The New Gender Paradigm

The New Paradigm Treatment Protocols

The New Paradigm Protocols are based on the fact that transsexuality is a manifestation of normal human diversity.   It's a biologic condition that's treatable.  You either have it or you don't.

     --  Diagnosis:  By history and medical findings

     --  Treatment Goal:  Best quality of life for the individual transsexual

     --  Treatment should begin as soon as the diagnosis is firm;  preferably in early childhood

     --  Treatment should use the best & safest medications currently available, with the fewest side effects

              --  Usually there are at least two treatment phases:  "Puberty induction" and Maintenance. 

                   Each phase uses different meds at different doses

               --  At present, the best meds are: Transdermal estrogen & bicalutamide (Casodex)

               --  Progesterone should be given during the "puberty induction phase"

                   --  Treatment Endpoint:  maximum biologic effect possible with the fewest complications

The Waddell Protocols

Since their first introduction in 1979, the WPATH SOC have provoked outrage in the trans community -- primarily due to their use of Psychiatrist gatekeepers to prevent medical treatment.   The Tom Waddell Health Center in San Francisco developed an alternative protocol that switches treatment oversight from a psychiatrist to the individual patient -- that is, self-diagnosis.  The Waddell Protocol -- and others like it -- are generally known as "informed consent" guidelines.

For more, go to http://www.twtransgenderclinic.org/

Diagnosis

'I identify as..." is the underlying philosophy:  Anyone can choose to be anywhere on the gender map, with no supporting evidence needed.  However, society is supposed to honor the individual's declaration, with no questions asked.

No information is provided to help the individual through the diagnostic process, per se.  As long as the individual takes full responsibility, anything is possible.  The focus is on providing a full understanding of what outcomes can be expected from treatment, along with the associated risks & possible complications.

Treatment

The Waddell Protocols offer nothing new in the area of treatment:

-- Supposedly all forms of estrogen are bio-equivalent.  Liver toxicity & clotting is a major concern.

--  Minimal estrogen doses are recommended.  Because of clotting concerns (Deep Vein Thrombosis -- DVT), hormones should be stopped prior to any surgery.

"Estrogen doses can be reduced to a minimum dose after Gender Reassignment Surgery (GRS) or after maximum feminization is evident."   (Waddell p 11)

--  Progesterone is NOT recommended.

--  Spironolactone is good enough for trans people.  Finasteride may be used as an adjunct to Spironolactone or may be used solo in patients who can’t take Spironolactone.

Progress is gauged through physical changes,   Routine hormone level monitoring isn’t recommended.  Hormone dosage doesn’t change from transitioning to long-term maintenance.

WPATH "Standards of Care"

The World Professional Association for Transgender Health (WPATH) is generally regarded as the Final Word in all things Transgender.   So it's not surprising that their "Standards of Care" (SOC) are the basis for legislative policy -- such as the steps necessary to change legal documentation, etc.  Most Insurance companies (including Medicaid & Medicare) only reimburse WPATH-approved medical care (if they cover trans healthcare at all.)

Treatment Protocols

Disclaimer

This page is for educational purposes only.  Dosages are for comparison only and should not be used as a basis for medical treatment.  Treatment regimens must be individualized to the patient's unique circumstances and physiology.  The medications discussed have risks, possible complications and drug interactions that are not mentioned here -- see the individual package inserts.  Detailed information regarding these medications can be found in the New Paradigm Treatment Protocols.

The assumption that transsexuality is a mental illness leads directly to the following principles of medical care:

Treatment Goal

Minimize the number of people who are finally allowed to transition medically (ie, hormones & surgery).  Any outcome is better than transsexuality.  Even the remote possibility of redemption justifies any amount of injury to the transsexual population.

Diagnosis

Children are not allowed to transition, no matter what.  In fact, adolescents who demand transitioning are punished by preventing their entry into puberty unless they relent -- at a significant cost to their health.  (See Puberty Denial)


The WPATH SOC uses the "Mystery Box" approach to diagnosis.  Everyone who doesn't conform to society's gender stereotypes is marked as having a potential risk of medical transitioning (ie, hormones & surgery).  Which stereotypes and how much deviation it takes aren't specified.  People in the box range from someone who knows he's a man (Gender Identity), who loves football, pizza, beer and drives trucks (Gender), but he likes the color pink.  ...To a 7-year old XY-person who has maintained that she's a girl since birth -- and who attempts suicide after years of conflict with her parents and teachers.

Supposedly, all "gender non-conformers" have an equal chance of (A) deciding to conform, (B) becoming a homosexual, or (C) becoming a transsexual.   There are no individual characteristics that make one outcome more likely than another.   The only diagnostic approach is to establish a set of insurmountable obstacles.   Only those resolute souls who are able to clear ALL of the hurdles is allowed access to medical care.

Psychiatrists are the only people allowed to approve medical care.  ...Not just one psychiatrist, but TWO have to be convinced.

Treatment

The WPATH SOC focuses on preventing treatment.   Only a brief overview of medications & dosages is provided. 

“WPATH does not describe or endorse a particular feminizing / masculinizing hormone regimen.” (WPATH p 47)

“All other factors being equal, there is no evidence to suggest that any medically approved type or method of administering hormones is more effective than any other in producing the desired physical changes.”  (WPATH p 38)

The overall treatment goal is to maintain hormonal levels within the “normal adult female range” (WPATH p 46). 

An "Adult Puberty" or induction phase to promote physical changes isn't recommended.  In fact, surgical removal of the gonads should be followed by a reduction in dose regardless of anatomic status. (WPATH p 43)

Mental Illness or Not?

Is transsexuality a Mental Illness or not?  -- That's the question.   If it's a mental disease, then it obviously should be eradicated just like any other disease.  It should be treated by a psychiatrist. doing psychotherapy.  Hormones & surgery are a strange way to treat a mental illness, but many providers reluctantly allow them if nothing else works.  In other words, hormones & surgery are the unfortunate outcome of severe disease and treatment failure.  Make that the failure of TWO psychiatrists, just to be sure.

Except no one has ever identified any characteristic mental processing defects in transsexual patients.  They behave and react the same as any other human being.  Maybe the reason psychotherapy has never cured transsexuality is because it's NOT a mental illness!


Mental illness or not has always been WPATH's dilemma. During the 1970's "experts" had no doubts about the mental illness myth, and so the original versions of the WPATH "Standards of Care"  were designed on that basis -- psychiatrists, gatekeepers and all.  Forty years later, experts are beginning to have some doubts. 

Even the American Psychiatry Association (APA) has changed the name from Gender Identity Disorder to Gender Dysphoria to remove the presumption of mental illness.   They even made an announcement that transsexuality isn't a mental illness.   ...Even though the word continues to be listed in the DSM.  

Both WPATH & the APA are having difficulty breaking from the mental illness of the past to the currently growing acknowledgment of natural human diversity.  Here are conflicting statements from the WPATH SOC that reveal the internal conflict:


On one hand, the Guidelines offer unequivocal statements that psychotherapy is ineffective & unethical:

 "Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success.  Such treatment is no longer considered ethical."  

            --  Guidelines, p 16 -- this & the following references are from the current Version 7 (2011)


"Psychotherapy or ongoing counseling is not required for the initiation of hormone therapy." ( p 41)

 

"Psychotherapy – although highly recommended – is not a requirement. The [SOC] does not recommend a minimum number of psychotherapy sessions prior to hormone therapy or surgery."  (p 28)

 

But on the other hand, psychotherapy “often” provides the cure:

"Often with the help of psychotherapy, some individuals integrate their trans- or cross-gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body."  (p 8)

 

"Finding a comfortable gender role is, first and foremost, a psychosocial process."   (p 29)

 

"Before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken."   (p 18)

"[These Guidelines] put greater emphasis on the important role that mental health professionals can play in alleviating gender dysphoria and facilitating changes in gender role and psychosocial adjustment."   (p 36)

"Initiation of hormone therapy may be undertaken after a psychosocial assessment has been conducted by a qualified health professional.  A referral is required from the mental health professional who performed the assessment."  (p 34)

"If a patient has never had a psychosocial assessment as recommended by the [Guidelines], clinicians should refer the patient to a qualified mental health professional ."  (p 43 -- compare with the "not required" note on p 41, above)

The Treatment Portal

Hmmm.  We need to make those obstacles more difficult to overcome....

Comparison Shopping:  Treatment Guidelines

Surveys have shown that over half of healthcare professionals freely admit that they are untrained in the basics of transgender care -- what transsexuality is, and the major associated issues; much less how to diagnose & treat them.  Many of these physicians simply refuse to treat transsexuals in any setting -- including unrelated problems like fractures, cancer and major trauma.  Other physicians get their information from their patients, who in turn get their information from friends or the internet.

As a result, large numbers of transexuals receive inappropriate care, leading to poor outcomes and serious complications.

To resolve the education issue, various organizations have published Treatment Guidelines -- handbooks that go through the diagnosis & treatment process step by step.  Nowadays, anybody can treat a transsexual, regardless of their training or past experience.

Supposedly these Guidelines have been written by medical experts who know the best answers to every question.  In reality, the sponsoring organization has a certain political & religious perspective.  They hire experts who will make Guidelines to fit the organization's goals.

As a result, there's actually a wide variety of diagnosis & treatment regimens available.  The first step in choosing a healthcare provider is to find out which Treatment Protocol they use.  The ideology behind the Protocol should match the patient's point of view.

Veterans Administration Guidelines

The VA Pharmacy Benefits Management Service controls healthcare for transgender veterans.  Their guidelines (February 2012) are based on WPATH & Endocrine Society Guidelines:

     -- The diagnosis is to be made by psychiatrists, with no diagnostic criteria provided (page 3)

     --  Any estrogen product can be used (oral, transdermal or depot IM) except ethinyl estradiol (not FDA approved)

      --  Dose determined by serum levels:  testosterone level <55 ng/dl; estradiol level = 200 pg/ml

      --  Estrogen is reduced after orchiectomy; all meds given at lowest possible dose.

      --  No progesterone

      --  Spironolactone is used as anti-testosterone med.  Finasteride is a possible alternative.

     --  Individuals on other regimens are switched to the approved VA regimen.

In the VA system, pharmacists are the gatekeepers.  Hormones are only dispensed with documentation of psychiatric care, etc.

Dosage, Risks & Side Effects

The practical details of treatment aren't included here -- info such as dosage, frequency, possible complications, monitoring requirements, etc  Detailed recommendations can be found in the New Paradigm Treatment Protocols.

A summary of the major possible complications can be found HERE.

Key Treatment Issues

When choosing a treatment protocol, the following are treatment choices that could have serious negative health consequences:  

No Oral Estrogen

Oral Estrogen has been used by transsexuals since the dawn of time.  In fact, trans women in Ancient Rome & Greece drank horse urine to get their estrogen -- a product now sold as Premarin

After 1960, when oral contraceptives began to be widely used, it was realized that oral forms of estrogen carried a risk of serious side effects (blood clots and liver disease).  Manufacturers soon devised alternative routes of administration that were safer -- in particular, skin patches and long-lasting injections.


The other problem is that some forms of oral estrogen stay in the blood for a very short time.  For example, oral Estradiol [Estrace] has a half-life of 2-3 hours -- it's virtually gone after 6 - 9 hours.  The result is estrogen dominance in the AM and testosterone dominance in the PM -- busy reversing any changes made by the estrogen. 

Oral Estrogen should NOT be used in trans treatment regimens, especially during "puberty" induction.  Use patches or long-term injectable forms instead.

In order to have an anatomic impact, estrogen must be present continuously during puberty.  (See Gene Sets)


Spironolactone (Aldactone)

After its introduction in 1959, the diuretic (water-pill) Spironolactone caused a sensation in the trans world of when it was realized that it had feminizing side effects.  For a while, it was the only anti-testosterone med available.

Once again, pharmaceutical companies soon developed specific anti-testosterone products that were far more effective, with fewer side effects & complications.  Currently, bicalutamide (Casodex) is the most effective medication with the fewest side effects -- and it's carefully ignored in all of the protocols.  Outside of the United States, Cyproterone Acetate (Androcur) is widely used.  It's the most effective anti-testosterone, but it has problems with liver toxicity (not approved by the FDA).  

