• Initiate transgender hormone therapy for individuals over age 18

• Maintain gender affirming care near me with hormone therapy for individuals over age 18

• Referrals for gender affirming surgical procedures

• Letters of support for gender affirming surgical procedures

• Letters of medical necessity for electrolysis for gender affirming surgical procedures

Estrogen and Anti-Androgen Therapy Informed Consent

The informed consent model of care was created to respect your basic human right to self-determination and bodily autonomy. The purpose of this document is to give you enough information so you can you consent to estrogen hormone therapy with or without anti-androgen therapy as part of the gender affirmation process. 

Please read the following information and discuss any questions or concerns with your provider before starting medication.

This document relates to the hormones estrogen and progesterone, as well as testosterone-blocking medications. Your healthcare provider will discuss the information relating to hormone therapy with you. Hormone therapy affects every person differently, and there is no way to predict how each body will change. Some of the effects of this therapy are not known.

Please read the following:

Permanent changes expected while on estrogen therapy:

● Breast and nipple development (size is variable)

● Decreased size of testicles, up to 50% reduction

● Possible permanent infertility, this means you may not be able to have biological children

Reversible changes expected while on estrogen therapy:

● Softer skin

● Decreased acne

● Slowed rate of facial and body hair growth

● Slowed or stopped balding

● Tender breasts and nipples

● Improved cholesterol

● Decreased libido and fatigue

● Mood changes

Changes which may be reversible or permanent depending on age of starting estrogen and duration of taking it:

● Body fat redistribution and possible weight gain

● Improved cholesterol

● Reduced ability to achieve or sustain an erection

● Reduced ability to ejaculate and reduced volume of ejaculatory fluid

Please read the following potential side effects and risks of estrogen hormone therapy. Some medicines and recreational drugs can increase these risks:

● Headaches

● Nausea

● Blood pressure changes

● Increased urination and thirst if taking spironolactone

● Increased potassium in the blood if taking spironolactone, which

could lead to muscle weakness or heart problems

● Blood clots and risk of stroke

● Increased risk of cardiovascular (heart) disease

● Increased risk of diabetes

● Liver damage and gallbladder disease

● Electrolyte imbalances and kidney damage

● Osteoporosis (weak bones)

● Possible increase in the hormone prolactin, which can cause nipple

discharge and rarely a tumor on the pituitary gland (in the brain)

● Increased risk of breast cancer

The following will likely not change with estrogen if they have already developed:

● Bone structure

● Adam’s apple

● Tone and pitch of voice

● Facial and body hair growth will slow but not stop completely

Please read the following information about estrogen, fertility, and sexual health.

1. Estrogen can cause permanent loss of fertility. The best way to have a pregnancy after starting hormone therapy is to do sperm banking prior to starting estrogen.

2. Estrogen therapy does not guarantee infertility and contraception should be used when having sex that puts a  partner at risk of pregnancy, namely having penis-in-vagina sex with a partner with a vagina.

3. Estrogen does not protect against HIV or sexually transmitted infections. If having sex without using barrier methods such as internal or external condoms, it is recommended to discuss when and how to do STI testing with your provider. We also recommend discussing a medicine to prevent HIV called PrEP.

Please read the following expectations for your provider to be able to

prescribe estrogen and monitor your health safely.

1. I agree to the recommended appointments with my provider which may include regular blood tests.

2. I agree to inform my provider of all other medications, supplements, tests, and/or recreational drugs that I am using so they can assess interactions.

Note: Your provider will work with you to find ways to take hormones that are as safe as possible with any recreational drugs you use.

3. I agree to disclose any other health problems I am aware of that I have with my healthcare provider before starting estrogen therapy including high blood pressure, autoimmune disease, cancer, heart problems, blood vessel problems, mental health problems, etc.

Note: Most health issues are safe to take hormones with. Most commonly, your provider may need to have conversations with your other providers or change their recommendations for which medicines to take or how to take them. Rarely if your health needs are outside your provider’s scope of practice, your provider will work with you to find a provider who may be able to prescribe hormones.)

4. I can choose to stop gender-affirming hormone therapy at any time. If I choose to stop taking hormones, it is best that I do this in consultation with my provider.

5. I understand that hormone therapy should not be used in patients that have a history of hormone receptor positive cancers, because it can make the cancer come back or get worse.

