Self-medication: the basics for HSTS

The UK is suffering a backlash against transition and HSTS are affected disproportionately. This assault is being orchestrated by TERFs, so called ‘gender-crits’ and justifies itself using the words of individuals like Oren Amitay and Ken Zucker, while conspicuously ignoring the advice of those like Dr Diane Ehrensaft. As a result, a number of worrying developments have taken place recently which may lead to young trans people not being able to access the hormones and treatments they need. Self-medication, while not ideal, must be considered.

We note also, with concern, that various Government bodies in the UK have been deleting links to advice sites on transsexualism, for example Mermaids. We’ll be putting up these links up here so that people can access them.

Many thanks to Transit UK for their information.

https://transit.org.uk/hrt-internet.html

Continue reading “Self-medication: the basics for HSTS”

Georges Burou: Pioneer of trans surgery

No progress was made, unsurprisingly, during the dark days of World War II, but soon after the close of hostilities a French surgeon called Georges Burou (1910–1987) set up a pioneering clinic that provided Genital Reconstruction Surgery (GRS) and other plastic surgeries that transwomen required. He treated many of the most famous transwomen to appear in the 1950s and 60s. He carried out over 3000 GRS surgeries and advanced the surgical techniques enormously.

 

Burou’s work laid the foundation of the modern practice of Genital Reconstruction Surgery. While such surgeries had been carried out before, for example in Germany under Magnus Hirschfeld, these had really been at the limit of the surgical techniques then available. Without anti-biotics particularly, surgeons were reluctant to carry out major surgeries for conditions they thought were not life threatening.

World War 2 stopped the development of GRS techniques in Germany and, unfortunately, Hirschfeld’s notes were all destroyed by the Nazis.  Burou was beginning again, but he had bidg advantages.

The war had seen tremendous progress in all forms of surgery, largely as a result of treating battlefield injuries that only a decade or so earlier might have been fatal or have led to limb amputation.  Although a grisly thought, the war gave surgeons an opportunity to develop surgical technique beyond compare with pre-war standards. This was what gave Burou his chance.

 

He set up shop in Casablanca, because it was a French territory, but one in which genital surgeries of this type were permitted. In mainland France they

were seen as castration, which was illegal a that time. Before long Burou had perfected his technique and by 1950 his clinic was attracting clients from all over the world, including Coccinelle from France, April Ashley from the UK  and Christine Jorgensen from the USA.

Although surgical techniques of GRS have continued to improve in the decades since Burou was in practice, most of this is in regard to improving the cosmetic appearance of the neovagina and the depth of penetration it can accommodate. The basic principles of using the penile skin or sheath, inverted, as the inner lining of the vagina and relocating the glans to approximate the location of a natural clitoris, while preserving nervous integrity and sensation, were all established by Burou.

 

Burou’s Technique

The Interdisciplinary Symposium on Gender Dysphoria Syndrome was held at the Stanford University School of Medicine, February 2-4, 1973.

The purpose of the meeting was to provide a forum for the exchange of scientific information about the patient who desires and is considered for gender re-identification.

The symposium was sponsored by the Divisions of Urology and Plastic and Reconstructive Surgery at the Stanford School of Medicine. Its principal architect and chairman was Donald R. Laub, M.D., Chief of the Division of Plastic and Reconstructive Surgery.

In addition to the United States, numerous representatives from Canada, Mexico, England, Morocco and Australia were present. Below is a translation of Burou’s presentation.

Male to Female Transformation

Georges Burou, M.D.*

Dr. Burou is a gynecologist from Morocco who had previous experience making a neo-vagina in cases of vaginal atresia. He treated a male patient who insisted upon sex reassignment surgery and went into this field. When Dr. Burou created the operation, he was totally unaware of previous such work in the world. He thought at the time that the best thing to do was to utilize the live graft which can be made from the penile skin when properly dissected. this is what he is going to describe now. This is the first report on this new technique.

