Gender-affirming care: the Australian general practice approach

Gender-affirming care encompasses the social, psychological, and medical supports that help trans and gender diverse (TGD) people live in ways consistent with their gender identity. Estimates from the LGBTIQ+ Health Australia National Survey (2020) suggest approximately 2.7% of Australian adults identify as trans, non-binary, or gender diverse. Many first disclose their gender identity to a GP, making general practice a critical point of contact — one where a respectful, knowledgeable response prevents the healthcare avoidance that drives disproportionate psychological distress in TGD communities.

Australian guidance is anchored in the AusPATH Standards of Care (2022) and the international WPATH Standards of Care 8 (2022), both of which endorse an informed-consent model. A trained GP may initiate hormone therapy after comprehensive assessment and documented informed consent — no mandatory psychiatric clearance is required before prescribing. Referral to specialist gender services remains appropriate for complex presentations and adolescents.

A. Core clinical practice and hormone initiation

Inclusive practice. Before the first gender-health consultation, ensure the clinical environment is affirming:

• Records use the patient’s preferred name and pronouns across all system fields, not only the encounter note.
• Intake forms offer options beyond binary sex and gender.
• Reception and nursing staff use preferred name unprompted.
• Consulting space displays LGBTIQ+ affirming signage; the Rainbow Tick accreditation from LGBTIQ+ Health Australia provides a structured quality framework.

Initial assessment. At the first gender-health consultation:

1. Explore the patient’s goals — not everyone seeks hormone therapy; some want mental health support, a referral letter for a legal document change, or assistance navigating services.
2. Confirm the gender history is persistent and well-considered. The AusPATH informed-consent model does not require a set minimum duration, but an adequate shared exploration of the decision is documented in the notes.
3. Screen for contraindications specific to the intended regimen (detailed below for each pathway).
4. Discuss fertility: hormone therapy reduces fertility in most pathways. Gamete preservation (sperm or oocyte banking) should be discussed before commencing and referral offered to a fertility clinic if the patient wishes to explore it. Fertility preservation services are not always PBS-funded; out-of-pocket costs vary.
5. Document informed consent covering realistic outcomes, the timeline of changes, which effects are reversible and which are not, monitoring requirements, and the option to pause or discontinue.

Feminising hormone therapy. The therapeutic goal is serum oestradiol approximately 250–600 pmol/L and testosterone suppressed to the female reference range (below 2 nmol/L).

Oestradiol: Preferred preparations are transdermal — patches (50–200 mcg twice weekly) or gel (1.5–3 mg/day applied to skin) — or oral oestradiol valerate or hemihydrate (2–6 mg/day). Transdermal routes carry lower venous thromboembolism (VTE) risk than oral and are preferred for patients over 40, those who smoke, or those with cardiovascular risk factors. Ethinyl oestradiol — the synthetic oestrogen in oral contraceptives — is not used in gender-affirming care. VTE risk is substantially higher and oestradiol levels cannot be reliably monitored on this preparation.

Antiandrogens (when needed to suppress endogenous testosterone):

• Spironolactone (50–200 mg/day) is first-line in Australia given its availability and PBS listing. Monitor electrolytes and renal function at baseline and at 3 months, particularly in patients also taking ACE inhibitors, ARBs, or potassium supplements.
• Cyproterone acetate (Androcur, 12.5–25 mg/day) provides more potent androgen suppression and is widely used. The TGA issued a safety advisory (2020) linking cumulative high-dose cyproterone use to meningioma risk. Use the lowest effective dose, avoid lifetime cumulative dose exceeding approximately 35 g, and advise patients to report new persistent headache, visual change, or neurological symptoms promptly.
• GnRH agonists (e.g., leuprorelin depot monthly or 3-monthly) achieve complete androgen suppression and are appropriate when antiandrogens are insufficient or not tolerated. Cost is significant unless PBS Authority criteria are met; specialist initiation is typically required for PBS access.

Monitoring schedule: Serum oestradiol and total testosterone at 3 months after initiation, then 6-monthly once stable. Prolactin annually (cyproterone acetate increases the risk of hyperprolactinaemia). Haematocrit; liver function if using cyproterone; blood pressure; weight at each visit.

Masculinising hormone therapy. The therapeutic goal is total testosterone within the male reference range (10–30 nmol/L trough for long-acting injection; 15–35 nmol/L peak for gel).

Testosterone preparations: Transdermal testosterone gel (Testogel 1%, 50 mg/day; AndroForte 5%) is convenient for daily application and allows easy dose adjustment. Long-acting intramuscular testosterone undecanoate (Reandron 1000, 1,000 mg every 10–14 weeks after a loading dose at 6 weeks) is preferred by patients seeking less frequent administration and more stable hormone levels. Both are PBS-listed under Authority; the Authority application cites gender-affirming indication and is submitted via PBS Online.

Monitoring: Serum total testosterone at 3 months (trough timing for Reandron — draw just before the next injection), then 6-monthly. Erythrocytosis is the most common significant adverse effect — haematocrit above 0.54 requires dose reduction. Liver function; lipid profile; blood pressure; weight. Pelvic examination is not routinely required for TGD men without symptoms. Cervical screening continues based on anatomy (see Section C).

