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TransMed

A Defense for
Contrahormonal Treatment
In Non-Transsexuals

by Sheila Kirk, M.D.


Who should be considered appropriate to take medications that can alter the body in profound ways and when is it reasonable to initiate them?

Most of us are aware of the controversies that exist in determining what individuals are candidates for contrahormonal therapy and when a regimen should be initiated and monitored for those individuals. The Harry Benjamin International Gender Dysphoria Association conference held this September in Vancouver highlighted in its program the presentation of criteria revisions on this very point, trying to answer these very difficult concerns.

A committee of very experienced and knowledgeable physicians, surgeons and mental health care professionals, under the guidance of their chairperson, Dr. Stephen Levine, have labored vigorously to find answers to those questions along with others of complexity and decided importance. All are extraordinarily experienced in the diagnosis and management of the person with gender identity disorder. Some are transgendered themselves, others not, but all once again are gifted in their knowledge and experience. And they gave hours and days into weeks and months during a year or more to set criteria that will prove acceptable and beneficial to the patient/client and their professional caregivers. Professionals will review their work and use their wisdom in their approaches to those they care for in the future. And here I come ---proposing another concept-- another idea in the management and treatment plan of us; the Transgendered person. The spectrum or continuum of the transgendered individual can be complex and lengthy for some of you whose gender identity and even gender role is not clear. Some of you may go only so far in their assessment of self -- and never move beyond a certain place.

Others may move into more open and defined expressions of self -- into open contragender living or even full time roles and some of you may go on to consider genital reassignment and considerable cosmetic surgeries. You may go in and out of these modes. Sadly, some of you might even offend society, destroy family, carelessly decimate finances and work place status and carry various personality disorders into your lives in the contragender role to the point of destroying yourselves.

Others of you, probably most, are much more stable, cautious and thoughtful of what you intend but still you are unknowing, naïve, and in deep need of someone to talk with, discuss with, plan with, even to a degree, argue with.

That someone is the counselor, the therapist-the mental health care provider!

I vigorously endorse the involvement of the trained-therapist who is additionally trained in transgender gender care and management-and that is in strong disagreement with many I know who believe that they alone know what they want and need and will demand, without professional guidance. But I also believe that there are a number of gender confused or conflicted or as I like to think of us, gifted individuals who can be candidates for contra hormonal regimens even though:

a) they may not consider themselves as candidates for genital reassignment in the future or
b) even though, here and now, they are not considered by an experienced counselor to be candidates for surgical reassignment-at a later date-they may become candidates.
In essence, I am saying that hormonal therapy should be offered to a choice number of individuals who for whatever reason or reasons, who will not be candidates for genital surgery or even for a partial or full time assumption of a contra gender role. Now that is a stance that without doubt can create controversy like the controversy that surrounds the question of when to start hormones-before the start of the real life test or sometime after it is begun?

Why have I come to this thought and a comfortable acceptance of it? Because frankly, I have had so many experiences with individuals who want this approach, who feel it vital to their nature and spirit, who find it an appropriate therapy to their souls-if not at all a therapy to their bodies. Believe this: the number of calls I receive from you who want some opportunity for hormone use, far out distances the patient/client contacts professionals have with individuals who do want genital reassignment and who do want to bring conformity to their lives, in mind and body.

In the beginning many years ago I told all those not heading for GRS, it was not possible. That such a meddlesome approach to the human body's homeostasis was out of the question. That this kind of tampering with the genetically programmed biochemistry and physiology of our physical being was foolish, even ridiculous, because this very involved process was only for those who had to have a change in their anatomy. It was not appropriate to even contemplate such treatment on a lesser scale.

To "tiptoe" into hormones was not reasonable. One must plunge into the hormone pool and expect to come out drenched and transformed to whatever extent that was possible in the individual's organ capability and tissue responsivity. After a time, I began to think about those requests. I began to analyze my statements about "having one's cake and being able to eat it too"-about "having voluptuous breasts and penis quick to erect and bring satisfaction to the owner and to the partner." I began to think that maybe there was something else to consider. I began to think that between the extremes of the fetishistic crossdresser and the true high intensity transsexual, there were many compartments -- a few more than Dr. Harry Benjamin had allowed for in his sex orientation scale -- and that for whatever the reasons and the circumstances, people often moved through those compartments and their positions were not always stationary or static.

I began to think that they may impose restrictions upon themselves or have restrictions imposed upon them, to keep them in a compartment for a time but when permitted, they could advance to the very end of the spectrum or to some place near to it. And I began to believe that they needed some help, some therapy or treatment to assist them in that movement, rapid or slow as it may be, and that asking for that help deserved an answer a great deal less rigid that I had been offering.

