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Transgender Health

Trans Healthcare: HRT,
Surgery, and Affirming Care

Comprehensive, evidence-based information on gender-affirming healthcare for transgender and non-binary people. From hormone therapy to surgical options to finding providers who see and respect you.

Trans Health WPATH-Based Evidence-Based
This page is educational and based on WPATH Standards of Care (Version 8), Endocrine Society guidelines, and peer-reviewed research. It is not a substitute for medical advice. Gender-affirming care should be individualized with a qualified healthcare provider.
1.6M Trans adults in the U.S.
Williams Institute, 2022
73% Reduction in suicidality with gender-affirming care
JAMA Network, 2022
30% Report being denied healthcare
NCTE U.S. Trans Survey, 2022
94% Report improved wellbeing after transition
Cornell meta-analysis, 2018
Overview

What Is Gender-Affirming Care?

Gender-affirming care is a spectrum of healthcare practices that support transgender and non-binary people in living in alignment with their gender identity. It ranges from social transition (pronouns, name) through mental health support, hormone therapy, and surgical interventions. Not all trans people need or want all components of gender-affirming care. Transition is personal and self-directed.

The evidence base for gender-affirming care is extensive. A 2018 Cornell University meta-analysis of 55 studies found that 93% reported improvement in gender dysphoria after treatment, and 94% reported improved quality of life. A 2022 JAMA Network Open study found a 73% reduction in suicidal ideation among trans youth who had access to gender-affirming puberty blockers.

WPATH Standards of Care, Version 8

The World Professional Association for Transgender Health (WPATH) publishes the Standards of Care (SOC), the globally recognized clinical guidelines for trans healthcare. The 2022 Version 8 was the most significant update in a decade. Key changes in SOC8 include: removing mandatory letters of referral for many procedures, removing age minimums for some treatments, recognizing non-binary identities throughout, and incorporating extensive new research on adolescent trans healthcare. WPATH SOC8 is available free at wpath.org.

Hormone Therapy

Gender-Affirming Hormone Therapy (GAHT)

Gender-affirming hormone therapy (also called HRT or GAHT) uses hormones and hormone blockers to align a person's secondary sex characteristics with their gender identity. It is one of the most commonly sought components of gender-affirming care and has a strong evidence base for safety and effectiveness when properly monitored.

Feminizing HRT

For trans women, trans femmes, and non-binary people seeking feminization

Feminizing HRT typically involves estrogen (to develop feminine secondary sex characteristics) combined with an anti-androgen (to suppress testosterone). In some cases, progesterone is also included, though its evidence base for breast development is debated.

Common Medications

  • Estradiol (the primary estrogen used) in various forms
  • Spironolactone (most common anti-androgen in the U.S.)
  • Bicalutamide (alternative anti-androgen)
  • GnRH agonists (Lupron, Zoladex) as hormone blockers, more common in youth or post-orchiectomy
  • Progesterone (Prometrium) in some protocols

Routes of Administration

Injections

Subcutaneous or intramuscular, weekly or bi-weekly. Highest blood levels, most cost-effective.

Patches

Applied to skin twice weekly. Steady blood levels, preferred for some cardiovascular concerns.

Gel / Spray

Applied daily to skin. Convenient, requires careful application to avoid transfer to others.

Expected Changes (Timeline)

  • 1 to 3 months: Decreased libido, softer skin, reduced body/facial hair growth rate
  • 3 to 6 months: Breast development begins, redistribution of fat toward hips and thighs
  • 6 to 12 months: Continued breast and fat changes, muscle mass reduction
  • 1 to 3 years: Most physical changes reach full expression; breast development may continue up to 5 years
  • Permanent (if stopped): Breast tissue (small amount remains), genital atrophy changes may partially reverse
  • Permanent even if stopped: Facial hair electrolysis effects, facial bone structure (in adults, minimal)

Masculinizing HRT

For trans men, transmasculine, and non-binary people seeking masculinization

Masculinizing HRT primarily uses testosterone to develop masculine secondary sex characteristics. Testosterone is highly effective at producing most masculinizing changes and also has the effect of stopping menstrual periods, which is often a significant source of gender dysphoria for transmasculine people.

Common Medications

  • Testosterone cypionate (most common injection in the U.S.)
  • Testosterone enanthate (alternative injection)
  • Testosterone gel (AndroGel, Testim, generic)
  • Testosterone patches (Androderm)
  • Testosterone pellets (implanted under skin, every 3 to 6 months)

Routes of Administration

Injections

Every 1 to 2 weeks, subcutaneous or intramuscular. Most cost-effective with generics available.

Gel

Applied daily. Steady levels, requires caution with transfer to children and partners.

Pellets

Implanted under skin, last 3 to 6 months. Highly convenient but expensive and irreversible until absorbed.

Expected Changes (Timeline)

  • 1 to 3 months: Cessation of periods (usually), increased libido, clitoral growth begins, oilier skin
  • 3 to 6 months: Voice begins deepening, facial and body hair growth, increased muscle mass
  • 6 to 12 months: Continued voice deepening, fat redistribution toward waist, male pattern hair loss may begin
  • 1 to 5 years: Full beard development for those with genetic potential; most changes plateau
  • Potentially permanent even if stopped: Voice deepening, clitoral growth, facial hair, male pattern baldness
  • Will reverse if stopped: Menstrual periods typically return, some fat redistribution
Informed Consent Model

Many LGBTQ+ health centers and forward-thinking providers use an informed consent model for prescribing HRT, meaning they do not require a mental health letter of referral before prescribing. Under this model, the provider discusses risks, benefits, alternatives, and expected outcomes; the patient demonstrates understanding; and hormone therapy is prescribed. This model respects patient autonomy and follows WPATH SOC8, which no longer mandates letters for most hormone therapy. If a provider insists on a mental health letter before even discussing hormones, it may be worth seeking a second opinion.

Monitoring on HRT

Regular lab monitoring is essential on HRT for safety. For feminizing HRT, your provider will monitor estradiol levels, testosterone levels (to confirm suppression), a complete metabolic panel, and potentially liver function. For masculinizing HRT, monitoring includes testosterone levels, hematocrit (testosterone can increase red blood cell production), lipid panel, and liver enzymes. Labs are typically checked every 3 months for the first year, then annually once stable. Do not skip labs: HRT is safe when properly monitored.

Adolescent Care

Puberty Blockers: What the Science Actually Shows

GnRH agonists (gonadotropin-releasing hormone agonists), commonly called puberty blockers or puberty suppressants, temporarily pause the physical changes of puberty. They are fully reversible: when stopped, puberty resumes. They have been used safely in cisgender children with precocious puberty since the 1980s.

For transgender adolescents, puberty blockers provide time: time to explore gender identity, pursue mental health support, and make more informed decisions about future medical steps, without the distress of developing unwanted secondary sex characteristics that may require future surgical correction. For example, trans girls who block estrogen-driven puberty avoid developing a female-typical body they may later need to masculinize, while trans boys avoid developing breast tissue that may require chest surgery.

The Evidence on Puberty Blockers and Mental Health

A 2022 study in JAMA Network Open found a 73% reduction in suicidal ideation among trans youth who received puberty blockers, compared to those who wanted them but could not access them. A 2023 British Journal of Psychiatry study found puberty blockers associated with improved life satisfaction and reduced depression in adolescents with gender dysphoria. The American Academy of Pediatrics, Endocrine Society, and WPATH all support access to puberty blockers for eligible adolescents as part of a multidisciplinary care approach. Claims that puberty blockers are "experimental" are not supported by the medical evidence base.

Surgical Options

Gender-Affirming Surgical Procedures

Surgical procedures are one component of gender-affirming care, sought by some trans people and not others. No surgery is required to be trans. Surgical decisions are deeply personal and should be made with a qualified surgeon experienced in gender-affirming procedures. The following is an educational overview only.

Procedures for Transmasculine People

Chest Reconstruction ("Top Surgery")

The most commonly sought surgical procedure for transmasculine people. Involves bilateral mastectomy (removal of breast tissue) and nipple/areola repositioning to create a masculine chest contour. Multiple surgical techniques exist (double incision, periareolar, keyhole) chosen based on chest size and skin elasticity. Recovery is typically 4 to 6 weeks with activity restrictions. Results are highly effective and satisfaction rates are among the highest of any elective procedure in medicine.

Hysterectomy and Oophorectomy

Surgical removal of the uterus (hysterectomy) and/or ovaries (oophorectomy). May be sought to eliminate menstruation, resolve continued dysphoria, or allow reduction/elimination of testosterone dosing in those who no longer need estrogen suppression. Also relevant for people who have taken testosterone long-term and wish to reduce cancer screening complexity. Laparoscopic approaches are now standard for many patients, reducing recovery time significantly.

Phalloplasty and Metoidioplasty

Procedures to construct a neophallus. Metoidioplasty uses testosterone-enlarged clitoral tissue to create a smaller phallus; it is a less complex surgery with shorter recovery and may be combined with urethral lengthening (allowing standing urination) and scrotoplasty. Phalloplasty constructs a larger phallus using donor tissue (typically from the forearm or thigh) via a multi-stage process. Both can include erectile devices and testicular implants. These are complex surgeries with longer recovery times and higher complication rates; choose a surgeon with extensive experience and a dedicated surgical team.

