Gender dysphoria is defined as the psychological distress experienced by a person when their gender identity conflicts with their assigned sex at birth. It oftens begins at childhood, but differs for different people, sometimes occurring during or after puberty. “Transgender” is used to refer to a person whose assigned sex does not match their gender identity, and they frequently have to deal with gender dysphoria. In order to combat it, trans people seek several ways of gender affirmation, which can be social (changing one’s name and pronouns), legal (altering government-issued documents with gender markers), or medical (augmentation surgeries, hormone replacement therapy). It is imperative to remember that these procedures are highly personal decisions, and not every transgender person will seek out all of them.
Hormone replacement therapy (HRT) is a medical procedure which allows trans/non-binary/intersex people to more closely align their secondary sexual characteristics with their preferred gender identity. Cross-sex hormone therapy has been shown to have positive physical and psychological effects on the transitioning individual. The principle of HRT is that the body is artificially provided with hormones it does not synthesize, or suppresses hormones that produce undesirable physical expression. Testosterone therapy is primarily used to suppress female secondary sexual characters, i.e., masculinize the recepients, who tend to be transgender men. Expected changes include amenorrhea (suspension of menstrual cycles), increased facial and body hair, deepening of the voice, and atrophy of the vaginal epithelium. In some cases, male pattern hair loss is observed. Estrogen therapy, usually catering to transgender women, is intended to feminize patients by changing fat distribution, inducing breast formation, and reducing male pattern hair loss. A negative feedback loop suppresses gonadotropin (gonad-stimulating hormone) secretion from the pituitary gland, thus reducing androgen production. Often, estrogen therapy alone is not enough, anti-androgenic therapy is necessary for desirable androgen suppression.
These procedures are seen to improve the quality of life greatly. In fact, there is potential biological evidence that explains the positive effects on sexual function and mood. Kranz et al. observed that testosterone treatment in trans men increased SERT (serotonin reuptake transporter, whose expression is reduced in individuals with depression) binding in several places in the brain. It must be noted that the study had a relatively small sample size, and this data is preliminary. While undergoing hormonal treatment, it is also important to keep a close eye on bone density and cardiovascular health, however, routine laboratory monitoring can be difficult as results are reported as gender-specific intervals, which do not apply to all transgender individuals.
In the past, patients required a “real-life test” before initiating HT (hormone therapy), which stipulated that they must live as their self-affirmed gender for a specific period of time. However, the World Professional Association for Transgender Health (WPATH) and the Endocrine Society have recognised the unreasonable nature of this condition, and updated guidelines do not require this. Per WPATH, a referral by a qualified medical health professional is required, but several activists have spoken out against this, calling it out as “gatekeeping” which prevents individuals from transitioning. Howard Brown Health, an organisation in Chicago for LGBTQ+ healthcare, has brought in the concept of informed consent:
“Howard Brown believes that people have a right to make decisions about their gender, gender identity and whether they would like to use HT. In many places in the past, patients had to get a letter from a therapist saying that they could get HT before they could get hormones. Howard Brown does not believe that people need therapy before they can make a decision about whether HT is right for them. Howard Brown believes that people should be given complete, accurate information, and supported in making their own decisions about whether to get HT or not.”
According to the draft of the Transgender Persons (Protection of Rights) Rules 2020, it is mandatory for at least one government hospital in a state to offer sex reassignment surgeries along with hormone therapy free of cost. Hormone Replacement Therapy remains a frequently sought-after choice, and it is the country’s duty to provide for those who need it, as it plays a pivotal role in ensuring the mental well-being of transgender people.
-Shreya Venkatesan B’19
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