Transition for HSTS: What Can Be Expected for Life?

 Foreword

One often hears only of the poor outcomes when transsexuals are discussed in public forums or in the press and visual media. The prostitute, the public spectacle of the middle aged man dressed up as being “brave” or the publication of a tragic suicide or murder of yet another transsexual. This is, I know from personal experience, what many people fear for someone they love when that person tells them they are transsexual and intend to transition. Though it was some considerable time ago now I know my own mother and father held these same fears for me and vocalised them in an attempt to dissuade me.

I am a Homosexual Transsexual (HSTS). It should be noted that the vast majority of transgender people one sees in the media are not HSTS, but are instead men who suffer from Autogynephillia (AGP) and whose gender dysphoria has lead them to adopt an alternative personality, of someone of the opposite sex. These people have usually led successful lives as men and tend to transition much later in life than HSTS do. These transgender women rarely manage to integrate themselves back into society as their acquired gender after transition and often fulfil some position within the trans community or LGBT movement.

This is not true of HSTS who can usually pass as the opposite sex very early in the transition process and go on to live very normal lives, accepted as women by all those around them.

If you are reading this as a parent of a young HSTS and are concerned about what kind of life your child can expect or if you are a young HSTS with similar worries about your own future, I can assure you that it is possible to live a very normal and successful life after transition, especially these days, where medical help to transition is available to children under 18. To that end I have opted to give a very brief outline of my life so far after 31 years post transition, as part of the information on this site in the hope of perhaps allaying some of those fears.

My History

I was born in 1964 in the UK to a working class family, the eldest of 3 boys. From early childhood I was always gender non-conforming, somewhat feminine in my expression and behaviours and physically small (the complete opposite of my brothers). Fortunately my parents were loving and after I didn’t grow out of my behaviours after a few years simply assumed I was homosexual, which as I approached puberty I and everyone else around me realised I was.

There was, though, something more going on. I recognised that the disconnect I felt to my natal sex and the anguish it caused me was an issue and learned very early that I was transsexual, but kept this secret to myself until my late teens. Back then there was no medical help in the UK for under 18’s and the first gender clinic for children did not open its doors there until I was in my 40’s.

Childhood was difficult, trying to fit in to an expected gender role which required me to try to adopt (unsuccessfully) behaviours which were quite unnatural to me, while coping with the problems Gender Dysphoria caused me. This recognition, though, made me quite resolute and capable as a child and young adult. I was determined not to fail or let this thing beat me, a trait I have witnessed often in other HSTS. We tend to be quite strong willed individuals. I was also, ultimately, very fortunate that puberty had next to no physical effect upon my body and I still looked like a pre-pubertal small boy at 20 years old.

More or less as soon as I was an adult, I left home and tried to exist in the world as a young gay male, afraid of what transitioning would do my life. This  was an abject failure. The cognitive dissonance caused by the gender dysphoria coupled with the recognition that I was no more like the gay men I met than I was the straight men around me, was causing my mental health to suffer. By the time I was 21 I had sought psychiatric help and had been officially diagnosed as suffering from Gender Identity Disorder. By the time I was 23 I had transitioned and was living as a woman in society. By 25 I had undergone Gender Reassignment Surgery.

Concerns about transition

At the time of my announcing my transition to my parents, they expressed many of the fears I have hinted at above and more besides, about what my future (if any) might look like. I too had my own concerns but I knew that this was the only way I was ever going to be happy with my life. They worried about things such as who would employ me, who would love me as a transsexual and they were concerned if I would have to live a sad and lonely life?

Outcomes

I am pleased to report that I experienced no such problems. I passed as female from the moment I began my transition and unlike so few seem to do today, I told nobody of my transsexuality. There were no protections back then for transsexuals or even gay people and secrecy was our greatest ally.

Relationships

While the first couple of years were tricky on the dating front I was never short of male attention, even after disclosing my trans status. Nor was employment an issue I had previously been working as an insurance clerk before transition and I got a similar job in a neighbouring city but as young woman and began to study to become a lawyer at night school. Two years later after my GRS I moved back to my home city and continued with my life and studies while now working at a law firm as a paralegal.

