By: Tomye Kelley, M.D. Copyright 1987


       The Standards of Care state that one must be in
psychotherapy 90 days prior to hormones.  That's all the document
says about the qualification for hormones.  Not infrequently the
client thinks that this means "attending" therapy sessions for
about thirteen weeks and stopping by to pick up a letter from the
endocrinologist. In this paper I want to look at just what needs
to happen during those first 90 days, or whatever time it may
take.  Remember, the Standards of Care is bare-bones guide, a
minimum standard that should not be undercut.  It is not a
schedule that says, in this tie what needs to be done, can be
        There are several things that must be explored and
resolution begun before any consideration of hormones.  This is
not a situation of entitlement, nor is it a situation of self
diagnosis and self determination.  Hormones are not a benign
medication; this medication carries all sorts of possible
complications, beginning with the very real possibility of
creating a "pseudo transsexual" by hormonally feminizing a
genetic male who may only be cycling up or over-reacting to a
temporary situation in his life.   
        This is a process that cannot be rushed, as in-depth case
history is essential.  Observation of the client over time is an
aid to this procedure.  It is not enough for a sincere and
well-meaning client to come into the office and emotionally
insist that he has felt like a woman all his life, or that he is
not a "transsexual" but a "woman". The client is paying the
clinician to be stronger and more objective than he can be
himself.  The client is paying for the therapist to spend her
time and energy in studying and researching this subject, in
fact, to have more information and awareness than he can have. 
It is though this information and objectivity that evaluation
must come.
         The client needs to explore in depth his experience in
relationships, especially love relationships.  He needs to be
freshly aware of the attitudes and expectations that he took into
those relationships and how well those attitudes and expectations
worked. He needs to look at what he got from the relationship and
how he will deal with the changes that hormone therapy will bring
         If he is in a marital relationship, that must be
resolved before hormones. The marriage contract implies sexual
activity.  Taking estrogen will interfere with such activity, if
not make it entirely impossible.  It is unethical to provide an
extraneous medication that is deliberately calculated to
interfere with one's ability to fulfill the implied contract.
Simply for a spouse to come into the office and state that it is
alright with her for her husband to take estrogen is not enough. 
It is the responsibility of the therapist to see some reasonable
resolution between the primary client and the relationship
partner before hormones are administered.  If the therapist
cannot see resolution in which she feels comfortable, it is
inappropriate to prescribe hormones.
         If the primary client is not ready to resolve the
relationship, then he is not ready to make the ultimate
sacrifices for his "womanhood".  This gives the therapeutic
relationship a luxury of time in which the client and the
therapist can further explore other explanations for his feelings
of gender conflict.  Such an event should not be viewed as a
failure or a difficulty.  It is an advantage and may be the most
important element of recovery or discovery for the client. (After
all, the therapeutic goal should be finding out what is necessary
for the client.)
        The therapeutic process needs to focus on the client's
attitude toward his genitals.  Both the therapist and the client
must keep in mind that the medication under consideration is
(possibly) going to render his genitals flaccid and
non-functional.  Even masturbation may become difficult or nearly
impossible.  What has the attitude toward the genitals been over
time?  What are the ways in which this attitude has been
demonstrated?  What time period are we talking about?
         During the first 90 days the therapist needs to listen
closely for self-reports of cyclical feelings in the compulsive
behaviors and feelings.  It is the intensity of the feelings and
thought processes on which these observations need to focus, and
not the frequency.  In exploring the episodes from the past when
the client sought, or considered seeking, help with the dressing
or gender problem, when suicide was attempted or seriously
considered, a cyclic pattern of thoughts and feelings emerge.
        When the client can be made aware of such a pattern in
his own self-report and encouraged to examine this pattern in
order to more clearly chart its course, he may well be able to
see that what has occurred in the past may very well reoccur in
his life although at the moment that feels quite improbable.  A
full familiarity with the nature of cycling is essential prior to
any consideration of hormones.  
