Appendix one - Document 1
Consent form for feminising hormone therapy This consent form outlines important
information you might want to talk to your
Fertility
health team about before starting hormones
Taking the hormones stops your testicles producing
to feminise the body.
testosterone. Your testicles may shrink by up to 50%
and may eventually stop sperm production. If it is
Progynova (estradiol valerate) tablets or
Estradot
important for you to preserve your fertility you
(estradiol hemihydrate) patches provide the
might want to freeze your sperm before you start
feminising hormone estrogen. Testosterone
treatment. Your health team will talk to you about
blockers are needed as well unless gender
this.
reassignment surgery has occurred.
Sex
Taking the tablets may lower your sex drive so that
Estrogen tablets/patches will gradually feminise
you are not as interested in having sex anymore.
the body.
You may find that you get erections less often and
Permanent body changes (even if you stop taking
that your penis doesn’t get as hard anymore. If you
want to be able to use your penis for sexual
the tablets):
• Gradual increase in breast size over 2-3 years pleasure talk to your health team and they will
• Your estrogen dose is increased slowly for
review your medications.
best breast development
• It is not known if taking estrogen increases
Mental health
the risk of breast cancer. Take care of your
Some people may feel more emotional taking
breasts - it is recommended to follow the
estrogen. Some people find their mental health
normal breast screening guidelines for
women
improves – the effects of hormones on the brain are
not fully understood. Transitioning can be a stressful
Non-permanent body changes (that may reverse if
time and many people need some help adjusting to
you stop the estrogen):
the physical and emotional changes. It is really
• Softer skin
important that you let your health team know if you
• Decreased muscle mass
are having problems so that they can help you
• Less body hair
•
access the support you need.
More fat on buttocks, hips and thighs
Common side effects
Things that don’t change much:
•
•
Nausea
Facial hair slows down but doesn’t stop
•
completely
Headaches
• Voice stays the same
• Tender breasts
• Bone structure of your face and Adam’s apple
• Weight gain
doesn’t change
Most side effects should settle within a few days to
If you stop taking your hormones some body
weeks of starting the medications. Please tell your
changes stay but you may find that your body will
health team if you have any side effects, especially
slowly masculinise.
headaches or migraines.
Adapted with permission from Hauora Tāhine.
Appendix One - Document 1
Some of these risks are reduced by using estrogen
Potential risks of estrogen
patches instead of tablets.
The full medical effects and safety of taking
hormones are not fully known. The potential risks of Go to the emergency department or seek medical
taking estrogen must be weighed against the
help urgently if:
benefits that hormones can have on your health and
• You have a swollen painful leg
quality of life.
• Chest pain or difficulty breathing
• Vision or speech problems
Likely increased risk
These symptoms might mean you have a serious
• Blood clots - deep vein thrombosis (DVT),
problem like a blood clot.
pulmonary embolism (blood clot in the lung),
stroke, heart attack
• Changes to cholesterol (may increase risk of
The risk of having a blood clot is much higher if you
pancreatitis and heart disease)
smoke or are overweight.
• Gallstones
Blood clots are more common as you get older.
Possible increased risk
• Increased blood pressure
Stopping estrogen before and after surgery can
• Liver problems
help reduce the risks of blood clots around this
• Increased prolactin and possibility of benign
time.
pituitary tumours
Keeping in touch with your health team for regular
Possible increased risk if you have extra risk factors
•
checkups and blood tests is an important part of
Heart disease
• Diabetes
your care and will reduce the risks of taking
hormonal therapy.
No increased risk/unknown risk
• Breast cancer
Are there any other questions you want to ask?
It is your health team’s responsibility to best support you to make the decisions that are right for you and
to keep ourselves up to date so that we can best inform you.
For many different reasons people question whether or not they want to continue to take hormones. This
can be a normal part of your journey. Please feel free to discuss this with your prescriber before you stop
your medication. Come and talk – your health team is always ready to listen.
I wish to start feminising hormone therapy:
Name Date
Prescribed by:
Name Date
Adapted with permission from Hauora Tāhine.
