This guide is current as of January 2025. Medical standards and the individual standards of practitioners are always evolving, so this document may not exactly describe your experience.

An Introduction to Trans Care for McGill Students

What is this document? 

The process to receive HRT at the McGill Wellness Hub is a series of three appointments and additional blood work. The Hub’s HRT process is currently longer and more complicated than the processes at many other informed-consent clinics in Montreal. This document is principally a guide to simplify the Hub’s HRT process for patients and presents some tips for navigating the logistics of receiving HRT at the Hub. We also provide some information on alternative paths to care; the patients that have reached out to us with information about care outside of the Hub have generally had positive experiences. While we include some basic health information about HRT, we encourage all trans patients to learn as much about the medical process of HRT as possible, sources like Fenway Health’s 2021 guide on trans care and Transfeminine Science are good places to start.

A word of caution for trans patients

For many patients, trans care at the Hub is their first time extensively interacting with the Quebec medical system. Unfortunately, when interacting with an under-resourced and difficult to navigate bureaucratic medical system a lot of responsibility falls on patients, who often experience trans related care as a long and grating process, full of unexpected delays, bureaucratic barriers, and even transphobia. So, it is our recommendation that trans patients be as proactive as possible about accessing care that they know they want and be ready to advocate for themselves.

Research on trans care is insufficient and doctors often have outdated or questionable health practices. We encourage patients to research their care as much as they are able. If a provider says something that you find suspicious, we recommend you do your own research, consult other patients with relevant experiences, and if possible ask for a second or third medical opinion. 

Models of care: informed consent vs psychological evaluation 

The primary standards of care used by doctors for providing trans care are those of the World Professional Organization for Transgender Health (WPATH). The 8th and latest edition of the WPATH standards does not dictate a care model for doctors to use, but generally doctors’ pre-prescription processes for HRT fall into one of models.

One model requires a prospective patient to first obtain a diagnosis of Gender Dysphoria.  This requires seeing a psychologist and meeting their standards for a diagnosis.

The other model, generally called the informed-consent model, only requires a patient to sign a form saying that they understand the effects and risks of HRT before the doctor prescribes it. Ideally, an informed-consent process should only require one appointment before the prescription of HRT. This is care that most Planned Parenthoods and Quebec private doctors provide.

The McGill Wellness Hub uses an informed-consent model, though as we later explain it is a slower and more complicated version of the model than many other clinics use. We recommend that all patients receive HRT from informed-consent clinics when possible. 

Getting Care Outside of the Wellness Hub

The Quebec public system

We have recently spoken to McGill students who have had good experiences getting HRT outside of the Hub as non-Quebec residents. A downside is that this will require paying out of pocket and getting partially reimbursed through your insurance: Blue Cross for international students or StudentCare or an out-of-province public insurance for Canadian students. 

You can try one of the many public clinics that offer HRT; here is a collection we made of HRT providers lists by other Montreal queer organizations. All of these clinics are covered by out-of-province Canadian insurance, StudentCare, or RAMQ. However, unless you are using RAMQ, you usually need to pay upfront and get partially reimbursed later. If you have Blue Cross, you would have to reach out to a clinic to find out if it accepts your insurance. Additionally, the wait times for public clinics vary from months to years, so while some may provide better care than the Hub, the initial wait is likely to be much much longer. 

The Quebec private system

Blue Cross and StudentCare coverage allows you to get partly reimbursed for care from private clinics. Private providers are generally less gatekept, more convenient, and often provide faster care than the McGill Wellness Hub. On the other hand, the private system tends to be expensive and securing reimbursement from insurance can be a precarious process. Additionally, going private requires you to pay upfront for these services and get reimbursed later. Ultimately some McGill patients will prefer the convenience of private care over the Hub. 

• Dr. Donovan Pham:
  • One patient reported a good experience with Dr. Pham
  • One patient had a mid experience with Dr. Pham, and mentioned that he has patients fill out a gender dysphoria checklist.
  • Both patients we spoke to got a blood test requisition on their first appointment. They also got prescriptions at this appointment, which they could only fill after the doctor reviewed their blood test result. One patient mentioned that for them this wait was about a month and was very unpleasant.
  • A patient with Blue Cross (international student insurance) was able to get all appointments reimbursed at 80%. A patient with StudentCare insurance was able to get reimbursed for the blood test ($50), but not the appointment itself ($250)
  • One patient reported that Dr. Pham initially prescribed 50mg spironolactone and 1mg estradiol, and later increased the prescription to 200mg spironolactone and 2mg estradiol

• Dr. Gabrielle Landry
  • Dr. Landry is a popular private HRT provider, but wait times at her clinic have recently increased; a patient who submitted a request in August was given the option to schedule an appointment in October.
  • Dr. Landry has patients read a long (24 page) informed consent document in the waiting room before their appointment. She typically prescribes HRT in one appointment, as well as giving patients a blood test referral that must be completed before they can begin HRT.
    • In the past, she has also provided referrals to other medical services during the same appointment.
  • Dr. Landry is generally well-informed, trans-positive, and offers relatively fast wait times compared to many public clinics. However, her services are expensive and patients have reported that she can be rushed during appointments.
    • A handful of patients have reported receiving incorrect information from Dr. Landry or the nurses who do follow-up appointments. All of the experiences with this that we are aware of happened several years ago.
  • Dr. Landry’s services are expensive: Her website lists the cost of an initial consultation as $400 and follow ups (with nurses over phone) as $150-250.
    • One patient in Fall 2022 paid $295 for an initial appointment, $195 for their first follow-up appointment, and $75 for follow-ups after that.