        I have interviewed dozens of patients who were in the
hospital for sex-reassignment surgery only to find they have no
idea of the effects of that hormone therapy was having or going
to have upon their bodies.  It boggles the mind to think of a
medical profession that proclaims itself to be the caretakers and
protectors of our physical welfare, being content to administer a
powerful chemical without full disclosure and full understanding
on the part of the patient.  Perhaps a part of the explanation
for such an occurrence is that the medical profession is
reluctant to accept the patient as a partner in their own health
care.  If such a change in attitude is to occur, it is the
responsibility of the patient to cause it to occur.  As we hear
in the woman's movement so frequently, power is never
relinquished willingly; it must be wrestled free if it is to be
         In all events, the client can and must be a partner in
the critical decision of whether or not hormone therapy is to
occur.  An intelligent decision can be arrived at only when the
client has full knowledge of what he can and cannot expect from
the medication on all three levels: physical, psychological, and
emotional.  He must know the risks and the early warning signs of
these risks.  He must have an accurate expectation of all the
various kinds of changes he can expect to happen.  Equally as
important, he needs to know what will not be affected by hormone
        The client must know the complicated monitoring process
that is essential to his future health.  The frequency of these
tests must be clearly understood; monitoring too frequently
causes undue expense and inconvenience for the client. 
Monitoring that does not occur with sufficient frequency and
thoroughness takes unnecessary risks with the client's health.
        Abuse of the medication can result in excessive atrophy
of the genital tissue, resulting in insufficient tissue from
which to construct female genitalia.  Continued or extreme abuse
of hormone therapy can cause a break in the client's health and
in some cases has resulted in death.  Abuse of hormones coupled
with substance abuse (such as alcohol) can surely lead to death. 
Hormones are not a benign or recreational medication, and their
misuse without proper supervision can have critical results.   
        Before anyone goes on extraneous hormone therapy they
need to have a clear understanding of the anticipated effects as
well as the time frame in which they can expect these effects to
take place.  It is improper for the physician to administer
hormone therapy with no plans to deal with the problems that such
medication will surely cause. Physical changes will take place. 
Psychological effects will occur. Some emotional changes may be
evident.  All these frequently observed changes should be made
known to the client and the most frequent time frame should also
be made known.  It becomes the client's responsibility to explore
possible resolutions for these change- points before they cause a
        Clients are often wrapped up in themselves and focusing
almost entirely on self and self-needs.  The outside world has
been seen as so controlling and demanding, without concern for
the client's needs and feelings, that now he is saying, "It's my
time!"  In this light, clients may view their taking or not
taking hormones as being their business and theirs alone.  Seldom
can any of us live (for very long) in a vacuum.  Family or
professional emergencies or celebrations do occur, and it has
become essential that the client make an appearance. If the
client has decided to make his changes in hiding, his appearance
at this point in an androgynous state or (more confusingly) as a
partially womanly person can produce extreme discomfort for
himself and for others.  The point at which secrecy can no longer
be tolerated is certainly at the point of starting hormone
therapy.  Thus a clear understanding of the time frame for
changes and the beginning of resolution with the family are
        For the business place, the client must again be aware of
the time frame for physical, psychological, and perhaps emotional
changes. He should be considering what his options are.  It very
well may be necessary that he develop some new options.  The time
for such development is BEFORE the need arises.
        As a matter of fact, given the progression of the effects
of hormone therapy, the client needs about three steps in his
plan. These steps should be based on three levels of development
and change.  Until and unless the client is willing to do
effective work in this area, it is not appropriate that hormone
therapy be administered. It further might be mentioned that a
pre-transitional client who is not employed, who has not resolved
the issue of supporting one's self and establishing a plan for
the future, is not an appropriate candidate for hormone therapy. 
The reasons for this position are self-evident.   
        To many this seems an unnecessary consideration.  In
fact, it may be.  However, I require that it be covered.  This is
a paradoxical item, also.  First, hormone therapy is not a
recreational medication. It is not appropriate that it be used to
produce a she-male body for sexual satisfaction or personal
titillation.  Hormone therapy, as stated several times, is not a
benign medication.  It is not appropriate that it be taken just
to "see how it feels", or to "try it on for a while and see if I
really want to be a woman".  These are issues that need to be
explored in therapy, not with chemicals.
        Hormones are not a substitute for tranquilizers to be
used to help a person get through his days and make it easier for
him to cope with life.  Nor should hormones ever be prescribed to
allow the client to "keep up with the others".  don't disallow
this one too quickly!  As needed as peer support is, and as many
needs as it does fill, one of its major drawbacks is that it can
generate a seductive atmosphere with a "keeping up with the other
girls" feeling likely to creep in.
         The Standards of Care says the client should receive 90
days minimum of ongoing psychotherapy with a single clinician
before hormones.  I have tried in this paper to spell out for you
some of the tasks that must be completed prior to any
consideration of hormone therapy, regardless of how much time it
takes.  Remember, the person you are taking care of is YOU!  No
one else can do that as well as you can.

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