October 2, 2013

Why Transfolk Should Not Self-Medicate HRT


One of the common things one encounters in the transgender community is self-administration of HRT, most often nowadays obtained via online pharmacy. And it’s totally understandable why some transfolk would choose this route. Going through normal psychological and physiological medical channels to obtain HRT is time-consuming and expensive under the best of circumstances; and since the trans community is one that suffers significantly from unemployment, poverty, and medical stigmatization, it seems like the barriers between us and our needed medical care can be insurmountable. 

Unfortunately, all the scientific evidence shows that self-administering HRT is a dangerous choice. The impact of HRT on the body goes far beyond breast development or clitoris enlargement. Drastically altering the hormones in the body impacts virtually every system in the body to some degree, and it also increases the risk for certain medical complications. 

A fascinating overview of the level of impact HRT has on the human body was published a few months ago in the journal Andrologia. The article is not a research study in and of itself; instead, it is a conformational study that collects and organizes all sorts of observational data points and prior research about how hormone replacement therapy (HRT) affects the human body. The overall picture is a daunting one for anyone considering HRT.

The article’s authors are Dr. Louis Gooren, a Dutch endocrinologist known for his work in transsexual science; and Erik J. Gitlay, a Dutch psychiatrist who has worked with Gooren’s clinic. The aim of this article was not to contribute new results; instead, they’ve gathered the reported results of thirty other studies, many of them produced in part by Gooren and/or Giltay. The result is a rough but compelling picture of the overall effects of HRT on the human body and the ways in which “a large part of sex differences in biological function are not irreversibly determined early in life or at puberty but appear to depend on the prevailing hormone milieu.” 

Here’s a laundry list of things that HRT affects in the human body, according to the compiled studies:

  • Both subcutaneous and visceral fat [i.e. fat under the skin and fat around the organs]
  • Cholesterol levels
  • Proteins and protein resistances correlated to cardiovascular risk
  • Blood pressure
  • Insulin sensitivity and insulin-like growth factors
  • Bone “turnover” [i.e. the rate at which the body makes new bone]
  • Bone density
  • Verbal fluency
  • Spatial visualization
  • Aggression
  • Sexual arousal
  • Cortisol levels
  • Immune system function
  • Hair density and growth
  • Skin temperature and suppleness

Even allowing that this is a rough list supported, in many cases, by only a single study (the researchers use the term “grosso-modo” to describe the list), that’s an impressive and daunting amount of potential impact. Messing with the immune system? Brain function? Risk for heart disease? HRT is not something to be trifled with.

It’s also important to understand that articles like this are still only scratching the surface of research into transsexual HRT. As the WPATH Standards of Care notes,

To date, no controlled clinical trials of any feminizing/masculinizing hormone regimen have been conducted to evaluate safety or efficacy in producing physical transition. As a result, wide variation in doses and types of hormones have been published in the medical literature.

Not only does this mean that there could still be unknown risks in undergoing HRT, but it also means that there’s no consistent guidelines out there for determining type and dosage of HRT components. Some websites offer up a range of regimens or dosages based on various published studies, but they’re hardly consistent. The result is that self-medicating transfolk are often taking dosages that are either ineffectively small or dangerously high. The website TransHealth did an informal survey of self-medicating transwomen, and found:

Of those who were not within the guidelines, the differences ranged from the possibly ineffective to the potentially dangerous. Five (25%) used an anti-androgen considered less effective by Asscheman and Gooren. Two (10%) reported cycling doses, which has no known therapeutic value. Five (25%) used a higher dose of anti-androgen than recommended, and four (19%) used a lower dose of anti-androgen than recommended. A high number (7, one third) reported using a lower dose of estrogen than recommended by Asscheman and Gooren, while one used a higher than recommended dose. Included in the numbers already reported, four (19%) used lower than recommended doses of both the anti-androgen and estrogen. Three (14%) who did not report having had orchiectomies said they used no anti-androgen. Of those reported above, one trans woman was taking three times the normal dose of anti-androgen, and another twice the normal dose of estrogen. 

Sure, there’s lots of information out there and if one does enough digging, one could make an educated guess and guess right. But then again, when you play Russian Roulette you have only a 1-in-6 chance of blowing your brains out. Does that mean you pull the trigger? 

Again, let me state clearly that I completely understand why so many people in the community self-medicate. The stigma, the expense, the gatekeeping — it’s all a deterrent to undertaking HRT under medical supervision. And for some some transfolk, the risk of death would be an option preferable to carrying on as is. Asian estrogens and black-market testosterone may be out there, but just because they’re available doesn’t mean they’re a smart choice. Personally  I’ll wait until I can do it under the care of a trained professional who’s aware of all these things and who knows how to monitor them. 

I’d love to hear your side of the self-medicating issue! What do you think? 

[Part of this article appeared in a draft form on Ali FInds Her Self.]


  • I’ll start by saying that I respect you for blogging on this subject and not to take this post the wrong way.

    There is a bit of a scare tactic feel to this post. As well as well meaning but misleading information. Any of the listed Transhealth issues could be resolved by reading links that were found by the same search query to find this page. And by misleading information, I’m referring to the ‘side effects’ of HRT list. More like intended effects/typical pharmacology.

    There are certainly some risks (like getting fake pills) but nothing that someone without heart/liver problems should worry about.

    I don’t know how much things have changed, but gate-keeping is horrible, and trans youth are undergoing unwanted irreversible change because of it.

    I followed the recommendations of tsroadmap and when I did finally go to the doctor he literally put me on the same meds and dose that I was already taking.

    I do hope that your post here is discouraging the ones who will not do the research to stay away. Because that *is* a good thing.


    • Thank you for your thoughts, and no I did not take offense at your disagreement. Did that post have a “scare tactics” feel to it? I would say instead it was a “cautionary” post. I honestly do hold to the principle that self-medication is a bad idea even under less than normal circumstances. Ultimately, each individual is responsible for their own medical choices, and the motivation for writing that was in part to warn people away from what I see as a bad choice. I do understand that gate-keeping is an issue (though that’s getting better, as my older trans friends like to point out to me as they watch my transition). I still would advise someone in 2014 to exhaust their efforts before choosing the self-medication route.

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