Part 3: Gender Affirming Healthcare

Welcome to the gender-affirming healthcare section of the guide. This section will cover information on primary and specialist care, mental and spiritual healthcare, puberty blockers, hormone therapy, gender-affirming surgeries, reproductive healthcare, and sexual healthcare.

Primary & Specialist Care

Primary care providers and walk-in clinics

A primary care provider (PCP) provides health care in non-emergency situations. For example, people may see PCPs for annual checkups, when they are sick, or when they have a health question or concern. A PCP can be a family doctor, general practitioner, or nurse practitioner. People who do not have a PCP may use walk-in or virtual clinics for routine health concerns.

Some PCPs provide gender-affirming health care. This can include hormone therapy, surgery referrals and addressing other gender-related health concerns (hair loss, stopping monthly bleeding, etc.). It can sometimes be challenging to find a PCP or walk in clinic staff who are knowledgeable, experienced, and supportive in working with Trans, Two-Spirit, and Nonbinary (TTNB) youth. Some PCPs who are not experienced with gender-affirming care may opt to refer patients to specialist clinicians, like endocrinologists. Walk-in clinics are less likely to be able to provide gender-affirming medical interventions because they do not have ongoing relationships with their patients. However, they can refer patients to providers who can address these needs. 

Finding a safe and inclusive primary care provider

There are online resources to help people find PCPs. The process for accessing a PCP varies by province and territory. Most provincial/territorial governments have websites to help you get matched up with a PCP (e.g., search online for “Find a primary care provider in [your province/territory]”). It may involve signing up for a waitlist where you describe your care needs. Another way to find a PCP is to search for a clinic nearby and contact their office directly to ask if they are accepting new patients.

If you are looking for a PCP to support gender-affirming medical interventions, you can ask for recommendations through online and in-person networks, read online provider reviews, or request information from local TTNB groups.

Before visiting a new provider, you may want to learn more about their experience working with TTNB people. If you are unable to find information about the provider online or through social networks, you can contact the provider’s office with questions before your visit.

Questions that may be helpful to ask:

  • Does this provider have experience working with TTNB people? If yes, what is their approach to providing care?
  • Does this provider have experience providing [specify type of care here] for TTNB people?

Questions about gender-affirming medical interventions include:

  • Is this provider familiar with the most recent version of the WPATH Standards of Care?
  • Does this clinician provide readiness assessments for gender-affirming hormone therapy and/or surgery?
  • Does this provider use an informed consent approach to gender-affirming care?
  • What steps are involved in accessing [hormones, referrals for surgery, etc.]?

Preparing for appointments

To prepare for appointments, think ahead about what information you want to share about yourself, including names, pronouns, gender, and gender health goals. You might decide not to share any of this information if you are accessing care that is not directly related to your gender. You may decide to share information about your gender, particularly if you are looking for support accessing puberty blockers, hormones or surgery.

Since most primary care appointments are short (about 10 minutes), it may not be possible to discuss more than one topic in each appointment. Prepare a list of goals, topics or questions in advance to ensure you get the information you need. Bringing a trusted friend or adult for support, advocacy, or note-taking can be helpful.

At your first visit, share your goals with your provider and make a plan together to address them. You can also discuss booking a series of appointments to address all of your goals.

Finding a specialist care provider

A medical specialist has expertise in a particular area of health care (like endocrinology, plastic surgery or gynecology). You need a referral from a PCP to see a specialist.

There are generally three steps in the specialist referral process:

  1. Speak with a PCP about the needed specialist service or referral
  2. The PCP sends a referral to the specialist or a centralized waitlist
  3. The specialist (or waitlist) contacts you or your provider with appointment details

You can help specialist referrals move forward as smoothly as possible by:

  • Getting the name of the clinic and physician a referral was sent to
  • Making sure a referral was sent from your provider and received by the specialist’s office with no missing information
  • Asking if there is anything you should do before the appointment
  • Asking for an approximate timeline for when you will hear from the specialist
  • Confirming the appointment when you receive the phone call, email or text

Finding a provider for puberty blockers or hormone therapy

Options for healthcare providers who can prescribe puberty blockers and hormone therapy vary depending on a person’s age and where they live. Some PCPs have the necessary training to prescribe and monitor puberty blockers and hormone therapy while others may refer youth to an endocrinologist (doctor specializing in hormones). Gender clinics are available in some places, including many children’s hospitals. PCPs can make referrals to these programs, and you may also be able to refer yourself.

Gender-affirming medical pathways

Many people have gender health goals which can be supported by medical interventions such as puberty blockers, hormone therapy, or gender-affirming surgery. A person may access any, all, or none of these kinds of care over their lifetime.

It is important to learn about the options available to support gender embodiment. There are many ways to achieve these goals, including different doses of hormones and different types of surgery. The WPATH Standards of Care Version 8 emphasizes the importance of providers working with their patients to provide the individualized care each person needs. Each person’s gender journey is unique, and gender-affirming medical interventions are some tools that may help people to comfortably embody their genders.

Assessment and Care Planning

People accessing gender-affirming medical interventions (i.e., puberty blockers, hormone therapy, gender affirming-surgery) will work with healthcare providers for assessment and care planning. Healthcare providers need to gather information about a person’s overall health and gender goals. The types of questions that a healthcare provider asks depends on the type of care a person is seeking. Generally, they will ask about medical history, gender, goals, and supports.

Some questions healthcare providers may ask as part of the assessment and care planning process include:

  • How would you describe your gender?
  • Do you remember when you realized your gender was different from what others thought?
  • Have you taken any steps to express or feel more comfortable in your gender (like names, pronouns, clothing, hairstyle, make-up, binding)? If yes, what has that been like for you?
  • Are you hoping to take any other steps in the future?
  • What is your health history? Questions under health history might include but are not limited to:
    • Current and past medical and mental health conditionsSurgical historyMedicationsUse of tobacco and cannabisAllergiesExercise and nutrition
    • Family history of medical and mental health conditions

Making decisions about gender-affirming medical interventions

Making decisions about gender-affirming medical interventions can be complex. It is important to have accurate information about the kind of care you are considering. Once you have general information, you can think about what it would be like for you to experience the intervention. Thinking through your options and talking with knowledgeable healthcare providers and supportive people can help you make the best decisions for your wellbeing. You might decide you are ready now or that you want to wait a while before you decide. Everyone’s path is unique.

You may have a range of emotions when you think about accessing puberty blockers, hormone therapy, or gender-affirming surgery. You might feel excited about some changes and nervous or uncertain about experiencing others. As with any big decision, it is ok to have doubts. It can be important to find support people to help you navigate emotional ups and downs, such as a healthcare provider, TTNB peer, or mentor.

Wait times

It is common to be placed on a waitlist to access healthcare services in Canada. Availability of gender-affirming care providers may be limited and wait times can be frustrating. If you are referred to a specialist, it can be helpful to ask what the wait time will be, so you know what to expect. Peer support and counselling may be helpful while waiting to receive needed care.                   

Costs and coverage

Coverage for gender-affirming care varies across Canada. Medically necessary services like primary care, specialist care, and hospital services in publicly funded facilities are covered through the public healthcare system. There may be out-of-pocket costs for other health services, such as counselling and prescription medications. Government-funded programs may cover the cost of prescription medications or other services, based on age, income, or disability. If you receive healthcare through an Indigenous program, such as your band or First Nations Health Authority, you can contact them to find out if certain services are covered.

Rules for out of province/territory coverage for care vary and can usually be found on each provincial/territorial government health website. Generally, medically necessary services like hospital or primary care in a publicly funded facility within Canada are covered if you present a valid provincial health insurance/services card. Sometimes you must pay and then apply for reimbursement.

Some people have coverage for gender-affirming healthcare expenses through extended health care plans. These may be cov­ered through an employer or post-secondary school. You may be eligible for coverage under another person’s extended health insurance, such as a parent, guardian or partner, depending on your age and living situation.

Some extended health care plans clearly indicate that gender-affirming care is covered, others may not. Check with the insurance provider to find out:

  • What providers, services and medications are covered
  • How much of the total cost will be covered
  • If there is an annual or lifetime maximum
  • If a referral or other documentation is required to qualify for coverage

In most cases, the primary holder of a private health insurance policy has access to information about what their insurance pays for. For example, a parent could access information about prescriptions and services covered through their plan. Youth can ask their healthcare provider what information their parents/guardians may receive or if there are alternate ways to report billing that are more discreet.

Newcomers or refugees may access gender-affirming care covered under the Interim Federal Health Program (IFHP).

If you are an international student, you may be eligible to receive coverage for certain types of gender-affirming medical interventions under your university’s health insurance plan.

You may also have access to supplementary insurance through your student union. Students are encouraged to reach out to their school and student union to see what types of care are covered.

Resources for providers

The World Professional Association for Transgender Health (WPATH) is an international organization of professionals who work in the field of TTNB health. WPATH publishes the Standards of Care, an internationally recognized guideline for healthcare providers to follow when offering gender-affirming care. As of 2022, the current version of the Standards of Care is Version 8. These standards provide recommendations related to puberty blockers and hormone therapy, gender-affirming surgeries, mental healthcare, and care for youth.

The Endocrine Society (an international organization of doctors and scientists who work in hormone science) publishes a guideline for clinicians that work with youth and adults called Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons

Other organizations provide resources for healthcare providers, including:

  • Trans Care BC’s Primary Care Toolkit and online courses
  • The Center of Excellence for Transgender Health Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Non-binary People
  • Sherbourne Health Centre (ON) Guidelines for the Gender-affirming Primary Care with Trans and Non-binary Patients

Some TTNB people find it helpful to review these guidelines to know what the requirements may be to access care and to be able to advocate for themselves if they find a clinician does not follow these guidelines.