Anti-testosterone agents that should NOT be used:  Flutamide (serious liver side effects),  Finasteride (Proscar, Propecia -- only works in the groin and in hair follicles), and Spironolactone (Aldactone -- short half-life, alters salt balance, sometimes fatal).


Progesterone

Progesterone is the other female hormone.  In theory, it’s the pregnancy hormone.  Usually, transsexuals don't get pregnant -- so the "experts" often don't recommend the medication for transitioning.  

In reality, progesterone is essential during breast development (the puberty phase of transitioning.)  Estrogen promotes the growth of breast tissue, whereas progesterone promotes glandular growth -- the "tree-like" framework that holds the breast tissue together.  (Basically, estrogen promotes breast projection from the chest wall, while progesterone determines the "fullness" -- width or cup size.)

When estrogen-driven tissue growth occurs without a glandular framework, breast pain & tenderness results.  Progesterone reduces breast tenderness during the breast-growth phase of treatment.   Frequent or chronic breast pain indicates that more progesterone is needed.

On the other hand, progesterone is the female androgen.  It counteracts any anti-testosterone that might be taken, and may lead to masculinization effects -- in addition to depression and/or mood swings.  

To balance between these concerns, the usual approach is to mimic the natural cycle of limiting exposure to 10-14 days each month.  It is then discontinued after 4-5 years "post-puberty" -- as tolerated.


Treatment of Youth

The earlier treatment begins, the better the final outcome.  In fact, children allowed to transition in early childhood integrate seamlessly into mainstream society -- general acceptance, no distress, usual levels of harassment.  In particular, no transsexual should ever go through wrong-gender puberty.  Transitioning MUST take place prior to puberty.  "Puberty Denial" by turning off the whole endocrine system is catastrophic to a teen's health.  

Early Diagnosis

Early treatment requires early diagnosis.  A system of reliable diagnostic criteria, especially in the case of young children, is essential.

We're the Best!

Endocrine Society Guidelines

The Endocrine Society Guidelines are an adjunct to the WPATH SOC.  WPATH selects the candidates, while the Endocrine Society provides the treatment details, such as  medications, monitoring & dosages.

Diagnosis:  Psychiatrist Gatekeepers

Endocrinologists are firmly committed to theGender is a Social Construct myth (Endocrine pp 6 - 8).  That means infants are born as empty neuter vessels.  Supposedly, society slowly pours gender into the waiting vessel.  If a vessel doesn't end up a model of gender stereotypes,  it must be defective -- either patch it up or throw it away.

Psychiatrists are tasked with finding the vessels that can be reverted to "normality" -- they're the gatekeepers for access to medical care:

“A mental health professional must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition.”  (Endocrine pp 3 & 8)

At least three months of psychotherapy or living full time as a woman is mandatory.  (Endocrine p 11)


Treatment Goals

The first priority in treatment is to avoid transitioning.  Harm done to transsexuals isn't a concern -- after all, they're delusional and deserve what they get:

“The Task Force placed a very high value on avoiding harm from hormone treatment to individuals who have conditions other than GID and placed a low value on any potential benefit these persons believe they may derive from hormone treatment.”  (Endocrine p 11)


Transphobia determines the treatment choices an endocrinologist makes.  Although the Guidelines claim to be evidence-based, almost every instruction is explained by, "[The possibility of reversion] justifies the strong recommendation in the face of very low quality evidence."

Treatment Recommendations

Supposedly, the best and brightest endocrinologists are still using the meds from 1970:    They say that any estrogen is acceptable, including once-daily oral doses.   Spironolactone is good enough for trans people in America, although other countries can continue to use the far more effective Cyproterone.

The Endocrine Society’s treatment goal is to achieve the “normal physiologic range” (p 18) — physical outcomes aren’t considered (p 20).  The target levels provided are:  Testosterone level <55 ng/dL and Estradiol level <200 pg/mL.  Treatment recommendations don’t change from initial transitioning (induction of physical changes) to long-term maintenance (that is, no special "Puberty-Induction" regimen.)