The use of hormone replacement therapy and reconstructive surgery in the trans community is a topic many cis people seem deeply fascinated by; either they’re always asking if we’ve had you know, the surgery,” or they want to condemn us for doing things that are “unnatural” by “destroying” the bodies we were born with. These things, though, are pretty basic and necessary medical treatments.
Just as you would have no qualms about extracting an infected tooth because it’s hurting you, some trans people1 need treatment for the parts of our bodies that are hurting us.
Hormones seem to stir up a lot of emotion from people who are upset/disturbed by the idea that we might use hormones to correct endocrine imbalances in our bodies, despite the fact that scores of cis women use hormones on a regular basis, starting when they become sexually active adults and pushing through into menopause, where hormone replacement therapy is standard.
Whether we’re talking birth control or HRT, the use of hormones in these settings is often considered pretty routine, which begs the question of why it’s such a point of concern trolling when it comes to trans people.
Like a lot of nonbinary trans people, I use birth control for purposes other than those intended2, namely for menstrual suppression, because menstruation triggers intense body dysphoria.
Intriguingly, there’s not a lot of criticism of cis women who need hormonal birth control to regulate their periods when they have extremely painful and unpleasant ones (which I do), but when people use it for what’s considered “convenience,” (for example not experiencing dysphoria so intense that you can’t function) suddenly it’s a problem.
Menstrual suppression is a very taboo topic in a lot of circles, because apparently I am supposed to be “embracing my woman power” or some such; in the haste to destigmatise menstruation, people have left many of us out in the cold. Thanks, folks.
When it comes to using birth control, I don’t follow “the rules.” I periodically order birth control from a sketchy online pharmacy that does not require a prescription, to extend the time between doctor visits. Happily, this is significantly cheaper than it is in the United States, which is good, because even if I did have health insurance, I doubt it would cover sketchy online pharmacies.
Pharmacologically, it’s identical to what my doctor would prescribe after a traumatizing medical examination that would leave both of us wishing one of us had stayed home that day. Ethically, it’s better than lying and saying “I had my exam at the other clinic, it was fine, I really just need a refill,” which is what I used to do.
Lisa Harney, of Questioning Transphobia, has discussed a common problem faced by a lot of trans women: getting regular access to hormones. “I've accessed estrogen via overseas pharmacies simply because it was cheaper to do that than to see a doctor to get a prescription,” she told me, and this was a not uncommon refrain from trans women I interviewed while preparing this piece. She’s never had to resort to using birth control pills as a stopgap HRT (hormone replacement therapy), but other women have.
Like her colleague, Queen Emily, who adds:
Trans women having been doing this for decades, using the birth control of lovers, friends, sisters. With the restrictive and arbitrary medical and psychiatric complex that surrounds official access to hormones—not to mention widespread discrimination and economic marginalization—a lot of women have had to scramble to put together their own treatment through the help of their loved ones. Doctors and psychiatrists admit the necessity of hormones for us, but regular access to hormones is difficult when you're struggling to find work. Borrowing birth control is not ideal, but sometimes you don't have a choice.
Normally I take Premarin twice a day, which is the estrogen pill mostly prescribed for menopausal cis women. A couple of times we haven't had the money to buy my hormones and I've had to use my cis partner's combination birth control pills. It's not near the same amount of estrogen, so there was a huge migraine-causing estrogen crash. I felt really, really rough, but at least it got me through the fortnight til we could afford to get me my drugs.
The trading of birth control pills between trans women is an open secret, just as the use of birth control for menstrual suppression in the genderqueer community is, just as some trans men have used it for the same purpose early in transition. The practice of ordering hormones -- birth control and otherwise -- from overseas pharmacies where there are fewer restrictions on access is also a common experience for many members of the trans community.
These are issues not often considered in discussions about unsanctioned or off-label uses of birth control, and in arguments for OTC availability.
Using hormones is often attacked; we’re exhorted to love the bodies we have and stop damaging ourselves. For us, though, not using hormones would be damaging, just as not using my asthma inhaler would have fatal consequences pretty rapidly. The lengths to which members of the trans community are willing to go to access basic treatment illustrate the depth of the fallacy, and offensiveness, in arguments levied against medical transition.
Do people really think that if we had any other choice, could “love the bodies we’re in,” that we’d be resorting to byzantine and sometimes dangerous measures?
My doctor probably wouldn’t condone what I’m doing, and neither would a lot of other people. Several pushes to make birth control available over the counter have been defeated by people arguing that it should remain prescription-only. Some of the reasons for that are sound; advocates argue, for example, that people who might otherwise never see a doctor at least see one once a year for a new prescription, which provides an opportunity to catch health problems early. Others point out that there are significant health risks associated with hormonal birth control2 and it’s important to make sure patients are aware of them.
And I get that, I do. But I’m sitting here with my order form for Sketchy Online Pharmacy open in the other window, thinking about the complexities of access and gatekeeping when it comes to hormones and the trans community, all in the name of “for your own good.” I’m also thinking about the fact that nonbinary trans people aren’t the only ones who use birth control pills for off-label, unsanctioned uses because of the medical gatekeeping when it comes to trans health care.
Discussions about birth control and access (along with other aspects of reproductive rights) often leave out the trans community, which is something that needs to end. We shouldn't have to slink around to access needed medical care any more than anyone else, and we deserve the same rights and protections as other people who need access to health services -- and that includes the right not to be judged for the treatments we use.
1. It should be noted that not all people choose to pursue medical transition.
2. In fact, the one thing I don’t need it for is what’s on the box. Ask what asexuality can do for you!
3. Blood clots, stroke, myocardial infarction, renal impairment, ocular lesions, hepatic impairment, elevated blood pressure, migraines...see, I do read the package inserts! Oh, and it doesn’t protect me from STIs, which is not really a major concern for me (see above footnote).