• Dr. Jean-Hughes Brossard (at Clinique d’Endocrinologie de Montréal)
  • One patient (who was being re-prescribed HRT, not beginning care) had a good experience with Dr. Brossard and reported that he was very polite and helpful.
  • Other endocrinologists at the same clinic (Clinique d’Endocrinologie de Montréal) may also provide HRT.

Getting Care at the Wellness Hub

Important Update: Dr. Perera is on Parental leave as of December 2024!

Dr. Perera – the only provider currently seeing patients at the Wellness Hub for HRT– will be taking parental leave from December 2024 to January 2026. During Dr. Perera’s leave she will be referring HRT patients to Hygea Endocrinology clinic. As of December 2024, we anticipate that no other doctors at the Hub will be able to provide HRT to new patients until she returns. However, for patients who are already seeing Dr. Perera and on HRT, she has told us that other doctors at Hub will refer her patients to Hygea and refill their HRT prescriptions until they are able to see an endocrinologist there, and new patients will receive referrals to Hygea.

We know little about Hygea clinic and the practices of their providers, although we have talked to several patients who seemed to have neutral or positive experiences there and have not heard of any major issues. According to Perera, the wait for Hygea was 2-3 months as of early Fall 2024, but as she sends more patients to Hygea the wait times may increase. According to one patient who reached out to Hygea in mid-November, their earliest available appointments were in March. Currently, most patients seem to be able to get appointments there within a few months, but we have also heard from one patient who waited about two years. Additionally, two doctors at Hygea will be going on leave soon, which may further increase wait times. Nevertheless, most McGill students are probably unlikely to find a public clinic better than Hygea.

For patients with out-of-province or Blue Cross insurance, note that Hygea will directly bill your insurance, unlike most clinics which require you to pay upfront and wait for reimbursement. Dr. Perera may have told you that you will need to submit claims for reimbursement after going to Hygea, but we confirmed with them as of November 2024 that they do bill insurance directly.

What does the process currently look like?

The first appointment is a brief consultation between Dr. Perera (the Hub doctor who provides HRT) and the patient, where she provides a cursory look into the process. Based on previous patient experience, you are likely to discuss: how long you have felt you were trans or non-binary, how long have you been sure you want HRT, if you want fertility preservation, and sometimes the Wellness Hub’s ‘Pride Team’ mental health services. Afterwards, patients receive an informed consent form which patients will be asked to consider and have signed for their next appointment: this form for transmasculine patients, and this form for transfeminine patients. If you choose to pursue fertility preservation, Dr. Perera will discuss referring you to one of Montreal’s preservation clinics. You will be able to continue the process of receiving HRT from the Hub as usual, but you will not receive your HRT prescription until the fertility preservation is completed.

At the second appointment, the patient returns the signed informed consent form and Dr. Perera follows up on whether the patient has any concerns and does a short physical examination, usually just checking their blood pressure. She then provides a requisition for a blood test to be completed before the third appointment.

The third appointment is often by telehealth (on Microsoft Teams). Be sure to have a lot of open time in your schedule, as it may take up to an hour after the scheduled appointment time for the doctor to call you, although they usually try to initiate the call within a half hour of the scheduled call time. Dr. Perera looks over the blood test results and, if they are as expected for baseline hormone values, ideally goes over your dosage and sends a prescription for HRT to your pharmacy. Occasionally, trans masculine patients’ blood test results have been outside of the normal ranges, in which case they may have to do additional testing before they can get HRT; see this section for further information.

For all of these appointments, it is helpful to be direct and ask as many questions as you need. We have heard reports that Dr. Perera may not always be upfront about giving out information, but is very accommodating and responsive once you ask. This may range from more general aspects of medical transition to more specific things like dosing.

For a guide of recommended steps to avoid bureaucratic delays to care, see this infographic. 

Potentially speeding your HRT access from three appointments to two

Contrary to the norms for the informed consent models, Dr. Perera does not let patients consent to care as soon as they receive the form; she requires patients to wait until the next appointment to provide her with a signed consent sheet. This means patients have to have an additional appointment before they can access HRT. We provide copies of this form for transfeminine and transmasculine patients. 