Effect of estrogen

1-3 months 

● Decreased testosterone in the body

● Decreased libido (sex drive)

● Decreased acne

● Decreased muscle mass

● Decrease in ability to achieve and sustain erections,

including spontaneous morning erections

● Decrease in ejaculatory fluid and sperm count

Gradual changes over 1-2 years 

● Slowed growth of facial and body hair

● Slowed or stopped balding

● Redistribution of body fat to hips, breasts, and thighs, and possible weight gain

● Decrease in size of testes, up to 50%*

● Nipple and breast development, although size

varies*

Permanent changes marked with *

Other therapies that can help with gender affirmation in patients seeking estrogen:

Hormone therapy is not the only way for a person to feel and appear more feminine or less masculine and/or live as a woman. Your provider can discuss additional gender affirming options with you. These include, but are not limited to:

● Voice therapy

● Garments/devices such as breast forms

● Surgical options such as breast augmentation

● Laser hair removal/ electrolysis

Clinical Resources

● Fenway Health National LGBTQIA Health Education Center

● World Professional Association for Transgender Health (WPATH)

● UCSF Center of Excellence for Transgender Health

Undergoing gender affirming treatment can be challenging socially and emotionally. Some people have experienced discrimination, harassment, and violence. Others have lost the support of loved ones. Please talk with your provider if you are experiencing difficulties so they can provide you

with additional resources. Resources your provider can help with include:

● Referral to therapy

● Referral to a psychiatric prescriber

● Referral to surgery

Pros and Cons to different forms of estrogen:

1. Estrogen pills. This is the easiest form of hormone therapy to take. It usually involves taking estrogen pills twice daily by dissolving them under the tongue, and taking a testosterone blocking medication called spironolactone. Pills are not the fastest or the slowest method to achieve changes, but are in the middle. Pills have the highest risk of blood clots compared to other methods and are typically safest for people under age 35, who do not use tobacco, and do not have problems with blood pressure or blood sugar. 

2. Estrogen patches. Estrogen patches are the safest method to take estrogen in the long term. Patches either need to be changed once weekly or twice weekly depending on which brand your insurance pays for. Estrogen patches are typically the most gradual method of physical changes, though you will eventually achieve the same results as with other methods. Most people typically have to take testosterone blocking medication such as spironolactone if you take patches because they are not strong enough to block your testosterone alone.

3.  Estrogen injections. Estrogen injections are the strongest and fastest way to achieve physical changes with estrogen. Injections are typically once per week and done in the layer of fat below the skin with a small needle or an injection in the muscle. Estrogen injections are typically strong enough to suppress your testosterone without taking a testosterone blocking medication. These are typically safer than estrogen pills but not as safe as estrogen patches from a blood clot risk. 

Testosterone Therapy Informed Consent

The informed consent model of care was created to respect your basic human right to self-determination and bodily autonomy. The purpose of this document is to give you enough information so that you can decide if you want to consent to testosterone hormone therapy as part of the gender affirmation process. 

Please read the following information and discuss any questions or concerns with your provider before starting hormone therapy.

This document relates to the hormone testosterone. Your healthcare provider will discuss the information relating to hormone therapy with you. Testosterone hormone therapy affects every person differently, and there is no way to predict how each body will change. Some of the effects of this therapy are not known.

Permanent changes expected while on testosterone therapy:

● Increased facial and body hair that is thicker and coarser, and may grow in new places such as beard or mustache, stomach, chest, between your buttocks, larger expanse of genital hair

● Deepened voice

● Enlargement of erectile genital tissue (clitoris) or “bottom growth”

● Possible male pattern balding

● Possible permanent infertility, this means you may not be able to have biological children, though the risk of this is low

● Changes in facial structure depending on your age

Reversible changes expected while on testosterone therapy:

● Increased energy and libido

● Coarser and more oily skin

● Acne of face, chest, scalp, back, buttocks, neck, or other parts of the body

● Stopping menstrual periods

● Mood changes

● Increased muscle mass

● Increased sweating and changes in body odor

Changes which may be reversible or permanent depending on the age of starting testosterone and the duration of taking it:

● Body fat redistribution and possible weight gain

● Raised cholesterol

● Increased blood pressure

● Vaginal dryness, atrophy, and pain with vaginal sex (likely to reverse if stopped prior to the age of menopause or treatment with vaginal estrogen)

Please read the potential side effects and risks of testosterone hormone therapy. Some medicines and recreational drugs can increase these risks:

● Increased number of red blood cells (polycythemia)

● Increased risk of cardiovascular disease

● Increased risk of diabetes

● New or worsened obstructive sleep apnea

● Liver damage

Please read the following information about testosterone, fertility, and sexual health.

1. Most people on testosterone experience a return of fertility after stopping testosterone, but this is not guaranteed for everyone and it is possible that you may become infertile, meaning unable to have biological children.

2. Testosterone therapy does not guarantee infertility and contraception should be used when having sex that puts you at risk of pregnancy, namely having vaginal sex with a person who makes sperm.

3. Getting pregnant while taking testosterone can cause harm or even death to the fetus.

4. If you have sex that puts you at risk of pregnancy while on testosterone and you wish to avoid pregnancy, it is recommended to use birth control options such as internal or external condoms, birth control pills, IUD, depo-provera injections, or contraceptive implant (Nexplanon).

