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Review| Volume 130, ISSUE 11, P1238-1245, November 2017
Ten Most Important Things to Know About Caring for Transgender Patients
Stuart R. Chipkin, MD
Stuart R. Chipkin
Requests for reprints should be addressed to Stuart R. Chipkin, MD, University of Massachusetts, 215 Arnold, 715 North Pleasant St, Amherst, MA 01003.
University of Massachusetts School of Public Health and Health Sciences, Amherst
Valley Medical Group, Amherst, Mass
Fred Kim, MD
Fred Kim
Valley Medical Group, Florence, Mass
Published:July 14, 2017DOI:https://doi.org/10.1016/j.amjmed.2017.06.019
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Transgender people have a gender that is not in agreement with their birth sex. Previous barriers, including lack of provider knowledge, have created significant healthcare disparities for this population. Recent societal changes are increasing the numbers of transgender people seen by primary care practitioners. Ten key principles are provided to help primary care practitioners create more welcoming environments and provide quality care to transgender patients. Overall, all members of the healthcare team (primary and specialty) need to become aware of the transition process and maintain communication regarding risks, benefits, and goals. Transwomen (aka male to female) can be treated with estrogens, antiandrogens, or a combination. Benefits include change in fat distribution, skin softening, and breast development. Significant risks for thrombosis from estrogens have been linked to genetic mutations, smoking, prolonged inactivity, and hormone formulation. Oral administration may provide increased risk over peripheral administration. Transmen (aka female to male) can be treated with peripheral testosterone preparations. Benefits include deepening of voice and development of facial and body hair with variable changes in muscle mass. Risks from testosterone appear to be less common than from estrogen. Laboratory monitoring can guide treatment decisions and provide early detection of some complications. Monitoring of "existing" anatomy (either hormonally or surgically created or removed) is an important component of healthcare for transgender patients. Primary care providers also should be aware of resources in their community and online, which can help patients optimize their transition.
Cross-sex hormone therapy
Male to female
Clinical Significance
Transgender people have avoided primary care in part because of a lack of provider understanding about approaches and standards and differences among sex, gender, and sexuality.
Transwomen (male to female) treated with estrogens should be monitored for possible deep venous thrombosis.
Transmen (female to male) can be treated with testosterone with few adverse events.
Patients need care for whatever anatomy remains or has developed from clinical therapies.
Transgender individuals are presenting increasingly in social, business, and clinical settings. The most recent estimate for the prevalence of transgender (or transsexual) individuals in the United States is 1 to 1.4 million,
Crissman H.P.
Berger M.B.
Graham L.F.
Dalton V.K.
Transgender demographics: a household probability sample of US adults, 2014.
Am J Public Health. 2017; 107: 213-215https://doi.org/10.2105/AJPH.2016.303571
Flores A.R.
Herman J.L.
Gates G.H.
Brown T.N.T.
How many adults identify as transgender in the United States?.
http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf
Date accessed: August 23, 2016
which is double from 2011.
Gates G.J.
How many people are lesbian, gay, bisexual, and transgender?.
http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
Date accessed: December 22, 2015
The incidence of transgender people likely has not changed, rather it is their willingness to identify themselves that has made the number increase so quickly. Further, this number still presumably represents an underestimation.
The hesitancy to inform others about their identity has led to a lack of healthcare. Some of this may have been due to cost barriers (where care for transsexualism is not covered), but transgender people also have reported problems in healthcare encounters. Nineteen percent of transgender individuals reported being denied care in inpatient and outpatient settings.
Grant J.M.
Mottet L.A.
Tanis J.
National Transgender Discrimination Survey Report on Health and Health Care.
National Center for Transgender Equality and National Gay and Lesbian Task Force, Washington, DC2010
Even when patients were seen in the office, 28% reported verbal harassment. It is not surprising that 48% of female to male (transmen) patients and 33% of male to female (transwomen) patients delayed or avoided preventive care.
Fifty percent of transgender patients stated that they had to inform their healthcare provider about transgender healthcare. Knowledge gaps have contributed to a disparity in healthcare delivery for this population.
With increasing public awareness, primary care providers in all settings need more information to provide appropriate care and reduce disparities. The 10 points of information that follow apply to transgender individuals who accept gender as a binary state. Some patients will consider gender as a spectrum and may refer to themselves as gender nonconforming (also referred to as "gender-queer," "gender fluid," and "gender nonbinary") with different needs than those reviewed in this article. A brief glossary of terms is provided in Table 1.
Table 1Brief Glossary of Terms
Sex Biological phenotype present at birth (some use terms male/female)
Gender How a person sees himself/herself (some use terms man/woman)
Transgender/transsexual Circumstance in which the person's birth sex does not match his/her gender.
Transman (female to male) A biological female who sees himself as a man
Transwoman (male to female) A biological male who sees herself as a female
Dysphoria Emotional distress, which can manifest as anxiety, depression, or other behavioral symptoms. Gender dysphoria occurs when an individual's assigned gender does not match his/her biological sex.
Note: Sexuality is independent of sex or gender. Thus, a transman could be attracted to biological females (heterosexual) or biological males (homosexual).
1. Understand the difference among gender, sex, and sexuality
A patient's sex is their anatomy based on their chromosomal phenotype. Their sexuality is the gender of the person to whom they are attracted. Their gender is how they want to be viewed by the world around them. Figure demonstrates the areas of overlap and distinction among these 3 constructs.
FigureOverlap of biological sex, gender perception, and sexual identification. A = Overlap conforming to societal expectations; sex and gender match and person is heterosexual (eg, a biological male who sees himself as male and is attracted to females; a biological female who sees herself as female and is attracted to males). B = Biological sex and gender overlap but sexuality does not; homosexual (a biological male who sees himself as male and is attracted to males; a biological female who sees herself as female and is attracted to females). C = Gender and sexuality align but not congruous with biological sex; straight, transgender person (a biological male who sees herself as female and is attracted to males; a biological female who sees himself as male and is attracted to biological females). D = Biological sex and sexuality align but are not congruous with gender; homosexual and transgender (a biological male who sees herself as female and is attracted to females; a biological female who sees himself as male and is attracted to males).
2. Clinicians should be part of a team
Transgender patients often describe their transition to their preferred gender as a journey. Table 2 lists other potential members of the transgender patient's guiding team. Mental health providers often initially identify and address gender dysphoria and subsequently support patients through hormone or surgical therapy and their interactions with family, friends, colleagues, employers, and public institutions. They also can play a vital role helping with other behavioral health issues. Endocrinologists can recommend regimens to suppress endogenous sex hormones and augment target hormone concentrations. In addition, they help with clinically more complicated scenarios. There is a spectrum of opinions regarding the involvement of behavioral health and hormone prescribers, which can vary from extensive involvement to minimal interaction. Although not all patients go through gender reassignment surgery, many will opt for some type of procedure (see item 8). It is important to identify whether local providers are knowledgeable and welcoming of transgender patients. If not, regional centers are increasingly publicizing their services.
Table 2Members of Transgender Support Team
Primary Care Provider: Coordinate overall care of patient.
Administrative Staff: reception, practice managers
Clinical Staff: medical assistants, nurses
Mental Health Provider: Identify, address, and support patients through transition in personal, public, family, and work settings.
Endocrinologist: Develop regimens to suppress natal hormones and augment goal hormones.
Male to female: estrogen delivery and antiandrogens medications
Female to male: testosterone delivery
Surgeon: Create changes that conform to patient's preferred gender.
Male to female: breast augmentation, facial feminization, orchiectomy, vaginoplasty
Female to male: mastectomies, hysterectomy/oophorectomy, metoidioplasty, voice/speech therapist: assist transwomen with female speech styles
Aesthetician (electrolysis): Remove facial and body hair for more female appearance.