I dated a couple of men after my GRS but it was clear the relationships were not going to last. At 26 I was also working a second part time job in a local bar to help pay the bills for my study and living expenses where I met a charming and funny man the same age as myself who played on the football (soccer) team. I very quickly developed a friendship and a crush on him, though it took him another 4 months for him to ask me on a date!

After we had been dating a couple of weeks, quite terrified at what his reaction might be, I told him of my past. He was shocked of course and struggled with it and the implications of it for a day or two, but he said it didn’t matter and that he loved me and within a few months he had moved in to my flat. We bought our first home together about a year later and today, 27 years on I am still very happily married to this man. Tick that one off mum and dad!

Career

Obviously not being able to have children (and this was before gay adoption was accepted in the UK) I threw myself into my career and despite the latent sexism of many of the men I worked with was very successful. By the time I was in my mid 30’s I was managing a large law firm and at 40 I set up my own niche law firm with a colleague which we built to be the largest of its kind in the UK before selling it to a multi-national. By the time I was 48 I had moved into corporate governance and we either set up or acquired various other companies including amongst various others 3 additional law firms. Today I am a senior executive and shareholder of a large business group with circa 600 employees. Tick two mum and dad!

Conclusion

I have personally known and corresponded with other HSTS who have had similarly successful life paths. One owns and runs a successful model agency having been a model herself. Another is a senior corporate lawyer at a “Magic Circle” law firm and a third owns and runs a string of hair salons. Each of these women are married to their long term partners. Similarly each of these women live stealth with few if any knowing of their transsexuality. While I don’t know her personally, Kay Brown, another HSTS woman, owns several tech companies in the USA and has led a successful life as mother and business woman.

The point is, as MtF HSTS we have the opportunity to lead normal lives within wider society. We have little difficulty attracting sexual partners or life partners. Our career prospects are no different to those of natal women and if anything they are improved (unfairly so) by not usually suffering the career interruptions caused by childbearing. We are not all sex workers as seems to be the opinion of many people or those who exist only in the “trans/queer community”. We are accepted by all around us and by the men in our lives as women.

Transition for HTST is not the doomsday scenario it is painted to be by the media and others. Have faith, stay grounded and things have a tendency to work out.

Relationships for HSTS: A Survivors Guide

When I first transitioned over 32 years ago in my early 20’s and in a major metropolitan city in the UK, where there were a small but reasonable number of homosexual transsexuals even back then, I wondered if I would ever have the relationship, the home and husband I so desired. The future was an unknown and a main source of concern for my parent’s was what kind of future I could expect as a transsexual. I am thankful to report that at the time of writing I have been with my husband for 27 very happy years and lots of people (not just those who are transsexual) ask me how we have endured when so many others in our peer group’s relationships have ended in divorce.

This article which I hope will serve as some guidance is a collection of my thoughts and observations gleaned from the experience of my own life and relationship with my husband and the relationships of the people I have encountered in life, both HSTS women and natal women. The two are really not that different from each other.

Target Awareness

There are many men who are willing to form relationships with HSTS and there is a good deal of misunderstanding about them, both on the part of other men in society but also by the transsexuals who do or would date and form relationships with them.

We are not for these purposes referring to “Chasers” as they are called by trans women. Chasers will usually date both Autogynephilic transsexuals and HSTS alike as they are specifically attracted to pre-operative trans women, but should be avoided at all costs if you are HSTS. Chasers are men who are fixated on transwomen and are not interested in the woman herself only the body parts!

So many of these men, though not all, will only see you on their terms, secretly and without ever introducing you into his social life or wider peer group. These men have no interest in a serious relationship and are simply using you for their own sexual gratification.

Take my advice and don’t be a doormat, it will not last and these men are interested in only attractive youthful transgirls and youth has a shelf life! Time is your most precious asset, don’t waste it on anything or anyone who is bad for you or sees you as something to be hidden away.

Understanding Behaviour Profiles

There are, though, otherwise heterosexual or bisexual men who are willing to consider and form relationships with HSTS. The misunderstandings referred to in this article can and do often lead to many HSTS having difficulty in forming and maintaining long term relationships with these men and knowing about these misunderstandings and keeping them foremost in your mind can help you avoid them.

