A couple of summers ago, I met a transwoman in New York City who was planning on ordering estrogen and an anti-androgen over the Internet. She had conducted meticulous research and claimed to have figured out the proper dosage, given her weight, her medical history, and other factors.
My reaction: “Isn’t that dangerous?”
Hormones produce sweeping effects on the body. In addition to encouraging the development of secondary sex characteristics, hormones also affect one’s libido, alcohol tolerance, and behaviour. Testosterone affects heart functioning and can increase the risk of sleep apnea. Estrogen generally produces sterility in transwomen in under a year.
Many buyers lack the information to determine the correct dosage, which varies from person to person. And without the help of medical providers, most people either cannot or do not monitor their hormone levels – which is necessary to prevent harmful effects.
The way you take hormones can produce additional risks. Hormone pills strain the liver, which has to process the hormones that one’s body produces naturally and those delivered by the pills at the same time. Hormone injections necessarily involve needle use – without safeguards, some people use unclean needles or share them with other people, increasing the risk of spreading HIV and other infections.
The black market also leaves buyers without legal protections. Unscrupulous sellers can scam them by providing impure dosages or substituting the wrong substance without legal repercussions.
Despite all of these risks, I never had to wonder why she chose that way to transition. For her, the other options were extreme depression or suicide. When those are the alternative, dangerous choices make sense.
However, depression isn’t the only reason why some trans people turn to the black market. Systemic factors also encourage people to pursue bootleg hormones. Some “gender specialists” still require a “real-life test” before allowing trans people access to transition services. Under this model, trans people have to prove that they can function in the “opposite” gender role without changing their bodies in order to receive treatment. For many people, following that test would force them to risk harassment or losing their jobs and families. Other doctors use decades-old research to try to restrict hormones to straight trans people only. So a transwoman who likes other women is less likely to be eligible. The World Professional Association for Transgender Health, the traditional reference point for trans health issues, no longer includes either of these criteria as part of its standards of care.
I didn’t have to deal with these barriers, but even with more progressive health care providers, I still had to undergo a semester of psychotherapy before receiving a recommendation for hormone replacement therapy (HRT). Some trans people can’t afford to wait that long for relief from depression or suicidal thoughts.
Other trans people who want HRT choose to do so through the black market in order to avoid a stigmatized mental health diagnosis. The Diagnostic Statistical Manual (DSM), the handbook put out by the American Psychiatric Association to assist in the diagnosis of mental disorders, labels anyone in the U.S. who seeks to transition through the medical establishment as mentally ill for life. The DSM also affects trans people in Canada, since some mental health providers here use it.
I would never condemn anyone who takes black market hormones, though I would encourage everyone to avoid doing so if they can. If someone has no other alternative, though, we should ensure that they use hormones as safely as possible.
Some doctors are starting to agree. Harm reduction techniques, such as offering to prescribe hormones to those obtaining them through the black market and providing safe injection sites, are increasingly becoming considered good practice, since they lower the risks of over- or misdosing and needle-sharing.
But harm reduction only mitigates the effects of a system that denies many people the opportunity to obtain hormones through legal channels. If we want people to avoid black market hormones, we have to make HRT more accessible through the medical establishment.
Quinn Albaugh writes in this space every week. Share your thoughts with Quinn: firstname.lastname@example.org.