Gender-Affirming Hormone Therapy (GAHT)

The following section outlines the information that pertains to assessing, prescribing, and monitoring GAHT. This section is comprised of both visual and written material, and should be completed in the following order:

Watch the Community Based Research Centre’s Gender-Affirming Hormone Prescription Training for Healthcare Professionals.

1

Review the written guidelines and information outlined below.

2

Gatekeeping and Bias

Gatekeeping happens when health professionals create unnecessary and unfair hurdles for those accessing gender-affirming care, requiring Two-Spirit, trans, Indigiqueer, and gender-diverse (2STIGD) patients to ‘prove’ who they are and that they really want or need access to medically-affirming care. Gatekeeping can look like: requiring unnecessary steps in order to access gender-affirming care; denying or delaying gender-affirming care; requiring 2STIGD patients to adopt a binary identity (i.e not accepting of non-binary identities); or using a deficit/distressed-based approach when discussing gender identity (i.e requiring a diagnosis of or centering gender dysphoria as opposed to gender euphoria).

Asking questions that are unrelated to the direct care of the patient can feel invasive and can sometimes be referred to as microaggressions. This can also look like expressing cisnormative and heteroromative ideas about 2STIGD people’s bodies, sexuality, and their goals for transition.

Questions to Ask Yourself

What assumptions am I making about the needs (or lack thereof) of a patient who self-identifies as 2STIGD?
Am I thinking critically about my implicit biases and the ways they impact care delivery?
Am I listening to the needs of my patients?
Are the questions I am asking related to the direct care of the patient?
Am I creating unnecessary barriers for patients to receive the care they need?
How can I broaden my understanding of what gender-affirming care looks like beyond the gender binary framework?

Patient Misconceptions

As with any other process, patients may have some false (or partially false) assumptions about GAHT. In particular, it has been anecdotally noted that some patients see the higher dosage levels as the goal, in thinking that the maximum amount will produce the strongest results, however this is not always the case, and can in fact increase health risks. That said, in cases where patients are experiencing gender dysphoria, they may be experiencing distress and wanting the quickest results possible. It is important to navigate this with care and understanding, as it may be difficult for some patients to accept. In these cases, being clear and transparent about the process of how dosages are determined may be helpful.

Patients will also need to be carefully instructed in what to do should they miss a dose, as well as the dangers of overdosing. While a patient’s pharmacist should provide them with dosage information, it is important for a PCP to be extra clear, as it is not guaranteed that a pharmacist will adequately provide patients with this information.

Hormone Readiness Assessment

A hormone readiness assessment is an evaluation conducted by a health care professional to determine if a patient is ready to begin GAHT.

The World Professional Association for Transgender Health Standards of Care requires an assessment before GAHT is started. Gender-affirming care in N.B. is guided by Version 7 of the Standards, which were published in 2011. In N.B., a WPATH letter of

recommendation for the initiation of hormones is not required. However, it should be noted that version 8 of the standards of care have recently been published and will soon replace SoC-7 on all NB forms.

While there is no waiting period required prior to initiating GAHT, there are a number of preparatory steps needed to ensure GAHT is provided in the safest manner possible.

The decision to initiate GAHT is a collaborative, patient-centered process that focuses on both psychosocial preparation and informed consent (see Informed Consent Model for more information). The PCP (with or without the support of a multidisciplinary team) can facilitate a decision-making process that informs, educates, and supports patients. For each patient seeking GAHT, it is important to not only consider the possible risks of GAHT but also to consider the often substantial risks of withholding treatment, as gender-affirming care is life-saving care.

Assessment by a psychologist or psychiatrist is not required for most people, however the PCP should assess both mental and physical health as part of the hormone readiness assessment and refer to appropriate specialists as needed (see Part 7: Mental Health for more information). Where the PCP feels a referral is necessary, they should be as transparent and honest as possible with the patient about their own lack of expertise around mental health care, rather than it being the “fault” of the patient (as this is how it can often sound). Additionally, care should be taken to refer the patient to a mental health provider who is supportive of 2STIGD individuals to ensure as safe an environment as possible for the patient.

Assessment often takes place over a number of visits, depending on the length of time available per visit, the clinical situation, and the experience of the clinician. More visits may be required for patients with complex physical or mental health issues, or for patients who are socially isolated. That said, care should be taken to not lengthen the process more than is necessary, as many patients will want to move forward with their transition as quickly as possible. Fewer visits may be appropriate for a “straightforward” patient, for more experienced clinicians, if appointments are longer, or if the patient has a referral from a WPATH mental health provider. Fewer visits may also be recommended in situations where harm reduction is the priority (e.g., extreme distress, is currently taking hormones unprescribed, etc.).

The purpose of these visits is to ensure the patient is ready from a medical and psychosocial perspective to begin GAHT. This is ideally done within a primary care setting using a gender-affirming, informed consent approach. This period of time is referred to as the Hormone Planning Period and involves the provider establishing rapport with the patient, conducting an overview of patient history, collecting baseline data including blood work, providing education about the anticipated effects and potential risks of GAHT, determining the need for services such as fertility prevention, and obtaining informed consent.

The checklist below covers the important considerations and steps to take when getting ready to initiate GAHT with a patient.

Hormone Readiness Assessment Steps

Initiation of GAHT in some cases may be undertaken without completing the usual tasks of the planning period and from a harm reduction perspective. Examples of this include a patient who is already using hormones without a prescription, or someone who is experiencing extreme distress regarding their gender presentation. Other situations may warrant a degree of fast-tracking through the planning period, such as when a patient and their medical and/or gender history are well-known to the provider prior to the patient seeking GAHT, or if the patient has a WPATH referral letter from a mental health provider.

PATIENT HISTORY

Discuss the rationale for assessment period: Establish rapport
Ensure optimal readiness
Ensure patient has all information they need to start GAHT
General medical intake & medical history

PATIENT EDUCATION, READINESS AND SUPPORTS

Allow patient to articulate their transition goals
Ensure patient expresses reasonable expectations
- Patient understands timeline of changes
- Patient understands limitations of GAHT
Discuss effects on fertility and options available for preservationa (see Part 6: Sexual Health and Reproduction)
- Discuss pregnancy risk and options for contraception & implement these if needed
- GAHT can impact an individual’s reproductive health, and they should be made aware of options and consequences before treatment begins.
Discuss psychosocial readiness
- Ensure supports are in place to facilitate healthy adjustment
- Refer to psychological support/counselling if necessary (see Referrals to Mental Health Care)
- Review potential costs (e.g. medication, hair removal, fertility)
Discuss risks, side effects, potential benefits and expected changes (reversible vs. irreversible) associated with treatment and ensure patient demonstrates understanding
Ensure patient possesses capacity to consent (see Informed Consent Model)
Review medication options/treatment routes

RISK MANAGEMENT

Ensure absence of absolute contraindications
Optimally manage precautions
Manage psychiatric comorbidity, if present
If smoker, advise smoking cessation counselling
- Smoking cessation is recommended for individuals looking to start hormones due to increased health risks of smoking tobacco products while on hormones (e.g., blood clots, heart attacks, strokes, diabetes, and cancer). In addition, most gender-affirming surgeries require that an individual stop or restrict smoking to access surgery. Currently, there is not enough research on the effects of smoking cannabis while on estrogen- or testosterone-based hormones. However, patients will be required to stop or restrict smoking cannabis to undergo surgery.

Exploration of Gender Identity and Expression

Speaking with patients about their history and experience with gender is not something that health care providers are typically taught during their training. It is, however, an important part of getting to know a patient, and it informs the discussion around the development of an individualized care plan.

Reassure your patient that there are no ‘wrong answers’, nor any specific narrative that you are looking to hear. Not all 2STIGD people experience gender dysphoria or display gender diversity in childhood; gender is fluid and therefore gender diversity may emerge at any point in the life cycle.