HSTS bring two sets of problems to the issue of relationships, one set is obvious: being transsexual we have a unique set of physical and mental obstacles which natal women don’t present. In addition we also have and exhibit so many of the same behavioural and interpersonal difficulties that natal women do in relationships with men (seriously it’s a wonder the species ever survived). We may be genetically male but we are not men and we don’t think like them, though because of our histories we often have a distinct advantage in navigating this second area because we were socialised with boys and so while we don’t experience the same issues as men we understand why it is that they do.

It has been some years since I had personal contact with other HSTS but I used to know a few HSTS women who had stable relationships with their male partners and many more who’s relationships were so often transient and who seemed unable select a suitable long term partner or maintain what appeared to others to be a perfectly viable relationship with a good man. I have also had many more non-trans friends who’s marriages and relationships have sadly failed for the same reasons as set out in this article and so often the reasons are clearly identifiable to the outside observer and could have been so easily remedied.

Bad Timing

Transition is a difficult time and sadly relationships which start mid transition are often doomed to fail. As are same sex relationships which existed before a decision was made to transition by one party. Gay men do not want women, trans or otherwise, so if you are in a gay relationship and decide to transition it will not survive.

Any new relationship is difficult enough when it turns long term and the reality of forming a partnership and moulding all of the financial liabilities associated with it in Western society begin to be realised. Add to this the emotional upheaval and fallout a HSTS experiences from starting a new life, difficulties with other family relationships and the financial burdens of transition itself and it is a wonder any such relationships ever succeed. However it is not unheard of.

Once a HSTS has reached a stable point in their transition, their thoughts inevitable turn to dating men as the new girl and I have experienced and witnessed some of the difficulties that ensue. A lot of HSTS, myself included, have experience of dating men, usually gay men prior to their transition but this is very different to dating straight men who perceive you to be female.

While I myself was always quite demure, my husband told me when he first witnessed other young HSTS friends of mine that the overt public displays of sexuality they made towards men, which are common among gay men, are very unnerving to a straight man especially when they are coming from a woman and it is certainly not the behaviour they would typically expect of a female. The rules of engagement with men have to be rethought, which can be difficult for some HSTS to pick up on as most of us were never socialised as girls. If you have an active history within gay dating pre transition be prepared for a shock once you are presenting full time as a woman.

Some of the girls I used to know threw themselves headlong into dating; “making up for lost time” dating a different man (men) every week. This is all well and good when you are young and feel you have plenty of time but don’t linger too long in this hedonistic revelry. We may not have the same biological clock as natal women but we experience the same disadvantages with ageing and attracting straight men as they do. “The Wall” is real.

Realistic Expectations

We all have the notion of an ideal partner in our heads but so often this is a complete fantasy and totally unrealistic. You need only listen to MGTOW videos on the internet to hear the unrealistic list of expectations they claim women display towards men and the damage this does to their chances of finding lasting and fulfilling relationships.

Transsexual women are no different; we all dream of having that 6’4” athletic, strong, handsome and successful or sometimes slightly dangerous man sweep us off our feet, but that is all it is, a fantasy! Everybody, including men, come with flaws and limitations which have to be balanced with their good points and accepted by their partners if a relationship is to survive.

I have witnessed women both trans and natal to their continued detriment, chose time and time again typical “bad boys” because they are exciting and these women thinking they can change them. Trust me you can’t! These men won’t change for natal women who have their children and they certainly won’t change for you. A man with a criminal history will most likely continue that way and your life will forever be in a state of uncertainty. My advice is no matter how cute they may be, stay away from these men.

Men’s overt masculinity, activities and risk taking propensity is driven by increased or high levels of testosterone. These men so often do not make good long term partners and there is a fair body of evidence that excessive levels of testosterone actually inhibits pair bonding in human males. See Human Male Testosterone and Pair Bonding. Gray et al Chapter 12 Click Here

What to Look For

The vast majority of men in the world are of average attractiveness and have stable financial lives and while they are completely masculine they have been raised to be respectful and protective of women. Learn to recognise these qualities in men, do not dismiss them as being “too nice” these men are the keepers!

Don’t be afraid to widen your demographic either. Dating slightly older men has many advantages especially if he has already farthered children in a previous marriage as this will go some way to avoiding his own wish for biological offspring interfering with your relationship.

