Masculinising hormones

Hormonal gender affirmation is an important part of many trans and gender diverse people’s lives. Masculinising hormones are typically used by trans people who were presumed female at birth (PFAB), including men and non-binary people.

Masculinising hormones are testosterones. The physical and psychological effects testosterone has on the body depend on the type of testosterone prescribed as well as personal factors including age, body, hormonal history, any existing contraindications, and what a patient wants to take. Generally though, using testosterone is a very effective way of masculinising.

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.

Information and resources for community members seeking gender affirming masculinising hormones can be found here.

Testosterone is the primary masculinising hormone used by trans men and non-binary people (PFAB). Sometimes just known as ‘T’, it is not generally used in combination with estrogen hormone blockers.

The Australian Position Statement on the Hormonal Management of Adult Transgender and Gender Diverse Individuals 1, published in the Medical Journal of Australia on 5 August 2019, states that “for people requiring masculinising hormone therapy, we use the authority indication “androgen deficiency due to an established testicular disorder”.

This acknowledges that prescribing gender affirming hormones does not need to be based on a patient’s identity, but rather their physiology, which is accurate since bodies presumed female at birth don’t naturally produce enough testosterone on their own. Patient’s do not need to be registered with Medicare as male in order to access PBS-listed testosterone. A Registered Medical Practitioner or Registered Psychologist can also assist their patients to update Medicare records.

Accessing PBS-listed testosterone does currently require an additional step where a doctor (or patient) will need to consult with an Endocrinologist, Sexual Health Doctor or Urologist. This only needs to happen once.

Testosterone regimens

Regimens that are recommended in the Australian Position Statement 1 are marked with the symbol ª:

The Australian Position Statement 1 also states that “treatment should be adjusted based on clinical response”. This acknowledges that the clinical management of gender affirming hormones should be individualised, and requires partnership between a treating physician and the trans patient.

This means prescribing testosterone based on how a patient responds to treatment and alongside risk factors, rather than based solely on specifically targeted levels.

Notwithstanding this, the Position Statement does recommend targeting trough total testosterone levels in the lower end of the male reference interval (10-15 nmol/L)

It is recommended that levels are monitored at baseline, every 3-4 months for the first year, including prior to the application of testosterone to assess trough total testosterone, and then annually once your patient’s testosterone levels are adequate and stable. This includes a full blood count, renal and liver function, blood pressure and lipids, and blood glucose for patients with risk factors.

The Position Statement has been endorsed by AusPATH, the Endocrine Society of Australia (ESA) and the Royal Australasian College of Physicians (RACP).

Lower doses and temporary use

For some trans people, being on a lower dose of testosterone, or using testosterone occasionally or temporarily is central to how they want to hormonally affirm their gender.

It is difficult to try and implement one masculinising change and not another, as once a hormonal threshold is reached, a range of secondary sex characteristics will begin to change.

Consultation with a specialist Endocrinologist may be helpful.

The use of hormonal suppression without gender affirming hormonal therapy can lead to adverse health effects, and so is to be undertaken carefully, and with regular oversight.

A Family Court of Australia ruling (Re Kelvin, 2017) overturned an existing law that required all young people and their family to go to Court to commence gender affirming hormones prior to age 18. Treatment can be commenced in Australia with people under 18 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 20204.

Medical practitioners seeing patients under the age of 18 are unable to initiate puberty blockers or 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 puberty blockers (“Stage 1”), hormones (“Stage 2”) or surgical intervention (“Stage 3”) without court authorisation.

For trans people under 18 whose parents, carers or guardians will not consent to starting hormones, the Family Court must be involved. Unfortunately, in many cases where parents, carers or guardians do not consent, this may result in a trans person simply waiting until they are 18 to access puberty blockers and hormones, or seeking to access them outside of medical care and oversight.

Further assistance is also available at Inner City Legal Centre who offer a NSW-wide free legal service for trans and gender diverse people.

“Ideally, the decision regarding timing of hormone commencement should be individualised to provide best care for the adolescent …The decision should be shared between the clinicians, the adolescent and their family with the values and belief systems of all contributors being respectfully considered.”

Australian Standards of Care and Treatment Guidelines For trans and gender diverse children and adolescents 5