In the past a patient has come to their appointment with a form already signed and Dr.Perera still refused to accept their form until the next appointment, but it is always possible this will change in the future. If a patient wishes to increase the likelihood that they will be allowed to consent to HRT on their first appointment, we suggest they arrive already very well informed on the topic, be firm in their decision to start HRT as soon as possible, and bring with them a signed consent sheet in hand. 

Reaching out to the hub and scheduling appointments

Hub medical care is available to all insured McGill students physically in Quebec. The specifics of booking appointments is always changing, and we suggest patients try as many paths as possible to get the quickest results. Currently, to access trans care at the Wellness Hub, you need to call them at (514) 398-6017 between 8:30am-12:00pm and 1:30pm-3:30pm Mondays-Fridays to book an appointment. The phone line tends to be busiest in the first hour, and same day appointments are typically unavailable after that. However, even though most Hub appointments must be booked same-day, if you mention that you are seeking trans care from Dr. Perera, you should be able to book an appointment further in advance. Anecdotally, the Hub is easiest to book appointments with during the very start and very end of the semester, as well as during the summer break. 

We have recently heard that the time between appointments can range from one to two weeks. As such, the three appointment process may now take around one to two months. However, due to the Hub’s understaffing, the wait time for an appointment can still be multiple weeks during the academic year.

If you are interested in getting care faster, you can try to get a same day appointment with Dr. Perera. These require you to be one of the few callers to get a spot as soon as the phone lines open at 8:30am on one of the days she is working. You can call the Hub to ask which days she is currently working, as her schedule changes over time. 

For follow-up appointments, Dr. Perera will place you on her waiting list. Patients on her waitlist will receive a call from the Hub once her availabilities open for the upcoming week or two, though you can also call the Hub proactively (a couple weeks in advance if possible) and say that you need a follow-up appointment with Dr. Perera. At times, patients seeking a first appointment have been put on her waitlist when they call for an appointment. 

What if I am already on HRT ? Choosing whether to transfer to the Hub

Many patients who already have access to HRT through a doctor at their home outside of Montreal may simply want Dr. Perera to refill their prescription. This is an especially common ask from international students, since Canadian pharmacies do not accept prescriptions from outside of Canada. Unfortunately Dr. Perera doesn’t usually like to just refill prescriptions for trans patients who are primarily being overseen by another doctor. Typically if she is going to prescribe a patient HRT she prefers to take over care entirely, often making patients sign a consent form and have their blood tests monitored by her. However, transfering to her care doesn’t create any practical barrier preventing you from seeing your other doctor for HRT or other trans related care. Also, we have spoken to some patients who were able to get Dr. Perera to refill their prescriptions without being made to go through her onboarding process and with the understanding they still see their other doctor, including for other aspects of gender affirming care like top surgery. Usually these patients convince her they need to be a special exception to onboarding for some reason. 

This means people with doctors at home generally have a few options to consider: 

1.  Continue getting all your HRT related care when you visit home, including traveling to Montreal with months worth of HRT. 
2. Transfer your HRT related care to Dr. Perera, where she will take over testing your levels, and providing you with prescriptions that you can take to Canadian pharmacies and get reimbursed via medavie, StudentCare or other applicable insurance. 
3. Ask Dr. Perera to transfer your care, as mentioned in option 2, but still check in with your other doctor when at home. 

There are a few things to consider when deciding if you want to become Dr. Perera’s patient. 

• Dealing with the Hub is generally a pain. If you have a system that works for you at home, it may be worth dealing with the logistics of only getting care while home. 
• There are some aspects of how Perera handles her care that some patients do not like (read through the rest of this guide to learn about them), and you should keep in mind if those are going to pose problems for you. For example, she does not prescribe anti-androgens other than spironolactone, and makes patients already on other anti-androgens get on a waitlist to see an endocrinologist while she refills their existing prescription with the understanding that she is acting as a placeholder. So if you want to be able to adjust your dosage, or switch anti-androgens other than spiro in the future, and your home doctor seems more open to this, then remaining with your current provider may be something you should consider. 
• Getting HRT only at home can be precarious. This is especially an issue for international students, since without proper planning and reliable medical care at home you may end up in a situation where you can’t get an appointment or a refill while you are visiting home. For any HRT, but especially testosterone, your pharmacist will likely ask for special documents before they give you more than a month’s worth of your prescription. Often a doctors’ note, proof of travel, or proof of university admission is sufficient. 
• If you are very likely to stay in Canada after you graduate, you can ask Dr. Perera to facilitate your transfer into the Quebec public system. A good way of doing this is getting on a waitlist to see an endocrinologist about a year and a half before you intend to graduate. 
• If you are still early in the HRT process or expect complications in your care that require blood testing or changes in doses, having your care spaced out only to when you are home can really delay your access to care. Getting care at home is definitely easiest for patients who are well established and only need yearly monitoring. 

