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This chapter focuses on the recommended approach to prescribing gender-affirming hormone therapy (GAHT). It includes guidance for the health care professional in recognizing an individual’s appropriateness for hormone therapy, providing informed consent, and developing a patient-centered, individualized approach to treatment. Various hormone therapy options are discussed, as is the rationale for decision making in choosing specific medications. Additionally, this chapter provides information on the importance of understanding patient goals and providing education on expectations, the wide-ranging effects of GAHT, and guidelines for monitoring treatment. Hormonal gender affirmation is still a relatively new field of study, with data on health outcomes and medication safety being actively researched, and recommendations for best practices modified frequently. The dynamic nature of this field is both exciting and challenging; this chapter presents current guidelines.
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BACKGROUND AND DEFINITION
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Gender affirmation for many transgender and gender diverse (TGD) individuals is a multidimensional process involving aspects of social, emotional, and physical affirmation to reduce gender dysphoria. Gender dysphoria refers to the range of emotional distress experienced when there is a misalignment of one’s physical body and perceived gender with the internal sense of self. GAHT refers to sex steroids (mainly testosterone or estrogen) administered in various forms to produce or enhance secondary sex characteristics that promote physical affirmation. Using GAHT can reduce the internal stress of gender dysphoria as one’s physical body begins to align with the desired sense of self. Physical affirmation may also allow some people to move more comfortably or safely through the world as their affirmed and authentic self. Several studies have shown significant reductions in mental health comorbidities (depression, suicidality, substance use) and an overall improvement in quality of life with the ability to access GAHT.1–4 As such, for many individuals, access to GAHT is an important and necessary part of their self-actualization process.
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The goal of GAHT is to create the internal hormone environment that best aligns with one’s gender identity, with the aim of achieving physical characteristics that are culturally accepted and expected as a presentation of that gender. GAHT often involves taking hormone medications (exogenous hormones) that are affirming and suppressing the body’s production of hormones (endogenous hormones) that do not align with one’s gender identity. GAHT therapy is most often focused on increasing or decreasing estrogen and testosterone with various medication options to produce a combination of reversible and permanent changes to the body. Not all TGD-identified individuals seek hormonal therapy as part of their affirmation. There is a great diversity of gender identities and expressions, and health care professionals must assess each individual’s goal for accessing care in a nonjudgmental and supportive way. According to the 2015 U.S. Transgender Survey, 79% of TGD respondents desired hormone therapy as part of their gender affirmation (which corresponded to 95% of transgender men and women respondents and 49% of nonbinary respondents).5 The TGD ...