Dr. Burou want to thank very much many American physicians who supported him in this work, referring many American patients, and who have been extremely helpful in corresponding with him.

The entire surgical operation is done in one stage, consisting of two successive steps. All of the patients who under go surgery have been prepared, undergo psychiatric care, on hormones, and made quite feminine. The first step is made on a very narrow surgical field and the goal of this first step is to create a space between the rectum and the prostate. The fist incision is made posteriorly between the anal area and the scrotal ridge. This first part is extremely important, because you can determine at any time by intrarectal inspection that there is no lesion to the rectal wall. This is very important to avoid any further complications during the dissection in the rectum in the prerectal space.

Figure 1 shows the first incision going from the anal area through the ridge of the scrotum. On the left of the figure is the first dissection of the bulb and both corpora cavernosa. The cleavage between the rectum and the prostate is made by cutting all the ligaments between the bulb and the rectum. Then Dr. Burou positions the cleavage with his finger in the natural space which is between the rectal wall and the prostate. The cleavage is done when you admit easily two fingers of a vaginal retractor. One can meet at the end of this new space a natural formation which makes you feel that you are really meeting the natural vaginal cul-de-sac, Douglas space. The first step is over.

The first step is in fact the most important and most dangerous. The second one is relatively easy. One enlarges the surgical field in the most usual way, taking all the usual precautions. The initial incision is now prolonged under the scrotum to the root of the penis. The surgical field is widened by retracting and widely exposing the scrotal skin on both sides. On the neocolporrhaphy we have both the corpora cavernosa, spongiosa, and the two testes. The testes and its beaker will be cleaved by cleavage of the fiberous tunica.

Figure 2 shows that the high testes has been dissected through the fat pad attached to it. It is separated on the inside from the corpora cavernosa, and it is also freed from the lateral wall. Once the testes and all the surrounding pedicle have been freed, the spermatic chord is cut and ligated, as can be seen in Figure 3. Removing the section of the testes and all the mass surrounding it, requires very careful hemostatis and the right sectioning of the bulb, corresponding to the future urethra. The right of Figure 3 shows where both corpora cavernosa will be sutured; the needle is visible. On the right the corpora cavernosa is shown firmly sutured with the future urethra pending on the right. Above are the erectile bodies of the penis. The left side of Figure 4 shows the erectile bodies being pushed out and dissected from the penile skin. Figure 5 shows that practically all of the skin of the penis now has been completely freed from the erectile bodies. Figure 6 shows the complete dissection of the penile skin; you even keep the foreskin when available. It is at this stage that the end of the penile skin is being sutured and closed. This will constitute later on the neovagina.

Figure 6 shows the neovagina quite ready to be inserted in the prerectal space which was created. On the lower abdominal skin is a slight skin slit which will allow the future urethra to be passed through. The figure also shows an important feature coming through the skin near the anal area – two threads which are being inserted on the anterior ani muscle.

These two threads will serve to support a bougie of Eggar, a prosthetic instrument known in obstetrics. This bougie of Eggar will be placed in the neovagina to provide support. Figure 7 shows a drain with aspiration which is being placed in the posterior commissure. The bougie of Eggar is in place, and the two threads coming from the skin are tightening very closely and very firmly that bougie of Eggar into the neovagina. It is easy to regulate or test the firmness and tension on the two threads. At this stage excess skin flap must be removed in order to obtain a good appearance. Figure 7 shows the exit of the levator cannula with catheter. There is no skin suture. The urethra is being sutured on the catheter, about .5 cm from the skin. Some kind of retraction must always be foreseen. Figure 7 also shows the drainage at the posterior commissure.

Eight days after surgery, the bougie of Eggar was maintained for 48 hours. The aspiration is also removed after 48 hours. The urethral catheter is maintained for four days. The management of the new vagina is being made by frequent and daily introductions of small vaginal retractors. In the next few days permeability of the urethra must also be maintained by daily introduction of the catheter and making sure that there is no stenosis that it is completely patent. With the catheter, the urethra is immediately introduced at the appropriate place during the final step.