5. Testosterone does not protect against sexually transmitted infections. If having sex without using barrier methods such as internal or external condoms, it is recommended to discuss when and how to do STI testing with your provider. If engaging in receptive anal or vaginal

sex with people who have a penis, you may want to consider using an HIV prevention medicine called PrEP. Talk to your provider about this medicine.

Please read the following expectations for your provider to be able to prescribe testosterone and monitor your health safely.

1. I agree to the recommended appointments with my provider which may include regular blood tests.

2. I agree to inform my provider of all other medications, supplements, tests, and/or recreational drugs that I am using so they can assess interactions.

Note: Your provider will work with you to find ways to take hormones that are as safe as possible with any recreational drugs you use.

3. I agree to disclose any other health problems I am aware of that I have with my healthcare provider before starting testosterone therapy including high blood pressure, autoimmune disease, cancer, heart problems, blood vessel problems, mental health problems, etc.

Note: Most health issues are safe to take hormones with. Most commonly, your provider may need to have conversations with your other providers or change their recommendations for which medicines to take or how to take them. Rarely if your health needs are outside your provider’s scope of practice, your provider will work

with you to find a provider who may be able to prescribe hormones.)

4. I can choose to stop gender-affirming hormone therapy at any time. If I choose to stop taking hormones, it is best that I do this in consultation with my provider.

5. I understand that hormone therapy should not be used in patients that have a history of hormone receptor positive cancers, because it can make the cancer come back or get worse.

6. I understand that testosterone is a controlled substance, and it is illegal to share, sell of distribute, and I will not do so under any circumstances. I understand that doing so is grounds for my provider to stop providing it to me.

Patient Information Sheet: Changes on Testosterone Therapy

Average timeline after starting testosterone

Effect of testosterone 1-3 months 

● Decreased estrogen in the body

● Increased libido (sex drive)

● Vaginal dryness

● Increased acne

● Increased muscle mass to upper body

● Redistribution of body fat to waist, less in hips, chest, and thighs

● Growth of clitoris- typically 1-3cm*

● Increased growth, coarseness, and thickness of

body hair* 

1-6 months 

● Menstrual periods may stop

Deepening of voice- voice starts to crack and drop within the first 3-6 months, but can take a year to finish changing*

1 year+ 

● Gradual face hair growth (1-4 years)*

● Possible male pattern balding*

Permanent changes marked with *

Other therapies that can help with gender affirmation in patients seeking testosterone:

Hormone therapy is not the only way for a person to feel or appear more masculine or less feminine and/or live as a man. Your provider can discuss additional gender affirming options with you. These include, but are not limited to:

● Voice therapy

● Garments/devices such as chest binders or packers

● Surgical options such as hysterectomy (removing uterus) or gender-affirming chest reconstruction (“top surgery”)

Clinical Resources

● Fenway Health National LGBTQIA Health Education Center

● World Professional Association for Transgender Health (WPATH)

● UCSF Center of Excellence for Transgender Health

Undergoing gender affirming treatment can be challenging socially and emotionally. Some people have experienced discrimination, harassment, and violence. Others have lost the support of loved ones. Please talk with your provider if you are experiencing difficulties so they can provide you with additional resources. Resources your provider can help with include:

● Referral to therapy

● Referral to a psychiatric prescriber

● Referral to surgery

Pros and Cons of Different forms of testosterone:

1. Testosterone gel. Gel is applied once daily to the stomach, upper arms, forearms, or upper back. The dose is typically 1-4 pumps of gel or packets of testosterone per day. Gel can be transferred to pets, children, or partners, so it is important to store it away from others in a locked cabinet, wash hands carefully after applying, apply to areas that don’t come in contact with partners, pets or children. If you share a bed with others, it may be best to apply your gel in the morning. Wait for gel to dry completely before putting on clothing. 

2. Testosterone injections. Testosterone injections are given typically either once every 7 days or once every 14 days. Injections are done in the fat under the skin or in the muscle. You can learn to do your own injections, a trusted partner or family member can do them, or we can do them for you in the clinic. Changes are typically faster with injections compared to gel. If you have fatigue or mood swings in the 1-2 days prior to your injection, we can change your injections to a smaller dose more frequently. 

3.  Finasteride. Finasteride is a once daily pill which blocks DHT, which is what testosterone is converted to in the body. Taking this pill can reduce hair loss, though it will also reduce body and facial hair, as well as enlargement of your clitoris (“bottom growth”). There is a very small risk of worsening mental health problems with this medication, estimated at less than 1 in 100 people. 

• Provide gender-affirming hormone therapy for individuals younger than age 18. We are hoping to change that soon.