B. Mental health, minority stress, and wellbeing

The minority stress model (Meyer 2003) describes how TGD people experience elevated rates of depression, anxiety, and suicidal ideation not as an inherent feature of gender diversity, but as a response to chronic external stressors: discrimination, family rejection, fear of violence, and encounters with health systems that pathologise their identity. A landmark meta-analysis by Lucassen et al. found suicide attempt rates in TGD people are substantially higher than in the general population, with family rejection as a key risk factor.

Affirming mental health care in general practice means:

• Providing psychological support for wellbeing, not requiring psychiatric assessment as a prerequisite for hormone therapy.
• Recognising that gender-affirming hormone therapy is independently associated with reductions in depression, anxiety, and suicidal ideation in most patients; care itself is therapeutic.
• Addressing comorbidities — anxiety, PTSD related to discrimination, disordered eating that can co-occur — specifically and not attributed to gender identity itself.
• Issuing Mental Health Care Plans (MBS items 2715 and 2717) routinely; refer to psychologists with gender-affirming experience listed through LGBTIQ+ Health Australia or AusPATH member directories.

Conversion practices — any deliberate attempt to change or suppress a person’s gender identity — are banned by law in Victoria (Change or Suppression (Conversion) Practices Prohibition Act 2021), Queensland, the ACT, and New South Wales. Federal legislation is under active consideration. Conversion practices cause psychological harm and are explicitly contrary to both AusPATH and WPATH guidance.

Family and social support is among the strongest predictors of wellbeing in TGD youth and adults. Where family relationships are strained, GP-facilitated family counselling or referral to PFLAG Australia can be protective. Social connection, school safety, and community belonging matter; isolation is a risk factor for suicidality.

Crisis resources. QLife (1800 184 527, 3 pm–midnight daily, phone and webchat) provides LGBTIQ+ peer support and referral nationally. Lifeline (13 11 14) and Beyond Blue (1300 22 4636) operate 24 hours a day for crisis support.

C. Preventive screening and monitoring by anatomy

Preventive screening recommendations for TGD patients follow the organs present, not the legal gender marker or assumed sex. This requires a sensitive, anatomy-focused history at patient enrolment — framed as ensuring all appropriate preventive care is offered rather than as an intrusive interrogation.

Screening area	Who needs it (by anatomy)	Key notes
Cervical screening	People with a cervix, aged 25–74	Every 5 years; self-collection available — often preferred by trans men/non-binary people; testosterone causes vaginal atrophy, so offer self-collection proactively
Breast screening	People with breast tissue ≥50 years; or TGD women/non-binary people who have taken oestrogen for ≥5 years	Enrol directly with BreastScreen Australia
Prostate	TGD women and non-binary people who retain a prostate	PSA discussion from age 50 (or 45 with risk factors); oestrogen lowers PSA — interpret in context of feminising therapy
STI screening	Based on sexual practices and exposures	Ask about partners and practices sensitively; do not assume based on gender identity
Bone density (DEXA)	Those on prolonged GnRH agonists, or with sustained sex hormone deficiency	At 5 years of treatment; earlier if additional osteoporosis risk factors present
Cardiovascular	TGD women on oestrogen; TGD men on testosterone	Lipids, blood pressure, and weight at each 6-monthly monitoring visit
Mental health screening	All TGD patients	Brief validated screen (K10 or PHQ-9) at every visit given elevated background prevalence

Medicare gender marker updates. A patient may hold a Medicare card marked with the non-preferred binary sex, or an “X” marker. GPs can provide a supporting letter for a Medicare gender-marker update — no surgery is required and no specific letter template is mandated. This simple step significantly reduces the distress of identity mismatch at every health encounter.

D. Australian operations

MBS attendance. Gender-affirming consultations attract standard GP attendance items (Level B item 23, Level C item 36, prolonged item 44 for complex initial assessments). There is no special gender-affirming item number; bill by time and complexity as for any complex chronic disease consultation.

PBS prescribing.

• Testosterone: Authority items (gel: items 4707Q, 4708R; Reandron 1000: item 4710T) explicitly include gender-affirming indications. Apply online via PBS Online; routine approvals are returned electronically.
• Oestradiol: General schedule listings (tablets, patches, gel) — no Authority required. Prescribe by brand name to avoid substitution across delivery routes.
• Spironolactone: PBS-listed for heart failure and hypertension; prescribed on private script for gender-affirming antiandrogen use unless another PBS indication exists.
• Cyproterone acetate: PBS-listed for prostate cancer; off-label for gender-affirming use; prescribe on private script in most gender-affirming contexts.

Legal documents and identity. GPs frequently provide supporting letters for Medicare gender-marker changes (no surgery required), passport sex-marker updates (self-identification policy since 2013), and state and territory birth certificate amendments (requirements vary; surgery is no longer required in any Australian state or territory; some require a statutory declaration only). These letters are brief — confirm identity, note clinical relationship, state the patient’s lived gender.