Beyond the multiple professionals who help transgender patients, administrative and clinical staff can be crucial team members. Staff need to understand and learn about preferred names and pronouns. Information technology staff should identify options for electronic medical/health records to include gender and sex. Respectful responses from administrative and clinical staff can determine whether a patient feels welcome and comfortable discussing difficult topics, seeking care, and responding to recommendations.
3. Conduct a complete history and physical examination
Initial visits can identify potential risk factors for complications of gender-affirming therapies. Most observational studies have identified higher risks of thrombosis in transwomen with at least one of the following risk factors: smoking, genetic predisposition, prolonged immobility, or use of ethinyl estradiol or conjugated estrogens.
Asscheman H.
Giltay E.J.
Megens J.A.
A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones.
Eur J Endocrinol. 2011; 164: 635-642
Gooren L.J.
Bunck M.C.
Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience.
J Clin Endocrinol Metab. 2008; 93: 19-25
Wierckx K.
Elaut E.
Declercq E.
Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study.
Eur J Endocrinol. 2013; 169: 471-478https://doi.org/10.1530/EJE-13-0493
Transwomen who will potentially receive high doses of estrogen need to be asked about personal or family histories of breast cancer and thrombotic disorders. Histories of migraines or hypertriglyceridemia also are relevant. Medical concerns before initiating testosterone therapy for transmen should follow those for genetic men receiving replacement testosterone therapy.
Bhasin S.
Cunningham G.R.
Hayes F.J.
Testosterone therapy in adult men with androgen deficiency syndromes: an Endocrine Society Clinical Practice Guideline.
J Clin Endocrinol Metab. 2010; 95: 2536-2559https://doi.org/10.1210/jc.2009-2354
Although not all studies have documented increases in blood pressure in transmen receiving testosterone,
Review of studies of androgen treatment of female-to-male transsexuals: effects and risks of administration of androgens to females.
J Sex Med. 2008; 5: 765-776
Elamin M.B.
Garcia M.Z.
Murad M.H.
Erwin P.J.
Montori V.M.
Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses.
Clin Endocrinol (Oxf). 2010; 72: 1-10
the potential impact of androgens on vascular tone and resistance should be considered.
The importance of smoking cessation cannot be overstated. For transwomen who typically use high doses of estrogen, smoking augments the risk for thrombosis. Some practitioners will not prescribe estrogen to transwomen who smoke. Although transmen have not demonstrated increased risk for cardiovascular events, the potential additive risk of smoking is worth considering. At a minimum, transmen should be counseled in the same way as all patients to stop smoking.
Primary care providers need to be able to have open and honest discussions with transmen and transwomen about sexual practices to reduce risks for sexually transmitted illnesses.
Bauer G.R.
Redman N.
Bradley K.
Scheim A.I.
Sexual health of trans men who are gay, bisexual, or who have sex with men: results from Ontario, Canada.
Int J Transgend. 2013; 14: 66-74
Reisner S.L.
White J.M.
Mayer K.H.
Mimiaga M.J.
Sexual risk behaviors and psychosocial health concerns of female-to-male transgender men screening for STDs at an urban community health center.
AIDS Care. 2014; 26: 857-864
Cross-sex hormone therapy also has the potential to affect reproductive function, although this has not been well studied. Without clear evidence, patients should be counseled about options before beginning hormone therapy.
Wylie K.
Knudson G.
Khan S.I.
Serving transgender people: clinical care considerations and service delivery models in transgender health.
Lancet. 2016; 388: 401-411https://doi.org/10.1016/S0140-6736(16)00682-6
A corollary of acknowledging transgender health issues is to remember that "not everything is a transgender issue." Patients receiving cross-gender therapy need to have routine primary care needs addressed in the same manner as nontransgender patients. Routine immunizations, chronic disease screening and management, and new diagnostic problems may be the principal purpose of many visits. However, it is important to recognize that some problems occur more frequently among transgender patients, including depression, suicidality, hepatitis, and human immunodeficiency virus.
Gooren L.
Eklund P.
Mortality and morbidity in transsexual patients with crossgender hormone treatment.
Metabolism. 1989; 38: 869-873
4. Hormonal treatment of transwomen: estrogen and antiandrogens
The goal for most transwomen will be to maximize feminine aspects and minimize male features. Antiandrogens reduce testosterone concentrations or block testosterone receptors. Because these agents do not increase estrogen levels, the impact on maximizing feminine aspects is relatively small. Spironolactone is used in the United States; cyproterone is available in Europe, Canada, Mexico, and other countries. Side effects for spironolactone can include dizziness and hyperkalemia. Use of antiandrogens without estrogen can result in decreased bone density.
Mueller S.
Weyers S.
Long-term evaluation of cross-sex hormone treatment in transsexual persons.
J Sex Med. 2012; 9: 2641-2651
Estrogen therapy can, at pharmacologic doses, increase feminine features and suppress androgens. Estrogenic effects likely are related to several factors, including serum concentrations, age, and genetics. Continued increases in estrogen dosing beyond certain levels may not yield significant physical changes but may increase the risk for complications.
Estrogens can be delivered as pills, patches, topical gel, or injections. Sample regimens are provided in Table 3. In general, estrogen therapy should begin at low doses and progress based on serum concentrations. Rare cases of hyperprolactinemia have been reported.
Safer J.
Weinland J.
Hormone therapy in transgender adults is safe with provider supervision: a review of hormone therapy sequelae for transgender individuals.
J Clin Transl Endocrinol. 2015; 2: 55-60
Although previous observational studies noted increased thrombotic and cardiovascular risk due to ethinyl estradiol,
more recent studies using estradiol have reported less risk.
Tsjoen G.
Lemaire A.
Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review.
Andrologia. 2014; 46: 791-795https://doi.org/10.1111/and.12150
Arnold J.D.
Sarkodie E.P.
Coleman M.E.
Goldstein D.A.
Incidence of venous thromboembolism in transgender women receiving oral estradiol.
J Sex Med. 2016; 13: 1773-1777https://doi.org/10.1016/j.jsxm.2016.09.001
A presumed mechanism for the increased risk in thrombosis relates to hepatic exposure to high portal concentrations of hormone after intestinal absorption. The increased portal estradiol causes resistance to activated protein C with resulting increases in plasma protein C and a large decrease in plasma protein S.
Toorians A.W.
Thomassen M.C.
Zweegman S.
Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people.
J Clin Endocrinol Metab. 2003; 88: 5723-5729
Higher estrogen doses also can produce hypertriglyceridemia.
Roberts T.
Kraft C.
French D.
Interpreting laboratory results in transgender patients on HRT.
Am J Med. 2014; 127: 159-162
Patients may opt for transdermal or intramuscular estrogen therapy in an effort to avoid a "first pass" liver effect. Although there are no long-term studies comparing one form of estrogen therapy with another, it may be reasonable for patients at increased risk to use a nonoral route of administration.
Table 3Hormone Regimens for Transgender Individuals (Adapted in Part from the World Professional Association of Transgender Health)
- Oral (estradiol) 2.0-6.0 mg/d Oral medication Portal metabolism
- Transdermal:
o Patch 0.1-0.4 mg twice weekly No portal delivery Multiple patches usually needed
- Parenteral (valerate or cypionate) 5-20 mg im every 2 wk
2-10 mg im every 1 wk No portal delivery Injections
Gonadotropin agonist 3.75 mg sc monthly Long duration
Stops puberty Expense
Does not increase estrogen
Antiandrogens
- Spironolactone 100-200 mg/d Oral medication
No risk for thrombosis Little estrogenic effect
Dehydration/dizziness
- Cyproterone 50-100 mg/d Oral medication
No risk for thrombosis Not available in United States
Little estrogenic effect
Hyperprolactinemia
- Finasteride 1-5 mg/d Inhibit peripheral androgen action Less useful with androgen suppression
- Dutasteride 0.5 mg/d
- Parenteral
o Enanthate or cypionate 100-200 mg im every 2 wk or half dose weekly Injections
o Undecanoate 1000 mg every 12 wk Limited availability in United States
- Transdermal
o Gel 2.5-10 g/d Consistent serum levels Skin-to-skin transmission
o Patch 2.5-7.5 mg/d Irritation
im = intramuscularly; sc = subcutaneously.
Modified from Hembree et al.
Hembree W.C.
Cohen-Kettenis P.
Delemarre-van de Waal H.A.
Guidelines on the endocrine treatment of transsexuals.
Some patients may request providers to prescribe progesterone. However, there is no good evidence that chronic progesterone augments breast development or provides any other benefits to transwomen. Side effects of progesterone include depression and weight gain.
Meyer III, W.J.
Stuart C.A.
Physical and hormonal evaluation of transsexual patients: a longitudinal study.
Arch Sex Behav. 1986; 15: 121-138https://doi.org/10.1007/BF01542220
Medroxyprogesterone may have a more negative impact on lipid parameters than micronized progesterone
Fitzpatrick L.A.
Pace C.
Wiita B.
Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey.
J Womens Health Gend Based Med. 2000; 9: 381-387
and may increase risks for breast and cardiovascular risk.
Rossouw J.E.
Anderson G.L.
Prentice R.L.
Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial.
JAMA. 2002; 288: 321-333
