Consent for Testosterone Treatment Newest

Informed Consent for Testosterone Hormone Therapy
What is Testosterone?

It is the sex hormone that makes certain features appear typically male. It builds muscle and causes the development of facial hair and a deeper voice.

How is Testosterone Taken?

It is usually injected every 1-2 weeks. It is not used as a pill because the body does not absorb it properly and it can cause liver problems. Some people use skin creams or gels, but they tend to be more expensive and may not be covered by insurance.

The doses used for injection differ from patient to patient. They may range from 25 mg - 200 mg. The injections are into a large muscle, such as the thigh, to slow the release of the hormone. There may be some unwanted swings in hormone levels. You and your doctor may control the swings by changing how often the dose is given, how much of a dose is given, or by switching to a cream or a patch.

You want to take testosterone to masculinize your body. Before taking it, there are several things you need to know about. They are the possible advantages, disadvantages, risks, warning signs, and alternatives. We have listed them here for you. It's important that you understand all of this information before you start. We are happy to answer any questions you have.

Warning - Who should not take testosterone?
- - It should not be used by anyone who is pregnant or has uncontrolled coronary artery disease.
- -It should be used with caution and only after a full discussion of risks by anyone who:
  - has personal or family history of heart disease, diabetes or breast cancer
  - has had a blood clot
  - has high levels of cholesterol
  - has liver disease
  - has a high red-blood-cell count
  - is obese
  - smokes cigarettes
  - has acne
Periodic blood tests to check on the effects of the hormone will be needed. Routine chest exams and pelvic exams with Pap tests should be continued, when applicable.
Benefits:

- appearing more masculine

- bigger clitoris*

- coarser skin

- Lower Voice*

- more body hair*

- more facial hair*

- more strength

- decreased menstrual periods

- more physical energy

- more sex drive

- protection against bone thinning (osteoporosis)

Risks:

- acne (may permanently scar)

- blood clots (thrombophlebitis)

- emotional changes - for example,

- more aggression

- headache

- high blood pressure (hypertension)

- increased red-blood-cell count

- infertility

- inflamed liver

- interaction with drugs for diabetes and blood thinning - for example Coumadin and Warfarin

- male pattern baldness

- more abdominal fat

- swelling of hands, feet, and legs

- weight gain
Please initial each statement on this form to show that you understand the benefits, risks, and changes that may occur from taking testosterone.
I know it can take many months or longer for the effects to become noticeable*

Clear
I understand that no one can predict how fast - or how much - change will happen.*

Clear
I know that the changes may not be complete for 3-5 years after I start.*

Clear
I know that the following changes are likely and permanent even if I stop taking testosterone: - bigger clitoris - typically about half an inch to a little more than an inch - menstrual periods typically stop 6-12 months after starting T - more abdominal fat - redistributed to an apple shape: decreased on buttocks, hips, and thighs; increased in abdomen. - more muscle mass and strength - more sex drive - vaginal dryness (possibly discomfort with vaginal penetration)*

Clear
I know that the following changes are usually not permanent - they are likely to go away if I stop taking testosterone: - acne (may permanently scar) - menstrual periods typically stop 6-12 months after starting T - more abdominal fat - redistributed to an apple shape: decreased on buttocks, hips, and thighs; increased in abdomen. - more muscle mass and strength - vaginal dryness (possibly discomfort with vaginal penetration)*

Clear
I know that the effects of testosterone on fertility are unknown. I have been told that I may or may not be able to get pregnant even if I stop taking testosterone.*

Clear
I understand that I might still get pregnant even after testosterone stops my menstrual periods.*

Clear
I know about my birth control options (if applicable I know that I can't take testosterone if I am pregnant and that it causes birth defects.*

Clear
I know that some aspects of my body will not be changed: - Losing some fat may make my chest appear slightly smaller, but it will not shrink very much. - Although my voice will deepen, other aspects of the way I speak may not sound masculine.*

Clear
I know that there are other treatments that may be helpful to make my chest smaller or my speech more masculine.*

Clear
Risks of Testosterone
I know the medical effects and the safety of testosterone are not completely known. There may be long-term risks that are not yet known.*

Clear
I know not to take more testosterone than prescribed. I know it increases health risks. I know that taking more than I am prescribed won't make changes happen more quickly or more significantly.*

Clear
I understand that my body can convert extra testosterone into estrogen, and that can lead to an increased risk of estrogen related problems such as blood clots/breast cancer. *

