It's a blessing to be the same gender on the outside that one feels oneself to be on the inside, though many take this miracle for granted. For those who don't feel this harmony, there are still formidable social barriers to sexual transformation, but trans folk now have more possibilities than ever to make the switch - through either presentation of self or surgery and hormones. If you choose the latter course, you need to know something about minimizing the risks of sex-changing substances. Fact is, there are few long-term studies on the lifetime use of hormones for sex change purposes, so trans individuals are truly on the frontiers not only in the social sense but medically as well.
Your number-one priority is to find a doc willing to work with you. Your personal and family medical history and current health status need to be thoroughly assessed by an expert before it's possible to know the right hormone prescription for you. Then you need regular monitoring. Some in the alt-health community say you can further lower your risk of side effects by using what are called bioidentical hormones . These aren't, strictly speaking, natural - they're synthesized in a lab from plant molecules. But the difference between these and many (not all) commercially available hormones is that they exactly replicate the molecular structure of human sex hormones. Those who work with them say bioidentical hormones (available in Canada by prescription from compounding pharmacies) are safer and their side effect profile lower. Trouble is, again, the research literature on them is practically non-existent. Any way you look at it, trans folk are our pioneers.
"I have never come across problems in a patient who's been given hormones in a supervised manner. The only complications I've seen have been in patients who self-medicated. If anything, it's trans people who don't take hormones who expose themselves to greater risk. A male-to-female who has had her testes removed exposes herself to huge risks, especially of osteoporosis, if she receives no estrogen. Likewise, taking the ovaries out of a female-to-male removes the source of osteoporosis prevention. My personal practice is to use progesterone (to balance estrogen). It helps reduce testosterone without having to raise estrogen too high. (I don't use bioidentical hormones) because there's an absolute dearth of good randomized, controlled trials."
SHAUN TREGONING , reproductive endocrinologist, Abbotsford, BC
"My patients (on hormones) didn't feel right, didn't look right - they were overweight, had headaches, an increased incidence of breast cancer. That's why I started to research bioidentical hormones 10 years ago. They are better accepted by the body (and the body can get rid of them within 12 hours) as long as you monitor them and keep them at physiological levels. The best way to monitor is by saliva testing. I have one patient who is transitioning from male to female. Her doctors were giving her Premarin only (a form of estrogen). But in a woman, estrogen is always balanced by progesterone. The number-one organ that has progesterone receptors is the brain. Headaches, PMS, irritability and anxiety all come from estrogen dominance."
ALVIN PETTLE , MD, obstetrician/gynecologist, Toronto
"One study concluded that hormone therapy under appropriate medical supervision is acceptably safe over the long term. There weren't increased deaths, but there was increased disease, (especially) blood clots (a common side effect of estrogen). Unopposed estrogen is standard, though some hormone protocols for male-to-female transgendered people use progesterone. Taking unopposed estrogen can lead to endometrial (uterine) cancer, but this isn't a concern in the transgendered population. Bioidentical hormones are not something I'm using in my practice."
LESLIE SHANKS , MD, medical director, Sherbourne Health Centre, which delivers a specialized lesbian/gay/bisexual/transsexual/transgender health program
"I have no experience with the dosing of bioidentical hormones for transgender purposes. I feel that the bioidentical hormones therapy would be much safer. Generally, synthetic progesterone carries more health risks. There's much more tendency to weight gain, fluid retention and headaches. The general feeling is that the cancer danger is more on the synthetic estrogen side than the bioidentical. I think the side-effect situation is better with bioidentical testosterone as well. Specialists really need to know what they're doing. On principle, I feel bioidentical hormone therapy would be much safer."
PETER SMITH , compounding pharmacist, owner, Smith's Pharmacy, Toronto
"The protocols for prescribing hormones for trans people differ significantly from clinic to clinic. (Differences include) the types of hormones, the dosages and the scheduling of the taking of the hormones. Some suggest going whole hog at a really high dose from the beginning, others recommend ramping up slowly over a long period, and final doses may vary widely."
KYLE SCANLON , trans programs coordinator, the 519 Church Street Community Centre
"I believe that culture does interact with gender dysphoria (unhappiness) in determining whether or how much a person desires alteration. However, I think that the main effect of different cultures is in how much they permit an individual to pursue hormonal or surgical treatment, not in how much they pressure an individual into such treatment."
RAY BLANCHARD head, clinical sexology services, Centre for Addiction and Mental Health, professor of psychiatry, U of T