Transgender Health (Adults)

• Many, but not all, transgender people take hormone therapy. In medicine we usually use the term gender affirming hormone therapy (GAHT) but patients often refer to this as “HRT”.

• GAHT is started more gradually in younger adolescents (who may be on puberty blockers/GnRH agonists). Please redirect to Child and Adolescent page for further information.

• Oestrogen based GAHT (abbreviated here to E-GAHT and sometimes still known as ‘feminising’ GAHT) involves taking oestrogen as well as a testosterone blocker (the testosterone blocker is no longer needed if the patient has an orchiectomy).

• Testosterone based GAHT (abbreviated here to T-GAHT and sometimes still known as “masculinising” GAHT) involves taking testosterone, which is available as injections or patches.

• In Aotearoa New Zealand GAHT may be started by general practitioners, nurse practitioners, endocrinologists, sexual health physicians, adolescent physicians or paediatricians. Referral pathways vary between areas so check your health pathways for local guidance. In areas where GPs are not starting GAHT there is often a requirement for patients to see a mental health professional for a “readiness assessment” prior to being prescribed hormones.

• There is a move towards using an informed consent model of starting GAHT in primary care. This is happening in pockets around the country and the number of GPs who initiate GAHT is growing. If you are interested in becoming more involved in this area you can contact us to join the national transgender health GP peer group.

• Guidelines for primary care are coming out soon. These aim to support primary care prescribers who are commencing GAHT in primary care. They will be posted on this site once published.

• Maintenance or repeat prescriptions for GAHT are managed in primary care by the patient's GP or NP.

• Discuss social and legal transition options as described below.

• Give information about supports. Click here.

• Some areas have trans peer supporters.

• Offer menstrual cessation (if this is desired) for trans masculine patients. Download document.

• Discuss fertility preservation with trans feminine patients - sperm preservation is usually funded and can be done while waiting for GAHT to be started. This referral usually requires a blood test for HIV, Syphilis, Hep B & C. See Fertility Associates info sheet Transgender fertility information

• Offer an SLT referral for voice therapy to trans feminine patients if this is available in your region.

• If a readiness for hormone assessment is required in your region refer to an appropriate provider for this or consider using the primary care guidelines to initiate GAHT yourself.

• If you would like to initiate GAHT for your patient read the Primary Care Guidelines (coming soon).

• Laser hair removal funding can be accessed through a WINZ disability allowance and may be desired by trans feminine patients.

• As described above there is wide regional variation in NZ when it comes to accessing an initial GAHT prescription. Some areas use assessment based secondary care referrals, whilst in other regions GAHT can be accessed from the GP under an informed consent model of care.

• Transgender people have a right to self-determination of their gender. The upcoming primary care guidelines for starting GAHT outline an affirmative, person-centered approach to commencing in GAHT in primary care. This is initiated under an informed consent model which views the patient as a competent adult who has the capacity to make their own decisions about their body and health.

By working in partnership with the patient, this approach will enhance the patient’s developing understanding of the benefits and risks of GAHT. The GP is there to ensure safety by following dosing guidelines, assessing medical risk and monitoring treatment, but it is the patient who is making the decision to start hormones.

The protocol for initiating hormones is described in detail in the primary care guidelines and hasn’t been replicated here, but an overview of the stages in this process are as follows:

• Stage 1 Introduction, relationship building, information gathering

• Stage 2 Medical review (including fertility discussion)

• Stage 3 Hormone information & education

• Stage 4 Hormone initiation (first prescription)

• Stage 5 Maintenance prescribing and long term follow up

The WPATH SOC7 criteria for commencing hormone therapy are:

1. Persistent, well-documented gender dysphoria;

2. Capacity to make a fully informed decision and to consent for treatment;

3. Age of majority in a given country (if younger, follow the SOC outlined in section VI);

4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

The WPATH SOC8 (standards of care) are due to be released in late 2022.

• This refers to changes such a clothing, hair, voice, name, and pronouns which a transgender person may wish to make. This can be helpful in relieving dysphoria and is something people may wish to do before or instead of medical treatment.

Remember: It is not necessary to socially transition before seeking medical gender affirming healthcare. This is outdated advice.

How can I support my patient’s social transition?

• Ensure you use your patient's chosen name and pronouns when speaking about them and when writing clinical notes, referrals or talking about them to others. It is important to have systems in your clinic to ensure you record these correctly on IT systems. In primary care adding an alert to the patient file is one solution.

• Provide information about community supports and peer networks

• Provide information on safe binder use if applicable

• Offer an SLT referral for voice therapy if desired (for trans feminine patients)

• Gender affirming physiotherapy may be available, for example in CCDHB

Many transgender and non-binary people have not changed their legal documents due to the process being very difficult. Patients may ask you for a letter of support. If writing a letter for a birth certificate change, it needs to include:

• Medical opinion stating the patient has assumed (or has always had) the gender identity of their nominated sex

• The patient has undergone medical treatment desirable by medical experts to acquire a physical conformation with their nominated sex. Include what this treatment is.

• Show that as a result of the medical treatment they will maintain the gender identity of their nominated sex. To do this explain what parts of the medical treatment are permanent in addition to a medical opinion they will live as their nominated sex.

The Ministry of Health are working on ways sex and gender data can be more accurately and safely gathered in primary care. If you use the practice management system Indici, you can record your patients gender, then click the box “self-identified” and record their sex assigned at birth in the “sex” box. This also ensures screening recalls are not lost, as the recalls are pulled from the “sex” box.

Patients may wish their name to be changed with NHI and this can be done by administration staff. This is important for ensuring their correct name is on their covid vaccine pass, lab forms etc.

If gender has been changed on the IT record please ensure that you are not missing relevant cancer screening recalls e.g. a trans masculine person with a cervix is eligible for cervical screening, but if their gender has been changed to ‘M’ this may be missed.

Access to surgical gender affirmation procedures vary widely around the country and are very dependent on where you live. Please check your local health pathways for localised information. For some regions your local hospital specialist may need to do the referral.

Orchiectomy, Hysterectomy, Mastectomy (often known as “top surgery”) and breast augmentation services are managed by what were DHB’s and so referral pathways currently vary based on which area you are in. A surgical readiness assessment by a mental health professional may be required by the surgeon prior to referral.

Facial feminisation surgery is not available in Aotearoa New Zealand.

Tracheal shave may be undertaken by some private providers.

Gender affirming genital surgery referrals are managed by Te Whatu Ora Genital surgery service

Please use the referral form on the MOH website and include all relevant medical notes/information and any psychological readiness assessments.

If accepted onto the wait list this is for a first surgical assessment. The wait list is extraordinarily long and at this stage only one surgeon in Wellington (Dr Rita Yang) does Transgender genital surgery. She is funded to do approximately 12 per year