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1.
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I have been informed that masculinizing effects of testosterone may
take several months to become noticeable, up to five years to be
complete.
Some of these changes will be permanent, including:
- Hair loss, especially at my temples and crown of my head and,
possibly, becoming completely bald
- Beard and mustache growth
- Deepening of my voice
- Increased hair growth on my arms, legs, chest, back, and abdomen
- Enlargement of my clitoris
These additional changes will not be permanent if I stop
testosterone:
- Decrease of fat in my breasts, buttocks and thighs
- Increase of fat in my abdomen
- More muscle development
- More red blood cells in my blood
- Behavioral changes, similar to those experienced at puberty, and
increased sex drive
- Acne, which may become severe and may cause permanent scarring if
not treated
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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2.
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I understand that it is not known exactly what the effects of
testosterone are on fertility. I have been informed that, if I stop
taking testosterone, I may or may not be able to become pregnant in the
future.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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3.
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I understand that there are brain structures which are affected by
testosterone and estrogen, and that current medical science does not
understand these adequately. I understand that taking a hormone may have
long-term effects on the functioning of my brain which are impossible to
predict. These effects may be beneficial, damaging, or both.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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4.
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I understand that everyone’s body is different and that there is no
way to predict what will be my response to hormones. There is a very
complex interaction in each person between all the different hormones. I
understand that the right dosage for me may not be the same as for
someone else.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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5.
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I will have physical examinations and blood tests periodically to
make sure I am not having a bad reaction to the hormones. I understand
this is required to continue testosterone therapy through this clinic.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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6.
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I have been informed that using testosterone may increase my risk of
developing diabetes in the future because of changes in my ovaries.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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7.
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I understand that the endometrium (the lining of my uterus) is able
to turn testosterone into estrogen and so increase my risk of cancer of
the endometrium. I have been informed that not having my period for
prolonged times may increases this risk. In order to reduce this risk,
another hormone may be recommended to induce a menstrual period (shed
the endometrium) several times a year.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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8.
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I understand that through an interaction in the blood, my taking
testosterone may actually increase the effectiveness of the estrogen in
my body. The results of this are not known.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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9.
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I have been informed that if my periods stop while I am taking
testosterone I probably will not be able to become pregnant. I
understand that testosterone should not be used to prevent pregnancy.
Even if I have stopped having periods I should still use birth control
(preferably barrier methods) if I am having sex where semen could enter
my vagina or uterus.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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10.
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I understand the effects of testosterone will not protect me from
sexually transmitted diseases or from HIV.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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11.
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I understand that the effects of testosterone will not protect me
from cervical cancer or breast cancer. It is important to continue to be
alert to the health care needs of my body. I understand that annual
breast exams and monthly self-breast exams are recommended, even after
chest reconstruction. My provider may also recommend periodic pap
smears.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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12.
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I understand that fatty tissue in my breasts is able to turn
testosterone into estrogen, which may increase my risk of breast cancer
in the future.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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13.
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I have been informed that testosterone puts a stress on the liver
which may lead to liver inflammation. I will be monitored for liver
problems before starting testosterone and periodically during therapy.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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14.
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I have been informed that if I take testosterone my good cholesterol
(HDL) will probably go down and my bad cholesterol (LDL) will probably
go up. This will likely increase my risk of a heart attack or stroke in
the future. The rates of risks for FTMs on testosterone are similar to
the risks that are found in non-transgender men.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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15.
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I understand that there are emotional changes I will likely
experience as a result of testosterone therapy, and that clinic staff
can assist me in finding resources to explore these changes.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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16.
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I understand that once injected, if I have any adverse reactions to
testosterone I must wait for them to wear off.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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17.
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I agree to tell my medical provider about any non-clinic hormones,
dietary supplements, herbs, recreational drugs or medications I might be
taking. I understand that being honest with my provider is crucial to
developing a trusting relationship. Sharing this information will help
my provider to prevent potentially harmful interactions. I have been
informed that clinic staff will continue to provide me with medical
care, regardless of what information I share with them.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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18.
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I agree to take hormones as prescribed and to inform my provider of
any problems or dissatisfactions I may have with the treatment. I’ve
been informed that if I take too much testosterone that my body may
convert it into estrogen. This may slow or stop the desired effects of
the hormone.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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19.
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I understand that there are medical conditions that could make taking
testosterone either dangerous or damaging. I agree that if clinic staff
suspect I may have one of these conditions, I will be evaluated for it
before the decision to start or continue testosterone therapy is made.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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20.
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I understand that I can choose to stop taking testosterone at any
time. I also understand that my provider can discontinue treatment for
clinical reasons.
_____________ ---_____________---
___/___/___
------Patient----------------Provider------------------Date
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