Initiating hormone therapy

Primary Author(s): 
Madeline B. Deutsch, MD, MPH
Publication Date: 
June 17, 2016

Assessing readiness and appropriateness

While historically a "referral letter" from a mental health professional was required prior to initiation of hormone therapy, many large volume and experienced providers of transgender care have for years used an "informed consent" pathway to hormone initiation. WPATH Standards of Care, Seventh Version recognizes both of these pathways to the initiation of gender affirming hormone therapy as valid. Medical providers who feel comfortable making an assessment and diagnosis of gender dysphoria, as well as assessing for capacity to provide informed consent (able to understand risks, benefits, alternatives, unknowns, limitations, risks of no treatment) are able to initiate gender affirming hormones without a prior assessment or referral from a mental health provider.[1] A study of the practices of 12 such clinics in a diversity of settings found minimal risk of regret and no known cases of malpractice suits.[2] More detail on assessing readiness and appropriateness for various gender affirming treatments can be found in the topic on mental health.

Qualifications of the prescribing provider

Prescribing gender affirming hormones is well within the scope of a range of medical providers, including primary care physicians, obstetricians-gynecologists, and endocrinologists, advanced practice nurses, and physician assistants.[1] Depending on the practice setting and juris diction, other providers with prescriptive rights (naturopathic providers, nurse midwives) may also be appropriate to prescribe and manage this care. Most medications used in gender affirming hormone therapy are commonly used substances with which most prescribers are already familiar due to their use in the management of menopause, contraception, hirsutism, male pattern baldness, prostatism, or abnormal uterine bleeding.


  1. Deutsch MB, Feldman JL. Updated recommendations from the world professional association for transgender health standards of care. Am Fam Physician. 2013 Jan 15;87(2):89-93.
  2. Deutsch MB. Use of the informed consent model in the provision of cross-sex hormone therapy: a survey of the practices of selected clinics. Int J Transgenderism. 2012 May;13(3):140-6.

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