How I Got Hormones (With No Money, Insurance, or Access to a Gender Therapist)
This story may be helpful to those trans people in poverty, forced to get creative in order to get the care we need.
Getting hormones, as a transgender person, is a multi-step process. Generally speaking, this is how it’s supposed to work, in theory:
- Change your name and start living as your authentic gender.
- Find a gender therapist and acquire a note from them recommending hormones as the next course of action for you, in terms of your transition.
- Find an endocrinologist who specializes in trans care.
- Have lab work done to assess your baseline hormone levels.
- If everything seems okay, you’ll probably get a prescription.
- Depending on your location and any specific needs you have, you might have to send away to get it filled.
Especially in the United States, things don’t always work as expected. When that happens, you have to adapt to it and find another way forward.
What’s wrong with the above process?
In theory? Not a whole lot. But it’s tough to find people who are both willing and able to prescribe hormones to trans people. They come in two main types:
- Specialists: people who have training that relates specifically to transgender hormone therapy. These are considerably rare.
- That One Guy Who’s Too Old to Give a Fuck: even rarer than specialists, these are people who can prescribe the hormones and aren’t worried about transgender specifics.
Any doctor or medical professional who can write prescriptions is theoretically able to prescribe anything they feel is appropriate for their patients, according to the best interests of each patient as an individual. The exception is that non-doctor practitioners (nurse practitioners, for example) are not authorized to prescribe controlled substances.
Gender Shenanigans
Some Potentially-Needed Vocabulary
This is by no means an exhaustive list, but to get you started, here are some words you should know.
- cisgender (cis): anyone who fully identifies with the gender they were assigned at birth
- transgender (trans): anyone who does not identify fully with the gender they were assigned at birth
- gender binary: men/male and women/female; male and female are used interchangeably with men and women, respectively, but these terms do not refer to physical sex or secondary sex characteristics
- nonbinary (non-binary): anyone who does not identify fully as a man/male or woman/female
- transmasculine: describes a trans person who identifies (fully or in part) with masculinity
- transfeminine: describes a trans person who identifies (fully or in part) with femininity
- genderfluid: describes a trans person whose gender identity shifts or changes
- gender expression: how an individual does or does not express their gender identity
Feminizing Hormones
Trans women are women who, at birth, were determined to be male based on genital shape and structure. At some point, they made a conscious decision to accept themselves as being women, and their goal is to live a good life as a woman.
Trans women are also sometimes referred to as MTF (male-to-female) trans people, but in my experience, that abbreviation tends to be more for the sake of cis people’s understanding. In any case, many trans women choose to take estrogen, and possibly one or more other medications, to help them look and feel more feminine. Hormones that assist them in this endeavor are called feminizing hormones.
Masculinizing Hormones
Trans men, sometimes called FTM trans people, often take testosterone for its masculinizing effects. Some supplements can complement testosterone in this way, but testosterone itself is considered the standard line of hormonal therapy for trans men.
What About Nonbinary/Non-Binary People?
Being nonbinary means that your gender isn’t fully captured by the gender binary. There is no “conventional” or “traditional” way to be nonbinary, at least in Western culture, the way there is a “conventional” or “traditional” way to be a man or a woman. For that reason, many people find the notion confusing.
Nonbinary people who were assigned female at birth (often abbreviated AFAB) and who would like to appear more masculine might take masculinizing hormones. On the other hand, nonbinary people who were assigned male at birth (AMAB) and who would like to look more feminine might take feminizing hormones.
Sometimes, nonbinary people take a lower dose of hormones than do binary trans people — transgender folks who identify fully as either men or women. Dose requirements will depend in part on an individual’s objectives.
More Is Not Always Better
Bioavailability and individual reactions play a role that must be recognized.
Bioavailability: How Effectively Does It Get Used in the Body?
Your body can only make use of so much. That’s why, if you take in more energy than you use, the extra energy has to go somewhere and often gets stored as fat. Some (but not all) vitamins, supplements, and drugs work in similar ways.
Taking too much testosterone (or estrogen) is entirely possible. Overall health needs to be monitored during treatment, and routine blood work is advised. A healthy liver, for example, is essential to processing and synthesizing hormones like both testosterone and estrogen, among others.
Excess testosterone can cause “roid rage” and other stereotypical side effects, but it can also be converted into estradiol, an estrogen analog. If you’re transgender, and your goal is to look more masculine, this is not what you want to have happen.
YMMV: How Effectively Does YOUR Body Use It?
Think about it like this: to make a pastry, you need certain supplies and equipment. If you don’t have something you need, or a reasonable substitution, it won’t turn out right, no matter what you do.
Your body works in a way that, while much more complex, uses mainly the same principles. If it doesn’t have everything it needs, it won’t break down immediately, but it also won’t work as well as it could.
There are many ways the body’s use of hormones (whether prescribed or produced naturally in the body) can take an unexpected turn. If you’re taking hormones and aren’t seeing the results you’d like, you need to figure out why that is. It may be that you aren’t using a high enough dose, but it may also point to a deficiency of some sort or to another condition that you and your doctor should be aware of, trans or not.
