Hormone Readiness Assessment in BC: A Quick Guide for Starting HRT in BC

Nearly ten years ago, when I first reached out to a Registered Psychologist about a hormone therapy assessment, the landscape of transgender healthcare was quite different. I remember feeling uncertain and overwhelmed about the process, unsure of what steps to take or where to find the information I needed. Today, with the revised WPATH Standards of Care 8 and its widespread adoption by gender-affirming healthcare providers in British Columbia, the journey towards hormone therapy has become more accessible and better understood. My motivation for writing this blog post was to provide the most up-to-date information on initiating hormone therapy in BC, which echoes that of Trans Care BC. In doing so, I hope to provide support to anyone who may be exploring this unique aspect of the medical side of your gender transition.

Embracing the Journey: Let’s Explore HRT Readiness in BC

Hormone readiness assessments play a vital role for individuals considering changing their appearance to match their identity. The process of obtaining this assessment can be a bit confusing with every other primary care clinic seeming to have a different policy or procedure in mind. The purpose of this blog post is to provide a clear and informative guide on the process of getting a hormone readiness assessment in BC. By understanding the steps involved, I hope you can make better-informed decisions about your transition journey and access the care you need to transition medically.

Understanding Hormone Readiness Assessment

A hormone readiness assessment is an evaluation conducted by a healthcare professional to determine if a patient is ready to begin hormone therapy. This assessment is essential for ensuring that individuals receive appropriate care and support throughout their gender transition journey. In years past this assessment was conducted by a Registered Psychologist or a Registered Clinical Counsellor. Today there are more options, and some doctors are trained to provide an assessment. Still, some may want to meet with an RP or an RCC to explore gender transition or discuss mental health issues more openly and thoroughly. Whether you complete an assessment from your doctor or nurse practitioner or meet with a therapist, it’s 100% up to you.

In BC, care is guided by the World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (SOC-8), which were published in July 2022. You can read more about SOC 8 here. These guidelines serve as a framework for gender-affirming healthcare providers to follow when working with transgender, nonbinary, and gender-nonconforming individuals. By adhering to the WPATH SOC-8 guidelines, healthcare professionals in BC can ensure that they are providing the best possible care for individuals seeking hormone therapy as part of their gender transition.

Finding a Healthcare Provider for the Assessment

As mentioned above, there are several types of healthcare providers who can conduct a hormone readiness assessment, including family physicians, nurse practitioners, endocrinologists, and mental health professionals with experience in transgender healthcare. It is essential (and sometimes difficult) to find a healthcare provider who is knowledgeable about gender transition and has experience working with trans* and nonbinary individuals.

Trans Care BC, a program of the Provincial Health Services Authority, provides a health navigation team that can help you find a suitable healthcare provider for your hormone readiness assessment. Their team can also connect you with other resources and support services relevant to your transition.

It is important to note that you may need to work with multiple healthcare providers for different aspects of your care. For instance, you may have a primary care provider for your hormone therapy and a separate mental health professional for counselling or support during your gender transition.

Important: In BC, you are not required to have a psychological assessment completed by a mental health professional. What this means is that you are free to have your hormone assessment completed by your medical provider, a nurse or social worker at a clinic, or a qualified online therapist. Online therapists with specific training in gender-affirming care are available when you need support, and we can also complete the assessment. This broadening of options available to you prevents a select few from gatekeeping the process and withholding an assessment from you.

Assessment Process and Eligibility Criteria

The assessment period for hormone readiness varies from person to person and can be influenced by factors such as the individual’s health history, ability to manage mental health to ensure that you can keep up with the HRT routine, and support systems. Generally, the process takes two to three sessions to complete by an online therapist. You may need to schedule one or two appointments with your medical practitioner if you go that route. The best advice I can give here is to contact your provider and ask them what the assessment process entails, including how long it will take to complete.

Assessment with a medical practitioner: During the assessment process with a primary care physician or nurse practitioner, you can expect a questionnaire, a physical exam, and laboratory work may be requested before you begin HRT or before your referral to an endocrinologist to help you begin HRT. The physical exam typically includes measurements of height, weight, and blood pressure. Laboratory work may involve blood tests to evaluate hormone levels, liver function, and other relevant health markers.

Assessment with a mental health professional: During the assessment process with an online therapist like me, we will complete the questionnaire together, and the results of my assessment will be shared with your physician, nurse practitioner, or endocrinologist. It takes me one week to fax over the assessment. That gives your medical practitioner what they need to do one or all of the following: meet with you to start HRT: supply you with a requisition for bloodwork; and/or refer you to an endocrinologist to begin and manage the proper dosing necessary for your HRT.

