[Lisa_W]

Oh Liz, that is great news about your daughter. Congratulations! It reminds me of the time I told a work colleague about being trans. She replied”, is that all. I thought you were going to tell me that you had cancer.”
This sounds off topic but here are two examples that it is a gift – a hard gift, but definitely a gift.
Lisa

[Lisa_W]

Hi Caroline
I have the advantage of having a German partner.
The word for poison is “vergiften” & synonyms are – verpesten or verseuchen

The responses to your OP have been very interesting. I believe we can only view being trans from our own individual perspective. How how our life has changed (good or bad), how others have responded to us ( good or bad), what the future holds ( good or bad). And the list goes on…..
From my perspective, it is a gift but it is the hardest gift that we will ever be given. Dealing with this gift may be too hard for some & easier for others. But it is never easy. I have always said you would not wish this on your worse enemy.
But in the end we are better for this gift. That which does not kill you will only make you stronger and other platitudes along that line.
I hope everyone can eventually see be trans as a gift. For if you do, that means you have successfully transitioned.

[Lisa_W]

That is something that you would have to discuss with Dr Hart.

[Lisa_W]

Today I saw one of my patients who has just had GAS by Dr Hart. I thought I would give you an idea of the costs.
The surgeon charged $14,000; the anaesthetist $4,000. Her health insurance covered the hospital costs. She had to stay in hospital for a week.
She appeared fit and well and could sit down without using a donut cushion!

[Lisa_W]

This topic has not been re-visited in years. Just to let people know Dr Kieran Hart, a Urological surgeon, is performing GAS (gender affirming surgery) in Canberra. He is speaking at the AusPATH conference in Perth in October.

[Lisa_W]

I have a couple of points to make about this topic and an off topic point that was raised.
Firstly no one knows why Jon Hayes resigned. Both APHRA and the medical board deny any restrictions put on his practice of medicine. Also he is not the only research endocrinologist in Australia. I agree his retirement left a temporary but very large hole in TG care in Sydney. But that has largely been resolved now.
I had a look at Dr Powers presentation. At one point he was advocating cross sex hormones for pre-pubertal people. That does not happen anywhere else in the world and WPATH does not advocate it. Injectable oestradiol is only used in the US &A. Have you ever wondered why? Do you think it might be dangerous and also give widely fluctuating E levels. Americans are smart people but not all the time.
I agree with Adrian, anecdotes do not make valid research.
I admire Dr Powers compassion but be aware of messianic zeal.

[Lisa_W]

Bambi in Brisbane, a long time TGR member, provides this service. She can also arrange a makeover prior to the photo shoot.

[Lisa_W]

I have known Christine/ Larry both professionally and socially for almost 15 years. She was the most wonderful person and helped me in many different ways. Eg; Literally pulling me into a female toilet for the very first time.
I last spoke to her in early November and we made plans to catch up in the new year. She sounded quite good, so her death came as a big shock to me and left me in tears for days. I am tearing up as I write this.
I just want to acknowledge her work especially with TG people, her continuing love and consideration of her family, her friendship and just being the person she was.
Fairwell my friend.

[Lisa_W]

Adrian
I guess I could be one of the girls that you mention, but I am not offended. I wish to thank you for the opportunity to correct some misconceptions.
“The reported side effects of taking testosterone include growing breasts and shrinking testicles. Hormones are artificial chemicals that have been created by the pharmaceutical industry to meet marketing goals – those goals may not match exactly what you hope or expect to achieve.”
I assume there is a typo here, or are you referring to the peripheral aromatisation of T to E? When giving advice outside of your specialty you must be careful. Hormones are hormones. They are chemically active compounds produced by the body’s endocrine system. The chemicals that we swallow are indeed produced by the pharmaceutical industry. They try to mimic the action of hormones. Some are more successful at this than others and possibly with fewer side effects.
Do not be deluded, there are no drugs/hormones specifically produced by the pharmaceutical industry for TG’s. It is just not profitable because there are so few of us. The drugs/hormones that are used to treat TG’s have been selected from drugs used to treat genetic women, treat conditions in genetic men eg; prostate cancer, or the known side effects of certain drugs may be beneficial in TG’s eg; Spiro. Is it any wonder that the ” goals may not match what you hope or expect to achieve “, plus throw in the inherent variability of the absorption and metabolism of these drugs/hormones.

