Eligibility for GAHT may require an assessment forgender dysphoria or persistent gender incongruence; many medical institutions now use aninformed consent model, which ensures patients are informed of the procedure process, including possible benefits and risks, while removing many of the historical barriers needed to start hormone therapy. Treatment guidelines for therapy have been developed by several medical associations.[citation needed]
Non-binary people may also engage in hormone therapy in order to achieve a desired balance of sex hormones or to help align their bodies with their gender identities.[1] Many transgender people obtain hormone replacement therapy from a licensed health care provider, while othersobtain and self-administer hormones.
The formal requirements to begin gender-affirming hormone therapy vary widely depending on geographiclocation and specific institution.[citation needed] Gender-affirming hormones can be prescribed by a wide range of medical providers including, but not limited to, primary care physicians, endocrinologists, and gynecologists.[2] Requirements to be prescribed these hormones generally include a minimum age. According to theEndocrine Society, there has been little research on taking cross-sex hormones before theage of about 14.[3]
Historically, many health centers required apsychiatric evaluation and/or a letter from atherapist before beginning hormone replacement therapy. Many centers now use aninformed consent model that does not require any routine formal psychiatric evaluation, but rather focuses on reducing barriers to care while ensuring a person can understand therisks and benefits of treatment.[4] SomeLGBT health organizations, including Chicago'sHoward Brown Health Center[5] andPlanned Parenthood,[6] advocate for this type of informed consent model.
The World Professional Association for Transgender Health (WPATH) Standards of Care, 7th edition, note that both of these approaches to care are appropriate.[2]
Many international guidelines and institutions require persistent, well-documented gender dysphoria as a pre-requisite to starting gender-affirmation therapy.Gender dysphoria refers to the psychological discomfort or distress that an individual can experience if their sex assigned at birth is incongruent with that person's gender identity.[7] Signs of gender dysphoria can include comorbid mental health stressors such asdepression, anxiety, lowself-esteem, andsocial isolation.[8] Not allgender nonconforming individuals experience gender dysphoria, and measuring a person's gender dysphoria is critical when considering medical intervention for gender nonconformity.[9]
For transgender youth, the Dutch protocol existed as among the earlier guidelines for hormone therapy by delaying puberty until age 16.[10][11] TheWorld Professional Association for Transgender Health (WPATH) and theEndocrine Society later formulated guidelines that created a foundation for health care providers to care for transgender patients.[12][13]UCSF guidelines are also sometimes used.[4] There is no generally agreed-upon set of guidelines, however.[14]
Tanner Stages for Female Sexual CharacteristicsTanner Stages for Male Sexual Characteristics
Adolescents experiencing gender dysphoria may opt to undergo puberty-suppressing hormone therapy at the onset of puberty. The Standards of Care set forth byWPATH recommend individuals pursuing puberty-suppressing hormone therapy wait until at least experiencing Tanner Stage 2 pubertal development.[7]Tanner Stage 2 is defined by the appearance of scant pubic hair, breast bud development, and/or slight testicular growth.[15]WPATH classifies puberty-suppressing hormone therapy as a "fully reversible" intervention. Delaying puberty allows individuals more time to explore their gender identity before deciding on more permanent interventions and prevents the physical changes associated with puberty.[7]
The preferred puberty-suppressing agent for both individuals assigned male at birth and individuals assigned female at birth is aGnRH Analogue.[7] This approach temporarily shuts down theHypothalamic-Pituitary-Gonadal (HPG) Axis, which is responsible for the production of hormones (estrogen, testosterone) that cause the development of secondary sexual characteristics in puberty.[16]
According to a study byJAMA Pediatrics published in January of 2025, less than 0.1% of adolescents covered by private medical insurance in the US take gender-affirming medication to treatgender dysphoria.[17]
Feminizing hormone therapy is typically used by transgender women, who desire the development of femininesecondary sex characteristics. Individuals who identify as non-binary may also opt-in for feminizing hormone treatment to better align their body with their desired gender expression.[18] Feminizing hormone therapy usually includes medication to suppresstestosteroneproduction and inducefeminization. Types of medications includeestrogens,antiandrogens (testosterone blockers), andprogestogens.[19] Most commonly, an estrogen is combined with an antiandrogen to suppress and block testosterone.[20] This allows fordemasculinization and promotion of feminization andbreast development. Estrogens are administered in various modalities including injection, transdermal patch, and oral tablets.[20]
The desired effects of feminizing hormone therapy focus on the development of femininesecondary sex characteristics. These desired effects include: breast tissue development, redistribution of body fat, decreased body hair, reduction of muscle mass, and more.[20] The table below summarizes some of the effects of feminizing hormone therapy in transgender women:
^abEstimates represent published and unpublished clinical observations.
