Guideline Transgender

GUIDELINE FOR HANDLING OF TRANSGENDER

 

Definition

 

  • A person whose gender identity does not correspond to the biological sex assigned at birth, i.e. transgender persons typically say: I was given the wrong body at birth”.
  • A transgender female was born as a male
  • A transgender male was born as a female

 

Transgender is only a matter of sexual identity. Transgender is not a matter of sexual orientation, unethical behavior, disease, especially not a psychiatric disease and certainly not a sexological problem.

 

Epidemiology

 

  • The estimated frequency of transgender is 0.5 – 0.6 %.

 

Thus, in Uganda there are probably 175.000 – 210.000 transgender citizens. There are probably no differences between races or gender.

 

Symptoms and clinical appearance

 

Transgenders become aware of their transgender during puberty. They appear as any other normal citizen, but with a different sexual identity. Thus, any sign of pathology is not a symptom of transgender, but a symptom of something else!

 

Symptoms could be somatic, psychiatric or sexologic. Dont forget, that some symptoms may be caused by transgender especially stress, low self-esteem, dysphoria and even psychosis due to lack of accept, discrimination, anger and remorse. Other symptoms may be due to overdose hormonal therapy (self medication), e.g. tender breasts, cardiovascular disease and liver disease (body builder syndrome)

 

Diagnostic tests

 

There is only one reliable diagnostic test: Ask your client! You meet your client with accept: As long as you say that you are transgender, you are transgender, and I will support you as long as I can!

 

 


 

THE FEMALE TRANSGENDER

 

First evaluation of the female transgender

You may very well be the first person who meets your transgender client with acknowledgement and acceptance. You become an important person in your client’ life. Dont let your client down! If possible, protect yourself by being thorough and by doing many tests – se below

 

The client wants a copy per mail: _

Summary: Socially: _. CAVE: 0. Medicine: _, hormones: _. Abuse: Tobacco: _, alcohol: _, narcitics: _. Hereditary diseases of relevance: Breast cancer: _, ovarian cancer: _, colon cancer: _, osteoporosis: _, thrombosis: _. HPV vaccinated: _. Breast: _. Previous: _, laboratory data of relevnce _.

Actual contact: Transgender _, wishes hormonal therapy _ / surgery _ / psychological support _.  GU: UL testicles _, volume _ ml, _ consistensy, UL-score _, palpation of the prostata

Lifestyle: Heigth _, weight _, BMI _, BP _, U-stix _

Laboratory test: Chlamydia/gonorrhoea, ECG, X-ray lungs and heart

Blood tests: Blood (Hb, MCV, MCHC, CRP), liver (ALAT, alcalic phosphtase), kidney (creatinine, glomerular filtration), prostate (PSA), fat (HDL, LDL, total-cholesterol, triglyceride), metabolism (TSH, free T3, free T4, TPO), parathyroid gland (Ca++, PTH), sex hormones (oestradiol, androgenes, prolactin), serologi (HIV 1+2, hepatitis B/C, syphilis)

Diagnose: Transgender DZ768E

Conclusion: Adult transgender with personal authority, psycologically and mentally healthy, wishes _. Guidance regarding pretreatment evaluation, treatment with low dose transdermal natural hormone and regime for control.

Plan:

  • In general: As long as you regard yourself as transgender, you are transgender. Communication fx. test results per mail, only short messages per SMS.
  • Prior to medication: Read the leaflet carefully and/or look for further information on the internet.
  • Treatment first choice: Transdermal natural estradiol (Vivelle Dot® 50 ug/day, Evorel® 50 ug/day, Divigel® 1 mg/day or Estrogel® 0.6 mg/day applied on a clean skin free of lotion, no lotion on the hands at application. Alternative treatment: estradol 2 mg per day.
  • Effects of estradiol: Feminine breasts visible after 3-6 months, maximal effect after 2-3 years; feminine skin: 3-6 months/1-2 years; feminine hair growth: 6-12 months/>3 years; reduced muscle mass: 3-6 months/1-2 years; feminine fat distribution: 3-6 months/2-5 years; reduced libido: 1-3 months/1-2 years; ceasement of erection: variable; ceasement of semen production: variable.
  • Side effects of estradiol: May be a tiny increased risk of deep venous thrombosis, stroke and breast cancer.
  • Initial control and adjustment of treatment: At 2-4 weeks, 3 months and when neccessary: Personal evaluation of effect and side effects and measurement of P-estradiol (aim 0.15-0.25 nmol/l).
  • Yearly control: Personal evaluation of treatment and testing as above, i.e. Chlamydia … syphilis and Blood … serology).
  • Androgenic manifestations if bothersome are treated with Androcur (Cyproteronacetate) 50 mg x 2.
  • Psycological support is recommended i.e. _, who has experience with transgenderism.