Appendix One - Document 1
Consent form for starting masculinising hormone therapy This consent form outlines important
information you might want to talk to your
Fertility
health team about before starting hormones
While it is not known what the long term effects are
to masculinise the body.
of taking testosterone some transmen find that if
they stop their testosterone they will become fertile
There are different types of testosterone that are
again and can get pregnant. There are no
taken to masculinise the body. Everyone is different guarantees for anyone and it is probably harder to
in how quickly they respond to testosterone but you get pregnant the older you are and the longer you
will start to notice changes in your body gradually
have been on testosterone.
over the first few months. It may take several years
Testosterone is dangerous for the developing fetus
before the full effect is felt. While there are
–
you must not get pregnant while you are on
different ways of getting testosterone into the body
testosterone. Even after your periods stop you
most people are on injections.
might still be at risk of getting pregnant. If you are
having any sexual contact that puts you at risk of
Permanent body changes
(even if you stop taking
pregnancy you must talk to your health team about
testosterone):
contraception options.
•
Deeper voice
•
Sex
Increased growth of hair – with thicker hairs
on arms, legs, chest, back and abdomen
Taking testosterone causes your vagina to become
•
dryer and more fragile. This increases the risk of
Gradual growth of moustache/beard hair
• Hair loss at the temples – possibly becoming
sexually transmitted infections (STIs), including HIV
bald with time
if you are having any sexual contact with this part of
• Genital changes – clitoral growth (typically 1 - the body. Condoms provide good protection against
3 cm) and vaginal dryness
STIs and lubricant helps to prevent any discomfort.
Mental health
Non-permanent body changes
(that may reverse if
Some people find that testosterone can cause
you stop the testosterone):
•
emotional changes such as increased irritation,
Skin changes – increased oil and acne
• Change in body shape – less fat on buttocks,
frustration and anger. Some people find their
hips and thighs
mental health improves – the effects of hormones
• Increased muscle mass and upper body
on the brain are not fully understood. Transitioning
strength
•
can be a stressful time and many people need some
Increased sex drive
•
help adjusting to the physical and emotional
Periods usually stop after 1-6 months
changes. It is really important that you let your
health team know if you are having problems so
Things that don’t change much:
• Breast tissue looks a bit smaller due to fat
that they can help you access the support you need.
loss
• Possible weight gain or loss
Adapted with permission from Hauora Tāhine.
Appendix One - Document 1
Potential risks of testosterone
No increased risk or unknown
The full medical effects and safety of taking
• Breast cancer
hormones are not fully known. The potential risks of
• Cervical, ovarian, uterine cancer
taking testosterone must be weighed against the
• Blood clots – deep vein thrombosis (DVT)
benefits that hormones can have on your health and
quality of life.
The risk of health problems is higher if you are a
Likely increased risk
smoker or overweight.
• Increased red blood cells (polycythemia) -
might thicken the blood and increase the risk of Keeping in touch with your health team for regular
a stroke or heart attack
checkups and blood tests is an important part of
• Sleep apnoea (sleep disorder)
your care and will reduce the risks of taking
Possible increased risk
hormonal therapy.
• Changes to cholesterol (may increase risk for
heart disease)
Are there any other questions you want to ask?
• Liver problems
Possible increased risk if you have additional risk
factors
• Diabetes
• Increased blood pressure
It is your health team’s responsibility to best support you to make the decisions that are right for you and
to keep ourselves up to date so that we can best inform you.
For many different reasons people question whether or not they want to continue to take hormones. This
can be a normal part of your journey. Please feel free to discuss this with your prescriber before you stop
your medication. Come and talk – your health team is always ready to listen.
I wish to start masculinising hormone therapy:
Name Date
Prescribed by:
Name Date
Adapted with permission from Hauora Tāhine.
Appendix one - Document 2
Appendix One - Document 2
Appendix One - Document 2
Appendix One - Document 2
Appendix one - Document 3
INFORMED CONSENT for HORMONE TREATMENT - Oestrogen
For treatment of Gender Dysphoria
Patient Label
I have been assessed by a psychiatrist and have a formal diagnosis of gender dysphoria.
I agree that I have had the implications of having oestrogen therapy (in conjunction with
medication to reduce the production of testosterone – delete if not applicable) explained to me in
full by ……………………………….. (Name of clinician).
Effects of Oestrogen
I have gender dysphoria and therefore will be treated with oestrogen. As a result of taking
oestrogen I expect to experience: some breast growth; some redistribution of body fat to
approximate to a female pattern; decreased upper body strength; softening of skin; decrease in
body hair; a slowing of the loss of scalp hair; decreased fertility and testicular size and less
frequent, less firm erections. Some of these changes are reversible, but breast enlargement,
which will occur slowly over a period of up to two years, will not completely reverse after
treatment is discontinued. The degree of change is unpredictable and may not fulfil my
expectations.
