Hormonal care

For many trans and gender diverse people, working with a doctor to access hormonal care is an important and regular part of their lives. Hormonal affirmation, for those who seek it, is an essential part of how we see, care for, and envision ourselves.

Exactly what this means can vary from person to person, and there is no one correct path to hormonal affirmation. Using hormones doesn’t change someone into the woman, man, or non-binary person they already are but for people who experience dysphoria, hormones often alleviate this.

Gender affirming medicine sits well within primary care, GPs can and should feel confident to initiate and manage this treatment with trans people, it can be a critical part of providing medical care to them. Learn more about this model of care here.

Trans and gender diverse people have a right to the highest attainable standard of healthcare, just like everyone else. Access to healthcare, freedom from discrimination and violence, legal gender recognition without requiring surgical intervention and having the ability to participate freely in civil society remain pressing human rights issues for the trans community in Australia. It is important that clinicians providing healthcare to trans people consider this work through a human rights lens. This means recognising that all gender affirming care is medically necessary and life saving, and that the trans experience is not a mental illness.

The World Health Organization made a strong policy decision with the release of the ICD-111, by actively de-pathologising trans and gender diverse people accessing gender affirming healthcare. This also means that the medical community will need to integrate this new way of thinking about, responding to and treating trans patients. It is only in the application of this policy, through practice, that the experiences of trans people within healthcare settings can improve.

Transgender Europe2 write that the human rights principles of gender affirming healthcare include:

• The principle of non-discrimination

• The principles of bodily integrity, bodily autonomy and informed consent

• The principle of freedom from torture and degrading and inhuman treatment

• The principle of free self-determination of gender

• The principles of quality, specialised and decentralised care

• The principles of the right to decide on number and spacing of own children

• The principle of the best interest of the child

Currently, medical providers hold the power to assess or diagnose trans people, allow or deny access to care, and establish in what terms they do so. This traditional model is rigid and the steps that people have to go through are based on a binary understanding of gender.

It does not respect the diversity of trans experiences, and it violates the principles of being free from discrimination, self-determination and informed consent, among others.

Transgender Europe, Guidelines to Human Rights-Based Trans Specific Healthcare, 2019

TransHub uses the terms masculinising and feminising hormones to describe the effects that hormonal affirmation has on bodies, but not to describe the genders of the people using them. Someone can be a woman who uses feminising hormones, and non-binary people also use feminising hormones, there is no one correct form of hormonal therapy. Being on feminising hormones isn’t the thing that makes someone who they are.

Hormonal care is broadly divided into two categories:

• Masculinising hormones, including testosterone.

• Feminising hormones, including estrogen, progesterone and progestins, and anti-androgens.

Some young trans people entering endogenous puberty (Tanner 2-3) may wish to commence puberty suppression using gonadotrophin releasing hormone analogues (GnRHa) prior to commencement of gender affirming hormone treatment, if sought. Find out more about this at the Puberty Blockers page.

Gender affirming hormonal care can be initiated and managed by doctors, including general practitioners, however, people aged under 18 are able to commence treatment only when there is no dispute between parents (or those with parental responsibility), the medical practitioner and the young person themselves with regard to:

• The Gillick competence of an adolescent; or

• A diagnosis of gender dysphoria; or

• Proposed treatment for gender dysphoria

Any dispute requires a mandatory application to the Family Court of Australia as per the judgement of Re. Imogen 2020.

Models of hormone provision

The two main models of hormonal affirmation are the informed consent (or affirmation enablement) model, and the approval letter model.

Medical practitioners seeing patients under the age of 18 are unable to initiate gender affirming hormonal treatment without first ascertaining whether or not a child’s parents or legal guardians consent to the proposed treatment.

If there is a dispute about consent or treatment, a doctor should not administer stage 1, 2 or 3 treatment without court authorisation.

Informed consent places the experiences, expertise and needs of the trans patient first, while ensuring they work with a doctor who can help them navigate potential risks. You can read more about how this model fits into a healthcare framework here.

The approval letter model is where a trans person sees a mental health professional for endorsement prior to starting hormones. While this model is beginning to fade from standard clinical practice, if a patient wants to use the approval letter model, that should be supported.

Information and resources about these models of care for community members can be found here.

The important thing is working with your patient so they can make a decision that is best for them.

For more information and advice, we recommend watching the training video embedded here. This education session was designed for GPs and explores gender affirmation and trans health within the general practice setting.

Delivered on 4 February 2021 in Lismore NSW and online via Zoom, attendees gained new insights into the medical care of trans and gender diverse patients including medical management, hormone therapy and trans-affirming consultation approaches.

This session was delivered by Dr Emanuel Vlahakis (Sexual Health Physician), Dr Fiona Bisshop (GP and President, AusPATH) and Teddy Cook (ACON’s Manager, Trans and Gender Diverse Health Equity and Vice President, AusPATH).

GPs can use this recording to support and strengthen their practice with trans patients seeking medical gender affirmation.