How to start | Trans Care BC

The options below describe three routes to access to care. That said, your individual pathway will depend on many factors that are unique to you.

Three pathways for accessing hormones or puberty blockers

1. Primary care provider

Many people choose to start the process by making an appointment with a primary care provider.

If you feel anxious about talking to your doctor, visit Speaking with Your Provider about Gender-Affirming Care for tips.

Before prescribing hormones, a provider must assess your readiness for treatment (see below to learn how readiness is assessed). Many primary care providers can provide readiness assessments for hormone therapy. However, not all primary care providers feel comfortable assessing hormone readiness or initiating treatment. In this case, they may refer you to other providers.

If your primary care provider is able to provide this care, you won’t need to follow any further steps. They will assess your readiness and begin prescribing hormones (if appropriate).
If your provider is willing to help but doesn’t know where to start, they can begin with the Trans Care BC Primary Care Toolkit. They can also consult with an experienced clinician by calling the RACE line. If they require further support, they can contact Trans Care BC for more information and practice support. Depending on their confidence, they may refer you to another provider (like a mental health clinician) for the readiness assessment and then proceed with treatment themselves. Alternatively, they may refer you to another provider (such specialized primary care provider for both readiness assessment and treatment or an endocrinologist). See below for more information about accessing care from an endocrinologist.
If you do not have a primary care provider, you can visit Finding a Primary Care Provider for resources that may help. Or you can visit a walk-in clinic or virtual doctor to be referred for care.

2. Referral to an endocrinologist

Your primary care provider can refer you to an endocrinologist (hormone specialist). Before they start treatment, an endocrinologist will require a hormone readiness assessment completed by another clinician (like a mental health clinician).

Before you start the assessment process, it is important to ask the endocrinologist which providers they accept hormone readiness assessment letters from. Either you or the assessor can check with the endocrinologist’s office before starting the readiness assessment.

3. Trans-specific clinic or care provider

Depending on where you live, your age and other factors, you may be able to access a clinic or provider that provides trans-specific care. There is a lot of variability across these clinics and providers in B.C. Some require referrals and some do not. Unfortunately, these options are not available everywhere in all regions of B.C.

You can contact Trans Care BC’s health navigation team for more information on trans-specific clinics and care providers.

Getting a hormone readiness assessment

As we mentioned above, you do not need to engage an assessor if your primary care provider can provide the readiness assessment. In some cases, however, a primary care provider may recommend an assessment from a mental health provider.

If you choose to work with an endocrinologist, you’ll need to engage a mental health professional who can provide a readiness assessment (such as a counsellor, social worker, psychologist or psychiatrist).

Most mental health providers are private-pay. There are some public (free) options for hormone readiness assessment in the community; these may require a referral. If you have been told to get an assessment from a mental health provider or if you need information on low-cost options, you can contact Trans Care BC.

What is a hormone readiness assessment?

A hormone readiness assessment is an evaluation conducted by a qualified professional to determine if a patient is ready to begin hormone therapy. The WPATH Standards of Care requires an assessment before hormone therapy starts.

How long does it take to get a readiness assessment?

The length of the assessment period depends on the health care provider, clinic protocols and your needs.

Assessments may take longer if someone has physical health, mental health or substance use issues. These concerns are not barriers to hormone therapy, but need to be considered when making a plan for treatment.

What happens during a readiness assessment?

Some people feel anxious about the readiness assessment. They worry about saying the wrong thing and being denied treatment that is very important to their health and wellbeing.

It may ease your fears to know that the focus of the assessment is on supporting you. Your assessor or primary care provider will ask you about:

Your gender and feelings about your body, including your embodiment goals
The effects you expect to see from estrogen-based or testosterone-based hormone therapies and effects you would rather avoid
Your expectations for timing of desired changes and understanding that responses are individual and are influenced by many factors (for example, your genetics and metabolics)
Your health history (current and past medical and mental health conditions, surgical history, medications, allergies, smoking status, exercise, nutrition, family history, etc.)
Your understanding of the risks and benefits associated with hormone therapy
Your support network and strategies for thriving in your changing gender expression with family and friends, at work and at school

Your prescribing provider may recommend a physical exam to check your heart and lungs. They will give you a requisition to do some laboratory work, such as a blood test.

What is the process for youth?

If you are a young person seeking puberty blockers or hormone therapy, your health care provider will need to consider additional factors because of your age and stage of development.

For more information about the readiness assessment for puberty blockers, visit Puberty Blockers.

When you visit your health care provider to talk about starting hormones, they will likely want to discuss:

How you understand your gender and how long you have felt this way
The way you express your gender
How you feel about your body
How you are doing emotionally
Your relationships with peers and family
Your experiences at school and in the community
What to expect from puberty blockers and hormone treatments
What puberty blockers and hormone treatments won’t do
Your understanding of the risks and benefits associated with puberty blockers or hormone therapy

Youth typically live with parents or guardians, who may need additional information or support related to gender-affirming health care. You can follow up with your health care team to discuss sources of support for yourself, your family and other people in your life.

Eligibility criteria for hormone therapy

First, it’s important to note that you do not have to be trans to be eligible for hormone therapy. Hormone therapy can be medically necessary for a range of people of all genders.

In B.C., health care is guided by Version 8 of the Standards of Care, which were published in 2022 by WPATH. These standards of care outline a number of criteria for hormone therapy. As part of your assessment, the assessor will confirm you meet these criteria.

For adults, the WPATH SOC-8 criteria for hormone eligibility are:

Gender incongruence is marked and sustained.
Meets diagnostic criteria for gender incongruence and other possible causes of apparent gender incongruence have been identified and excluded.
Demonstrates capacity to consent for the specific gender-affirming hormone treatment.
Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed.
Understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options.

For adolescents, WPATH SOC-8 criteria for hormone therapy eligibility are:

Gender diversity or incongruence is marked and sustained over time.
Meets the diagnostic criteria of gender incongruence and other possible causes of apparent gender incongruence have been identified and excluded.
Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment and understands the implications for starting a therapy that may change their gender expression.
Mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed; sufficiently so that gender-affirming medical treatment can be provided optimally.
Informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility.
Reached at least Tanner 2 (applies more to puberty suppression but is listed in hormone criteria as well).

What happens if a person doesn’t meet all the criteria?

In some cases, health care providers may prescribe hormones even when these criteria are not met. For example, a health care provider may use a harm reduction approach and prescribe hormone therapy as an alternative to someone obtaining hormones outside the health care system.

It is important to note that having mental health concerns (such as depression or anxiety) or addiction does not necessarily mean you do not meet the criteria. Instead, these concerns will need to be reasonably managed prior to, or during, hormone therapy.

Is counselling required?

Counselling is not typically required to get a prescription for hormones although it can be very helpful for some people. It may be recommended or required if:

You are uncertain about whether hormone therapy is the right decision for you at this time
You are not out to significant others and do not have a plan in place to come out
You have significant mental health or substance use concerns

Hormones obtained without a prescription

There are health risks associated with buying or borrowing hormone medications rather than getting a prescription from a health care provider.

You cannot be sure about the quality and dosage of the product. Unlike medications from a pharmacy, they may be diluted or mixed with unknown substances. In addition, the safe dosage required for optimal effects varies from person to person and cannot be determined without blood work.

If you are currently taking hormones without a prescription and would like to connect with a health care provider for a prescription and blood work, please contact the Trans Care BC health navigation team.