CONSENT FORM - TESTOSTERONE FOR TRANSGENDER CLIENTS

Transcription

1 CONSENT FORM - TESTOSTERONE FOR TRANSGENDER CLIENTS Yu want t take teststerne t masculinize yur bdy. Befre taking it, there are several things yu need t knw abut. They are the pssible advantages, disadvantages, risks, warning signs, and alternatives. We have listed them here fr yu. It's imprtant that yu understand all f this infrmatin befre yu start. We are happy t answer any questins yu have. What is teststerne? It is the sex hrmne that makes certain features appear typically male. It builds muscle and causes the develpment f facial hair and a deeper vice. Hw is teststerne taken? It is usually injected every ne t fur weeks. It is nt used as a pill because the bdy may nt absrb it prperly. And it may cause liver prblems. Sme peple use skin creams and patches, but they tend t be mre expensive. The dses used fr injectin differ frm prduct t prduct and frm patient t patient. They may range frm 100 t 400mg. The injectins are made in a large muscle t slw the release f the hrmne. But there may be unwanted swings in hrmne levels. Yu may cntrl the swings by changing hw ften the dse is given, hw much f a dse is given, r by switching t a cream r a patch. Warning Wh shuld nt take teststerne? It shuld nt be used by anyne wh is pregnant r has uncntrlled crnary artery disease. It shuld be used with cautin and nly after a full discussin f risks by anyne wh has acne has a family histry f heart disease r breast cancer has had a bld clt has high levels f chlesterl has liver disease has a high red-bld-cell cunt is bese smkes cigarettes Peridic bld tests t check n the effects f the hrmne will be needed. Rutine breast exams and pelvic exams with Pap tests shuld be cntinued, when applicable. Page 1 f 5

2 BENEFITS RISKS appearing mre like a man bigger clitris* carser skin lwer vice * mre bdy hair* mre facial hair* mre muscle mass mre strength n mre menstrual perids mre physical energy mre sex drive prtectin against bne thinning (steprsis) *These are permanent changes. acne (may permanently scar) bld clts (thrmbphlebitis) emtinal changes fr example, mre aggressin headache high bld pressure (hypertensin) increased red-bld-cell cunt infertility inflamed liver interactin with drugs fr diabetes and bld thinning fr example Cumadin and Warfarin male pattern baldness mre abdminal fat redistributed t a male shape* mre risk f heart disease swelling f hands, feet, and legs weight gain Please initial and date each statement n this frm t shw that yu understand the benefits, risks, and changes that may ccur frm taking teststerne. Masculinizing I knw that teststerne may be prescribed t make me appear less like a wman and mre like a man. I knw it can take several mnths r lnger fr the effects t becme nticeable. I knw that n ne can predict hw fast r hw much change will happen. I knw that the changes may nt be cmplete fr tw t five years after I start. I knw that the fllwing changes are likely and permanent even if I stp taking teststerne: bigger clitris typically abut half an inch t a little mre than an inch deeper vice gradual grwth f mustache and beard hair lss at the temples and crwn f the head pssibility f being cmpletely bald mre, thicker, and carser hairs n abdmen, arms, back, chest, and legs I knw that the fllwing changes are usually nt permanent they are likely t g away if I stp taking teststerne: acne (many permanently scar) menstrual perids typically stp ne t six mnths after starting mre abdminal fat redistributed t a male shape: decreased n buttcks, hips, and thighs; increased in abdmen changing frm pear shaped t apple shaped mre muscle mass and strength mre sex drive vaginal dryness I knw that the effects f teststerne n fertility are unknwn. I have been tld that I Page 2 f 5

