Identifying as transgender or gender noncomforming is not uncommon in the college population. In a recent survey of college students, 0.2% of respondents (from a pool of 123,078) identified as transgender (National College Health Assessment II: Reference Group Executive Summary Spring 2013. Hanover, MD: American College Health Association; 2013).
Professional medical organizations are increasingly recognizing the medical necessity of treating gender dysphoria. Many insurance companies, including student health insurance carriers, now provide coverage for hormone therapy for transgender individuals. As a result, more transgender students are presenting for care, including psychiatric care, in college health centers.
In this article, I provide a brief overview of what types of hormone treatment transgender young adults may undergo and cover some of the particular psychiatric concerns in this population. For more information on interactions between hormone therapy and psychotropic medicines, see the chart “Estrogen and Testosterone for Gender Transition: Interactions with Psychotropics” on the CCPR web site.
Hormone treatment is usually managed by endocrinologists or primary care physicians with particular experience in this area. While it is uncommon for psychiatrists to manage these medications, knowing how they are used and their typical effects and side effects will be invaluable when you treat transgender patients for psychiatric issues.
Feminizing therapy generally consists of estrogen and possibly anti-androgen treatment (with a medication such as spironolactone). Commonly used doses of estrogen include transdermal estradiol 100 mcg to 200 mcg/day, sublingual estradiol 1 mg to 4 mg/day, and an initial dose of intramuscular estradiol valerate of 10 mg to 20 mg every two weeks. Lower doses may be used during the maintenance phase of treatment and after gonadectomy (UCSF Center of Excellence for Transgender Health, http://bit.ly/MqzOf9). Transdermal estrogen is preferable over oral estrogen in those with risk factors for venous thromboembolism since oral estrogen can increase the risk of this adverse event.
A commonly prescribed dose of spironolactone (an anti-androgen) is 100 mg/day, often in a divided dose, titrated up to 200 mg/day. Other medications that are at times prescribed as part of feminizing hormone therapy include 5-alpha reductase inhibitors (to help reduce scalp hair loss and improve skin condition), gonadotropin-releasing hormone agonists, and progestins (to possibly aid in breast development, although this is controversial and progestin treatment may negatively impact mood, weight, and lipids) (Coleman E et al, Int J Transgenderism 2011;13(4):165–232).
The following physical changes, which happen on a variable timeline and often over the course of two years, are expected to occur in patients receiving feminizing therapy: decreased testicular size and erectile function, breast growth, skin softening, decreased growth of body hair, and increased percentage of body fat relative to muscle mass (Coleman E et al, op.cit).
Possible adverse effects of feminizing hormones include venous thromboembolism, increase in triglycerides, increase in body weight, gallstones, and an increase in liver enzymes. Blood pressure and prolactin levels may also be elevated, and there may be an increased risk of prolactinoma. There may also be an increased risk of cardiovascular disease and diabetes when other risk factors for these diseases are present (Coleman E et al, op.cit).
Masculinizing therapy usually consists of testosterone treatment. A common dose is depo-testosterone 200 mg IM (intramuscular) every two weeks, although at times lower or even slightly higher doses may be used. Transdermal testosterone may be used if a slower transition is desired, or for maintenance treatment following initial treatment with intramuscular testosterone. Progestins may also occasionally be used for a short period of time at the beginning of treatment if a patient is having difficulty stopping menstruation (UCSF Center of Excellence for Transgender Health, op.cit).
The following physical changes, which again happen on a variable timeline and often over the course of two years, are expected to occur in patients receiving masculinizing therapy: increase in muscle mass, menstrual cycle cessation, clitoral enlargement, deepening of voice, more facial and body hair, oilier skin, and vaginal atrophy. Male pattern baldness may also occur.
Possible adverse effects of testosterone include weight gain, acne, sleep apnea, elevated liver function enzymes, hyperlipidemia, and polycythemia. If other risk factors are present testosterone can increase the risk of hypertension, diabetes, and cardiovascular disease (Coleman E et al, op.cit).
Psychiatric Concerns in Transgender Youth
While transgender youth may present with the full range of psychiatric disorders common to their age group, their mental health issues may be compounded by long struggles with gender dysphoria, discrimination, stigma, and sometimes trauma.
A recent national survey of transgender and gender non-conforming individuals (6,450 respondents from all 50 states) found that 41% of respondents reported attempting suicide, compared with 1.6% of the general population. Of the 41% who attempted suicide, rates rose for those who had been victims of discrimination, harassment, and assault (National Center for Transgender Equality and the National Gay and Lesbian Task Force, 2011, available at http://bit.ly/1teXC7Y).
As with other populations, you should periodically re-evaluate transgender patients for the need for treatment of depression and anxiety. Often symptoms of depression and anxiety will improve substantially following gender affirming treatment, so that antidepressant treatment may no longer be needed. However, in rare instances some underlying psychiatric conditions may be exacerbated by hormone treatment. For example, testosterone treatment may increase the risk of manic/hypomanic relapse in those with underlying bipolar disorder, so increased mood monitoring especially at the start of treatment is recommended (Coleman E et al, op.cit).
When you treat transgender patients, you should collaborate closely with the broader treatment team, including psychotherapists and the primary care clinicians, endocrinologists, and/or surgeons who are providing gender affirming medical treatment. Increasingly this type of collaboration is provided in the context of formal gender teams, including in some college health centers.