Resources

Deutsch, M. B. (2016, June 17). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people (2nd Ed.). Center of Excellence for Transgender Health. https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf

Government of Canada (2017, September 13). Interim federal health program: About the program. https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/interim-federal-health-program.html

Rainbow Health Ontario (2023). Sherbourne’s guidelines for gender-affirming primary care with trans and non-binary patients. Sherbourne Health. https://www.rainbowhealthontario.ca/product/4th-edition-sherbournes-guidelines-for-gender-affirming-primary-care-with-trans-and-non-binary-patients/

Trans Care BC (2023). Gender-affirming care for trans, Two-Spirit, and gender diverse patients in BC. A primary care toolkit. https://www.transcarebc.ca/sites/default/files/2024-03/Primary-Care-Toolkit.pdf

Trans Care BC (n.d.). How to get care. https://www.transcarebc.ca/how-to-get-care

Mental & Spiritual Healthcare

Overview

Mental and spiritual health are important parts of wellbeing. Mental healthcare can help people manage challenging experiences and emotions. Youth may seek mental health support for many reasons, including for support exploring their genders, navigating experiences of oppression, or dealing with depression or anxiety. Some mental healthcare providers support youth with social and/or medical transition, such as by conducting readiness assessments, writing letters of support, and offering education or coaching to parents or caregivers. 

Spirituality can shape identities and how people see the world. It can sometimes take the form of identifying with a faith or belief system or a sense of connectedness, belonging, meaning, or transcendence. Connecting with a spiritual community or accessing spiritual healthcare services can help individuals understand or make meaning of their lives and improve mental health by helping individuals see their experiences, including their gender journeys, through a spiritual lens.

A person may seek out mental or spiritual healthcare that is long term (like seeing a counsellor weekly for several months), short term (a one-time appointment), or urgent (a crisis line or emergency room). Mental and spiritual healthcare may be available in person, online, by phone, or by text, depending on location and preference.

Finding mental healthcare 

Connecting with a healthcare provider who understands your needs and can provide you with support can be helpful for your overall wellbeing. Finding affordable and accessible mental health care can be challenging. When looking for a healthcare provider, ask what their credentials are and what training they have in working with Trans, Two-Spirit, and Nonbinary (TTNB) people. You can check to see what different credentials mean. Look for credentials like CCC (Canadian Certified Counsellor), RSW (Registered Social Worker), or RCSW (Registered Clinical Social Worker) to find healthcare providers with a high level of training and supervision, and who follow a professional Code of Ethics in their work.

Here are some ways to begin looking for mental health support:

Community referrals

Check with community members you know and trust for recommendations of mental and spiritual healthcare providers. TTNB organizations may provide referrals to mental healthcare providers experienced in working with TTNB youth. Religious or culturally specific organizations may suggest culturally relevant resources and/or spiritual care that aligns with their beliefs. 

University- or Hospital-affiliated clinic for TTNB youth

Children’s hospitals that have specialized clinics for TTNB youth may have information about mental and spiritual healthcare providers within their organizations or in the community.

Clinician referrals

A primary care provider or other healthcare professional may be able to refer you to a mental health provider. 

Online directories

Online directories of mental health providers can help you to search for a clinician who meets your needs. 

  • Psychology Today is an online directory that allows users to search for therapists based on their qualifications, approach, and areas of expertise, including knowledge of TTNB experiences. The website also has a search tool that can be used to filter based on factors like the therapist’s religious identity, gender, sexual orientation, languages, and those who specialize in working with Indigenous or racialized clients. 
  • Each province or territory has a psychological association with a website that includes a directory of registered psychologists you can browse through.
  • The Canadian Mental Health Association (CMHA) has information on mental health education resources including mental health, symptom management, and self-care. Their website can also help you find a CMHA location in your area, province-specific guides, and programs for TTNB youth. 

School resources

Elementary and high school students may meet with a guidance counsellor, social worker, or psychologist through their school. A trusted adult in the school can help you learn about and access these resources. 

Post-secondary resources

Many universities and colleges have free counselling available for students. You can check your school’s website or speak with someone you trust on campus to find out more about these resources.

Finding Spiritual Healthcare

Many areas have TTNB-friendly spiritual and religious spaces. It may be possible to connect with these groups through post-secondary schools, local TTNB community groups, or by searching online for TTNB-friendly mosques, temples, churches, or faith resource guides.

Local Indigenous communities may have groups or activities for their members who identify as TTNB. There are also Indigenous queer and TTNB groups that gather folks together across Nations.

When searching online, look for places that say they are inclusive of gender and sexual diversity and positive. You may be able to connect with spiritual healthcare providers through local organizations.

Some affirming spiritual and religious groups provide support for families of TTNB youth. These may include informational resources and in-person or virtual support groups. For some family members, connecting with other families of TTNB youth who share their religious or spiritual values may be helpful.

Spiritual counselling can follow a specific religion or be non-religious and open to everyone. Professionals who provide spiritual healthcare may or may not be certified mental health professionals. Some providers may use a combination of spiritual and clinical mental health methods in their practice. It may be helpful to talk with other TTNB people about whether a spiritual leader or spiritual healthcare provider will be gender-affirming.

Finding Crisis Support

There are many crisis support lines you can call or text in the event of a crisis. You can search for region-specific crisis resources online.

Some resources that are available at anytime, anywhere in Canada, are:

  • Trans Lifeline’s peer support hotline at 877-330-6366 
  • Kids Help Phone at 1-800-668-6868 or by text at 686868 
  • Indigenous Hope for Wellness Helpline at 1-855-242-3310 or by online chat

Anyone having a mental health crisis or at risk of hurting themselves or others can call 911 or seek care at a hospital’s emergency department.

Things to Think About 

Costs, Coverage, and Wait Times

Some services may be free, such as care provided through schools, hospitals, or publicly funded programs (e.g., youth mental health agencies). Other services cost money, such as seeing a private therapist. Sometimes therapists have sliding scale rates or low-cost options available that may make counselling more affordable.  

You can check a healthcare provider’s website or call their office to find information about wait times for services. Services that are free and publicly funded tend to have waitlists. Private services may have faster access to services but cost more. Joining waitlists for multiple organizations can help to increase your chances of receiving care as soon as possible.

Safety in Crisis

Some community resources, mental health providers, and crisis support services are required to call police and/or paramedics if they believe that someone is in danger (e.g., if a youth is at risk of hurting themselves or someone else). Interactions with police and emergency services may be helpful. However, they can also carry risk, especially for TTNB and racialized people, who are disproportionately likely to experience mistreatment. 

Some strategies youth can use to stay safe while seeking crisis support include:

  • Ask the person who is supporting them what their policies are about calling police and emergency services in a crisis. When might they need to make this call? What would it look like if this happened?
  • If possible, bring a trusted person who can advocate for you when visiting an emergency room or crisis service. Let the support person know in advance how they can help (correcting staff who use the wrong name and/or pronouns, getting a referral to ongoing counselling, etc.).

The Trans Lifeline does not call police or emergency services unless someone specifically requests this.

Finding the Right Resources

Before meeting with a therapist, consider talking to people you know and trust who have worked with the therapist, check the therapist’s website, or consult via phone to find out more about them and their approach to therapy.

Many therapists will offer a short free consultation call. This can be an opportunity to ask them about themselves, their values, their approach as a therapist, and their experiences and knowledge of working with people who have similar goals. If a therapist does not feel like the right fit, it is ok to keep looking.

Mental Health and Gender Affirming Care

Some mental healthcare providers can help support access to gender-affirming medical interventions. For example, they may be able to write a letter of support or complete hormone therapy readiness assessments. Seeking mental health support should not negatively impact a person’s access to gender-affirming care.

Guidelines for accessing gender-affirming care recommend addressing the mental health concerns of people receiving gender-affirming medical treatments. Having mental health issues (like depression or anxiety) or substance use does not mean you can’t access the gender-related care that you need. It is recommended that these concerns be reasonably well-managed before or during the treatment.

A healthcare provider assessing a person’s readiness for a gender-affirming medical intervention will likely confirm that the person is certain about their gender, has the capacity to understand and consent to the care they are seeking, and will be able to complete necessary follow-up care (like taking medications as prescribed, doing post-operative care, or coming to follow up appointments).

Resources

2-Spirited People of the 1st Nations. https://2spirits.org/resource-guide

Bockting, W. O., & Cesaretti, C. (2001). Spirituality, transgender Identity, and coming out. Journal of Sex Education and Therapy, 26(4), 291-300. https://doi.org/10.1080/01614576.2001.11074435

Canadian Association of Social Workers (CASW) find a social worker: https://www.casw-acts.ca/en/find-social-worker

Canadian Counselling and Psychotherapy Association (CCPA) find a certified counsellor: https://www.ccpa-accp.ca/find-a-canadian-certified-counsellor/

ENAGB Indigenous Youth Agency. https://enagb-iya.ca/

Indigenous Hope for Wellness Helpline: https://www.hopeforwellness.ca/

Kaufman, C. C., Mohr, O., & Olezeski, C. L. (2023). Spirituality, religion, and transgender and gender nonconforming affirmative care with youth and families: Guidelines and recommendations. Journal of Clinical Psychology in Medical Settings, 30(2), 318-329. https://doi.org/10.1007/s10880-022-09892-7

Kids Help Phone: https://kidshelpphone.ca/

Lekwauwa, R., Funaro, M. C., & Doolittle, B. (2023). Systematic review: The relationship between religion, spirituality and mental health in adolescents who identify as transgender. Journal of Gay & Lesbian Mental Health, 27(4), 421-438. https://doi.org/10.1080/19359705.2022.2107592

Native Youth Sexual Health Network has many resources on culture, including “You Are Made of Medicine: A Mental Health Peer Support Manual for Indigiqueer, Two-Spirit, LGBTQ+, and Gender-Non Conforming Indigenous Youth”: https://www.nativeyouthsexualhealth.com/toolkits

Trans Care BC (n.d.). Finding a counsellor. https://www.transcarebc.ca/how-to-get-care/finding-counsellor

Trans Lifeline. https://translifeline.org/hotline/

Puberty Blockers

Overview

Puberty blockers are medications that are used to pause puberty. They can give Trans, Two-Spirit, and Nonbinary (TTNB) youth more time to explore their gender goals without experiencing unwanted changes to the body.

Once puberty blockers are stopped, a person will restart puberty in 3 to 6 months. People may choose to start hormone therapy after stopping or while taking puberty blockers, depending on their embodiment goals.

Puberty blockers cannot undo any changes that have already occurred, but can prevent further changes. Access to puberty blockers can improve mental health and may reduce the need for some gender-affirming surgeries in the future, like masculinizing chest surgery.