What happens if you decide you want to transfer your HRT related care to the Hub

If you do decide to transfer your care to Dr. Perera, the process is typically much easier than starting with Perera as a new patient. Patients with existing HRT prescriptions report that they need 1-2 appointments to receive an HRT prescription from the Wellness Hub. Typically, if you insist, Dr. Perera will allow you to sign the consent form at your first appointment, do a brief physical, and then order blood work. Often patients have been able to receive a prescription at their first appointment if they insist that they are running out. The Hub may ask for your existing provider to send a copy of your existing prescription to them. Additionally, this first appointment may include a discussion of your current dosage and if you would like to change it in the future. 

 At your second appointment, if you have not already received a prescription you should receive one. Depending on when you last had your levels checked, she will likely give you a blood test and inform you on when to expect a follow up (generally 3 to 6 months later). Some patients have been able to do the blood work in between their first and second appointments with Dr. Perera. She may require copies of your previous blood tests. 

What If I am doing DIY HRT and want to transfer to the Hub?

We have only spoken to one patient who did this a few years ago at the Hub, so our data on this is quite limited. Still, we believe it is reasonable to assume that Dr.Perera maintains the same process or something similar. 

The patient we spoke to told us that in their first appointment with Dr.Perera they were told to go off of their HRT for 4 weeks, so that Dr. Perera could take a baseline blood test and essentially start the HRT process the way they would with a brand new patient who had never been on HRT before. Given this, we infer that if a patient is looking to transfer from DIY to the Hub, they could simply be sure to go off of HRT for 4 weeks before seeing Dr.Perera to save themselves the extra appointment. Of course, that patient may still have to disclose that they did DIY HRT for some time. 

HRT for minors

The Wellness Hub will refuse to let minors sign the informed consent form for HRT. In particular, this means that only the first appointment is possible before the patient turns 18. Dr. Perera may refer a patient to an outside clinic—the wait times of which usually exceed the time till the patient turns 18—but will typically instead tell them to schedule their second appointment after their 18th birthday. 

The TPU does not find this acceptable, and we have been told by trans legal experts that there is nothing legal preventing Dr. Perera from allowing 17 y-o patients from signing an informed consent sheet or getting care from Perera. 

HRT methods and administration at the Wellness Hub

Transmasculine HRT at the Hub

For transmasculine patients, Dr. Perera prescribes testosterone, which can be delivered via weekly injection, daily topical gels (applied on the skin), and patches. For a complete medical guide of testosterone options see Fenway Health’s guide.

Effect	Onset	Maximum
Skin oiliness/acne	1-6 months	1-2 years
Facial/body hair growth	6-12 months	>5 years
Scalp hair loss	6-12 months	>5 years
Increased muscle mass/strength	6-12 months	2-5 years
Fat redistribution	1-6 months	2-5 years
Cessation of menses (period)	1-6 months	1-2 years
Clitoral enlargement	1-6 months	1-2 years
Vaginal atrophy	1-6 months	1-2 years
Deepening of voice	1-6 months	1-2 years

Table of Effects (WPATH SOC 8, p. 254)

These are the clinically proven average effects for patients taking testosterone in the typical male range. Results vary from person to person, but most patients can expect most of these effects within the given time ranges. Changes to the voice, body/facial hair growth, male pattern baldness, and increased phallic size may be permanent once they occur. Hair loss may or may not occur depending on one’s genetics and age.

Usually, Dr. Perera will recommend subcutaneous injections (injections in the fat layer, as opposed to the more painful intramuscular injections in the muscle layer). Injections are widely considered the most reliable method of testosterone delivery. Some practitioners recommend intramuscular over subcutaneous, claiming it is a more effective method of delivery, but this is not well supported by the medical literature, and is widely considered an outdated view. Existing research says both methods are about as effective (see here and here).

Patches are another method of delivery. They typically consist of a sticker that needs to be changed twice a week. Some patients may develop allergic reactions to the adhesives (which can be cleaned with rubbing alcohol); if these reactions persist the patient should consider other methods of delivery. 

Topical gels, while considered reliable, have some disadvantages. They may not be covered by medical insurance, and they have some restrictions patients find annoying: gel has to be applied at relatively the same time daily; you can’t swim or shower for 6 hours after applying it; and it is transferable to anyone who comes in contact with the applied area for the following 6 hours (so you can’t apply it before bed if you have a bed partner). 

Additionally, as gel is applied daily, measuring T levels in blood tests is different than for people on injections, since levels peak and drop over the course of a day instead of over the course of a week. One patient’s endocrinologist told him that he needed to do the blood test about 24 hours after his last application of T gel for reliable blood test results. We are not sure Dr. Perera understands blood testing on T gel, since one patient reported being given no information on when to test relative to time of administration, and Dr. Perera was very confused by his results, lowered his dose, and referred him to an endocrinologist. To avoid being referred to an endocrinologist we recommend patients on T gel do the above testing method. 