Pharmacologic estrogen doses typically provide benefits to skin and subcutaneous fat. Patients can develop breasts and increased body fat around hips. In general, patients also report softening of skin, which often improves hair-removal treatments. Because increased estrogen levels suppress pituitary gonadotropins, testosterone levels decrease and patients may notice thinning and lightening of body hair, and decreases in skeletal muscle strength, testicular volume, and sperm production. Many patients report a decrease in libido. Loss of erectile function is not generally considered to be an adverse consequence for most transwomen. Patients should be informed that cross-gender therapy will not decrease penile size, raise the pitch of their voice, reduce their thyroid cartilage (Adam's apple), or cause regrowth of hair lost from baldness.
5. Laboratory tests to monitor in transwomen
Estradiol monitoring can be useful to determine the impact of dosing. Guidelines from the Endocrine Society and World Professional Association of Transgender Health have been published
Coleman E.
Bockting W.
Botzer M.
Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
Int J Transgend. 2011; 13: 165-232
(Table 4). Additional testing may be indicated when doses are increased. Testosterone levels can document the degree of suppression by estradiol or antiandrogens. If serum levels of estradiol are elevated without significant clinical impact, it can be helpful to measure sex hormone-binding globulin. Sex hormone-binding globulin is stimulated by estradiol, and increased levels reduce tissue availability of estrogens. Although guidelines recommend monitoring prolactin levels in transwomen receiving medical therapy, the risk is likely strongest for cyproterone (not available in the United States).
Table 4Monitoring Male to Female (Transwomen) on Cross-Sex Hormone Therapy
Evaluate patient every 2-3 mo in the first year and then 1-2 times per year afterward to monitor for appropriate signs of feminization and for development of adverse reactions.
Measure serum testosterone (total) and estradiol every 3 mo.
Total serum testosterone levels should be <55 ng/dL.
Serum estradiol should not exceed the peak physiologic range for young healthy females, with ideal levels <200 pg/mL.
Doses of estrogen should be adjusted according to the serum levels of estradiol.
For individuals on spironolactone, serum electrolytes (particularly potassium) should be monitored every 2-3 mo initially (or after dose changes) during the first year.
Routine cancer screening is recommended as for nontranssexual (aka cisgender) individuals (breasts, colon, prostate).
Consider bone density testing at baseline if risk factors for osteoporotic fracture are present (eg, previous fracture, family history, glucocorticoid use, prolonged hypogonadism). If individuals are at low risk, screening for osteoporosis should be conducted at age 60 y and in those who are not compliant with cross-sex hormone therapy.
Other tests to be monitored include liver function tests and lipid panels. Recommendations for monitoring liver function tests
are largely based on older studies using high-dose oral contraceptives
Aldinger K.
Ben-Menachem Y.
Whalen G.
Focal nodular hyperplasia of the liver associated with high-dosage estrogens.
Arch Intern Med. 1977; 137: 357-359
Adlercreutz H.
Tenhunen R.
Some aspects of the interaction between natural and synthetic female sex hormones and the liver.
Am J Med. 1970; 49: 630-648
and ethinyl estradiol.
Van Kesteren P.
Megens J.
Mortality and morbidity in transsexual subjects treated with cross-sex hormones.
Clin Endocrinol (Oxf). 1997; 47: 337-342
Because estrogens can increase triglycerides, lipid panels should be followed. For triglyceride levels greater than 400 mg/dL, nutrition evaluation or alternative routes of administration should be considered. If triglyceride concentrations remain elevated after dietary modification, medications to target triglycerides should be implemented. For levels greater than 1000 mg/dL, estrogen doses should be decreased until triglyceride concentrations have been addressed.
6. Hormonal treatment for transmen: testosterone
Testosterone is a potent inhibitor of estrogen; therefore, doses rarely exceed those routinely used for genetic men. In the United States, testosterone may be administered as a topical gel, transdermal patch, subcutaneous pellets, or intramuscular injection (Table 3). Intramuscular injections are generally more cost-effective than other preparations. Intramuscular testosterone (valerate or cypionate) can be administered every 2 weeks. It is suspended in oil, which makes the buttocks the preferred site of administration; this makes self-administration problematic. If patients are willing to inject half the volume weekly, then most patients are able to self-inject in the thigh (vastus) muscle. Subcutaneous pellets can be placed as an outpatient procedure, but there is no ability to adjust or modify the dose. Patches can be irritating to the skin. If patients choose testosterone gel, they need to avoid skin-to-skin contact with others for at least 12 hours after administration.
Stahlman J.
Britto M.
Fitzpatrick S.
Serum testosterone levels in non-dosed females after secondary exposure to 1.62% testosterone gel: effects of clothing barrier on testosterone absorption.
Curr Med Res Opin. 2012; 28: 291-301https://doi.org/10.1185/03007995.2011.652732
Testosterone provides several benefits to transmen. Menstrual periods typically cease within a few months. After amenorrhea, unexplained vaginal bleeding requires further testing for possible endometrial hyperplasia. Testosterone will affect the vocal cords and cause a deepening of the patient's voice. Facial and body hair increase; changes in muscle mass are more variable but are often seen in those who exercise more. Although testosterone will not cause development of a penis, patients usually will note an increase in clitoral size and sensitivity along with an increase in libido. Additional changes can include an increase in acne and development of male pattern baldness.
Side effects of testosterone therapy are fairly minimal. Although some studies have reported increases in systolic blood pressure and low-density lipoprotein concentrations, others have found no association.
Most studies report some benefits to bone density with therapeutic levels.
Van Caenegem E.
Taes Y.
Body composition, bone turnover, and bone mass in trans men during testosterone treatment: 1-year follow-up data from a prospective case-controlled study (ENIGI).
Increases in hemoglobin and hematocrit have been noted.
Hampl R.
Stárka L.
Heresova J.
The use of andriol in treatment of androgen deficiency in transsexual women.
J Steroid Biochem. 1986; 24: 349-352
Jacobeit J.
Schulte H.
Safety aspects of 36 months of administration of long-acting intramuscular testosterone undecanoate for treatment of female-to-male transgender individuals.
Because doses used for transmen are similar to those used for genetic men, side effects of increased aggression or hostility are unusual. However, providers should monitor patients for any indication of behavioral changes.
7. Laboratory tests to monitor transmen
Monitoring of testosterone levels can provide insights about dosing (Table 5). In general, total testosterone is recommended because other estimates of "free" or "bioavailable" testosterone are not standardized or are calculated.
However, some transmen will still have elevated sex hormone-binding globulin levels in the initial months of cross-sex hormone therapy. Timing of intramuscular testosterone administration will affect decisions about when to measure concentrations. If administered every 2 weeks, variations in "peak" (1-4 days), mid-cycle (1 week), and "trough" (end of 2 weeks) levels can vary. If mid-cycle levels are above the upper limit of normal or if trough levels are below the lower limit of normal, dividing the dose over a smaller interval (eg, half the dose every week) can help smooth out serum concentrations. Topical testosterone (gel or patches) preparations usually provide greater consistency and less variability in testosterone concentrations.
Table 5Monitoring Female to Male (Transmen) on Cross-Sex Hormone Therapy
Evaluate patient every 2-3 mo in the first year and then 1-2 times per year to monitor for appropriate signs of virilization and development of adverse reactions.
Measure serum testosterone every 2-3 mo until levels are in the normal physiologic male range.
For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. If the level is >700 ng/dL or <350 ng/dL, adjust dose accordingly.
For parenteral testosterone undecanoate, testosterone should be measured just before the next injection.
For transdermal testosterone, the testosterone level can be measured at any time after 1 wk.
Note: During the first 3-9 mo of testosterone treatment, total testosterone levels may be high, although free testosterone levels are normal, because of high sex hormone-binding globulin levels in some biological women.
Measure estradiol levels during the first 6 mo of testosterone treatment or until there has been no uterine bleeding for 6 mo. Monitor weight, blood pressure, lipids, fasting blood glucose (if family history of diabetes), and hemoglobin A1c (if diabetic) at regular visits.
Measure complete blood count and liver function tests at baseline and every 3 mo for the first year and then 1-2 times per year. Monitor weight, blood pressure, lipids, and fasting blood glucose (especially if history of prediabetes or family history of diabetes) at regular visits.
Consider bone density testing at baseline if risk factors for osteoporotic fracture are present (eg, previous fracture, family history, glucocorticoid use, prolonged hypogonadism). In individuals at low risk, screening for osteoporosis should be conducted at age 60 y and in those who are not compliant with hormone therapy.
If cervical tissue is present, routine Pap smear is recommended by professional organizations.
If mastectomy is not performed, then consider mammogram as recommended by professional organizations.
