Hormone Replacement Therapy 101

Curious about the basics of gender-affirming care? The use of HRT has been foundational and approved as the best form of treatment for transgender people for nearly a century. Learn the facts about hormone replacement therapy and its importance in this week’s post. Looking for other transgender resources? Click here.

What is HRT?

HRT, also known as hormone replacement therapy, is the use of synthetic hormones to mimic traditional sex hormones. Hormone treatments were originally invented in the early 1900s, related to when researchers discovered how to isolate and synthesize testosterone and estrogen, and became widely prescribed to cisgender folks by the 1960s.

Even though HRT is commonly associated with transgender people and our transitions, it’s utilized more often by cisgender individuals – these hormone treatments were created to help with the lower levels of sex hormones cisgender men and women experience as they age. The use of hormone replacement therapy as gender-affirming care and a means to allow transgender people to medically transition began in the 1950s through the John Hopkins School of Medicine, Harry Benjamin, and Christian Hamburger. Gender-affirming hormone therapy (GAHT)/hormone replacement therapy (HRT) is the use of prescribed synthetic hormones to align one’s secondary sex characteristics with their gender identity – which ranges from body fat, breast growth, muscle mass, vocal range, hair, Adam’s apple, etc.

What are Puberty Blockers?

Puberty inhibitors and blockers suppress the natural production of sex hormones like testosterone and estrogen, created and approved by the FDA to treat precocious puberty in cisgender children. Due to the growing trend of children starting puberty earlier than normal, puberty blockers became more commonplace for doctors to prescribe to cisgender patients. Around the same time, puberty blockers were being used experimentally abroad to help transgender children explore their gender identity more thoroughly by the 1990s via the Dutch Protocol. The primary purpose of puberty blockers is to pause cisgender-associated puberty in youth wanting to explore their gender identity without the use of HRT. After spending an ample amount of time solidifying their gender identity, they can continue their medical transition through hormone replacement therapy to mimic puberty aligned with their internal gender; if they change their mind regarding their gender identity, puberty blockers can be stopped at any time and puberty will begin/resume as normal.

Before continuing, I cannot stress enough that puberty blockers and hormone replacement therapy are widely considered safe by the scientific community. Both treatments have been used to treat gender dysphoria for decades and it’s been established blockers are the best and most humane way to allow gender-diverse children to explore gender since blockers are entirely reversible. The only genuine negative side effect associated with blockers is lower bone density that is created by bone mineralization during puberty – but this is easily managed with exercise, calcium, and Vitamin D. There is not much high-quality research on the long-term effects of puberty blockers, just as there is little long-term research on transgender people as a whole – but information available supports that the use of puberty blockers. Even if all parents/legal guardians approve of a child receiving puberty blockers, many additional steps are required to ensure they are the best option for the child’s health and well-being. Despite this consensus, many bad actors intentionally lie to harm transgender people: it has been leaked and proven that anti-trans politicians are purposely using funds to back pseudo-scientific research against gender-affirming care in their bills. It is incredibly easy for institutions and figures to create misleading research to support inaccurate beliefs; the foundations that host their findings are non-profit, using governmental 501(c)(3) status to legitimize their work even though anyone can create a non-profit by filling the appropriate paperwork. Many organizations have tried to ‘debunk’ puberty blockers and the Dutch protocol out of a political agenda – but none of them can debunk the actual use of blockers in trans children, which is to simply pause puberty temporarily (not ‘cure’ gender dysphoria, force children to take cross-sex hormones, etc.) As such, there are no reputable organizations, institutions, or research groups that dispute the effectiveness of gender-affirming care.

Puberty blockers are most often prescribed for gender-diverse youth between the ages of 9 to 16, but this can vary based on your needs since bodies vary. Once prescribed, blockers come in two forms: the histrelin acetate rod can be inserted under the skin in your arm and lasts for one year, while the leuprolide acetate shot can work up to 1, 3, or 4 months at a time. However, puberty blockers and gender-affirming care for minors are currently highly controversial for reasons stated above – as of 2025, there are six states that make it a felony crime to provide gender-affirming care to transgender youth.

On January 28th, 2025, President Donald Trump signed the executive order “Protecting Children from Chemical and Surgical Mutilation,” which prohibits federal funding and research on gender-affirming care for all individuals under the age of 18 in the United States. On paper, this bans the use of Medicaid, TRICARE, and other government programs from prescribing puberty blockers, hormone replacement therapy, and other well-supported forms of care until age 19. However, this order has long-reaching effects which is why it is being challenged in court – hundreds of hospitals and clinics are preemptively stopping gender-affirming care entirely out of fear, and even more facilities have stopped providing gender-affirming care entirely to all transgender people regardless of age since they rely heavily on federal funding.

I would normally try and insert an information video about puberty blockers – but YouTube is infested with anti-transgender content on the topic due to recent news from both the Trump administration and overseas in the United Kingdom.

Mythbusting HRT: Fact-Checking Gender-Affirming Care

MYTH: GENDER-AFFIRMING CARE IS UNSAFE.
FACT: As I mentioned above, gender-affirming care is supported by every major medical and mental health association. Age-appropriate transition care is considered both medically necessary and life-saving for individuals who experience gender dysphoria, or a disconnect between their internal gender identity and sex assigned at birth. While there are some negative health risks associated with hormone replacement therapy that I will cover later, they are immensely manageable and outweighed by the positive impacts of gender-affirming care. Over 1.3 million licensed doctors in the US support gender-affirming care, as well as leading organizations like the American Medical Association, American Academy of Pediatrics, and American Psychological Association.

MYTH: ONLY EXTREMIST LEFTIST DOCTORS SUPPORT GENDER-AFFIRMING CARE.
FACT: In the United States alone, over 1.3 million licensed doctors support gender-affirming care. That’s because transgender healthcare is overwhelmingly backed by research! That’s essentially every single registered physician considered active by the American Medical Association. Not every doctor agrees on gender-affirming care, and there are plenty of physicians that are not well-informed on how to interact with transgender patients – but the underlying consensus no matter what is that gender-affirming care is necessary.

MYTH: BUT [INSERT STUDY HERE] SAYS GENDER-AFFIRMING CARE IS DANGEROUS!
FACT: Also mentioned above, there is a growing wave of anti-trans pseudoscience being funded by politicians with bigoted and nonscientific agendas. We live in a universe where you can purchase a degree from nonreputable sources, and astroturfing proves how widespread fake movements are in funneling money to bad science. If someone lacks integrity, it is not hard to manipulate research into creating “proof” that supports your claim – most commonly, these individuals will manipulate the data gathered in their research by deleting objecting evidence and using misleading questions. The amount of junk science that opposes transgender rights and healthcare is overwhelmingly outweighed by real researchers and associations – which have real relevant experience, qualifications, peer-reviewed work, and publications by reputable journals.

MYTH: GENDER-AFFIRMING CARE IS EXPERIMENTAL, OPTIONAL, AND EXPENSIVE, SO IT SHOULDN’T BE COVERED BY HEALTHCARE INSURERS.
FACT: Again, gender-affirming care is well-documented as necessary and life-saving by all major medical institutions in the United States. It’s not experimental – transgender healthcare supporting transgender people and their identities has been around since the early 1900s, through the evidence of Magnus Hirschfeld and the Institute for Sexual Science before Nazi Germany purposely burned the research hospital down. It’s also deemed medically necessary – so it’s not optional. Not every transgender person medically transitions, but the ability to do so is a fundamental right and is supported by science.

It’s estimated that transgender people make up 1.6% of the American public – which is roughly the same number of natural redheads in the US. Transition-related care accounts for 0.1% of overall medical costs. When considering the number of total Americans in the healthcare system paying for coverage, the cost of coverage for gender-affirming care for insurance providers ranges between 4¢ to 10¢ per insured payee. It’d be unfathomable for providers to refuse coverage for other conditions like depression and diabetes – even though they’re more costly to insurance providers.

Lastly, federal law states that insurance providers can limit care, even if it’s deemed medically necessary – but they are not allowed to deny care based on patients. If a provider covers mastectomy for cancer or genetic predisposition, they must also cover it for gender dysphoria. Providers that cover hormone treatments for cisgender people cannot deny HRT for transgender individuals. Doing so is considered discrimination and blatantly against the law.

