Endocrine Society Guidelines



Feminizing Effects in Transgender Females
a Complete removal of male sexual hair requires electrolysis or laser treatment or both. b Familial scalp hair loss may occur if estrogens are stopped. c Treatment by speech pathologists for voice training is most effective Abbreviations: Unk, Unknown.

Masculinizing Effects in Transgender Males
aPrevention and treatment as recommended for biological men. bMenorrhagia requires diagnosis and treatment by a gynecologist.

About Informed Consent
The ICATH model reflects the basic human right to self-actualization. ICATH is not an institution, an agency or an organization: the use of Informed Consent is a trans-affirmative Standard of Care that is acknowledged and honored by medical providers around the world. When giving informed consent, no therapist or letter is required, the patient is informed by the medical provider what a medication's effects (reversible, and irreversible) will be when administered. The patient, once informed, gives their consent to receive such treatment under the care of the provider. ICATH promotes a departure from the system that uses Gender Identity Disorder Diagnosis and Gender Dysphoria as a means for accessing gender-confirming health care, and follows the Standard of Care already established for non-trans people accessing gender affirming healthcare.

=== Introduce Informed Consent to Your Medical Provider Using This Letter === Dear Provider: Thank you for working with me. As my provider you are in the position to offer me medical care that can support me to express my gender physically. I am writing this letter to request that you follow the standards of care outlined for this medication or procedure and allow us to use informed consent. I am aware of the following in regards to this gender affirming care and expect to discuss this with you in our appointment: I am informed on the psychosocial impacts of this medical procedure and/or medication and am able to make an informed decision. Sincerely, _______
 * Potential social consequences
 * Potential occupational consequences
 * Potential effects on familial relationships
 * Potential financial costs
 * Potential impacts on mental and physical health

Writing a letter with a Mental Health Counselor
NOTE: Replace all Red Font with your details  DATE   PROVIDER NAME   ADDRESS   ADDRESS   PHONE/FAX  Dear  PROVIDER NAME:  ''' PATIENT NAME has met with a therapist/advocate regarding hormone use. ''' PATIENT PRONOUN has discussed the following in regards to beginning hormone use: ''' PATIENT NAME is informed on the psychosocial impacts of hormone use and is able to make an informed decision. Sincerely, ''' THERAPIST NAME, CREDENTIAL Therapist/Advocate I, ''' PATIENT NAME, have explored the potential psychosocial impacts of hormone use and am able to make an informed decision. Sincerely,
 * Potential social consequences
 * Potential occupational consequences
 * Potential effects on familial relationships
 * Potential financial costs
 * Potential impacts on mental and physical health

DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults
 A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:  A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)  A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender) A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)</li> </ol> The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.</li> Specify if: <ol> The condition exists with a disorder of sex development.</li> The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).</li> </ol> </ol>

ICD-10 Criteria for Transsexualism
NOTE: This is considered an outdated definition and it's revision is being discussed for future editions.
 * Transsexualism (F64.0) has three criteria:
 * 1) The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments.
 * 2) The transsexual identity has been present persistently for at least 2 y.
 * 3) The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality.

Tanner Stages of Breast Development and Male External Genitalia
The description of Tanner stages for breast development: <ol> Prepubertal</li> Breast and papilla elevated as small mound; areolar diameter increased</li> Breast and areola enlarged, no contour separation</li> Areola and papilla form secondary mound</li> Mature; nipple projects, areola part of general breast contour</li> </ol> For penis and testes: <ol> Prepubertal, testicular volume, 4 mL</li> Slight enlargement of penis; enlarged scrotum, pink, texture altered, testes 4–6 mL</li> Penis longer, testes larger (8–12 mL)</li> Penis and glans larger, including increase in breadth; testes larger (12–15 mL), scrotum dark</li> Penis adult size; testicular volume. 15 ml</li> </ol>

