Selected Podcast
Transgender Hormone Therapy
Dr. Srivastav discusses transgender hormone therapy. Dr. Srivastav talks about the positive physical and psychological effects, length of the treatment, and the effects of testosterone and estrogen.
Featuring:
Soni Srivastav, MD
Soni Srivastav, MD is fellowship trained in Endocrinology, Diabetes and Metabolism from the University of Alabama at Birmingham. She completed her medical training at Tribhuvan University Institute of Medicine in Nepal and her residency at Crozer Chester Medical Center near Philadelphia. Dr. Srivastav is board-certified in Internal Medicine and was a physician with the Himalayan Rescue Association. She is a member of the American Association of Clinical Endocrinologists and has an interest in patients with pituitary problems. Dr. Srivastav also sees transgender patients for hormone therapy. Transcription:
Bill Klaproth: Can you imagine growing up and not feeling right in your skin, feeling like you don't belong. That's how many transgender people feel, and individuals who are transitioning seek out hormone therapy as part of the transition process, as hormone therapy not only has benefits physically, but also mentally, which is really important. So let's talk about the transition process and the role of hormone therapy with Dr. Soni Srivastav, an endocrinologist with UPMC.
This is Healthier You, a podcast from UPMC in Central Pennsylvania. I'm Bill Klaproth. Dr. Srivastav, thank you for your time. We really appreciate this. Let's start with this, just so we all have an understanding of what we're talking about today. When we hear the term transgender, I think we all know what that means or do we? So can you set the record straight so we really understand this. What does transgender mean?
Dr. Soni Srivastav: So gender identity refers to a person's deep inner sense of being male, being female, being neither, or it being a combination of both. So the terms transgender is used. Transsexual, just trans, gender non-binary, gender incongruent and gender queer are some of the terms that are used to describe people whose gender identity does not align with the sex that is recorded at birth.
Bill Klaproth: Okay. So all of those fall under the umbrella then of transgender.
Dr. Soni Srivastav: That is correct, yes. Essentially, it's someone who's at birth, the gender was recorded as let's say female or a male, and they do not see themselves as either a female or male or what was recorded.
Bill Klaproth: Right. Okay. Well, thank you for that. So many transgender men and women seek hormone therapy as a part of the transition process. Can you explain to us what is the role of hormone therapy?
Dr. Soni Srivastav: So many trans people do not need hormone therapy or do not seek it. And there are many who do. Gender dysphoria is a term that's used when there is distress regarding the gender identity. But not everyone who is trans has gender dysphoria. Not everyone thinks that they need hormone therapy. Some people are comfortable being the way they are without hormones, even though they identify as another gender.
Bill Klaproth: So hormone therapy has been shown to have positive physical and psychological effects on those that want it. As you said, not everyone wants hormone therapy or needs it. But for those who do want it and do undergo hormone therapy, can you give us an example of how this is a benefit to them?
Dr. Soni Srivastav: Yes. So hormone therapy in those who want it is very beneficial, both mentally and physically, psychologically. It helps people to transition. So transitioning is the alignment of the physical characteristics with the preferred gender identity. And transitioning can be both expressing, so we call it gender expression. Gender expression relates to how a person signals their gender identity via clothing or hairstyle, actions, mannerisms and hormone therapy helps to align the physical characteristics with the preferred identity. Almost immediately, it helps mental wellbeing, it helps psychological wellbeing. And over time, as people get the physical traits of their preferred gender, then start to feel better both emotionally and physically.
Bill Klaproth: So when we talk about hormone therapy were basically talking about testosterone and estrogen, is that correct?
Dr. Soni Srivastav: That is correct. Many transgender women and many transgender men seek hormone therapy. Transgender women are those who identify as female, although they have been assigned a male gender at birth. And transgender women are treated with estrogen. Transgender men are those who identify as male. They have been assigned female gender at birth and they receive testosterone.
Bill Klaproth: So when that happens for the individuals that request this or need it, what is the length of the hormone therapy treatment?
Dr. Soni Srivastav: The length of the hormone treatment is variable in different people. So in trans females, so along with estrogen, we also prescribe a testosterone blocker called spironolactone. Sometimes the hormonal treatment is lifelong, because they need that added hormone for psychological wellbeing, for physical wellbeing, for bone health. And sometimes depending on what surgeries or procedures can be done down the line, the hormone treatment is modified after certain surgical procedures.
But, like I said, because gender identity is a very personal thing, the treatment choices are also personal. Some people choose to stay with it lifelong. Some people choose to stay with for a few years. And some people try it for a few years and say, "I'm comfortable in my skin. I am a trans female. I don't want the hormones anymore or I don't need them anymore." And so it's a very variable length of time.
Bill Klaproth: And then once hormone therapy has been started, how soon can someone expect to see the effects of this?
Dr. Soni Srivastav: The time that is reported is about tweet to six months. But in reality, I see that almost from day one, people start to feel better mentally. They feel better psychologically. It has a very positive effect on mood. A lot of trans people have other mental health conditions, such as anxiety and depression. Not everyone does, but a lot of people do. And the hormone treatment seems to help with these almost immediately with mood disorders almost immediately. Other changes such as less facial hair, less body hair in trans females or the stopping of periods in trans males, these can take usually months, anywhere between three to six months in different people.
Bill Klaproth: So the positive mental effects of hormone therapy should not be overlooked. You just cited many trans individuals are dealing with depression, anxiety, other mental disorders. This positive boost they get from hormone therapy really can help lift a cloud in their lives. Is that right?
Dr. Soni Srivastav: That's right. I feel, in my experience, because there is such a stigma around transgender health, I have found that usually trans people wait many, many years before they approach a healthcare provider to say, "I want to go on hormones." Many people have tried to suppress their transitioning, have tried to get away from it due to social reasons, financial reasons. And when they just cannot, because that is them, then they will approach a healthcare provider, family, friends. And so they have been waiting a long time when they see me to start hormonal treatment. So I think starting those hormones has an almost immediate effect of mental wellbeing and the physical effects we see gradually with time.
Bill Klaproth: Again, as you just said, that almost immediate positive mental effect really, really is a benefit. So we've been talking about the positives of hormone therapy. Are there any risks involved?
Dr. Soni Srivastav: There are and, therefore, therapy needs to be monitored and supervised by someone who is trained to do so. When we talk about. Estrogen treatment, it carries a risk of increased blood clots. There is a risk of possibly increased cardiovascular events, such as strokes or even heart attacks. And therefore, it's very important to monitor treatment, make sure that levels are in the right range, that they're not what we call superphysiologic, which is way above normal range. So that's with the estrogen.
With the spironolactone, which is a testosterone blocker, which is also used in trans females to block the effects of testosterone, it can cause high potassium. It can cause changes in blood pressure. It can cause problems in the kidneys. So those levels have to be watched very carefully as well. When I say problems in the kidneys, it does not cause them but extremely high levels can be detrimental to renal health. And so the levels need to be monitored carefully, but if they are generally, transgender hormone therapy is considered relatively safe in people who don't have other co-morbid conditions that could be affecting hormonal treatment.
Bill Klaproth: So then the monitoring of transgender hormonal therapy only happens when they're on the medicine. Is that right?
Dr. Soni Srivastav: Yes. If they were to come off it, then we would monitor them as well. But the side effects really are when they're on the medicine and for a short time afterwards. And in trans males who are on testosterone, we watch testosterone levels closely as well. We don't want those levels to get too high, because testosterone also can potentially increase the risk of strokes or other cardiovascular events. In people who have a predisposition to sleep apnea, it can make sleep apnea worse. It can make the red blood cells go too high. It can worsen lipid profile. We watch the liver when we put people on these medications. So just a host of things that we keep an eye on. But again, even though we tend to monitor all of these for potential side effects, in general, transgender hormone therapy is considered relatively safe.
Bill Klaproth: So that is good to know. So are all transgender patients candidates for hormone therapy?
Dr. Soni Srivastav: So most people are relatively good candidates. In the past, the requirement was that anyone who wanted hormone therapy should be evaluated by a mental health professional. That is no longer a mandatory requirement. It's still recommended, because sometimes hormonal treatments can cause mood changes and it's good to have a support person that you can just talk to and go things over. So one thing is we do like people to be emotionally relativity stable, at least in terms of their mood or to have someone that they can turn to.
There are some relative contraindications. It's really a case by case. People who've had a blood clot in the past who have a history of strokes, for those people, it's really a case by case basis to say in what situations that those happen, because that could cause further strokes or blood clots. So, things like that can say this is not a great idea for you, because it could really cause harm. But most people tend to be candidates.
Bill Klaproth: Which is good news, because obviously the benefits are very positive. So as we wrap up, Dr. Srivastav, any additional thoughts you can share with us on hormone therapy or transitioning in general?
Dr. Soni Srivastav: I think the world is changing. I think that there's more acceptance for trans people, but we still have a long way to go. I think that trans people unfortunately have less access to high quality health care for trans medicine, because more and more providers need to get on board and be comfortable with treating trans people. And I think we all just need to keep an open mind about this.
The other thing I would just touch on briefly as well as surgical intervention is also a treatment option later on after hormone therapy. So just something to make people aware of. Not everyone needs surgical treatments, not everyone wants it, but it is a treatment option to help people align with their preferred identity.
Bill Klaproth: Yeah, that is good to mention. Dr. Srivastav, this has really been interesting. Thank you for your work. I know that you're helping a lot of people that grow up with a lot of conflicted feelings and in a difficult spot. And I know that you're helping them out. So thank you for all the work you do. And thank you for the information on this podcast. We appreciate it.