MYTH: MOST PEOPLE THAT TRANSITION REGRET THEIR DECISION!
FACT: Any “research” you read regarding this, I invite you to reread the above section on junk science. Detransitioning, or the act of reverting to your sex assigned at birth, is exceedingly rare and studies report “transition regret” as low as 1% to 2% of all cases – although these numbers vary drastically due to the political slant in the research. In reality, gender-affirming care actually has the lowest regret rates in the medical field – your average major surgery has a 5% to 10% regret rate, knee replacement surgeries have rates up to 30%, and pregnancies have roughly a 7% rate of regret. You wouldn’t dream of preventing someone from having knee surgery or a baby because they might regret it later.

Potential regret is why puberty blockers exist for trans kids. Blockers allow transgender youth to explore their gender identity before medical transition since they’re reversible. Even for adults, gender-affirming care is not someone people just wake up and decide one day. Surgery requires letters of approval from mental health professionals, which can take three to twelve months of appointments to get. While informed consent clinics make it easy for transgender adults to access hormone replacement therapy, they’re still not going to prescribe hormones for someone who “decided” they were trans that same day – they’re going to make sure you have fully thought through your decision and can give medical consent.

MYTH: PEOPLE ARE ONLY BECOMING TRANSGENDER NOW BECAUSE IT’S TRENDY.
FACT: Transgender people have existed as long as humanity has existed. We will continue to exist no matter what laws are passed, even if we are forced back into the closet. While more people are open about their transgender identities, it’s not because it’s suddenly trendy – it’s just safer and more socially acceptable to be open about it. Language changes, so more people are able to become familiar with words like transgender to describe their experiences – in the past, people who would identify as transgender today might have identified as drag performers, crossdressers, transsexuals, transvestites, or even butch women and femme men.

The right-wing “social contagion” theory has been repeatedly debunked. The theory asserts that “rapid onset gender dysphoria” occurs in today’s youth due to social media – but there is zero empirical evidence to support this claim. This conspiracy theory is used by lawmakers to justify anti-trans legislation, and most medical associations have made official statements to eliminate this term from being used.

MYTH: CHILDREN SUBJECTED TO GENDER-AFFIRMING CARE HAVE MEDICAL PROCEDURES THAT WILL PERMANENTLY ALTER THEIR LIVES.
FACT: News articles that claim this are sensational and intentionally trying to mislead you. Before puberty, transition is entirely social for children – as well as for most adults in the beginning processes of exploring their gender. Social transition involves no medical interventions and therefore is completely reversible, such as using a new name, pronouns, clothing, or hairstyle. The only possible negative consequence of social transition is potential bullying and discrimination – but it is in no way that person’s fault they are being bullied or harmed due to a society that is adverse to exploration.

If a child is exploring their gender identity at the onset of puberty and they have supportive parents, they might have access to puberty blockers to pause puberty temporarily while they continue to explore. Blockers have been approved as the gold standard by the FDA since 1993 to pause puberty. Complications like bone density are easily remedied with supplements and existing research on puberty blockers used on cisgender youth with precocious puberty shows normal fertility and reproductive functioning after reversing their blockers.

There are no young children who are being subjected to transgender-related surgeries. In extremely rare cases, 16 and 17-year-olds can get specific surgeries like chest/top surgery only if they have been consistent in their current gender identity for years, have been taking gender-affirming hormones for an extended amount of time, and have approval from all parents/legal guardians and doctors. Once all of those factors are achieved, they still have to get additional approval from multiple mental health providers and physicians to determine that surgery is the best course of action. By the time that process is done, that young person is most likely 18 – which is why the overwhelming majority of transgender youth wait until that age to pursue gender-affirming care.

The only form of “mutilating” sex surgery performed on children is perpetrated by conservatives. Intersex medical interventions, or genital mutilations, are performed on intersex infants to align with stereotypes on how male and female genitals should look – with or without parental knowledge.