Criteria for Gender-Affirming Hormone Therapy for Adolescents
Adolescents are eligible for GnRH agonist treatment if: <ol> A qualified MHP has confirmed that:</li> <ul> the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),</li> gender dysphoria worsened with the onset of puberty,</li> <li>any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,</li> <li>the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,</li> </ul> <li>And the adolescent:</li> <ul> <li>has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,</li> <li>has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending onb applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,</li> </ul> <li>And a pediatric endocrinologist or other clinician experienced in pubertal assessment</li> <ul> <li>agrees with the indication for GnRH agonist treatment,</li> <li>has confirmed that puberty has started in the adolescent (Tanner stage G2/B2),</li> <li>has confirmed that there are no medical contraindications to GnRH agonist treatment.</li> </ul> </ol> Adolescents are eligible for subsequent sex hormone treatment if: <ol> <li>A qualified MHP has confirmed:</li> <ul> <li>the persistence of gender dysphoria,</li> <li>any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,</li> <li>the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,</li> </ul> <li>And the adolescent:</li> <ul> <li>has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility),</li> <li>has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,</li> </ul> <li>And a pediatric endocrinologist or other clinician experienced in pubertal induction:</li> <ul> <li>agrees with the indication for sex hormone treatment,</li> <li>has confirmed that there are no medical contraindications to sex hormone treatment.</li> </ul> </ol>

Criteria for Gender-Affirming Hormone Therapy for Adults
<ol> <li>Persistent, well-documented gender dysphoria/gender incongruence</li> <li>The capacity to make a fully informed decision and to consent for treatment</li> <li>The age of majority in a given country (if younger, follow the criteria for adolescents)</li> <li>Mental health concerns, if present, must be reasonably well controlled</li> </ol>

Competency of Mental Health Professionals Working with Children or Adolescents with Gender Dysphoria
The following are recommended minimum credentials for mental health professionals who assess, refer, and offer therapy to children and adolescents presenting with gender dysphoria:
 * 1) Meet the competency requirements for mental health professionals working with adults, as outlined in  "Qualified Mental Health Proffessionals"
 * 2) Trained in childhood and adolescent developmental psychopathology;
 * 3) Competent in diagnosing and treating the ordinary problems of children and adolescents.

Competency of Mental Health Professionals Working with Adults Who Present with Gender Dysphoria

 * 1) A master’s degree or its equivalent in a clinical behavioral science field. This degree or a more advanced one should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country.
 * 2) Competence in using the  Diagnostic Statistical Manual of Mental Disorders and/or the  International Classification of Diseases for diagnostic purposes.
 * 3) Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria.
 * 4) Documented supervised training and competence in psychotherapy or counseling.
 * 5) Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
 * 6) Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

Psychosocial Assessment

 * 1) Assess gender dysphoria
 * 2) Provide information regarding options for gender identity and expression and possible medical interventions
 * 3) Assess, diagnose, and discuss treatment options for co-existing mental health concerns Clients presenting with gender dysphoria may struggle with a range of mental health concerns (Gómez-Gil, Trilla, Salamero, Godás, & Valdés, 2009; Murad et al., 2010) whether related or unrelated to what is often a long history of gender dysphoria and/or chronic minority stress. Possible concerns include anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders (Bockting et al., 2006; Nuttbrock et al., 2010; Robinow, 2009). Mental health professionals should screen for these and other mental health concerns and incorporate the identified concerns into the overall treatment plan. These concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender dysphoria (Bockting et al., 2006; Fraser, 2009a; Lev, 2009). Addressing these concerns can greatly facilitate the resolution of gender dysphoria, possible changes in gender role, the making of informed decisions about medical interventions, and improvements in quality of life.

Some clients may benefit from psychotropic medications to alleviate symptoms or treat coexisting mental health concerns. Mental health professionals are expected to recognize this and either provide pharmacotherapy or refer to a colleague who is qualified to do so. The presence of co-existing mental health concerns does not necessarily preclude possible changes in gender role or access to feminizing/masculinizing hormones or surgery; rather, these concerns need to be optimally managed prior to or concurrent with treatment of gender dysphoria. In addition clients should be assessed for their ability to provide educated and informed consent for medical treatments.