Measuring estradiol levels in transmen has 2 purposes. The first is to confirm the dose at which suppression of estradiol occurs. The second is to monitor for increases in estradiol that occur because of physiologic aromatization of testosterone to estradiol.
Other useful tests include liver function tests, lipid panels, and complete blood counts. Liver function tests are not typically affected by intramuscular or topical testosterone,
although transient elevations have been reported.
However, testosterone still carries a Food and Drug Administration warning for hepatic adenomas, hepatocellular carcinoma, and peliosis hepatitis, and so periodic monitoring may be prudent.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/085635s030lbl.pdf
Testosterone-induced changes in low-density lipoprotein in transmen have been modest
Goh H.H.
Loke D.F.M.
Ratnam S.S.
The impact of long-term testosterone replacement therapy on lipid and lipoprotein profiles in women.
Maturitas. 1995; 21: 65-70https://doi.org/10.1016/03785122(94)00861-Z
or nonsignificant.
Elbers J.M.
Teerlink T.
Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects.
Treatment for hyperlipidemia probably should be based on other risk factors for cardiovascular disease. Hematocrit and hemoglobin levels often increase in those receiving testosterone.
8. Surgical options
Many patients continue on cross-sex hormone therapy without ever undergoing any type of surgery. However, increasing numbers of patients are opting for some surgical therapy to optimize their gender congruence. Primary care providers should understand surgical procedures that patients may consider.
Trum H.W.
Hoebeke P.
Sex reassignment of transsexual people from a gynecologist's and urologist's perspective.
Acta Obstet Gynecol Scand. 2015; 94: 563-567https://doi.org/10.1111/aogs.12618
Horbach S.E.
Bouman M.B.
Smit J.M.
Özer M.
Buncamper M.E.
Mullender M.G.
Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques.
J Sex Med. 2015; 12: 1499-1512https://doi.org/10.1111/jsm.12868
Transwomen: The simplest surgical option for transwomen is orchiectomy, which, by eliminating endogenous testosterone production, often allows patients to use lower doses of estradiol with similar clinical effects. The more significant procedure is a vaginoplasty (often referred to by patients as "bottom surgery") with surgical removal of the penis and testicles and creation of a neo-vagina. Electrolysis of scrotal hair is an important step in preparation for vaginoplasty. Once a vagina has been created, patients need to use dilators to maintain maximum functionality. Although these operations typically leave small amounts of residual prostate tissue, continued estrogen use likely will suppress any prostatic hypertrophy. Other appropriate and helpful procedures include breast implantation ("top surgery") and facial feminization surgery.
Transmen: The initial procedure for many transmen is often bilateral mastectomies ("top surgery"), which relieves the need for binding and allows patients to more effectively and comfortably wear male clothing. "Bottom surgery" for transmen has several options, including total hysterectomy with bilateral oophorectomy, metoidioplasty, and phalloplasty. Total hysterectomy with bilateral oophorectomy removes concerns about potential endometrial hyperplasia (from conversion of testosterone to estradiol). Metoidioplasty and phalloplasty do not often result in a penis with sexual and urological function. However, many patients find great therapeutic value in an operation that will allow them to urinate while standing.
9. Health maintenance of existing anatomy
Many patients have the potential to minimize concerns about their birth sex organs and tissues. A worthwhile recommendation to patients is that "if they have the anatomy, they need to take care of the anatomy." Transwomen who have not had gender-affirming surgery can have abnormalities of the penis, scrotum, testicles, and prostate; previous publications have summarized existing case reports.
Tangpricha V.
Ducharme S.H.
Barber T.W.
Chipkin S.R.
Endocrinologic treatment of gender identity disorders.
Endocr Pract. 2003; 9: 12-21
Transwomen with estrogen-induced breast tissue can have breast masses that require investigation, although the rates of breast cancer in transwomen appear to be low.
van Trotsenburg M.A.
van Diest P.J.
Breast cancer development in transsexual subjects receiving cross-sex hormone treatment.
J Sex Med. 2013; 10 (Epub 2013 Sep 9): 3129-3134https://doi.org/10.1111/jsm.12319
Transmen receiving testosterone who have not had gender-affirming surgery can still have breast masses and abnormalities of the vagina, cervix, uterus, and ovaries.
Peitzmeier S.M.
Harigopal P.
Potter J.
Female-to-male patients have high prevalence of unsatisfactory Paps compared to nontransgender females: implications for cervical cancer screening.
J Gen Intern Med. 2014; 29: 778-784
In general, recommendations have encouraged using standard primary care guidelines for preventative strategies.
10. Logistics and resources
Transgender individuals who transition will need assistance with legal documentation. Documents under state control include driver's licenses and birth certificates. Although a majority of states will allow changes to name and "sex" on these documents, there is considerable variability as to what formal statements from healthcare professionals are required to make these changes. In general, driver's licenses are easier to change than birth certificates. It is very important for providers to learn the proper wording necessary to help patients move through this portion of their transition.
Patients need to be cautious about selecting insurance coverage. Depending on the state, some third-party payers may still try to exclude some or all services related to changes in gender. Questions about the legality of coverage and possible discrimination can be directed to the state Department of Insurance of the US Department of Health and Human Services Office for Civil Rights (Table 6).
Table 6Resources
Site/Reference
US Department of Health and Human Services, Department of Insurance,
Office for Civil Rights https://www.healthcare.gov/transgender-health-care/
US State Department (for change of gender on passport) https://travel.state.gov/content/passports/en/passports/information/gender.html
Letter should state:
medical license information
state of jurisdiction
the provider has a doctor/patient relationship
the provider has treated the patient (or reviewed and evaluated the patient's history)
the provider is overseeing "clinical treatment for transition to the updated gender"
Required statement: "I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct" ().
Social Security https://faq.ssa.gov/ics/support/KBAnswer.asp?questionID=2856&hitOffset=
WPATH http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351
Endocrine Society file:///C:/Users/schipkin/Downloads/Endocrine-Treatment-of-Transsexual-Persons%20(1).pdf
ACOG http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for-Transgender-Individuals
Gay and Lesbian Medical Association http://glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf
Center for Excellence for Transgender Health www.transhealth.ucsf.edu
National LGBT Health Education Center (Fenway Institute) https://www.lgbthealtheducation.org/
https://www.lgbthealtheducation.org/transtalks/
ACOG = American College of Obstetricians and Gynecologists; LGBT = Lesbian, Gay, Bisexual, and Transgender; WPATH = World Professional Association for Transgender Health.
Changing gender on a passport is under the jurisdiction of the US State Department and requires a signed, original letter with specific contents (Table 6). Details about specific treatments or surgical procedures are not required.
The World Professional Association for Transgender Health is a nonprofit interdisciplinary organization whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect in transgender health. The organization has published standards of care since 1979 regarding behavioral health, medical, and surgical management of transgender individuals.
The Endocrine Society has published medical guidelines
that provide more detailed options, risks, and benefits regarding hormone therapy. Several institutions provide websites with reviews and recommendations (Table 6).
Transgender individuals frequently have avoided care and have been an underserved population. As some societal gains have been made, increasing numbers are presenting for primary and specialty care. Providers need to understand differences among sex, sexuality, and gender. They should be part of a team who treat transgender patients with respect, sensitivity, and consideration. Initial evaluations should focus on risk factors for complications of cross-sex hormone therapy. Decisions about therapeutic plans should consider goals and routes of administration. Ongoing care involves evaluating hormone-sensitive tissues and organs for the impact of cross-sex hormone therapy and its related potential consequences. Hormone levels can provide therapeutic goals and insights about efficacy. Other laboratory tests can be used to monitor risk for hormone-related complications. Some but not all patients may proceed with surgical procedures as part of their care. When questions arise, local, national, and international resources are available to provide assistance. Building an open and trusting relationship with patients for all of their healthcare needs will promote openness and dialogue about specific transgender issues. More research is needed to better identify the risks and benefits of care for transgender individuals.
(Los Angeles, CA: The Williams Institute; Available at)
(Williams Institute; Available at)
(Available at)
(Accessed April 25, 2017)
Funding: None.
Conflict of Interest: None.
Authorship: All authors had access to the data and played a role in writing this manuscript.
DOI: https://doi.org/10.1016/j.amjmed.2017.06.019
© 2017 Elsevier Inc. All rights reserved.
Green Journal Blog