Pair Bonding in relationships

Clearly HSTS are not going to be able to provide offspring and this can be a disadvantage in forming such bonds but pair bonding in humans is directly linked to reward reinforcement and dopamine release and other hormonal factors and not just to obligation such as fatherhood. This is not as simple as just having sex with a partner, though that is clearly a part of the pair bond reinforcement dynamic. Dopamine is released whenever we experience any sensation which we enjoy. So ensuring that your behaviours elicit happy responses in your partner and do not cause him to experience relationship anxiety is key to establishing a lasting pair bond. Too much negativity will offset any reward he may experience early in a relationship and tip the balance against him forming a bond with you.

This means you need keep things like irrational behaviour, tantrums and jealousy firmly locked away. If you keep accusing him of sleeping with your room-mate chances are he will eventually do it as men have little patience for continued false accusations! Also do not bombard him with trans related stuff, don’t take him to support groups or lectures on transsexuality, learn to keep that side of your life separate. Trust me they may be understanding of your condition but they don’t want to live it 24/7 for long.

But most of all keep the negativity to a minimum.

What Men Want

As a HSTS, depending on the age you transitioned (pre-adolescents won’t have this) you should have had sufficient exposure to males growing up to form a reasonable understanding of what “makes men tick” and what they value in women. Rod calls this “The Boy Box” You won’t have experienced these desires yourself but you may well as can I, recall males recounting to each other what they valued about their relationships with women. It is not all about the way they look, contrary to what many women believe. They also adore women who are feminine and who accept their partner’s masculinity and don’t seek to criticise or curtail their man’s natural behaviours. Men often need other men as friends (male bonding) and women very often fail to appreciate this and the role it plays in a man’s mental well-being. Women who try to cut their husband’s friends out of his life usually have very unhappy husbands and strained relationships.

Men are not at all complicated when it comes to relationships. The sex thing is obvious (more about that later), but they expect attention from their partner in equal measure to that which they supply (it’s not all about you). They loath drama and in my experience they highly value women who embrace traditional female roles and behavioural traits. They are not really interested, except at a cursory level in beauty queens who spend every waking hour preening themselves, but they are attracted women who reflect the values the historic significant female relatives (mother, grandmother, aunt) in their lives exhibited. That does not mean you have to be a “meek little house wife”, confident men will relish the success of their wives careers so long as it does not come at the expense of their relationship’s quality.

The point is men seeking lasting relationships are not looking for Divas or sex bomb superstars, any sane man is looking for stable partner who is willing to reflect and compliment his perceived societal role, where he doesn’t feel taken advantage of or de-masculinised.

Sex

If I and other HSTS I have known are anything to go by when it comes to sexual appetite, then for the men who date us it is like all their Christmases have come at once at the beginning of a relationship. We so often it seems have elevated sex drives in comparison to most natal women. We are usually much more adventurous in bed as we were not subject to female socialisation. Nobody ever taught me or reinforced the concept that “Nice Girls Don’t”. Clearly though, this cannot continue indefinitely; things calm down as relationships develop and age and unless your partner is young he is soon going to be exhausted.

As many non-trans relationships mature sex or lack thereof is often an obstacle to the health of the relationship. So many times I have heard women complain that sex with their husbands has become routine and unsatisfactory. This leads to women going off sex when their husbands desire it and to tensions which, would make otherwise trivial issues become major points of contention and the relationships end up breaking down. So many times this is wholly due to a lack of communication about sex between men and women and unrealistic expectations on the part of women.

Back into the “Boy Box”! Contrary to what many women seem to expect, we HSTS know that men are not mind readers! Ladies he does not know what you are thinking or what you want any more than you know what he is thinking or wants. Tell him, you will be surprised how happy he is to finally know.
HSTS are not totally immune to this, they equally with natal women, can become disenchanted with their sex lives. This cooling of the sexual component can be an inevitable symptom of long term relationships with men who still love and cherish their wives. Loving and sensual sex can be the backbone of a stable relationship and is enjoyable most of the time and reinforces the pair bond.