In the longer term, the size of my genitalia will be reduced. I may become permanently infertile
after prolonged treatment. I have been given specific information regarding local fertility services.
I understand that if I have not made use of those facilities before treatment is undertaken, I may
be unable to do so later through irreversible infertility.
I understand that the changes outlined above will start shortly after treatment is initiated, but that
the full physical impact of taking hormones may not be evident until several years of continuous
treatment have been undergone.
I have had the opportunity to discuss, with my clinician, the effects of the proposed medication
and any side effects I may experience, and to clarify any points I did not understand.
Potential Risks and Negative Side Effects
• I understand that the most likely side effects are: venous thrombosis; pulmonary
embolism; benign pituitary prolactinoma (non-malignant tumour in the brain); weight gain;
mood swings; liver disease; gallstones; breast cancer; high blood pressure and diabetes
mellitus.
• I understand that I will be at increased risk of unwanted side effects if any of the following
pre-existing factors apply: cigarette smoking; obesity; alcohol and/or drug misuse and
advanced age.
• I understand that, after genital surgery, a lifelong maintenance dose of oestrogen is
almost certain to be required to maintain feminisation and protect against osteoporosis.
• I understand that any surgical procedures will require further psychiatric evaluation.
• I agree to take the hormones in the dosage prescribed by my clinician and undertake not
to take additional doses of oestrogen as this will pose an extra health risk.
• I understand that other medication available on or off prescription may be contra-
indicated whilst I am on hormone medication.
Appendix one - Document 3
•
I agree to my hormone treatment being monitored by my clinician. I understand that
physical examinations and blood tests are needed on a regular basis to check for
negative side-effects of feminizing medication.
•
I understand that I may be discharged to my GP for long term monitoring when deemed
appropriate by my clinician
•
I agree to ongoing psychiatric support as advised/necessary.
•
I am over 16 years old.
•
I agree / I do not agree (delete as appropriate) to take part in any anonymised surveys.
Signed ……………………………………………………….. Date ………………………………….
(Individual undergoing hormone treatment)
I (Clinician) am satisfied that ……………………………………………(patient) understands the
nature of the proposed treatment and has a full appreciation of the consequences of both the
treatment in terms of intended and possible side-effects and, also, the consequences of not
following this treatment.
Signed ……………………………………………………….. Date ………………………………….
(Clinician)
Appendix one - Document 3
Feminizing effects
Effect
Onset
Maximum
Redistribution of body fat
3–6 months
2–3 yrs
Decrease in muscle mass and strength
3–6 months
1–2 yrs
Softening of skin/decreased oiliness 3–6 months
Unknown
Decreased libido
1–3 months
3–6 months
Decreased spontaneous erections 1-3 months
3-6 months
Male sexual dysfunction
Variable
Variable
Breast growth
3–6 months
2–3 yrs
Decreased testicular volume
3–6 months
2–3 yrs
Decreased sperm production
Unknown
>3 yrs
Decreased terminal hair growth a 6–12 months
>3 yrs
Scalp hair b
No regrowth
Voice changes c
None
a Complete removal of male sexual hair requires electrolysis, or laser
treatment or both.
b Familial scalp hair loss may occur if oestrogens are stopped.
c Treatment by speech pathologists is most effective
Appendix one - document 3
Medical conditions that can be exacerbated
by cross-sex hormone therapy
Oestrogen
Very high risk of serious adverse outcomes:
Thromboembolic disease
Moderate to high risk of adverse outcomes:
Macroprolactinoma
Severe liver dysfunction (transaminases >3 x upper limit
of normal)
Breast cancer
Coronary artery disease
Cerebrovascular disease
Severe migraine headaches
There may be other conditions also affected by hormone therapy as every
individual responds differently.
Appendix one - Document 4
INFORMED CONSENT for HORMONE TREATMENT - Testosterone
For treatment of Gender Dysphoria
Patient Label
I have been assessed by a psychiatrist and have a formal diagnosis of gender dysphoria.
I agree that I have had the implications of testosterone administration explained to me in full by
……………………………(name of clinician).