Okay, Here’s How I Did It
Some preliminaries: I didn’t have insurance, money, or a job, and I was living in semi-rural northern Florida. There were no specialists. Half the doctors had likely never heard of being transgender, sort of like how many of them don’t know what a vegan is.
I was up against a challenge, and I was somewhat desperate to find a solution. The good news is, when it comes to solving a problem like this, I’m quite resourceful and creative.
The Free/Sliding-Scale Mental Health Clinic
In rural areas, especially, mental health services can be scarce or nonexistent. This was how it was in my town. Needless to say, rural swampland wasn’t my first choice, and I wonder why it would be anyone’s first choice. But you make the best of the situation, and nothing teaches you to make the best of tricky or unsavory circumstances, such as being poor.
With just a couple of exceptions, this clinic was all we had for mental health in the town. But it also runs on a sliding scale, and they won’t turn you away for not being able to pay for a visit. My copay for appointments with therapists and prescribing clinicians was $3 a visit, because I didn’t have any income or insurance, but even that was more than I could part with at times.
The flip side of the community health center model of healthcare is that you have to take what you can get. It worked out, as much as could be expected, but there certainly weren’t any gender therapists in this swampy little pocket of Florida. Gender therapists who would agree to telemed services — via Skype or phone — were far more expensive than I could afford.
I went to see the nurse practitioner at the mental health facility, who already knew I was trans. I’d been seeing him for a while already, so he could be reasonably confident that I wasn’t currently a danger to myself or anyone else. He also knew that this was something I felt very strongly about and that I understood what the effects of hormone therapy would likely be.
The hitch, of course, was that he couldn’t prescribe controlled substances. But he could write a letter that attested to my candidacy for receiving the hormones I wanted, which amounted, in my mind, to proof of my informed consent. Armed with this letter, I walked over to the health department the next morning.
The County Health Department
Like the mental health facility I mentioned above, the county health department isn’t supposed to turn anyone away for lack of funds.
And like the facility mentioned above, the county health department in this particular locale is somewhat poorly staffed. I don’t mean that the people working there aren’t qualified or that they don’t do their best. Some of them don’t, and most of them do, and that’s how most people are, most of the time.
The doctor I talked to was an elderly gentleman with a thick Indian accent. The head nurse was a woman who also worked for the VA hospital across town and told me, confidently, that she’d treated “guys who wanted to be girls” before, so she knew what she was doing.
This is how most people are when it comes to trans people: well-meaning, if clumsy with the wording and execution.
It turns out that the letter procured in the previous step may not have been necessary, but it may have helped. I’m not sure. The most important thing was that I got my prescription, which I did. He asked me for my preferred formulation and the dose I needed.
Incidentally, this was the first time I remember being so keenly aware of how uninformed medical professionals could be, even about things that I consider general knowledge.
The Pharmacy (and Payment)
For a while, I bought my testosterone at Walmart. It was a pain, because it involved Walmart. But I’d been approved for a Walmart credit card. Not having much in the way of cash flow, I used the card to keep myself alive.
It only had a $300 limit, though. It wasn’t like it could last forever.
Around this time, the mental health clinic finished the construction of its on-site pharmacy. Like the rest of the clinic, the pharmacy wouldn’t turn you away for lack of funds. The ladies who worked there were on the younger side and were more knowledgeable about my situation.
They were also more knowledgeable in general, including when it came to things like patient assistance programs offered by drug companies.
I still owe this pharmacy, whose parent is called Genoa, a few hundred dollars. To my knowledge, it hasn’t been sent to collections, and I think it’s because the clinic itself is funded by Medicaid and the state of Florida.
It’s been nearly four years. I received bills or statements from Genoa, but it was never sent to collections, as far as I know. They probably wrote it off, which suits me just fine. The point is, while not the best or the most convenient solution, I was able to get what I needed. Another pharmacy in a similar facility may have a similar setup.
Also, any medication you need, check to see if the manufacturer has any sort of patient assistance program (PAP) for the drug in question. For newer and more expensive drugs, especially, there’s often some low-income assistance available.
Other Means of Procurement
You can get this stuff online, if you know where to look. But if you’re going to go that route, there are a couple of things you need to remember.
- Be honest with your doctors. I’m serious. You don’t have to make a big deal about it, and unless you indicate to them that you’re in imminent danger, they can’t tell anyone what you say.
- Vet the supplier before making a purchase. There are certain forums and other networks where you can find lists of verified suppliers, along with what things different suppliers sell.
I’m not telling anyone to break the law. But, again, if you’re going to, you should have the information you need to be as safe as you can about it.
To that end, anyone interested in protecting their privacy should check out ProtonMail, an encrypted email service based in Switzerland. ProtonVPN, another of the services they offer, is a free VPN service. You’ll want to use a VPN of some sort. You’ll also want to get and use Tor, a browser geared toward safety and privacy. Beware of phishing and other cyber attacks.
Most of them take (and prefer) cryptocurrency as a form of payment. If you sign up for Coinbase using this link, I might get referral credit. That would be swell, but it’s not the point. You should know that purchasing crypto the first time typically requires verifying your identity, which may take a few days. Plan accordingly.