Magnus Hirschfeld, transsex pioneer

Magnus Hirschfeld was one of the most prominent early sexologists and, as a homosexual male himself, was trusted by both homosexuals and trans people.

A psychologist, he developed the first evidence-based treatments for HSTS. Although some of his ideas have become politically unfashionable, most still remain valid despite this.

The earliest real records we have of HSTS in the West come from the 20th century, principally from Hirschfeld. That HSTS appeared to be a  natural development of transgender homosexuality had certainly been widely noted and remarked on beforehand, but of individual life histories there are few, prior to Hirschfeld and his pioneering work in Germany.

Berthe Buttgereit

In 1912, a 21-year-old then named Berthe Buttgereit visited Hirschfeld as part of an application for a transvestite identity pass. Buttgereit was born female, had grown up in Berlin, and attended a coeducational school where she was described as “energetic and purposeful as a child, and behaved like a boy,” with little interest in the girls’ games. After receiving the pass, Buttgereit was able to live publicly as a man. In 1918, he also received a “transvestite passport,” permitting travel to Cologne.

Seven years later, now living as a man, Buttgereit submitted a request to officially become known as Berthold instead of Berthe. The request was granted. Later in life, he attempted, unsuccessfully, to marry the woman he had by that point lived with for eight years. This was denied by the authorities.

Katharina T

Another case was that of Katharina T, born female in 1910 in Berlin. Little is known about her life except that she was certainly trans and probably an HSTS transman. She was assisted, by Hirschfeld, in getting papers that protected her from routine police harassment for wearing men’s clothes. Hirshfeld certainly assisted others to do the same, but since his records were burned by the Nazis, we have no details.

Hirschfeld was, more famously, involved in the first two known Genital Reconstruction Surgeries (GRS) on Male-to-Feminine HSTS.

Dora or Dorchen Richter

Hirschfeld worked with Eugen Steinach, a surgeon from Vienna, to develop early Genital Reconstruction techniques. In 1931 the first complete male to feminine surgery was performed by Dr. Levy-Lenz, and Dr. Felix Abraham, two of Hirschfield’s co-workers at the Institute Sexual Science, which had been established in 1919. The patient was Dorchen Richter (previously Rudolf), who lived and worked in the Institute as a domestic servant. That same year the institute also reported two men undergoing genital surgery.

https://www.hirschfeld.in-berlin.de/institut/en/personen/pers_34.html

Dorchen’s surgeries proceeded over a period of years, beginning with an orchidectomy to remove the testes, which she requested in her late 20s. According to Felix Abraham, one of the Institute staff who published Dorchen’s gender transformation as case-study, ‘Her castration (orchidectomy) had the effect – albeit not very extensive – of making her body became fuller, restricting her beard growth, making visible the first signs of breast development, and giving the pelvic fat pad… a more feminine shape.’

Dorchen retained her penis, although she was completely homosexual, that is, was only attracted to men. In 1931, as the procedures had advanced, she asked for and was given penectomy and vaginoplasty; these, today are usually performed at the same time as the orchidectomy and the whole is called ‘Genital Reconstruction Surgery or Gender Reassignment Surgery.i

An Overview of Orchiectomy (Orchidectomy)

We don’t, alas, know what happened to Dorchen or the other transwomen who attended or worked at the Institute. The likelihood is that they were lost during the Nazi era. Although Nazi officers were notorious pederasts who routinely kidnapped boys for sex in their occupied territories, they had an implacable hatred of, in particular, male feminisation and what they considered to be transvestism.

Lili Elbe

Einer Wegener, left and Lili Elbe, right. Note her slight frame and feminine features.

Another of Magnus Hirschfeld’s patients was, Danish artist Einer Wegener. Einer became Lili Elbe and had the first publicly acknowledged male to feminine GRS; this caused a media sensation in Denmark and in Germany. Sadly she died following the final surgery in 1931, in which her surgeons attempted to transplant a womb intended to enable her to have children, but a book based on her personal writings about her experiences and a subsequent novel, The Danish Girl, made Lili  famous.

