Internationally and within Aotearoa, New Zealand, there has been a substantial increase in the demand for gender affirming healthcare over the past decade. The Youth’12 survey estimated that approximately 1.2% of adolescents in Aotearoa, New Zealand identify as transgender.1 As societal acceptance for trans people grows, it is likely that this level of referrals to health services will continue in the foreseeable future.1,2

Transgender healthcare is rapidly evolving. Table 1 includes some of the terminology healthcare professionals may encounter. The World Professional Association of Transgender Health (WPATH) is the international body responsible for producing standards of care (SOC) for transgender health based on international clinical consensus.3 These are currently being revised and version 8 will inform practice internationally and in Aotearoa, New Zealand.

Table 1: Terminology.

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The Guidelines for Gender Affirming Healthcare for Gender Diverse and Transgender Children, Young People and Adults in Aotearoa, New Zealand4 were developed following the recognition that the previous good practice guide required updating to be in step with current practice and international standards. This guideline is not intended to replace the WPATH SOC but to present additional guidance for the provision of gender affirming healthcare in Aotearoa, New Zealand. This article presents a summary of gender affirming healthcare discussed in the larger document.

Methods

This guideline was produced in collaboration with trans community members and after consultation with many services and health professionals throughout Aotearoa, New Zealand, who work professionally to advance healthcare for trans people. While regional differences in practice exist, the document describes principles and approaches that encompass this diversity. The gender affirming hormonal therapy guidelines in this document draw significantly on those published by the Endocrine Society.5

Principles of gender affirming healthcare

These guidelines are based on the principle of Te Mana Whakahaere; trans people’s autonomy of their own bodies, represented by healthcare provision based on informed consent.6 The informed consent process involves several conversations between the trans person and clinician(s) before starting treatments that have an irreversible component to increase certainty that they are adequately prepared and are making a fully informed decision.7

The use of Sir Mason Durie’s Te Whare Tapa Whā as a framework highlights the equal importance of spiritual, family, mental and physical health.8 Health providers have a duty to approach care holistically and in partnership.4 Involving practitioners with expertise in mental health is important for two reasons. Firstly, mental health professionals with the appropriate skills can assist with the informed consent process. Secondly, it is increasingly recognised that discrimination and marginalisation experienced by trans people contributes to high rates of anxiety and depression.9–11 The Youth’12 survey highlighted the mental health disparities experienced by trans young people compared to their cisgender peers with 41% vs 12% experiencing significant depressive symptoms and 20% vs 4% reporting an attempted suicide, respectively, in the past 12 months.1 While there is no New Zealand data for older trans people it is likely that they also experience elevated rates of anxiety and depression as overseas studies have found.9 Because of this, health services that have good links with peer support groups and mental health professionals will be more responsive to the needs of trans people accessing gender affirming healthcare.

Each person presenting to a health service has their own unique clinical presentation and needs. While many trans people will benefit from hormone therapies and surgical interventions, some may require only one or neither of these options.12 Clinicians should not assume that everyone wants to conform to binary (male or female) gender norms and be open to gender affirming healthcare that aligns with non-binary identities.3 When outer gender expression is congruent with an inner sense of self, most trans people will find increased comfort, confidence and improved function in everyday life.13 Avoiding harm is a fundamental ethical consideration for health professionals when considering healthcare. Withholding or delaying gender affirming treatment is not considered a neutral option, as this may cause harm by exacerbating any gender dysphoria or mental health problems. This is no different from harm that can be caused by withholding or delaying other medically necessary care.

Gender affirming healthcare

Gender affirming healthcare may include provision of puberty blockers in children and adolescents, and hormone therapy in older adolescents and adults. The criteria for access to gender affirming hormones are persistent well-documented gender dysphoria, the capacity to make a fully informed decision and to consent for treatment, 16 years of age or older, and significant medical or mental health concerns must be reasonably well controlled. However, it is increasingly recognised that there may be compelling reasons, such as final predicted height, to initiate hormones prior to the age of 16 years for some individuals, although there is as yet little published evidence to support this.5 There is no upper age limit to starting gender affirming hormone therapy. These criteria reflect the WPATH SOC which emphasise that having medical or mental health concerns does not mean gender affirming care cannot be commenced, rather that these need to be managed as part of an informed consent process.3 This readiness can be assessed by a prescribing provider or mental health professional who is experienced and competent at working with trans people.

The informed consent process for readiness for puberty blockers, gender affirming hormones or surgery are detailed in the WPATH SOC.3 The main components include assessing gender dysphoria, discussing social transition, gender expression and physical transition options, and providing a space to consider the implications of these options, with regard to safety, expectations and impact on social, emotional, academic/occupational functioning. For all trans, particularly children and young people, consideration of psychosocial supports, especially family/whānau support is essential. Provide support to families and additional guidance if this support is absent. If this aspect of the assessment is not completed by a medical professional, then communication between the mental health professional and the prescriber/surgeon should occur to ensure a holistic approach to assessment.

