Criteria for initiation of hormones

The criteria for initiating (starting) hormones will differ depending upon your age, and several other health factors.

For more information about the differences between the feeling and diagnosis of gender dysphoria, refer to our pages on gender dysphoria and gender diagnoses.

WPATH criteria for commencement of gender affirming hormone therapy (aged 16+) are as follows:

1. Persistent, well-documented gender incongruence (sometimes referred to as gender dysphoria);

2. Capacity to make a fully informed decision and to consent for treatment;

3. Age of majority in a given country

4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

Australian Standards of Care (SoC) criteria for adolescents to commence puberty suppression:

1. A diagnosis of Gender Dysphoria in Adolescence, made by a mental health clinician with expertise in child and adolescent development, psychopathology and experience with children and adolescents with gender dysphoria.

2. Medical assessment including fertility preservation counselling has been completed by a general practitioner, paediatrician, adolescent physician or endocrinologist. This assessment should include further fertility preservation counselling by a gynaecologist and/or andrologist as required with referral for fertility preservation when requested.

3. Tanner stage 2 pubertal status has been achieved. This can be confirmed via clinical examination with presence of breast buds or increased testicular volume (>4 mL) and elevation of luteinising hormone to ≥0.5 IU/L.

4. The treating team should agree that commencement of puberty suppression is in the best interest of the adolescent and assent from the adolescent and informed consent from their legal guardians has been obtained.

Australian SoC criteria for adolescents to commence gender affirming hormone treatment using estrogen or testosterone:

1. A diagnosis of Gender Dysphoria in Adolescence, made by a mental health clinician with expertise in child and adolescent development, psychopathology and experience with children and adolescents with gender dysphoria.

2. Medical assessment including fertility preservation counselling has been completed by a general practitioner, paediatrician, adolescent physician or endocrinologist. This assessment should include further fertility preservation counselling by a gynaecologist and/or andrologist as required with referral for fertility preservation when requested.

3. The treating team should agree that commencement of estrogen or testosterone is in the best interest of the adolescent and informed consent from the adolescent has been obtained. Although obtaining consent from parents/guardians for commencement of hormone treatment is ideal, parental consent is not required when the adolescent is considered to be competent to provide informed consent. For adolescents who are assessed as not being competent to provide informed consent, parents/legal guardians can provide informed consent on their behalf without requiring court authorisation

Under 18s

A Family Court of Australia ruling (Re Kelvin, 2017 1) overturned an existing law that required all young people and their parents/carers to go to Court to commence gender affirming hormones prior to age 18, this ruling was further clarified in the judgement of Re Imogen 20202 to mean that treatment can be commenced in Australia with people under 18 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.

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

The ruling from Re Imogen also stated that “absent any dispute by the child, the parents and the medical practitioner, it is a matter of the medical professional bodies to regulate what standards should apply to medical treatment” 2. This clarifies that the informed consent and approval letter protocols are lawful models to gender affirming healthcare.