However, men in long term relationships can very easily fall into the Madonna and Whore Syndrome trap, where they begin to see their wives as somehow pure and detached from raw sexual desire. Women relish tender caring sex but not as a continuous sexual diet and so many, as time passes, lament the lack of passion in their relationships. Of the many divorced couples I have known this has been the main cause of the beginning of their relationship’s failure. Women become unreceptive to sex because it has become perfunctory or routine, men denied sex in the relationship seek it elsewhere.

Men will not change this mind set on their own and need to be left in no uncertain terms that the Madonna is on vacation and that it is the Whore who requires his services tonight. TELL HIM and be delicate about it so as not to seem like you blame him. Seriously, if you cannot talk to your partner openly about your desires the relationship is doomed!

Conclusion

It was not my intention when writing this article to come off as an agony aunt. I have witnessed, read and listened to so many accounts of women complaining about being unable to find decent men, when in reality they are all around them and I have seen HSTS make these same mistakes. I have seen women discard perfectly good men and then instantly regret it. Hopefully knowing of some of these obstacles will help you avoid them.

Risk Analysis of Long Term Hormone Replacement Therapy in MtF Transsexuals

By Amanda Grimes

Author’s Note:

It is important to point out that this article is an observational piece and not a clinical study. As the author I am not medically qualified, or a clinical researcher. I have though, been a patient who has consistently used Hormone Replacement Therapy (HRT) as part of a treatment regime for Gender Identity Disorder (GID) and Transsexualism for the last 32 years. During that time I have meticulously monitored my general health and done my upmost to keep abreast of the latest clinical studies involving the use of HRT and hormone suppressant treatment. For this reason I will only address the use of HRT in Male to Feminine (MtF) transsexuals, with which I am familiar.

General

The treatment of transsexuals with HRT is often criticised by those who oppose the medical treatment of transsexuals generally, without any real understanding of the effects and risk factors surrounding their use. All too often, gender critical commentators will claim increased risks of cancer and other life threatening conditions inherent in the use of HRT. While there is some validity in the nature of their statements, these are often misdirected as there have been no long term studies carried out in relation to the use of HRT by transsexuals.

(Note: see Addendum. Ed.). All available studies of the effects on health of HRT use have to date been carried out on groups of postmenopausal natal females aged between 50-79 years old. While there are elevated risks from certain morbidities in long term use of HRT they are for the most part overstated or of more import not relevant to the treatment of MtF Transsexuals.

While taking any medication carries the risk of side effects and complications, claims that “taking hormones” causes cancer, stroke and cardio vascular disease, are vastly overstated and misleading. In this article I will examine these claims and in comparison to the significant and more up to date medical research in this field and I shall to reference it to its application in MtF Transsexual patients.

Medication

There are several types of hormonal medication in use for the treatment of transsexualism the more common of which are:

Oestrogen – Being either synthetic oestrogens such as Estradiol® or naturally occurring equine oestrogens such as Premarin®. Oestrogen is the primary feminising hormone and is responsible for the redistribution of fatty tissue on the body and the reduction in body hair.

Progesterone – Being ordinarily used for short term periods during the initial stages of transition. Long term use of this type of hormone should be avoided. These drugs are derivatives of Medroxyprogesterone such as Progestin® and Provera®. Use of progesterone is usually discontinued following Genital Reassignment Surgery (GRS) such as Vaginoplasty or Orchiectomy as they are primarily used to consolidate the redistributed body fats and after that their use is limited if not null in respect to non-uterine conditions (i.e. they are only relevant if you have a uterus).

In addition to these drugs, though I personally have no first hand experience of effects of them, as they were not in use when I transitioned, are Hormone Blockers used to negate or “block” the effects of the natal hormones of the patient. These are split into two types of drugs: Gonadotropin Releasing Hormones (GnRH) antagonists such as Lupron® and hormonal suppression drugs like Spironalactone and similar based drugs like Aldactone®. GnRH derivatives are used in pre-pubertal subjects to “block” the onset or continuance of natal puberty and Spironalactone-type drugs are used to suppress natal hormone production in post-pubertal subjects. We shall address these and the risk/benefit of these types of drugs in another article, as they deserve closer examination.

The Claims

HRT increases the risk of Cancer!