Fertility preservation should be discussed prior to starting puberty blockers, gender affirming hormone therapy or gonadectomy.5 Refer to local fertility services for access to funded cryopreservation of gametes. For those starting feminising hormones, who have reached at least Tanner stage 3, it is recommended that cyropreservation of sperm be considered.5 For those in early adolescence (Tanner stage 2–3), collection of mature sperm will not usually be possible as mature sperm are produced from mid puberty (Tanner stage 3–4).7 For those starting masculinising hormones, the option of egg or ovarian tissue storage should be discussed, recognising however, that this involves invasive procedures that are not currently funded where reproductive organs remain. There is no current evidence to suggest that testosterone exposure affects the likelihood of future healthy egg harvesting, and there are many reports of trans men who have ceased testosterone, for the purposes of achieving conception, having successful pregnancy outcomes.14 However, it is unknown what effect the duration of testosterone therapy has on ovarian function.

Testosterone therapy does not provide a guarantee of adequate contraception and is contraindicated in pregnancy because of potential harm to the fetus from the androgenising effects of treatment.15 Provide contraceptive advice prior to starting testosterone. Progesterone based Long Acting Reversible Contraception (LARCs) such as (Depo provera®, Jadelle®) or Intrauterine Devices (IUDs) such as Mirena®/ IUCDs are suitable options. Note that IUD insertion may be technically more challenging in those with a degree of cervical atrophy from testosterone therapy.

Puberty suppression using gonadotropin releasing hormone (GnRH) agonists

Puberty blockers can be prescribed from Tanner stage 2 to suppress the development of secondary sex characteristics and may be still beneficial when prescribed later in puberty to prevent ongoing masculinisation/feminisation.5 Puberty blockers are considered to be fully reversible and allow the adolescent time prior to making a decision on starting hormonal therapies. Monitoring of height is recommended as adult height may potentially be increased if prolonged puberty suppression delays epiphyseal fusing.5 A bone age may be helpful to assess whether epiphyseal closure has occurred when considering what rate of hormonal induction to use. Concern has been raised regarding the long-term impact of puberty suppression on bone mineral density.5 It is therefore advisable to encourage young people on puberty blockers to have an adequate calcium intake, provide vitamin D supplementation where needed and encourage weight bearing exercise.7 Bone density measurements (DEXA) can be considered in those requiring a prolonged period on puberty blockers or have significant additional risks for reduced bone density.

Puberty blockers halt the continuing development of secondary sexual characteristics, such as breast growth or voice deepening, and relieve distress associated with these bodily changes for trans young people.16,17 For trans men and others assigned female at birth, the puberty blockers will induce amenorrhoea, reducing distress associated with menstruation.

Currently goserelin (Zoladex®) implants have sole subsidy status, although leuprorelin (Lucrin®) injections are fully funded for children and adolescents who are unable to tolerate administration of goserelin.18 Table 2 presents clinical recommendations for puberty blockers, and standard dosing schedules. Puberty blockers should be continued until further treatments such as initiating other anti-androgens, accessing orchiectomy or other surgical interventions are decided on.

Table 2: Clinical recommendations and dosing schedules for puberty blockade.

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*Frequency can be reduced to 10 weeks if incomplete LH suppression, puberty progression, or ongoing menses.

Gender affirming hormonal therapy

Adults should undergo a medical examination and investigations prior to starting hormones (Table 3). It is important to evaluate and address any medical conditions that could be exacerbated by treatment.5 As with the use of oestrogen or testosterone in any context, clinicians should consider whether patients are; smokers, have a history of heart failure, cerebrovascular disease, coronary artery disease, atrial fibrillation, or personal risk factors for cardiovascular disease, history or family history of venous thromboembolism (VTE), migraine, history of sleep apnoea or hormone-sensitive cancers (eg, breast, prostate, uterine or testicular). Prescribers are advised to not consider any of the above conditions as absolute contraindications, but to consider and discuss any risks presented as part of the informed consent process.

Table 3: Medical examination and investigations prior to commencing gender affirming hormonal therapy.

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Feminising hormonal therapy (Table 4)

Table 4: Feminising gender affirming hormonal therapy dosing regimen and expected effects.5

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a - Complete removal of hair requires laser treatment;
b - Familial scalp hair loss may occur if estrogens are stopped;
c - Treatment by speech-language therapists for voice training is most effective.

Oestradiol valerate can be started in conjunction with an anti-androgen agent or added to a GnRH agonist (leuprorelin/goserelin). Goserelin (Zoladex®) is an option where oral anti-androgen agents are not tolerated. Anti-androgens are no longer required following orchiectomy or genital gender reassignment surgery. Start a low dose of oestradiol valerate (Progynova®/Estradot®) and increase the dose every 6–12 months depending on the clinical effect.

Potential complications for feminising oestrogen therapy include VTE particularly if aged >40 years and within the first two years of treatment.5 Transdermal oestrogen has lower risks for thromboembolism than oral oestrogen and should be considered particularly if increased risks are present. It is unclear whether oestrogen therapy may adversely affect the lipid profile and blood pressure, but any effect is likely to be modest.19,20 Liver dysfunction and gallstones are occasionally seen, although a clinically significant rise in the prolactin level is an uncommon occurrence.21 There may be alterations in mood and libido.

