Untitled

www.vlpp.org

III

Table of Contents

Section 1

Roadmap ........................................................................................................ 1

The Basics ...................................................................................................... 2

Locations ....................................................................................................... 3

Care We Offer ................................................................................................ 4

Contact Outside of Appointments ................................................................... 5

 Tips for getting in touch with us

 When to call and when to come in

 Email guidelines

Section 2

Your First Medical Appointment—What to Expect! ......................................... 6

 Pre-Appointment

 Appointment

 Post appointment

Checklist for Your Follow Up Appointments ................................................... 7

Lab Work ....................................................................................................... 8

Pharmacy & Insurance Information ......................................................... 9-10

 Prior authorizations

 Refills

 Broken/leaking vials

Section 3

Surgery Information .............................................................................. 11-12

Name & Gender Marker Change ............................................................. 13-15

Troubleshooting ........................................................................................... 16

General FAQ ........................................................................................... 17-19

Telehealth FAQ............................................................................................. 20

Testosterone Factsheet ................................................................................ 21

 Controlled substance

 Administration

 Refill lead time

 Prescription authorization

 Labels

Estrogen Factsheet ................................................................................ 22-23

 Administration method

 Treatment approaches

 Injectable Estradiol and other options

 Refill lead time

 Labels

 Prescription authorization

Injection Tips ......................................................................................... 24-25

Safe Needle Disposal ............................................................................. 26-28

 Cleared sharps containers

 Used sharps in Virginia

 Disposal locations

Appendices

All About Medicaid ..................................................................................... B-E

Terms to Know Glossary ............................................................................ F-G

Effects of Estrogen Hormone Therapy ........................................................... H

Effects of Testosterone Hormone Therapy ..................................................... I

Self-Injection Guide (Intramuscular) ......................................................... J-L

Self-Injection Guide (Subcutaneous) ........................................................ M-O

Acknowledgements: This guide is the product of the me, eort, and hard work of both sta and

interns. We’d like to thank the various team members and interns who have spent countless

hours formang, eding, and making this a robust resource.

The Basics

We have proudly served the trans and nonbinary community since

2016. Our Gender Affirming Hormone Therapy program was devel-

oped and implemented by trans and nonbinary individuals and we

follow the informed consent model. As of late 2022, we have seen

over 4,000 patients who are trans and/or nonbinary.

You can find more information about our program on our website:

https://tinyurl.com/GAHTVLPP

1. Call Us

Let us know you’re seeking Gender Affirming Hormone

Therapy and our scheduling team will help make an appointment.

2. Schedule a Preliminary Appointment

We’ll discuss your desires and goals for Gender Affirming

Hormone Therapy, basic health history, and discuss options for

establishing care.

3. Meet Your Clinician

We’ll discuss your detailed health

history, do a basic routine exam,

discuss your care plan at greater

length. We may finish your ap-

pointment off with labs.

4. Pick Up Your First Prescription

If you are prescribed injectable

medication, we can also schedule you for self-injection training.

Please tell your provider if you are interested in training so we

can get you scheduled! Most patients perform their own injec-

tions at home. It's important to us that you can inject correctly

and safely.

5. Come back every three months during your first year

These appointments are very important to renew prescriptions,

monitor lab work, and make sure everything is going well for you

and your medical transition. Prescriptions are only for three

months at a time, in the first year, so it's important that we see

you regularly.

Telehealth Options

Locations

Richmond

Hampton Roads

Hamilton Clinic

201 N. Hamilton St

Richmond, VA 23221

East End Clinic

1122 25th St

Richmond, VA 23223

Virginia Beach Clinic

515 Newtown Road

Virginia Beach, VA 23456

Hampton Clinic

403 Yale Drive

Hampton, VA 23666

In addition to our physical locations, many of our

appointments can be conducted over telehealth

when necessary or preferred. However, if it’s the

first time you’re seeing us, whether you’re brand-

new to hormone care or transferring from another

care provider, we will likely need to see you in

person to get started.

There may also be intervals where we need to see

you in person in order to comply with certain laws

and policies (ex: once annually). Policy is rapidly

changing in 2023 and our team is following this

topic closely.

Direct line to program staff: 757-238-5461

Care We Offer

Primary and Preventative Care

Trans care isn’t just hormones - it’s healthcare for trans

people! We know that many patients worry about finding a

gender-affirming care provider. We’re proud to offer com-

prehensive primary care, including annual check-ups, well-

ness exams, pap smears, gynecology visits, and more. Our

team can also assist you with a referral

if you need to see a specialist.

Gender-Affirming Hormone Therapy

Sometimes called hormone replacement therapy (HRT) or

gender-affirming hormone therapy (GAHT), this is an

essential part of transition for many people. We follow

guidelines from both the Endocrine Society and WPATH.

We can also help you navigate other transition-related

goals, like pursuing gender-affirming surgeries, making

legal changes, and more!

Other Services

We also offer birth control options, testing and treatment

for sexually transmitted infections (STI’s),

preventing unwanted pregnancy, and abortion care. Within

the scope of primary care, we are also able to provide

some services for managing medications related to mental

health needs such as anxiety and depression. If it’s beyond

our expertise, we’ll do our best to help with a referral.

Contact Outside of Appointments

Tips for Getting in Touch With Us

*When reaching out to our staff, please leave your name, date of birth and

good phone number to reach you. This is important so that we can respond

promptly to your request.