 

Informed consent before treatment of the female transgender

Your client is an adult, personally responsible and psychologically and mentally healthy and capable of taking care of her/himself. You have carefully guided your client regarding the effects and side effects of medication and clinical control. Your client has agreed to a practicable and suitable scheme for control and a safe way of communication both ways

 

Hormonal treatment of the female transgender

Give the natural hormone in a low dose on the skin, i.e. the natural hormone passes unchanged through the skin to the blood, whereby your client gets a low normal plasma level of the natural hormone. Alternatively use tablets

 

Estradiol to the female transgender

Aim: P-estradiol 0,15-0,20 nmol/l

Vivelle Dot® pad 100 ug/day 1 pad on dry, clean skin for 3-4 days
Evorel® pad 100 ug/day 1 pad on dry, clean skin for 3-4 days
Estrogel® 0,6 mg/dose 2 daily doses on dry, clean skin
Divigel® 1 mg/dose 2 daily doses on dry, clean skin
Estradiol tablets 2 mg 1 tablet per day
Effects of estradiol in the female transgender
Effect starts Maximal effect Effect starts Maximal effect
Skin 3-6 mths 1-2 yrs Libido 1-3 mths 1-2 yrs
Hair 6-12 mths >3 yrs 0 erection Variable
Hair loss 1-3 mths 1-2 yrs 0 semen variable
Muscles 3-6 mths 1-2 yrs Breast 3-6 mths 2-3 yrs
Fat distribution 3-6 mths 2-5 yrs

 

Treatment of other somatic problems of the female transgender

Acne, hair and beard i.e. androgenic manifestations Antiandrogenic therapy

Cyprosteronacetate 50 mg, 1-2/day

Spironolactone 50 mg, 1-2/day, check Na and K

Finasteride 5 mg, ¼ /day

Deep voice Speech therapist

 

Surgical treatment of the female transgender

  • Castration
  • Penectomia
  • Neovulva and –clitoris
  • Neovagina

 

Support of the female transgender

You are there for your client whenever your client needs you! Therefore you have established a practicable and suitable scheme for control as well as a safe and secure way of communication both ways


 

THE MALE TRANSGENDER

 

First evaluation of the male transgender

You may very well be the first person who meets your transgender client with acknowledgement and acceptance. You become an important person in your client’ life. Dont let your client down! If possible, protect yourself by being thorough and by doing many tests – se below

 

The client wants a copy per mail: _

Summary: Socially: _. CAVE: 0. Medicine: _, hormones: _. Abuse: Tobacco: _, alcohol: _, narcitics: _. Hereditary diseases of relevance: Breast cancer: _, ovarian cancer: _, colon cancer: _, osteoporosis: _, thrombosis: _. HPV vaccinated: _. Breast: _. Previous: _, laboratory data of relevnce _.

Actual contact: Transgender _, wishes hormonal therapy _ / surgery _ / psychological support _.  GU: UL ca. cycle day _ shows uterus _, canal _, right ovary _, left ovary _, free fluid _, Douglas _, bladder _. Inspection: vulva _, vagina _, pH in the vagina _, wetsmear in NaCl _, wetsmear in KOH _, portio _. Exploration: Internal genitals _, Douglas _, sacrouterine ligg _, pelvic walls and – bottom _.