Some have questioned whether Lili was in fact HSTS or autogynephilic, but at the time she had her surgery, this distinction was not understood. It hs also been suggested that she might have been intersexual, possibly with either Partial Androgen Insensivity Syndrome or Klinefelter’s. Hirschfeld does not appear to have noted this.

Wegener was born into a wealthy middle-class Danish family, whereas Richter and other subjects were working people. The social constraints of the day, to conform to sexual and gender stereotypes, were very strong; it seems likely that Wegener’s marriage was the result of this and that she was in fact HSTS.

Hormonal Treatments for HSTS

These divide into hormonal (endocrine) and surgical treatments. This article discusses the former.

Hormonal or endocrine therapies and treatments have three basic strategies.

  • Preventing or delaying the onset of puberty. These are known as ‘puberty blockers’
  • Preventing the body’s natural sex hormones from inducing physical changes. These are known as ‘hormone blockers’ or, in males, ‘testosterone blockers’ (T-blockers)
  • Introducing cross-sex hormones, ie those typical of the opposite sex, to induce physical changes more like those found in the opposite sex. In males the principal one will be oestrogen and in females, testosterone.

Hormones.

The differences between adult men and women exist mainly because of the actions of sex hormones on their bodies, during the pre-natal period, then in childhood, adolescence and young adulthood. This is what causes the noticeable physical differences between the sexes and also most of the psychological ones, though some people dispute this.

Transgender homosexuals are individuals who have one sex but whose sexual orientation is similar to that found normally in the other. So, boys are attracted to males and girls to females. However, in addition to this sexual orientation, they have strong cross-gender ideation, that is to say they identify, either wholly or partly, as the opposite sex. They are likely to show significant gender non-conformity (GNC) indulging in cross-sex role play and appearance and this will be consistent and persistent, that is, not a passing phase; and they are likely to show more or less childhood gender dysphoria, that is, feelings of strong discomfort at being identified as the sex they were born.

Usually, in transgender homosexuality, this manifests prior to puberty and in those most likely to be HSTS, as young as 2-4 years of age. But this is a scale of variation; some transgender homosexual males, while feminised on some parameters, are less so on others. At the same time, they may feel a sense of discomfort at the mismatch between what their sexuality makes them feel they should look like and present as, and their actual appearance and presentation, which is called Gender Dysphoria. This too, is on a variable scale, so some people feel this very strongly and others less so.

If these parameters come together such that the individual’s Gender Dysphoria is stronger than his or her fear of social rejection or intolerance, that individual is likely to desire to transition.

Modification

To do that, HSTS desire to modify their bodies and faces so that they appear to be of the opposite sex. This goes far beyond cross-dressing or wearing feminine make-up (for a male). They desire to ‘pass’ in society and they know that in order to do so, their resemblance to conventional opposite-sex models must be convincing.

The place they usually will begin is with growing their hair, if male, or cutting it if female. Then they will explore feminine, for males, or masculine, for female, clothing styles. HSTS MtF might grow their hair long and wear dresses and heels, for example. This can work as long as the individual is young, but, especially for MtF, their natural sex hormones make it increasingly difficult to maintain a cross-sex appearance.

The way to combat this to impact the endocrine system. Today, in the West, this is done using a two-prong approach: firstly to counter the effects of the natural sex hormones and secondly to introduce cross-sex ones.

In this, the sexes are not equal.

Male-to-Feminine (MtF) or Transfeminine

The primary sex hormone for males is testosterone, which is, unsurprisingly, produced in the testes. For females there are two, oestrogen and progesterone, but the former has far greater effect on physical appearance.

Endocrine therapy for males consists of two stages. The first sets out to prevent a male puberty occurring, to minimise its effects or to delay it.

