A transfusion medicine colleague in Ohio wonders what other colleagues would do about acceptance or deferral of a regular blood donor who has recently disclosed that he intends to have a sex change operation in a year or so to become a female. Although he has NOT yet had the sex change operation, he is in the stage of dressing like a woman and taking female hormones. In fact, at his most recent donation, he wore a dress and actually passed for a woman during a pre-donation interview with a newly hired interviewer. Because the interviewer thought that the donor was a woman, it is unlikely that the male gender-specific questions were asked at the most recent donation. However, in the past this donor (when dressed like a male) denied having male-male sex since 1977. A unit of blood was collected, but eventually, some of the veteran donor room staff noted that in spite of his 'female' attire, that he was a regular donor, and really a male. The collected blood was discarded. The staff is uncomfortable with the situation and believes that this individual should no longer be allowed to donate blood. The medical director has talked to several other blood bank experts and has received conflicting recommendations. Please share your opinions, but base them on a scientific foundation, not merely gut reaction.

The following responses were received.

ADDENDA June 9, 2003

1. A colleague in Kentucky reports that his first-hand experience in dealing with the same donor situation when he was at his regional blood center was that the male-gendered individual was accepted/rejected based on the male gender health history questions. This individual had always denied any high-risk activity and was accepted for donation. The biological gender of the donor will always be male and was so treated in health history. The donor understood why we were asking the "male" questions and there was never an issue with the staff or donor.

2. A colleague in California reports that his regional blood collection center would approach such a potential donor by applying the regulations and standards very literally. In other words, he believes that all FDA regulations and AABB standards should apply according to his gender at the time the individual comes in to donate. If such a donor answers all of their questions appropriately, the responding colleague would accept the donation. Two caveats: (i) in a case like this, if the donor interviewer does not ask about direct, male-to-male sexual contact since 1977, they also will discard the unit (but not defer the donor) - not because the donor wears female clothes or is preparing for transgender surgery, but because the answer to this "high-risk" question has been omitted (i.e., after a donor has left their collection site, they generally will not allow their staff to call him/her asking a high-risk question they previously forgot to ask); and (ii) if he were to have had sex with another male prior to his sex change procedure (i.e., while he was still male), then the responding blood banker believes the resultant deferral would have to remain in effect indefinitely, even after the donor changes gender and becomes a woman.

ADDENDA June 10, 2003

3. A colleague in New York reports that at her regional blood center they have had this situation from time to time. They treat male donors according to their native gender. For example, if the donor starts out as male, the center records the donor's gender as male in their record, even after a sex change operation. If the gender changing donor reports having sex with a man, the donor is out. If the donor denies sex with a man (there are trans-sexuals who do not have sex), the donor can be accepted (provided other reasons for deferral are absent). The donor center explains all this to the donor and requests his cooperation. If there is concern that the donor will not be honest or cooperative, the donor is deferred.

ADDENDA June 11, 2003

4. A transfusion medicine physician in Maryland reports that a question involving a very similar case was posed to him recently. He answered that he would defer the donor, but admits that his answer may be based mostly on an instinct that he would not want his family member to receive this donor's blood.  He also attempted to provide a 'scientific' reason to give to the donor when refusing him. He would tell the donor he was deferred based on his history of hormone therapy as part of the sex conversion. The Maryland physician does not believe that the medications being used to induce the sex change have been licensed for that indication or even adequately studied in this setting.  He performed a Medline search using the Mesh headings 'sex reversal' and 'estrogens' and found that there are very few references on the effect of female hormones on human male physiology, but many animal studies that show a change in the expression of many enzymes. Because of this, the Maryland physician would be concerned that this donor's blood is not 'normal' and may not have the expected levels of various factors involved in the clotting cascade. Although this has not been studied, there is evidence that the levels of other plasma constituents are abnormal in males taking female hormones (Morbidity in transsexual patients with cross-gender hormone self-treatment: Med Clin (Barc). 1999 Oct 23; 113(13):484-7). Also, he would be concerned about the effect of the donor's plasma, which would be expected to contain supra-physiologic levels of estrogen, on the embryos of pregnant females. (No threshold dose for estradiol-induced sex reversal of turtle embryos: how little is too much?: Environ Health Perspect. 1999 Feb; 107(2):155-9)

5. A colleague in Pennsylvania would treat this donor based on his biological gender (i.e., as a male) and continue to ask him/her the male high-risk questions. Of course, the staff would have to be alerted each time she/he comes in to donate, but the Pennsylvanian sees no reason why this person should not be otherwise acceptable as a blood donor.

ADDENDA June 12, 2003

6. A colleague in Southern California reports that she and the facility Medical Director agreed that they shall apply all applicable regulations, standards and hospital SOP's very literally to the question of a gender-changing donor. In other words, they believe that this donor shall be excluded pre-surgically due to the excessive dose of hormones being ingested and excluded post-surgically due to the fact that this donor shall remain genetically male. Post-surgery he will be excluded because of the question regarding male-to-male sexual contact since 1977.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator

W. Tait Stevens, MD
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