Informed consent model of care

The informed consent model of care respects your fundamental human right to self-determination and bodily autonomy. The purpose of this document is to indicate, in writing, that you consent to feminising hormone therapy as part of a gender aﬃrmation process. This form may be signed by any person of sound mind over the age of 18, or over the age of 16 with the co-signatures of all primary legal guardians. 

This document relates to the hormones oestrogen and progesterone, as well as testosterone blocking medications. Your doctor will make a medical decision, in consultation with you, about the medications that are best for you, keeping in mind your overall health during your gender aﬃrmation process. Your doctor will discuss with you all of the information relating to starting hormone therapy. You are asked to read and understand the following information, and raise any questions you have with your doctor. 

Patient information sheet: expected changes on feminising hormone therapy 

Typical changes from Oestrogen (varies from person to person) 
Average timeline	Eﬀect of Oestrogen 	
1–3 months after starting oestrogen	• softening of skin 
• decrease in muscle mass and increase in body fat 
• redistribution of body fat to buttocks and hips 
• decrease in sex drive 
• fewer instances of waking up with an erection or spontaneously having an erection; some trans women also ﬁnd their erections are less ﬁrm during sex, or can’t get erect at all 
• decreased ability to make sperm and ejaculatory ﬂuid	
Gradual changes (maximum change after 1–2 years on oestrogen)	• nipple and breast growth 
• slower growth of facial and body hair 
• slowed or stopped balding 
• decrease in testicular size	
   
Typical changes from Anti-Androgens (varies from person to person) 
Average timeline	Eﬀect of blocking	
Testosterone 1–3 months after starting antiandrogens	• decreased testosterone in the body 
• decrease in sex drive 
• fewer instances of waking up with an erection or spontaneously having an erection; some trans women also have diﬃculty getting an erection even when they are sexually aroused; some have painful erections
• decreased ability to make sperm and ejaculatory ﬂuid	
Gradual changes (usually at least 2 years)	• slower growth of facial and body hair 
• slowed or stopped balding 
• slight breast growth (reversible in some cases, not in others)	

Consent Form:  Feminising Hormone Therapy 

I, <PtFullName>, acknowledge that I have read and understood the following information in consultation with my doctor, <DrName>:

Tick the boxes to acknowledge the following:

• Permanent changes expected whilst on feminising hormone therapy:
	• Breast and nipple development
	• Decreased testicular size
	• Possible permanent infertility. I have been advised by my doctor to consider storing 		sperm in case I decide to have children at a later date, and I have been given the opportunity to delay starting hormones until I have stored sperm.

• Reversible changes expected whilst on feminising hormone therapy:
	• Softening of skin
	• Decreased muscle mass and increased body fat
	• Decreased libido
	• Reduced spontaneous morning erections
	• Reduced ability to achieve or sustain an erection
	• Reduced ability to ejaculate and reduced volume of ejaculatory ﬂuid
	• Slowed or stopped balding
	• Slowed rate of growth of facial and body hair
	• Improved cholesterol

• I acknowledge the following side effects of feminising hormone therapy 
	• Headaches
	• Nausea
	• Fluid retention and bloating
	• Breast and nipple tenderness
	• Mood disturbance, such as teariness, depression or anxiety
	• Fatigue
• I acknowledge the following potential risks of feminising hormone therapy: 
	• Blood clots, deep vein thrombosis or potentially fatal pulmonary embolism
	• Stroke
	• Increased risk of heart disease or heart attack
	• Raised blood pressure
	• Liver damage
	• Osteoporosis
	• Potentially increased risk of certain cancers, including breast & prostate cancer
	• Development of prolactinoma (a rare brain tumour that results in milk production from the breasts)
	• Diﬃcultly controlling blood sugars in people with diabetes

• I understand that feminising hormone therapy aﬀects everyone diﬀerently, and that there is no way to predict exactly how my body will change. Some of the long term eﬀects of feminising hormone therapy are not yet known. 

• I acknowledge that continuing to smoke any product containing nicotine (cigarettes, tobacco, electronic vaporisers) whilst taking oestrogen increases my risk of developing a blood clot, deep vein thrombosis or a potentially fatal pulmonary embolism. 

• I have been informed that the use of feminising hormones does not guarantee infertility, and that contraception should be used to avoid unwanted pregnancy if I have sex with someone who could become pregnant.

• I understand that gender aﬃrming hormone therapy means that I will need to see my doctor and have blood tests at regular intervals throughout my life. Appointments will be more frequent at ﬁrst, and then every 6-12 months when my hormone levels are stable. I am ready to make this commitment to my health.

• I acknowledge that gender aﬃrming hormones are only a part of my overall health, and that a range of preventative health activities are recommended so that I remain happy and healthy in my aﬃrmed gender. These include but are not limited to:
	• Monthly breast self-examination. I should tell my doctor if I discover any new lumps
	• Regular breast mammograms from an appropriate age, in consultation with my doctor
	 Quitting smoking
	• Immunisations
	• Regular STI screening, depending on my level of risk
	• HIV prevention, depending on my level of risk
	• Regular physical activity, including resistance exercise for bone health
	• Healthy eating

I can choose to stop gender aﬃrming hormone therapy at any time. If I choose to stop taking hormones, it is best that I do this in consultation with my doctor, to ensure that I remain safe and healthy.

<PtFullName>	<DrName>	
Signature: 
	Signature:	
Date:	Date: