Authors: Dr Julian Grace & Dr Sav Zwickl.
Content Warning: This article contains brief mentions of genitalia, and other body parts. When referring to specific parts of the body, we use anatomical/medical terms e.g., clitoris, breast.
I’m over 18 and thinking about gender-affirming hormone therapy. Where do I start?
There is a lot of information out there about gender-affirming hormone therapy (GAHT). Not all of it is correct, and some of it might be applicable elsewhere, but not in Australia. So, let’s start with the basics.
Trans and gender diverse people have all different types of feelings about GAHT. While some people want to start hormones and see big changes as quickly as possible, others want to take it slowly, and it may take years to decide that GAHT is right for them. Some people might pause their GAHT for different reasons (e.g., to achieve a pregnancy), some are happy to stop their GAHT after achieving certain physical changes, and others don’t want GAHT at all. All of these are valid pathways, and no one pathway makes a person more or less trans.
Reandron, which is used by some trans people. Credit: Steve Tritton via Shutterstock.
Some people who were presumed female at birth may use testosterone GAHT as part of their gender affirmation. Typical changes from testosterone (although this can vary from person to person) include deepening of the voice, increase in muscle mass, increased sex-drive, growth of the clitoris (commonly referred to as ‘lower/bottom growth’), increase in body hair and development of facial hair. You can read more about these changes and different options for testosterone in Australia here.
Estradot, which is used by some trans people. Credit: Nicola K via Shutterstock.
Similarly, some people who were presumed male at birth may use oestrogen (and sometimes testosterone-blockers and progesterone). Typical changes include softening of the skin, decreased muscle mass, increased body fat/changes in where fat is distributed on the body, breast development, decreased sex drive, and decreased frequency of/ability to get erections. You can read more about these changes and different options for oestrogen, testosterone-blockers and progesterone in Australia here.
In considering whether GAHT is right for you, it’s important to realise that you cannot control exactly how or when your body changes. Some of this will come down to factors such as genetics and how your body responds to GAHT. While some changes will remain if you stop GAHT, other changes are reversible. It's important to factor this into your decision, and you can find more information about which changes are reversible or not in the blogs above.
A non-binary person and their mother. Credit: Irina via Adobe Stock.
I need some support as part of my decision-making process. What are my options?
There is often a lot to consider when deciding if or when to start GAHT. This may include: dealing with transphobia and/or fear of having to deal with it; potential changing dynamics of your relationships with family, friends, intimate partners, and the broader community; your individual health and how that may interact with GAHT; coming to terms with any feelings of gender dysphoria you may have; and exploring what gender euphoria can feel like for you.
This can be a lot to deal with, and you may want to seek out support from affirming mental health professionals and peers. They can help connect you to reliable and evidence-based information (you’ve already found your way here, which is fantastic!), talk through any concerns you may have, as well as things you might be excited about, and to ultimately support you in your decision-making process.
There are several resources available to help you find affirming mental health professionals, peer support and more information:
DocDir is a national online directory that allows you to search based on your location for mental health support. Listed clinicians are all nominated as ‘safe’ by other community members.
The Australian Professional Association for Trans Health (AusPATH) is the peak body for professionals who work in trans health. AusPATH members can self-nominate to be listed as a provider. AusPATH also published the Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy.
QLife is a national LGBTIQA+ phoneline and webchat service (3pm-midnight everyday) that can provide support and information about local services. The QDirectory lists key services in different states/territories.
Some LGBTIQA+ organisations run facilitated online and/or in-person peer support groups. There are also more informal opportunities to connect with other trans and gender diverse people, including online and/or in-person community meetups (e.g., book clubs, picnics). Contacting QLife or checking out the services listed in the QDirectory are both good starting points for exploring what options are available in your area.
A trans doctor. Credit: Wagner Okasaki via iStock.
I’m feeling ready. What’s next?
In Australia, all general practitioners (GPs), endocrinologists and sexual health physicians who are informed and competent in GAHT, can prescribe GAHT to people over the age of 18. Unfortunately, however, most healthcare professionals in Australia are not taught about trans people in their university curriculum. This means that unless they seek out specific training about trans health, the average GP may not know how to initiate hormones or where to refer you.
