Transgender Teen Survival Guide

(Re: this post)

Lee says:

It really depends on the provider.

Some providers/clinics that provide HRT via informed consent will have an "information session" which is basically a presentation of the changes that will happen on HRT and the potential risks.

The "information session" might be a semi-informal individual consultation-style appointment where you discuss the effects of hormones one-on-one with the provider who will be prescribing them and they verify that you understand the changes that hormones can cause and you assert that it's something you're interested in.

The "information session" could also be a group presentation where a group of people planning on starting hormones attend a meeting where the provider does a PowerPoint-style presentation and then takes questions at the end.

Or you may not have a formal "information session". Instead, you might just have an appointment where they give you a packet of info that lists the changes and side effects that you can expect from hormones, and then you sign on the last page indicating that you understand the effects and consent to getting hormones.

Often informed consent does allow you to start HRT within only 1-3 appointments. First, you’ll have to schedule an appointment with said provider who is ideally in-network with your insurance. Then you'll have an initial consult/intake (which may be combined with your information session) where you discuss your goals and get blood drawn for labs. Finally, you'll have your information session if you didn't have that done in your intake, and you'll get your prescription.

Even if you don't have an informed-consent provider and they require you to have a WPATH letter from a mental health professional before you can get your prescription, you still may have to attend an information session or read a packet and sign papers asserting your consent.

But yeah, the way informed consent works varies a lot by the particular clinic or provider, and there isn't a standardized order of appointments or steps that every single provider follows so the way I got testosterone may or may not be the way you get your HRT.

Lee says:

If you live in the USA and you are an emancipated minor then you no longer have to obtain consent from your parent for anything because your parent isn’t your legal guardian anymore. You’re legally responsible for yourself and you don’t need anyone to consent on your behalf.

In general, an emancipated minor does not require parental consent to enter into contracts, get married, join the armed forces, receive medical treatment, apply for a passport, open a bank account and control finances, etc.

(Side note: emancipated minors aren’t usually treated as 21 year-olds which means you can’t necessarily buy alcohol; you’re more or less considered to be 18 in terms of your legal obligations and responsibilities.)

To become an emancipated minor you usually have to file a petition to prove to the court you are responsible enough to take care of yourself, and you generally also must show proof that you have enough income to be financially self-sufficient. 

You basically are showing the court that you’re already fending for yourself and/or are able to do so, and you don’t need your guardian to provide for you anymore.

So when you’re an emancipated minor you don’t need parental permission for most things, but the flip side is now they aren’t legally required to take care of you. That means they don’t need to provide housing and can legally kick you out, they don’t need to buy you food and it isn’t neglect if they choose not to feed you, and so on. If you are reliant on them, then this isn’t great for you.

You should look up “emancipated minor [your state/county]” to find out more if you’re interested in petitioning the court; laws are different in different places, and some states set a minimum age at which emancipation can be granted. So you can’t necessarily become an emancipated minor at 6 years old, for example, not that that applies to you haha.

Of course, just because you’re able to legally consent to starting testosterone doesn’t mean that a provider is required to prescribe it. Some doctors may refuse to prescribe it to you because they don’t feel comfortable prescribing testosterone to someone of your age, even through they legally could if they wanted to. But there are providers who would be okay with it, you’d just have to find them. More info on the process of starting testosterone is in our Testosterone FAQ.

TL;DR: No, you would not need the permission of your legal guardian to start hormone replacement therapy if you become an emancipated minor because you would no longer have a legal guardian.

Lee says:

Their website’s FAQ says:

Plume is currently only available for people 18 and over, so you can’t be a minor.

You cannot use insurance, Medicaid, or Medicare to pay for Plume. 

The out-of-pocket total cost for Plume is $1,188 (one thousand, one hundred, and eighty eight dollars) per year, plus the cost of the copay for buying the HRT from the pharmacy.

Breaking it down:

I think it really depends on your situation. When I started testosterone, I lived in CT, which isn’t a state that they offer services in.

You have live in one of the following states:

Whether or not Plume is a good option for you depends on a few factors. Do you live in one of the states they cover? Is paying $1,188.00 per year going to be less expensive than the cost of seeing a doctor and getting lab work using your insurance? 

Here’s an example: I had an appointment when I started T, then another at 3 months, at 6 months, and at 1 year on T. Each appointment was covered by my insurance because I saw an in-network provider, and it had a $40 specialist fee copay. So that’s a total of $160 out of pocket for appointments in one year. 

But of course, that’s only the appointments! I also had blood work done each time, which my insurance mostly covered, and I’ll put that at $100 per lab. So that’s a total of $400 out of pocket for labs. 

So in one year, I paid $560 in total, which means Plume would have been more expensive for me.

Let’s note here that I was not even including the price of testosterone, which for both options you’d be either paying out of pocket, paying with a GoodRx coupon, or trying to get insurance to cover it and paying a copay. So let’s say I was on testosterone gel and had a $30/month copay because it was covered by my insurance but more expensive than injections. So let’s put that at $360.

In one year, I’d pay:

Now I had pretty bad insurance. If you have better insurance which charged you only a $20 copay for your appointments, or you only had to pay $50 per lab, or you were on testosterone enanthate injections and only paid $10 for a three month’s supply of testosterone, you’d be saving even more money.

Of course, the reverse is also true- if you have worse insurance than I did, your costs could be higher than the ones you’d be paying with Plume, especially if you were paying for all your lab work out of pocket. That’s where the costs really add up.

The Plume website offered these suggestions for defraying the cost:

The easier access with Plume also factors in to people’s calculations as well. 

But of course, minors can’t use Plume right now, even if they have parental consent.

Note that you can start HRT as a minor elsewhere, you just have to have permission from your legal guardian to start HRT if you’re under 18 unless you’re an emancipated minor. This post should help with getting the conversation started with your parents about starting HRT.

Some endocrinologists don’t allow someone to start HRT until they’re 16, but this is up to the prescriber’s discretion because there are no laws saying what age is too young to start hormones- some people even start HRT at 13. You do have to have started puberty to get HRT. If you haven’t started puberty yet, you should look into puberty blockers.

If you’re a minor and can’t use Plume, or you’re 18+ and want to explore your other options, here are the two most common methods for accessing HRT:

Option 1: Informed consent

Informed consent. This means that you discuss the effects of transition with a doctor, typically an endocrinologist or urologist (which more common for AMAB people), and confirm that you understand what you’re getting into.

Legally any medical provider who can prescribe medication can prescribe testosterone, but few of them are willing to do so because they don’t have experience with prescribing testosterone and ordering and interpreting the blood work and ensuring you’re healthy, so they aren’t comfortable doing it.

You’ll have to read and sign a document that lists all the changes to expect and potential health risks. (Examples of that document are here). You’ll get some tests done and then you’ll be good to go!

Important to note: You must be 18 years of age or older to consent for yourself. I haven’t heard of any minors getting informed consent without their parents’/guardian’s help, although it may be possible. Also, not all insurances will cover informed consent services because they may require WPATH letters sent to them to approve gender dysphoria treatment/coverage. If you want insurance to cover your HRT, speak to your insurance provider (call the number on the back of your insurance card).

Resources: ICATH has some good US-specific resources for informed consent. @plannedparenthood also provides informed consent services for HRT in some locations.. This Google Maps list here has a lot of informed consent clinics listed as well to check out, although it’s not a full list of all of them.

Option 2: Therapist’s letter

Therapist’s letter. This is the “traditional” method, based on the WPATH Standards of Care. Basically, you talk to a therapist, sometimes for several months. Usually, the therapist is one who knows about gender identity issues, or even specializes in them, but it doesn’t have to be - the main idea is that you’re looking for someone who can keep up with you and isn’t going to tell you that you’re mentally ill because you’re trans, so finding an LGBTQ-friendly therapist is a must. They write a letter that follows the guidelines in the example below, hand it off to insurance and your doctor, and you’re on your way. An example of that letter is here.

How long you have to see your therapist before their letter will work for you depends on a) the therapist, b) the doctor you want to see, and c) your insurance (if you plan on seeking coverage). You’ll have to communicate with all of these people in order to work out their requirements. The timeframe is typically around 3 months, but it can be longer or shorter depending on those factors. Information on getting a trans-friendly therapist is here.

Important to note: Not all insurances will cover HRT with a therapist’s letter, either, although many states are making it illegal to deny transition-related services. Be sure to check with your insurance provider first! Check out our Getting insurance to cover your transition post.

After that:

Finding a doctor can also be hit-or-miss. You can speak to your GP (general practitioner; i.e. the doctor you go to for regular checkups) - sometimes they know what they’re doing, and I’ve definitely heard of GPs prescribing HRT or hormone blockers to their patients.

You can start with contacting your primary care doctor and asking if they can prescribe your T, or if they have any referrals to places that do prescribe HRT. Some people can get their HRT prescribed by pediatrician/general practitioner!

However, most of them will refer you to an endocrinologist (and many insurance plans require referrals before you can skip off to a specialist, too) for the actual hormones. Then you can also check with local Planned Parenthoods to see if they prescribe HRT or if they can refer you to someone who does.