Lifestyle: Heigth _, weight _, BMI _, BP _, U-stix _

Laboratory test: Chlamydia/gonorrhoea, ECG, X-ray lungs and heart

Blood tests: Blood (Hb, MCV, MCHC, CRP), liver (ALAT, alcalic phosphtase), kidney (creatinine, glomerular filtration), ovaries (CA125), fat (HDL, LDL, total-cholesterol, triglyceride), metabolism (TSH, free T3, free T4, TPO), parathyroid gland (Ca++, PTH), sex hormones (estradiol, androgenes, prolactin), serologi (HIV 1+2, hepatitis B/C, syphilis)

Diagnose: Transgender DZ768E

Conclusion: Adult transgender with personal authority, psycologically and mentally healthy, wishes _. Guidance regarding pretreatment evaluation, treatment with low dose transdermal natural hormone and regime for control.

Plan:

  • In general: As long as you regard yourself as transgender, you are transgender. Communication fx. test results per mail, only short messages per SMS.
  • Prior to medication: Read the leaflet carefully and/or look for further information on the internet.
  • Treatment first choice: Testogel® 1 dose per day applied on a clean skin free of lotion, no lotion on the hands at application. Alternative treatment: Testoviron® 1 dose every 3rd month
  • Effects of testosteron: Masculine skin visible after 1-6 months/maximal effect after 1-2 years; masculine hairgrowth and beard: 3-6 months/3-5 years; baldness: >12 months/variable; increased muscle mass: 6-12 months/2-5 years; masculine fat distribution: 3-6 months/2-5 years; menostasia: 2-6 months; hypertrophy of clitoris: 3-6 months/1-2 years; dryness of vagina: 3-6 months/1-2 years; masculine voice 3-12 months/1-2 years,
  • Side effects of testosterone especially with higher doses: Increased BP, aggravation of epilepsy and migraene, increased insulin sensitivity, i.e. lower dose of insulin in diabetes, headache, dizziness, increased sweating, irritability, nervousness, aggressiveness, depression, fluid retention.
  • Doping: Testosterone may give a positive doping test.
  • Initial control and adjustment of treatment: At 2-4 weeks, 3 months and when neccessary: Personal evaluation of effect and side effects and measurement of P-testosteron (aim 10-15 nmol/l).
  • Yearly control: Personal evaluation of treatment and testing as above, i.e. Chlamydia … syphilis and Blood … serology).
  • Psycological support is recommended i.e. _, who has experience with transgenderism.

 

Informed consent before treatment of the male transgender

Your client is an adult, personally responsible and psychologically and mentally healthy and capable of taking care of her/himself. You have carefully guided your client regarding the effects and side effects of medication and clinical control. Your client has agreed to a practicable and suitable scheme for control and a safe way of communication both ways

 

Hormonal treatment of the male transgender

Give the natural hormone in a low dose on the skin, i.e. the natural hormone passes unchanged through the skin to the blood, whereby your client gets a low normal plasma level of the natural hormone. Alternatively use depot injections. No oral alternative.

 

Testosterone for the male transgender

Aim: P-testosterone 8-15 nmol/l

Testogel® 50 ug/dose 1 dose daily on dry, clean skin
Testoviron® depot 250 mg 1 dose every 3rd month
No oral alternative

 

Effects of testosterone in the male transgender
Effect starts Maximal effect Effect starts Maximal effect
Skin 1-6 mths 1-2 yrs Menostasia 2-6 mths
Hair 3-6 mths 3-5 yrs Clitoris 3-6 mths 1-2 yrs
Baldness >12 mths Variable Dry vagina 3-6 mths 1-2 yrs
Musculature 6-12 mths 2-5 yrs Voice 3-12 mths 1-2 yrs
Fat distribution 3-6 mths 2-5 yrs

 

Treatment of other somatic problems of the male transgender

Menstruation Levonorgestrel IUD

Oral contraceptive pill without breaks

Ceases normally within 2-6 months with testosterone

PMS Oral contraceptive pill without breaks
Contraception Levonorgestrel IUD

Oral contraceptive pill without breaks

Female voice Speech therapist

 

Surgical treatment of the male transgender

  • Mastectomy
  • Castration i.e. oophorectomy
  • Neovulva and –penis

 

Support of the male transgender

You are there for your client whenever your client needs you! Therefore you have established a practicable and suitable scheme for control as well as a safe and secure way of communication both ways

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