Requires An Appointment

Changing dose/method of medication or adding medications

Email Communication

*Please note that our clinicians are not available by email.

The GAHT Navigator team can sometimes correspond by email, but patients

should be aware that email is not HIPAA compliant and may not be appropriate

for all communication. If you initiate contact with the team, we may reach out by

phone in response. Please include your name and phone number in any communi-

cations with the clinic!

You can reach out to tgnbser[email protected]

What can be answered via phone vs.

what needs an appointment:

Phone

Verify, Reschedule/Cancel Appointments

Prescription refills (unless you are due for a

follow-up)

Pharmacy/Insurance Issues

Surgery/Legal ID Support

*We cannot receive text messages. Although

patients may sometimes receive reminder

texts from VLPP, please do not text any

numbers for the clinic.

Your First Medical Appointment—What to Expect!

Pre-Appointment

1. For blood draws, it’s important to be hydrated! Drink plenty of water, starting 72

hours in advance. Make sure you have a meal or snack beforehand, too.

2. Plan to arrive approx. 15 minutes early to complete registration.

Appointment

When your appointment begins, a health care assistant will call you back by your last

name, take your vitals, and confirm some of your medical history. Once that’s done,

you’ll meet with your provider to discuss health and safety in relation to starting

hormones.

The first medical appointment is the soonest you may receive a prescription, but there

is no guarantee that you will receive hormones at this appointment. If we have con-

cerns about your health or safety, we will talk to you about these concerns and collab-

orate with you to help you move forward as safely as possible.

Historically, the field of transgender health has been associated with gatekeeping.

While there are certain things we need to do to ensure both your safety and to work

with insurance, it is important to us that we minimize barriers. That is why we use an

informed consent model and w ill do everything w e can to support your

transition.

What does informed consent mean? Informed Consent is a model of care in

which patients are able to access hormones during a visit with their provider, where

they'll discuss the risks and benefits of care. No visit with a mental health professional

is required to schedule an appointment.

Post Appointment

1. Make your three month follow-up appointment with a health care assistant or front

desk employee before you leaving your appointment. If you forget to make an

appt., call our main line as soon as you realize!

2. If prescribed injectable medication, talk to our team to schedule self-injection

training.

3. Pick up your medication! Take your first dose when you are ready *or if you are

scheduled for a Self Injection Training visit, bring your needles, syringes, and

medicine to that appointment to take your first dose! If you have any questions or

concerns about your medication after starting, please reach out to us.

Checklist for Your Follow Up Appointments

Here are some ideas of the things that you can discuss during your follow

up appointments with us. Please take a look at the progress sheet that you

can use to track progress/concerns/ things you would like to discuss with

your clinician during follow up visits.

● Medication concerns including changing method/dose

● Sex and Sexuality

● Name/Gender Marker changes

● Gender Affirming Surgery

● Concerns around Genitals

● Concerns about tucking/binding

● The way you feel including mental health concerns/referrals

● Connecting to support groups

● Housing Resources

● Substance use

● Relationship with food/weight

● Something else ________________________

Sometimes it’s helpful to keep a list of questions, observations, or

concerns for your next visit!

Lab Work

When Do We Look?

The first time is typically at the end of your first appointment. Please hydrate before

coming to your appointments as it helps with having your blood drawn. We need to

draw blood work every time we see you.

Where Do We Do Labs?

Labs are usually done at Planned Parenthood and can also be done at a LabCorp

location. You and your clinician will discuss which option is best for you.

How Often Will Labs Be Drawn?

Lab work is usually done more frequently in the first year of hormone therapy and

then less frequently as time passes. You can expect labs as frequently as every 3

months, or at some point, only annually. Some health conditions and circumstances

require more frequent bloodwork.

How Do I Know the Results of My Labs?

No news is good news! Unless there is an abnormal result, we will not be calling you

with lab results. We will discuss lab results during follow up appointments. But, if

desired, you can view your labs by registering for an account on the LabCorp

website, found at this address: www.labcorp.com/patients/results

You will need to use your legal name (or the name associated with your insurance) to

make your LabCorp account and see your lab results.

Pharmacy & Insurance Information

Check Your Prescriptions!

Before leaving the pharmacy,

ensure your medication

quantity, type, refill count, and

size are accurate to you. For

those who use syringes and

needles, please ensure the

needle length, gauge, and

syringe volume are accurate to

you. The pharmacist will be the

most helpful person in resolving

any issues with this.

If you are prescribed two

different needle sizes for one

syringe, it is important that you

are able to attach and detach

each of the needles to the

syringe. Syringes should meas-

ure in milliliters (ml), NOT units.

If your syringes are in units,

please ask the pharmacist for

the correct syringes (1ml

preferred, 3ml otherwise).

Please be sure to check your prescriptions before leaving the pharmacy to

see if these are the needles and syringes provided to you.

Prescription Authorization

When you first start hormones, it may take us some time to get the

medication covered by your insurance. If you have any issues with

insurance coverage that can’t be resolved at the pharmacy, please call us

804-500-5797. Please make sure you Leave a voicemail or we don't know

you called! We will do everything we can to get your medication covered.

Due to the nature of collaboration with insurance, this can sometimes take

up to 5-7 business days. We appreciate your patience.

Refills

Hormone prescriptions require regular appointments and lab work with a clini-

cian. To put it simply, remaining diligent with follow-up visits (every three

months on your first year on hormones) on the provided timeline will ensure

you will always have your medication. We have a precise understanding of

how often each patient will need a refill, and have designed the program to

meet every patients’ needs.

*Please note that we can not send refills if we have not seen you before at

one of our four clinics, even if you have been seen at another Planned

Parenthood out of state.

**TIP: Ask your pharmacist if you need refill authorization or clarification

from your provider or if you need a prior authorization for your insurance

Syringes/needles. Contact your pharmacy for a refill on syringes and

needles. Syringes/needles are not a controlled substance but if you are

having issues obtaining them, please call us. Most pharmacies dispense an

individualized amount based on your dose, mainly out of caution. Syringes

and needles are not a controlled substance, therefore if you have

issues refilling them at your pharmacy, you may order them online from a

trusted medical supply company (be sure you double check your needle

gauges and syringe size!)

Needle kits of 12 needles/syringes are available for purchase at the Planned

Parenthood on 201 N. Hamilton St. Currently we aren’t able to sell them

through our other locations, but hope to in the future.

*Please see page 29 for information on syringes/needles as well as resources

to purchase them online if interested.

Broken/Leaking Vials

Please be careful with vials! On rare occasions, a vial breaks or a punctured

seal leaks. We understand this. If this happens to you, please call us and

request to speak with someone about a refill, and we’ll get that passed on to

your clinician. Please do not dispose of the broken vial, as we may need to

see the broken vial or present it to the pharmacy.

To whom it may apply: Since Testosterone is a DEA schedule

III controlled substance, replacing a broken/leaking vial may

be challenging. Please be patient as this request is processed.

If you are having issues with your pharmacy please contact us

so that we can assist you. This may take two business days to

resolve.

Surgery Information

“I am interested in getting gender affirming surgery.

What do I need to do?”

1. Call your insurance (if applicable) to plan and find out what they

need from you to cover partial or full cost.

2. Research surgeons and find out if they take your insurance. If you

are interested in the list* we have compiled, please call or email

[email protected].

3. Schedule consultations with surgeons. Often, but not always,

consultations cost money and are a down payment toward your

surgery, so do thorough research before scheduling!

4. If needed, get a surgery referral letter(s). This often requires a

medical provider referral letter (which we can provide) and at least

one mental health provider referral letter (which VLPP cannot pro-

vide). Let us know if you need a surgery referral letter from or need

help finding a mental health provider to write your second letter.

Please give us 2-3 weeks to process this letter. We will need to call

and talk with you about this letter request before writing it.

5. Have a consultation to decide if this surgeon is right for you and your

body. Be sure to ask about preparing for surgery and

follow-up care.

*We do not endorse nor rebuke any surgeons who provide these services.

Surgeon decisions are the sole responsibility of you, as the patient, and are

determined by your research to select a surgeon who can best meet your

needs. Our list is made up of surgeons our patients have used in the past

or are known to work with trans and non-binary patients. VLPP is not liable

for any adverse experiences or unsatisfactory surgical outcomes, which

would be the sole responsibility of the surgeon and/or their own practice.

Surgery Information (contd)

Gender Affirming Surgery Glossary

Common terms in this patient population include 'top surgery' and

'bottom surgery.' Top surgery most commonly refers to the removal of

breast tissue. Bottom surgery typically refers to any gender-affirming

surgery 'below the belt' (top and bottom, get it??). It may also be re-

ferred to as ‘SRS’ (sex-reassignment surgery) or ‘GCS’ (gender confir-

mation surgery).

Here are some common names and brief descriptions of gender-

affirming surgeries that patients sometimes seek as part of their transi-

tion or gender affirmation process:

For trans men, trans masculine and

nonbinary AFAB people:

Chest Reconstruction (top surgery): removal

of breast tissue to help construct a more

typically masculine appearance

Chest wall contouring: reshaping of the

chest wall to have a more typically

masculine appearance

Hysterectomy: removal of the uterus. May

also involve removal of ovaries, fallopian

tubes, and cervix

Metoidioplasty: bottom surgery that involved

increasing the length of the clitoris

Oophorectomy: removal of ovary(s), which

may or may not include the removal of the

Fallopian tube(s)

Phalloplasty: bottom surgery involving a skin

and tissue graft from a larger area to create

a penis

Scrotoplasty: bottom surgery involving crea-

tion of a scrotum

Vaginectomy: removal of all or parts

of the vagina

Vulvectomy: total or partial removal

of the vulva

For trans women, trans feminine and

nonbinary AMAB people:

Augmentation mammoplasty (breast aug-

mentation): surgery to increase the size of

breasts

Clitoroplasty: bottom surgery involving crea-

tion of a clitoris, typically as part of a

vaginoplasty

Facial feminization surgery (FFS): refers to a

variety of facial reconstruction procedures to

have a more typically feminine appearance

Labiaplasty: bottom surgery involving crea-

tion or revision of labia

Orchiectomy: bottom surgery involving re-

moval of the testicles

Penectomy: bottom surgery involving re-

moval of the penis without the construction

of a vagina

Vaginoplasty: bottom surgery involving crea-

tion of a vagina and vulva

Name & Gender Marker Change

Disclaimer: this information was produced by clinic staff who assist patients with making

these changes. We are not lawyers, and cannot offer legal advice. The tips outlined here

are based on experience in engaging legal and government systems for making these

changes. It is possible that future changes in state or federal policy will change the require-

ments for updating your information.

This guide outlines the steps for updating both legal names and gender markers in

the state of Virginia, as well as federal documents and records. We understand that

not everyone changes both, but the information here is still relevant. Gender mark-

er (or sex marker) refers to the gender designated on a license, passport, or other

government ID. It is separate from your birth certificate.

Changing Both Legal Name and Gender Markers

Legal Name Change in Virginia: If you are

updating both your name and gender mark-

er, then you must change your legal name

prior to updating your gender with the DMV

or Social Security Administration.

Virginia has a simple process for legally

changing your name; however certain cir-

cumstances may require additional docu-

mentation or appearing before a judge.

These circumstances may include being a

minor, prior felony conviction, current pro-

bation status, or other conditions where the

court may be concerned in relation to fraud

or other legal implications.

In these circumstances, there are additional considerations, and existing patients

may request support documentation regarding hormone treatment to advocate for a

name change. If none of these circumstances apply to you, the courts are unlikely

to request medical letters for a name change.

To change your name, go to the website for your city or county for vital records and

look up the local requirements for name changes. These vary by locality, and may

have specific applications, or they may use one provided by the state. Fill out the

application, and take it in person to the clerk’s office, usually located in the court-

house. If you do not have access to the internet, you can also go in person to your

local circuit court clerk’s office (contd on next page).

Name & Gender Marker Change

(contd) While there, you will fill out an order for the judge and pay a fee, and once

the order has been processed (this may take a week, a month, or longer) the court

will mail you documentation confirming your legal name has been changed through

the court system. If you cannot afford this fee, we may have resources or referrals

to assist you so please let us know.

Once you have obtained the court order for your name change, please call the clinic

(804-482-6154) to request documents to assist in updating your gender marker. If

the court mails you a different document stating you need to appear in court, please

Gender Marker Changes (DMV-issued ID and Social Security)

Updating your gender marker in VA is not difficult, but requires multiple steps. If

you change your gender marker on your license, you must also update it with the

Social Security Administration. If you are not changing your legal name, these steps

are still the same.

Social Security: As of October 2022 you no longer need a letter from a clinician to

update your gender with the Social Security Administration. This means you can up-

date your gender by selecting your

correct gender when updating your

social security card. Currently the

gender options are M or F, with

hopes to include a X option in the

future.

Department of Motor Vehicles: As of July 1, 2020, the DMV allows self-identification

of gender with no age restriction. This means the DMV does not require a signature

from a medical or mental health provider. They also have a non-binary option which

will appear as an ‘X’ on your license or photo ID. Note: as of November 2022, this

option is not available for other state-issued documents, such as birth certificates or

Medicaid plans, which still require ’M’ or ’F.’ This may change in the future.

To change your gender marker with the DMV, fill out the application to request a re-

placement license. This is the same form you would fill out to process a name

change, so they can be done simultaneously. A replacement license has a $20 fee

as of July 2020. If you are only changing your gender marker, it’s possible you can

do it by mail. If you are also changing your name, you need to be present in person

to do this AND will need to have already received a new Social Security card with

your new name.

Please note that the DMV requires your name be

changed with Social Security first. You can read

more here: https://www.dmv.org/va-virginia/

changing-your-name.php

Name & Gender Marker Change

Passports: As of October 2021, it is no longer necessary to obtain a letter in order

to update your gender on a passport. As of 4/2022 you may self-select M,F, or X.

You can read more at https://transequality.org/know-your-rights/passports

Birth Certificates: As of September 2020, updating a birth certificate in Virginia will

no longer require a court order. To update the gender marker on a birth certificate,

visit the Virginia Department of Health’s website for instructions and what is needed

including the application. You will need a Changing Sex Designation form (called the

VS42) completed by your healthcare provider. This form needs to be signed in ink

and cannot be signed or submitted electronically. Currently there is no non-

binary ‘X’ marker for VA-issued birth certificates.

What if I was born in another state?

You can go to https://transequality.org/documents and

enter the state you were born in to look up information

on what is required to update birth certificates in states

other than Virginia. If you need any supporting docu-

mentation/letters please let us know so we can assist.

Immigration Documents

Please visit https://transequality.org/know-your-rights/immigration-documents for

more information on updating your immigration documents. In most cases a provid-

er certification letter is required so please contact us so we can process this for

you.

Other Federal IDs and Records

Please visit https://transequality.org/documents for more information on updating

other IDs such as Military Records and Consular Birth Certificates. If you need sup-

porting documentation please contact us so we can assist you.

Troubleshooting

The pharmacy said they need a pre-authorization, can you help?

These are sent electronically from the pharmacy to the clinic, and our team

will submit them on your behalf. Please allow up to five business days for

processing pre-authorizations. If you have been waiting over seven days

please call us!

The pharmacy has questions about my prescription. Please call us

so we can speak to your pharmacy on your behalf.

I need to schedule a follow-up or verify an appointment time.

Please call the main number (804-355-4358) and follow the prompts for the

respective need. During business hours, our Patient Services team can

schedule follow-ups, verify appointment times, or cancel appointments if

needed. You can also schedule online, but calling is recommended to make

sure you see the same provider each time.