Currently, only a relatively small number of GPs, endocrinologists and sexual health specialists prescribe GAHT. Because there are so few doctors who are competent in trans health, waitlists for a first appointment with these doctors are often long, from several months to over a year. In some cases, due to excessive demand, clinics may be closed to new patients and have a waitlist. This means that you may need to enquire with a few clinics to compare wait times and cost before booking an appointment.
If you live in a regional or remote area you may need to travel outside your local area to see a doctor who can prescribe GAHT. Telehealth may be an option in some cases (depending on your personal circumstance and Medicare guidelines) so if physically accessing a clinic is a barrier for you, it’s worth asking clinics/practitioners whether they can provide care via telehealth.
There are two main resources for finding an affirming GAHT prescriber:
DocDir is a national online directory that allows you to search based on your location for GAHT prescribers. Listed prescribers are all nominated as ‘safe’ by other community members.
The Australian Professional Association for Trans Health (AusPATH) is the peak body for professionals who work in trans health. AusPATH members can self-nominate to be listed as a provider.
Some services have trans staff members called ‘peer navigators’ who can help you to find an affirming prescriber that suits your needs. This is quite location-dependent, but contacting resource and information services like QLife can be a good way to find out if there’s a peer navigator in your area.
A doctor and her patient. Credit: Getty Images via Unsplash.
What does the process of being prescribed hormones look like?
Trans healthcare has changed a lot in recent decades. For many years, most prescribing doctors in Australia relied on the World Professional Association for Trans Health (WPATH) guidelines when it came to prescribing GAHT. Earlier versions of the WPATH guidelines stipulated that every trans person needed to be assessed by a mental health professional before starting GAHT. This typically involved extensive exploration of a trans person’s gender history and feelings of gender dysphoria or incongruence by a psychiatrist, who would then write an ‘approval letter’.
While some people support this approach, others consider it pathologizing and see it as creating unnecessary barriers to accessing healthcare.
Since the early 2000s, a growing number of GAHT prescribers have adopted what is called the Informed Consent Model which is now considered best practice in Australia and is also included in the latest edition of the WPATH guidelines. In a nutshell, the Informed Consent Model centers you, as a trans person, as the expert of your own gender. The role of the doctor is to listen to you and your gender affirmation goals, explain the potential effects (benefits and risks) of GAHT, and assess whether you can understand these effects to give informed consent to starting GAHT.
Within the Informed Consent Model of care, most people will receive their prescription for GAHT after a few appointments with their prescriber. However, about one in ten trans people are referred for additional mental health assessment as part of this process. Importantly, under the Informed Consent Model this referral is about your decision-making capacity, and not about scrutinising your gender identity. It doesn’t mean that you can’t access gender-affirming hormones, it just means that you and your doctor may need support from another health professional (e.g., a psychiatrist) to help establish consent.
No matter which model of care the prescriber is using, there are also some health conditions that may need specialist involvement, including certain blood, liver, or hormone conditions which may interact with GAHT. Medicare regulations also mean that a specialist (usually an endocrinologist or sexual health physician) needs to be consulted for the initial testosterone prescription.
The personal stories of peers can be really useful, but it’s a good idea to look at evidence-based resources like the AusPATH and Equinox guidelines too, because the process has changed over time and looks different for each person and their individual situation.
A trans woman and a non-binary person talking. Credit: Annie via Adobe Stock.
You are on your own journey
Many people find peer connection and support helpful throughout this process. We can see and hear from people like us, use their stories and experiences to imagine what our own futures might look like, and sometimes this can help inform our decisions about affirming our gender. But it’s important not to compare yourself to other people and their milestones too much – everyone is on their own journey! Your genetics are unique, as are your goals, experiences, and life circumstances. We can’t have complete control over which changes GAHT might facilitate and how. But most importantly, you are valid in your gender, no matter what – and you deserve to access healthcare that reflects that.
About the authors
Dr Julian Grace (they/them) is a non-binary researcher, allied health clinician, advocate, and educator with a wealth of experience across the national trans health sector. They're passionate about uplifting health workers with trans lived experience, and building the evidence base for depathologised approaches to gender-affirming care across disciplines.
Dr Sav Zwickl (they/them) is a non-binary researcher and educator who is passionate about improving the health and wellbeing of the trans community through research. They have a Masters degree in Sexology, a PhD in Gender, Sexuality and Diversity Studies, and experience working in peer support roles with LGBTIQA+ young people and sexual health education. Sav has been part of the Trans Health Research team since early 2019.