Trans Women Impacted by U.S. Estrogen Shortage

woman injecting herself in the arm with hormones

ACROSS THE U.S., hundreds of thousands of women and girls face a potentially endless shortage of life-saving medication. You likely haven’t heard about the crisis, however, because the injectable estrogen shortage disproportionately impacts trans women. With some women reporting pharmacy outages that predate Out Magazine‘s exposé by more than one year, however, it’s high time everyone demanded swift action on the part of the U.S. Food and Drug Administration.

In mid-2015, the 40mg dosage of injectable estrogen went off the market. For the main active ingredient in the medication, manufacturers had been forced to change suppliers, but the FDA has not acted quickly to approve the change. Par spokesperson Heather Zoumas Lubeski told Out that batches at all dosage levels have been “manufactured … but cannot [be] distribute[d] until they receive FDA approval.”

When the 40mg concentration ran out, doctors began to prescribe two 20mg doses instead. Now, the 20mg concentration is becoming scarce, and health care professionals are loathe to prescribe four 10mg doses to patients, because injecting such a large amount of fluid into the muscle can cause extreme pain.

Women who usually receive shots have been forced to rely on alternatives, such as pills or patches. However, these methods must be taken according to schedules different from the injections, which are administered every two weeks, and many women have misgivings about them.

Estrogen pills, which must be taken every day, put women at risk for liver damage not caused by the injectable variety. Both pills and patches are less discreet than injections, meaning the women who are now forced to use them must risk outing to do so. Regarding the difference between shots and pills in her opinion piece for The Guardian, Hannah Simpson wrote:

Many trans women, myself included, feel that shots and the cyclic nature of the estrogen levels rising and falling across bi-weekly doses feels more natural, and more effective, than the continuous levels from daily pills.

You might be wondering what would happen if a trans woman facing the injectable estrogen shortage were to go off her medication altogether, rather than use inferior methods. Simpson said that “[m]issing hormones …. lead[s] to anxiety, depression and the return of certain male features,” including body and facial hair, a deeper voice, and “spontaneous erections, which trans women find uncomfortable and terrifying.” Like less discreet medications, the return of these characteristics weakens trans women’s ability to pass as cis. It endangers not only their mental health, but also their jobs, homes, and lives. As Fusion writer John Walker noted:

Not every trans person chooses to medically transition. Not every trans person is socioeconomically privileged enough to make that choice in the first place. But for the trans women and transfeminine people who do, Bamby Salcedo said, the regimen has the potential to make that “target” on their backs just a little bit smaller.

Because of this, the shortage may soon spawn a public health crisis. Although many reputable online pharmacies exist for those with the means to access them, desperate, more compromised women may resort to buying injections from untrustworthy sources that prey on their desperation, providing women with liquid poison just to make a quick buck.

The shortage of high-dose injectable estrogen has had a disproportionate impact on trans women. Menopausal women who take estrogen do not often use the 40mg dosage that has become so scarce in the U.S., and many opt to use pills, patches, or creams instead of injectables altogether. Additionally, menopause is the only FDA-approved usage of injectable estrogen, which means that doctors who prescribe shots to trans patients do so at their discretion.

Unfortunately, the FDA’s lack of expedience in approving the new ingredient supplier — and approving injectable estrogen for trans women — is the latest incident in a long history of inaction where issues affecting marginalized communities are concerned. Ronald Reagan and his administration did not speak out on the AIDS epidemic until more than 20,000 citizens had died of the disease, simply because it was believed that AIDS was spread only through intravenous drug use and sex between men. Today, this prejudice lives on in bans that prohibit both trans women and men who have sex with men from donating blood in the U.S.

In September 2016, the Human Rights Campaign began a letter-writing campaign designed to gain the attention of FDA Commissioner Robert Califf, and it may have worked. By mid-October, some women were able to fill their prescriptions for injectable estrogen once again.

As WIRED writer Megan Molteni noted, “the supply is unstable,” but adding medical transitions to the FDA’s approved-use list for injectable estrogen could help remedy that instability. Callen-Lorde Community Health Center’s Kimberleigh Joy Smith has organized a 2-day meeting with the FDA in November, in hopes of making trans women’s issues a medical priority in the wake of the crisis.