Purpose & intended effects

For youth assigned male at birth, puberty blockers will stop or limit:

  • Growth of facial and body hair;
  • Deepening of the voice;
  • Broadening of the shoulders;
  • Growth of the Adam’s apple;
  • Growth of gonads (testes) and erectile tissue (penis).

For youth assigned female at birth, puberty blockers will stop or limit:

  • Breast/chest tissue development;
  • Broadening of the hips;
  • Monthly bleeding.

For all youth, puberty blockers will temporarily stop or slow:

  • Growth in height;
  • Development of the sex drive;
  • Fertility;
  • Accumulation of calcium in the bones.

Safety & side effects

Puberty blockers are used to treat a variety of conditions and are considered safe overall. As with all medications, side effects are possible. These include:

  • Hot flashes;
  • Headaches;
  • Fatigue;
  • Muscle aches;
  • Weight gain;
  • Changes in mood.

Research shows that there are significant mental health and gender embodiment benefits for TTNB youth accessing puberty blockers. With support from their care team, youth taking puberty blockers can effectively manage side effects.

Bone Health

During puberty, the increase in sex hormones helps people build stronger bones. Youth taking puberty blockers will not build up calcium in their bones as quickly as youth going through puberty. Once youth start puberty, by stopping puberty blockers and/or starting hormone therapy, youth will begin to build stronger bones.

Youth can proactively support their bone health by taking calcium and vitamin D, and doing weight-bearing exercise as recommended by their healthcare provider. Some providers may ask youth taking puberty blockers to get bone density scans to monitor bone health.

How to access puberty blockers

Eligibility

Puberty blockers are prescribed to youth who are experiencing gender incongruence/dysphoria. They may be a good option when distress related to gender worsens as puberty starts. When starting puberty blockers, healthcare providers will ensure that medical and mental health issues are also addressed.

There are five stages of puberty, called the Tanner stages. Tanner Stage 1 is pre-puberty (childhood) and Tanner Stage 5 is when puberty has finished (adulthood). People move through these stages at different rates and ages. Puberty blockers can be taken while puberty is in progress, starting at Tanner Stage 2.

Youth in later stages of puberty (Tanner Stage 3 or 4) can take puberty blockers, too. Youth in these stages may also find other medications to be helpful. For example, progestin-only medications can stop monthly bleedings (periods). Antiandrogens (also called testosterone blockers) can reduce the effects of testosterone.

The length of time a person takes puberty blockers varies depending on their gender goals, Tanner Stage, and bone health. Healthcare providers work with youth to develop care plans that fit their gender goals.

Assessment and care planning

A readiness assessment is needed prior to starting puberty blockers. This process is an opportunity to explore gender, goals, health needs, and capacity to consent to starting puberty blockers. Sometimes, primary care providers can complete a readiness assessment. Other times, this is done with a specialist, such as a psychologist.

Some questions that healthcare providers may ask include:

  • How would you describe your gender?
  • Do you remember when you realized your gender was different from what others thought?
  • Have you taken any steps to express or feel more comfortable in your gender (e.g., names, pronouns, clothing, hairstyle, make-up, binding)? If yes, what has that been like for you?
  • When did you start thinking about taking puberty blockers?
  • What do you anticipate the main benefits of puberty blockers will be for you?
  • Do you anticipate any challenges?

Care planning for puberty blockers includes talking with a healthcare provider (like a primary care provider or endocrinologist) about a youth’s health history.

Sometimes a physical exam will be needed. A physical exam typically includes checking vital signs, listening to the heart and lungs, gently palpating (touching) the abdomen, and the neck (to check the thyroid). Sometimes a brief examination of the groin and genital area or chest area is recommended to confirm what Tanner stage of puberty someone is in. Healthcare providers should work with youth to do this exam in a sensitive and respectful manner.

Depending on an individual’s health history and needs, additional tests, exams, or bloodwork may be requested. Since hormone therapy (sometimes used after starting puberty blockers) can affect fertility, your provider might talk to you about options for creating families and fertility preservation.

Health care providers follow guidelines for prescribing puberty blockers and work with youth to create care plans that fit their gender goals, health needs, and budget. A care plan may include hormone blockers, hormone therapy, or a combination of both. Healthcare providers may recommend taking puberty blockers first before deciding whether to start hormone therapy. Other times, hormone therapy may be recommended without taking puberty blockers first.

Care plans are updated as needed. For example, the length of time a person takes puberty blockers and hormone therapy can be changed to best meet each person’s needs.

Administration

Puberty blockers are prescribed by an endocrinologist, family doctor, or nurse practitioner with training in how to provide this type of gender-affirming care. In Canada, puberty blockers are given by intramuscular injection either monthly or every three months. Following the schedule prescribed helps ensure puberty does not restart.

Signs of puberty may increase after the first injection. However, this should stop after two months of taking the medication. If signs of puberty continue, the dose or timing may need to be adjusted.

Puberty blocking implants are available in some countries, but in Canada, puberty blockers are currently only given by injection.

Follow-up care

Monitoring may be provided by an endocrinologist, family doctor, or nurse practitioner. This usually includes regular blood tests. It may also include bone density scans.

Things to think about

Cost

The puberty blocker used most in Canada is called Lupron Depot. It costs around $400 a month. Some insurance plans cover all or part of this cost.

Pregnancy

Puberty blockers can suppress monthly bleeding (periods) but they are not a method of birth control and do not prevent sexually transmitted infections. Non-hormonal forms of contraception (like condoms) are recommended if sexual activity could result in pregnancy. If a pregnancy occurs while taking puberty blockers-your health care provider should be notified right away.

Trans Care BC’s Puberty Blockers for Youth: https://www.transcarebc.ca/hormone-therapy/puberty-blockers

Rainbow Health Ontario Reference Guide: https://www.rainbowhealthontario.ca/resource-library/pubertal-suppression-hormone-blocking-in-trans-gender-diverse-youth-a-quick-reference-guide/

Resources

BC Children’s Hospital. Gender Clinic. http://www.bcchildrens.ca/our-services/clinics/gender#Getting–a–referral

de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. https://doi.org/10.1542/peds.2013-2958

Doernbecher Children’s Hospital. (n.d.). About puberty blockers. Oregon Health & Science University. https://www.ohsu.edu/sites/default/files/2020-12/Gender-Clinic-Puberty-Blockers-Handout.pdf

Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., & Rotteveel, J. (2015). Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. The Journal of Clinical Endocrinology and Metabolism, 100(2), E270-5. https://doi.org/10.1210/jc.2014-2439

Lupron depot. Important safety information. https://www.lupron.com/isi.html

Rainbow Health Ontario Reference Guide: https://www.rainbowhealthontario.ca/resource-library/pubertal-suppression-hormone-blocking-in-trans-gender-diverse-youth-a-quick-reference-guide/

Schagen, S. E. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. The Journal of Sexual Medicine, 13(7), 1125–1132. https://doi.org/10.1016/j.jsxm.2016.05.004

Schagen, S. E. E., Wouters, F. M., Cohen-Kettenis, P. T., Gooren, L. J., & Hannema, S. E. (2020). Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. The Journal of Clinical Endocrinology and Metabolism, 105(12). https://doi.org/10.1210/clinem/dgaa604

Trans Care BC. Hormone therapy. https://www.transcarebc.ca/hormone-therapy

Trans Care BC. Information for Indigenous people. https://www.transcarebc.ca/information-for/indigenous-people

Trans Care BC. Primary Care Toolkit. https://transcarebcprod.prod.acquia-sites.com/sites/default/files/2024-03/Primary-Care-Toolkit.pdf

Willemsen, L. A., Boogers, L. S., Wiepjes, C. M., Klink, D. T., van Trotsenburg, A. S. P., den Heijer, M., & Hannema, S. E. (2023). Just as Tall on Testosterone; a Neutral to Positive Effect on Adult Height of GnRHa and Testosterone in Trans Boys. The Journal of Clinical Endocrinology and Metabolism, 108(2), 414–421. https://doi.org/10.1210/clinem/dgac571

Hormone Therapy

Overview

Hormone therapy is used to change a person’s physical appearance to better align with their gender. Hormone therapy can improve emotional wellbeing, relieve gender-related distress, and help people feel more at ease in their bodies. Trans, Two-Spirit, and Nonbinary (TTNB) people may choose to take hormone therapy long-term, short-term, or take breaks, depending on what is right for them. Treatment plans, including dosages, can be customized for different gender goals.

Estrogen therapies (sometimes including a testosterone blocker) and testosterone therapies are used to induce different secondary sex characteristics (e.g., breast growth, facial hair). Some of the effects of hormone therapy are permanent, and others will reverse if the medication is stopped.

Purpose and intended effects

The results of hormone therapy can be different for everyone. The effects listed below are common changes based on maximum hormone therapy dosing. Timeframes and effects will vary based on the individual and the amount of medications taken.

