The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals

     Results of an online, self-reported survey of a population of predominantly young, white, and educated female-to-male transsexuals demonstrated improved quality of life and reduced prevalence of mood disorders with the administration of testosterone. (1)

     Little data exist on the effects of cross gender HRT (cHRT) alone with respect to satisfaction and quality of life outcomes or the effect of cHRT on the prevalence of mood disorders in transgender persons.  Much of the existing data on these measures focuses on surgical interventions.  The authors distributed a self-reported survey to female-to-male (FTM) transsexuals via online discussion groups, measuring symptoms of depression, anxiety and stress as well as current perceived social support and health-related quality of life. The authors hypothesized that cHRT in FTM transsexuals reduced reported symptoms of depression, anxiety and stress and improved perceived social support and health-related quality of life.

     A total of 448 responses were collected, of which 369 were complete and met the minimum age requirement of 18 years.  The sample had an average age of 28, was predominantly white (76%), and educated (88% at least some college),  with 85% living in the US and 50% reporting sexual attraction to both men and women.  Sixty-six percent of respondents were on cHRT, and 41% of respondents had undergone male chest reconstruction (all but 7 of whom were also on cHRT).

     FTM transsexuals receiving cHRT reported statistically significantly lower levels of depression, anxiety and stress and higher levels of perceived social support and health-related quality of life.  Interestingly FTM transsexuals not on cHRT in this sample reported depression, anxiety, stress close to the control range.  Both groups reported lower than average perceived social support.  Both groups reported health-related quality of life higher than the control average.

Comment:

     This groundbreaking study looks at cHRT as a specific intervention with respect to mental health outcomes and quality of life measures.  Most outcome-based research on transgender populations have been focused on surgical interventions.  Looking at cHRT alone as an intervention that improves quality of life and mental health outcomes has significant implications for healthcare systems that offer limited (or no) access to more expensive surgical procedures which require additional resources and highly skilled surgeons, as well as for transgender persons who may simply not want to pursue genital surgery for a variety of reasons.

     One additional result of note is that 50% of respondents reported a sexual attraction to both men and women, further supporting the growing awareness of diversity of sexual orientations in transgender persons.

     One limitation mentioned by the authors is that the use of a psychological screening process to gain access to cHRT in some cases may color the differences between the cHRT and non-cHRT populations.  In fact, transsexuals with more severe mood symptoms may be more likely to be denied cHRT; Data on the reason(s) that the non-cHRT users were in fact not on cHRT would be helpful.  Additionally, nearly 62% of the cHRT users had undergone chest reconstruction while only 6% of the non-cHRT users had done so;  A subgroup analysis around this variable would have been helpful in determining any confounding of the results from this high prevalence of chest surgery in the study sample, as well as evaluating any incremental effects between cHRT alone and cHRT + chest surgery.  Nevertheless, chest reconstruction in its most rudimentary form is a much less painful, costly and specialized procedure than phalloplasty and as such these data are still quite relevant in the context of resources, availability and individual patient desires.

     It is interesting that respondents reported higher perceived social support on cHRT;  Was this simply an issue of perception, or was the actual provided support higher once on cHRT?  Additional study would be useful to determine the role of the former and the latter and to determine the community and societal factors driving this difference.   It is also interesting that FTM transsexuals not on cHRT reported levels of mood disorders not far from general population controls and that across all respondents reported health-related quality of life was higher than average.   This along with the somewhat homogeneous, white, educated sample limits the applicability of this study across other demographics;  Nonetheless it is a welcome addition to the nascent field of research on transgender persons undergoing cHRT alone and will hopefully lead to more study in this area.

References:

1) Colton Meier SL, Fitzgerald KM, Pardo ST, Babcock J. The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals. Journal of Gay & Lesbian Mental Health. 2011 Jul;15(3):281-299. 

Incidence of Thrombophilia and Venous Thrombosis in Transsexuals Under Cross-Sex Hormone Therapy

     Retrospective cohort study of 162 MTF patients on transdermal estradiol + cyproterone acetate with an 8% prevalence of baseline thrombophilic conditions showed no incidents of venous thromboembolism over an average 49.6 months. (1)

     Venous thromboembolism (VTE) is a common concern for providers providing cross gender hormone therapy (cHRT) for male-to-female (MTF) transgender persons.  Additional concern may exist for patients with pre-existing prothrombotic mutations, and the question arises as to weather or not it is important to pre-screen MTF persons for hypercoagulability prior to initiation of cHRT.

     Researchers conducted a retrospective review of outcomes in a cohort of 162 MTF women who had a baseline prevalence of 8% (13/162) prothrombotic mutations, which is consistant with the baseline prevalence in non-transgender caucasian persons.  All 13 patients exhibited activated protein C (aPC) resistance and four were smokers.  No cases of antithrombin III or protein C deficiency were found the study population.  Only one patient (a smoker) was on anticoagulation therapy.  161/162 patients received either transdermal estradiol monotherapy (if post-op) or transdermal estradiol + cyproterone acetate + finasteride (if pre-op).  One patient with multiple cardiovascular risk factors and aPC resistance (not on anticoagulation) was given cyproterone acetate monotherapy.  60/162 patients had reported prior self-directed cHRT use, all had been off cHRT for a minimum of 4 weeks prior to treatment at the study site.

     Over a mean duration of 49.6 months on cHRT (range 12-135 months), no incidents of VTE were observed in the study cohort.  The expected incidence of VTE in 0.43/18 patients with a prothrombotic mutation did not differ significantly from the observed incidence of 0/18.  The authors concluded that cHRT in transgender persons with a prothrombotic mutation is safe, and that routine pre-cHRT screening for prothrombotic mutations is not recommended if there is no family or personal history of VTE.

Comment:

     Venous thromboembolism is a commonly feared outcome of cross gender hormone therapy, but a growing body of recent evidence has shown that the use of transdermal estradiol (or oral estradiol as opposed to conjugated equine or synthetic estrogens) minimizes this risk.  The authors chose to look at the risk of VTE in a cohort of MTF women who were pre-screened for the presence of a prothrombotic mutation.  None of the women, with or without a mutation had a VTE during the study period of an average 49.6 months.  Since most incidents of VTE occur in the first year of HRT in non-transgender contexts, their conclusions that cHRT with respect to thrombophilia is safe seems reasonable.  This study should help reassure the clinician that the use of safe cHRT such as transdermal estradiol minimizes VTE risk in the general population and in those with minor prothrombotic mutations such as aPC resistance / factor V Leiden.

     Shortcomings include the relatively small number of patients, retrospective nature and the lack of any patients in the cohort with more serious prothrombotic mutations such as antithrombin III or protein C deficiency.

     Of note, the study also looked at an FTM cohort and found similar results.  While the authors cite several basic science articles suggesting testosterone increase thrombotic risk in lab animals, this is not congruent with publications in trauma research which suggest that testosterone leads to a hypocoaguable state. (2)

References:

1) Ott J, Kaufmann U, Bentz E-K, Huber JC, Tempfer CB; Incidence of Thrombophilia and Venous Thrombosis in Transsexuals Under Cross-Sex Hormone Therapy; Fertil Steril 2010;93:1267-72

2) Gee AC, Sawai RS, Differding J, Muller P, Underwood S, Schreiber MA; The Influence of Sex Hormones on Coagulation and Inflammation in the Trauma Patient; Shock 2008;29:334-41