MYTH: ANTI-TRANS BILLS ARE ALL ABOUT PROTECTING KIDS!
FACT: Politicians who insert partisan debates in private conversations never genuinely care about science, medicine, or evidence. If these bills were about protecting kids, anti-abortion politicians would ensure the United States has an immaculate foster care system, education program, and policies to uplift youth. Instead, those same politicians have zero empathy for new mothers, purposely try to destroy public education, disavow sexual education entirely, attempt to dismantle foster care systems, create higher costs for giving birth and parenthood, and penalize youth at every possible chance. Anti-trans bills and their lawmakers are fueled by bad faith – politicians that regularly try to defund services like mental health cannot be taken seriously when they try to claim they are “protecting kids.”

There have been clear, well-established, and evidence-based standards of care for transgender people for nearly a century – the World Professional Association of Transgender Health (WPATH) has maintained these standards for decades. These standards advocate that gender-expansive youth have access to socially explore their gender before anything else.

How Do I Get HRT?

There are two primary routes to get prescribed hormone replacement therapy: letter approval and informed consent. Both are acceptable ways to legally get access to hormones – but the path you should take will depend on your needs and local laws.

INFORMED CONSENT

The informed consent model of care is the most modern and reduces gatekeeping that bars many folks from receiving healthcare. The idea behind informed consent is that most adults can make decisions about their own healthcare when given accurate and in-context information. After finding a provider that uses the informed consent model, they’ll educate you on the possible benefits and risks to HRT before having you sign off on the paperwork needed to state you are officially consenting to the medication plan.

To be able to use informed consent, you will need to be your own legal guardian. Most people automatically do this upon turning 18, although your situation may vary. Upon meeting that standard, your provider must feel confident that you understand the information given to you, so they’ll likely break down medical terms and videos, photographs, and guides.

Wanting to find an in-person informed consent provider? Erin Reed has a detailed map and Planned Parenthood is one of the largest providers in the United States. Due to the current administration, it is advised to find a provider you can see in person – political attacks on trans-related telehealth make online options less viable for the immediate future. However, FOLX and Plume are the best telehealth HRT providers that prescribe hormones online.

The greatest pro to informed consent HRT is the speed of the entire process. Some clinics will prescribe you hormones the same day that you make your appointment. A common complaint about the traditional route where you’re required to get a letter from a mental health professional is that trans folks feel like they’re performing their transness for their provider – giving a long story on when they first realized they were transgender, often embedded with many of the stereotypes cisgender people have about transness to get their medication. By removing that barrier, trans people are more free to be themselves.

LETTER APPROVAL

Until 2012 upon the release of WPATH’s 7th edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, the approval letter model was the only way to access hormone replacement therapy – the 7th edition officially opened the path for providers to prescribe HRT through informed consent.

The letter approval model requires transgender people to acquire a letter from a therapist or other mental health professional stating that gender-affirming care like HRT is medically necessary for their well-being. This method is becoming less common since it encourages negative stereotypes about transgender people as they’re forced to cater to the understanding (or lack thereof) of transness that a mental health provider has to receive their letter of approval.

The process can take anywhere from three to twelve months since it requires the therapist to feel fully confident that gender-affirming care is medically necessary for their client before signing the letter. However, the letter approval model is more stable and tends to offer more financial stability – most insurance companies will put up a fight on covering any sort of medical care, and this is definitely the case within transgender healthcare. It’s also worth noting that since the letter approval model is more traditional and has been used for decades, it’s less likely to be impacted by anti-transgender laws or executive orders in the years to come.

Providers that offer gender-affirming care through the letter approval process often work on a much smaller scale and are significantly more common in rural settings. While large gender clinics have specialized staff to prescribe informed consent HRT, these providers may be primary care physicians, endocrinologists, gynecologists, urologists, psychologists, or psychiatrists.

Feminizing Hormone Therapy (FHT)

Feminizing HRT uses a combination of several hormones to create physical changes in the body typically caused by female puberty. Gender-affirming hormones stimulate nearly all of the same changes that occur during puberty for cisgender girls. Most individuals take a combination of estrogen (estradiol) and antiandrogens (spironolactone) since a testosterone-blocking medication is required to ensure the synthetic estrogen works best. While it’s not as common, some providers also prescribe progesterone to aid FHT.