Estrogen Therapy

Breast development:

  • Usually starts in 3 to 6 months
  • Breasts reach full size in 2 to 5 years
  • Size varies; A or B cup size is typical
  • A permanent change

Body fat redistribution

  • Usually starts in 3 to 6 months
  • Reaches maximum effect in 2 to 5 years
  • Less fat on abdomen; more fat on buttocks, hips, and thighs
  • Not a permanent change if hormones are stopped

Reduced muscle mass and strength

  • Usually starts in 3 to 6 months
  • Reaches maximum effect in 1 to 2 years
  • Reduced muscle and strength in upper body
  • Not a permanent change if hormones are stopped

Softening of skin

  • Usually starts in 3 to 6 months
  • Skin will be softer and less oily
  • Not a permanent change if hormones are stopped

Thinning of  facial and body hair

  • Usually starts in 6 to 12 months
  • Maximum effect in more than 3 years
  • Body hair will appear less noticeable and grow more slowly
  • Facial hair may grow more slowly and appear less noticeable, but will not go away
  • If there is scalp hair loss, it may slow down; hair that has already been lost will not grow back
  • Not a permanent change if hormones are stopped

Reduced sex drive

  • Varies by individual
  • Usually starts in 1 to 3 months
  • Reaches maximum effect in 1 to 2 years
  • Less spontaneous physical arousal (erections)
  • Not a permanent change if hormones are stopped

Fertility

  • Timeline varies
  • Sperm may no longer reach maturity
  • Won’t produce as much semen
  • May not be able to have erections for penetrative sex
  • It is possible to become permanently unable to make someone pregnant (but birth control and condom use is still recommended since this is not the case for everyone)

Smaller erogenous tissue (penis) and gonads (testes)

  • Usually starts in 3 to 6 months
  • Erogenous tissue may get smaller
  • Gonads may shrink down to half their initial size
  • May or may not be a permanent change if hormones are stopped

Emotional changes

  • Overall emotional state may or may not change; this varies from person to person
  • May experience a narrower or wider range of emotions or feelings
  • Not a permanent change

Testosterone Therapy

Body fat redistribution

  • Usually starts in 1 to 6 months
  • Maximum effect in 2 to 5 years
  • More abdominal fat
  • Less fat around buttocks, hips, and thighs
  • Not a permanent change if testosterone is stopped

Increased muscle mass and strength

  • Usually starts in 6 to 12 months
  • Maximum effect in 2 to 5 years
  • Not a permanent change if testosterone is stopped

Oily skin and acne

  • Usually starts in 1 to 6 months
  • Often improves in 1 to 2 years
  • There are medications that can be taken to minimize this
  • Not a permanent change if testosterone is stopped

More facial & body hair

  • Usually starts in 6 to 12 months
  • Maximum effect in 5 years or more
  • Gradual growth of facial hair
  • More hair and thicker and coarser hairs on abdomen, arms, chest, back and legs
  • It is likely a permanent change and hair will continue to grow, even if taking testosterone is stopped

Scalp hair loss

  • Usually starts in less than 12 months
  • Hair loss at temples and along the crown of head
  • Possibility of becoming completely bald but will vary depending on one’s genes, like cisgender men
  • A permanent change, even if testosterone is stopped
  • There are medications that can be taken to minimize this

Deepened voice

  • Usually starts in 1 to 6 months
  • Maximum effect in 1 to 2 years
  • Voice may deepen but other aspects of the way one speaks may not be perceived as typically male; it is possible to work with a speech language pathologist to achieve this as desired
  • A permanent change

Increased sex drive

  • Usually starts in 1 to 3 months
  • This change is usually temporary as hormone levels balance, and reversible when the treatment is stopped

Monthly bleeding stops

  • Usually happens within 1 to 6 months
  • May require a change in dose or additional medications (e.g., progesterone) to fully stop monthly bleeding
  • Pregnancy may still be possible even when monthly bleeding stops (note: it is not safe to take testosterone while pregnant)
  • Reversible change if testosterone is taken intermittently or stopped

Bigger erectile tissue (clitoris)

  • Usually starts in 1 to 6 months
  • Reaches full size in 1 to 2 years
  • Size typically ranges from 1 to 3 cm
  • A permanent change, even if taking testosterone stops

Changes to lining of internal genitals (vagina)

  • Usually starts in 1 to 6 months
  • Maximum effect in 1 to 2 years
  • Thinning and drying of the lining of the internal genitals (vagina)
  • May make penetration uncomfortable (treatments are available)

Emotional changes

  • Overall emotional state may or may not change; this varies from person to person
  • Many people experience positive mood changes
  • May experience a narrower range of emotions or feelings
  • May become irritable, frustrated, or angry more easily

Safety and side effects

Hormone therapy is considered safe and effective for youth and the overall risk is low. As with all medications, side effects are possible, including:

  • Weight gain
  • Acne (with testosterone)
  • Mood changes, may be positive or negative
  • Fertility changes
  • Possible increased risk of blood clots (with estrogen) and high blood pressure

How to access hormone therapy

Eligibility

Hormone therapy can be prescribed for TTNB youth who have started puberty and are experiencing gender incongruence/dysphoria. When starting hormone therapy, healthcare providers will make sure medical and mental health issues are addressed. The length of time a person takes hormone therapy varies depending on their gender goals. It can range from a few weeks or months to the rest of the person’s life. Healthcare providers work with youth to develop care plans that fit their gender goals.

Assessment and care planning

A readiness assessment is needed prior to starting hormone therapy. This process is an opportunity to explore gender, goals, health needs, and capacity to consent to hormone therapy. Sometimes primary care providers can complete readiness assessments and care planning. Other times this is done with a specialist, such as a psychologist. 

Some questions that healthcare providers may include:

  • How would you describe your gender?
  • Do you remember when you realized your gender was different from what others thought?
  • Have you taken any steps to express or feel more comfortable in your gender (e.g., names, pronouns, clothing, hairstyle, make-up, binding)? If yes, what has that been like for you?
  • What is your health history (current and past medical and mental health conditions, surgical history, medications, tobacco and cannabis use, allergies, exercise, nutrition, family history, etc.)?
  • When did you start thinking about taking hormone therapy?
  • What do you anticipate the main benefits of puberty blockers/hormone therapy will be for you?
  • Do you anticipate any challenges?

Care planning for hormone therapy will include talking with a healthcare provider about health history. Sometimes a physical exam and bloodwork tests will be required. Guidelines for starting hormone therapy recommend addressing mental health concerns. Having mental health issues (like depression or anxiety) or addiction does not mean you can’t access hormone therapy. It is recommended that these concerns be reasonably well-managed before or during the treatment. Since hormone therapy can affect reproduction, providers will discuss options for creating families and preserving fertility.

The dosage, duration, and types of hormone therapy can be customized to fit gender goals, health needs, and budget. For example, doses can be customized for individuals who are seeking slower or more subtle changes. Care plans are updated as needed.

Administration

Hormone therapy is prescribed by an endocrinologist, family doctor, or nurse practitioner with training in gender-affirming care. Both estrogen and testosterone therapies are available in different forms. 

  • Testosterone is often administered as a weekly or bi-weekly injection. It is also available as a gel or pill taken daily. 
  • Estrogen is often taken daily as a pill. It is also available as a patch or injection. Testosterone blockers are also available as a pill and can be taken with estrogen.

Injectable hormones can be administered with intramuscular or subcutaneous injections. They are both safe and effective techniques. An intramuscular injection uses a longer needle to go directly into the muscle. The medication is absorbed quickly into the bloodstream with this method. A subcutaneous injection uses a shorter needle in the layer of tissue directly under the skin. The medication is absorbed more slowly into the bloodstream with this method. For more information about how to safely inject hormones, you can consult the injection guides from Trans Care BC or Fenway Health.

People whose hormones are administered by gel, patch, or pill may experience a slower onset of changes compared to injections, although the same effects happen eventually. Hormone levels are often more stable on gel, patches, or pills since the hormones are administered every day. Some people using injections may experience changes in mood due to fluctuating hormone levels between doses. A healthcare provider might suggest switching to more frequent injections or a type of hormone taken daily.

Healthcare providers will work with you to determine the best type of hormone therapy based on your gender goals, health needs, and budget.

Follow-up care

Monitoring may be provided by an endocrinologist, family doctor, or nurse practitioner. This usually includes regular blood tests.

Youth who have anxiety related to needles may opt for a type of hormone therapy that does not require injection, but needles will be used for blood tests. If you are afraid of needles, speak with your care provider to get support managing and/or overcoming this fear.

When a person decides to stop or take a break from hormone therapy, their healthcare provider may recommend slowly lowering the dose of hormone medication over a few weeks. This can minimize the side effects of changing hormone levels. If hormone therapy is stopped for individuals who no longer have ovaries or testes (the parts of the body that produce hormones), additional measures may be taken to support physical wellbeing (e.g., taking different hormone medications).

It is important to discuss any change to hormone therapy with a healthcare provider. Hormones impact a person’s overall health and healthcare providers can provide advice on how to adjust care plans to meet a person’s needs.

Things to think about

Supplies

Injection supplies (e.g. needles, syringes) are available for purchase at many pharmacies and medical supply stores. Sharps containers are often available at pharmacies free of charge. Harm reduction sites or needle exchanges may also supply hormone therapy injection supplies free of charge.

Community organizations or care providers may have further information about where to access injection supplies in a youth’s region. 

Recalls

Drug recalls remove malfunctioning medications from the market and inform users of their potential risk. If there is a recall on hormone medication, Health Canada is responsible for tracking and informing the public.

There is a database that contains recall information on the Health Canada website. Additionally, it is possible to sign up for a free email notification service called MedEffect. This tool sends alerts to subscribers whenever a new advisory or recall is issued by Health Canada.

Shortages

Drug shortages can happen when there is not enough supply of a medication to fill everyone’s prescription in a specific region. Although shortages can happen with any medication, injectable testosterone is the hormone medication that has most often been in short supply recently. 

For concerns about a shortage, you can: 

  1. Check with your usual pharmacy to see if they have the prescription in stock or if they can locate it at another site
  2. Call different local pharmacies to ask about the availability of a prescription. It may be especially helpful to try smaller pharmacies (as opposed to large chain pharmacies)
  3. Consider a temporary switch to another form (different brand or method of administration) of your medication, if possible. If your usual medication cannot be found, your pharmacist may contact your prescriber to approve a temporary change
  4. Contact your healthcare provider to discuss the situation. They may be able to prescribe a different form of your medication until the usual medication is available

Hormones obtained without a prescription

Some people use hormones that have not been prescribed to them. There are health risks associated with buying or borrowing hormone medications rather than getting a prescription from a health care provider. Two potential issues are the quality and dosage of the product. Unlike medications from a pharmacy, medications from other sources may be diluted or mixed with unknown substances. A person using non-prescribed hormones will not have dosage and health risks monitored by a healthcare provider through regular bloodwork. When possible, it is recommended to access prescribed hormone therapy through a healthcare provider.

Cost

The price of hormone therapy medications varies depending on the type of hormone a youth is prescribed. Testosterone can range from about $10/month for injections to $130/month for pills or gel. Estrogen can range from about $20/month for pills or patches to $140/month for injections. The costs of these medications may be covered by private (extended), government (pharmacare), or other health plans. Some people pay for hormone prescriptions out of pocket.

Fertility and pregnancy

Hormone therapy can impact fertility and ability to reproduce. However, hormone therapy is not a form of birth control. Pregnancy is possible while taking hormones.

