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How Is Hormone Replacement Therapy (HRT) Prescribed?

What cis allies need to know about HRT for trans kids.

Before we start on the specifics, it’s important to note that, like puberty blockers, no trans kid and their family are walking into a provider’s office, saying they’re trans and need hormone replacement therapy, and walking out with a prescription.

Additionally, not all trans and non-binary kids choose HRT.

As trans kids begin to approach the time when peers in their gender cohort start to experience puberty, discussions around hormone replacement therapy start taking place.

Similar to how puberty blockers are prescribed, trans kids who want to begin HRT are assessed by both health care and mental health professionals.(Trans boys start testosterone and trans girls start estrogen, non-binary kids who want either masculinized or feminized features start either testosterone or estrogen).

Unlike with puberty blockers, some of the effects of HRT are irreversible, but not all.

This is one example of a resource that parents and trans kids receive when discussing HRT. This resources specifically details the effects of testosterone.

Chart describing the effects of hormone replacement therapy for trans kids, specifically testosterone.

During discussions leading up to the start of HRT, families frankly and honestly discuss with health care providers the changes that will be irreversible, changes that will reverse if HRT is stopped, when changes will start occurring, what changes a kid is most looking forward to, as well as what changes might be causing some anxiety. Risks are talked over and reality checks given. Fertility and options around fertility preservation are also discussed.

At this point in gender-affirming care, the treatment becomes very individualized. Some kids who have already gone through a puberty, for example, may start HRT at a higher dose. Other kids, particularly those who’ve been on puberty blockers, start at lower doses so the changes they experience occur at a pace that more accurately mirrors puberty. After hormone levels reach a high enough level, growth plates close, so some kids will start HRT at lower levels so they can maximize opportunity for height.

1. Initial appointment for HRT preparation. The first appointment around starting HRT, especially for kids who have been on blockers and are regular patients at a gender clinic, may happen during a regular check up. Kids who receive a puberty blocker via injection, for example, are seen in clinic every month to every three months to receive the injection.

At this appointment, consent forms are signed giving health care providers permission to exchange information. So, for example, the medical providers can talk with the mental health care providers and vice versa.

2. Mental health assessments, informed consent and testing. At this point, many trans kids have already been regularly seeing a mental health care professional and have likely already been talking through their readiness for HRT. As with puberty blockers, explicitly talking with both medical and mental health care providers about the effects of testosterone, what is reversible and what is irreversible, a child’s feelings around HRT, is part of informed consent.

Here, it’s important to note that trans kids are often working through their medical health care alongside therapists on an ongoing basis, meaning that timelines around when a family might first talk about HRT, prescriptions being secured and HRT starting probably don’t accurately reflect the real conversations happening between a trans kid and their therapist.

Additionally, bloodwork is required to assess overall health and another Dexa scan is done to assess bone health.

3. Letters and insurance. Mental health care providers talk to social workers at a gender clinic or health care provider’s office and they work together to make sure the letter of readiness has all the information an insurance provider needs to approve HRT.

Often, readiness is measured by longevity of living and identifying as the gender they’d like HRT prescribed for, persistence of dysphoria, understanding the effects of treatment and retelling of conversations with supportive family members, to name a few. All things that seem necessary, but don’t really speak to the experience of trans kids.

There are few — if any — parents of trans kids who are not in favor of informed consent, of having discussions around care, untangling feelings and coming to some certainty around what care is necessary and appropriate. (The same way parents approach any health care decision for their children).

But again, gender-affirming health care is some of the most scrutinized health care in the system. Trans kids are not allowed any nuance and their feelings are often expected (in the larger world and medical landscape) to be flattened and definitive, and that’s not how humans work.

We are complex; we have complicated feelings around loads of things. And trans kids are really allowed none of that — without risking the gender-affirming care they need — and it’s a real shame and a real indictment of the larger medical system today.

SHORT PERSONAL TANGENT: My trans son grew up relatively neutral though definitely mostly gender nonconforming in regards to how femininity is expected to be performed. But, he didn’t think much about gender outside of when he was directly challenged (and as he got older, challenges became more and more frequent).

Puberty, as with some trans kids, is when my son realized the changes that were starting to happen in his body didn’t feel right for him.

But, my kid does not hate seeing pictures of themselves as a younger child who presented in a more feminine way. He absolutely without question is trans, and I would describe our journey this way: He does not hate his assigned sex; he is more himself as a trans boy.

At this point, some people will say: “You don’t have a trans boy you have a tomboy and you need to make sure they understand there is more than one way to be a woman/female instead of pumping them full of hormones because they’re too afraid to be different.”

