Though not all trans people seek out HRT, for many it is an important aspect of their transition. Making HRT more accessible is integral to advocating for trans clients.
This chapter will provide information to guide frontline workers and community organizations in the process of referring trans people to appropriate services and supporting them through the process of accessing hormones. Initiating Cross-Gender Hormone Replacement Therapy Many health care professionals harbour fears surrounding prescribing hormones to trans people, feeling as though they are not qualified or do not have the proper expertise or training.
People who get hormones by prescription rather than through friends or the underground market usually get them in three main ways: A GP or family doctor works with patients with a wide variety of needs and medical conditions.
They may work out of a private practice or through a local CLSC. The job of a GP is to look after the overall health of their patients. Many family doctors provide HRT as part of primary care. Whether or not a GP will prescribe hormones to a trans person usually depends on both their comfort level and their knowledge base about trans health issues.
If a family doctor is comfortable with providing a prescription for hormones to a trans patient, but is not knowledgeable on the subject, they might agree to do some research, and then prescribe once they are more informed. Unfortunately, some doctors are uncomfortable providing hormone therapy to trans people under any circumstances, and a person trying to access trans-specific care might have to find a new GP. Other than GPs, two types of doctors who are qualified and most likely to be willing to prescribe hormones are endocrinologists and gynecologists.
For the most part, these specialists require a referral from a general practitioner to book an appointment, but a person can technically self-refer. Some specialists will initiate HRT only with a letter from a mental health professional that indicates an official diagnosis of Gender Dysphoria. Often the waiting list to see a specialist is very long. An endocrinologist is a medical specialist dealing with internal medicine.
They have a special understanding of the role of hormones and other biochemical mediators in regulating bodily functions. They are also trained to treat hormone imbalances. A gynecologist is a medical and surgical specialist concerned with the care of women from pregnancy until after delivery and with the diagnosis and treatment of disorders of the female reproductive tract.
A gender clinic is an interdisciplinary specialty clinic usually located within a hospital. While these clinics do not provide direct access to hormone therapies and surgeries on site, they have the capacity to perform assessments and treatment of concerns relating to gender identity, including counseling, psychotherapy, hormone assessment and monitoring, and documentation for approval of surgeries.
Staff at gender clinics will be able to refer those accepted into the program to a GP or specialist who will write the prescription for hormones after certain requirements have been met. This does not include the cost of hormones, surgeries, or electrolysis; it only includes therapy.
Due to the cost and duration of this channel, it is inaccessible for much of the trans population. Trans people, as a group, face discrimination in employment, education, and in housing, and as such the majority live at or below the poverty line. Even in the best-case scenario, if a trans person is able to raise the money needed to complete the program, very few doctors are willing to prescribe hormones and the gender clinic does not have doctors on staff to prescribe them.
While for many years, the Human Sexuality Unit was understood to be the only option for trans and gender-variant people to access relevant services and Sex Reassignment Surgery covered by the Quebec government, there are currently many other options.
For references to trans-positive mental health professionals, family doctors, and specialists, contact ASTT e Q at At gender clinics in general, the common intake procedures involve the trans person answering a host of personal questions, including questions about sexual fantasies, favourite sexual positions, etc.
Protocols and Standards of Care Health care professionals use a variety of protocols when assessing readiness for HRT. Below is an outline of some of the protocols available, along with brief descriptions of the frameworks on which they are based. The WPATH formerly known as the Harry Benjamin International Gender Dysphoria Association Standards of Care are put forward by a professional body made up of psychiatrists, endocrinologists, surgeons, and other health care professionals.
Some of the topics addressed in the Standards of Care include suggested requirements for HRT, surgery, and post-transition follow-up. This prerequisite for hormone therapy initiation is based on the belief that in order to be able to make an informed choice about whether or not to transition change sex , a transsexual person must live in their desired gender role full time. This includes seeking employment or attending school as this gender.
For some professionals, only once this criteria has been met will they consider a transsexual ready for medical intervention hormones, surgery, etc. According to this model of treatment, once the RLE period is over the person can decide if they would like to begin hormone treatment. The concept behind this belief is that transsexuals need to experience socialization in their chosen gender role in order to have a clearer understanding of the realities of life in that gender.
On the other hand, it does place transsexual people at significant risk. Pre-transition transsexuals undertaking RLE are often easily identifiable as trans people, and thus often become targets of hate crimes and discrimination. There is no scientific evidence that supports the belief that the RLE is beneficial or even necessary to transitioning. In fact, research done on the RLE indicates the contrary. The version of the Standards required six months of RLE before a person was permitted to access surgery or hormones, while RLE was dropped completely in the revision.