Blocking Puberty

This is the first step for most MtF HSTS. These are male and testosterone is extremely powerful. It masculinises a boy rapidly. Although HSTS MtF are often remarkably neotenous, or baby-faced, eventually testosterone will catch up. But in order to pass successfully as a woman in society, the exposure to the masculinising effects of testosterone must be limited. This means that puberty-blockers should be prescribed as soon as a confirmed diagnosis has been made. In order to initiate the system that allows for bone growth to be halted and to avoid excessive tallness, puberty should be allowed to initiate and then be stopped. The height-limiting function is not affected by the puberty-blockers and any increase in tallness will be minimal.

 

Testosterone’s ongoing effects can be suppressed using three different drugs. These are  Cryptosterone acetate, Spironolactone and Finasteride. The last was developed as a counter to male-pattern baldness and is usually not used alone, in transitioning.

Using testosterone-blockers like these allows a far lower, and therefore less risky, dose of oestrogen and still produce significant feminisation. It is important, however, to realise that the feminising effects of oestrogen apply only to bodily soft tissues and not to bones.

This means that an MtF using oestrogen, with or without a t-blocker (although the dose will have to be much higher in this case) can look forward to, for example: softening of facial features through changes in fat distribution; similar effects to the hips, legs and buttocks, some thinning of the waist and the development of breasts, which are mainly made up of fat. At the same time, she can expect to acheive a softer, smoother skin. Finally, through time, some changes to musculature may occur, leading to reduced upper-body strength and muscle mass.

What she cannot expect to change is her skeleton. Bony material, once laid down, is fixed, more or less for life. Some minor adjustments may be achieved through cosmetic surgery, such as reshaping jaw or brow lines, reducing a prominent nose and so on, but things like overall height, shoulder width and so on are not mutable.

This means that, for the MtF HSTS, time is of the essence. As she progresses through adolescence, she will rapidly masculinise and this may reach a point where it becomes so marked that it will be impossible for her to pass successfully as a woman. This means that, as soon as an the MtF HSTS is identified as such, hormonal treatment should begin. It is unwise to begin t-blockers prior to puberty, for the reason of possible height increase, but as soon after puberty, with a confirmed diagnosis of homosexual Gender Dysphoria, they should begin. By age 16, if possible, full doses of feminising oestrogen should be administered.i

Female-to-Masculine (FtM) or Transmasculine

For FtM, something similar is indicated, but parents iun particular ahould remember that genuine HSTS in females is far more rare than it is in males. Why this should be is not clear. However, another condition, called ‘Rapid Onset Gender Dysphoria, can easily be mistaken for genuine homosexual Gender Dysphoria. As we explain in the diagnostic guide, however, genuine homosexual GD, in almost all cases, gives many years of forecast, in childhood GNC, childhood Gender Dysphoria and in their expressions of sexuality. It almost never sets on quickly and in cases where it does, especially in females, extreme care should be taken.

While Mtf cross-sex therapy does have some raised risk of certain complications, like various cardio-vascular diseases,ii the effects of the treatment are mainly cosmetic. Despite the known tendency for feminising HRT to reduce the size of the penis and testes and render the subject unable to gain an erection or to ejaculate, there are reported cases of MtF transwomen getting women pregnant, even after many years of cross-sex HRT. (Clearly, these are not HSTS.)

For the female body, however, testosterone is a literal poison. It will effectively destroy the ovaries in short order, rendering the subject permanently sterile. This makes accurate diagnosis of Gender Dysphoria that much more critical in young females. At present, we advise that no cross-sex HRT should be administered to any female whose claim of Gender Dysphoria is suspected to be ROGD.

The simple fact is that the transition window of opportunity for females is much longer than that for males. There is not the time pressure, but instead significantly raised risk of misdiagnosis and harm.

i In some circles, today, there is an unfortunate move by some to delay t-blocker and oestrogen treatment, for MtF HSTS, until after the age of 18 or even later. This is a catastrophic approach that must be resisted. Doing so will compromise the individual’s ability to pass as a woman, perhaps to the extent that she abandons hope of a successful transition. We strongly suspect that this is, in fact, the covert intention of those who propose this.