Dr. Soni Srivastav: Thank you very much. It's my privilege. And I'm honored to be able to do what I do. And I appreciate your reaching out to me. Thank you.
Bill Klaproth: And once again, that's Dr. Soni Srivastav. And for more information, please visit UPMC.com/CentralPA. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC. I'm Bill Klaproth. Thanks for listening.
Bill Klaproth: Can you imagine growing up and not feeling right in your skin, feeling like you don't belong. That's how many transgender people feel, and individuals who are transitioning seek out hormone therapy as part of the transition process, as hormone therapy not only has benefits physically, but also mentally, which is really important. So let's talk about the transition process and the role of hormone therapy with Dr. Soni Srivastav, an endocrinologist with UPMC.
This is Healthier You, a podcast from UPMC in Central Pennsylvania. I'm Bill Klaproth. Dr. Srivastav, thank you for your time. We really appreciate this. Let's start with this, just so we all have an understanding of what we're talking about today. When we hear the term transgender, I think we all know what that means or do we? So can you set the record straight so we really understand this. What does transgender mean?
Dr. Soni Srivastav: So gender identity refers to a person's deep inner sense of being male, being female, being neither, or it being a combination of both. So the terms transgender is used. Transsexual, just trans, gender non-binary, gender incongruent and gender queer are some of the terms that are used to describe people whose gender identity does not align with the sex that is recorded at birth.
Bill Klaproth: Okay. So all of those fall under the umbrella then of transgender.
Dr. Soni Srivastav: That is correct, yes. Essentially, it's someone who's at birth, the gender was recorded as let's say female or a male, and they do not see themselves as either a female or male or what was recorded.
Bill Klaproth: Right. Okay. Well, thank you for that. So many transgender men and women seek hormone therapy as a part of the transition process. Can you explain to us what is the role of hormone therapy?
Dr. Soni Srivastav: So many trans people do not need hormone therapy or do not seek it. And there are many who do. Gender dysphoria is a term that's used when there is distress regarding the gender identity. But not everyone who is trans has gender dysphoria. Not everyone thinks that they need hormone therapy. Some people are comfortable being the way they are without hormones, even though they identify as another gender.
Bill Klaproth: So hormone therapy has been shown to have positive physical and psychological effects on those that want it. As you said, not everyone wants hormone therapy or needs it. But for those who do want it and do undergo hormone therapy, can you give us an example of how this is a benefit to them?
Dr. Soni Srivastav: Yes. So hormone therapy in those who want it is very beneficial, both mentally and physically, psychologically. It helps people to transition. So transitioning is the alignment of the physical characteristics with the preferred gender identity. And transitioning can be both expressing, so we call it gender expression. Gender expression relates to how a person signals their gender identity via clothing or hairstyle, actions, mannerisms and hormone therapy helps to align the physical characteristics with the preferred identity. Almost immediately, it helps mental wellbeing, it helps psychological wellbeing. And over time, as people get the physical traits of their preferred gender, then start to feel better both emotionally and physically.
Bill Klaproth: So when we talk about hormone therapy were basically talking about testosterone and estrogen, is that correct?
Dr. Soni Srivastav: That is correct. Many transgender women and many transgender men seek hormone therapy. Transgender women are those who identify as female, although they have been assigned a male gender at birth. And transgender women are treated with estrogen. Transgender men are those who identify as male. They have been assigned female gender at birth and they receive testosterone.
Bill Klaproth: So when that happens for the individuals that request this or need it, what is the length of the hormone therapy treatment?
Dr. Soni Srivastav: The length of the hormone treatment is variable in different people. So in trans females, so along with estrogen, we also prescribe a testosterone blocker called spironolactone. Sometimes the hormonal treatment is lifelong, because they need that added hormone for psychological wellbeing, for physical wellbeing, for bone health. And sometimes depending on what surgeries or procedures can be done down the line, the hormone treatment is modified after certain surgical procedures.
But, like I said, because gender identity is a very personal thing, the treatment choices are also personal. Some people choose to stay with it lifelong. Some people choose to stay with for a few years. And some people try it for a few years and say, "I'm comfortable in my skin. I am a trans female. I don't want the hormones anymore or I don't need them anymore." And so it's a very variable length of time.
Bill Klaproth: And then once hormone therapy has been started, how soon can someone expect to see the effects of this?
Dr. Soni Srivastav: The time that is reported is about tweet to six months. But in reality, I see that almost from day one, people start to feel better mentally. They feel better psychologically. It has a very positive effect on mood. A lot of trans people have other mental health conditions, such as anxiety and depression. Not everyone does, but a lot of people do. And the hormone treatment seems to help with these almost immediately with mood disorders almost immediately. Other changes such as less facial hair, less body hair in trans females or the stopping of periods in trans males, these can take usually months, anywhere between three to six months in different people.