It is not safe to continue testosterone therapy while pregnant as it can cause harm to the fetus. It is important to use contraception when having sex that could result in pregnancy. Hormonal contraception methods containing estrogen can be taken at the same time as testosterone. The two medications will not impact each other. Non-hormonal contraception, like condoms or copper IUDs, are also an option.

When people taking hormone therapy are interested in having a family, there are many options. See the Reproductive Health section for more information.

Customizing Hormone Therapy

Hormone therapy produces many changes. A person may find some effects affirming while not desiring others. Unfortunately, it is not possible to fully customize the effects of hormones. If youth are concerned about some hormones’ effects or start to experience discomfort while taking them, they should speak to their provider about their concerns and the available options.

Some options may include:

  • Taking a lower dose of hormones so that changes happen more slowly
  • Taking hormones for a short time until certain desired permanent effects have been achieved (e.g., lowered voice, breast growth) and then stopping
  • Stopping hormones. Youth can stop and start hormones multiple times. If changes are beginning to cause discomfort, stopping hormones can allow youth take time to re-evaluate. There is always an option to restart hormones in the future if desired
  • Taking other medications to for specific effects (e.g., Finasteride to limit hair loss)
  • Taking a combination of different hormone therapies

Youth should speak with their healthcare provider about their embodiment goals and what options make most sense for them. Youth may also wish to do their own research by seeking information online from trusted organizations and speaking with other TTNB people.

Resources

Ahmad, S., & Leinung, M. (2017). The response of the menstrual cycle to initiation of hormonal therapy in transgender men. Transgender Health, 2(1), 176–179. https://doi.org/10.1089/trgh.2017.0023

BC Children’s Hospital. (n.d.). Gender Clinic. http://www.bcchildrens.ca/our-services/clinics/gender#Getting–a–referral

Defreyne, J., Elaut, E., Kreukels, B., Fisher, A. D., Castellini, G., Staphorsius, A., Den Heijer, M., Heylens, G., & T’Sjoen, G. (2020). Sexual desire changes in transgender individuals upon initiation of hormone treatment: Results from the longitudinal European network for the investigation of gender incongruence. The Journal of Sexual Medicine, 17(4), 812–825. https://doi.org/10.1016/j.jsxm.2019.12.020

Fenway Health. Transgender health injection guide. https://fenwayhealth.org/wp-content/uploads/2015/07/COM-1880-trans-health_injection-guide_small_v2.pdf

Folx Health. Does testosterone stop periods?: Menstruation, menopause, phantom periods, and GAHT/HRT. https://www.folxhealth.com/library/does-testosterone-stop-periods

Folx Health. Microdosing (low dose) estrogen HRT. https://www.folxhealth.com/library/microdosing-estrogen

Folx Health. Testosterone HRT and bottom growth. https://www.folxhealth.com/library/testosterone-bottom-growth

Government of Canada, H. C. (2021, November 1). Find recalls, advisories and safety alerts [Navigation page – search page]. https://recalls-rappels.canada.ca/en

Grimstad, F., Kremen, J., Shim, J., Charlton, B. M., & Boskey, E. R. (2021). Breakthrough Bleeding in Transgender and Gender Diverse Adolescents and Young Adults on Long-Term Testosterone. Journal of Pediatric and Adolescent Gynecology, 34(5), 706–716. https://doi.org/10.1016/j.jpag.2021.04.004

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658

Mosser, S. Microdosing testosterone. Gender Confirmation Center. https://www.genderconfirmation.com/non-binary/microdosing-testosterone/

Planned Parenthood. I’m trans. Does birth control affect HRT treatment? https://www.plannedparenthood.org/blog/im-trans-does-birth-control-affect-hrt-treatment

Proschan, K. (2021). Microdosing hormones expands gender-affirming care options for non-binary folks. San Francisco AIDS Foundation. https://www.sfaf.org/collections/beta/microdosing-hormones-expands-gender-affirming-care-options-for-non-binary-folks/

Rainbow Health Ontario. Trans men; trans health matters. https://www.rainbowhealthontario.ca/wp-content/uploads/2012/12/Transmen-THT.pdf

Rainbow Health Ontario. Trans women; trans health matters. https://www.rainbowhealthontario.ca/wp-content/uploads/2012/12/Trans-Women-THT.pdf

Rainbow Health Ontario and Sherbourne Health Hormone Guide. https://www.rainbowhealthontario.ca/wp-content/uploads/2021/06/Guidelines-FINAL-4TH-EDITION-c.pdf

Trans Care BC. Hormone Therapy.  https://www.transcarebc.ca/hormone-therapy

Trans Care BC. Understanding the B.C. health system. https://www.transcarebc.ca/how-to-get-care/understanding-health-system-bc?term=coverage

Trans Care BC. Indigenous people. https://www.transcarebc.ca/information-for/indigenous-people

Gender Affirming Surgeries

Overview

Gender-affirming surgeries change physical characteristics to support a person’s gender embodiment goals. Older Trans, Two-Spirit, and Nonbinary (TTNB) youth may choose to have gender-affirming surgeries as part of gender transition or affirmation. Surgeries are not part of everyone’s gender embodiment goals, and many people choose not to have surgery. 

Purpose & intended effects

Gender-affirming surgeries can help TTNB youth feel more comfortable in their bodies and may help them be perceived by others in ways that are affirming. Having certain surgeries may allow people to stop binding, packing, padding, or tucking. There are many types of surgeries and procedures available. 

Upper Body Surgeries

Breast construction

Surgeries that create, enlarge, or shape one’s breasts. These surgeries are performed when the breast growth from hormone therapy is less than desired.

Chest reduction/construction

Surgeries that remove or reduce chest tissue and skin to make a flatter chest. It may involve changing the size or position of the nipples, or removing the nipples. There are two primary options to consider when having chest reduction/construction surgery:

  • Chest construction surgery (bilateral mastectomy with contouring) involves the removal and sculpting of chest tissue to create a flatter and/or more sculpted chest.
  • Chest reduction surgery is a procedure to reduce the amount of chest tissue present.

Lower Body Surgeries

Orchiectomy

Surgery to remove the gonads (testes) and spermatic cord. It can be done with or without scrotectomy (removal of scrotal sac). 

Hysterectomy with bilateral salpingo-oophorectomy

Surgery to remove the uterus, fallopian tubes, and ovaries. At times, one or both ovaries are left in place. 

Vaginoplasty and vulvoplasty

Surgery to remove the penis, scrotum, and testes and includes the creation of a vulva (including mons, labia, clitoris, and urethral opening) and vagina. Vulvoplasty refers to the same outcomes, but without the creation of a vaginal opening.

Erectile tissue release

Procedure that involves cutting ligaments around the erectile tissue (sometimes called a clitoris) to release it and give it more length (2 to 4 cm).

Metoidioplasty

This procedure also involves cutting ligaments around the erectile tissue to release and lengthen it. Skin from the external genitals (sometimes called labia or outer labia) is then wrapped around the penis to add girth. As part of this procedure, one may opt for urethral lengthening, vaginectomy (removal of the vagina) and scrotoplasty (creation of a scrotum).

Phalloplasty

Surgery to create a penis from tissue grafted from another part of the body, often the forearm or thigh. It is common, but not necessary, to undergo urethral lengthening, vaginectomy (removal of the vagina), and/or scrotoplasty (creation of a scrotum).

Testicular implants

Implants can be inserted following a scrotoplasty. This is done in a separate surgery, months later.

Penile implant

A device that can be implanted following phalloplasty to allow for erections following phalloplasty. This is done in a separate surgery, months later.

Additional Procedures

Facial procedures

This refers to a variety of plastic surgeries including face lifts, procedures to reduce Adam’s apple, changes to the nose or facial bones, or rejuvenation of the eyelids.

Hair reconstruction or rejuvenation

These are procedures involving medications and surgeries to change hairlines and patterns.

Liposuction or lipofilling

These procedures involve moving or removing fat to change body contours.

Voice Surgery

These are procedures that change the length, tightness, or size of the vocal cords to produce a higher pitched voice.

Eligibility

Gender-affirming surgeries are available for TTNB people experiencing gender incongruence. When assessing readiness and care planning, healthcare providers will ask questions about a person’s gender, health history, health issues that could affect surgery outcomes, and ensure the person has the capacity to consent to the surgery. Guidelines for accessing surgery recommend addressing mental health concerns. Having mental health issues (like depression or anxiety) or addiction does not mean you can’t access surgery. These concerns just need to be reasonably managed before or during the treatment. This helps ensure that you can prepare for the procedure and heal safely afterwards.

The WPATH Standards of Care Version 8 recommend 6 months of hormone therapy prior to undergoing lower surgeries, unless hormone therapy is inconsistent with the patient’s gender goals and identity. Specific surgeons may have additional criteria.

Chest construction or reduction may be accessed by youth under the age of 18, but in Canada, other gender-affirming surgeries are typically only available to those over the age of majority (age 18 and older).

Safety and risks

As with all surgeries, gender-affirming surgeries have potential benefits and risks. Surgical teams will take a wide variety of steps to minimize risks and respond to any complications appropriately.

Depending on the surgery, potential risks include:

  • Negative reactions to anesthesia
  • Infections
  • Cardiovascular issues (blood loss, blood clots, and artery blockages)
  • Hematomas (blood collects at the surgery site) 
  • Seromas (fluid accumulation at the surgical site)
  • Nipple necrosis (when the nipple, or part of it, comes off)
  • Injury to the nerves or muscles
  • Urological complications (bladder or the pathway through which urine flows)
  • Implant complications
  • Loss of sensation
  • Dissatisfaction with results (for example, size, shape, asymmetry, visible scarring)

It is important to discuss these risks in detail with their surgeon and learn how to minimize risk throughout the preparation and recovery processes.      

How to access surgery

Surgical readiness assessment

Before a surgical consultation with a specialist, one or more surgical readiness assessments may be required. These readiness assessments can be completed during a surgical care planning appointment with a qualified healthcare provider.