Possible Questions to Explore Gender Identity and Expression

* All questions listed below are intended to be guiding questions. When establishing a rapport with a patient it is important that you make these questions your own, personalize them, or come up with questions that better suit your patient.

How do you identify in terms of gender?
How do you feel about your gender identity?
What actions, words, and attitudes from others help you feel the most affirmed in your gender?
What has prevented you from feeling positive about your gender identity?
What types of support have been helpful to you?
How do you relate to the gender binary? In what ways do or don't you identify with expectations based on gender binary?
What does it mean to you to transition? How do you understand the starting and ending points of transition, if they exist? Transition can include many different components and stages. Which parts are necessary for you to feel affirmed in your gender?
Have you taken any steps to express your gender differently/to feel more comfortable in your gender? If prompting is needed: Some people ask others to use a different name and pronoun, or make changes to their hair or clothing styles. If they have taken steps to express their gender differently: What was that like for you? How did that feel?

Adapted from: Trans Care BC: Primary Care Toolkit, 2018 and A Clinician's Guide to Gender-Affirming Care by Chang, Singh & Dickey, 2018

Psychosocial Preparation and Support

Part of the hormone readiness assessment involves discussing a patient's psychosocial readiness and support networks. The purpose of this portion of the assessment is not to make judgements about a patient's socio-economic status, but to identify areas where the PCP can facilitate access to additional resources and support.

While some patients may benefit from individual therapy with a gender-positive therapist, it is important to note potential financial barriers that make obtaining adequate and consistent mental health support difficult. As previously mentioned, mental health counselling is not a requirement to initiate GAHT. However, should patients be interested in mental health support, referrals should be made. Moreover, support in a peer group setting can also be immensely beneficial for some patients.

It is not a requirement for patients to discuss their transition with family members (including chosen family) and friends before the initiation of GAHT. Although it is ideal for a patient to have an established support network, it is not uncommon for there to be safety concerns that accompany social transition. It is important to take the time with each patient to understand their support network and help them identify possible supports should they not already have a supportive network.

Asking about how transitioning may influence the employment or educational situation of the patient is important, though it should be made clear that this is not meant to deter patients from transitioning. Instead, providers can help the patient develop positive strategies for dealing with transition-related changes in school or the workplace and/or refer to another provider (i.e., mental health) or support network (i.e., community groups).

In the past, WPATH advocated for a three-month period of life experience in the congruent gender role prior to GAHT. The rationale for this step was to enable the establishment of coping mechanisms for the above mentioned social stressors. In reality, however, this requirement served as a gatekeeping strategy. This requirement for a “real life experience” has been shown to be both stressful and harmful, since it involves longer wait times and the invalidation of already very real lived experience. Additionally, some individuals may not feel comfortable or safe presenting publicly until they have achieved certain results from GAHT. Accordingly, this is no longer a requirement for GAHT or surgical interventions, with the exception of external genital surgery (see Part 5: Gender-Affirming Surgery).

Asking about psychosocial preparation and supports

What concerns or thoughts do you have about how transition will affect and be affected by your work/school life?
Who has supported you along the way? If the patient has not spoken with anyone else yet: Who do you think might be supportive if you bring this up with them?
Have you done anything to prepare yourself for this step? If prompting is needed: Have you talked with any peers or asked friends or family for support? Have you done any reading or research?
Some people find it helpful to have the support of a counsellor for either decision-making or ongoing support after beginning hormones—would you be interested in a referral to a trans-competent counsellor?
In what ways do concerns related to your gender affect your mental health or emotional well-being and vice versa?
What sources of support do you have to help buffer the stressors that you are facing?
What kinds of support and advocacy do you need at this time?