It is definitely the case that, while some individuals may be able to transition successfully without beginning HRT before 18, most will have a happier result if they do and parents and carers of MtF HSTS, and the individuals themselves, may have to strongly oppose attempts by ‘gender critical’ individuals, be they therapists or others, to delay beginning the process of transition.

ii This elevation of risk is tiny: according to a recent study, around 0.16% over 8 years.

HSTS and medicine in history

Today, HSTS has become a subject for medical intervention on two levels: hormonal (endocrine) and surgical. But for thousands of years, HSTS lived without the benefits of modern medicine and science. So how did they manage?

Ancient Sumer: a tradition that persisted.

The earliest references that we have to HSTS come from Sumer, a region of Eastern Mesopotamia, now Iraq. This was made up of independent city-states, some of which, including the most prominent, Uruk, were Goddess cities. Although we can’t be sure of the political make-up of these societies, there is considerable evidence that there was at least a power-balance between men and women in them, even if this did not extend to full female authority. (There has never been, as far as we know, a culture that was genuinely ‘ruled’ by women.)

However, these societies do appear to have been matrifocal with women, and motherhood, at their centre. This replicates circumstances found in other, more modern cultures in which motherhood is venerated.

One intervention that was common in these ancient societies, amongst HSTS, was castration. Typically a young boy would enter the temple in service of the Goddess. In Sumer this was Inanna, who had a sister, Ereshkigal. These were actually two aspects of the same goddess. Inanna was the light or daytime aspect; she represented birth and life, love, physicality and the pleasures and pains of the flesh. Ereshkigal was the dark aspect; she represented death but also regeneration, reflection and mysticism. Inanna walked the Earth while Ereshkigal was the Queen of Darkness and her abode was the Underworld.

This binary pair was the model for many, across the region and down the centuries, notably Aset (later Isis) and Nephthys, who played exactly the same roles in Egyptian culture. Aset was married to the god of life and light, Osiris, while Nephthys was the consort of Seti (Set), who is the model for the Biblical Satan. Aset was the mother of the saviour god Horus, who was the model, or own of them, for the Christian Jesus.

In mythology, deities that are equivalent to others, in different cultures, are called ‘cogantes’. One cognate of Ereshkigal was the Phrygian goddess Cybele and we know a lot about her and her devotees, because her cult was imported to Rome.

In the cult of Cybele, young males known as ‘galli’ by the Romans (this was pejorative) would work themselves into a trance using music, dance and narcotics, and then, after tying a blessed cord around their penis and scrotum, would, with one upward cut, remove all at once. If they survived, they would be ‘reborn’ as women. They would then enter the service of the goddess as priestesses.

This practice, in every detail, is carried on even today amongst the hijra of India.

We know from accounts of its effects on castrati, the Italian opera singers whose voices were once so prized, that castration prior to puberty tends to have different effects to when it is carried out after. In the former case, one side-effect can be excessive tallness. This was clearly not an issue for the opera-house managers; in an era when most Italian males were around 5’8″, castrati might reach 6’6″. When carried out after puberty, however, this effect does not occur. In both cases, castration produces an immediate cessation of masculinisation.

This was the effect that the galli, the hijra and others sought. Unfortunately, it does carry a risk of osteoporosis, since the body requires normal levels of sex hormones to prevent this.

What about less drastic methods? Well, there are tantalising accounts, from the Roman author Herotodus and others, of Scythian transwomen using the distilled urine of pregnant mares. We presume the function of the distillation was to drive off excess water and to concentrate the solution. It must have tasted disgusting. Nevertheless, the story is plausible, since pregnant mare urine is used even today as a source of oestrogen, notably in the preparation PreMarIn. Pharmaceutical companies, producing this and similar products today, keep herds of horses simply for the production of urine.

Today, thankfully, more palatable methods of feminisation are available and these have crossed the sex barrier and can be used to treat FtM transitioners too. But in essence they are not so very different from the ancient methods.

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.