It was in London, England while on a lecture tour that I had opportunity to speak with Dr. Russell Reid on several occasions about his management of a large group of transsexuals in his practice. As we spoke of a number of things he told me of his early use of low dose hormonal therapy to aid him in his impressions and subsequent diagnosis of individuals as candidates for hormones and eventual surgical treatment. He told me of how it helped to sort out those who self-diagnose erroneously and how even low dose medication assisted the anxiety and stress of individuals struggling with so many issues in their lives. Thinking about this I recalled Dr. Benjamin's sex orientation scale-in his category IV, the transsexual-non-surgical patient, hormones were a real potential and often needed for comfort and emotional balance in that patient.

I began to revise my thoughts, my black and white belief that hormones must be reserved for the well-defined, 'moving forward' transsexual. Was there perhaps a person or two who could be a candidate for low dose hormones? What evaluations would be necessary? What criteria established what education and instruction needed? This was not a venture for the light hearted or flippant. It meant careful evaluation and selection, monitoring as was planned and executed for the confirmed transsexual and most important, clear, precise and in depth education of the patient/client. There must be no place for fantasy or false expectations. The patient/client has to know what ground they are going to tread upon, and with continued counseling to resolve issues that have to do with confusion in self and perhaps a goal and a plan for reaching it in later life.

Truly, it means close cooperation with counselor and physician and patient/client. It means that no one is offended or destroyed in the process-wife, children, native family in particular. It means rational and realistic understanding of what this is all about and perhaps what it is leading up to.

Who are candidates for such a program?

When we look at the MTF and FTM perspectives: 1) The need for absolute comfort with a spouse and other involved family members. No one can embark on a regime that can lead to marital disruption. This in practice can be a real difficulty for many.

2) There is no place for dare-deviling or embarking on programs in excess of the regimens limits

3) Some degrees of ongoing counseling is necessary and important. Life situations change. Individuals will find stimulus or reason to move to another place on the continuum. Whatever it may be with such potentials, individuals need to assess and reassess what they are doing or intend to do.

4) Medical monitoring is vastly important. Any ill health developing independently or because of the regimen must be guarded against and dealt with fully and competently by the physician who understands and is empathetic to the individual. This can be a problem of major importance.

To begin with what do I suggest for individuals who want low dose medication such that they can retain their male characteristics and activities including sex and yet feel a degree of contragender change and attitude?

Natural occurring medications, which not a worthwhile approach for the person seeking energetic feminization or masculanization, are still very acceptable to this person wishing to attain a lesser level of accomplishment.

While we have no good data on dosages in various preparations and no good control studies that I'm aware of in individuals wanting some degree of contrahormonal changes-they can be very satisfying and bring about huge amounts of psyche comfort and a small degree of physical change. Though not near to the results of prescribed medications.

Do they need medical monitoring still? Absolutely and because there products are easily obtained without a prescription, good rapport and understanding is absolute between patient and the professional.

Low dose prescription medication is also possible in these patients. Marital and family circumstances and social/workplace situations could allow for low dose therapy properly monitored.

These patient/clients can be selected with care and good success. And what of individuals with no marital or family ties with no special impediments to hormone use-are they not in a position for even more in depth consideration? Are the results rewarding to the patient and to the therapist and physician? They are, unreservedly, and my clinical experience tells me this is so. Irreversible problems of major nature may not be encountered with individuals who want to feminize.

They are encountered with genetic females who want to masculinize. In real terms, testosterone is much more powerful and energetic in reversing many systems in the female body than is estrogen in the male body. Many of these disruptions are truly permanent and irreversible. In summary, I add a new concern, a new problem, to ones we are trying to resolve.

I could be considered a maverick transgendered physician in my approach to the treatment of my patients. But my pleas are for the Transgendered individual no matter where they reside on the spectrum. Our population is underserved so often in so many ways. Thoughtful, careful and considered evaluation and care is a mandate for all caring for our community.


Sheila Kirk, MD is a Transgender Medicine Specialist, board-certified in Obstetrics and Gynecology and in practice in Pittsburgh, PA. She is on the board of the Harry Benjamin International Gender Dysphoria Association. She is also a well-known author and leading authority on transgendered medical care and research. Dr. Kirk provides international and national consultations and referrals to the TG community and health care professionals who assist in their care.

She can be reached the following ways:

    E-mail: SheilaKirk@aol.com
    Phone: (412) 781-1092 Fax: (412) 781-1096
    mailing address: Sheila Kirk, P.O. Box 38114, Blawnox, Pa 15238-8114


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