Qualified mental health professionals are specifically trained to assess, diagnose, and treat (or refer to treatment for) these co-existing mental health concerns. Other health professionals with appropriate training in behavioral health, particularly when functioning as part of a multidisciplinary specialty team providing access to feminizing/masculinizing hormone therapy, may also screen for mental health concerns and, if indicated, provide referral for comprehensive assessment and treatment by a qualified mental health professional. <div style="border:1px; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;">
 * 1) If applicable, assess eligibility, prepare, and refer for hormone therapy
 * HRT referral letter overview:
 * The client’s general identifying characteristics;
 * Results of the client’s psychosocial assessment, including any diagnoses;
 * The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
 * An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;
 * A statement about the fact that informed consent has been obtained from the patient;
 * A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

Protocol Induction of Puberty

 * Induction of female puberty with oral 17b-estradiol, increasing the dose every 6 mo:
 * 5 μg/kg/d
 * 10 μg/kg/d
 * 15 μg/kg/d
 * 20 μg/kg/d
 * Adult dose = 2–6 mg/d
 * In postpubertal transgender female adolescents, the dose of 17b-estradiol can be increased more rapidly:
 * 1 mg/d for 6 mo
 * 2 mg/d


 * Induction of female puberty with transdermal 17b-estradiol, increasing the dose every 6 mo (new patch is placed every 3.5 d):
 * 6.25–12.5 μg/24 h (cut 25-μg patch into quarters, then halves)
 * 25 μg/24 h
 * 37.5 μg/24 h
 * Adult dose 5 50–200 μg/24 h
 * For alternatives once at adult dose, see "Hormone Regimens in Transgender Persons"
 * Adjust maintenance dose to mimic physiological estradiol levels (see "Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female").


 * Induction of male puberty with testosterone esters increasing the dose every 6 mo (IM or SC):
 * 25 mg/m2/2 wk (or alternatively, half this dose weekly, or double the dose every 4 wk)
 * 50 mg/m2/2 wk
 * 75 mg/m2/2 wk
 * 100 mg/m2/2 wk
 * Adult dose = 100–200 mg every 2 wk
 * In postpubertal transgender male adolescents the dose of testosterone esters can be increased more rapidly:
 * 75 mg/2 wk for 6 mo
 * 125 mg/2 wk
 * For alternatives once at adult dose, see "Hormone Regimens in Transgender Persons"
 * Adjust maintenance dose to mimic physiological testosterone levels (see "Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Male").

Abbreviations: IM, intramuscularly; SC, subcutaneously.

Hormone Regimens in Transgender Persons
Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously. aEstrogens used with or without antiandrogens or GnRH agonist. bNot available in the United States cOne thousand milligrams initially followed by an injection at 6 wk then at 12-wk intervals. dAvoid cutaneous transfer to other individuals.

Baseline and Follow-Up Protocol During Suppression of Puberty
NOTE:"Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs . If the gonadal axis is not completely suppressed—as evidenced by (for example) menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased. During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. The following table illustrates a suggested clinical protocol."


 * Every 3–6 mo
 * Anthropometry: height, weight, sitting height, blood pressure, Tanner stages


 * Every 6–12 mo
 * Laboratory: LH, FSH, E2/T, 25OH vitamin D


 * Every 1–2 y
 * Bone density using DXA
 * Bone age on X-ray of the left hand (if clinically indicated)

Abbreviations: DXA, dual-energy X-ray absorptiometry; E2, estradiol; FSH, follicle stimulating hormone; LH, luteinizing hormone; T, testosterone;

