This is just a SAMPLE of a form you may see at your Doctors Office
Patient Handout: Guidelines for Hormone Therapy: Male to Female

The process of changing one’s gender is a serious, important, and potentially dangerous project.  The normal process of going through puberty is a gradual one, and to transform a male body to a female one also takes time.  There are several things you can do to achieve optimum results both physically and psychologically in a safe manner.

Though your individual experience may differ, many individuals experience the following feelings when transitioning gender: 

1.I’ve now decided to make this change, I want it finished very quickly!
2.Unless my breasts are “bigger” I’ll never be truly female.  They should be bigger and               
I've been on hormones six months already.
3. If a little estrogen is giving me these wonderful changes, more estrogen would
make it happen faster!  Others are on higher doses of estrogen, or say estrogen shots are better.

In our program, we have some general principles that we will address with you numerous times.  They may be difficult to hear at times, and they may be different from things you may hear from other programs, other doctors or other patients.  However, in reviewing the medical literature, communicating with other gender centers, and following patients for years, we have found them to be sound principles that result in safer transitions with excellent results.

1. Gender change is a gradual change both physically and psychologically.  Your body and
mind need time to adjust in a healthy manner.  It takes approximately five years to complete the process.
2. LIVING IN YOUR CHOSEN ROLE is the single most important thing that you must do
in this process.
3. Hormones are potent medications with potentially serious side effects.  They
must be used carefully and with regular monitoring.
4. Your body and mind have enough stressors, they do not need the additional stress of
cigarettes, alcohol, illicit drugs and medication, or obesity.

We will ask that you agree to and follow these guidelines as you go through your treatment.

1. Since living in the role is the most important change, we expect you to have a defined plan to make this change.  You should have a definite plan to complete this process within two years.  If you do not complete this step we may discuss discontinuing or decreasing hormones until you make this change.  We will continue to check-in about your plan, and may request permission to talk to your therapist about progress in this direction.
2. Larger hormone doses are more dangerous than small.  If you do not choose to or cannot
have surgery after one to two years of living in the role full-time, your hormone doses may be reduced to postoperative levels. 

3. It is important you take the hormones and medications as prescribed by your physician.   Violation of this may mean termination from hormone therapy.
4. Cigarette smoking and estrogen are not compatible.  If you choose to smoke, you will 
either not be given estrogens or will be given only very small amounts.
5. Abuse of alcohol and other drugs must be dealt with before any other therapy is initiated.
6. We strongly recommend a continued relationship with a therapist who is experienced with transgendered issues.  In many cases, hormonal therapy will be contingent on a continued relationship with a therapist.  If you need assistance finding a therapist, we can help. 
7. You are responsible for your medical bills.  Many insurances do not pay for gender change and will reject your claims.  Your insurance company may ask for your medical records.  We cannot and will not falsify records to suggest another diagnosis.  In general, the cost for initial consultation, physical exam, and laboratory testing is very expensive.  Follow-up visits at 3 months, 6 months, and a year tend to be less costly with fewer laboratory studies. 
8. Our transgendered program has as the highest priority the medical safety of persons receiving hormone therapy.

Consent Form: Administration of Female Hormones to Biologic Males 

The use of female hormones (estrogen) in males has profound and often irreversible effects.  These effects include, but are not limited to, enlargement and increased sensitivity of the breasts, weight change, decreased muscle mass, shrinkage of the genitals, infertility, decreased libido (sex drive), and changes in mood and personality.

The use of female hormones can cause the following conditions: fluid retention, nausea, jaundice (yellowing of the skin), headache, dizziness, depression, changes in vision, and decreased glucose tolerance.

Estrogen use in biologic males has been associated with increased risk of liver abnormalities (including noncancerous and cancerous tumors), elevated blood pressure, gallbladder disease, milk production from the breasts, noncancerous growths of the pituitary gland (a part of the brain), blood clots in the veins which may be crippling, blood clots in the lungs, stroke, heart attack, and breast tumors have all been documented in persons receiving female hormones.

Complications occurring from the use of female hormones can, very rarely, cause death.

Additional effects, risks and adverse reactions not at this time known to arise or on which research data is at present inconclusive may also exist.

The effects associated with the use of female hormones may, or may not, be reversible by discontinuing their use.

I have read this document and have been given the opportunity to discuss the effects, risks and possible adverse reactions of the use of female hormones with Doctor(s)                                      .  Having discussed these matters I voluntarily give my informed consent to use female hormones (estrogen and possibly progesterone), along with the anti-testosterone drug spironolactone for the purpose of transition to the female gender.  I agree to undergo regular physical examinations and laboratory testing as required by my treating physician.  I agree not to change hormone dosages without consultation with my physician.  I realize that doing so may result in my discontinuation in the gender change program.

                (Signature)                        (Date)

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