You can also check with your insurance to see if they cover any endocrinologists in the area, then contact those endocrinologists who see If they can prescribe your T, or if they have any referrals to places that do prescribe HRT.

You should also reach out to the trans community IRL- they have to be getting their hormones from someone! If there are any trans support groups in your area, or LGBT organizations, ask them if they have any providers they can point you to.

And finally, it can also be helpful to simply do some googling! I (mod Lee) found my endo by google. It can take some legwork to find a trans-competent doctor who will prescribe HRT, but you just gotta keep trying!

I started HRT at Planned Parenthood with a nurse, then I switched to an endocrinologist associated with a local hospital, then I moved states and got my T from a nurse at Callen-Lorde. So I saw two nurses and one MD— you don’t need to see an endocrinologist!

While endocrinologists often specialize in HRT because hormones are part of the endocrine system, you can get HRT prescribed by many nurses, and by pretty much all doctors including psychiatrists and urologists.

Some doctors won’t let you do HRT. It’s okay if you shop around. Look around online; call their office first to make sure they work with trans patients. Remember, if a doctor refuses you healthcare, you have a right to refuse them your business!

Once you get to a doctor, you’ll get a preliminary blood test and a general health screening to check for contraindications (any medical conditions that might make it difficult or impossible for you to be on HRT). Nearly every contraindication is possible to work around, though, so don’t worry too much! They’ll likely be looking at your cholesterol levels and heart and liver functions in particular, although this may vary from doctor to doctor and treatment to treatment.

Finally - as long as all medical conditions are sorted out - you’ll be prescribed your hormones. You can choose which delivery method you receive.

For testosterone, the most common forms include injections (which involve needles, but typically only need to be administered once a week or every 10 days), patches (daily, can badly irritate sensitive skin), and creams / gels (daily, have to be careful so that you don’t get it on another person). More info on testosterone is in the Testosterone FAQ.

AMAB folks will need to take both estrogen and an anti-androgen. Typically, estrogen is oral, but can also come in the forms of injections; anti-androgens are nearly always oral. More info on estrogen is in the Estrogen & anti-androgens/testosterone blockers FAQ.

Stick to the instructions they give you in terms of dosage and administration - they give these instructions for good reason! Your doctor should monitor your hormone levels and health status / conditions, and will likely adjust your dosage as time goes by to ensure it is still accurate, so make sure you continue to go in for checkups.

So that was how you’d be looking into starting HRT if you weren’t using Plume.

But if you live in a rural area, and there’s no Planned Parenthood that’ll prescribe testosterone near you, there’s no LGBTQ+ clinic anywhere, your primary care provider refuses to prescribe your testosterone, you’ve called around to other general practitioners in the area and nobody else is willing to do it either, and after a bunch of back and forth phone tag with their office the only endocrinologist in a 500 mile radius eventually says they won’t treat trans people, you can’t find urologist or psychiatrist who feels comfortable doing it, etc, and you find yourself having to first jump though the WPATH hoop and find a therapist willing to write you a letter and then find a way to travel 4 or 5 hours for your HRT appointment and then you have to fight with your insurance to get blood work covered... Plume is going to start looking more appealing even if you do end up having to pay more.

Personally, as someone who is on HRT, and has recently moved to a Plume-covered state, am not tempted to switch to Plume at all. I’m lucky enough to have moved to NY and while it does take me around an hour and a half to two hours on public transport to get to my doctor, I was just approved for NY Medicaid and now I basically pay $0 in total for my appointments, blood work, and my prescription costs are capped at $3 per prescription. So at max I’m paying $36 per year now.

Another alternative to Plume is QMed.

They write “QMed accepts patients of all ages and provides puberty blockers for those yet to enter puberty,” so you can get HRT or puberty blockers from them as a minor, but you do need to have permission from your parent/legal guardian to do so.

They do say that “All states require that patients receiving testosterone need to have at least one in-person appointment prior to starting hormone therapy. When we receive your first appointment request, we will help you determine if and when you will need that required visit,” so it may be an easier for people starting estrogen than people starting testosterone. But I think that’s different now- their most recent update says: “Prior to the spread of COVID-19, an in office visit was required for the initial consultation for testosterone. However, the government has waived this requirement until further notice, so we are only offering video visits until the pandemic is under control to protect our patients, families, and staff.”

They say they accept Aetna, SOME Blue Cross PPO plans, Cigna, Humana, PHCS. But they do not take Medicare, Medicaid, Peachstate, Ambetter, United, or Kaiser. If your insurance is accepted, the cost will be the same as it would be to go to an IRL prescriber.