^Time at which further changes are unlikely at maximum maintained dose. Maximum effects vary widely depending ongenetics,body habitus,age, and status ofgonad removal. Generally, older individuals with intactgonads may have lessfeminization overall.
^Additional research is needed to determine permanency, but a permanent impact of estrogen therapy onsperm quality is likely andsperm preservation options should be counseled on and considered before initiation of therapy.
Unlike feminizing hormone therapy, individuals undergoing masculinizing hormone therapy do not usually require additional hormone suppression such as estrogen suppression. Therapeutic doses of testosterone are usually sufficient to inhibit the production of estrogen to desired physiologic levels.[16]
The desired effects of masculinizing hormone therapy focus on the development of masculinesecondary sex characteristics. These desired effects include: increased muscle mass, increased bone turnover,[36] development of facial hair, voice deepening, increase and thickening of body hair, and more.[37]
Hormone therapy for transgender individuals has been shown in medical literature to be generally safe, when supervised by a qualified medical professional.[46] There are potential risks with hormone treatment that will be monitored through screenings and lab tests such as blood count (hemoglobin), kidney and liver function, blood sugar, potassium, and cholesterol.[35][19] Taking more medication than directed may lead to health problems such as increased risk of cancer, heart attack from thickening of the blood, blood clots, and elevated cholesterol.[35][47] Hormone therapy has been shown to improve the psychosocial well-being among transgender individuals. It's been seen to lower levels of distress in transgender individuals.[48]
The Standards of Care published by the World Professional Association for Transgender Health (WPATH) summarize many of the risks associated with feminizing hormone therapy (outlined below).[7]
The Standards of Care published by the World Professional Association for Transgender Health (WPATH) summarize many of the risks associated with masculinizing hormone therapy (outlined below).[7]
A study presented at ENDO 2019 (theEndocrine Society's conference) shows that even after one year of treatment with testosterone, atransgender man can preserve his fertility potential.[52] A 2015 study demonstrated normalspermatogenesis in some transgender women who were long-term estrogen therapy patients.[53] In other cases, there is some research showing effective restoration of fertility by alternative means than HRT cessation alone. Dr. Will Powers has demonstrated the effectiveness ofclomifene in restoring spermatogenesis in trans women.[54] His study also includes an in-depth description of other methods for fertility restoration.[54]
Somemolecular biology research suggests that GAHT induces a "unique molecular profile" with potential relevance to the recipient's immune system, or (in)susceptibility to certain health conditions (whichare sometimes sexually dimorphic in people); one 2022 analysis found that GAHT (both feminizing and masculinizing) influencedgene expression.[55][56][57] The study's lead author stated that they observed "changes [to] theepigenetic landscape ofDNA" in some regions but not others, and that of the observed "epigenetic changes in regions of DNA that were distinct between sexes before hormone therapy, these regions consistently shifted towards the profile of the affirmed gender after 12 months of hormone therapy."[55] A 2023 molecular study on the breast tissue of transgender men found that adding androgens induced such changes, appearing to silence genes across the breast tissue, including a suppression of genes linked tobreast cancer.[58][59]
Some online scammers have been targeting trans consumers with products that do not contain any hormones or contain ones that are opposite of what is advertised. This can happen when legislations outlaw or restrict access to treatments by legitimate medical professionals.[60]
Many providers useinformed consent, whereby someone seeking hormone therapy can sign a statement of informed consent and begin treatment without much gatekeeping. For other providers, eligibility is determined using major diagnostic tools such asICD-11 or theDiagnostic and Statistical Manual of Mental Disorders (DSM) to classify a patient withgender dysphoria. The Endocrine Society requires physicians that diagnose gender dysphoria and gender incongruence to be trained in psychiatric disorders with competency in ICD-11 and DSM-5. The healthcare provider should also obtain a thorough assessment of the patient's mental health and identify potential psychosocial factors that can affect therapy.[61]
The WPATH Standards of Care, most recently published in 2022, outlines a series of guidelines which should be met before a patient should be allowed gender-affirming hormone therapy:[49]
Gender incongruence is marked and sustained
Patient meets diagnostic criteria for gender incongruence prior to gender-affirming hormone treatment in regions where a diagnosis is necessary to access health care
Patient has capacity to consent to hormone therapy treatment
Other possible causes of apparent gender incongruence have been identified and excluded
Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed
Understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options
The WPATH standards of care distinguish between gender-affirming hormone therapy, and hormone replacement therapy, with the latter referring to the replacement of endogenous hormones after a gonadectomy to prevent cardiovascular and musculoskeletal issues.[49]
Some organizations—but fewer than in the past—require that patients spend a certain period of time living in their desired gender role before starting hormone therapy. This period is sometimes called real-life experience (RLE).