I didn’t get enough needles. How do I get more? Our clinicians

write prescriptions for a year’s supply of syringes and needles. Pharmacies

fill what they estimate is a proper number for you before your next refill. If

it’s not enough, call your pharmacy to refill this prescription using the Rx

number provided. You may also purchase a 12 count supply from reception

at the 201 N. Hamilton Planned Parenthood location by walking in during

open hours. Additionally, you can order medical supplies in bulk from a

medical supply store.

General FAQ

How do I get a refill? Oftentimes, a follow -up

visit with your clinician is required for a refill.

Please call the main number and leave a message

with the prescription line. If more than 72 hours

have passed and you have not been assisted,

please contact the clinic. Please include the name

that appears in your chart, and phone number so

we can easily identify your

medical record.

Routine refills can not be done via email. I f you are overdue for a

visit, you may not be able to get a refill until you are seen.

If you are not yet due for a visit and you have run out of medicine,

please call your pharmacy to confirm if you still have refills available.

How often will I need to come in for follow up visits? New patients

need to be seen every three months for the first year after the first time you

were prescribed hormones. This is so we can assess how you’re feeling on the

hormones and optimize your medications for safety and desired effect,

following best practice guidelines.

How do I make my appointments? P lease call the main number

804-355-4358 and follow the prompts for your respective needs. During busi-

ness hours, our Patient Services team can schedule follow-ups, verify appoint-

ment times, or cancel appointments if needed. You can also schedule online, but

calling is recommended to make sure you see the same provider each time.

Please note: It is your responsibility to make these follow up appointments.

They are not automatically scheduled. We recommend making follow up

appointments at the end of your appointments.

I want to ask for an increase or change to my prescription, how do I do that?

Changes to dosage in medication can only be done during an appointment by a clinician.

If you feel it is necessary for health reasons (i.e. you don’t feel good on your current

dose), please call and schedule an appointment with your clinician, and make sure to

mention why you’re coming in. Please note, changes in medication dosage may require

additional lab work. You will need to have a follow up visit to change your medications

and this request can not be made via email or over the phone.

If you desire a change in dose for other reasons, it is best to discuss this with your clini-

cian at your next appointment. Our clinicians greatly value patient preferences and will

prescribe based on your needs and preferences, with consideration to existing medical

guidelines, research, and consensus opinion, and as safe for your unique health circum-

stances. We support whatever goals and desires you have for yourself with various

aspects of gender affirming care.

What about lab results? No news is good news! For many patients, labs are routine and

you will not be notified if everything is within safe / typical / healthy ranges. This includes

negative results for STI testing as well as hormone labs. If you are interested in seeing

your lab results or need to access them, you can go to www.labcorp.com/patient/results

and register an account. Any labs processed by Labcorp will be attached to your legal

name, DOB, and other demographic information.

How will I learn to inject my hormones if I am prescribed injectable hormones?

At any point in time, as our patient, you may call and request a free self-injection training

(SIT) appointment at one of our clinics. Additionally, the internet (Youtube, Google) is a

rich resource for injection training--both intramuscular and subcutaneous. We also have

materials that you can request at any time! If you have any friends or family who inject

medications, they may also be a valuable resource for assistance your first few times.

How much will things cost if I do not have insurance? Please do not let cost

bar you from access to care. If cost is a concern, please call or email the patient

navigation team (contact info located at the beginning of this packet!) and let them

know. Or, bring it up during one of your appointments. We may be able to help identify

financial resources and/or other community organizations that can help out!

Since early 2022, VLPP is part of Title X, a federal program designed to help make

healthcare affordable. If you don’t have insurance OR you can’t use your insurance at

VLPP, you are probably eligible for a sliding scale rate based on income.

Please do not let cost discourage you from remaining consistent with your care appoint-

ments, as they are necessary to receive prescriptions. Patients who are concerned

about being able to pay for their next visit or medication should contact the Trans

Health Team, as we may have some options available to help make cost more afforda-

ble. This varies case by case but we welcome the communication. It's important to us

that you are able to continue your care with us.

How much do prescriptions usually cost without insurance P rescription costs

may vary, but usually they are around $50 for a 3-month supply. We recommend using

GoodRx with your chosen pharmacy in order to get these prices. If you are having a

hard time finding a pharmacy with low enough medication costs, please call or email us

and we will assist you in finding a better pharmacy for your needs.

How much does all of this cost with insurance? Planned P arenthood takes

most insurances, including Medicaid, Medicare, and Tricare. Our team does everything

in its power to get your care covered. However, some insurances can be harder to work

with than others and we can’t guarantee your insurance will approve your care. If you

have any issues please call our main line and follow the instructions to speak to the in-

surance/billing department.

I need a trans affirming referral i.e. therapist/psychiatrist/surgery letter/

voice therapy. P lease contact the clinic or discuss this w ith your clinician dur-

ing one of your follow up visits. Section 3 also details some of this.

I have questions about updating my legal name or gender marker. There is

detailed information on how to do this earlier in Section 3!

Telehealth FAQ

What will I need for a remote visit via telehealth?

Ideally you will need a computer or laptop with a webcam and access to a

private room where we can speak without interruption for the duration of

your appointment. If you are using a phone or tablet (iPad, Android, etc.)

it may work fine, as long as you are on Wi-Fi. Mobile (4g, etc.) connec-

tions do not work well. If you’re having trouble connecting, try a different

web browser. Please note that video is necessary for telehealth.

How will I do labs or give my blood pressure if I am doing

telehealth visits?

You can check your blood pressure at a pharmacy when you pick up your pre-

scription, make a note of it,

and tell us at your next tele-

health visit. You can also

schedule an appointment to

come in. It is important that if

you are doing follow up visits

telehealth with us that you

check this anytime you get a

chance and to inform your cli-

nician the next time you see

them. Labs can be done at a

LabCorp location close to you.

You and your clinician will dis-

cuss this. Please note that

your initial appointment to meet with the clinician will most likely be in

person where labs/blood pressure will be checked unless discussed other-

wise with the Social Work team.

I prefer telehealth, why do I need to come in person?

In-person requirements may be present for initiating care or at a specific

interval depending on changes to state or federal policies. For example,

testosterone is a controlled substance (more about this on the next page!)

and requires an in-person visit to initiate as of 2023. We will also need to

see you in person every so often to satisfy certain legal requirements.

Testosterone Fact Sheet

Controlled Substance

Testosterone is a DEA schedule III controlled substance. If your insurance requires a

pre-authorization (and it probably does!), this authorization is usually renewed every 12

months. We are only able to write the prescription for a maximum of 120 days of refills,

and some insurance plans will only pay for one month of medication at a time.

Method of Injection

The pharmacist may have questions about how the testosterone is administered. Many

of our patients take the testosterone through Subcutaneous injection (under the skin)

or Intramuscular injection (into the muscle). Though the medication is labeled for

intramuscular use only, subcutaneous injection is a safe and common off-label

administration method.* If necessary, you can let the pharmacist know that the

subcutaneous route--and related needle type--is not a mistake.

*This only applies to testosterone. Estrogen by injection is not prescribed for

subcutaneous use.

Labels

If your prescription directions are different from what you discussed with your provider,

please take the medication the way your provider explained it to you. You can always

call or email a care coordinator for any clarification.

*If you are having issues with your pharmacy, please call us so we can speak to

someone on your behalf to authorize this. The label may have your legal name on it, so

that insurance will cover it. We can help with a legal name change process if desired.

Prescription Authorization

When you first start testosterone, it may take us some time to get the medication

covered by your insurance. If you have any issues with insurance coverage that can’t be

resolved at the pharmacy, please call us. We will do everything we can to get your

medication covered. Sometimes this can take a few days. We appreciate your patience.

Refill Lead Time

prescription in a timely manner. This lead time also allows us to ensure you’ve had

recent labs/appointments so the clinician can confidently refill your prescription. If you

are due for a follow up *you need to make your follow up appointment in order to

discuss refills. During the first year, your prescriptions will only last for approximately

three months, so if you are out of refills, that means it's time to come back and see us!

Estrogen Fact Sheet

Administration Method

Estrogen medications are often called estradiol and can be prescribed as a daily

tablet, weekly injection, or patch. Estradiol is most commonly prescribed as an

oral tablet, meaning to dissolve the tablet under the tongue. Please note that

this medication can be taken sublingually or orally (swallowed). Pharmacists

sometimes need clarification from us that the medication is written correctly as

sublingual use. Please contact us if you are having issues with your pharmacy

and we will reach out to them on your behalf.

Injectable Estradiol and other options

Patients sometimes request switching to an injectable form of estradiol after they

have been on other methods of estrogen. This is a discussion we encourage you

to have with your clinician. Also, injectable estrogen requires a yearly

insurance authorization process, injection training, and supplies. Please note that

injectable estradiol often has shortages throughout the country and you may not

be able to fill this prescription. We can work with you to change to a different

formulation of the injectable estradiol, a different method of estrogen, and/or

you can call other pharmacies in your area and ask if they can source it.

Sometimes patients are prescribed estrogen patches, known as a transdermal

patch. These go on your skin, under your clothes, and are usually changed at set

intervals determined by your provider.

For each method of dosing (tablets, injections, or patches), insurance or out of

pocket cost may influence what is accessible to you. Estradiol tablets tend to be

the most affordable and the most widely available. There are also certain medical

conditions which may determine which method of dosing is the best fit for you.

Treatment Approaches

Our patients are commonly prescribed oral or sublingual estradiol and oral

spironolactone, but there may be other treatment options, depending on your

desires, where you are in your gender affirmation process, your specific clinician,

your insurance plan, and regional availability. Please note, not all options that

you read about online are able to be prescribed by our clinicians. This is due to

lack of robust research to support safe and effective treatment with certain

medications. Please come to us with questions and concerns.

Estrogen Fact Sheet

Refill Lead Time

can refill your prescription in a timely manner. This lead time also allows us to

ensure you’ve had recent labs so the clinician can confidently refill your

prescription. Please note if you are due for an appointment for a refill, we

may not be able to refill your medication until you have an appointment.

Labels

If your prescription directions are different from what you discussed with your

provider, please take the medication the way your provider explained it to

you. You can always call or email a care coordinator for any clarification. Vials

may be used more than once, when sanitized before use. Due to insurance

and billing requirements, the prescription label may have your legal name on

it. We can help with a legal name change process if desired.

Prescription Authorization

Topical forms of estradiol, injectable estradiol and micronized progesterone

often require yearly authorization from your insurance, and some plans won’t

cover progesterone. If you have any issues with insurance coverage that can’t

be resolved at the pharmacy, please call our directory. We will do everything

we can to get your medication covered. Sometimes this can take a few days.