Early trial studies were carried out by the Women’s Health Initiative (WHI) between 1993 and 2006 and the results published at various points throughout the trial. 160,000 subjects were studied. They were in three groups, two receiving active HRT and one a placebo. One using HRT took a combined 0.625mg of conjugated oestrogens and 2.5mg Progestin daily, a second group took oestrogen only HRT and the third was a control group medicated with a placebo. All groups were monitored for instances of increased colorectal, breast, ovarian and uterine cancers. In addition subjects were monitored and recorded for instance of venous thromboembolism, stroke and coronary heart disease (CHD).
Increased risks were noted in all but a few morbidities for the groups using HRT, though the elevated risks were not significant. We shall deal with the elevated numbers and what they mean in a moment, but there are certain aspects here which are important to note.

1. MtF TS are at no risk from uterine or ovarian cancers as we possess neither a uterus nor ovaries.

2. The elevated risks in other areas were in a group who commenced HRT between 50 and 79 years old; that demographic is already at increased risk for all listed morbidities.

3. The study looked only at subjects taking the combined Oestrogen and Progesterone HRT.

Results in both the HRT groups showed that cases of endometrial cancers were decreased in relation to those in the general population. However the results were affected by the larger number of women who had undergone hysterectomy before or during the trial period.

The combined oestrogen/progesterone (EP) group showed a marked increase in the instances of breast cancer, being an increase of +8 cases on the Attributable Risk to the Global Index, of 19 cases per 10,000 person-years seen in the general population.

In the findings of the 2002 stage report and a review of all papers brought together by James Clarke carried out in 2006, significant risk reductions were noted in the Oestrogen (E) only group across a wide number of risk factors. Below are excerpts from the report in respect of each of the significant risk to TS patients. The links to the reports via the Lancet review are contained at the end of this article.

Invasive breast cancer (IBC) 2002 paper

Risk ratio

The value of 26% increase in the relative risk of invasive breast cancer in the E+P group has been cited over and over by many people in the scientific and non-scientific media, even though the authors of the WHI paper acknowledge that it “almost reached nominal statistical significance”. Since “almost” is not statistical significance, the statement should have been: there was no significant difference in IBC risk between the placebo group and the E+P group. As in the analysis of CHD, if the authors had used adjusted confidence intervals there would be no doubt that risks were not increased.

The authors then indicate that “the weighted test statistic used for monitoring was highly significant”. This statistic would not have been elevated if the authors had examined the data more carefully. The apparent increase in risk ratios from years 2-5 is accompanied by a decline in the placebo groups (Figure 3A and Figure 3B). As discussed below, in the final analysis of these data this upward trend is not statistically significant (Figure 4A and Figure 4B). The final hazard ratio of 1.26 has an adjusted 95% confidence interval of 0.83-1.92, and the absolute risk increase is 0.08% or 8/10,000 person years. Such a broad confidence interval which includes 1.0 indicates there is no significant increase in risks due to hormone use. In addition, mere inspection of the data in Figure 3A clearly shows that four of the six values are not different from the no effect level, thus making it very unlikely that any real differences in risk existed.

Invasive breast cancer in the estrogen only studies

In the estrogen only arm of the WHI study invasive breast cancer was decreased by estrogen treatment [Anderson et al., 2004]. The hazard ratio was not statistically significant: 0.77 (CI, 0.59-1.01). A protective effect may be likely since the number of risk ratios which were near or below the no effect level were greater than those above this level (data not shown). In the final report on this aspect of the study similar data and conclusions were reached [Stefanick et al., 2006]

Venous thromboembolism in the estrogen only study

No data on a yearly basis were published for VTE in the estrogen only study; therefore, it was not possible to graph risk ratios or percent incidence as a function of time [Anderson et al., 2004]. The authors indicate the final hazard ratio was 1.33 (95% CI, 0.86-2.08) and that this was not significant. However, they say that the risk for the subgroup, deep vein thrombosis (DVT), is significant (HR 1.47; CI, 0.87-2.47). Since no yearly data were provided for DVT it was not possible to draw a graph; however, the authors did provide yearly data for pulmonary thrombosis (PE) which show the same erratic risk ratio and incidence values as in most of their other data (data not shown). Therefore, it is likely that the data for deep vein thrombosis shows similar, if not greater variation. This likelihood, plus the small absolute increase (0.06%) and the broad confidence intervals which cross 1.0, make it difficult to accept these values as significant.
This expectation of a high degree of variability and uncertainty was borne out by the data in the final paper from the WHI studies on venous thrombosis [Curb et al., 2006]. In this paper the authors provide hazard ratios and non-adjusted 95% confidence intervals for DVT, PE and venous thrombosis, VT (Figure 7). If adjusted 95% CIs had been used, all values would have included 1.0 and would have been judged insignificant. It is clear why the authors of this paper make no statement concerning statistical significance.