Procedures for Transfeminine People

Vaginoplasty ("Bottom Surgery")

Surgical construction of a vagina and external genitalia. The most common technique is penile inversion vaginoplasty, using penile and scrotal tissue to create the vaginal canal and labia. Zero-depth vaginoplasty (vulvoplasty, without a vaginal canal) is an option for those who do not desire penetrative sexual function or whose anatomy is not well-suited to full vaginoplasty. Peritoneal pull-through (PPT) is a newer technique using peritoneal tissue for the vaginal lining, with the advantage of self-lubrication. Post-surgical dilation is required for months to years to maintain depth. Satisfaction rates are very high when performed by experienced surgeons.

Orchiectomy

Surgical removal of the testicles. Often sought before or instead of full vaginoplasty. Eliminates testosterone production, frequently allowing reduction or elimination of anti-androgen medications. Simpler procedure with shorter recovery than vaginoplasty. Does not create a vagina but does remove a significant source of gender dysphoria for many trans women.

Breast Augmentation

Surgical breast implants may be sought by trans women who are unsatisfied with HRT-induced breast development. Standard techniques used in cisgender breast augmentation apply. Many trans women find that their breast development on HRT is sufficient; augmentation is a personal and optional choice. Implants are placed under the pectoral muscle or under the breast tissue, with saline or silicone options. WPATH SOC8 removed the mandatory 12-month hormone requirement for breast augmentation.

Facial Feminization Surgery (FFS)

A set of craniofacial procedures to feminize facial features: brow bone reduction and contouring, rhinoplasty (nose reshaping), jaw and chin contouring, cheek augmentation, tracheal shave (reducing the Adam's apple prominence), and hairline lowering. FFS can have a profound impact on how a person is perceived in daily life and is associated with significant improvements in mental health and quality of life. Highly specialized; not all plastic surgeons perform FFS. Costs are substantial and insurance coverage varies significantly.

Surgery Is Not Required. Nor Should It Be Gatekept.

Many trans people live full, healthy lives without ever having surgery. Surgical procedures involve real risks including complications, anesthesia, lengthy recovery, and imperfect outcomes. They also involve real benefits that are deeply meaningful for those who want them. Under WPATH SOC8, the era of requiring extensive psychological evaluation and multiple letters to access most gender-affirming surgeries is being phased out in favor of informed consent models. If a provider is demanding years of therapy as a condition of even discussing surgical referrals, a second opinion is warranted.

Finding Care

Finding Affirming Trans Healthcare Providers

GLMA Provider Directory

GLMA (LGBTQ+ Medical Association) maintains a directory of self-identified LGBTQ+-affirming providers including endocrinologists, primary care physicians, gynecologists, and mental health providers. Searchable by specialty and location.

glma.org

Trans Care Site (Planned Parenthood)

Planned Parenthood provides gender-affirming hormone therapy at many locations using an informed consent model. A significant access point for trans people in cities and suburban areas with limited LGBTQ+-specific health centers. Call your nearest Planned Parenthood to ask about HRT services.

plannedparenthood.org

Folx Health / Plume

Telehealth platforms specifically built for gender-affirming care. Plume (getplume.co) and Folx Health (folxhealth.com) both use informed consent, offer telehealth prescribing in many states, and ship medications directly. Particularly valuable for people in rural areas or states with limited in-person options. Check their state availability lists.

getplume.co | folxhealth.com

LGBTQ+ Health Centers

Comprehensive LGBTQ+ health centers offer hormone therapy, mental health, primary care, and navigation support. Sliding scale fees are common. Examples: Howard Brown Health (Chicago), Callen-Lorde Community Health Center (New York), LA LGBT Center, Fenway Health (Boston). Use the QueerLine resource finder for centers in your area.

Local Resource Finder

USPATH / WPATH Surgeon Directory

For gender-affirming surgeries, USPATH (U.S. branch of WPATH) and WPATH itself maintain directories of surgeons who practice in accordance with the Standards of Care. For major procedures (vaginoplasty, phalloplasty, FFS), choosing a surgeon with extensive case volume in the specific procedure is critical for outcomes and safety.

wpath.org

Community Referrals

Trans community members are often the best source of current provider recommendations, including information on bedside manner, wait times, and insurance navigation. Reddit communities (r/TransMasc, r/asktransgender), Trans community Facebook groups, and local LGBTQ+ center networks are valuable peer knowledge sources.

Community-sourced recommendations
Insurance and Cost

Navigating Insurance for Gender-Affirming Care

Insurance coverage for gender-affirming care has improved significantly in recent years but remains inconsistent. Here is how to navigate the system.

  1. Know Your Plan's Coverage

    Most ACA marketplace plans and employer plans that cover prescription drugs and surgical procedures are required to offer trans-inclusive coverage. Call your insurance member services line and specifically ask: "Does my plan cover gender-affirming hormone therapy?" and "Does my plan cover gender-affirming surgeries?" Request answers in writing if possible.

  2. Use the Right Diagnosis Codes

    Gender dysphoria (ICD-10 code F64.0 or F64.8 for non-binary) is the diagnosis used to bill gender-affirming care. Without the correct diagnosis code, claims may be denied as "not medically necessary." Confirm with your provider that they are using appropriate ICD-10 codes.

  3. Get Prior Authorization in Writing

    Before surgery especially, always get prior authorization from your insurance company in writing. Verbal approvals are not reliable. Prior authorization requests should include a letter of medical necessity from your provider and relevant supporting documentation. Keep copies of everything.

  4. Appeal Denials

    If a claim is denied, you have the right to appeal. Many denials are overturned on appeal, especially with documentation from your provider and a letter citing your state's nondiscrimination protections. Lambda Legal's Help Desk and the National Center for Transgender Equality's insurance guide can assist with appeals.

  5. Know Your Legal Protections

    Section 1557 of the ACA prohibits sex discrimination in healthcare, which federal courts have increasingly interpreted to include gender identity discrimination. Many states have additional protections. If an insurer denies coverage for reasons that appear discriminatory, contact Lambda Legal or your state insurance commissioner.

Cost Assistance for the Uninsured and Underinsured

Federally Qualified Health Centers (FQHCs) offer trans healthcare on a sliding scale fee. The Jim Collins Foundation provides grants for gender-affirming surgeries for people who cannot afford them (jimcollinsfoundation.org). Point of Pride offers an annual chest binder donation program and HRT access fund. The Trans Wellness Fund and several state-based programs also exist. Out2Enroll (out2enroll.org) helps LGBTQ+ people find and enroll in ACA marketplace plans with trans-inclusive coverage in their state.

Ongoing Health

Trans-Specific Health Considerations

Beyond HRT and surgical care, trans people have specific health screening needs that do not always fit neatly into binary-gendered healthcare protocols. Here is what to discuss with your provider.

Cancer Screening for Trans Women

  • Prostate cancer: Trans women on estrogen are not protected from prostate cancer. PSA screening should continue as per guidelines for people with prostate glands, regardless of HRT
  • Breast cancer: Trans women on long-term estrogen have a small but real breast cancer risk. Screening guidelines vary; discuss with your provider, especially after 10 or more years on estrogen
  • Testicular cancer: If orchiectomy has not been performed, testicular self-exams and clinical exams remain relevant

Cancer Screening for Trans Men

  • Cervical cancer: If the cervix is still present, Pap smears are needed on the standard schedule (every 3 years for ages 21 to 65). Testosterone use does not eliminate cervical cancer risk and can cause changes in Pap results that need specialist interpretation
  • Ovarian cancer: If ovaries are still present, ovarian health should be discussed with your provider
  • Breast/chest cancer: Trans men who retain breast tissue, especially those who have not had chest surgery, should follow standard mammography guidelines

Bone Health

  • Both estrogen and testosterone are important for maintaining bone density
  • Trans people who have had gonads removed (orchiectomy, oophorectomy) and are not on hormone replacement are at elevated risk for bone density loss
  • DEXA scans (bone density scans) are recommended for trans people who have periods of hormone interruption
  • Adequate calcium and vitamin D intake is important for all trans people on hormones

Cardiovascular Health

  • Feminizing HRT, particularly oral estrogen at higher doses, may increase risk of blood clots (deep vein thrombosis). Transdermal estrogen carries lower risk than oral
  • Testosterone can affect lipid profiles (often decreasing HDL, increasing LDL) and increase red blood cell count (hematocrit), both of which require monitoring
  • Trans women should avoid smoking, which significantly amplifies estrogen-related cardiovascular risks
  • Regular cardiovascular checkups and lipid panels are part of standard HRT monitoring
Related Topics
Sources and References
  • WPATH. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022.
  • Hembree WC, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.
  • Turban JL, et al. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics. 2020;145(2):e20191725.
  • Tordoff DM, et al. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open. 2022;5(2):e220978.
  • Murad MH, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol. 2010;72(2):214-231. (Cornell meta-analysis)
  • National Center for Transgender Equality. 2022 U.S. Transgender Survey. transequality.org
  • Williams Institute, UCLA. How Many Adults Identify as Transgender in the United States? 2022.
  • American Academy of Pediatrics. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018;142(4).
  • Lambda Legal. Transgender Rights Toolkit. lambdalegal.org
  • Point of Pride. Annual Trans Wellness Resources. pointofpride.org
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