Gender Affirming Care
Patient-led, evidence-informed care.
Gender affirming care at Bywater Health is shaped by deep clinical expertise, long-standing involvement in transgender medicine, and most importantly: what transgender patients themselves have taught us over decades of care. We believe the most meaningful and effective care comes from listening closely to patients and responding to their stated goals, bodies, and lived realities.
Our founder, Chuck Williamson, ANP-BC, PMHNP-BC, wrote and published primary care guidelines on gender affirming care in 2008 and has been an active member of the World Professional Association for Transgender Health (WPATH) since that time.
We provide medically supervised hormone therapy, surgical referrals, and insurance-required documentation for patients seeking standard-dose gender affirming care as part of a full medical transition or for those who have already transitioned and are continuing care.
Please Note: While WPATH guidelines are often necessary for insurance approval, they are also highly restrictive and can be a barrier to care. When required for coverage purposes, we follow WPATH documentation standards. Clinically, however, we also rely on other evidence-based guidelines to better meet patient goals and reduce unnecessary obstacles to treatment.
Our Clinical Philosophy
Much of what medicine knows about transgender health exists because transgender patients have consistently advocated for themselves, corrected systems that failed them, and shared their experiences when clinicians were willing to listen.
At Bywater Health, we recognize transgender patients as the experts on their own bodies. Our approach prioritizes patient goals, informed consent, and flexibility within evidence-based medicine—rather than rigid adherence to protocols that may not serve everyone equally.
Guidelines we Use
We draw from multiple clinical frameworks to ensure care is both medically sound and practically accessible:
UCSF Gender Affirming Care Guidelines – authored by a transgender physician, Dr. Maddie Deutsch, M.D. and widely regarded as one of the most patient-centered resources in transgender medicine.
Fenway Clinic Medical Guidelines – affiliated with Harvard School of Medicine, Fenway Clinic has a well earned reputation as being one of the best LGBTQ+ clinics in the world.
A note from our providers: There are currently no evidence based guidelines on using HRT “micro-dosing” for non-binary affirming care. Although we do offer some options, every individual responds to HRT diffrently and some individuals will have greater than expected effects from even the smallest doses. We encourage non-binary individuals looking for micro-dosing options to also consider seeing a naturopathic physician as they can prescribe micro-dose HRT and offer other options to achieve holistic support.
Our Services
Hormone Replacement Therapy (HRT)
We provide comprehensive hormone therapy for both feminizing and masculinizing care.
Feminizing HRT may include:
Estrogen (tablets, injections, or patches)
NOW OFFERING IMPLANTED ESTROGEN PELLETS, placed under the skin and lasting 4-6 months
Not covered by most insurance
Self pay rate is $300 (can set up auto-pay for $75/month)
Progesterone (capsules or injections)
Anti-androgens (spironolactone, finasteride)
Masculinizing HRT may include:
Testosterone (topical gel, oral tablets, or injectable forms)
NOW OFFERING IMPLANTED TESTOSTERONE PELLETS, placed under the skin and lasting up to four months
Not be covered by most insurance
Self pay rate is $300 (can set up auto-pay for $75/month)
In addition to prescribing hormones, we actively support patients in managing side effects of HRT, including concerns such as hair loss.
A note from our providers: We do not currently offer microdosing HRT protocols for gender affirmation due to the lack of established evidence-based treatment guidelines. We recommend patients interested in microdosing explore care with local naturopathic providers who specialize in this approach.
Surgical Referrals
For patients pursuing gender affirming surgery, we provide knowledgeable referrals to trusted surgeons and specialty providers, informed by both clinical standards and patient experiences.
Letters of Support (LOS)
We write Letters of Support (LOS) for gender affirming surgeries for established patients. These letters can include both medical and mental health attestations, as required by insurers or surgical teams. Our documentation balances insurance requirements with language that affirms patient autonomy and avoids unnecessary pathologizing whenever possible.
Ongoing Primary & Preventive Care
In addition to gender affirming services, we offer:
Wellness-focused primary care for transgender patients
Preventive care and screenings
Sexual health services
Contraception counseling and management
Important Care Limitations
Because we are a small clinic with limited staffing, we are not able to manage patients with complex or high-acuity medical needs, including: POTS (Postural Orthostatic Tachycardia Syndrome) MCAS (Mast Cell Activation Syndrome) EDS (Ehlers-Danlos Syndrome) SIBO (Small Intestinal Bacterial Overgrowth) Lyme Disease or Long Covid.
We share this transparently so patients can make informed decisions about whether our clinic is the right fit for their care needs.
Request an Appointment
Gender affirming care that listens first and treats accordingly.
If you’re looking for thoughtful, evidence-informed care that honors your identity and your goals, we welcome you to begin care with us.