In Sweden, for instance, patients seeking to access gender affirming healthcare must first undergo extended evaluations with psychiatric professionals, during which they must—without any form of medical transition—successfully live for one full year as their desired gender in all professional, social, and personal matters. Gender clinics are recommended to provide patients with wigs and breast prostheses for the endeavor. The evaluation additionally involves, if possible, meetings with family members and/or other individuals close to the patient. Patients may be denied care for any number of "psychosocial dimensions", including their choice of job or their marital status.[62][63]
Transgender and gender non-conforming activists, such asKate Bornstein, have asserted that RLE is psychologically harmful and is a form of "gatekeeping", effectively barring individuals from transitioning for as long as possible, if not permanently.[64]
Some transgender people choose to self-administer hormone replacement medications, often because doctors have too little experience in this area, or because no doctor is available. Others self-administer because their doctor will not prescribe hormones without an approval letter from a psychotherapist. Many therapists require extended periods of continuous psychotherapy and/or real-life experience before they will write such a letter. Because many individuals must pay for evaluation and careout-of-pocket, costs can be prohibitive.[66]
Access to medication can be poor even where health care is provided free. In a patient survey conducted by theUnited Kingdom'sNational Health Service in 2008, 5% of respondents acknowledged resorting to self-medication, and 46% were dissatisfied with the amount of time it took to receive hormone therapy. The report concluded in part: "The NHS must provide a service that is easy to access so that vulnerable patients do not feel forced to turn to DIY remedies such as buying drugs online with all the risks that entails. Patients must be able to access professional help and advice so that they can make informed decisions about their care, whether they wish to take the NHS or private route without putting their health and indeed their lives in danger."[67] Self-administration of cross-gender hormones without medical supervision may have untoward health effects and risks.[68]
A number of private companies have attempted to increase accessibility for hormone replacement medications and help transgender people navigate the complexities of access to treatment.[citation needed]
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^Defreyne J, Elaut E, Kreukels B, Daphne Fisher A, Castellini G, Staphorsius A, Den Heijer M, Heylens G, T'Sjoen G (April 2020). "Sexual Desire Changes in Transgender Individuals Upon Initiation of Hormone Treatment: Results From the Longitudinal European Network for the Investigation of Gender Incongruence".The Journal of Sexual Medicine.17 (4):812–825.doi:10.1016/j.jsxm.2019.12.020.hdl:1854/LU-8723420.PMID32008926.
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^Higano CS (October 2012). "Sexuality and intimacy after definitive treatment and subsequent androgen deprivation therapy for prostate cancer".Journal of Clinical Oncology.30 (30):3720–3725.doi:10.1200/JCO.2012.41.8509.PMID23008326.
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^Pathoulas, James T.; Flanagan, Kelly E.; Walker, Chloe J.; Pupo Wiss, Isabel M.; Marks, Dustin; Senna, Maryanne M. (2022). "Characterizing the role of facial hair in gender identity and expression among transgender men".Journal of the American Academy of Dermatology.87:228–230.doi:10.1016/j.jaad.2021.07.060.PMID34363904.
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