We appreciate your patience.

 See our detailed injection guides in the Appendix!

 Gently massage the injection site after administering medication. This can help disperse

the oil.

 Check out this link for hormone self injection videos: https://www.familytreeclinic.org/

info-center/hormone-self-injection-resources/

 Store your vial upright and in a dry, dark place at room temperature between 68°F and

77°F (20°C and 25°C).

 If your vial forms crystals, warm it by rubbing it between your palms quickly but

gently, or placing it between your legs for 10-15 minutes.

 If your vial gets too hot or is left in sunlight, it may denature.

 You can purchase a needle kit at the 201 N. Hamilton location only as of 9/15/21.

These are $20 for a set of 12 needles/syringes. You can purchase them by walking in

during any open hours. You can buy up to two packs at once.

 For ease, and in some cases money saving, you can order bulk needles and syringes

from a medical supply company online. Provided below is an in-exhaustive list of

suppliers that our patients have used.

1. ADW Diabetes

2. Allegro Medical

3. Amazon

4. Bulk Syringes

5. Drug Supply Store

6. GPZ Med Lab

7. Health Warehouse

8. Healthy Kin

9. Mainland Medical Supply

10. Med Vet International

11. Trans Needles (Offers 1-month free supplies via Google Form)

12. Vitality Medical

 Please be sure to check your prescriptions before leaving the pharmacy to see if these

are the needles and syringes provided to you (you can refer to chart on page 9)

 1mL syringe

 18, 20, or 22 gauge 1” needle for drawing up medication

 25 or 27 gauge 5/8” needle with safety for injecting medication subcutaneously

 21-23 gauge 1” or 1.5” needle with safety for injecting medication

intramuscularly

Injection Tips

Fear of Sharps

If you have any issues preventing you from administering your shots,

please call us to set up an appointment. Sometimes it will get easier with

practice, watching training videos on the internet, or observing others. If

you’re still having trouble, bring it up with your clinician and together you

can discuss alternative methods of administration, such as topical

testosterone. Some insurance plans are more likely to cover different

formulations if you’ve tried the standard approach first.

Potential Reactions

It is common to get a bit of itching at the injection site, or some soreness

and mild swelling at the site for a few days. It is rare, but possible, to have

a true allergy to the oil in which the testosterone is suspended. In this

case, we will switch you to a different formulation. If you are concerned

you’re having an anaphylactic reaction (swelling, difficulty breathing,

nausea/vomiting), please call 911.

Safe Needle Disposal

(Image obtained from Monroe, IN Health Department)

Please refer to the CDC website for more sharps safety information.

*You are not required to spend extra on sharps containers. Oftentimes

patients will use rigid containers (i.e. milk jug, laundry detergent bottle)

and then tape it shut. You should label it on the side as "sharp" and can be

placed in regular trash.

Safe Needle Disposal

Link to more information on cleared sharps containers: https://

safeneedledisposal.org/sharps-management/fda-cleared-sharps-

containers/

Safe Needle Disposal

Images from https://safeneedledisposal.org/states/virginia/

Find disposal locations here: https://safeneedledisposal.org/states/

virginia/#showTable

APPENDIX

Welcome to the appendix! Here you’ll find resources which are aimed to help

educate and inform patients and their allies on a variety of topics.

All About Medicaid ......................................................................................B-E

Terms to Know Glossary ............................................................................ F-G

Effects of Estrogen Hormone Therapy ............................................................H

Effects of Testosterone Hormone Therapy ..................................................... I

Self-Injection Guide (Intramuscular) ......................................................... J-L

Self-Injection Guide (Subcutaneous) .........................................................M-O

All About Medicaid

What is Medicaid?

Medicaid is a form of health insurance which exists in all 50 states.

Each state is responsible for issuing and managing its own Medicaid

plans and has different requirements for eligibility. For example,

someone who qualifies for Medicaid in New York state may not qualify

for it in North Carolina.

Since 2019, Medicaid in Virginia is

based on income. It is designed to

provide medical coverage to low in-

come individuals and families. Its

purpose is to improve the health of

the people who might otherwise go

without medical coverage.

Does Medicaid cover gender-affirming care?

Most people in Virginia seeking gender-affirming care are able to use

their Medicaid benefits towards this care after satisfying certain

conditions. Certain things, like surgeries, will require documentation

and support letters in order to be approved (see Section 3 of this

guide for more information). The Virginia League for Planned

Parenthood accepts Virginia Medicaid for all patients.

How is this different from Medicare?

Medicaid is a partnership betw een the federal government and

individual state governments. In Virginia, eligibility is based on in-

come. To qualify, applicants must meet income requirements. Once

someone gets on Medicaid, they are assigned a Managed Care Organ-

ization, or MCO, to administer the plan.

Medicare is different. Medicare is a national health insurance

model most commonly available to senior citizens in retirement.

There are other circumstances where someone might qualify for

Medicare.

All About Medicaid

How to know if you’re eligible for Medicaid?

Cover Virginia has an online eligibility screening tool to verify if you

are eligible for Medicaid. You can also submit your application to find

out if you are eligible for Medicaid. Check this link for the tool:

https://www.coverva.org/en/screening-tool

Here are the income guidelines* for Medicaid for 2023:

*subject to change - check CoverVA for the most current figures.