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From the Comets
Looking for retribution from an earlier loss in Syracuse, the Comets wanted to apply a high pressure style of play and put this game away. Unfortunately, the Knights were ready for the pressure and countered it with several break-out attacks that left them with odd-man rushes against goalkeeper Boris Pardo. That and an unbelievable performance from Syracuse goalkeeper, Bryan O'Quinn, led to a 18-8 defeat of the Comets on Friday night.
Bryan Perez started the scoring for the Silver Knights four minutes into the game converting a pass from Andriy Budnyy. Cristiano found John Sosa three minutes later evening the score at two points each. The teams remained tied until the final two minutes of the quarter. Vahid Assadpour, trying to catch a streaking Knights forward, was called for holding and the Comets went on their first penalty kill of the night. Former Comets forward, Neto converted the penalty, putting the Comets down 4-2 at the first break. The Silver Knights, who previously had not scored a power play goal this season, converted three tonight, two of them from Neto.
Coming out of the break, the Silver Knights employed a very aggressive strategy that consisted of knocking the Comets speedy, skilled players off the ball or into the wall. Several times Comets players were taken down as they advanced play. When fouls weren't called, the Knights once again found themselves with more players than the Comets had defenders. Andriy Budnyy took advantage of this for two scores in the second quarter. Jamar Beasley joined his former Comet brethren scoring in the second, right before Bryan Perez got his second of the night. At halftime the Comets were down 12-4.
The two teams traded goals back and forth in the third quarter. Vahid Assadpour and Byron Alvarez each scored within thirty seconds of Syracuse goals. The Comets had several other chances, but Syracuse's goalkeeper, Bryan O'Quinn, was everywhere as he finished with 25 saves. At one point, the Comets rattled off six shots on target within a ten second span. O'Quinn was able to fly through his goal box and get in between every shot. Budniyy finished off the scoring with 41.5 seconds left in the third quarter before the Knights fell into a defensive shell in the fourth quarter. Neither team scored in the final frame and the final score was 18-8 in favor of Syracuse.
The Comets have to shake this off as they face the league leading Baltimore Blast tomorrow night at 6:00pm CST. Fans can watch the game online at MISLNation.com or at the Comets Nation sponsored Watch Party at Coach's Bar and Grill.
Labels: Byron Alvarez, John Sosa, Lucas Rodriguez, Missouri Comets, Syracuse Silver Knights, Vahid Assadpour