Adapted from: Trans Care BC: Primary Care Toolkit, 2021 and A Clinician's Guide to Gender-Affirming Care by Chang, Singh & Dickey, 2018

Diagnosis

The provision of GAHT has generally been preceded by a diagnosis of Gender Dysphoria as outlined in the Diagnostic and Statistical Manual, Volume 5 (DSM-5). However, there has been a great deal of debate in both medical and 2STIGD communities around the appropriateness of using a psychiatric diagnosis (or a diagnosis at all) for 2STIGD individuals. The aim to destigmatize gender diversity while securing access to care has been a central dilemma in this debate.

Since “transvestism” first appeared in the World Health Organization’s (WHO)’s 8th Edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-8) in 1965 (and ‘transexualism’ in the DSM-III in 1980), the evolution of the name, criteria and categorical placement for diagnoses about 2STIGD experiences has been continuous.

The revision of the diagnosis and its criteria in 2013’s DSM-5 represented a step toward depathologizing gender diversity and validating the spectrum of gender identities. In addition, a distinction was established between “gender nonconformity” and the diagnosis of gender dysphoria:

“Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.” “Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender nonconforming people experience gender dysphoria at some point in their lives.”

The WHO has taken a step further in depathologizing gender diversity in the ICD-11, released in May 2019. They have renamed the diagnosis Gender Incongruence and removed the diagnosis from the category of mental health disorders, placing it instead in a category of “Conditions Related to Sexual Health.” Additionally, in contrast to the DSM diagnosis, there is no criteria for significant distress or impairment.

This represents a concerted effort to abandon the psychopathological model of gender diversity, and supports the provision of gender-affirming care to a wider population of 2STIGD folks. As societal acceptance and access to supportive communities and care increases, the distress experienced by some 2STIGD people is likely to decrease. The absence of the criteria for significant distress or impairment as a prerequisite for those seeking GAHT allows for the timely provision of care as a preventive measure, rather than waiting for distress and impairment to manifest through the withholding of care.

2SQTP-NB/P2SQT-NB advocates for the provision of gender-affirming care in a manner that supports the self-determination and bodily autonomy of 2STIGD people. Although establishing a diagnosis of gender dysphoria is required by NB Medicare to obtain access to GAHT and surgery, PCPs should not require patients to experience significant distress or impairment as a prerequisite for care. Notably, 2STIGD people should not be faulted for a health care system that has not yet abandoned the psychopathological model of gender diversity.

The Criteria For The DSM-5 Diagnosis of Gender Dysphoria

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months duration, as manifested by at least two of the following:

A marked incongruence between one’s experienced/expressed gender and primary and/ or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
A strong desire for the primary and/or secondary sex characteristics of the other gender (or some alternative gender different from one's assigned gender).
A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

Description of gender incongruence in the ICD-11

Gender incongruence of adolescence and adulthood is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, which often leads to a desire to “transition” in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individuaĺs body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior to the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.

Physical Exam and Baseline Investigations

A focused physical exam is recommended prior to the initiation of GAHT. The exam should include screening for conditions such as hypertension and active liver disease, which may increase the risks of GAHT.

Physical examination, particularly of the chest and genitals, may be uncomfortable for patients. A physical examination of the chest and genitals is not required before the initiation of GAHT.

In addition to practicing trauma-informed care, it is advisable to use gender-affirming terms (e.g., “chest” for transmasculine patients, “breasts” for transfeminine patients) or general language (e.g., “genitals,” “gonads''). Whenever possible it is best to use gender neutral anatomy terminology or to ask patients if they prefer a particular term. Further discussion regarding sexual and reproductive care is located in Part 6: Sexual Health and Reproduction. To download the gender-affirming terms quick reference, please see the Body Terminology Quick Reference.

Vitals

Baseline measures include blood pressure, temperature, heart rate, height, and weight.

Bloodwork

Laboratory tests should reveal any existing health problems such as liver dysfunction, high cholesterol or diabetes. If present, these conditions should ideally be managed prior to or concurrently with the initiation of hormones. The values will also provide a useful baseline to help with future monitoring for endocrine changes. Measurement of hormone levels may reveal whether any exogenous hormones are being taken. Any major irregularities could also indicate if a person is Intersex (see section on Intersex Considerations for more information).