As of 2019 an oral form of T named Jatenzo has been on the market for cis men with low testosterone. While some guidelines exist for its use for medical transition, it has not been tested on transmasculine patients yet and some medical experts speculate it may not be very effective for medical transition (Fenway Health, page 16). To our knowledge, Dr. Perera has never prescribed oral testosterone for medical transition. 

Transfeminine HRT at the Hub

For transfeminine patients, Dr. Perera will start off by prescribing oral estrogen and spironolactone as an anti-androgen.

Table of Effects (WPATH SOC 8, p. 254)

These are the clinically proven average effects for patients taking estrogen in the typical female range. Results vary from person to person, but most patients can expect most of these effects within the given time ranges. Breast growth and testicular atrophy may be permanent once they occur. 

Delivery methods other than oral

If a patient asks, Dr. Perera will prescribe delivery methods for estrogen other than oral, such as injections or patches. Sublingual (absorbed under the tongue) or buccal (absorbed between your gums and cheek) estrogen administration uses the same pills as oral. There is a lot of medical debate about which method of delivering the pills leads to the best results. It is worth learning about if you want to be confident you are getting the best results possible. For in-depth articles on the different ways of delivering pills, see Transfeminine Science’s articles on estrogen.

There are potential complications associated with oral estrogen, leading some patients to prefer sublingual, injected, or transdermal estrogen.  Oral estrogen is processed through the liver, leading to increased strain on the liver and links to blood clots. Many patients take oral estrogen without either of these problems affecting them, but we recommend patients inform themselves about different delivery methods, as the Hub doesn’t typically bring up these issues with transfeminine patients. See here for a discussion of blood clot risks from estrogen and delivery methods.

Patches are another method of delivery. They typically consist of a sticker that needs to be changed twice a week. Some patients may develop allergic reactions to the adhesives in patches (which can be cleaned with rubbing alcohol); if these reactions persist the patient should consider other methods of delivery.

If you do ask Dr. Perera about injections, she will recommend subcutaneous injections (injections in the fat layer, as opposed to the more painful intramuscular injections in the muscle layer).  Injections are widely considered the most reliable method of delivery. Some practitioners recommend intramuscular over subcutaneous, claiming it is a more effective method of delivery, but this is not well supported by the medical literature, and is widely considered an outdated view. Existing research says both injection methods are about as effective (see here and here).

Anti-androgens other than spironolactone 

As of our last edit, Dr. Perera refuses to prescribe other anti-androgens like bicalutamide, or cyproterone, stating she doesn’t know enough about them to do so. Dr. Perera requires that transfeminine patients who want HRT other than estrogen and spironolactone get on a waitlist to see an endocrinologist who can take over their HRT. However, Perera has recently started refilling anti-androgens prescriptions other than spironolactone, but only under the understanding that she is acting as a placeholder until that patient’s care can be taken over by an endocrinologist, a process that can take months or even years.

Microdosing

In the past, Dr. Perera has asked patients whether they  ‘want to pursue a binary or non-binary transition’ (though she has told us she will not use this language going forward after many patients found it confusing). What is meant by this is whether you would like to microdose. Whereas typical HRT achieves hormone levels in the “normal male/female range,” microdosing puts you below that range. Dr. Perera may directly ask if you are looking to be in either a cis male/female or non-binary range if you are microdosing. We have heard that Dr. Perera was clear in stating that this is in reference to dosage, not your own identity, and that the effects are the same in the long run, just that they arrive more slowly. Some trans people regardless of identity prefer microdosing for their own transitions. Some prefer to start HRT and then stop after they get the changes they want, knowing that some of those changes are likely to be permanent or partially permanent. Many trans and non-binary patients who don’t feel an urgent need to see change and would prefer to “test the waters” chose to microdose. 

Self-Administering Injections

Many patients are initially anxious about having to do self-administered weekly injections. The Hub offers appointments with a nurse to walk you through the process, and most pharmacies offer a similar service when you pick up your prescription for the first time. Both pharmacist and nurse appointments are pretty easy to get; however, in both cases they will not actually do the injection for you. See this step-by-step guide on how to self-administer your injections safely. 

You can also get a friend to do the injection for you. Many trans patients have someone who is already familiar with HRT injections walk them through the process and administer the injection while they get used to the process of doing it themselves. Some also teach a trusted friend or family member how to do it for them. However, if you administer someone’s injection for them, do it incorrectly, and hurt them, they can take you to court over damages. Unsurprisingly, friends and family usually help each other with injections under the mutual understanding that they would not sue if that happened, but it’s important to know this is technically a liability. This is the reason nurses and pharmacists won’t do your injection for you. If possible, it is a good idea to learn to do the injection yourself, so you can still get your medication if you are ever unable to have someone else do the injection for you.