redpajama_set_name: RedPajamaCommonCrawl


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The prehistoric PS3 still surpasses the Xbox Series X / S
Under the supervision of IGN, the HowLongToBeat platform is responsible for listing many statistics related to the gaming market. Via its database of thousands of players, the platform recently announced, for example, that Resident Evil Village was the game that was finished by the largest number of players in 2021, in front of Metroid Dread (which we highly recommend) and Ratchet & Clank Rift Apart. Side consoles, in 360, it seems that a certain PS3 has managed to rank ahead of the new and powerful Xbox Series … We explain.
The PS3 still party?
Indeed, at the end of the year, the platform wanted to establish a ranking of the different gaming platforms, according to the number of hours played on each of them . And according to the HowLongToBeat database, players would have spent more time in 2021 at play on PS3… only on Xbox Series. In this regard, Christmas is approaching, find out here which console to buy to make / have fun .
The ranking allows the PC to rise to first position, the latter being followed by the PS4 and the Nintendo Switch. The PS5 is in fourth place, just ahead of the Xbox One. The PS3 is for its part sixth, ahead of the Xbox Series therefore, and the Xbox 92. Note that the ranking also makes it possible to find the Nintendo 3DS, as well as the PS2 in tenth position. However, it is difficult to know precisely how the hours of play were calculated on these platforms…
Most Played Platforms of 2021 pic. twitter.com/6ByvbUt3jX
– HowLongToBeat (@HowLongToBeat) December 19, 2021
Of course, it should be remembered that Sony PS3 has elapsed over 87 millions of copies in the world, when we estimate a little less than millions the installed fleet of Xbox Series. As for the PS5, the latest sales figures communicated by Sony showed a little less than 10 millions of machines passed. At Nintendo, we look at all this little world " next-gen " from very (very) high, the Switch showing more than 92 millions of sales according to figures unveiled last September.
So obviously, before giving your opinion in the comments under this article , it is necessary to agree (again) on the fact that this classification should in no case be interpreted as something absolute, but that it is based only on the data of the members of the platform. Also, whether you play on a first generation Xbox, on PS2, on Super Nintendo, on Game Gear, on PC Engine, on Amstrad or on Amiga, the essentials in 2021 is, again and again, to have fun, quite simply.
TikTok becomes the most visited site in the world and dethrones Google
Italy: record fines for four e-commerce companies


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Greece adopts controversial reforms ahead of crunch Eurogroup talks
Athens, Greece | May 9, 2016, Monday @ 08:02 in World » GENERAL | By: Hélène Colliopoulou | Views: 2126
Greek Prime Minister Alexis Tsipras delivers a speech during a parliamentary session in Athens on May 8, 2016 (AFP Photo/Angelos Tzortzinis)
(AFP) - Greek lawmakers adopted a controversial package of pension cuts and tax hikes as eurozone finance ministers geared up for an emergency meeting Monday to hammer out fresh reforms for Athens to stave off another eurozone crisis.
The ministers are expected to complete a long-stalled first review of Greece's massive EU-IMF bailout and discuss new debt relief measures at the crunch meeting in Brussels, which follows mass public opposition to the newly adopted measures in the cash-strapped country.
The talks have already suffered months of delays and Greece wants to wrap them up as quickly as possible so that it can unlock the next tranche of its 86-billion-euro ($95 billion) bailout -- the third for the debt-laden country since 2010 -- ahead of a huge European Central Bank payment due in July.
In its official agenda the ministers from the 19 countries that use the euro -- the Eurogroup -- said they would discuss the "progress achieved" by Greek and creditor officials in recent days on the reforms, "with a view to conclude them as soon as possible".
It added that it would "also discuss possible debt relief measures aiming at ensuring that Greece's gross financing needs remain at a sustainable level, with a view to reach a political agreement."
The meeting follows days of protests in Greece, where tens of thousands took to the streets to slam the unpopular reforms adopted Sunday.
The measures were passed thanks to the Syriza-led government's slim majority in the 300-seat parliament, with the 153 MPs of the far-left Syriza and the Independent Greeks coalition voting in favour of the measures.
As expected all the opposition parties voted against the bill, which will reduce Greece's highest pension payouts, merge several pension funds, increase contributions and raise taxes for those on medium and high incomes.
- Clashes -
In the run-up to the parliamentary debate, angry unions staged a general strike that paralysed public transport for a third straight day Sunday, while some 26,000 people took to the streets of Athens and Greece's second city Thessaloniki in protest at the pensions and tax overhaul.
Brief clashes erupted outside the parliament in Athens ahead of the vote, with youths throwing Molotov cocktails and flares at riot police who responded with volleys of tear gas, AFP reporters saw.
Numbers were, however, significantly down on February protests when 40,000 people marched in Athens alone.
"People are tired and disappointed by the leftist government in power... the rallies have not had the scale we had expected," said Maria, a private sector employee in her fifties who claims to be owed 30,000 euros ($34,000) in back pay from her employer.
Prime Minister Alexis Tsipras, who has said reform is needed to prevent the pension system collapsing in a few years, defended the changes in parliament earlier Sunday, which are part of the government's pledge to achieve 5.4 billion euros in spending cuts by 2018.
"The system requires root-and-branch reform that previous governments have not dared to undertake," he told lawmakers.
He also highlighted the fact that the Eurogroup meeting Monday will for the first time look at easing Greece's crippling debt burden, one of the only concessions granted to Tsipras when he secured the bailout.
"Tomorrow is a very important day. After six years (of crisis), the Eurogroup will meet to discuss debt relief," he said.
Ahead of the Brussels meeting, differences between the creditors themselves have emerged over extra reforms demanded by the IMF that could amount to another 3.6 billion euros of cuts by Greece.
IMF chief Christine Lagarde has warned that there were "significant gaps" in Greece's reform offers, while European Commission head Jean-Claude Juncker said Athens had "basically achieved" the objective of the measures required by creditors.
Greek Finance Minister Euclid Tsakalotos has called on the eurozone to back the reforms, warning of a "failed state" if the Brussels talks run aground.
Tags: pension cuts, tax hikes, Eurozone, reforms, Greece, EU, IMF
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Greece's last king Constantine laid to rest at former royal cemetery
Ghana reaches $3 bn deal with IMF
World » Africa |


A Catholic nun in Papua New Guinea's Western Province says Christian health workers alone cannot adequately fight tuberculosis in the remote province.
Western is one of three provinces in PNG that the national government recently identified as needing urgent health efforts to help address the spread of tuberculosis.
The Health Department has reportedly accelerated its response to the spiralling situation in Western province's capital Daru where health workers are now infected with drug-resistant TB.
However, Sister Anna Sanginawa says the sporadically-funded job that Christian Health Services commit themselves to is not enough to beat TB.
"Last whole year there wasn't any money given to provincial health. There was nothing done but from our churches, Christian Health Services, we are getting money but if only we are doing (it), it cannot help."


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How to Leverage Facebook Graph Search at Your Business
Business Technology | May 27, 2014
What to Make of Facebook Graph Search?
The latest in a never-ending stream of Facebook rollouts is now with us, and it's called Facebook Graph Search. It is Facebook's newest entry into the search game, and it appears as if they've actually found a new and different vein. Still in Beta, Facebook Graph Search might not yet be accessible for you, (still limited to the US, and there's a waiting list) but it is scheduled to rollout this summer. So now is the time to begin to understand how this might help your small business.
Facebook Graph search – What is it?
Facebook Graph Search is a search model whereby you are served up results based not on any keyword you entered, but rather results determined by your social spheres. For instance, your search will reveal people who share your interests, photos and videos they've liked, and connections you share. These outcomes are unique to you as they're based on you and your friend's interests.
How can you make full use of Facebook Graph search in your marketing?
One of the primary benefits here seems to be that Graph Search will reward those who are making a genuine effort with their social media, engaging and interacting with their fans and followers. Facebook is mum concerning the aspects of the actual search algorithm, but suffice it to say that it will go a long way towards removing pages that are wanting to game the system. Fake Likes and fans received from strange locations outside of your common spheres, are likely to be viewed with skepticism.
Rather, this appears as if it is going to significantly benefit businesses making a genuine attempt at engaging with social media. Some ways you can be ready for Facebook Graph Search are to:
Make sure your Facebook page profile is totally filled out with your information, so that users can locate and make contact with you.
Make sure to engage, not sell your visitors.
Be very careful of what is posted online, especially on Facebook itself, as this may come back to embarrass your business greatly!


Since 1977, The Queen's Trust has invested over £93m to help young people help others, and in doing so, benefit wider society. As one of Frontline's Founding Partners, The Queen's Trust has been an invaluable supporter, and with us from the beginning. Here, Nicola Brentnall MVO, the Trust's Director, discusses the work of the organisation and its involvement with Frontline.
What is The Queen's Trust?
Independent of the Royal Household, The Queen's Trust was established in 1977, the year of the Queen's Silver Jubilee. The Prince of Wales led a public fundraising appeal to create a fund that would help young people help others. In total, £14.5m was raised and £3m given away in initial grants in the early years. The balance was invested and the trustees have been distributing the proceeds ever since. In 2011, the trustees decided it was time to bring the work of The Queen's Trust to an end and we intend to spend out the balance of the fund by 2019.
What is The Queen's Trust approach to funding?
When making decisions on who to fund we look for boldness, ambition and belief in the potential of young people. We're committed to supporting young people in difficult situations to achieve long term success in life, and providing practical help to enable them to do so. This is illustrated by the charities and programmes we support; like Frontline, Teach First and IntoUniversity. We want to achieve the biggest possible impact by supporting charities that share the key characteristics of leadership, sustainability and strategic planning.
How did The Queen's Trust become involved with Frontline?
In 2013, Sam, a Teach First ambassador, heard that we were looking for new charities to support. He outlined what Frontline is trying to achieve and suggested that we get in touch with Josh MacAlister, Frontline's Chief Executive, also Teach First alumnus. I met with Josh and Mark Potter, the External Relations Director, and was immediately struck by their passion to help the most vulnerable children in the UK and by their intelligent, considered, strategic approach.
Of course, evaluation is another important part of a funder's decision-making, particularly in terms of demonstrable impact. We look for evidence that what we're backing works. But that didn't exist when we chose to fund Frontline. We made the decision to give a grant by looking at the evidence that was available to us – such as the IPPR report, the leadership team, the backing of Ark, the curriculum and the advisors supporting the development of the programme. In Frontline's case, even though there was no proof that what they wanted to do would work, the qualities listed above were great indicators of the likelihood of success. At the very least – it was well worth a try.
In order to help Frontline build the case for support, we initially supported Frontline's evaluation work, specifically looking at what difference Frontline Participants can make in terms of outcomes for children and families. This work is due to report in the second half of next year and is already generating interest.
We now offer unrestricted funding across the Leadership Development Programme. Unrestricted funding in this way works really well as it gives greater flexibility to charities to apply funding where the need is greatest, across a robust business plan and towards a long-term strategy.
Frontline is enabling more people to enter the social work profession, particularly those who might not otherwise have considered this to be a career option. It is increasing the number of professionals making a positive difference to the lives of vulnerable children and their families – which is great.
Trusts, companies and individuals alike, if you are interested in backing an organisation that's bright and ambitious, committed to enabling young people in difficult situations to secure better outcomes, and if you're interested in backing new ideas built on sound principles, Frontline is the right organisation to get behind. Why not join us?


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Wyoming Highway 371 (WYO 371) is a  north-south Wyoming State Road in Sweetwater County that provides travel to the old coal mining town of Superior.

Route description
Wyoming Highway 371 begins its southern end at exit 122 of Interstate 80/U.S. Route 30 south of Superior. From there, WYO 371 travels north and passes through the town of Superior between Mileposts 6.78 and 7.16. Not long after, Wyoming Highway 371 ends after 7.3 miles at Upper Superior Road.

Major intersections

References

External links

Wyoming State Routes 300-399
Wyoming Highway 371
Superior, WY - Ghosttowns.com

Transportation in Sweetwater County, Wyoming
371

redpajama_set_name: RedPajamaWikipedia


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Roseanne's Stand-Up Comeback Is Near
Razzies
Batman vs. Superman Isn't Even Best of the Worst
'Hillary's America' documentary gives Zack Snyder flop a run at the Razzies
Posted Feb 26, 2017 6:33 AM CST
Dinesh D'Souza leaves federal court in New York, Tuesday, Sept. 23, 2014 after being sentenced to spend eight months in community confinement and undergo therapeutic counseling for arranging straw donors for a Senate candidate. (AP Photo/Larry Neumeister)
View 1 more image
Neither Batman nor Dinesh D'Souza could finagle their way out of a Razzie. The annual Golden Raspberry Awards bestowed a tying four "honors" to both D'Souza's documentary Hillary's America: The Secret History of the Democratic Party and Batman v Superman: Dawn of Justice. D'Souza's film was named the worst picture of the year Saturday, marking a political turn for the awards, notes the Independent, and the conservative author got both worst director (with co-director Bruce Schooley) and worst actor for playing himself. Worst actress went to Rebekah Turner, who played Hillary Clinton. "This is absolutely fantastic," said D'Souza in a video. "My audience loves the fact that you hate me." Not to be outdone, Zack Snyder's $250 million Batman v Superman: Dawn of Justice also picked up four "wins" including worst remake, worst screenplay, and worst screen combo for Ben Affleck and Henry Cavill.
Jesse Eisenberg was also singled out as worst supporting actor for his over-the-top portrayal of Lex Luthor. Both films were widely panned by critics upon release—D'Souza's film for being biased and sensationalist and Snyder's for its messiness, reports the AP. While D'Souza's outing is likely a one-time deal, there is more to come in the DC Comic Book Universe from Snyder, whose Justice League hits theaters in November. Another poorly received film, Zoolander 2, got away with only one award, which went to Kristen Wiig for worst supporting actress. This year's "redeemer" award went to Mel Gibson, who was previously nominated for The Expendables 3 and this year is up for a best director Oscar for his World War II film, Hacksaw Ridge. The Razzies are determined by around 1,000 voting Razzie members from 25 countries, while Worst Screen Combo was voted on by "thousands" through a Rotten Tomatoes partnership. (Read more Razzies stories.)