If they don’t accept your insurance and you self-pay for some of their appointments the first visit will cost $299, and visits after that will cost $149. But you’ll only have to pay when you have an appointment, so there’s no monthly fee. Blood tests will be $99 each time they check hormone levels, which may be needed up to 4 times in the first year, and 1-2 times per year after that.

QMed uses the informed consent model for patients 18 or over, so a therapist visit is not required. But a letter from a mental health professional following WPATH standards is necessary to start hormones if you’re a minor.

Plume is currently only available for people 18 and over, so you can’t be a minor, but QMed does accept minors who have parental permission.

Anyway, back to the Plume thing! I haven’t heard anything bad about them in the posts I’ve read online though. Most people seem pleased but frustrated with the cost. One person wrote “The sign up process was on multiple apps and intake forms were disjointed. While this may be useful for new people who wanted to start HRT, for folks wanting to continue care I found the question about how long have you felt this way, how long have you been living in your gender offensive.”

I don’t personally know anyone who has done it because most of the folks I know don’t constantly have $99 each month to pay out of pocket so they tend to go the traditional route even if it’s harder logistics-wise, but I don’t live in a rural area so going the traditional route is a possibility for me, and it might not be so easy for others.

The one thing I’d remind everyone of is the cost. Losing access to testosterone can be a physical health issue if you’ve had a hysterectomy and oophorectomy and are worried about osteoporosis without having a dominant hormone, and the same if you’re on estrogen and had an orchiectomy, so remember that the $1,188/year cost for Plume doesn’t include your hormones themself! So consider how much the individual testosterone vial/estrogen patch/antiandrogen pills/etc will cost when you go to the pharmacy to pick it up!

I’m on Medicaid and it covers HRT because I live in a state that requires trans care, so I don’t have to pay any more than $2/month in copays for the testosterone and nothing at all for my appointments and blood work so even though I have to travel an hour and a half to the nearest city for my appointments, it’s still worth it.

Followers, has anyone over 18 used Plume to get their HRT prescription and would you recommend it? Or have you heard anything cautioning against it?

Lee says:

Legally any medical provider who can prescribe medication can prescribe testosterone, but few of them are willing to do so because they don’t have experience with prescribing testosterone and ordering and interpreting the blood work and ensuring you’re healthy, so they aren’t comfortable doing it.

You can start with contacting your primary care doctor and asking if they can prescribe your T, or if they have any referrals to places that do prescribe HRT.  

You can also check with local Planned Parenthoods to see if they prescribe HRT or if they can refer you to someone who does.

You can also check with your insurance to see if they cover any endocrinologists in the area, then contact those endocrinologists who see If they can prescribe your T, or if they have any referrals to places that do prescribe HRT.

You should also reach out to the trans community IRL- they have to be getting their hormones from someone! If there are any trans support groups in your area, or LGBT organizations, ask them if they have any providers they can point you to. 

And finally, it can also be helpful to simply do some googling! I found my endo by google. It can take some legwork to find a trans-competent doctor who will prescribe HRT, but you just gotta keep trying! 

Our Testosterone FAQ has a Here is how to get hormones in the US link, and read that for more info!

Lee says:

That’s definitely not true, no. The majority of trans people start HRT at 18 or after because they don’t have supportive family, and you get most of the same changes at 18 as you would earlier.

If you start T after you’re 18…

However, there are a few things that can only happen if you start HRT at a younger age, like growing taller. If your growth plates have already sealed, you won’t grow any taller on testosterone or without it. So if you’re 18 or older when you start T, it’s unlikely you’ll grow any taller with or without T.

The younger you are, the better your chances are at growing, and younger than 16 is the ideal time for you to have a chance of growing taller so if you start T before you’re done growing you may end up taller than you would have been if you didn’t start HRT until 18 or older.

If you haven’t finished puberty yet, check out our link on Puberty blockers!

But yeah, even if you’re not able to start HRT until 18, your window to get T changes isn’t over. You will find that HRT can change a lot of things about your bod even if you start it late. I’ve met many cis-male passing trans guys who didn’t start HRT until their 20′s and 30′s, so it is possible to get super masc looking even if you start T as an adult.

I’m non-binary and transmasculine, and I started T at 18 and I’ve definitely experienced changes! I have to shave now, for example.

Lee says:

It may be different depending on the laws of the state you live in, the custody agreement your parents have, and the particular policies the endocrinologist you’re seeing has.

Jay said in an earlier ask, “Personally, I only needed one parent’s consent for T and top surgery (my parents are divorced and they had joint legal custody, meaning they equally shared the right to make legal/medical decisions on my behalf, by the way). 