What’s in the questionnaire? This is a discussion between you and your healthcare provider. Topics covered often include:

• Your gender identity and history: An in-depth exploration of your gender identity, experiences, and journey, including any experiences with gender dysphoria or affirmation. Possible questions may include:
  • How would you describe your gender identity?
    An example of an answer to this question: Non-binary and first became aware of my gender identity at age 12
  • When did you first become aware of your gender identity?
    An example of an answer to this question: I identify as a trans man and started questioning my gender when I was 15
  • Have you experienced gender dysphoria or affirmation in the past? If so, can you provide examples?
    An example of an answer to this question: I am genderfluid, and my understanding of my gender identity has evolved over the years
• Mental health status, coping skills, and feelings of readiness: Assessment of your current mental health, coping mechanisms, and ability to handle the changes and challenges associated with hormone therapy. Possible questions may include:
  • How would you describe your current mental health status?
    An example of an answer to this question: My mental health is stable, and I’m currently managing my anxiety with therapy and medication
  • What coping mechanisms do you use when faced with stress or challenges?
    An example of an answer to this question: I practice mindfulness techniques and journaling to cope with stress
  • How prepared do you feel to handle the changes and challenges associated with hormone therapy?
    An example of an answer to this question: I feel ready to take on the challenges of hormone therapy and have a strong support system in place
• Family, friend, social, and medical support systems: Evaluation of the support you have available, including relationships with family, friends, community resources, and medical professionals. Possible questions may include:
  • Do you have supportive biological or chosen family members or friends who are aware of your gender identity and transition plans?
    An example of an answer to this question: My family is supportive, and I have a close group of friends who understand my transition journey
  • Are you connected with any community resources or support groups for transgender individuals?
    An example of an answer to this question: I attend the Trans Gathering (Medical) support group and have made connections within the community through Discord
  • Do you have a primary care provider or other medical professionals who are knowledgeable about transgender healthcare?
    An example of an answer to this question: My primary care provider is experienced in transgender healthcare and has helped me navigate the process
• Potential risks and benefits of hormone therapy: Discussion of the possible outcomes, risks, and advantages of undergoing hormone therapy, tailored to your specific medical history and needs. Possible questions may include:
  • What benefits do you expect from hormone therapy?
    An example of an answer to this question: I hope hormone therapy will help alleviate my gender dysphoria and help me feel more comfortable in my body
  • Are you aware of the potential risks and side effects of hormone therapy?
    An example of an answer to this question: Since I read through the Trans Care BC website, I understand there are potential risks, such as blood clots or changes in mood, but I’m willing to manage them with the help of my healthcare team
  • How do you plan to manage potential side effects or complications related to hormone therapy?
    An example of an answer to this question: I’ve discussed the side effects with my NP and have a plan in place for regular check-ups and monitoring
• Informed consent and your understanding of the treatment process: Ensuring that you have a comprehensive understanding of the hormone therapy process, including any potential side effects, and that you can provide informed consent for treatment. Possible questions may include:
  • Can you explain the hormone therapy process in your own words?
    An example of an answer to this question: Hormone therapy involves taking medications to change the balance of hormones in my body, which will cause physical and emotional changes over time
  • Are you aware of the potential long-term effects of hormone therapy on your body?
    An example of an answer to this question: I’m aware that some of the changes, like voice deepening or breast growth, may be irreversible
  • Do you have any concerns or questions about the hormone therapy process?
    An example of an answer to this question: I’ve read the informed consent materials and feel confident in my understanding of the process
• Goals and expectations for hormone therapy: Discussing your personal goals and expectations for treatment, as well as providing realistic information about the effects of hormone therapy. Possible questions may include:
  • What are your primary goals for undergoing hormone therapy?
    An example of an answer to this question: My primary goal is to feel more aligned with my gender identity and reduce my gender dysphoria
  • What changes do you hope to see as a result of hormone therapy?
    An example of an answer to this question: I hope to see changes such as facial hair growth, redistribution of body fat, and muscle development
  • Do you have any concerns or fears about the potential outcomes of hormone therapy?
    An example of an answer to this question: I’m aware that results may vary, and I’m prepared to be patient with the process
• Development of a personalized treatment plan: Collaborating with your healthcare provider to create a tailored hormone therapy plan that takes into account your individual needs and circumstances. Possible questions may include:
  • Are there any specific needs or concerns you have that should be taken into consideration when developing your treatment plan?
    An example of an answer to this question: I would like my healthcare provider to consider my mental health history when developing my treatment plan
  • How would you prefer to be involved in the decision-making process for your hormone therapy plan?
    An example of an answer to this question: I want to be actively involved in decision-making and have open communication with my healthcare team
  • Do you have any preferences for the type or administration method of hormone therapy?
    An example of an answer to this question: I prefer the idea of using hormone patches or gels over injections, but I’m open to discussing the best option for my situation

Eligibility criteria for hormone therapy are based on the WPATH SOC-8 guidelines. For adults, this typically includes:

• Gender dysphoria, gender euphoria, or other gender-affirming experiences: Evaluation of your feelings and experiences related to your gender, including any instances of gender dysphoria or gender euphoria. It’s important to note that gender dysphoria is no longer a strict requirement for starting HRT, and affirming experiences are also considered.
• Mental health and readiness: Ensuring that any mental health concerns, if present, have been reasonably managed and that you feel emotionally and mentally prepared to begin HRT.
• Capacity for informed decision-making and consent: Assessment of your ability to understand the implications, risks, and benefits of HRT, and to provide informed consent for treatment.
• Support systems in place: Acknowledging the importance of having a support network, including friends, family, and healthcare professionals, to help you navigate your transition journey.
• Goals and expectations: Discussing your personal goals and expectations for HRT, as well as providing realistic information about the effects and potential outcomes of treatment.
• Overall health assessment: Ensuring that you are in good overall health and that any pre-existing medical conditions have been considered and addressed before initiating HRT.
• Willingness to adhere to hormone-level monitoring: Commitment to ongoing hormone-level monitoring, including regular blood tests and follow-up appointments, to ensure the safety and effectiveness of HRT.

For adolescents, eligibility criteria are more stringent, and assessment must be conducted by a multidisciplinary team experienced in adolescent transgender healthcare. Criteria include:

• Confirmed diagnosis of gender dysphoria: Diagnosis by a qualified mental health professional, who has determined that the adolescent experiences significant gender dysphoria.
• Comprehensive mental health evaluation: Completion of a thorough mental health assessment, addressing any potential concerns or conditions, and ensuring that the adolescent is emotionally and mentally prepared for HRT.
• Age-appropriate understanding: Demonstration of an age-appropriate comprehension of the risks, benefits, and implications of hormone therapy, as well as the potential physical and emotional changes that may occur.
• Parental consent and involvement: Obtaining consent from a parent or legal guardian (if under the age of 18), as well as ensuring their active involvement and support in the treatment process.
• Multidisciplinary team evaluation: Consultation with a team of healthcare professionals experienced in adolescent transgender care, who will collectively evaluate the adolescent’s readiness for HRT and ensure that all aspects of their well-being are considered.
• Support systems in place: Confirmation that the adolescent has a strong support network, including friends, family, and healthcare professionals, to help them navigate their gender transition journey.
• Willingness to adhere to hormone-level monitoring: Commitment from the adolescent to participate in ongoing hormone-level monitoring, including regular blood tests and follow-up appointments, to ensure the safety and effectiveness of HRT.

Additional Considerations for Youth

Youth seeking puberty blockers or hormone therapy require special attention due to their developmental stage and the potential long-term implications of treatment, such as fertility disruption and coping skills for physical and social development. Healthcare providers need to carefully consider factors such as cognitive and emotional maturity, the impact of treatment on future fertility, and the possibility of changes in gender identity over time.

It is important to seek gender-affirming healthcare providers who specialize in working with transgender, nonbinary, and gender-expansive youth, as they have the experience and knowledge necessary to guide young people and their families through the complex decision-making process.

Preparing for the Hormone Readiness Assessment

To best prepare for your hormone readiness assessment, consider taking the following steps:

• Talk to peers who have undergone a similar process: Connecting with others who have been through the hormone therapy assessment and transition process can provide valuable insights, guidance, and firsthand experiences. They can also offer recommendations for healthcare providers and share tips on navigating the journey.
• Consult with medical providers experienced in transgender healthcare: Engaging with medical professionals who have expertise in transgender care can help you learn more about the hormone therapy process, what to expect, potential side effects, and how to manage them. They can also address any concerns or questions you may have.
• Seek support from a gender-affirming psychotherapist: Working with a therapist who specializes in gender-affirming care can be incredibly beneficial for exploring your thoughts, feelings, and identity in a safe, supportive environment. They can help you process your emotions, develop coping strategies, and guide you through the transition process.
• Attend support groups or workshops: Participating in support groups or workshops specifically for transgender individuals can be a great way to connect with others going through similar experiences, share stories, and learn from one another.
• Research online resources: Utilize reputable online resources to gather information about hormone therapy, the assessment process, and the experiences of others who have undergone similar transitions. This can help you feel more prepared and informed.
• Create a list of questions and concerns: Before your assessment appointment, make a list of questions or concerns you want to address with your healthcare provider. This can help ensure that you cover all important aspects and feel more confident in your understanding of the process.
• Develop a support network: Building a strong support network, including friends, family, and healthcare professionals, is crucial for navigating your gender transition journey. Having people to lean on and share your experiences with can make a significant difference in your overall well-being.

