Transitioning to womanhood

Womanhood is diverse, and women come from varied backgrounds. If you are a trans woman or a transfeminine non-binary person over the age of 18, this article will discuss some of the ways you may be able to access gender-affirming hormone therapy.

Not all trans people will want to start hormones - everyone is unique and different in their experience of gender and their bodies, so it's okay not to pursue hormones if you don't want to!

Accessing Gender-Affirming Hormone Therapy

If you are interested in starting hormone therapy, we recommend talking with your GP first. Your GP may be able to get you started on hormone therapy using an informed consent model. Informed consent is an ongoing decision-making process based on full understanding and knowledge of the treatments, including its risks, benefits and what changes may be permanent. The Sexual Health or Endocrine Departments support this across Aotearoa. At this stage, most GPs will refer to the Sexual Health or Endocrinology Department specialists (depending on your location) for hormone initiation.

Communicating with your GP

How can you start the conversation? 

• We would recommend starting out by being clear with your GP about your birth sex, including being intersex if you are aware.
• We also recommend letting them know how you would like to be referred to - your name, pronouns (e.g. she, they, etc), and gender identity.

You have rights to be treated with respect, and if you do not feel that you are being treated with respect or if you feel you are being denied access to care, you have rights to a second opinion.

What can I expect my GP to ask me?

• They may ask you about your journey so far in how you've come to consider hormone therapy.
• They may ask you about how long you've identified with your current gender.
• They should ask you whether you plan on having children in the future, as hormone therapy may have permanent effects on your fertility.
• They will need to ask some questions about your medical and mental health history to make sure they can discuss options that are safe and effective for you.

The purpose of asking about your mental health is to ensure that you are receiving adequate support. Most mental health issues should not be a barrier to accessing gender-affirming hormone therapy, but if there is concern about your capacity to make informed decisions, you may be referred onto a psychologist for further assessment.

What should I tell my GP?

• Let your GP know what your goals would be with hormone therapy - what changes would you like?
• What would you like to keep the same?

What tests can I expect?

• A brief examination for your blood pressure and weight to establish your baseline.
• Your GP should refer you for some baseline blood tests, to check your hormone levels and other safety checks prior to starting hormone therapy.
• Unless there are specific symptoms or concerns that you would like to raise, there is no need for a chest or genital examination.

After this, if you are still wanting to progress and your GP is not confident in prescribing hormone therapy medications and there are no medical reasons why you cannot start hormones, they should refer you onto the public transgender health services.

If your GP is confident, they may refer you to the fertility services first if you are wanting to preserve future fertility, then you should return for an appointment to discuss the medications.

If you are on hormone therapy, or beginning hormone therapy, your GP, sexual health or endocrinology specialist should arrange follow-up appointments to ensure things are progressing as they should, and to ensure there are no side effects.

Hormone therapy

Types of medications

• Estrogens - in the form of patches, tablets, and self funded injections or self-funded gels.
• Testosterone blockers - in the form of tablets or implants injected into the abdominal fat.

There are some things that cannot be changed with hormone therapy. For example, if you have completed puberty, it cannot reverse bone structure, increased facial/body hair growth, deepened voice, and height.

Effects of estrogen-based therapy

• Breast growth (usually up to about A-cup, depending on your body composition)
• Redistribution of body fat
• Decrease in muscle mass
• Softening of the skin
• Thinning and slowing of growth in facial/body hair

These changes are gradual and can progress for 3+ years.

Are these changes reversible?

Some changes, such as redistribution of body fat, decrease in muscle mass, softening of the skin, is reversible if estrogen-based therapy is stopped. Changes such as breast growth, reduced testicular volume and decreased sperm production may be permanent even if estrogen-based therapy is stopped.

If you did want to stop hormone therapy, you have the choice to stop hormone therapy whenever you want. It would be best to update your healthcare provider when you do, so that we can update your screening, follow-ups and ensure no other support may be required.

Non-hormonal gender affirming care

Some trans women or transfeminine non-binary people may want to pursue vocal therapy, laser hair removals, breast augmentation, or bottom surgery (including orchidectomy, vaginoplasty).

The funding for gender-affirming procedures are different in different regions within Aotearoa. The Gender Minorities Aotearoa website has some information about funding in different regions.

There are a wide range of resources and information available about accessing funded and non-funded, as well as financial support for different procedures on the Gender Minorities Aotearoa website.

Unfortunately for genital reconstruction surgery, the wait times in the public system are currently approximately 10 years, but this may change at any time. The first step to accessing this is to be referred to a specialist by your GP. You will need a psychological readiness assessment prior to this.

Important health reminders for trans women

Screenings

• Breast screening with mammograms from the age of 45 is recommended to anyone with breasts, regardless of gender.
• Prostate cancer is most common after the age of 50. If you develop trouble passing urine, poor flow, dribbling, trouble starting/stopping your flow, urinating more often or blood in your urine we recommend talking with your health provider.

Seeking general non-gender related healthcare

Being trans may not be relevant in every healthcare-related consultation, but there are many circumstances where it may be helpful for your care team to know, such as if you have abdominal pain, blood pressure issues, or starting new medications.

This is because our anatomy and hormonal profile can affect different aspects of our health. While we would encourage you to be open, we understand this may not be safe or practical in every consultation, and you should not be made to explain your transition unnecessarily (e.g. answering questions about what surgeries you had, when you present for a sore throat).

Most providers will want to be supportive, but they may not know how to do this, or may not have the right language to support you. Providing information to them may help, including resources such as Gender Minorities Aotearoa, Qtopia, and Rainbow Youth. Safe and appropriate health care is a human right, and everyone is entitled to get the right health care that you need, regardless of their gender.

Mental health

Transgender people are at an increased risk of poor mental health, due to social stigma and inequities. There are trans-friendly mental health services available, including:

• OutLine
• Gender Minorities Aotearoa counsellors and peer support workers
• Rainbow Youth‍
• Health improvement practitioners at your GP clinic.
• If you have experienced sexual abuse or assault, you are eligible for free therapy under ACC as well.

Healthcare for transgender women and transfeminine non-binary people is important, and is an ever-evolving area in Aotearoa. If you would like to discuss ongoing support and options for gender-affirming care, there are many organisations and healthcare professionals who can support you.

About Dr Ji-Young Park

Dr Ji-Young is a GP at Tend Pakuranga in Auckland/Tāmaki Makaurau. Ji-Young has a special interest in rainbow health and mental health. She is passionate about making healthcare more accessible for the rainbow and takatāpui community and aiming for equitable outcomes for all. When it comes to being a GP, she enjoys being able to walk alongside patients on their journey throughout their lives and getting opportunities to improve health equity in Aotearoa.