Due to concerns about safety, there is not a public recording of this session. If you would like a private link to view the session, please email Veronica Jordan at jordanv@sutterhealth.org. The link will be good for about 6-8 weeks.
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My notes:
- Flatten the power dynamic, flip the power
- "You can call me Dr. Beal, Dr. Crystal, or Crystal. I use they/them pronouns. What would you like me to call you?"
- Be person-centered, trauma informed and culturally humble
- Ask patients what they want for their body
- Gender identity should not be conflated with goals of care
- Individualize gender affirming care based on what the patient wants/needs (see image of the table patients pre-fill out prior to visits).
Now, onto the nitty gritty:
1) If a patient wants limited physical changes and/or more of an emotional experience. . . consider simply low dose hormones (estradiol 0.5mg daily to start, very low dose for someone desiring more estrogen, testosterone 5-10mg IM weekly, also very low). If for some reason, low dose hormones are not desirable, you can also consider anti-androgens only or selective estrogen modifiers (SERMS) only.
2) If a patient wants hair loss treatment, reduction or prevention. . .particularly in someone with a family history down the maternal line OR someone who has anxiety about potential hair loss with hormone treatment -- consider low-dose oral minoxidil (LDOM) 2.5-5mg/day. This is well tolerated, can cause more body hair in other places. Of note, topical minoxidil is toxic to pets. Finasteride has been associated with SI and can slow changes from testosterone so may be a less desirable. Estrogen protects head hair, so don't have to worry about this in patients on systemic estrogen. Other options include tattoos, make up. Of note, a lot of patients take biotin (a supplement which is thought to strengthen and increase hair growth); unfortunately, biotin can artificially elevate estrogen, so have patients stop 72 hours before having their labs drawn.
3) If a patient wants more/thicker facial hair. . .first, set reasonable expectations. It will take at least 6 months to notice change and maybe up to 10 years (!!!). Facial hair growth is a slow, gradual process. And depending on your family history, you may not be able to grow a ton. Topical minoxidil may speed the transition from peach fuzz to a full beard, but it's still low. Remember, it's toxic to pets. Also, it can be irritating to skin, so patients should try to apply daily but may need to space out depending on skin irritation side effect. Also consider micro-needling with ink and make up as alternate options.
4) If a patient wants bottom growth (i.e. clitoral enlargement). . .DHT (dihydrotestosterone) is not available in the US. Practitioners in the US tend to use 10% testosterone cream (compounded) daily at first, then weekly x 6 months. Dr. Beal notes that topical testosterone is always transdermal (i.e. some portion is absorbed).Alternatively, can use testosterone oil for injection>> it comes in 1ml supply, can apply 0.05 to 0.1ml topical to genitals. Of note, topical hormones can definitely transfer to partners and should be washed off prior to contact. Androgel should not be used on the genitals because it contains alcohol and can significantly burn genitals.
5) If a patient has a uterus and/or breasts and wants to prevent menses and/or slow/stop breast development. . .consider SERMS, specifically Raloxifene is the SERM of choice (tamoxifen is another option but has more side effects and probably less safe over time). Raloxifene rx is 60-120 mg/day. Can be taken indefinitely. Does also have bone marrow density protection.
6) If a patient wants to optimize breast development. . .again, important to set realistic expectations. Most trans people will not achieve larger than an A cup. There is some evidence for transdermal progesterone cream compounded 25mg/ml 1/2 ml pump daily. Some patients love it and feel like it makes a big difference, others do not. Of note, when starting estrogen, lower and slower estrogen dosing tends to help boost breast development. Of second note, there is a theoretical increase in breast cancer risk with progesterone, no data to support or refute that at this time.
7) If a patient has persistent bleeding. . .consider depo provera injections.
8) If a patient has painful erections. . .If the goal is to have continued erections (but make them less painful), you can use tadalafil or TD testosterone. If goal is to prevent erections, use more aggressive testosterone dosing/supplementation.
Common gender affirming procedures
- filler injections
- botox injections
Both are temporary and can make changes to brow, jaw, cheeks, lips. Allow people to experiment with changes before opting for something more permanent (surgery).
- Hair removal
- Liposuction/lipo-sculpting
- Implants
In response to an audience question, Dr. Beal spoke a bit about the unique experience of each individual's response to medical interventions. It is very personal and unique. For many people, hormonal treatment have some emotional effects. These effects may or may not be desirable for each patients. With testosterone, people describe their emotional experience as "more simple", less crying, more irritability and impatience, less access to empathy. With estrogen, people tend to describe the opposite set of effects: a more complex emotional experience with increased lability, increased crying frequency and even increased access to empathy.
In summary, Dr. Beal recommends whenever you are initiating treatment, starting low and going slow. Allow the patient to guide you in their experience of the intervention and have some power over next steps.
There are tons of resources on Dr. Beal's clinic website: https://www.queercme.com/blog
Specifically a blog post on testosterone and singing: https://www.queercme.com/blog/testosterone-and-singing
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