Masculinising hormonal therapy (Table 5)

Table 5: Masculinising gender affirming hormonal therapy dosing regimen and expected effects.5

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a - Sustanon contains peanut oil (arachis oil) and should be potentially avoided in those with peanut allergies.
b - Highly dependent on age and inheritance; may be minimal.

Testosterone can be added to a GnRH agonist or started on its own. Start a low dose of testosterone and increase gradually. Potential complications include polycythemia, which if severe, increases the risk of a thrombotic event. Periods will usually cease within the first 3–6 months of therapy. For those moving from GnRH agonists to testosterone, continue the blocker until the person is on the full testosterone dose and well virilised to avoid any undesired bleeding. For those not started on a GnRH agonist and not ready to start testosterone other interventions to achieve bleeding cessation include:

• Primolut® (norethisterone) po 5mg bd to 10mg tds. Note: Norethisterone is partially metabolised to ethinylestradiol, which at these high doses is equivalent to levels in the combined oral contraceptive.
  
• Provera® (medroxyprogesterone) po 10mg tds or 20mg nocte
  
• Combined Oral Contraception—continuous active pill taking to avoid menstruation
  
• Depo-provera® (medroxyprogesterone acetate) 150mg IM every 12 weeks
  
• Mirena® (levonorgestrel)—intra-uterine device
  

The additional consideration of need for adequate contraception may affect the choice made.

Trans people receiving maintenance hormonal therapy should have ongoing medical assessments and investigations as illustrated in Table 6.

Table 6: Maintenance surveillance for gender affirming hormone therapy.5

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a – testosterone should be measured midway between Depo T and Sustanon injections, immediately prior to a Reandron injection, and at least two hours after application of a testosterone patch.
b-consider testosterone dose reduction if Hct >0.54.

Gender affirming surgery

While many trans people are comfortable without, for others surgery is essential to alleviate their body dysphoria and live fully and authentically in their gender. Availability and funding are significant issues within Aotearoa, New Zealand. District health boards (DHBs) have expertise around provision of chest surgery (chest reconstruction to masculinise/breast augmentation to feminise where there has been no response to oestrogen), hysterectomy, oophorectomy and orchiectomy. Some DHBs have expertise in plastic surgical techniques such as laryngeal shaves and facial feminisation. Clinicians should be aware of local services and referral pathways. Currently access to genital reconstruction surgery (metoidioplasty or phalloplasty (masculinising) and vaginoplasty (feminising)) is via the Ministry of Health high-cost treatment pool (see website23).

Table 7 presents the surgical criteria recommended in the Aotearoa, New Zealand guidelines. These are the same as the current WPATH SOC.3

Table 7: Aotearoa, New Zealand Guidelines and WPATH SOC v7 criteria for access to gender affirming surgery.3

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Other gender affirming care

Laser hair removal is important, particularly as feminising therapies will not completely halt facial hair growth that is already established. Be aware of local providers and support access where possible. Wearing a chest binder to achieve a more masculine chest appearance may be important; discuss safe use to prevent health risks associated with prolonged use.24 Speech and communication are fundamental to people’s genders. The goal of speech-language therapy is to help trans people develop voice and communication that reflects their gender.

General healthcare

All New Zealanders have the right to healthcare that is respectful and non-discriminatory. Ensuring healthcare services are inclusive of gender diversity is fundamental to good health care for trans people. Apart from gender affirming healthcare, trans people experience the same health needs as others. Those who have not undergone surgical removal of their breasts, cervix, uterus, ovaries, prostate or testicles remain at risk of cancer in these organs and should undergo screening as recommended. Manage sensitively, as many trans people find cancer screening extremely challenging, both physically and emotionally. Refer trans women for mammograms as per the National Breast Screening programme. Use of internal oestrogen cream prior to cervical smears in trans men may reduce discomfort and reduce the risk of inadequate smear tests.

General recommendations

Based on the guidelines outlined above, to best support the needs of transgender people in Aotearoa, New Zealand, we recommend that:

1. All health services provide equitable and accessible gender affirming healthcare services that align with international standards, evidence-based literature and community feedback.
   
2. DHBs enable flexible and responsive pathways on the basis of informed consent and self-determination.
   
3. Health services enable the involvement of trans people, including Māori trans people, in decisions that affect them regarding the development and provision of services.
   
4. Health services must support the development of culturally appropriate practice within clinical settings that acknowledges kaupapa Māori health frameworks.
   
5. DHBs provide clear information about pathways to access gender affirming healthcare services. This is inclusive of health services delivered by DHBs and primary healthcare.
   

Conclusion

The Guidelines for Gender Affirming Healthcare for Gender Diverse and Transgender Children, Young People and Adults in Aotearoa, New Zealand have been developed in acknowledgement of the substantial increase in demand and significant evolution that has occurred in the period since the publication of currently used documents. The above summary provides an overview of gender affirming healthcare, while the full guideline details the role of the healthcare workforce in the provision of holistic healthcare for transgender people. We hope these guidelines will support the development of health services around the country, and provide helpful guidance to all health professionals involved in the care of transgender people.

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