Effects of Hormones
Have gender dysphoria and therefore will be treated with testosterone. I understand that I can
expect the following permanent changes: a deepening of the voice; clitoral enlargement;
possibly mild breast atrophy; increased facial and body hair and male pattern baldness.
The following changes are reversible: increased upper body strength; weight gain; increased
sexual arousability; and decreased hip fat. Cessation of menstruation, which normally
accompanies cross-hormone administration, may or may not be reversed if hormones are
ceased.
I understand that reproductive capacity will eventually be lost after treatment, although this may
take several years. I have been fully informed of the options to enable me to have a genetically
related child and having been given specific information regarding local fertility facilities. I
understand that if I have not made use of these facilities before treatment is undertaken, I will be
unlikely to be able to do so later.
I understand that the changes outlined above will start shortly after treatment is initiated, but that
the full physical impact of taking hormones may not be evident until several years of continuous
treatment have been undergone.
Potential Risks and Negative Side Effects
•
I understand that treatment with testosterone may cause the following side effects: acne,
mood swings, increased risk of cardiovascular disease heart and polycythaemia; rarely,
malignant liver tumours and/or liver dysfunction; in the longer term, skin atrophy in the
genital area may be experienced.
•
I understand that I will be at increased risk of unwanted side effects if any of the following
pre-existing factors apply: cigarette smoking; obesity; alcohol and/or drug misuse;
advanced age; high blood pressure; clotting abnormalities; cancer; endocrine
abnormalities.
•
I understand that, in the light of current knowledge and practice, an oophorectomy
(removal of ovaries) and hysterectomy (removal of uterus and cervix) may be
recommended after about five years of testosterone therapy. I understand that if these
are not undertaken then regular cervical smears are recommended because of the
increased risk of cancer.
•
I understand that any surgical procedures will require further psychiatric evaluation.
•
I understand that a lifelong maintenance dose of testosterone is likely to be required,
although a reduction in the dosage will be considered for health reasons after removal of
the ovaries.
Appendix one - Document 4
•
I understand that if I stop taking testosterone, there is a risk of developing osteoporosis
unless oestrogen therapy is undertaken. I understand that oestrogen therapy, itself, can
produce unwanted medical and physical side effects.
•
I agree to take the hormones in the dosage prescribed by my clinician and undertake not
to take additional doses of testosterone as this will pose an extra health risk.
•
I agree to my hormone treatment being monitored by my clinician. I understand that
physical examinations and blood tests are needed on a regular basis to check for
negative side-effects of masculinizing medication.
•
I understand that I may be discharged to my GP for long term monitoring when deemed
appropriate by my clinician.
•
I agree to ongoing psychiatric support as advised/necessary.
•
I understand that other medication available on or off prescription may be contra-
indicated whilst I am on hormone medication.
•
I am over 16 years old.
•
I agree / I do not agree (delete as appropriate) to take part in any anonymised surveys.
Signed ………………………..…………………………. date………………………………………….
(Individual undergoing hormone treatment)
I (Clinician) am satisfied that ……………………………………(patient) understands the nature of
the proposed treatment and has a full appreciation of the consequences of both the treatment in
terms of intended and possible side-effects and, also, the possible consequences of failure to
treat.
Signed ……………………………………….……….. Date………………………………….
(Clinician)
Appendix one - Document 4
Masculinizing effects
Effect
Onset
Maximum
Skin oiliness/acne
1–6 months
1–2 yrs
Facial/body hair growth
6–12 months
4–5 yrs
Scalp hair loss a
6–12 months
Increased muscle mass/strength
6–12 months
2–5 yrs
Fat redistribution
1–6 months
2–5 yrs
Cessation of menses b
2–6 months
Clitoral enlargement
3–6 months
1–2 yrs
Vaginal atrophy
3–6 months
1–2 yrs
Deepening of voice
6–12 months
1–2 yrs
a Prevention and treatment as recommended for biological men.
b Menorrhagia requires diagnosis and treatment by a gynaecologist
Appendix one - Document 4
Medical conditions that can be exacerbated
by cross-sex hormone therapy
Testosterone
Very high risk of serious adverse outcomes:
Breast or uterine cancer
Erythrocytosis (haematocrit >50%)
Moderate to high risk of adverse outcomes:
Severe liver dysfunction (transaminases >3 x upper limit of normal)
Appendix one - Document 4
There may be other conditions also affected by hormone therapy as every
individual responds differently.
Document Outline
