim to provide general practitioners, physicians and other medical professionals with specific Australian recommendations for the hormonal and related management of adult TGD individuals. Main recommendations Hormonal therapy is effective at aligning physical characteristics with gender identity and in addition to respectful care, may improve mental health symptoms. Masculinising hormone therapy options include transdermal or intramuscular testosterone at standard doses. Feminising hormone therapy options include transdermal or oral estradiol. Additional anti‐androgen therapy with cyproterone acetate or spironolactone is typically required. Treatment should be adjusted to clinical response. For biochemical monitoring, target estradiol and testosterone levels in the reference range of the affirmed gender. Monitoring is suggested for adverse effects of hormone therapy. Preferred names in use and pronouns should be used during consultations and reflected in medical records. While being TGD is not a mental health disorder, individualised mental health support to monitor mood during medical transition is recommended. Changes in management as result of this position statement Gender‐affirming hormone therapy is effective and, in the short term, relatively safe with appropriate monitoring. Further research is needed to guide clinical care and understand long term effects of hormonal therapies. We provide the first guidelines for medical practitioners to aid the provision of gender‐affirming care for Australian adult TGD individuals.

Hormone therapy for trans and gender diverse patients in the general practice setting

“…This is probably unnecessary as ovulation and menstruation typically resume on cessation of testosterone. 15,20 Many transmasculine people cease testosterone temporarily in order to start a family, either by harvesting and donating eggs or by carrying a biological child. 15…”

Perioperative considerations for transgender women undergoing routine surgery: a narrative review

“…However, specific issues relating to perioperative care were not specifically addressed. 12,13 Whilst there are anaesthetic issues relevant to both transgender women and men, there are many issues unique to transgender women that we believe should be highlighted and discussed in further detail than what is covered in the current anaesthetic literature; therefore, this article focuses in greater detail only on considerations for the perioperative care of the transgender woman and does not cover the issues unique to transgender men. Broader aspects pertaining to the perioperative care of all transgender patients, including important discussion on terminology and further discussion of psychosocial considerations, have been covered in recent review articles by Shah and colleagues 14 and Tollinche and colleagues 15 therefore have not been covered in detail in this article.…”

“…18 Anti-androgen therapy is not required if orchidopexy has occurred. 13 The potential effects of each of these to consider in a preoperative clinical assessment are summarised as follows.…”

Relationships between body mass index with oral estradiol dose and serum estradiol concentration in transgender adults undergoing feminising hormone therapy

“…No studies have examined the optimal estradiol concentrations in transfeminine individuals. Based on cross-sectional data, 12 Australian consensus guidelines recommend targeting trough estradiol concentrations of 250-600 pmol/l, 5 whereas the Endocrine Society Clinical Practice Guidelines recommend a target range of 367-734 pmol/l based on the physiological range of pre-menopausal women. 1 The estradiol assay used and timing of blood testing in relation to the estradiol dose are other important considerations when interpreting the estradiol concentration.…”

“…4 Several consensus guidelines give recommendations for estradiol concentrations to allow titration of estradiol therapy. 1,5 The Australian 'Position statement on the hormonal management of adult transgender and gender diverse individuals' recommends targeting estradiol concentrations of 250-600 pmol/l (68-163 pg/ml) (GRADE 2D recommendation) based on local cross-sectional data. 5 Notably, given the lack of data, this is an approximate guide and the position statement states that the value of biochemical testing in addition to clinical assessment is unclear.…”