During a readiness assessment, the healthcare provider will likely ask about gender, gender goals, health history, expectations for the surgery, and aftercare plans. Examples of questions include:

  • Have you taken any steps to live more fully in your gender?
  • Why are you interested in this surgery?
  • What is your understanding of the surgical procedure, risks, and post-operative healing process?
  • How do you think having surgery will impact you socially, emotionally, and financially?
  • Who is in your support network?
  • What is your surgical aftercare plan?

Once the readiness assessment is completed, the assessor will provide youth with a letter of recommendation and a referral can be made to a surgeon for consultation.

Referral for surgical consultation

Depending on availability and funding, patients may be able to request one or more consultations with specific surgeons. Primary care providers can refer patients to the type of surgeon trained in the surgery they seek. Examples of types of surgeons include:

  • A urologist for orchiectomy
  • A gynecologist for hysterectomy and salpingo-oophorectomy
  • A plastic surgeon for chest reduction/construction or breast construction 
  • Gender surgery programs for genital surgeries

Surgical consultation

Surgical consultation is a great opportunity to get a better understanding of what to expect and prepare for based on the surgeon’s specific practice. The consultation will help determine what procedure would be possible and best for a person’s body type, embodiment goals, and health needs. In addition to a physical exam, consultations may include discussion about: 

  • Different surgical techniques available and outcomes;
  • Advantages and disadvantages of different techniques;
  • Possible risks and complications of the various techniques;
  • What to do before surgery (e.g., blood work, pick up prescriptions);
  • Aftercare and recovery from surgery (e.g., expected recovery time, length of hospital stay, what type of support one may need from family and friends following the procedure).

The surgery date may be booked at the consultation, or the surgeon’s office might call later to schedule a surgery date.

If you are uncomfortable with the surgeon or would prefer a different provider, you will need to request a new referral.

Preparing for surgery

There are steps you can take to prepare for surgery and create a plan for recovery after surgery.

Prepare emotionally

Gender-affirming surgery can bring up a wide range of emotions. It can be helpful to:

  • Lean on family and friends for support;
  • Gather materials for wellness activities (like journaling, arts, ceremonial practice, etc.);
  • Connect with others who have had gender-affirming surgery through peer support groups or online networks;
  • Talk to a mental or spiritual healthcare provider prior to surgery and during recovery.

Prepare physically

Preparing physically for surgery can help improve surgical outcomes and promote healing later. Eating a well-balanced diet, staying active, and getting enough rest will help support a smooth recovery. Doctors also recommend or require quitting smoking and vaping, as substances that irritate the lungs can interfere with the body’s ability to heal and increase the chances of complications following anesthesia and surgery.

Prepare financially

If you have a job, you will likely need to arrange time off work for recovery. A letter from your PCP or surgeon may be required to request leave. This letter does not need to specify the reasons or provide any detail to the employer. Depending on the kind of work you do, you may need to request temporary accommodations or a gradual return to work.

If you do not live near a surgical centre, you will need to prepare for travel costs as well accommodation, meals, and parking.

If youth need support covering costs, the following resources may be applicable:

  • Paid leave (e.g. short-term disability, sick time, or vacation time) may be used during time off work to recover. Speak with your employer or Human Resources department to see what options are available.
  • Employment Insurance (EI) Sickness Benefits may be an option for individuals working and meeting the eligibility criteria.
  • Check with your healthcare provider about travel assistance programs, including Hope Air.
  • Fundraising may be an option to support youth in need of funds to cover surgery related costs. These can be organized online or in-person.

Prepare your home

Here are some steps you can take to prepare your home:

  • Do laundry ahead of time so bedding and clothing are clean after surgery;
  • Acquire loose-fitting, comfortable, and easy-to-slip on clothes;
  • Stock up on groceries; 
  • Prepare and freeze meals;
  • Collect the medical supplies the surgeon recommends;
  • Place essential items on low and easy to access shelves to avoid stretching or strain following surgery.

Prepare a support system

As you heal, you may be tired, sore, have limited mobility, and experience emotional ups and downs. It is a good idea to plan how others can support you after surgery. You will be required to have someone pick you up from the hospital. If you live alone, consider having someone stay with you or speak to your provider about community nursing supports that may be available to help for the first couple of days after surgery.  

Supports to plan: 

  • Meal preparation
  • Regular chores (cleaning, taking out the garbage)
  • Caring for children or pets
  • Connecting socially

Initial follow-up care

Post-operative care plan 

The recovery process can be different for different people and procedures. The length of hospital stays will depend on the post-operative plan and surgical site. Some procedures, including chest reduction and construction and breast construction, may be completed as a day-surgery. Other surgeries may require overnight stays in the hospital.

Providers will go over a detailed post-operative care plan which may include:  

  • Scheduling follow-up appointments;
  • Information about what to expect during the healing process and what to look out for;
  • Taking prescriptions including painkillers and antibiotics;
  • Instructions about when and how to remove or change surgical dressings; 
  • For lower surgeries, aftercare may include genital care, catheter care, and dilation (for vaginoplasty);
  • Activities to avoid while healing (heavy lifting, exercise, sexual activity, etc.);
  • Information about when you can return to your usual activities.

The surgeon should be available for support for aftercare and any complications that arise.

Pain management

It is recommended to follow the pain medication schedule recommended by your surgeon or PCP. This helps control post-operative pain and facilitate healing.

If you want to avoid the use of narcotic painkillers, healthcare providers can recommend alternative pain medications. Depending on the procedure, you may be able to manage pain with over-the-counter medications like acetaminophen (Tylenol) and ibuprofen (Advil).

Tips to promote healing

Consider the following strategies to promote healing during the early stages of recovery:

  • Get lots of rest: Following surgery one’s body needs extra rest to heal. Take naps or breaks throughout the day. This will let the body focus on healing and building up strength again.
  • Wash hands frequently: Especially before and after changing wound dressing, keeping up with hand washing will help prevent infection.
  • Walk: Walking can help relieve pain, improve blood flow and have a positive impact on mood. Start with short, slow-paced walks. After genital surgeries, some people find using a mobility aid, like a cane or a walker, to be helpful at first.
  • Enjoy foods that help with wound healing: Foods that are high in protein, zinc, vitamin A and vitamin C are good options to promote healing.
  • Drink lots of water: Especially following lower surgeries, drinking lots of water and emptying the bladder regularly can help prevent urinary tract infections.
  • Wear a high quality mask when seeing people and limit visits while you are recovering, and ask your visitors to mask as well: This can help you avoid getting a respiratory infection that could slow your recovery.

Longer term aftercare

Physiotherapy

Physiotherapy can be helpful for some people after gender-affirming surgery. Treatments can help with pain and scar management, monitoring healing, and improving one’s range of motion. For gonadectomies and genital surgeries,physical therapy can help strengthen pelvic floor muscles.

If you are interested in physiotherapy to support post-operative care, speak to your surgeon about when it would be safe to start treatments. Healthcare providers may be able to recommend or refer to physiotherapists with experience in gender-affirming surgery aftercare. 

Scar care

Some gender affirming surgeries will result in visible scarring. Surgeons will provide advice during the initial recovery to promote healing and prevent severe scarring (e.g., limit movement, avoid heavy lifting). They can also provide instructions for scar care in the months after surgery, including when it is safe to start.

There are steps one can take to minimize the appearance of scars overtime, including:

  • Avoid getting direct sun on scars for up to a year, to help prevent color changes on the scar tissue;
  • Follow the surgeon’s instructions for regular scar massage;
  • Follow the surgeon’s instructions for using silicone products, such as scar tape.

Complications

It is unlikely any new complications will occur after the initial healing process concludes. For example, there are unlikely to be any age-related complications later in life connected to having gender-affirming surgeries.

Revisions

In some cases, a surgical revision may be needed following gender-affirming surgery. You can speak with your surgeon about whether a surgical revision is appropriate. It is important to note that even if the initial procedure was covered by a provincial or territorial health program, revisions may not be. However, if the surgeon determines a revision is medically necessary, they may be able to apply for provincial funding.

Things to think about

Variations of procedures

There may be individually customized gender-affirming surgery options that would best fit your gender embodiment goals and health needs. For example, a person may opt for:

  • Chest reduction 
  • Chest construction without nipple grafts 
  • Vaginoplasty using a section of one’s intestine to create neovagina (this option may not be available at every surgical centre)
  • Orchiectomy and penectomy without vaginoplasty
  • Hysterectomy without bilateral salpingo-oophorectomy (one or both ovaries are not removed)

Ongoing hormone therapy

Sex hormones are important for overall wellbeing and especially for bone and cardiovascular health. Following gonadectomy (i.e., removal of ovaries or testes) most people need to take ongoing hormone therapy medications (e.g., estrogen, testosterone). 

Results

There are various online community spaces where TTNB people share their surgery results with other community members. People share photos throughout the recovery process so others can see how the body may change as it heals. These groups can be found on online social platforms like Facebook, Reddit, Discord, or on websites focused on specific procedures. Sometimes surgeons have before and after photos available on their websites.

It is important to note that no two bodies are the same and everyone’s surgery outcomes will be unique to them. However, looking at photos of several types of procedures can give you an idea of what results you could expect and help you determine what procedure you would prefer. You can bring pictures of results you like to a surgical consultation to help communicate desired outcomes to your surgeon. Surgeons may have photos available to share at the surgical consultation. 

Sexual health and fertility

Lower gender affirming surgeries can have a direct impact on reproductive capabilities. PCPs and surgeons can provide more information about how specific surgeries will affect fertility.

While research shows that gender affirming surgeries can result in a more satisfying sex life, genital surgeries can have an impact on sexual function. Outcomes vary depending on the type of surgery, technique used, customizations chosen, and individual outcomes.

Following lower surgery, it may take time to recover and experience erections or orgasms. Nerve regeneration begins after surgery, but the timeframe to regain sensation varies from person to person. It may take over a year for nerves to finish regenerating. Sensation may be different than what someone was used to prior to surgery and some areas may not regain sensation. Some people report experiencing pain or a tingling sensation as nerves regenerate.

Depending on the procedure, erections may or may not be possible. After phalloplasty, erections will only be possible with an erectile implant. This typically involves a separate surgery to implant the device once the initial healing has completed. For metoidioplasty and erectile tissue release, erections are possible without the assistance of an implant but may not enable sexual penetration.