All About Medicaid

Eligibility (contd)

Do you make less than $18,755 per year AND reside in Virginia? If

the answer is yes, then you may qualify for Medicaid (aka free insur-

ance through the state)!

Other considerations:

Green Card holders with five years or more of residency in the United

States may be eligible for free or low-cost Virginia Medicaid health

coverage. Visit https://coverva.org/en/health-coverage-for-non-

citizens for more information.

Former Foster Care Individuals: If you are between the ages of 18

and 26 and were previously in foster care, you might be eligible for

Medicaid regardless of income. The best way to confirm eligibility is to

apply via the methods below.

How to Apply to Medicaid:

Medicaid applications are accepted throughout the year. There are

multiple ways to apply:

1. Online at www.commonhelp.virginia.gov

2. Call the Cover Virginia Call Center at 1-833-5CALLVS. Call center

hours are Monday-Friday: 8:00am-7:00pm and Saturday: 9:00am-

12:00pm

3. Mail or drop off a paper application to your local Department of So-

cial Services. Mailing may take longer than other application methods.

According to the website, paper applications are available in English

and Spanish. 

4. Through www.healthcare.gov (see next page for details).

All About Medicaid

Applying for Medicaid Through healthcare.gov

Virginia residents can also apply through the healthcare.gov

Marketplace, the insurance marketplace that was created by the 2012

Affordable Care Act. Note: do NOT apply this way if you have already

applied through the Cover Virginia website or it may void your

application.

When screening for insurance coverage, if you meet the income re-

quirements you will receive an Eligibility Results Letter at the end of

the application stating either “you are eligible for Medicaid” or “we

think you may be eligible for Medicaid.”

The Eligibility Results Letter will have an appli-

cation number – write this down! This number

will be very helpful if you need to follow up by

phone to the Dept. of Social Services. This let-

ter also has contact numbers for the correct of-

fices. If it’s been more than a week since your

Marketplace application confirmed eligibility and

you haven’t heard anything, you should call

DSS and inquire with your application number.

Eligibility Results

Congratulaons! You are

eligible for Medicaid.

Applicaon # 00001

If the Marketplace application states

“you are eligible for Medicaid,” enroll-

ment should be automated and registra-

tion information will be mailed to you.

If the application states “we think you

may be eligible,” there may be a conflict

with past records. For example, if your

income in 2022 is very low but was very

high in 2021.]

Glossary

Here’s a glossary of terms you may come across as you are navigating your

care.

 Gender: A social construct referring to attitudes, feelings and

behaviors associated with a person’s biological sex.

 Gender-Affirmation Surgery: Surgery to change primary and/ or

secondary sex characteristics to affirm a person’s gender identity.

 Gender Dysphoria: Distress caused by a discrepancy between a person’s

gender identity and that person’s sex assigned at birth

(and associated with gender role and/or primary and secondary sex

characteristics).

 Gender Identity: A person’s deeply held knowledge of their own

gender, which can include being a man, woman, both, another gender,

or no gender.

 Non-Binary: Term used to refer to people whose gender identity is not

exclusively male or female, including those who identify with a different

gender, a combination or genders, or no gender. It may encompass

identities such as agender, bigender, genderqueer or gender-fluid.

 Primary Sex Characteristics: Any of the body structures directly

concerned with reproduction, including the testes, ovaries, and external

genitalia.

Glossary

Secondary Sex Characteristics: Characteristics that develop during

puberty and are specific to each sex, but they are not directly related to re-

production. This includes development of breasts, beard, muscularity, fat

distribution, and change in voice pitch.

Sex: A construct usually assigned at birth based on the appearance

of external genitalia. When external genitalia are ambiguous, internal geni-

talia, chromosomal status, and hormonal sex are considered when assign-

ing sex.

Sexual Orientation: The sexual attraction tow ard other people or

no people. While sexual activity involves the choices one makes regarding

behavior, one’s sexual activity does not define one’s sexual orientation.

Sexual orientation is part of the human condition, and all people have one.

Typically, it is attraction that helps determine orientation. (via PFLAG)

Sex-assigned-at-birth: A helpful phrase to refer to someone's as-

signed sex which acknowledges that someone's gender may not correlate.

This phrasing is sometimes useful in healthcare settings when evaluating

someone's health needs without referring to them as 'male' or 'female.'

These are often abbreviated as AMAB (assigned male at birth) and AFAB

(assigned female at birth). For example, you might say, "she is a woman

who was AMAB and transitioned 10 years ago."

Trans male/Transmasculine: Term used to describe transgender or

non-binary people who were assigned female at birth (AFAB), but identify

with masculinity to a greater extent than with femininity. They could be ei-

ther trans men or nonbinary.

Trans female/Transfeminine: Term used to describe transgender or

non-binary people who were assigned male at birth (AMAB), but identify

with femininity to a greater extent than with masculinity. They could be

either trans women or non-binary.

Effects of Estrogen Hormone

Therapy for Trans Women,

Transfeminine People,

and AMAB Nonbinary People

Estrogen and anti-androgen hormone therapy is medicine to make your body look more

feminine. Some of the changes may be permanent while others may be

reversible and go away when medication(s) are stopped.

Effects of Testosterone Hormone

Therapy for Trans Men,

Transmasculine People, and

AFAB Nonbinary People

Testosterone hormone therapy is medicine to make your body look more masculine. Some of

the changes may be permanent while others may be reversible and go

away when medication(s) are stopped.

Injection Tips