Nearly 10% of transgender hormone users take nonprescription hormones
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Almost one in 10 transgender adults who used hormones had not received a prescription for them, survey data showed. Also, among transgender adults who had insurance, about one in five had an insurance claim for hormones that was denied.
“People who need hormones for gender affirmation may forgo the hormones, along with the opportunity for affirmation and improvement in their mental health and well-being,” Daphna Stroumsa, MD, MPH, a clinical lecturer in obstetrics and gynecology at the University of Michigan School of Medicine, and colleagues wrote.
“Alternatively, if unable to fill a prescription through regulated pathways, transgender people may opt to acquire their medications through other sources; this practice may expose the hormone user to a variety of risks, including toxicity from unregulated substances, incorrect use of medication, and loss of opportunity for medication monitoring and risk mitigation,” the researchers added.
To better understand patterns of nonprescription hormone use and the link between insurance barriers and hormone prescriptions among transgender adults, Stroumsa and colleagues analyzed deidentified data from the 2015 United States Transgender Survey. The results of their analysis, published in Annals of Family Medicine, showed that survey responders (n = 27,715) were disproportionally young, white, highly educated and low income vs. the general U.S. population. Among the 21,237 transgender adults who expressed interest in using hormones, there was “substantial” variation in patterns of hormone use by gender and age, according to the researchers.
“Older age was correlated with a decrease in overall hormone use, as well as use of nonprescription hormones,” Stroumsa and colleagues wrote. “Cultural shifts, along with increasing health concerns, may be at play in explaining this trend.”
According to the researchers, 55.04% of adults who expressed interest in using hormones took them, and of these adults, 9.17% used nonprescription hormones. Among those with insurance, 20.81% had a claim denied. The proportion of the respondents who showed interest in using hormones for gender affirmation did not vary by insurance status (81.27% vs. 83.83%; OR = 1.19; 95% CI, 0.92-1.54), but those who had insurance were more likely to be using hormones than those who lacked insurance (57.4% vs. 41.5%; OR = 2.32; 95% CI, 1.57-3.45).
“It is clear that greater, not lesser, protections of transgender people and their access to care are needed,” Stroumsa and colleagues wrote.
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The findings of Stroumsa and colleagues align with a 2018 study in Archives of Sexual Behavior showing that transgender women without insurance were seven times more likely to misuse hormones (getting them from nonprescription sources) compared with their counterparts with insurance. However, the 2018 study was a much smaller analysis of only 207 patients from Los Angeles County.
In my clinical experiences, many transgender individuals have issues getting hormones covered despite having insurance — more so for testosterone compared with estrogen. Most of the patients I see in the clinic have some kind of insurance but when they tell me about their past experiences, a lot of them have tried obtaining hormones from nonprescription sources. Many transgender youths are discriminated against by their employers and at risk for being fired from the job or not getting a job and consequently, losing or not having health insurance. Another big issue that many transgender youths face is not having access to providers who are comfortable and experienced in transgender care. Transgender individuals also sometimes try to bypass medical care due to their prior bad experiences with health care providers, social stigma, etc.
Primary care and family physicians should be concerned about Stroumsa and colleagues’ findings since these doctors are often the first contact between health care and a transgender individual. PCPs who inquire about gender identity, use of hormones, and so on helps them triage these patients, provide proper medical care and refer to proper health care providers if they are not experienced in these areas. A pleasant experience in the primary care office can help build more trust in a patient population that has suffered discrimination from society and health care when seeking appropriate medical care. Also, many transgender individuals may not be aware of risks of using nonprescription hormones, and their hormone levels may not be regularly monitored. PCPs may be able to counsel and educate on these matters.
In addition, some claims over the internet suggest certain hormones can provide physical changes that some transgender women desire, and they are tempted to buy such things off the internet despite getting prescription hormonal therapy from providers. Thus, PCPs setting patient expectations regarding changes that transgender individuals will see with estrogen and educating them on adverse effects of using nonprescription hormones is very important from the patient’s very first visit.
Reference:
Clark K, et al. Arch Sex Behav. 2018;doi:10.1007/s10508-017-1143-x.
The University of Alabama at Birmingham
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Jose Delfin Castillo III, PhD, MSNA, CRNA, APRN
The results of Stroumsa and colleagues’ study highlight the problem that our transgender community across America faces today. As a certified registered nurse anesthetist, I have interviewed transgender individuals as part of case studies that I have presented in the perioperative care of transgender patients. In one of the interviews, a good friend undergoing the male to female transition process with hormone replacement therapy (HRT) stated that a lot of her friends undergoing transition, do not have health insurance and takes unprescribed HRT.
State-level data shows other concerns surrounding the transgender population. According to Equality Florida, in 2017, 50% of transgender patients experienced depression due to the continued marginalization that they face. In addition, approximately 27% do not have any health insurance and 30% have postponed medical care for fear of being discriminated against.
All health care providers, especially primary health care providers, must assist our transgender patients in having insurance companies provide coverage. We owe it to our communities of interest to avoid creating further harm. If this barrier is not surmounted, the ultimate burden will be on the community, state and nation as a whole.
Reference:
Equality Florida website.
Immediate past president of the Florida Association of Nurse Anesthetists
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