Many doctors will prescribe hormones with 1 parent’s consent because they see it as prescribing any other treatment. They also tend to assume that the other parent is fine with it because usually only 1 parent will be at the appointment, presumably speaking for the other too. Also, if the therapist’s letter says you have 1 unsupportive parent but you and the supportive parent are prepared to cope with that many doctors will be ok with that. A few doctors will want written consent from the parent that doesn’t go to the appointment. I’d contact the doctor’s office and ask what you need to do.”

Some legal precedent may exist in your state- for example, in one case in Florida that involved divorced parents and an ear surgery, a judge ruled that only one parent has to consent to medical procedures. So I’d look into the laws of your state as well.

But the parent who doesn’t support you starting testosterone may go to court to try to gain sole custody of you, or challenge saying that the other parent shouldn’t be allowed to choose if you start T without their consent too, and the court case may delay when you’re able to start T.

Plus, the parent who does support you starting T may not support it enough to go to court over it, or and they may not care enough about it to potentially significantly damage the working relationship with the other parent even more than it’s already been damaged.

Either way, the first place to start with this is by talking to the parent who supports you going on testosterone and seeing what they think is the best step forward. They may be able to convince your other parent, or be willing to give it a try even if the other parent wouldn’t like it. 

Lee says:

On mobile go to your web browser like Chrome and type transgenderteensurvivalguide.tumblr.com/faq and please read the FAQ before you send us an ask! 

And wouldn’t ya know it, our Transmasculine resources page, which is linked to in the faq, has a Testosterone FAQ page that explains how old you have to be to start T:

Tons of questions have been already stated on this blog if you know how to navigate the FAQ- and now you know!

Lee says:

Having more options is a better thing than only having one! I’d call your insurance and see which of those doctors are in-network. Or call the doctors and ask if they take your insurance (and if they’re experienced in trans-related care). 

Once you know that your insurance will cover seeing them, then I’d choose the closest 3 doctors and google them, see if you can find anything about trans care associated with their names online. Then see if any local trans folk you know see that doctor. 

Worst case scenario is you choose one, you have your intake appointment, and you decide that you don’t like them and/or you’re not getting the care you need from them- and you transfer care to another one of the doctors available.

Lee says:

No, you don’t need to go to a trans clinic to get HRT.

I’ve gotten my testosterone prescription from a regular ob-gyn at Planned Parenthood and then switched to get it from a regular endocrinologist associated with a local hospital- I’ve never been to a trans clinic and I don’t even know if my state (or most states) have them.

Some places offer hormones via informed consent and others follow the WPATH-SOC, so the process for starting hormones is different depending on which model the doctor you’re seeing or place you’re going to follows. More info on those two things is in the link below:

Other links:

Lee says:

Yes, if you’re 18 you should be able to make all your medical decisions on your own.

Tell the doctor “I’m transgender and I want to start [insert hormone], are you willing to prescribe that to me or can you refer me to someone who will?” And if they ask if your parents support your medical transition you can tell them “I’m 18 so I don’t need their consent.” 

Make sure you also tell them that you’d like to keep this confidential just to cover all your bases, but since you’re over 18 your doctor can’t disclose any of your medical information with your parents unless you sign a consent form that allows them to speak with your parents.

But if you’re on your parents insurance, they’ll be able to see the bills from your endocrinologist and the prescriptions and stuff so they’ll probably be able to figure out that you’re getting some sort of medical care that you haven’t discussed with them.

Here is more info on how to get hormones in the US.

Lee says:

You can try getting testosterone through informed consent. That means you don’t need a letter from a therapist to get T.

If you can’t do that, you should be direct about what you want when you contact a therapist- say something like “My primary goal in my sessions with you is getting a letter to start HRT. Here is the relevant portion from the WPATH-SOC on writing the letter. How long will it be/how many sessions do you think it’ll take before you’re comfortable writing this letter for me?”

If they aren’t willing to write you a letter, ask for a referral to someone who will. Info on finding a trans-friendly therapist is here.

Lee says:

It’s hard to say, since every individual PP clinic is different and there’s even more variety in private practitioners. 

Some private endocrinologists will take longer to prescribe hormones than others will, so that means sometimes you’ll have to wait and sometimes you can start almost immediately.

In my personal experience, I was able to start T quicker at Planned Parenthood than at a private endocrinologist, but not because of how quickly they were willing to prescribe it. There was just a six-month waiting period just to get a new patient appointment with the private endo, and less time to get an appointment at PP. So even if both providers would be willing to prescribe T after 2 appointments, it’s the amount of time before that appointment that determined things for me.

It’s worth checking into multiple providers and seeing who can see you soonest, and also who has a good reputation in the community.

Lee says:

Here’s a post about that!