During the surgery consultation, patients may want to speak to their surgeon about their goals, the possible results for each option, and what options would be available if they have difficulty with sexual function after surgery. This may help inform one’s decision and find the right surgery for their goals.

Cost

Most Canadian provinces and territories have programs to cover some or all the cost of specific gender-affirming surgeries. Each program is unique in terms of the covered costs. Extended healthcare programs may also cover some gender-affirming surgeries and procedures. For those paying privately, procedures often cost thousands of dollars. The total costs depend on the type of surgery, technique used, surgeon’s rate, and travel expenses.

Surgeries performed outside of Canada      

Some people travel outside of Canada to access a specific gender-affirming surgery or receive care from a specific surgeon.

Most government programs do not cover the cost of surgeries outside of Canada; however, there are some exceptions, for example, when a procedure cannot be accessed in Canada.

Resources

Almazan, A. N., & Keuroghlian, A. S. (2021). Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surgery, 156(7), 611–618. https://doi.org/10.1001/jamasurg.2021.0952

Government of BC. Medical services outside of Canada. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/msp/medical-services-outside-of-canada

GRS Montréal. Frequently asked questions. https://www.grsmontreal.com/en/frequently-asked-questions.html

Manitoba Health. Out-of-province coverage. https://www.gov.mb.ca/health/mhsip/out-of-province-coverage.html

McLean Clinic. How to reduce the appearance of top surgery scars. https://www.topsurgery.ca/blog/reduce-appearance-of-top-surgery-scars

Mertz, E. (2022). Gender-affirming health coverage by Canadian province, territory. Global News. https://globalnews.ca/news/8900413/gender-affirming-healthcare-province-territory-transgender/

Ontario Ministry of Health. Gender confirming surgery. http://www.ontario.ca/page/gender-confirming-surgery

Trans Bucket. https://www.transbucket.com/

Trans Care BC. Surgery. https://www.transcarebc.ca/surgery

Trans HealthCare. Canada has nation-wide funding for gender-affirming surgery. https://www.transhealthcare.org/news/canada-nation-wide-funding-for-gender-affirming-surgeries/

Wetherbe, J. (2023). The surprising impact of a physical therapist on gender-affirming surgery. USC Division of Biokinesiology and Physical Therapy. https://pt.usc.edu/news/the-surprising-impact-of-a-physical-therapist-on-gender-affirming-surgery/

Reproductive Healthcare

Overview

Trans, Two-Spirit, and Nonbinary (TTNB) people may have unique reproductive healthcare needs. Support from gender-affirming reproductive healthcare providers can help TTNB people make informed decisions about things like family creation, pregnancy, and fertility preservation. Primary care providers can answer many questions about reproductive healthcare, such as those related to cervical screening, STIs and pregnancy prevention. Other needs, such as fertility preservation, may require more specialized care.

Family Creation

Many TTNB people are interested in creating families. It is important to think about what options you want to keep open when considering gender-affirming medical interventions. There are many ways to create families, including:

Pregnancy

TTNB people may be able to become pregnant, even if they have taken hormone therapy or had some gender-affirming surgeries.

Surrogacy

Surrogacy is the process of gestating a child on behalf of another person, couple, or family. This often is supported through intrauterine insemination or in-vitro fertilization.

Adoption

Adoption is the process of becoming a permanent, legal guardian (parent) of a child.

Fostering

Fostering involves temporarily caring for a child.

Fertility preservation

Some gender-affirming medical interventions can impact fertility and future family creation options. Healthcare providers will discuss potential fertility risks before starting treatment, for example, hormone therapy or gender-affirming lower surgeries.

Gender-affirming care planning meetings often include the topic of fertility preservation. Healthcare providers can explain how fertility may be affected by different medications or procedures. They can also provide information about what options are available to youth interested in fertility preservation.

It may be possible to preserve (freeze) gametes (sperm or eggs) before or after starting hormone therapy. For surgeries that remove ovaries or testes, preservation must be done before surgery. These gametes can later be used to support pregnancy through intrauterine insemination (IUI) or in-vitro fertilization (IVF). IUI involves sperm being put directly inside the uterus, making it easier to fertilize an egg. IVF is a procedure in which a healthcare provider implants a fertilized egg into a uterus to induce pregnancy.

Youth who are interested in fertility preservation can speak to their primary care provider for a referral to a fertility specialist. When choosing a fertility clinic, TTNB youth may want to ask their provider about the clinic’s experience with TTNB patients. Youth may also want to ask for recommendations for a fertility clinic or specialist from TTNB people who have undergone the process.

Costs and coverage

Fertility preservation and fertility treatment are distinct procedures with different purposes. IVF and IUI are for those who are ready to become pregnant. Gamete (sperm or egg) preservation is for future pregnancies.

The processing fee to preserve sperm is about $200, and the storage costs are about $200 per year. The process of preserving eggs is more complex and expensive. Prior to the procedure, people need to have injections twice a day for 10 to 14 days. The procedure to retrieve the eggs costs about $8,000. Additionally, the medications cost about $3,000. Eggs can stay frozen for years, which may require payment of ongoing storage fees.

IVF fertility treatment can cost about $10,000 to $15,000 per cycle, but there might be additional costs for testing and medication that could increase costs. Before having IUI, a person may be prescribed fertility medications to stimulate ovulation. IUI costs can range from $300 to $1,000.

Extended health care plans through an employer may cover some of the cost of fertility preservation. Government health plan coverage for fertility treatment varies by province and territory. Coverage is usually in the form of a tax credit with a maximum that is based on the total cost of treatment (within a limit) or a subsidy program that a person must apply for.

Resources

Amato, P. (2016, June 17). Fertility options for transgender persons. University of California, San Francisco. https://transcare.ucsf.edu/guidelines/fertility

Rainbow Health Ontario (2014). Reproductive options for trans people. Sherbourne Health Centre. https://lgbtqhealth.ca/docs/FactSheet-ReproductiveOptionsForTransPeople.pdf

Sterling, J., & Garcia, M. M. (2020). Fertility preservation options for transgender individuals. Translational Andrology and Urology, 9(suppl 2), S215-S226. https://doi.org/10.21037/tau.2019.09.28 Trans Care BC (n.d.). Sexual & Reproductive Health. Provincial Health Services Authority. http://www.phsa.ca/transcarebc/care-support/access-care/sexual-hlth#Reproductive–health

Trans Care BC. Health and wellbeing. https://www.transcarebc.ca/health-wellbeing

Sexual Healthcare

Safer sex practices

Safer sex practices are actions that help to prevent pregnancy and/or lower the chances of getting or passing a sexually transmitted infection (STI). Safer sex practices include using barriers (such as external, internal condoms or oral dams), lubricant, contraception, emergency contraception, STI screening, cervical or HPV screening, vaccines, and HIV Pre- and Post-Exposure Prophylaxis (HIV PrEP and HIV PEP). 

This section of the guide covers some additional considerations for safer sex that may be relevant for trans, Two-Spirit, and nonbinary (TTNB) people. For example, gender-affirming hormone therapy and puberty blockers do not prevent pregnancy or reduce the chances of getting an STI.

Educational Resources

Educational resources about practicing safer sex can be found on websites for agencies that provide information for cisgender individuals (like Planned Parenthood). Some organizations like Rainbow Health Ontario and the 519 produce safer sex guides specifically for TTNB people. For example:

  • The Gay Men’s Sexual Health Alliance has an online sexual health resource called “the Sex you Want” for guys who are into guys, including trans guys
  • The 519 has a booklet called “Brazen 2.0: Trans Women’s Safer Sex Guide”
  • CATIE.ca is a website with lots of information about STIs and safer sex
  • The Trans Care BC website has information specific to safer sex after surgery and other resources about sexual health

Barriers

Barriers can significantly reduce the chance of getting or passing an STI and of becoming pregnant or getting another person pregnant. This category of safer sex supplies are items that prevent the genital and/or oral fluids of the people having sex from coming in to contact with each other’s mucous membranes.

Barriers include condoms (external and internal) and oral dams. Medical gloves or finger cots can be used as well. Barriers can be made of different types of effective materials, including latex and polyurethane. If you have allergies, be sure to check the materials used in a product before using it.

It is helpful to review instructions on how to use each barrier type correctly. Each barrier method is more effective when lubricant is used, because lubricant reduces friction, which lowers the chances of the barrier tearing. It is important to use the right kind of lubricant, because some lubricants can weaken the barrier (like an oil-based lube on a latex barrier). Water based lubricant is safe for all types of barriers.

There are some additional reasons why barriers are important for TTNB people who are on hormone therapy or who have had genital surgeries. Testosterone can lead to thinning of the tissue that lines the internal genitals/vagina. Thinner tissue tears more easily, making someone more vulnerable to infection.

Hormone therapy (testosterone; estrogen and testosterone blockers) are not effective methods of contraception. This means someone can still get pregnant on testosterone (even if they have stopped monthly bleeding) or get another person pregnant, even if on estrogen. Barriers can help prevent pregnancy.

After vaginoplasty surgery, the vaginal tissue can also tear from friction associated with dilation or sex play, or there may be some open or sensitive spots inside the vagina. Using barriers and lubricant reduces the chances of tearing, and of getting or passing an STI.

Lubricant

Lubricant (lube) is a safer sex product that is important for everyone no matter what their hormone or surgical status is. Anal and genital tissues are delicate and can tear easily, which makes people more vulnerable to sexually transmitted infections (STIs), because tears provide an entrance into the bloodstream. Lubricant reduces friction, which reduces the amount of tiny tears that happen during sex play.

There are different types of lubricant available. Be sure to use one that is safe for the type of barrier you are using (if you are using one). Water based lubricant is safe for all types of barriers and is safe to use after genital surgery.

There are some additional reasons why lubricant is important to use for trans people who are on hormone therapy or have had genital surgeries. Testosterone can lead to thinning of the tissue that lines the internal genitals/vagina. Thinner tissue tears more easily, making someone more vulnerable to infection. Using lubricant reduces friction, which reduces the chances of tearing (genital tissue, anal tissue and barriers), which reduces the chances of getting or passing an STI.