3 may r may nt be able t get pregnant even if I stp taking teststerne. I knw that I might still get pregnant even after teststerne stps my menstrual perids. I knw abut my birth cntrl ptins (if applicable). And I knw that I can t take teststerne if I am pregnant. I knw that sme aspects f my bdy will nt be changed: Lsing sme fat may make my breasts appear slightly smaller, but they will nt shrink very much. Althugh my vice will deepen, ther aspects f the way I speak may nt sund manlier. I knw that there are ther treatments that may be helpful t make my breasts smaller r my speech manlier. If I have cncerns, I knw yu can give me referrals t help me explre treatment ptins. Risks f Teststerne I knw the medical effects and the safety f teststerne are nt cmpletely knwn. There may be lng-term risks that are nt yet knwn. I knw nt t take mre teststerne than prescribed. I knw it increases health risks. I knw that taking mre than I am prescribed wn t make changes happen mre quickly r mre significantly. I knw my bdy can cnvert extra teststerne int estrgen, and that can slw dwn r stp my appearing manlier. I knw that teststerne can cause changes that increase my risk f heart disease. I knw these changes include having less gd chlesterl (HDL) that may prtect against heart disease and mre bad chlesterl (LDL) that may increase the risk f heart disease higher bld pressure mre depsits f fat arund my internal rgans I knw that my risk f heart disease is higher if peple in my family have had heart disease, if I am verweight, r if I smke. I knw that I shuld have peridic heart-health checkups fr as lng as I take teststerne. I knw that means I must watch my weight and chlesterl levels and have them checked by my clinician. I knw teststerne can damage the liver and pssibly lead t liver disease. I knw I shuld be checked fr pssible liver damage fr as lng as I take teststerne. I knw teststerne can increase my red bld cells and hemglbin. I knw that the increase is usually nly t what is nrmal fr a man. I knw that wuld have n health risks. But I als knw that a higher increase can cause prblems that can be lifethreatening. These prblems include strke and heart attack. That s why I knw I need t have peridic bld checks fr as lng as I take teststerne. I knw that taking teststerne can increase my risk fr diabetes. It may decrease my bdy s respnse t insulin, cause weight gain, and increase depsits f fat arund my internal rgans. I knw that I shuld have peridic checks f my bld glucse fr as lng as I take teststerne. I knw my bdy can turn teststerne int estrgen. And I knw that n ne knws if that culd increase the risk f cancers f the breast, the varies, r the uterus. Page 3 f 5

4 I knw taking teststerne can thin the tissue f my cervix and the walls f my vagina. This can lead t tears r abrasins during vaginal sex play. I knw it desn t matter if my partner is a wman r a man. This raises my risk f getting a sexually transmitted infectin, including HIV. I knw I shuld speak frankly with my clinician abut my sex life t learn the best ways t prevent and check fr infectins. I knw that teststerne can give me headaches r migraines. I knw that it s best t talk with my clinician if I get them a lt r if the pain is unusually severe. I knw that teststerne can cause emtinal changes. Fr example, I culd becme mre irritable, frustrated, r angry. I knw that my clinician can help me find resurces t explre and cpe with these changes. I knw that teststerne causes changes that ther peple will ntice. Sme transgender peple have experienced harassment, discriminatin, and vilence because f this. Others have lst the supprt f lved nes. I knw my clinician can help me find advcacy and supprt resurces. Preventin f Medical Cmplicatins I agree t take teststerne as prescribed. And I agree t tell my clinician if I have any prblems r am unhappy with the treatment. I knw that the dse and type f medicatin that s prescribed fr me may nt be the same as smene else s. I knw I need peridic physical exams and bld tests t check fr any side effects. I knw teststerne can interact with ther drugs and medicines. These include alchl, diet supplements, herbs, ther hrmnes, and street drugs. This kind f interactin can cause cmplicatins. I knw that I need t prevent cmplicatins because they can be life-threatening. That s why I need t be hnest with my clinician abut whatever else I take. I als knw that I will cntinue t get medical care here n matter what I share abut what I take. I knw that it can be risky fr anyne with certain cnditins t take teststerne. I agree t be evaluated if my clinician thinks I may have ne f them. Then we will decide if it s a gd idea t start r cntinue using teststerne. I knw that using teststerne t appear manlier is an ff-label use. I knw this means it is nt apprved by the gvernment. I knw that the medicine and dse that is recmmended fr me is based n the judgment and experience f the health care prvider. I knw that I can chse t stp taking teststerne at any time. I knw that if I decide t d that, I shuld d it with the help f my clinician. This will help me make sure there are n negative reactins. I als knw my clinician may suggest that I cut the dse r stp taking it at all if certain cnditins develp. This may happen if the side effects are severe r there are health risks that can t be cntrlled. Alternatives There are alternatives t using teststerne t help peple appear manlier. If yu are interested in alternatives t teststerne therapy, talk t yur clinician abut yur ptins. Page 4 f 5

5 My signature belw cnfirms that My dctr has talked with me abut the benefits and risks f taking teststerne the pssible r likely cnsequences f hrmne therapy alternative treatment ptins I understand the risks that may be invlved. I knw that the infrmatin in this frm includes the knwn effects and risks. I als knw that there may be unknwn lng-term effects r risks. I have had enugh pprtunity t discuss treatment ptins with my clinician. All f my questins have been answered t my satisfactin. I believe I knw enugh t give infrmed cnsent t take, refuse, r pstpne teststerne therapy. I am 18 years ld r lder. Based n all this infrmatin: I want t begin taking teststerne. I d nt want t begin taking teststerne at this time. Client Signature Date Client Name Prescribing Physician Signature Date Prescribing Physician Yur health is imprtant t us. If yu have any questins r cncerns please call us at. We are happy t help yu. Page 5 f 5