Starting Hormones

Pre-GAHT Considerations

Before GAHT, a psychosocial assessment must be conducted by a specialist. Individuals must always be asked for informed consent. The following criteria should be met

1. The diagnosis of gender dysphoria must be confirmed.
2. Individuals must be competent to make their own decisions and able to give consent for treatment.
3. Their age requirement is fulfilled in the country in which they are to receive treatment.
4. Any comorbidities or concomitant psychiatric diseases that may affect GAHT should first be treated and medically controlled.

However, in some specific circumstances, healthcare providers may administer hormonal therapy to individuals who do not fully meet criteria, such as those who have already received inappropriate hormone treatment but wish to switch to therapy under medical supervision. Another example is those who have lived a transgender lifestyle and have used hormones in the past. On the other hand, if the individuals have risk factors for complications or harmful effects of GAHT, it is the healthcare providers' responsibility to give appropriate counseling or offer non-hormonal transition alternatives.3 Before initiating GAHT, healthcare providers must always consider the cautions and contraindications of therapy, as shown in Table 1, to ensure proper treatment.

GAHT Cautions or Contraindications for Transgender Individuals

Furthermore, healthcare providers should advise individuals on abstinence from smoking, regular exercise, weight control, adjustment of eating behaviors, and a lifestyle conducive to the reduction of cardiovascular disease risk. Healthcare providers should counsel individuals of reproductive age who wish to have children with their own gametes on gamete preservation because GAHT may harm gamete production and development and reduce fertility.

The individual's age range is one of the most critical factors in choosing the drug and drug administration periods. In cases with transgender children, healthcare providers must be extra cautious in diagnosing gender dysphoria. A shared decision with the parents must be made before starting treatment. It may in fact not be necessary for children to receive GAHT. Instead, multidisciplinary specialists (such as pediatricians and child psychiatrists) should supervise individuals’ transition process to plan the appropriate treatment during adolescence. In cases with GAHT in transgender adolescents entering puberty, healthcare providers must take both short and long-term hormonal therapy effects on health (such as adverse effects on gametes, brain function, and behavior) into careful consideration. Furthermore, individuals may change their minds later and prefer detransitioning. This can be found in very young individuals.

When transgender adolescents reach Tanner stage 2 of sexual development (breast development in biologic females or testis development in biologic males), healthcare providers may consider starting GnRH agonists to temporarily suppress puberty until individuals reach an appropriate age. GnRH agonists are recommended in many countries to suppress individuals' gonads until the age of 16. Afterwards, healthcare providers may initiate GAHT.

Informed Consent

In a health setting, informed consent (also known as ‘affirmation enablement’) simply means being given correct and adequate information about gender affirming hormones, risks, effects, combinations and how they might work with other medications or recreational drugs. This is so you are able to make a decision (or consent) about your body, health and health care. Doctors need to ensure their patients are making informed decisions about their health every day.

As it relates to trans people and gender affirming care, informed consent is a model that places the experiences, expertise and needs of the trans patient first. This means we are also working with a doctor to not take undue risks or place ourselves at risk of harm.

Your doctor will need to assess that you understand:

• What gender affirming hormones are available
• Potential effects and side-effects
• Risks and benefits
• Doses and application methods (patch, gel, tablet, injection etc)
• Your doctor’s experience in providing this kind of care
• How to consent and have the capacity to

“For trans people, informed consent represents autonomy and a departure from stigma, allowing patients to make their own choices about their bodies. The individual nature of this model allows care providers and patients to tailor it to individual needs” Ruben Hopwood, Transgender Health Program Coordinator, Fenway Health, Boston

The informed consent model, developed at the Callen Lorde Community Centre in New York, recognises that trans people are able to understand and consent to medical and surgical interventions ourselves, by understanding the risks, impacts and limitations. It places self-determination and autonomy at the centre of trans healthcare.

In NSW, people aged 18+, who are able to consent to their own medical care, can initiate (or start) gender affirming hormones with a GP under the informed consent/affirmation enablement model. It’s important to book the longest appointment possible for starting this and it’s recommended to work with an experienced GP, where possible.  

The process may look like (aged 18+):

• A consultation with your doctor, across 2-3 appointments. You’ll be asked about your physical health, medical and family history, previous hormonal or gender affirmation experience.
• Talking about how you want to affirm your gender medically, and associated goals.
• Discussion of risks factors.
• Your doctor may ask you about your specific history with migraines, liver disease, seizures, breast tissue lumps and irregular bleeding. This is to ensure the right gender affirming hormone combination is prescribed. Your doctor may want to further investigate any issues.
• You’ll also have a conversation about your current medications, allergies, if you smoke, how much you drink or use drugs, and how much support you have at home, and at work
• Arranging blood tests to establish base line levels of estrogen, testosterone and a range of other indicators such as liver function, thyroid levels, cholesterol, full blood count, electrolytes, glucose, lipids, and if applicable, pregnancy. They’ll also take your blood pressure and might ask you to jump on the scales.
• You should also be asked about fertility goals and reproductive health needs, and provided with information about fertility preservation
• Signing some informed consent paperwork, like the documents below, that show you’ve heard/read all the necessary information, understand what the risks, impacts and outcomes might look like, and consent to the process
• You may be asked about your last cervical screen, STI test, the contraception methods you use, if you’ve had a bowel cancer screen, etc.
• Throughout this process, your doctor will be assessing that you understand what’s going on, have the capacity to make an informed decision and consent to treatment, ensuring that you are making a decision of your own free will.
• A genital exam is not required and is against recommendations

It’s important to build a trusting and honest relationship with your doctor. It’s their job to help you stay healthy.

Refer: Gender-Affirming Hormone Treatment in Transgender People - The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University, INFORMED CONSENT (Transhub)