Accessing safer sex supplies

In addition to being available for purchase at any pharmacy or drugstore, safer sex supplies are often available free of charge at various organizations, including:

  • Sexual health clinics
  • Youth clinics
  • Community health centres
  • Harm reduction centres
  • School guidance counsellor
  • Campus wellness centers
  • TTNB organizations or events

Contraception

Hormone therapy is not an effective form of contraception.

A person on testosterone can still get pregnant, even if they are no longer having monthly bleeding (periods). A person on estrogen and testosterone blockers can still get another person pregnant, even if the volume of their genital fluid (ejaculate) is reduced. When used correctly, barrier methods (external or internal condoms) are very effective at reducing the chances of pregnancy.

People taking testosterone can use any form of birth control, including hormonal types like the pill, IUDs, the implant, and the shot. Hormonal contraception will not interfere with the effectiveness of testosterone therapy.

Youth taking puberty blockers should use a non-hormonal method, like the copper IUD or barrier methods like condoms.

The types of birth control that require a prescription can be accessed through primary care providers, walk-in clinics, youth clinics and sexual health clinics. Also, pharmacists can prescribe contraceptives in British Columbia, Alberta, Saskatchewan, Quebec, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador.

If someone has had a gonadectomy (e.g., hysterectomy, bilateral oophorectomy, or orchiectomy), they cannot become pregnant or get another person pregnant. If you have not had a gonadectomy, there is still a risk of pregnancy if genital/vaginal tissue is coming in to contact with ejaculate, even if you and/or your partner are on hormone therapy.

Emergency contraception

Emergency contraception can be used after sex when a condom was not used, or broke, and there is risk of pregnancy. There are different types of emergency contraceptives, including pills (can be taken up to 5 days after sex) and the copper IUD (inserted up to 7 days after sex). The faster it is accessed, the more effective it will be.

Sometimes people will have an emergency contraceptive pill “in advance of need”, meaning they have it at home in case they need it. Always check that the pill has not expired when using this method. People taking testosterone can use any form of emergency contraception and it will not interfere with the effectiveness of their hormone therapy.

The emergency contraception pill can be purchased at pharmacies in Canada without a prescription. Emergency contraception pills can also be accessed through primary care providers, walk-in clinics, youth clinics and sexual health clinics.

STI screening

It is recommended that youth who are sexually active have sexually transmitted infection (STI) testing. Depending on the type of test, this may involve a swab, urine test, blood test, and visual exam. You can access STI testing without a visual or physical exam. You can ask to do the swabs yourself or have help from a clinician.

It is recommended to screen any parts of your body that are coming in contact with another person’s genital fluids for chlamydia and gonorrhea. This includes the genitals (done by urine sample or a swab), the anus (done by swab), and the throat (done by swab). Blood tests for HIV and syphilis are also recommended for anyone who is sexually active. Sometimes bloodwork for Hepatitis A and Hepatitis C may be recommended as well.

STI screening is recommended for TTNB people who are sexually active, or who have been sexually active in the past. It is safe to have STI screening if you have had genital surgery.

Free and confidential testing can be completed by primary care providers, at sexual health clinics, youth clinics or walk-in clinics.  

Action Canada for Sexual Health and Rights has a resource to help find sexual health services. Educational resources on STIs and testing can be found on the Government of Canada’s website.

Cervix (Pap) or HPV screening

A Pap test is a screening exam that checks for abnormal cell growth in the cells of the cervix (the area at the back of the internal genitals/vagina). The abnormal cell growth is caused by the human papilloma virus and is not visible to the naked eye. A Pap test is done during a pelvic exam, when cells are gently taken from the cervix and then sent to a lab to be examined under a microscope.

Different provinces and territories have different cervical screening guidelines- some start at age 21 and others at age 25. Pap tests are recommended for TTNB people who have a cervix, whether or not someone is on testosterone therapy. Pap tests are not recommended for TTNB people who have had vaginoplasty.

Some provinces and territories are switching from Pap tests (which involve a pelvic exam) to HPV screening (which involves a genital swab and can be self-collected). If you aren’t sure whether you need a Pap test, you can speak with a healthcare provider. Pap tests and HPV screening can be provided by primary care providers, youth clinics, walk-in clinics and some sexual health clinics.  

Vaccines

Vaccines are biological medications that help the body to create anti-bodies to a specific bacteria or virus to help protect against infection in the future. Vaccines need to be given before exposure to the virus or bacteria to be effective. There are vaccines for some sexually transmitted infections and respiratory infections that can be transmitted during sex, including the ones below. Many of these vaccines are available for free through publicly funded programs.

  • Hepatitis A
  • Hepatitis B
  • HPV
  • MPox
  • Covid-19
  • Flu

Most of these vaccines can be accessed through youth clinics, public health clinics, sexual health clinics and some primary care providers. Pharmacists can also provide some vaccines without a prescription.

HIV Pre Exposure Prophylaxis (HIV PrEP)

HIV Pre Exposure Prophylaxis (HIV PrEP) is a daily pill that can help reduce a person’s chances of getting HIV (it does not prevent other sexually transmitted infections). HIV PrEP works by interfering with HIV’s ability to copy itself. HIV PrEP can be taken by anyone who is HIV-negative and whose sexual activities put them at a higher risk for getting HIV.

If taken every day, HIV PrEP is highly effective at preventing HIV infection, even after exposure. It is important to know, however, that HIV PrEP is not 100% effective, so it is recommended to use barrier methods as well (e.g., condoms).

HIV PrEP needs to be prescribed by a doctor or nurse practitioner and requires regular follow-up visits. It can be provided by some primary care providers and at some sexual health and youth clinics.

While there is less research about the effectiveness of HIV PrEP in TTNB people than in cisgender people, HIV PrEP is a good option for TTNB people at high risk for getting HIV.

There are additional considerations for some TTNB people with HIV PrEP:

  • For transmasculine people, it can be helpful to know that the tissue of the internal genitals/vagina takes longer to respond to HIV PrEP than rectal tissues. As such, it is recommended to take HIV PrEP consistently for three weeks before having genital/vaginal sex. Additionally, HIV PrEP needs to be taken almost perfectly (daily with very few missed doses) to effectively prevent against HIV during genital/vaginal sex. For people on testosterone, HIV PrEP does not interfere with hormone levels.
  • HIV PrEP does not interfere with hormone levels for people taking estrogen therapy. People on estrogen may need to take HIV PrEP almost perfectly (daily with very few missed doses) to effectively prevent HIV. For TTNB people who have had vaginoplasty, there is no data on the effectiveness of HIV PrEP in vaginal tissue.

HIV Post Exposure Prophylaxis (HIV PEP)

HIV Post Exposure Prophylaxis (HIV PEP) is when an HIV negative person takes medications within 72 hours after a potential HIV exposure to reduce the chances of an HIV infection. While there is less research about the effectiveness of HIV PEP in TTNB people than in cisgender people, HIV PEP is a good option for TTNB people who had a potential exposure to HIV.

HIV PEP needs to be prescribed by a doctor or nurse practitioner and requires regular follow-up visits. It can be provided by some urgent and primary care providers, and at some emergency rooms, sexual health clinics and youth clinics. Regular follow-up will always be needed, even if you get it in an emergency room).

Sexual assault

Sexual assault is any unwanted sexual contact or behavior that happens without consent. If you or someone you know has experienced sexual assault, it’s important to know that help and support are available. You can reach out to trusted adults, school counselors, or a local sexual violence support centre.

Many communities have organizations that provide confidential support, counseling, and medical care. Many of these organizations are trans-inclusive, but it can be helpful to double-check.

Remember, sexual assault is not your fault, and you don’t have to go through it alone. The organization Forge Forward has excellent self-help resources one can use while healing from difficult experiences.

Sex therapy

Sex therapy is a type of counselling that addresses issues a person may experience related to sex and sexuality. Examples of these issues include sexual anxiety, questions about sex drive, body image and relationship issues. A therapist may be able to offer support to work through challenges and help people to have satisfying relationships and pleasurable sex.

Resources

Action Canada for Sexual Health & Rights Find Sexual Health Services Near You: https://www.actioncanadashr.org/resources/services

Canadian Partnership Against Cancer Cervical cancer screening guidelines (2021/2022): https://www.partnershipagainstcancer.ca/topics/cervical-cancer-screening-in-canada-2021-2022/programs/guidelines/#:~:text=Provinces%20and%20territories%20recommend%20that,every%20two%20to%20three%20years.

Canadian Pharmacists Association (2023). Pharmacist contraceptive prescribing across Canada. https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Contraception-Infographic.pdf

CATIE. Canada’s source for HIV and hepatitis C information. https://www.catie.ca/catieca

Forge Forward. Self-help resources for healing. https://forge-forward.org/collections/self-help/

Gay Men’s Sexual Health Alliance (2024). The sex you want. https://thesexyouwant.ca/

Government of Canada. Getting tested for sexually transmitted infections (STI). https://www.canada.ca/en/public-health/services/sexual-health/getting-tested-sexually-transmitted-infections.html

Planned Parenthood. What do I need to know about sexual health as a trans or nonbinary person? https://www.plannedparenthood.org/learn/gender-identity/transgender/sexual-health-trans-nonbinary

Planned Parenthood of Greater Washington and North Idaho. Safer sex for trans bodies. https://www.plannedparenthood.org/planned-parenthood-greater-washington-north-idaho/get-care/our-services/transgender-and-gender-affirming-health-care/safer-sex-for-trans-bodies

The 519. Brazen 2.0: Trans women’s safer sex guide. https://www.the519.org/resources/brazen/

Trans Care BC. Health and wellbeing. https://www.transcarebc.ca/health-wellbeing

Disclaimers

We published this guide in 2024. We know that laws, policies, and options for healthcare change over time and vary across provinces, territories, and Nations. To find specific information for your region and to keep up to date on changes that may affect you, look for trustworthy resources near you. This guide is not intended to provide medical or legal advice. If you have questions about accessing gender-affirming healthcare for yourself or a loved one, we encourage you to reach out to a trusted healthcare provider or organization.

More Resources

For a downloadable version of this guide, quick reference infosheets and our community report, please visit the Just Be Yourself Resources page.

Copyright

Copyright 2024 under a Creative Commons license CC BY-NC-ND 4.0.