Harry Benjamin and Magnus Hirschfeld were the pioneers of the transsexualism phenomenon [Citation1]. Gender dysphoria is characterized by suffering from strong, persistent discomfort between biological sex and experienced expressed gender, with significant impairment in interpersonal, familial, social, professional and other important area of functioning [Citation2]. Transgender individuals desire to have secondary sexual characteristics of the opposite sex. Transsexual identification is permanently present and the disorder is not a part of some other disease [Citation3]. Diagnostic procedure of sex reassignment is a multidisciplinary task that requires diagnostic assessment, psychotherapy or consulting by a mental health professional (MHP), endocrine investigations and finally surgeon involvement. The diagnosis of gender identity disorder (GID) is made by a MHP. The endocrinologist has to exclude other endocrine diseases, to confirm diagnosis, initiate hormone affirming therapy and perform subsequent individual follow-ups. After at least one year of hormone affirming therapy highly qualified surgeons can perform operations. Sex reassignment surgery is recommended only after both endocrinologist and MHPs find surgery advisable.
The etiology of transsexualism is not known even today. Some hypotheses include: the effects of gonadal steroids on hypothalamus during the first trimester of pregnancy, disorder of androgen to estrogen conversion, receptor disorders and aromatase changes [Citation4]. Hormonal imprinting can prenatally influence psychosexual differentiation [Citation5]. Swaab et al. [Citation6] found changes in the volume of both suprachiasmatic and striae terminalis nucleus [Citation6]. The ratio between transfemale and transmale changed from 6:1 to 1:1 [Citation7,Citation8].
Transsexual individuals seek to develop the physical characteristics of the desired gender (gender fell to depend to). They require hormone affirming therapy regimen that will suppress endogenous hormone secretion, determined by the person’s genetic sex that will maintain sex hormone levels within the normal range for the person’s desired sex. Absolute contraindications for estrogen therapy have to be excluded and before initiation of hormone affirming therapy information about oocyte or sperm cryopreservation has to be given. Current recommended treatment for transadolescent is gonadotropin releasing hormone analogue in order to stop puberty until the age of 16 after which hormone affirming therapy may be given. Unfortunately, this approach used for a long term period shows many unacceptable complications. New approach to this sensitive group will be made according to new studies and, hopefully, the current guidelines will be changed. Gender affirming therapy in transfemale include estrogens, antiandrogens and progesterone. The choice of estrogen formulation is vital to ensure safety and treatment efficacy. Data from recent literature supports the use of estradiol valerate over ethynyl estradiol/conjugated equine estrogens [Citation9,Citation10]. Feminizing effects of estrogens, antiandrogen and progesterone in transfemales include: breast growth, voice changes, loss of erection, ejaculation, softening of the skin, decreased libido, muscle mass and terminal hair growth. Progesterone acts in every tissue during lifespan of both sexes. Oral micronized progesterone induces more rapid feminization, leads to optimal breast maturation and size, increases bone mineral density, improves sleep, hot flushes and cardiovascular physiology. Progesterone stops spermatogenesis at the level of spermatogonia, induces seminal tubular atrophy, decreases Leydig cell number and induces epithelial cell hyperplasia. These findings from our previous studies was later confirmed by Prior et al. [Citation11]. Masculinizing effects of testosterone therapy (ampules, tablets, gels, patches) in transmales include: acne, oily skin, body shape changes, increased libido, muscle mass, among others. Individual lifelong tailoring of therapy is necessary because hypogonadal status (hypoestrogenism in transfemale or hypotestosteronaemia in transmale) represents individual risk factors for cardiovascular diseases (i.e. hyperlipidemia, hypertension, insulin resistance, obesity, etc). Higher doses of estrogens and antiandrogens in transfemales can induce thromboembolism, myocardial infarction, hyperprolactinemia, depression, prostate hypertrophy and breast carcinomas [Citation12]; whereas adverse effects of higher doses of testosterone therapy may include: cardiovascular diseases, metabolic changes, liver adenoma, or carcinoma.
Treating individuals with respect requires a good understanding of their gender identity. It is necessary to further improve knowledge regarding transsexualism and gender identity in medical schools and between health care providers. All medical professionals are trying to find the best individual approach to transgender individuals. All insufficient hormones have to be added in order to sculpture the body the best way and maintain an optimal health condition. In the future, with modern technologies and brilliant human ideas, we hope that the etiology will be finally discovered and treatment will be adequate.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
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