Baseline and Follow-up Protocol During Induction of Puberty
''BMD should be monitored into adulthood (until the age of 25–30 y or until peak bone mass has been reached). For recommendations on monitoring once pubertal induction has been completed, see Tables 14 and 15.'' Abbreviation: DXA, dual-energy X-ray absorptiometry
 * Every 3–6 mo
 * Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
 * Every 6–12 mo
 * In transgender males: hemoglobin/hematocrit, lipids, testosterone, 25OH vitamin D
 * In transgender females: prolactin, estradiol, 25OH vitamin D
 * Every 1–2 y
 * BMD using DXA
 * Bone age on X-ray of the left hand (if clinically indicated)

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Male
<ol> <li>Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions.</li> <li>Measure serum testosterone every 3 mo until levels are in the normal physiologic male range: </li> <ol style="list-style-type:lower-alpha"> <li>For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. The target level is 400–700 ng/dL to 400 ng/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range.</li> <li>For parenteral testosterone undecanoate, testosterone should be measured just before the following injection. If the level is, 400 ng/dL, adjust dosing interval.</li> <li>For transdermal testosterone, the testosterone level can be measured no sooner than after 1 wk of daily application (at least 2 h after application).</li> </ol> <li>Measure hematocrit or hemoglobin at baseline and every 3 mo for the first year and then one to two times a year. Monitor weight, blood pressure, and lipids at regular intervals.</li> <li>Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss.</li> <li>If cervical tissue is present, monitoring as recommended by the American College of Obstetricians and Gynecologists.</li> <li>Ovariectomy can be considered after completion of hormone transition.</li> <li>Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society.</li> </ol>

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female
<ol> <li>. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of feminization and for development of adverse reactions.</li> <ol style="list-style-type:lower-alpha"> <li>Serum testosterone levels should be ,50 ng/dL.</li> <li>Serum estradiol should not exceed the peak physiologic range: 100–200 pg/mL.</li> </ol> <li>For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter.</li> <li>Routine cancer screening is recommended, as in nontransgender individuals (all tissues present).</li> <li>. Consider BMD testing at baseline (160). In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.</li> </ol>

Transgender female: estrogen

 * Very high risk of adverse outcomes:
 * Thromboembolic disease
 * Moderate risk of adverse outcomes:
 * Macroprolactinoma
 * Breast cancer
 * Coronary artery disease
 * Cerebrovascular disease
 * Cholelithiasis
 * Hypertriglyceridemia

Transgender male: testosterone

 * Very high risk of adverse outcomes:
 * Erythrocytosis (hematocrit . 50%)
 * Severe liver dysfunction (transaminases . threefold upper limit of normal)
 * Coronary artery disease
 * Cerebrovascular disease
 * Hypertension
 * Breast or uterine cancer

Continued Reading

 * This overview of HRT guidelines is a synopsis of "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline" and as the primary source it is an excellent source for further information.
 * Another widely recognized resource that the above article references many times is the "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People"

Feminizing Effects in Transgender Females
a Complete removal of male sexual hair requires electrolysis or laser treatment or both. b Familial scalp hair loss may occur if estrogens are stopped. c Treatment by speech pathologists for voice training is most effective Abbreviations: Unk, Unknown.

Masculinizing Effects in Transgender Males
aPrevention and treatment as recommended for biological men. bMenorrhagia requires diagnosis and treatment by a gynecologist.

About Informed Consent
The ICATH model reflects the basic human right to self-actualization. ICATH is not an institution, an agency or an organization: the use of Informed Consent is a trans-affirmative Standard of Care that is acknowledged and honored by medical providers around the world. When giving informed consent, no therapist or letter is required, the patient is informed by the medical provider what a medication's effects (reversible, and irreversible) will be when administered. The patient, once informed, gives their consent to receive such treatment under the care of the provider. ICATH promotes a departure from the system that uses Gender Identity Disorder Diagnosis and Gender Dysphoria as a means for accessing gender-confirming health care, and follows the Standard of Care already established for non-trans people accessing gender affirming healthcare.