Without scientific basis to prove its usefulness, the RLE is now sometimes used as an indicator of someone being serious about transitioning, but is no longer considered by most professionals, and even the WPATH, to be a required step in this process. Because the RLE can actually place transsexuals at physical and emotional risk, a responsible service provider may conclude that the RLE should remain an optional experience, rather than a requirement, for cross-gender transitions.
The document suggests that health care providers use the Standards of Care guidelines that can be modified depending on the individual needs and life circumstances of the patient. Furthermore, the Standards of Care document also recommends a harm-reduction approach applied in circumstances where trans people are using black-market hormones. Although the WPATH Standards of Care are the protocols most widely used by health care providers, many clinics and individual doctors prefer to create their own guidelines and assess readiness for HRT using models based in harm reduction, self-determination, and informed consent.
Such protocols assume that the individual is best equipped to make decisions about their own body, while providing the tools to ensure that the client has all the necessary information to make an informed decision.
The relationship between these kinds of protocols and the WPATH Standards of Care changed when the 7th version of the latter was released in The new WPATH Standards of Care are more flexible, and they support the initiatives of individual clinics and doctors who alter and tailor the document to suit the needs of their clients.
Alternative Protocols Both the Tom Waddell and Callen-Lorde Protocols are guidelines for health care providers and are based on the principles of harm reduction and informed consent. These guidelines do not determine who is eligible for treatment; they are working protocols designed to provide care to people who already self-identify as transgender and contain the assumption that people know what is best for their own bodies.
These two protocols are the most commonly used by health care professionals and clinics working within a harm-reduction framework.
Other protocols and standards, developed by individual doctors or clinics, are also available. Initiating hormone therapies for trans people within a harm-reduction framework is one way of advocating for trans people, who experience multiple barriers to access to adequate and respectful health care. Doing so acknowledges the ways in which the systems in place to access trans-specific health care services do not take into account many of the realities that trans people face every day.
Assessing Readiness for Hormone Replacement Therapy An ethical approach to determining whether HRT is suitable for someone will necessarily include enhancing patient knowledge and emphasizing patient self-determination. As a health care practitioner, you will undoubtedly come into contact with trans people who want to receive hormone therapy and have differing levels of information regarding the risks and benefits of this treatment. Therefore it is essential that you can provide them with accurate information.
They need to be aware of possible side effects as well as the consequences of short- and long-term hormone use. Someone who has accurate information about the effects and risks of HRT, as well as the mental capacity to make a decision, will be the best judge of whether or not they should undergo this therapy. Once your client has made the decision to begin hormone therapy, you may wish to have them sign a consent form stating that they are aware of the risks and permanent or temporary changes that might occur should they begin treatment, as well as to confirm their desire to begin treatment.
Many trans people choose not to—or are unable to—access HRT through a doctor, with a prescription. As a result, people access hormones on the underground market, over the internet, through a dealer, or from a friend who has a prescription.
Often, when trans people access hormones without a prescription, the brand or kind of hormones they are taking are inconsistent. They also might not have information on the proper dosage or how to administer the hormones. Please consider and be sensitive to the individual journeys of the trans patients you encounter when you are discussing HRT with them.
Liability The use of an informed consent form, baseline tests and proper monitoring of patients on HRT are the best protection you have against liability. Informed consent in the context a patient who wishes to undergo HRT involves communicating to them the risks and side effects associated with hormone therapy and making sure the patient understands these risks. A frank discussion with your patient can help determine what they already know about hormones and what information you can offer.
Physicians must be able to offer accurate and complete information regarding risks and side effects of hormones to patients.
Therefore, the more you as a doctor know about hormones, the better you can inform your patient and thereby reduce your liability. The more a patient knows about hormones, the better equipped they are to make good decisions about their transition and be happy with the results. The consent form must state clearly that the patient has been informed of the risks associated with HRT, and that they are willingly receiving hormone treatment. It must also state that the medical practitioner is not responsible for this decision but that they will, however, ensure the best care possible through the transitional process and follow-up.
All patients who are about to begin HRT should be given a series of baseline tests, which will be important in determining hormone dosage and useful in future monitoring. Below are the baseline tests suggested prior to commencement of HRT. It is recommended that the tests be repeated two months after starting or increasing the dosage and every six months after establishing a stable dosage.
Baseline tests for patients planning to begin HRT: