Informed consent

In a health setting, informed consent (also known as ‘affirmation enablement’) simply means being given correct and adequate information about gender affirming hormones, risks, effects, combinations and how they might work with other medications or recreational drugs.

This is so you are able to make a decision (or consent) about your body, health and health care. Doctors need to ensure their patients are making informed decisions about their health every day.

As it relates to trans people and gender affirming care, informed consent is a model that places the experiences, expertise and needs of the trans patient first. This means we are also working with a doctor to not take undue risks or place ourselves at risk of harm.

Your doctor will need to assess that you understand:

• What gender affirming hormones are available

• Potential effects and side-effects

• Risks and benefits

• Doses and application methods (patch, gel, tablet, injection etc)

• Your doctor’s experience in providing this kind of care

• How to consent and have the capacity to

“For trans people, informed consent represents autonomy and a departure from stigma, allowing patients to make their own choices about their bodies. The individual nature of this model allows care providers and patients to tailor it to individual needs”

Ruben Hopwood, Transgender Health Program Coordinator, Fenway Health, Boston

The informed consent model, developed at the Callen Lorde Community Centre in New York1, recognises that trans people are able to understand and consent to medical and surgical interventions ourselves, by understanding the risks, impacts and limitations. It places self-determination and autonomy at the centre of trans healthcare.

In the Informed Consent Model, the focus is on obtaining informed consent as the threshold for the initiation of hormone therapy in a multidisciplinary, harm-reduction environment. Less emphasis is placed on the provision of mental health care until the patient requests it, unless significant mental health concerns are identified that would need to be addressed before hormone prescription.

WPATH Standards of Care v7

In NSW, people aged 18+, who are able to consent to their own medical care, can initiate (or start) gender affirming hormones with a GP under the informed consent/affirmation enablement model. It’s important to book the longest appointment possible for starting this and it’s recommended to work with an experienced GP, where possible.

The process may look like (aged 18+):

• A consultation with your doctor, across 2-3 appointments. You’ll be asked about your physical health, medical and family history, previous hormonal or gender affirmation experience.

• Talking about how you want to affirm your gender medically, and associated goals.

• Discussion of risks factors.

• Your doctor may ask you about your specific history with migraines, liver disease, seizures, breast tissue lumps and irregular bleeding. This is to ensure the right gender affirming hormone combination is prescribed. Your doctor may want to further investigate any issues.

• You’ll also have a conversation about your current medications, allergies, if you smoke, how much you drink or use drugs, and how much support you have at home, and at work

• Arranging blood tests to establish base line levels of estrogen, testosterone and a range of other indicators such as liver function, thyroid levels, cholesterol, full blood count, electrolytes, glucose, lipids, and if applicable, pregnancy. They’ll also take your blood pressure and might ask you to jump on the scales.

• You should also be asked about fertility goals and reproductive health needs, and provided with information about fertility preservation

• Signing some informed consent paperwork, like the documents below, that show you’ve heard/read all the necessary information, understand what the risks, impacts and outcomes might look like, and consent to the process

• You may be asked about your last cervical screen, STI test, the contraception methods you use, if you’ve had a bowel cancer screen, etc.

• Throughout this process, your doctor will be assessing that you understand what’s going on, have the capacity to make an informed decision and consent to treatment, ensuring that you are making a decision of your own free will.

• A genital exam is not required and is against recommendations 2

It’s important to build a trusting and honest relationship with your doctor. It’s their job to help you stay healthy.

See below for standards, guidelines and templates, including a GP Gender Affirming Management Plan and informed consent paperwork. These templates require individualising to remain Medicare compliant, but provide all the information required for feminising and masculinising medical affirmation. Your doctor may have similar forms of their own, or you can print these out and take them to work through together.

A Family Court of Australia ruling (Re Kelvin, 2017 ) overturned an existing law that required all young people and their parents/carers to go to Court to commence gender affirming hormones prior to age 18. This ruling was further clarified in the judgement of Re Imogen 2020 to mean that treatment can be commenced in Australia with people under 18 when there is no dispute between parents (or those with parental responsibility), the medical practitioner and the young person themselves with regard to:

• The Gillick competence of an adolescent; or

• A diagnosis of gender dysphoria; or

• Proposed treatment for gender dysphoria

Any dispute requires a mandatory application to the Family Court of Australia as per the judgement of Re Imogen 2020.

Medical practitioners seeing patients under the age of 18 are unable to initiate puberty blockers or gender affirming hormonal treatment without first ascertaining whether or not a child’s parents or legal guardians consent to the proposed treatment. If there is a dispute about consent or treatment, a doctor should not administer puberty blockers (“Stage 1”), hormones (“Stage 2”) or surgical intervention (“Stage 3”) without court authorisation.

For trans people under 18 whose parents, carers or guardians will not consent to starting hormones, the Family Court must be involved. Unfortunately, in many cases where parents, carers or guardians do not consent, this results in a trans person simply waiting until they are 18 to access hormones.

The ruling from Re Imogen also stated that absent any dispute by the child, the parents and the medical practitioner, it is a matter of the medical professional bodies to regulate what standards should apply to medical treatment 3. This clarifies that the informed consent and approval letter protocols are lawful models to gender affirming healthcare.”

Further assistance for trans people is also available at Inner City Legal Centre who offer a NSW-wide free legal service for trans and gender diverse people.

“Ideally, the decision regarding timing of hormone commencement should be individualised to provide best care for the adolescent …The decision should be shared between the clinicians, the adolescent and their family with the values and belief systems of all contributors being respectfully considered.”

Australian Standards of Care and Treatment Guidelines For trans and gender diverse children and adolescents v1.1

For more information about accessing hormones as a younger person, go to our Under 18s page here.