=== Introduce Informed Consent to Your Medical Provider Using This Letter === Dear Provider: Thank you for working with me. As my provider you are in the position to offer me medical care that can support me to express my gender physically. I am writing this letter to request that you follow the standards of care outlined for this medication or procedure and allow us to use informed consent. I am aware of the following in regards to this gender affirming care and expect to discuss this with you in our appointment: I am informed on the psychosocial impacts of this medical procedure and/or medication and am able to make an informed decision. Sincerely, _______
 * Potential social consequences
 * Potential occupational consequences
 * Potential effects on familial relationships
 * Potential financial costs
 * Potential impacts on mental and physical health

Writing a letter with a Mental Health Counselor
NOTE: Replace all Red Font with your details  DATE   PROVIDER NAME   ADDRESS   ADDRESS   PHONE/FAX  Dear  PROVIDER NAME:  ''' PATIENT NAME has met with a therapist/advocate regarding hormone use. ''' PATIENT PRONOUN has discussed the following in regards to beginning hormone use: ''' PATIENT NAME is informed on the psychosocial impacts of hormone use and is able to make an informed decision. Sincerely, ''' THERAPIST NAME, CREDENTIAL Therapist/Advocate I, ''' PATIENT NAME, have explored the potential psychosocial impacts of hormone use and am able to make an informed decision. Sincerely,
 * Potential social consequences
 * Potential occupational consequences
 * Potential effects on familial relationships
 * Potential financial costs
 * Potential impacts on mental and physical health

DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults
<div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;"> <ol style="list-style-type:lower-alpha"> <li>A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 mo in duration, as manifested by at least two of the following:</li> <ol> <li>A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)</li> <li>A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)</li> <li>A strong desire for the primary and/or secondary sex characteristics of the other gender</li> <li>A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)</li> <li> A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)</li> <li>A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)</li> </ol> <li>The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.</li> Specify if: <ol> <li>The condition exists with a disorder of sex development.</li> <li>The condition is posttransitional, in that the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one sex-related medical procedure or treatment regimen—namely, regular sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).</li> </ol> </ol>

ICD-10 Criteria for Transsexualism
<div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;"> NOTE: This is considered an outdated definition and it's revision is being discussed for future editions.
 * Transsexualism (F64.0) has three criteria:
 * 1) The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments.
 * 2) The transsexual identity has been present persistently for at least 2 y.
 * 3) The disorder is not a symptom of another mental disorder or a genetic, DSD, or chromosomal abnormality.

Tanner Stages of Breast Development and Male External Genitalia
<div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;">

The description of Tanner stages for breast development: <ol> <li>Prepubertal</li> <li>Breast and papilla elevated as small mound; areolar diameter increased</li> <li>Breast and areola enlarged, no contour separation</li> <li>Areola and papilla form secondary mound</li> <li>Mature; nipple projects, areola part of general breast contour</li> </ol> For penis and testes: <ol> <li>Prepubertal, testicular volume, 4 mL</li> <li>Slight enlargement of penis; enlarged scrotum, pink, texture altered, testes 4–6 mL</li> <li>Penis longer, testes larger (8–12 mL)</li> <li>Penis and glans larger, including increase in breadth; testes larger (12–15 mL), scrotum dark</li> <li>Penis adult size; testicular volume. 15 ml</li> </ol>