Which … no. I have a trans son who has always known there are multiple ways to be human and has found, through talking and exploring and thinking about what makes him feel best, his truth.

When you allow kids the opportunity to explore their own complexity, they will arrive where they need to be to live a full, meaningful and happy life on their own. And that journey, unlike what many people demand, can contain multitudes and be full of nuance.

4. Prescription, dosing and learning how to administer medication. Once insurance is approved, dose is decided and an appointment is made with a nurse who walks through how to administer the medication. Testosterone, for example, is available as a gel or injection, but most often the gel is more expensive so injections are used.

It can’t be overstated that gender-affirming care, particularly at this point, is very individualized.

For example, some trans boys who started puberty blockers begin HRT on a lower dose of testosterone so they can grow as much as possible before their growth plates close, which happens with higher doses of hormone. But, if they still want to stop menstruation, they continue on Lupron because lower doses of hormone won’t stop a period. So, as they start HRT, they continue on puberty blockers until doses are increased to the point that levels stop unwanted processes like menstruation.

Dosing is decided amongst families and health care providers, and also takes into consideration variables like where a trans kid’s peers are in development, how quickly they want changes to occur, if they need a dose that still allows for growth or can slow the development of changes that they might have some anxiety around.

When dose is decided and medication prescribed, a nurse will walk the patient through administering their first dose and go over where on the needle the dose is, how to inject, where on the body to inject, what happens if a dose is accidentally missed and possible side effects.

5. The age question. Many anti-trans people will argue that no hormones should be given to minors, meaning, effectively, that HRT should not start before the age of 18.

The problem with that thinking is that you’re then forcing trans kids to either pause puberty throughout adolescence and begin the process at 18 or you’re forcing trans kids to go through the puberty that aligns with their assigned sex and develop primary and secondary sex characteristics they do not want.

Studies have show that trans people who begin HRT in adolescence had lower odds of experiencing severe psychological distress and suicidal ideation, as well as lower odds of binge drinking and drug use.

Read a more lay person explanation of the study.

In practice, many gender-affirming providers are starting trans kids on HRT before 18, with some of the earliest starts at around 14.

If you are thinking (or if you know people who think) that 14 is way too young, you need to stop and take a breath and review the information just above this section about dosing.

The start of HRT in earlier adolescence is done slowly, starting with very small doses. Bloodwork is continually monitored to track hormone levels. Providers check in with trans kids regularly, asking what changes they’re noticing, if there are changes they’d like to see more of, and if there are changes that make them uncomfortable.

Additionally, all of this medical care is being done in tandem with mental health care.

6. The fertility question. One of the strangest things about people interested in trans kids especially is how invested they are in a child’s ability to have children who are biologically related to them.

Is the question wrong? Not necessarily. Is the question something I, as the parent of a trans kid, thought about? Absolutely.

I should be able to help my kid navigate some of these bigger questions because they directly affect my child. Strangers, on the other hand, should have no opinion on whether trans kids’ fertility is something they need to worry about.

The short answer to this curiosity, however, is: Yes, HRT does affect the fertility of trans kids, especially if that trans kid used puberty blockers prior to hormone replacement therapy.

For example, a trans boy who went on puberty blockers before having a period and then started hormone replacement therapy (testosterone) to continue transition may become infertile unless they choose to preserve eggs prior to starting HRT, which requires they allow enough of an estrogen puberty to occur to mature eggs.

For trans girls, preserving sperm would be necessary prior to start of HRT.

For non-binary kids, the above applies based on sex assigned at birth. For example, a non-binary kid assigned female at birth would need to preserve mature eggs before starting testosterone.

It’s important to note, however, that research is starting to show that trans people who undergo even longer periods of hormone replacement therapy (with cross-sex hormones) can still successfully have children biologically related to them with about the same success as their cisgender peers.

SHORT PERSONAL TANGENT: When talking with my son’s elementary principal about some of his health care and the support and advocacy I need in the education environment, she specifically told me:

“I just can’t imagine knowing I wanted to be a different gender at such a young age.”

I didn’t answer her, but instead shared one of my own thoughts that had been niggling at the back of my head:

“Eh. I do think about fertility and what a big decision that feels like at this age.”

She didn’t miss a beat:

“Oh, I always knew I didn’t want kids of my own.”

This is a great example of how often cis people take autonomy for granted. This person never thought twice about not wanting kids of her own, and took the right to know that and act on that for herself as a given.

Trans people are seldom extended this same right about any health care they access.

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