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Translated by Florence Bois-Villeneuve. 

They say necessity is the mother of invention. But when trans and non-binary people find themselves turning to the black market for hormones, it’s mostly because they don’t really have any other option.

But why go this more complicated and risky route when you could just ask your doctor for a prescription? Les 3 sex* investigated the matter.

Imagine you need a treatment with the potential to relieve the long-standing pain that’s affecting your quality of life. Now imagine your family doctor refuses to help you because they’re not familiar enough with the treatment. So they refer you to a specialist. But the specialist works at a clinic with a waiting list months or even years long. This clinic is located in a big city far from home. You’ll have to pay to get there plus you’ll lose a day’s salary because you have to miss work.

What would you do? Would you wait patiently while your pain continues to wear you down? Or would you try to find a Plan B, a faster way to access the treatment you need?

When gender-diverse people opt for the non-medical—and illegal—route, it’s most often because they are trying to bypass access barriers to gender-affirming care. It’s so they can get what they need to alleviate their gender dysphoria or instill gender euphoria. It’s so they can feel fully themselves in their affirmed gender.

That’s what happened to Judith L., who generously agreed to share her story with Les 3 sex*. After years of contemplating a medical transition, only to find herself on a waiting list for a family doctor, Judith turned to Clinique médicale La Licorne.

This Montreal-based medical clinic adopts an informed-consent model for gender-affirming care. In other words, patients don’t need a referral from a family doctor or a letter of recommendation from a psychologist or a sexologist to access the clinic’s services. And that’s exactly what Judith was looking for.

The only hiccup was that she still had to wait six to nine months before she could see a doctor at the clinic (a wait time comparable to other informed-consent clinics at the moment). But for Judith, another nine months, on top of years of waiting, was the straw that broke the camel’s back. That’s when she decided to start “DIY (do-it-yourself) hormone therapy” based on information gathered from online trans communities.

When you picture someone buying drugs illegally, a person in Canada buying estradiol online from a pharmacy in Turkey using bitcoins probably doesn’t spring to mind.

But that’s what happened to Judith the first time she turned to online channels for hormones. As she points out, the term “grey market” is more accurate than “black market” in this case, since it involves buying products that are legal but through distribution channels that are not approved by the manufacturers.

Other than having to learn the ropes of bitcoin transactions and then waiting five weeks for her package to arrive, Judith describes her experience as positive. “Even though I didn’t have any medical supervision at the beginning, the treatments went well. I felt better, calmer. I’m glad I went that route, even though it was complicated,” she says, adding that she was especially inspired by Paul B. Preciado’s book Testo Junkie: Sex, Drugs, and Biopolitics in The Pharmacopornographic Era before starting her transition.

Judith is not the only person to have opted for the non-medical route. A systematic review of Western and European studies revealed that many trans people buy hormones online (Heng et al., 2018). According to the researchers, these people do so because they do not have access to the health system, or they want to avoid it altogether for fear of experiencing transphobia or of being misgendered.¹

Sexologist Alexandre Drouin, co-founder of Clinique sexologique Mestra, spoke to Les 3 sex* about the subject, mentioning that some of his clients have confessed to having taken hormones without a prescription. More often than not, these people obtained the hormones from friends or acquaintances. Others got them from connections in online support groups for trans and non-binary people. In rare cases, some bought hormones from a drug dealer.

We should also recall that, in the past, some trans people were denied the option of a medical transition by Québec’s health system. In her book C’était du spectacle! : l’histoire des artistes transsexuelles à Montréal, 1955-1985, Viviane Namaste discusses the barriers to gender transition-related care during the years in question. Trans sex workers, considered pariahs by doctors at the time, were denied prescription hormone therapy, forcing them to turn to the black market.

The prevailing discourse surrounding self-medicating with hormones is negative, and even catastrophic.

Yet many gender-diverse people believe it is entirely possible to do without the services of doctors and endocrinologists. They claim to be able to manage their own hormone therapy, with informal support from online communities, among other sources.

But are online communities really a substitute for medical doctors? Judith points out that these communities are brimming with information for people who want to take charge of their own gender-affirming hormone therapy. According to her, the underground hormone market isn’t the “wild west” one might imagine, and not all trans and non-binary people who go this route do so “cowboy-style, throwing all caution to the wind.” On the contrary.

For example, on Trans DIY, a Reddit community with more than 38,000 members, there are step-by-step instructions posted for how to administer hormone therapy without a medical prescription. Among other things, members recommend that anyone starting hormone therapy first have a blood test done at a clinic to establish their baseline levels.

They also share advice about the initial dose based on weight and the subsequent doses. And they recommend going for follow-up blood tests at three months and six months, and then once a year after that. “It’s a form of community empowerment,” says Judith. “Group members have access to information and warnings.”

One of the advantages of online communities, according to Judith, is that they provide access to information about treatments other than those currently recommended in the Standards of Care of the World Professional Association for Transgender Health (WPATH) and prescribed by doctors.