“Do your own research on how the endocrine system organises itself to give genetic women a monthly fertility cycle – it is amazing. Adding or removing hormonal agents to such a complex system will often produce unexpected (and possibly unwanted) results. Certainly the results will be hard to predict in a particular individual”.
I agree that the endocrine system is amazing, but modifying the menstrual cycle in a TG female???? I know there have been uterine transplants with successful pregnancies but these have been in genetic females. Are you really suggesting that trans females can have a menstrual cycle?

“Don’t ask your clinician for statistically valid, peer reviewed, clinical trial data for the journey you are going on. It just doesn’t exist. In the absence of scientific data you have to accept that the treatments you elect to have may be shown in future times to be at best ineffective and at worst dangerous.”
In general I would agree that there was a lack of studies about the treatment of TG people. I have been to the last two biannual WPATH world congresses and I can assure you that information about TG’s and their treatment is expanding exponentially.

Madeline as you can see the answers to your questions are very complex, and I agree with Adrian that you should ask these questions but be very careful about where you seek your information from. People with incomplete knowledge can give you incomplete or worse wrong answers. Remember anecdotal evidence is not “statistically valid”.

[Lisa_W]

I have been using a hair piece for years and have tried many different types. I was eventually found Kylie Clarke wig making. I was her first TG customer but I have sent many people to her since. She is in Sydney. She makes wigs for films, plays and TV and shared an Emmy award last year. Check out her web site.
The reason I mention this is, she taught me that human hair wigs should NOT be cut with scissors. She recommends that a razor only be used. So I suggest that if your hairdresser is using scissors on your expensive hair piece seek further advice.

[Lisa_W]

Hi Sabrina
I have heard this story many times. Don’t forget that HRT even in small doses is possibly lethal. You would need to see a suitable Dr to asses the risks. Some of the changes can be irreversible therefore you would need to be assessed that HRT is appropriate for you. Remember, being TG is not a mental illness but can be associated with mental illness, as evidenced by the very high suicide rate.
Also are you prepared to give up some of the effects of T such as penile erection and enhanced libido. So if penetrative intercourse is important to you or your partner, then I would suggest delaying HRT until you are ready to accept the effects of decreased T.

[Lisa_W]

Not all GP’s are comfortable prescribing HRT, however there is a large cohort who are, and their numbers are growing. Try contacting ANZPATH Australian New Zealand Professional Association of Transgendered Health. If you email them and ask if they could name some GP,s in your area who prescribe HRT, I am sure that they would help. The contact details are on their website.

[Lisa_W]

Much of what I was going to say has been covered in the above replies. In my clinical experience I have seen physical changes continue for at least 5 years after commencing HRT. The final size of your breasts is also partially determined by your genetics. A general guide is 1-2 cup sizes smaller than your mother. Remember cis women have big and small breasts, that is why breast augmentation in cis women is such big business.

As already mentioned the type of oestrogen supplementation is also important. Topical oestrogen has problems with variable absorption as does oral oestrogen. Implants do appear to give a better response.

Blocking testosterone is not the only answer. I am convinced that there is another unrecognised hormone produced by the testes. The reason I make that statement is that I have seen a number of times quite profound physical changes following GAS. That is even when the T level has been unmeasurable for many years prior to the surgery.

[Lisa_W]

Thank you A/A for addressing such a daunting topic. I have been researching this topic for many years. Both for my own information & to garner the world’s best practice so that I can apply that to my patients . So a number of the references that you quoted are already familiar to me.
My conclusion is similar to yours & that is; evidenced based medicine as regards HRT for transsexuals does not exist. The Royal College of Psychiatrists in their 2013 “Good practice guidelines for the assessment & treatment of adults with gender dysphoria” state under the heading Guidelines for hormonal interventions “accepting the desire for the guidelines to be evidence based, there is a great paucity of such evidence.”