Bill Klaproth: So the positive mental effects of hormone therapy should not be overlooked. You just cited many trans individuals are dealing with depression, anxiety, other mental disorders. This positive boost they get from hormone therapy really can help lift a cloud in their lives. Is that right?
Dr. Soni Srivastav: That's right. I feel, in my experience, because there is such a stigma around transgender health, I have found that usually trans people wait many, many years before they approach a healthcare provider to say, "I want to go on hormones." Many people have tried to suppress their transitioning, have tried to get away from it due to social reasons, financial reasons. And when they just cannot, because that is them, then they will approach a healthcare provider, family, friends. And so they have been waiting a long time when they see me to start hormonal treatment. So I think starting those hormones has an almost immediate effect of mental wellbeing and the physical effects we see gradually with time.
Bill Klaproth: Again, as you just said, that almost immediate positive mental effect really, really is a benefit. So we've been talking about the positives of hormone therapy. Are there any risks involved?
Dr. Soni Srivastav: There are and, therefore, therapy needs to be monitored and supervised by someone who is trained to do so. When we talk about. Estrogen treatment, it carries a risk of increased blood clots. There is a risk of possibly increased cardiovascular events, such as strokes or even heart attacks. And therefore, it's very important to monitor treatment, make sure that levels are in the right range, that they're not what we call superphysiologic, which is way above normal range. So that's with the estrogen.
With the spironolactone, which is a testosterone blocker, which is also used in trans females to block the effects of testosterone, it can cause high potassium. It can cause changes in blood pressure. It can cause problems in the kidneys. So those levels have to be watched very carefully as well. When I say problems in the kidneys, it does not cause them but extremely high levels can be detrimental to renal health. And so the levels need to be monitored carefully, but if they are generally, transgender hormone therapy is considered relatively safe in people who don't have other co-morbid conditions that could be affecting hormonal treatment.
Bill Klaproth: So then the monitoring of transgender hormonal therapy only happens when they're on the medicine. Is that right?
Dr. Soni Srivastav: Yes. If they were to come off it, then we would monitor them as well. But the side effects really are when they're on the medicine and for a short time afterwards. And in trans males who are on testosterone, we watch testosterone levels closely as well. We don't want those levels to get too high, because testosterone also can potentially increase the risk of strokes or other cardiovascular events. In people who have a predisposition to sleep apnea, it can make sleep apnea worse. It can make the red blood cells go too high. It can worsen lipid profile. We watch the liver when we put people on these medications. So just a host of things that we keep an eye on. But again, even though we tend to monitor all of these for potential side effects, in general, transgender hormone therapy is considered relatively safe.
Bill Klaproth: So that is good to know. So are all transgender patients candidates for hormone therapy?
Dr. Soni Srivastav: So most people are relatively good candidates. In the past, the requirement was that anyone who wanted hormone therapy should be evaluated by a mental health professional. That is no longer a mandatory requirement. It's still recommended, because sometimes hormonal treatments can cause mood changes and it's good to have a support person that you can just talk to and go things over. So one thing is we do like people to be emotionally relativity stable, at least in terms of their mood or to have someone that they can turn to.
There are some relative contraindications. It's really a case by case. People who've had a blood clot in the past who have a history of strokes, for those people, it's really a case by case basis to say in what situations that those happen, because that could cause further strokes or blood clots. So, things like that can say this is not a great idea for you, because it could really cause harm. But most people tend to be candidates.
Bill Klaproth: Which is good news, because obviously the benefits are very positive. So as we wrap up, Dr. Srivastav, any additional thoughts you can share with us on hormone therapy or transitioning in general?
Dr. Soni Srivastav: I think the world is changing. I think that there's more acceptance for trans people, but we still have a long way to go. I think that trans people unfortunately have less access to high quality health care for trans medicine, because more and more providers need to get on board and be comfortable with treating trans people. And I think we all just need to keep an open mind about this.
The other thing I would just touch on briefly as well as surgical intervention is also a treatment option later on after hormone therapy. So just something to make people aware of. Not everyone needs surgical treatments, not everyone wants it, but it is a treatment option to help people align with their preferred identity.
Bill Klaproth: Yeah, that is good to mention. Dr. Srivastav, this has really been interesting. Thank you for your work. I know that you're helping a lot of people that grow up with a lot of conflicted feelings and in a difficult spot. And I know that you're helping them out. So thank you for all the work you do. And thank you for the information on this podcast. We appreciate it.
Dr. Soni Srivastav: Thank you very much. It's my privilege. And I'm honored to be able to do what I do. And I appreciate your reaching out to me. Thank you.
Bill Klaproth: And once again, that's Dr. Soni Srivastav. And for more information, please visit UPMC.com/CentralPA. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC. I'm Bill Klaproth. Thanks for listening.