Criteria for Gender-Affirming Hormone Therapy for Adolescents
<div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;"> Adolescents are eligible for GnRH agonist treatment if: <ol> <li>A qualified MHP has confirmed that:</li> <ul> <li>the adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed),</li> <li>gender dysphoria worsened with the onset of puberty,</li> <li>any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment,</li> <li>the adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment,</li> </ul> <li>And the adolescent:</li> <ul> <li>has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility,</li> <li>has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending onb applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,</li> </ul> <li>And a pediatric endocrinologist or other clinician experienced in pubertal assessment</li> <ul> <li>agrees with the indication for GnRH agonist treatment,</li> <li>has confirmed that puberty has started in the adolescent (Tanner stage G2/B2),</li> <li>has confirmed that there are no medical contraindications to GnRH agonist treatment.</li> </ul> </ol> Adolescents are eligible for subsequent sex hormone treatment if: <ol> <li>A qualified MHP has confirmed:</li> <ul> <li>the persistence of gender dysphoria,</li> <li>any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start sex hormone treatment,</li> <li>the adolescent has sufficient mental capacity (which most adolescents have by age 16 years) to estimate the consequences of this (partly) irreversible treatment, weigh the benefits and risks, and give informed consent to this (partly) irreversible treatment,</li> </ul> <li>And the adolescent:</li> <ul> <li>has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility),</li> <li>has given informed consent and (particularly when the adolescent has not reached the age of legal medical consent, depending on applicable legislation) the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process,</li> </ul> <li>And a pediatric endocrinologist or other clinician experienced in pubertal induction:</li> <ul> <li>agrees with the indication for sex hormone treatment,</li> <li>has confirmed that there are no medical contraindications to sex hormone treatment.</li> </ul> </ol>

Criteria for Gender-Affirming Hormone Therapy for Adults
<div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;"> <ol> <li>Persistent, well-documented gender dysphoria/gender incongruence</li> <li>The capacity to make a fully informed decision and to consent for treatment</li> <li>The age of majority in a given country (if younger, follow the criteria for adolescents)</li> <li>Mental health concerns, if present, must be reasonably well controlled</li> </ol>

Competency of Mental Health Professionals Working with Children or Adolescents with Gender Dysphoria
The following are recommended minimum credentials for mental health professionals who assess, refer, and offer therapy to children and adolescents presenting with gender dysphoria: <div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;">
 * 1) Meet the competency requirements for mental health professionals working with adults, as outlined in  "Qualified Mental Health Proffessionals"
 * 2) Trained in childhood and adolescent developmental psychopathology;
 * 3) Competent in diagnosing and treating the ordinary problems of children and adolescents.

Competency of Mental Health Professionals Working with Adults Who Present with Gender Dysphoria

 * 1) A master’s degree or its equivalent in a clinical behavioral science field. This degree or a more advanced one should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country.
 * 2) Competence in using the  Diagnostic Statistical Manual of Mental Disorders and/or the  International Classification of Diseases for diagnostic purposes.
 * 3) Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria.
 * 4) Documented supervised training and competence in psychotherapy or counseling.
 * 5) Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
 * 6) Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

Psychosocial Assessment

 * 1) Assess gender dysphoria
 * 2) Provide information regarding options for gender identity and expression and possible medical interventions
 * 3) Assess, diagnose, and discuss treatment options for co-existing mental health concerns Clients presenting with gender dysphoria may struggle with a range of mental health concerns (Gómez-Gil, Trilla, Salamero, Godás, & Valdés, 2009; Murad et al., 2010) whether related or unrelated to what is often a long history of gender dysphoria and/or chronic minority stress. Possible concerns include anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders (Bockting et al., 2006; Nuttbrock et al., 2010; Robinow, 2009). Mental health professionals should screen for these and other mental health concerns and incorporate the identified concerns into the overall treatment plan. These concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender dysphoria (Bockting et al., 2006; Fraser, 2009a; Lev, 2009). Addressing these concerns can greatly facilitate the resolution of gender dysphoria, possible changes in gender role, the making of informed decisions about medical interventions, and improvements in quality of life.

Some clients may benefit from psychotropic medications to alleviate symptoms or treat coexisting mental health concerns. Mental health professionals are expected to recognize this and either provide pharmacotherapy or refer to a colleague who is qualified to do so. The presence of co-existing mental health concerns does not necessarily preclude possible changes in gender role or access to feminizing/masculinizing hormones or surgery; rather, these concerns need to be optimally managed prior to or concurrent with treatment of gender dysphoria. In addition clients should be assessed for their ability to provide educated and informed consent for medical treatments.

Qualified mental health professionals are specifically trained to assess, diagnose, and treat (or refer to treatment for) these co-existing mental health concerns. Other health professionals with appropriate training in behavioral health, particularly when functioning as part of a multidisciplinary specialty team providing access to feminizing/masculinizing hormone therapy, may also screen for mental health concerns and, if indicated, provide referral for comprehensive assessment and treatment by a qualified mental health professional. <div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;">
 * 1) If applicable, assess eligibility, prepare, and refer for hormone therapy
 * HRT referral letter overview:
 * 1) The client’s general identifying characteristics;
 * 2) Results of the client’s psychosocial assessment, including any diagnoses;
 * 3) The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
 * 4) An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;
 * 5) A statement about the fact that informed consent has been obtained from the patient;
 * 6) A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

Protocol Induction of Puberty

 * Induction of female puberty with oral 17b-estradiol, increasing the dose every 6 mo:
 * 5 μg/kg/d
 * 10 μg/kg/d
 * 15 μg/kg/d
 * 20 μg/kg/d
 * Adult dose = 2–6 mg/d
 * In postpubertal transgender female adolescents, the dose of 17b-estradiol can be increased more rapidly:
 * 1 mg/d for 6 mo
 * 2 mg/d


 * Induction of female puberty with transdermal 17b-estradiol, increasing the dose every 6 mo (new patch is placed every 3.5 d):
 * 6.25–12.5 μg/24 h (cut 25-μg patch into quarters, then halves)
 * 25 μg/24 h
 * 37.5 μg/24 h
 * Adult dose 5 50–200 μg/24 h
 * For alternatives once at adult dose, see "Hormone Regimens in Transgender Persons"
 * Adjust maintenance dose to mimic physiological estradiol levels (see "Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female").


 * Induction of male puberty with testosterone esters increasing the dose every 6 mo (IM or SC):
 * 25 mg/m2/2 wk (or alternatively, half this dose weekly, or double the dose every 4 wk)
 * 50 mg/m2/2 wk
 * 75 mg/m2/2 wk
 * 100 mg/m2/2 wk
 * Adult dose = 100–200 mg every 2 wk
 * In postpubertal transgender male adolescents the dose of testosterone esters can be increased more rapidly:
 * 75 mg/2 wk for 6 mo
 * 125 mg/2 wk
 * For alternatives once at adult dose, see "Hormone Regimens in Transgender Persons"
 * Adjust maintenance dose to mimic physiological testosterone levels (see "Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Male").

Abbreviations: IM, intramuscularly; SC, subcutaneously.

Hormone Regimens in Transgender Persons
Transgender females a Estrogen <div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;"> Anti-androgens GnRH agonist
 * Oral
 * Transdermal
 * Parenteral

Transgender males Testosterone <div style="border:1px solid black; padding: 5px; margin-left: 5px; margin-right: 5px; margin-top: 10px; margin-bottom: 10px;">
 * Parenteral testosterone
 * Transdermal testosterone

Abbreviations: IM, intramuscularly; SQ, sequentially; SC, subcutaneously. aEstrogens used with or without antiandrogens or GnRH agonist. bNot available in the United States cOne thousand milligrams initially followed by an injection at 6 wk then at 12-wk intervals. dAvoid cutaneous transfer to other individuals.

Baseline and Follow-Up Protocol During Suppression of Puberty
NOTE:"Measurements of gonadotropin and sex steroid levels give precise information about gonadal axis suppression, although there is insufficient evidence for any specific short-term monitoring scheme in children treated with GnRH analogs . If the gonadal axis is not completely suppressed—as evidenced by (for example) menses, erections, or progressive hair growth—the interval of GnRH analog treatment can be shortened or the dose increased. During treatment, adolescents should be monitored for negative effects of delaying puberty, including a halted growth spurt and impaired bone mineral accretion. The following table illustrates a suggested clinical protocol."


