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Hormone Treatment in Transsexuals

Henk Asscheman, M.D. and Louis J.G. Gooren, M.D.
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TransGenderCare Medical Feminizing Program

INTRODUCTION

Except for the sex chromosomes and gonads all bodily differences between men and women must be attributed to the actions of sex hormones. While the inherent tendency of the prenatal human organism is to develop along female lines, prenatal differentiation as a male depends on testicular hormones (Mullerian-inhibiting hormone and testosterone and its derivates). The wider bony pelvis in girls in comparison with boys, is probably dependent on local effects of prenatal ovarian estrogen production. There is no known fundamental difference in sensitivity to the biological action of sex steroids on the basis of the genetic patterns of 46,XY and 46,XX.

The prepubertal period is hormonally relatively quiescent (Conte, Grumbach, Kaplan & Reiter, 1980). The hormones of puberty accentuate sex differences. Testosterone and its potent derivate 5alpha-dihydrotestosterone (DHT) induce penile growth and secondary sex characteristics as sexual hair, deepening of the voice, a muscular build and the greater average height in males in comparison to the females. In girls, estrogens in conjunction with progestagens induce breast formation and a fat distribution predominantly around the hips; subcutaneous fat padding produces a softness of the body configuration and of the skin. The skin in women is further generally less oily than in men; the latter on the basis of activation of the sebaceous glands by androgens.

Fundamental to sex reassignment treatment is the acquisition to the fullest extent possible of the sex characteristics of the other sex. With the exception of the internal and external genitalia, these characteristics are contingent of the biological effects of the respective sex steroids. Therefore (semi)synthetic sex steroids are indispensable tools in sex reassignment treatment. The use of cross-gender hormone treatment is associated with a better outcome (Hamburger, 1969; Leavitt et al., 1980).

The "two year real-life test" (Money & Ambinder, 1978) is pivotal in diagnostic-therapeutic approach of gender dysphoria. It allows both the gender-dysphoric subject and the psychologist/physician to examine whether sex reassignment relieves the burden of gender dysphorla. The emerging physical changes associated with cross-gender sex hormone treatment will facilitate the assumption of the role as a member of the other sex both in private life and in society.

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