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When Mel Cohen first began injecting estrogen, the benefits were immediate. “It was like night and day,” she says. “I went from being suicidal to having so much energy and a clear head for the first time in a long time.”
Hormone therapy, along with facial feminization and gender confirmation surgery, goes a long way towards making male-to-female trans people feel at home in their bodies. Whether injected, swallowed, or applied as a transdermal patch, the medication increases breast tissue, decreases sperm production, thins body hair, and softens skin.
Like other trans women, Mel found that injecting estrogen, rather than taking it in its pill form, resulted in a more dramatic physical transformation in a shorter period of time. “I was starting to see a lot of changes in my body—my hips were finally appearing, and I had some significant breast growth,” she says. “It felt like I was finally having a breakthrough.”
But over the past few months, Cohen has been unable to refill her prescription for the drug that’s saved her psyche. She spends her days calling local pharmacies in her newly adopted neighborhood in Pittsburgh as well as in her hometown of Detroit. No pharmacy has injectable estrogen in stock.
Cohen isn’t alone. Across the country, trans people say that their lives have been upended by the sporadic availability of a drug that alleviates their gender dysphoria (or the persistent feeling that their bodies don’t belong to them). While a shortage of the active ingredients used by one brand of injectable estrogen was resolved in 2016, trans people say the broader supply of estrogen still remains frustratingly out of reach in different parts of the country.
“There was a three month period where I could not hear of anyone finding injectable estrogen in the 20/dl dosage,” says Olivia Danforth, a trans primary care physician in Oregon specializing in trans health. “Now, it’s more like scattered, unpredictable scarcity with even less explanation.”
The World Professional Association for Transgender Health says hormone therapy is a medical necessity for those with “persistent, well-documented gender dysphoria,” and it can be especially helpful for those who don’t feel comfortable presenting as non-binary. After four months on injections, Lauren Walker says she was starting to feel more like herself. “I finally had thinner body hair and the fat on my face was redistributing,” she says. But when she ran out and was unable to refill her prescription, it felt like a slide back into stasis. “It’s frustrating,” she says. “It’s another setback after years and years of feeling like I have had to compromise my transition due to forces outside my control.”
Those who can’t find injectable estrogen in their zip code are more likely to turn to the black market for DIY injections, relying on dark web marketplaces like Valhalla to refill their medications. Even on Amazon and eBay, you can find “feminizing supplements” for men. One, called “Ova-Glan” promises to help buyers “achieve maximum feminine results.”
On Reddit, trans people also look for vials in far-flung cities. “Am I just screwed and need to just go back to tablets?” one comment reads. “Or is there something I'm missing here? Or a prominent pharmacy that I haven't thought of?” In response to inquiries like these, users trade tips on Sam’s Clubs or Rite Aids that haven’t run out of stock yet, discuss how to ration the medications they’ve already secured and share advice on compounding pharmacies, which can produce estrogen injections in-house, but have spotty records with regard to sterility.
The market for estrogen injections is dominated by two manufacturers. Delestrogen, the brand name-version of the drug, is manufactured by Par Pharmaceuticals, while Estradiol Valerate, a generic, is made by Perrigo. In larger cities like New York, Los Angeles, and San Francisco, Delestrogen seems to be widely available, but it can be prohibitively expensive. Estradiol Valerate, in comparison, is significantly less expensive but seems to be almost completely unavailable. (The FDA’s website lists the drug as “currently in shortage” but provides no further information about when the shortage might be resolved.)
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Anthony Fortenberry, the chief nursing officer at Callen-Lorde Community Health Center, says his clinic is out of generic injectable estrogen and that the patients he serves are having to pay for the brand name version out-of-pocket. “The populations we serve tend to be more disenfranchised and don’t necessarily have the resources to pay out-of-pocket,” he adds. “This is also increases the risk that patients will purchase medications on the street or share with friends and that increases the dangers for many reasons.”
Fortenberry believes distributors favor higher-utilizing markets like New York and that’s why the city hasn’t run out of the brand name version of the drug. “But what that means is that a rural area in Pennsylvania might see a shortage [of both drugs] sooner.”
In response to an inquiry from Tonic, a representative for Delestrogen said that the company has “plenty of supply to support the market” while Perrigo, the makers of Estradiol Valerate, said they had “no comment” on claims of a shortage. But in one Reddit post, a user wrote that he received an official response from Perrigo saying that the company had “temporarily discontinued” producing generic estrogen.
Advocacy groups believe pushing the FDA towards approving injectable estrogen for use in feminization therapy would go a long way towards ending these shortages for good. So far, due to lack of funding and interest, there’s a dearth of studies even looking at the benefits of injections over pills. (By contrast, there are over 17 estrogen medications with approval from the FDA for cisgender menopausal women.)
Because of the lack of studies, doctors and patients are forced to rely on anecdotal evidence when deciding between treatments. “You can put two different people on medications and they’ll have radically different timelines and experiences,” Fortenbery says. “Someone might have facial changes, someone might have muscle changes, and someone might not get the results they’re looking for. It’s very specific to the individual.”
Rahne Alexander, an artist in Baltimore, has been taking injectable estrogen off-and-on for the past twenty years. “It goes through ebbs and flows, but in recent years we’ve been seeing more of these shortages happening. They come with no real notice—I’ll go to refill my prescription and I just can’t.”
She believes injectable estrogen is easier on her liver, “but the lack of stability is a really hard thing. I know I’m not the only one who’s struggling to manage her own stability and mental health throughout this. You know, often it just feels like a very isolating sort of circumstance.”
Alexander says the burden is entirely on trans people to lobby and advocate for themselves, a process she calls “exhausting.” Roughly a third of all trans people say they’ve faced discrimination in a doctor’s office, and half say they’ve had to educate their own doctors about hormone replacement therapy. Those in rural areas are often at the greatest disadvantage.
In the past, when she’s run out of meds, Alexander says she’s felt despondent, “like everything was moving slower. It was harder just to connect with people and do the things I needed to do in any given day.”
“I’m in an apocalyptic headspace these days,” she adds. “I wonder what will happen when the few companies making these injections just stop. Because we’re such a small population, if a company decided they didn’t want to support us anymore, they could just do that. And what do we do then? If they’re not being regulated or compelled to serve us with this thing we need, what are we going to do?”
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