It is essential to build a network of resources and support systems during your gender transition journey. This may include joining support groups like Qmunity’s Trans Gathering, attending workshops like UVic’s Moving Trans History Forward conference, or connecting with advocacy groups like Trans Rights BC. Remember that there are organizations dedicated to supporting you on your gender transition journey, including Catherine White Holman Wellness Centre and Qmunity. For a comprehensive list of support groups across BC, visit my local resources page for transgender British Columbians.

Affordability and Accessibility

The cost of hormone readiness assessments can be a financial barrier for some individuals. The $470 fee that RCCs often charge may be covered by extended healthcare coverage. If you don’t have workplace insurance, there are some low-barrier options. There are choices to access low-cost or free assessments through Trans Care BC, Catherine White Holman Wellness Centre, and other organizations that offer financial assistance for trans* folx.

Trans Care BC’s health navigation team can help you find healthcare providers who offer assessments at reduced fees or on a sliding scale, based on your financial situation. Additionally, some community health clinics or non-profit organizations may provide free or low-cost assessments. Ask around.

Remember, access to gender-affirming healthcare is a fundamental right, and resources are available to support you on your gender-affirming journey.

Booking a Telehealth-Based Hormone Assessment

Telehealth-based hormone assessments offer a convenient and accessible alternative to in-person appointments. Some benefits of telehealth assessments include:

• Reducing travel time and costs: Telehealth-based assessments eliminate the need for lengthy commutes and associated transportation expenses, making the process more convenient and cost-effective for individuals seeking hormone therapy assessments.
• Increasing access to specialized care: Telehealth services can significantly improve access to specialized transgender healthcare providers, especially for those living in remote or rural areas where such resources may be limited or unavailable. This ensures that individuals can receive expert care and guidance, regardless of their location.
• Providing a comfortable and familiar environment: For some individuals, attending in-person appointments may provoke anxiety or discomfort. Telehealth-based assessments offer the opportunity to undergo the evaluation from the comfort and familiarity of one’s own home, which can help alleviate stress and make the process more manageable.
• Enhancing privacy and confidentiality: Telehealth appointments can provide an additional layer of privacy for individuals who may be concerned about the stigma surrounding gender transition or who may not yet be comfortable discussing their situation openly. This can contribute to a sense of security and safety during the assessment process.
• Flexible scheduling options: Telehealth services often offer more flexibility in terms of scheduling appointments, making it easier for individuals to find times that work best for them and fit seamlessly into their daily routines.
• Reducing wait times: With telehealth-based assessments, there may be shorter wait times to access specialized care providers, as geographical restrictions are no longer a barrier. This can help individuals begin their transition journey more efficiently and without unnecessary delays.

To book a telehealth-based hormone assessment, book your HRT assessment with me or follow these steps to find a list of other qualified assessors:

1. Contact Trans Care BC’s health navigation team: Reach out to the Trans Care BC’s health navigation team by calling 1-866-999-1514 or emailing transcareteam@phsa.ca. They can provide you with a list of healthcare providers who offer telehealth-based hormone assessments.
2. Research and verify provider credentials: Once you have a list of potential providers, take the time to verify their credentials and experience in transgender healthcare. You can do this by reading their about page, checking for testimonials or reviews, or getting in touch with them directly to ask about their experience.
3. Schedule a virtual appointment: When you have selected a provider, schedule a virtual appointment with them. Make sure you have a stable internet connection, a device with a camera and microphone, and a private, quiet space to conduct the session.
4. Gather relevant medical records: Prepare for your assessment as you would for an in-person appointment by gathering any relevant medical records, such as previous assessments or mental health evaluations, that may be useful during your session.
5. Prepare questions and concerns: Jot down any questions or concerns you may have about the assessment process, hormone therapy, or your gender transition journey. Having a list prepared beforehand can help ensure you address everything you want to discuss during your appointment.
6. Create a comfortable environment: Set up your space for the virtual appointment in a way that makes you feel comfortable and at ease. This could include having a glass of water nearby, adjusting the lighting, or ensuring the room’s temperature is comfortable.

Conclusion

A hormone readiness assessment is a vital step for individuals considering or undergoing medical transition. This guide has provided an overview of the assessment process, eligibility criteria, and the importance of finding a healthcare provider experienced in transgender healthcare. We’ve also discussed considerations for youth, preparing for the assessment, affordability and accessibility, and the benefits of online therapy-based HRT assessments.

Throughout your gender transition journey, remember to seek support and guidance from peers, healthcare providers, and community resources. Your unique transition process is an opportunity for growth, self-discovery, and empowerment. Take charge of your journey and embrace your authentic self.