 * Every 3–6 mo
 * Anthropometry: height, weight, sitting height, blood pressure, Tanner stages


 * Every 6–12 mo
 * Laboratory: LH, FSH, E2/T, 25OH vitamin D


 * Every 1–2 y
 * Bone density using DXA
 * Bone age on X-ray of the left hand (if clinically indicated)

Abbreviations: DXA, dual-energy X-ray absorptiometry; E2, estradiol; FSH, follicle stimulating hormone; LH, luteinizing hormone; T, testosterone;

Baseline and Follow-up Protocol During Induction of Puberty
''BMD should be monitored into adulthood (until the age of 25–30 y or until peak bone mass has been reached). For recommendations on monitoring once pubertal induction has been completed, see Tables 14 and 15.'' Abbreviation: DXA, dual-energy X-ray absorptiometry
 * Every 3–6 mo
 * Anthropometry: height, weight, sitting height, blood pressure, Tanner stages
 * Every 6–12 mo
 * In transgender males: hemoglobin/hematocrit, lipids, testosterone, 25OH vitamin D
 * In transgender females: prolactin, estradiol, 25OH vitamin D
 * Every 1–2 y
 * BMD using DXA
 * Bone age on X-ray of the left hand (if clinically indicated)

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Male
<ol> <li>Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of virilization and for development of adverse reactions.</li> <li>Measure serum testosterone every 3 mo until levels are in the normal physiologic male range: </li> <ol style="list-style-type:lower-alpha"> <li>For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. The target level is 400–700 ng/dL to 400 ng/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range.</li> <li>For parenteral testosterone undecanoate, testosterone should be measured just before the following injection. If the level is, 400 ng/dL, adjust dosing interval.</li> <li>For transdermal testosterone, the testosterone level can be measured no sooner than after 1 wk of daily application (at least 2 h after application).</li> </ol> <li>Measure hematocrit or hemoglobin at baseline and every 3 mo for the first year and then one to two times a year. Monitor weight, blood pressure, and lipids at regular intervals.</li> <li>Screening for osteoporosis should be conducted in those who stop testosterone treatment, are not compliant with hormone therapy, or who develop risks for bone loss.</li> <li>If cervical tissue is present, monitoring as recommended by the American College of Obstetricians and Gynecologists.</li> <li>Ovariectomy can be considered after completion of hormone transition.</li> <li>Conduct sub- and periareolar annual breast examinations if mastectomy performed. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society.</li> </ol>

Monitoring of Transgender Persons on Gender-Affirming Hormone Therapy: Transgender Female
<ol> <li>. Evaluate patient every 3 mo in the first year and then one to two times per year to monitor for appropriate signs of feminization and for development of adverse reactions.</li> <ol style="list-style-type:lower-alpha"> <li>Serum testosterone levels should be ,50 ng/dL.</li> <li>Serum estradiol should not exceed the peak physiologic range: 100–200 pg/mL.</li> </ol> <li>For individuals on spironolactone, serum electrolytes, particularly potassium, should be monitored every 3 mo in the first year and annually thereafter.</li> <li>Routine cancer screening is recommended, as in nontransgender individuals (all tissues present).</li> <li>. Consider BMD testing at baseline (160). In individuals at low risk, screening for osteoporosis should be conducted at age 60 years or in those who are not compliant with hormone therapy.</li> </ol>

Transgender female: estrogen

 * Very high risk of adverse outcomes:
 * Thromboembolic disease
 * Moderate risk of adverse outcomes:
 * Macroprolactinoma
 * Breast cancer
 * Coronary artery disease
 * Cerebrovascular disease
 * Cholelithiasis
 * Hypertriglyceridemia

Transgender male: testosterone

 * Very high risk of adverse outcomes:
 * Erythrocytosis (hematocrit . 50%)
 * Severe liver dysfunction (transaminases . threefold upper limit of normal)
 * Coronary artery disease
 * Cerebrovascular disease
 * Hypertension
 * Breast or uterine cancer

Continued Reading

 * This overview of HRT guidelines is a synopsis of "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline" and as the primary source it is an excellent source for further information.
 * Another widely recognized resource that the above article references many times is the "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People"