The most accurate estimation of the rate of gender dysphoria in the UK population is 1%. Given the fact that multinational drug companies do most of the world’s research, they are not going to invest many millions of dollars into the best treatment options for us because they are not going to get a return on investment. Therefore what research is done, is done by gender clinics & universities. The most identifiable transgender group are those wanting SRS & therefore they are the ones that are studied. Other gender diverse groups are too hard to identify or do not attend gender clinics.

There are a number of statements in your excellent post that I would like to comment on.

There was a significant “typo” in your critique of the Asscheman et al paper. The number of FTM transsexuals was 365 not 265.
You have also left off two other causes of increased mortality in the MTF group – drug abuse (which was significant) & “unknown”. You have inferred that the authors state that oral oestrogen is no longer recommended. That is NOT true. They recommend that ethinyl oestradiol should not be used but low dose oral oestrogen is acceptable.

In the section on SRS you implied that suicide was the major adverse outcome. Yet the above paper states “Psychological evaluation has shown that sex reassignment increases the well-being of transsexuals, but it should not be considered as a cure-all; it is rehabilitative relieving gender dysphoria, but some transsexual subjects may still experience other problems (e.g. comorbid psychiatric problems, social isolation, troubled relationships, prejudice, and discrimination). “
Therefore assessment of other psychological factors is very import & I agree with your conclusion that the “real risk is mental health” & the conclusions of the second paper that you quote.
Other important issues are unemployment & harassment.

I agree with your conclusion that there may not be any difference in seeing an endocrinologist & an experienced GP who is familiar with managing TG issues. In fact I would argue that the GP is better because, the Endo is seen once or twice a year. Yet the GP may be seen very often & thus he/she would be more in touch with social or mental issues.

The optimum hormonal dose! What a thorny issue. Assuming that treatment should produce oestrogen levels similar to that of a cis woman. The problem is that during her monthly cycle there are 4 different hormonal phases. Which one do you pick? There is no EBM for guidelines here. The easy answer is the one that gives the desired results with the lowest oestrogen dose & that it is in the most appropriate delivery form. I aim for 2/3 of the cis woman’s oestrogen level in the follicular phase. But my opinion is not EBM.
One of the major problems I have found is that MTF’s want to develop breasts overnight.

A/A I fully endorse your conclusion that the major problem is not HRT but the psychological stresses of being transgendered.

I think that we would both agree with the 10th recommendation of the RCPsych Guidelines;
“There remains a paucity of research in the field. Research should be
encouraged and funding set aside to offer specific grants looking at
outcome and satisfaction with interventions and transition.”

Thank you once again A/A on a thoughtful post.

On re-reading my post, I think that I could be considered going off topic. I will leave that to your discretion.

[Lisa_W]

I am not going to try to defend past surgical practices that have altered the external genitalia of intersex babies. But I will give you some facts & then ask a question.

The testes first develop near the kidneys & then descend into the scrotum. This occurs between 25- 35 weeks.The tract can be traced by following the course of the testicular arteries.
The descent of the testes can be arrested at any stage along that tract, especially at the inguinal canal.

This occurs in 5% of boys (1:20) rising to 100% of very premature babies weighing about 1Kg or less. The intra-abdominal testicle is surgically brought down into the scrotum if the testicular artery &/or spermatic cord is long enough. This surgery is ideally performed at 6-12 months.

If the testes remain in the abdomen & are therefore exposed to a higher temperature compared to that of the scrotum two things happen. Spermatogenesis does not occur ie; they are infertile. Secondly there is an increased risk of testicular cancer. If one testes is undescended the life time risk is about 1:120, if both testes are involved the risk around 1:40.

I agree babies cannot give consent, but parents can & do. Now my question is what would you do?