Blood Tests

When to get blood taken relative to your administration schedule

Each patient will need different levels of HRT to end up in their target hormonal range. Being in your target range is critical for having the best chance of getting the results you want. So, doing and interpreting your blood tests correctly is very important. Failure to get your blood taken at the right time relative to your administration schedule could lead to unreliable test results. We also stress this here because we have noticed that Dr. Perera is not always super clear to patients when they should get their blood tested. 

For patients doing injections, you should definitely not get your blood taken just after your injection. There is a lot of contentious debate about if it is better to get your blood taken mid-way between two injections, or just before you take your new dose; but generally it is agreed that it doesn’t matter too much which you do so long as your doctor knows which one you are doing so they can properly interpret your results. Dr. Perera typically asks her patient to get their blood taken mid-way. 

On oral or sublingual estrogen, we recommend that you have your blood test at “trough” hormone levels, right before you take your next dose of medication.

If you are on patches the timing of your blood test is less important as the medication is continuously released. 

 For T gel, one endocrinologist we spoke to advises their patients to get their blood taken at “trough” hormone levels, 24 hours after they applied the gel, right before their next dose.

Additionally, some doctors will require that patients avoid eating before their hormonal blood test, though this is not the case for Dr. Perera last we checked. Be sure to ask your doctor if you can eat before your blood test to avoid possibly being required to repeat your test.

ID Marker Issues and Blood Testing

Trans and NB patients at the Hub and in Montreal have reported a number of issues when submitting blood tests. The Hub’s blood tests are sent to a Montreal hospital for evaluation. These hospitals have been known for throwing out or incorrectly administering blood tests if the gender marker on a patient’s referral or health card does not ‘align’ with the hormonal blood tests they are getting, or if the patient has an X marker on their IDs. For example, if you are on T and getting a blood test for the male range but have a F on your ID, the hospital staff may assume an error was made and complete the incorrect test or throw out your test all together. Often there is little the Hub can do about this aside from ordering another blood test. 

Additionally, at the Hub patients with an X gender marker on their legal documents typically have their birth sex/gender marker put on their blood test referrals, even though putting their birth sex as opposed to the opposite sex risks them getting their blood test thrown out when testing HRT. Because of how Quebec’s medical system works, blood test requisitions do not accommodate an X marker and the provider must mark either M or F.

Booking a Blood Test at the Hub

Although the Hub usually offers blood tests on site, as of December 2024 this service is not available and it is unclear if or when they will be available again. However, getting blood tests at the Hub if they are available is probably the easiest and most convenient option for most students, so we recommend checking their website for the most recent updates on their availability. When blood tests are available, appointments can be booked on their website. Generally, appointments are available 1-2 weeks in advance. The listings are not always updated at the same time, but we recommend checking for new appointments on Wednesdays and Thursdays.

Booking a Blood Test at a Hospital

While the Hub is not doing blood tests, the most accessible place to receive blood tests is at a hospital that will directly bill your insurance. To our knowledge, any Montreal Hospital will accept out-of-province insurance (or RAMQ). All McGill affiliated hospitals and some others will process international students’ Blue Cross insurance. McGill affiliated hospitals include Saint Mary’s, Jewish General, and Hôpital Lachine. However, note that some MUHC hospitals, namely Montreal General and Royal Victoria, have recently restricted blood tests to only their own patients. It is our understanding Hub patients with RAMQ and Blue Cross will not be able to access appointments at these hospitals, but we were told by Dr. Perera this fall that there is an exception for Hub patients with out-of-province insurance. Also, some patients have also confirmed that Hôpital Notre-Dame and Hôpital Santa Cabrini accepted their international student insurance (Blue Cross). Tests at MUHC (McGill University Health Services) locations can be booked here and at any of these hospitals using Clic Santé. However, the MUHC appointment slots are sometimes full as far as a month and a half in advance, so we recommend being proactive and booking early. Using Clic Santé you can compare the availabilities of different hospitals and make sure you catch availabilities as soon as the next appointments open. Every hospital opens their availabilities for blood work appointments at different times—usually either every week, or every two, three, or four weeks.

You only need a requisition for blood work at the appointment itself; one can  book a blood without a requisition. Thus, once you have the second appointment at the Hub scheduled, you may want to book the earliest possible blood test slot after the appointment. 

To prepare for a blood test, follow the instructions on the location’s website. In general, you will want to bring a physical health insurance card, a piece of photo ID, and a printed copy of the requisition. For those unfamiliar with Canadian healthcare, this generally involves bringing a piece of photo ID and your health insurance card to the “Hospital Card” office, having a card issued, and then going to the blood test department. Once there, they will ask for your printed lab requisition, hospital card, and insurance card. They may send you to the billing department (located nearby) to put your insurance on file, and then return to have your blood drawn. 

How Blood Test Complications Impact the HRT Process

Occasionally, patients will have baseline blood test results that are out of the typical hormone range. Dr. Perera may require that patients get further testing if she thinks these hormonal levels may be a sign of a separate underlying health condition. For some patients, this additional testing has included more blood tests, endocrinology appointments, and transvaginal ultrasounds. 