Instead, they state that VT risk is associated with the use of estrogen during the first two years of exposure. It is clear that the very wide non-adjusted confidence intervals associated with the 0-2 year span for all three groups make it impossible to conclude anything concerning this period. The later time periods show no increased risk due to hormone treatment. It is puzzling why the authors in the 2004 paper conclude that the HR for DVT is significant and yet in the 2006 paper they conclude the HR is not significant, yet the data are virtually identical.

Coronary heart disease in the estrogen only study

In this study the authors conclude that estrogen alone does not affect the risk of CHD in post-menopausal women (HR, 0.91; 95% CI, 0.75-1.12; [Anderson et al., 2004]). The final results of the estrogen alone study were divided into age groups of 50-59, 60-69 and 70-79 years [Hsia et al., 2006]. The conclusion was that estrogens provide no protection against CHD with the possible exception of those in the 50-59 age group (HR, 0.61; 95% nominal CI, 0.25-1.50). However, the incidence and risk ratio data for CHD in each of these groups is more erratic and variable than any of the data shown thus far. These results will be the subject of another paper and will not be discussed further here.

Stroke in the estrogen only study

Risk ratios and incidence

The risk ratios for stroke in this study are low but generally above the no effect level (Figure 9A). These minimal ratio values are the result of very variable incidence levels, which indicate that these groups were not different from one another for the first five years of the study (Figure 9B). This period is followed by a small increase in the estrogen group at year 5, which is followed by a steady decline to low levels equal to those of the placebo group. Such declines in the risk ratio and incidence in the estrogen group suggest a beneficial effect of estrogen treatment. The authors indicate that the final hazard ratio of 1.39 was significant; however, this was based on non-adjusted 95% CI. When the adjusted 95% CI is used (0.97-1.99), the HR becomes statistically insignificant.

What This Means

Cancer

These and further studies, carried out by Stamford University and the WHI in 2012, 2015 and 2016, support the initial findings that increased risks of breast cancer are associated only with combined Oestrogen and Progesterone HRT and that no significant increase arises from Oestrogen only HRT. So if you are taking Oestrogen-Only HRT you are at no more risk of developing breast cancer than the general population.

Since the publication of those later reports Wyeth has withdrawn its production and sale of combined HRT such as PremPak C® in most Western countries.
In respect of colorectal cancers, there was a small but marked reduction in the instances of these in both the Oestrogen Only and Combined HRT groups. This means you would be less likely to contract bowel cancer than a woman who is not prescribed HRT.

Coronary Heart Disease (CHD)

The studies in Oestrogen Only HRT showed no significant change in instances of CHD except in the 50-59 age group where a reduction of CHD was noted. No conclusions are drawn from this and the issue is subject to further studies.

Venous Thromboembolism (DVT)

A slight increase of 0.06% risk was noted in the instances of DVT in the Oestrogen Only group and that was only noted within the first 2 years of treatment. This is a strong indicator that these instances were elevated in subjects with a predisposition for DVT and other venal condition. After year 2 there was no noted increased risk.

Stroke

There is an elevated risk of stroke in both Combined and Oestrogen Only HRT though that equates to a hazard ration of 1.99 compared to 0.97 Global Index. This means for every 10,000 women per year taking Oestrogen Only HRT and additional 1 will be subject to stroke. The authors of the report concluded that this was insignificant.

Conclusion

As can be seen from the results of the studies cited above the risk from HRT in FtM Transsexuals is minimal and often overstated by the general media and those who are critical of their use in TS. Many of the elevated cancer risks associated with HRT affects body parts which are not relevant to TS patients. There is it seems no elevated risk beyond that of the general female population for those body parts which are common to both natal female and MtF TS.
It is though important to note that all the risks listed herein are subject to environmental and lifestyle factors.

It is essential therefore that TS do their best to avoid things like excessive alcohol consumption, smoking and higher levels of obesity just as it is for the general population. Where possible TS should also keep regular checks on their general health including blood pressure, liver function and breast health as a precaution. Personally as a woman in my 50’s now I have a doctor applied blood pressure check every six months, liver function every twelve months and mammogram every eighteen months in addition to my own personal checks.

In addition to these it is also reasonable to assume a decreased risk in typical male cancers such as testicular and prostate cancer. The first is obvious in post-operative TS and the second results from the fact that the majority of treatments available for men with prostate cancers involve blocking testosterone or the administration of female hormones.

The risks therefore are at best positive or neutral and at worst minimal and I would encourage all those concerned with transsexuals and their care to carefully research all the available data for themselves before believing statistics bandied around on the main or social media platforms.

Note

Much of the criticism of the use of HRT in TS patients is poised in such a way as to appear revelatory to the unsuspecting user of such drugs. It is however important to recognise that the propensity for elevated risk of cardio conditions and cancers has been highlighted for decades by those prescribing HRT to their TS patients.

Every time one opens a new pack of oestrogen pills the manufacturer’s warning list is enclosed advising of all possible side effects from the mundane to the potentially life threatening ones. This does little or nothing to deter these patients from taking these drugs or undertaking much more risky surgical procedures. For myself (and I have heard similar things to this from others) if the doctor had said unequivocally, “Take this it will allow you to can live as a woman but in 30 years it will kill you!” I would still have elected to take the HRT, so unacceptable would be the alternative.

Amanda Grimes

Links
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1630688/
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(12)70075-X/fulltext

Addendum (Ed.)

While this article was in editorial review, a paper was published, entitled
‘Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study’. This paper, detailed a broad research study into the incidences of ‘venous thromboembolism (VTE), ischemic stroke (IS) and myocardial infarction in transgender persons’ to see if there was correlation with hormone use.

The study, which is available HERE (link) concluded that ‘The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.’

However, though some elevation of risk was observed, this was very low, less than for other risk factors like smoking or alcohol consumption and the authors did not recommend changes to the prescribed hormone regimes for transitioning subjects, only that their doctors and other health advisors should maintain vigilance. This is in line with observations in the article above.

We found a number of questionable areas in the 2018 paper:
• There is no mention of the age of the patients at the date of ACVE
• There is no direct subject contact; all data is taken from electronic client records only
• These are variable drug dosages rather than dose-specific studies with only estrodiol (synthetic oestrogen) and Spironalactone (No equine derived HRT was considered, nor alternative testosterone-blockers.)
• There was no distinction between the effects of estrodiol and those of Spironolactone.
• No separation of studies with post-operative TS, who would not have used Spiro; comparable studies in natal females never use testosterone suppressants such as Spiro
• The study could not determine whether patients were obtaining alternative or further HRT outside of the Kaiser Permanente treatment centres or not
• VTE peaked at 2 Years, thereafter levelling just over the control, as in previous studies; showing an inclination towards pre-disposition to such events (in other words, the subjects were already high-risk)
• IS peaked at 6 years after which results levelled to those in the control (similar to above)
• ACVE was only elevated in the higher dosage patients (2-10mg estrodiol 5.6mg mean average daily); there was no elevated level of ACVE detected in the lower dosage group (0.3mg-10mg 4.1mg mean average daily) It is likely that the lower dosages are Post-Operative and so not using Spironalactone.
• It considered only patients using Spironalactone (Spiro) as a testosterone blocker. This is important because while Spiro is widely used in the USA it is much less so elsewhere, with Cyproterone acetate (CPA) being more popular. This may have different side-effects.

As regards ‘transmasculine’ (FtM) respondents, the study was inconclusive and made no comment.

Conclusion:

This is an interesting study, but the level of increased risks that were identified would only amount to an increase in hazard of a percentage point or so above that for natal women. That tiny increase in risk, less than for smoking or alcohol use, has to be set against the documented successfulness of transition in cases of Gender Dysphoria, especially Homosexual GD or HSTS, as well as potential reduction of risk in other clinical areas.