For example, one widespread community practice for trans women is monotherapy, which involves taking estradiol on a regular basis without the testosterone blockers that are currently prescribed in tandem by doctors. Advocates of monotherapy say it comes with fewer health risks than taking estradiol in combination with the blockers.

According to Judith, trans medicine has major shortcomings. She recommends reading the book Trans Medicine, by stef m. shuster for more information on the subject: “There is no clear scientific basis for current medical practices. Most of the data used by the WPATH come from studies on cisgender men with prostate cancer or cisgender women, or from animal testing.”

For some trans and non-binary people, DIY hormone therapy is part of a self-determination process through which they take control over their body and their transition journey. Some trans people with a background in chemistry even produce their own hormone treatments, circumventing the need for both traditional pharmaceuticals and unreliable underground supply channels.

That said, DIY hormone therapy is still a more complicated option than medically supervised treatment, warns Judith. It is very important to research the right doses for your weight, blood levels and transition stage. “But if you don’t want to put in the research about your body and the appropriate treatments, go see a doctor,” she recommends. “DIY means learning to do it correctly on your own.”

Not everything is rosy on the black market... First of all, as with any illegal substance, there’s a risk you may not get what you think you paid for.

For example, hormones sold online may contain lower doses than the ones generally used for gender transition. In that case, the treatment will be mostly useless and will fail to alleviate the person’s gender dysphoria. Conversely, the doses may be too high, which can lead to serious health consequences, including mood swings and depression, liver damage, blood clots, high blood pressure, breast cancer and cardiovascular disease (Amnesty International, 2019).

And that’s not to mention the risks related to sexual function. While medically supervised hormone therapy can affect sexual function, the side effects are very likely to be worse with uneven doses.

“For example, taking massive doses of birth control pills can make it more difficult to get an erection,” says sexologist Alexandre Drouin. The wrong dose can also affect sex drive and even cause infertility.

He adds that an excess dose of hormones can actually be converted by the endocrine system. For example, if someone takes too much testosterone, the surplus will be converted to estrogen, which can cancel out the treatment or cause unwanted side effects.

It should also be noted that certain health conditions require taking medication that does not pair well with hormone therapy. In that case, taking hormone therapy can be harmful to a person’s health. Someone who is buying hormones illegally may not have access to this vital information about contraindications with their regular medication.

Not being followed by a doctor can be risky, as this means there is no one to monitor and control the effects of the hormone therapy. The Association des médecins endocrinologues du Québec recommends that trans and non-binary people who take hormones be followed by a doctor. According to the Association’s website, it’s also important they have regular blood tests to make sure their blood levels stay within normal range.

For some people, the black or grey market is often a last resort for bypassing access barriers.

Despite major inroads in gender-affirming care in the Canadian health system over the last few decades (but that’s not to forget the sad days when being a transgender person was considered a mental illness), there is still a long way to go before gender-diverse people have guaranteed access to quality care and services.

Difficulty getting prescriptions is just one of the many barriers to gender-affirming care. While family doctors can prescribe hormones to trans and non-binary patients, many would rather refer their patients to a specialist. But seeing a specialist also means longer wait times and less accessible services.

This was demonstrated in a study by Clark et al. (2018a) on the primary care accessibility barriers for trans and non-binary youth in Canada. The results of this study revealed that the (overly) long wait time for services is a major access barrier for these young people. For people living in rural areas or small towns, the distance to obtain services in a big city was also seen as an access barrier.

Informed-consent clinics offer the advantage of direct access to hormone therapy. There is no need for a doctor’s referral or a psychological evaluation². However, many of these clinics are currently victims of their own success. Some have long wait times, and others have even had to close their waiting list due to lack of availability.

Supply issues are yet another access barrier. Alexandre Drouin explains that there are two main pharmaceutical companies that sell injectable testosterone in Québec: Bausch Health and Pfizer, the makers of Delatestryl and Depo-Testosterone, respectively. To maintain their monopoly, these companies produce a limited amount of testosterone.

Often, one company’s testosterone is out of stock in pharmacies, forcing some people to ask their doctor for a prescription for the other company’s testosterone. However, this request is not always accepted. “Many doctors prefer not to write the prescription because switching brands can lead to side effects and an imbalance,” says Léo-Frédérik Leroux, Vice-president and Diffusion Director at Les 3 sex*.

Others temporarily turn to illegal supply channels (e.g., the Internet or social media).

The sexologist also says there was a serious supply problem with injectable testosterone during the first few waves of COVID: “The two main pharmaceutical companies were out of stock. People were also having a lot of trouble getting an appointment with their doctor or endocrinologist to have their prescription renewed. In-person appointments were impossible for several months, and doctors were overwhelmed bypatients consulting for COVID symptoms.” This situation led to the formation of self-help networks for the supply of testosterone.

A TransPulse survey of trans and non-binary people in Canada showed that 28% of respondents had to interrupt their hormone therapy during the pandemic, and 46% were unable to get a prescription renewal or a referral for hormone therapy.

Ironically, people who have already started taking hormones without a prescription appear to have an easier time getting an actual prescription from a doctor.

“If you tell a doctor you’re already taking hormones illegally, they’re much more likely to prescribe them for harm reduction reasons,” says Judith.

Her observation is corroborated by studies that have shown taking black market hormones can make it easier to access prescription hormone therapy. For example, Linander et al. (2016) reported that taking illegal hormones was perceived in some cases by the medical team as a “sign” of the person’s seriousness, further highlighting the importance of prompt medical management. In other words, buying hormones on the black or grey market could be a stepping stone to medical supervision.

Another way to obtain hormones legally is to consult an endocrinologist in private practice. While this has the advantage of faster access to hormone therapy, it is much more expensive than consulting in the public sector (between $200 and $300 per appointment).

For example, Dr. Gabrielle Landry, who recently opened the Centre d’expertise en hormonothérapie, médico-esthétique et santé sexuelle, offers hormone therapy without a referral. And it takes only two to three weeks to get a prescription for hormones at her clinic.

According to the sexologist we interviewed, some trans and non-binary people simply can’t afford to buy the prescription hormones sold in pharmacies. In other words, economic barriers prevent them from accessing hormone therapy under medical supervision.

While legal hormones for transfeminine people cost roughly the same amount as grey market hormones (around $40 per month), depending on the administration route legal hormones for transmasculine people are apparently more expensive. Injectable testosterone costs around $20 per month both in pharmacies and on the black market. However, testosterone gels and patches cost between $100 and $150 per month at the pharmacy.

“That’s a huge amount of money, especially since the transition process involves many other costs that aren’t covered, such as laser hair removal, some surgical procedures, and name changes on official documents,” explains Mx. Drouin.

Is the black market really cheaper? According to Judith, some hormones are cheaper when purchased illegally, especially for people who don’t have private insurance and rely on the Régie de l’assurance maladie du Québec (RAMQ). That’s also why some people in vulnerable situations are willing to risk the physical cost of nonprescription hormone therapy. Because they simply can’t afford any other option.

Low-income gender-diverse people aren’t the only ones who have trouble accessing medically supervised hormone therapy. Other subgroups of Canada’s trans communities appear to be in the same situation.

It would seem non-binary people are at a disadvantage compared to binary trans people. For example, one Canadian study reported that non-binary youth are twice as likely as their binary trans counterparts to be unable to access hormone therapy considered necessary (Clark et al., 2018b).

According to sexologist Alexandre Drouin, discrimination against non-binary people (enbyphobia) is still rife within the medical profession: “Many doctors will require a non-binary person to actually have an appointment with a sexologist; a letter is not enough. These doctors say they need to make sure the person’s gender identity will remain stable and that they won’t “change their mind.” Many non-binary people shun the health system to avoid the microaggressions and feelings of invalidation.

What’s more, minors under the age of 14 in Québec need a parent’s permission to access hormone blockers. In other words, if a parent is transphobic, a trans or non-binary teenager will be forced to go through puberty against their will, unless they buy hormones themselves on the black market.

And let’s not forget asylum seekers and undocumented people, who are not eligible for RAMQ coverage of their transition costs, effectively blocking them from obtaining gender-affirming care through legal channels.

As trans health specialist Dr. Ruth Pearce points out in a Sky News report, trans and non-binary people will keep turning to the black market for as long as the health system continues to underfund gender-affirming care. Because, for them, the risks of no treatment at all outweigh the risks of nonprescription hormone therapy. Because it’s better than nothing.

Would it be better if gender-diverse people didn’t turn to the black market for hormones? Far from blaming people who go the non-medical route, Mx. Drouin instead points the finger at the failings of the health system:

“First and foremost, we need to make it so that people don’t need to turn to the black market. There’s also a pressing need to train family doctors, to open up more specialized clinics, and to improve the RAMQ coverage for certain trans medicine treatments.”

In Judith’s opinion, greater community support is needed for hormone therapy. In other words, trans and non-binary people need to be allowed to support each other and share safe resources. The young woman would also like to see the widespread adoption of the informed-consent model of trans medicine. “Information also needs to be available to make sure the consent process is well and truly informed,” she adds.

Finally, beyond better access to hormone therapy for gender-diverse people, Judith would like to see oral contraceptives and hormones for perimenopausal and menopausal people become more readily available. And in an ideal world? “Ultimately, I’d like everyone to have the right to quality medical information, appropriate hormone therapy, and bodily autonomy.”

***

¹ Misgendering “refers to the action of addressing or talking about someone using the incorrect pronoun(s)” (Drouin, 2022). Taking a person’s gender for granted or assuming it is also a form of misgendering.
² It’s worth pointing out, however, that a doctor’s referral can shorten the wait time.