In particular, Dr. Perera has made some transmasculine patients with higher than average baseline testosterone levels take additional testing to rule out the possibility that they have PCOS. To our knowledge, transmasculine patients who underwent additional testing due to higher than average T did not usually have PCOS in the end. More often than not, such individuals had normal T results when their blood was tested a second time. 

If you have to do additional testing, rest assured that while additional testing delays the process, it is basically unheard of for patients to be disqualified from HRT due to their baseline hormone levels.

If you have to do additional testing that involves being referred outside of the Hub, contact us and we can help you through the process, including seeing an endocrinologist without going on the provincial waiting list. We have spoken to Hub trans patients who have been on that wait list for over a year even though the estimated wait time is only six months. Patients who need ultrasounds generally get referred to RadiMed. Two patients reported being denied access to a transvaginal ultrasound at RadiMed because ‘they were a virgin’. However, when one of those patients called a second time they were not asked that question again.

Last year, we also heard from several patients who had to redo blood tests for testosterone due to a reagent shortage. We have not heard of this happening after spring of 2024, so we believe the issue has likely been resolved. 

Fertility Preservation

HRT’s impact on fertility

Currently, the common understanding of HRT is that both transfeminine and transmasculine patients will become broadly infertile while on it. However, HRT is not a reliable contraceptive. We recommend patients practice safe sex regardless of one’s fertility status. While there are cases of trans people going off of HRT and having genetic children (especially for transmasculine people), as well as some promising medical studies on this issue for transmasculine patients (see here), this topic has not been widely studied enough to confirm whether stopping HRT will reliably restore your fertility to what it would have been without HRT, or if it will restore it at all. If having genetic children is important to you, you should consider getting your sperm or eggs frozen before going on HRT. Also, if you have already started HRT, pausing your HRT to get your sperm frozen may still be an option, and pausing to freeze your eggs is even more so still an option (see more here). 

Preservation is quite reliable! 

The odds of frozen eggs leading to births are quite good, but they are not guaranteed. Egg freezing procedures for patients under 36 who get many eggs frozen (10-20) have a live birth rate of 70%-90% (according to this source), and the odds are likely even higher for someone in their early 20s. Also note that a patient’s frozen eggs don’t need to be carried by them; a patient’s embryo can be put into the uterus of a surrogate. As such, transmasculine patients can have genetic off-spring without needing to become pregnant themselves. 

For transfeminine people the odds are even better, depending on how you are using frozen sperm, the success rate is either the same or slightly lower than of never-frozen sperm (see here). 

How much does it cost? What are my insurance options?

Fertility preservation can be pricey without appropriate insurance, for an example of costs without insurance see these quotes for egg freezing at Clinique Ovo and this quote for sperm and egg freezing at Fertilys. If you are a trans person planning to get preservation before you start HRT or pause your HRT for fertility preservation, some of the insurance options may be an option for you. Here is the breakdown of how different insurance plans available to various McGill students cover fertility preservation: 

• RAMQ (Quebec’s public insurance): Extraction, the first freezing, and 5 years of storage are covered (or until you turn 25, whichever is longer). After that it’s $200 a year to keep it frozen.
  • In order to get RAMQ to cover you preservation, your provider needs to send a referral to a relevant clinic (see below) saying you need fertility preservation because you are beginning HRT
• DesJardin (SSMU & PGSS Health Plan) plan provided for McGill Canadians: doesn’t cover any fertility preservation according to this booklet. 
• BlueCross McGill international student plan: doesn’t cover any fertility preservation 
• GreenShield Gender-Affirming Care plan (Canadian & International): doesn’t cover any fertility preservation according to GreenShield’s description. 

Where do I go for fertility preservation in Montreal? 

To our knowledge there are three clinics in Montreal that provide this service: Clinique ovo, MUHC reproductive center, and Fertilys. Note that many of these clinics will say on their website that they do not accept RAMQ. Despite this, we can confirm that at least some of them are covered by RAMQ for people starting HRT or who have other medical necessities. 

In the past, Dr. Perera has referred patients to MUHC Fertility Clinic and Clinique ovo. We can confirm that at least Clinique ovo accepts RAMQ coverage for sperm and egg preservation.

Discussing preservation at the Hub

During the first appointment, Dr. Perera typically asks if you are interested in fertility preservation. Please note that accessing fertility preservation will delay the start of HRT.  One transmasculine Hub patient reported that freezing their eggs delayed their access to HRT by a year (although this was during COVID-19 lockdowns). Transfeminine Hub patients have reported that it took them anywhere from 3-5 months to see through an appointment with a sperm bank. However, in discussion with Dr. Perera, we have been assured by her that delays to HRT do not typically differ for transmasculine and transfeminine patients, and that the delay is normally only a few months

When accessing care at the McGill Wellness Hub, we recommend that patients consider fertility preservation before seeking care. In the past, trans and non-binary patients have reported being second-guessed in their choice to not seek fertility preservation, though this does not seem to be as much of an issue recently. Still, we recommend that patients research fertility preservation ahead of their appointment; in particular, if you are certain you do not want fertility preservation, being well-informed and firm about your decision reduces the chance that you will be second-guessed.

