Patient discussions
Terminology
The terminology used to describe transgender people is complex, changing, and has the potential to cause distress if used inappropriately. Healthcare professionals are advised to address transgender people as they would prefer to be addressed, whether or not they have officially changed their name. A simple way to do this is to ask the person what pronouns they use. It may also be helpful to share your own pronouns too, if you wish. Some transgender people prefer gendered pronouns such as ‘she’, ‘her’, and ‘hers’ or ‘he’, ‘him’, and ‘his’. Others prefer gender-neutral pronouns such as ‘they’, ‘them’, and ‘theirs’. A change in pronouns may be an important aspect of transition.[60] Clinicians may be concerned about the possibility of using the wrong pronoun when talking to a transgender person (often described as ‘misgendering’). If this happens, often the best way to approach this is simply to apologise and carry on with the conversation, and aim to use the correct pronouns in future.
Fertility, pregnancy, and contraception
Pre-treatment discussion of the consequence of medical and surgical treatment on fertility is essential, including a discussion of fertility preservation options, including sperm banking, oocyte preservation, embryo preservation, and (less commonly) ovarian or testicular tissue cryopreservation.[31][44] All patients should be counseled on barrier methods of contraception for prevention of sexually transmitted infections. Gender-affirming hormone therapy is not effective contraception; transgender people with retained gonads should be counselled about the possibility of pregnancy if they are having sexual activity that involves sperm and oocytes. Testosterone treatment is contraindicated during pregnancy, but transgender men may safely achieve pregnancy after cessation of testosterone.[44]
Thromboembolic disease
Transgender people receiving hormone therapy should be educated on the symptoms and signs of thromboembolic disease and advised to present promptly for investigation, should these symptoms occur.
Timing of hormone-induced changes
People receiving hormone treatment require information on the likely extent and timing of hormone-induced changes. Although the data on this is limited, and a large degree of natural variation can be expected, the following information from the Endocrine Society is helpful as a general guide.[31]
Expected timing of masculinising effects of testosterone[31]
Onset in the first 1-6 months:
Increased skin oiliness/acne (maximum effect 1-2 years)
Fat redistribution (maximum effect 2-5 years)
Cessation of menses
Clitoral enlargement (maximum effect 1-2 years)
Vaginal atrophy (maximum effect 1-2 years).
Onset in the first 6-12 months:
Facial/body hair growth (maximum effect 4-5 years)
Scalp hair loss
Increased muscle mass/strength (maximum effect 2-5 years)
Deepening of voice (maximum effect 1-2 years).
Expected timing of feminising effects of oestrogen and anti-androgen therapy[31]
Onset in the first 1-3 months:
Decreased sexual desire (maximum effect 3-6 months)
Decreased spontaneous erections (maximum effect 3-6 months).
Onset in the first 3-6 months:
Redistribution of body fat (maximum effect 2-3 years)
Decreased muscle mass and strength (maximum effect 1-2 years)
Softening of skin and decreased oiliness (maximum effect unknown)
Breast growth (maximum effect 2-3 years)
Decreased testicular volume (maximum effect 2-3 years).
Onset in the first 6-12 months:
Decreased terminal hair growth (maximum effect greater than 3 years).
Variable timing of onset:
Male sexual dysfunction
Decreased sperm production (maximum effect greater than 3 years)
Scalp hair.
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