Estradiol is prescribed as a pill, injection, and skin patch. Throughout your healthcare journey, your provider will regularly check your hormone levels with blood tests to ensure they’re in an optimal and healthy range. The effects of FHT vary from person to person – puberty is different for cisgender and transgender people alike, and the best way to predict what your results will be is to look at women you’re immediately related to. The combination of testosterone blockers and estrogen causes breast growth, softer skin, less facial and body hair, decreased muscle mass, and more – but FHT can’t change the pitch or sound of your voice, which is why some people opt for voice feminization surgery or voice therapy.

There is a lack of substantial research on the long-term effects of hormone replacement therapy on transgender bodies – however, it’s important to note in any research that you read regarding the risks that HRT makes your body medically female. Women are more at risk of developing conditions like osteoporosis and osteopenia. Current information about transgender healthcare will reflect this, but older studies are often cited with bad intentions without including this. Genuine risks associated with gender-affirming care include things like infertility and erectile dysfunction. In the event that you wish to pursue parenthood, some transgender people pause their FHT temporarily to increase their fertility – but it’s not guaranteed since the longer you are on HRT, the more likely you are to become permanently infertile. Complications with HRT can be lowered and managed by regularly seeing your healthcare provider.

Masculinizing Hormone Therapy (MHT)

Masculinizing HRT primarily uses testosterone to create physical changes in the body typically caused by male puberty. Gender-affirming hormones stimulate nearly all of the same changes that occur during puberty for cisgender boys. Compared to FHT, only one medication is prescribed – testosterone does not need additional medication used since it naturally overpowers the effects and production of estrogen. That process is the exact reason why FHT tends to require both estrogen and testosterone blockers to have a noticeable effect.

Transgender people are most commonly prescribed testosterone as a shot, skin patch, pellet, or gel. Testosterone also comes in a pill form, but it is not often prescribed as gender-affirming care since its pill variant is harsh on the body long-term. Throughout your healthcare journey, your provider will regularly check your hormone levels with blood tests to ensure they’re in an optimal and healthy range. The effects of MHT vary from person to person – puberty is different for cisgender and transgender people alike, and the best way to predict what your results will be is to look at men you’re immediately related to. Testosterone generally causes facial hair, body hair, voice changes, greater muscle mass, oily skin, possible hair loss, and more – like with FHT, you can’t choose which effects of hormone replacement therapy you’ll receive since it’s based on genetics.

As mentioned above regarding feminizing hormone therapy, there is a lack of substantial research on the long-term effects on transgender bodies. Despite this, gender-affirming care is considered medically necessary and important to provide since it alleviates gender dysphoria and allows transgender people to live as their authentic selves. Many of the associated risks documented in older research on HRT are common health risks that cisgender men are generally more likely to have than women – like high blood pressure, male-pattern baldness, acne, and diabetes. The most typical genuine risk associated with gender-affirming care is infertility; while testosterone may decrease the chance of pregnancy, it is not an effective birth control method and does not fully prevent it. In the event that you wish to pursue parenthood, some transgender people pause their MHT temporarily to increase their fertility – but it’s not guaranteed since the longer you are on HRT, the more likely you are to become permanently infertile. Complications with HRT can be lowered and managed by regularly seeing your healthcare provider.

Nonbinary Hormone Therapy (NHT)

There is no one way to be nonbinary – but some nonbinary people pursue hormone replacement therapy as part of their journey to live comfortably in their own bodies. Compared to FHT and MHT, nonbinary hormone treatments aim to balance the levels of estrogen and testosterone in the body to create an androgynous appearance. The most common route is microdose HRT, or when hormone replacement therapy is prescribed at a much lower dose than traditional levels. Changes take significantly longer to occur but allow the individual to stop more immediately when they are satisfied with the changes. Since it is impossible to directly choose what changes will occur on HRT, this gives a small level of control since the changes associated with HRT are gradual like cisgender puberty.

For individuals assigned female at birth, testosterone is often prescribed at a low dose for a short period of time. Those assigned male at birth may choose to use a low dose of both testosterone blockers and estrogen or opt for just estrogen. In both cases, it is important to remember that not all changes caused by HRT are permanent – some, like voice changes, breast growth, and clitoral growth are permanent while others like fat redistribution, acne, and periods are not.

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