Further Considerations for Transmasculine Patients about Freezing Eggs

There are a few things to consider for transmasculine patients interested in fertility preservation. Patients report that the process is quite invasive and painful, much more so than they had anticipated from discussions with medical staff. The process involves 8–12 days of self-administered injections and retrieving eggs from your ovaries using a needle through the vaginal wall under light sedation (learn more here). 

Importantly, despite the setbacks, there are many transmasculine patients who are glad they underwent the process because they wanted to secure their chance at future offspring as much as possible. We encourage interested patients to consult blogs and vlogs where patients share their experience of getting their eggs frozen to get an idea of the process. We can also connect interested patients with patients who got their eggs frozen through the Hub in the past if they want to hear about their experience. 

Pharmacies

Once Dr. Perera sends the prescription to the patient’s pharmacy, they need to go to the pharmacy to pick it up. You can show up and the pharmacy will prepare it for you or call in advance. If the pharmacy has not received the prescription by the next day, call the Wellness Hub and ask them to re-fax it.

It is not uncommon for a pharmacy to not have a specific kind of HRT, either because they don’t have that medication in store unless a patient makes a special request, or because a specific medication is back ordered (meaning the manufacturer isn’t making enough of that brand of medication to meet demand, and so it’s impossible to get that brand of medication in some areas, sometimes for months or years at a time). If your prescription is back ordered, it’s possible that your pharmacist will provide you with an available alternative brand. However, some pharmacists will only give you the alternative after approval from your doctor. To avoid a situation where access to your prescription is delayed due to back orders, we recommend two things:  

1. Call various pharmacies in your area before your third appointment with Dr. Perera to find one that has the kind of HRT you want so Dr. Perera can send your prescription there.
2. Ask Dr. Perera to write a prescription that says a pharmacist can substitute one brand of medication for another if necessary.

For transmasculine patients doing injections, there are two main medications for injectable T (Delatestryl and Depo Testosterone) and at any given time, it is likely one of them is back ordered. If you are transmasculine and doing injections, we recommend you ask Dr. Perera to write a prescription that says Delatestryl can be substituted for Depo Testosterone or vice versa.

Insurance Coverage for HRT Prescriptions

For Quebec residents and Canadian out-of-province students

If you have Quebec provincial coverage (RAMQ) or other provincial prescription insurance coverage, it will cover the majority of your prescription cost for HRT. Some forms of HRT are harder to get covered than others, T-gel often isn’t covered without a note saying it is medically necessary. 

If you are a Canadian student and you haven’t opted out of the SSMU Health plan (covered by DesJardins), this plan can reimburse your HRT prescription up to 80%. Follow this SSMU guide to register. You don’t have to pay up front at the pharmacy with this coverage! Presenting this ID card (SSMU & PGSS) at your pharmacy (which you can complete yourself), allows your pharmacist to bill DesJardin directly. 

Important, note that SSMU Health plan is different from the newer gender-affirming care coverage. HRT is covered under the general prescription drug coverage, not the gender-affirming care plan.

For International Students

If you are on international student insurance, you will need to pay full price for the medication at the pharmacy. Keep the receipt and upload a picture to the claims portal on the Medavie Blue Cross website or app; you should be reimbursed 80% of the cost within a few weeks. However, many patients have had trouble getting Blue Cross to cover their HRT prescriptions (and other prescriptions) over the years. Unfortunately even in some cases where patients have gotten prior-authorization, they were still rejected after the fact. Some patients have also expressed that the prior-authorization process has unclear requirements and is confusing. 

Generally when you are denied, your medications are being flagged as “unnecessary”. In our experience we have found that the best way to address being denied coverage is for patients to complete a form that Blue Cross hopefully will send when coverage is denied, this form must be emailed to the Hub and signed by your provider establishing that it is medically necessary. Our patient reports suggest this is a fairly reliable way to ensure coverage, but we can’t guarantee that it will always be successful given the unreliability of Blue Cross. 

Have Any Questions or Concerns After Reading This Document?

Do you still have questions or concerns about the HRT Hub process?  Message us on instagram @transpatients, or email us at assistance.tpu@gmail.com anytime for transition troubleshooting at McGill and in Quebec. 

Want to share your experience at the Hub to help inform this document and others? Fill out this form to meet with our Patient Reporting Coordinator, or email us at reporting.tpu@gmail.com. 

Have feedback on this resource? Fill out this form to inform our Resources Coordinator, or email us at resources.tpu@gmail.com