Specialist gender services (adult). Referral options include:

• Equinox Gender Diverse Health Centre — Melbourne; trans-led; bulk bills eligible patients; also provides GP mentoring.
• Monash Health Gender Clinic — Victoria.
• ACON and LGBTIQ+ Health Australia — maintain national directories of affirming GPs, endocrinologists, and psychologists.

E. Special populations

Adolescents and puberty suppression. Gender-affirming care for minors is a specialist domain and should be coordinated with a paediatric gender service, primarily the Royal Children’s Hospital Melbourne Gender Service or equivalent in other states. Puberty-suppressing GnRH agonists pause endogenous puberty; they are considered reversible and provide time for exploration without committing to permanent changes. Since the Re: Kelvin [2017] FamCAFC 258 decision, Family Court authorisation is no longer required for Stage 1 (puberty suppression) or Stage 2 (cross-sex hormone) gender-affirming treatment — parental consent plus the young person’s own consent (assessed for Gillick competence where under 18) is sufficient. GPs should not delay referral for adolescents with a persistent, consistent, and insistent gender identity incongruence; earlier specialist input supports better planning.

Older adults. TGD people aged over 65 may have received less affirming care historically and may present with significant, longstanding psychological distress. Hormone therapy can be initiated in older adults with appropriate cardiovascular and metabolic risk assessment. Bone health monitoring is especially important given the additive effect of ageing on osteoporosis risk when gonadal suppression has been prolonged.

Intersex people. Intersex refers to people born with sex characteristics that do not fit typical binary male or female definitions — distinct from gender diversity. Intersex people may or may not identify as TGD. Intersex Human Rights Australia and AusPATH guidance advise against non-consensual medical interventions on intersex infants and children. GPs should be familiar with the distinction and not conflate intersex with gender diversity.

Aboriginal and Torres Strait Islander TGD people. The terms Brotherboy (for TGD people whose spirit is male) and Sistergirl (for TGD people whose spirit is female) are used within many First Nations communities and reflect distinct cultural identities. Culturally safe care acknowledges these identities without imposing Western gender frameworks. Black Rainbow supports LGBTIQ+ Aboriginal and Torres Strait Islander people; QLife (1800 184 527) has dedicated Aboriginal and Torres Strait Islander peer support. RACGP Cultural Competency guidelines provide additional framing.

Rural and regional access. Standard MBS telehealth items fund gender-affirming consultations where the patient is in an eligible location (Modified Monash categories 2–7) or has an established patient relationship. Several services offer dedicated national telehealth gender-affirming GP care; LGBTIQ+ Health Australia maintains a searchable directory by location and telehealth availability.

When to escalate

Refer to a specialist or emergency service in the following circumstances:

• Psychiatry or psychology: Active suicidal ideation or recent attempt; complex psychiatric comorbidity where diagnostic clarification affects management; significant diagnostic uncertainty after thorough GP assessment.
• Endocrinology: Refractory erythrocytosis on testosterone (haematocrit persistently above 0.54 despite dose reduction); suspected pituitary lesion (prolactinoma on cyproterone; unexpected microadenoma); complex hormone interactions; initiation in the context of significant cardiovascular disease or poorly controlled diabetes.
• Neurology or neurosurgery: New persistent headache, visual disturbance, or cognitive change in a patient on cyproterone acetate — MRI brain is required to exclude meningioma.
• Adolescent or paediatric gender service: Any young person under 16 seeking puberty suppression or hormone initiation — specialist assessment at a paediatric gender service is recommended; do not delay the referral.
• Emergency: Acute suicidality — contact QLife (1800 184 527) for peer support while arranging emergency assessment; Lifeline (13 11 14) for crisis support; ED referral if risk is immediate.

What this article is and is not

This article is a clinician-facing educational resource for Australian GPs, summarising gender-affirming care principles, hormone prescribing guidance, screening frameworks, and referral pathways based on AusPATH, WPATH, Endocrine Society, and RACGP evidence frameworks as of mid-2026. It is not a prescription of care for any individual and does not replace clinical judgement, the treating clinician–patient relationship, or the full text of the referenced clinical guidelines. All prescribing decisions must account for individual clinical circumstances, patient goals, and the most current TGA and PBS schedules. TGA product information and PBS Authority restrictions apply to all medications mentioned.

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Sources cited

1. AusPATH Standards of Care for Trans and Gender Diverse People (2022) — AU-specialty
2. WPATH Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (Coleman et al., 2022) — specialty-society
3. Endocrine Society Clinical Practice Guideline: Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons (Hembree et al., 2017) — specialty-society
4. RACGP — LGBTIQ+ Health Resources — RACGP
5. Royal Children’s Hospital Melbourne Gender Service — AU-specialty
6. Cheung AS et al. Approach to the Patient: Feminizing Hormone Therapy. J Clin Endocrinol Metab. 2021 — peer-reviewed
7. TGA Safety Advisory: Meningioma and cyproterone-containing medicines (2020) — TGA
8. QLife — LGBTIQ+ peer support and referral — AU-consumer
9. ACON Health — AU-consumer
10. LGBTIQ+ Health Australia — AU-specialty
11. HealthDirect — Gender Dysphoria — AU-consumer
12. Better Health Channel — Gender Dysphoria — AU-consumer