Clear
I know that testosterone can cause changes that increase my risk of heart disease. I know these changes include having: - less good cholesterol (HDL) that may protect against heart disease and more bad cholesterol (LDL) that may increase the risk of heart disease - higher blood pressure - more deposits of fat around my internal organs*

Clear
I know that my risk of heart disease is higher if people in my family have had heart disease, if I am overweight, or if I smoke.*

Clear
I know that I should have periodic heart-health checkups for as long as I take testosterone. I know that means I must watch my weight and cholesterol levels and have them check by my clinician.*

Clear
I understand that testosterone can increase my red blood cells and hemoglobin. A very high increase can cause problems that can be life threatening, including stroke and heart attack. That's why I know I need to have periodic blood checks for as long as I take testosterone and if my level is very high I may be asked to donate blood.*

Clear
I understand that taking testosterone can increase my risk for diabetes. It may decrease my body's response to insulin, cause weight gain, and increase deposits of fat around my internal organs. I know that I should have periodic checks of my blood sugar.*

Clear
I know my body can turn testosterone into estrogen. And I know that no one knows if that could increase the risk of cancers of the breast, the ovaries, or the uterus.*

Clear
I know taking testosterone can thin the tissue of the cervix and the walls of the vagina. This can lead to tears or abrasions during vaginal sex. This raises my risk of getting a sexually transmitted infection, including HIV. I know I should speak frankly with my clinician about my sex life to learn the best ways to prevent and check for infections.*

Clear
I know that testosterone can give me headaches or migraines.*

Clear
I know that testosterone can cause emotional changes. For example, I could become more irritable, frustrated, or angry.*

Clear
I know that testosterone causes changes that other people will notice. Some transgender people have experienced harassment, discrimination, and violence because of this. Others have lost the support of loved ones. I have been advised to work with a therapist to help me through this process, to best deal with any difficult situations that arise.*

Clear
Prevention of Medical Complications
I agree to take testosterone as prescribed and I agree to tell my clinician if I have any problems or am unhappy with the treatment.*

Clear
I know that the dose and type of medication that's prescribed for me may not be the same as someone else's.*

Clear
I know I need periodic physical exams and blood tests to check for any side effects.*

Clear
I know testosterone can interact with other drugs and medicines. These include alcohol, diet supplements, herbs, other hormones, and street drugs. This kind of interaction can cause complications. I know that I need to prevent complications because they can be life threatening. That's why I need to be honest with my clinician about whatever else I take. I also know that I will continue to get medical care no matter what I share about what I take.*

Clear
I know that it can be risky for anyone with certain conditions to take testosterone. I agree to be evaluated if my clinician thinks I may have one of them. Then we will decide if it's a good idea to start or continue using testosterone.*

Clear
I know that using testosterone for treatment of gender identity affirmation is an off label use. I know this means it is not approved by the government or FDA. I know that the medicine and dose that is recommended for me is based on the judgment and experience of the health care provider.*

Clear
I know that I can choose to stop taking testosterone at any time. I know that if I decide to do that, I should do it with the help of my clinician. This will help me make sure there are no negative reactions. I also know my clinician may suggest that I cut the dose or stop taking it at all if certain conditions develop. This may happen if the side effects are severe or there are health risks that can't be controlled.*

Clear
Alternatives
There are alternatives to using testosterone to help affirm gender identity. If you are interested in alternatives to testosterone therapy or concerned about the potential health risks associated with testosterone, you may choose to present as a masculine person without using testosterone therapy.

My signature below confirms that my doctor has talked with me about the benefits and risks of taking testosterone.

- I understand the risks that may be involved.

- I know that the information in this form includes the known effects and risks. I also know that there may be unknown long-term effects or risks.

- I have had enough opportunity to discuss treatment options.

- All of my questions have been answered to my satisfaction.

- I believe I know enough to give informed consent to take, refuse, or postpone testosterone therapy.
I am 18 Years old or Older

Clear
I am under 18 and my legal guardian is supportive of my decision.

Clear
Based on all this information:
I want to begin taking testosterone.

Clear
I do not want to begin taking testosterone at this time.

Clear
Patient Signature*

Clear
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Guardian #1 Signature

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Guardian #2 Signature

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Informed Consent for Testosterone Hormone Therapy

Please initial each statement on this form to show that you understand the benefits, risks, and changes that may occur from taking testosterone.

Risks of Testosterone

Prevention of Medical Complications

Alternatives

Based on all this information: