Transitioning Bodies. The Case of Self-Prescribing… by Georgios Karamanis

Transitioning Bodies. The Case of Self-Prescribing Sexual Hormones in Gender Affirmation in Individuals Attending Psychiatric Services

Metastasio A, et al. Brain Sci. 2018.


WPATH eligibility criteria for feminising or masculinising hormone therapy. These include

  • persistent, well-documented gender dysphoria
  • capacity to make a fully informed decision and to consent for treatment
  • age of majority in a given country
  • if significant medical or mental concerns are present, they must be reasonably well-controlled


Masculinizing treatments (testosterone and suppressors of HPG activity): Avoid smoking (risk of thrombosis)

Feminizing treatments (estradiol and suppressors of HPG activity): Avoid if BMI>40, Avoid smoking (risk of thrombosis)

**Ornithine decarboxylase inhibitors (eflornithine, Vaniqa, can be recommended as adjunct for face hair reduction): Avoid smoking (risk of thrombosis)


UK: 23% of those referred to gender reassignment clinics were self-medicating (70% bought online, 32% of trans women)

Estrogens requires diuretics to counteract water retention (?), need to monitor

Widespread and underreported use

Proactively ask about self medication and sourcing. TGNC individuals suffer from a higher rate of mental illnesses and mental discomfort (often due to stigma, discrimination and non-acceptance by family and society). For this reason, mental health professionals are more likely to encounter TGNC individuals in need of support but also have a crucial role to play as an advocate.

Clinicians have the duty not only to inform the patients of the risk but also to suggest safer alternatives and support if necessary, the individuals in this process.


  • untested and unregulated medicinal products
  • unsupervised medical practices such as intramuscular (IM) injections
  • The shipping process is also questionable with the risk that even where the product is genuine, it may arrive in a condition that renders it unsafe for use
  • Buyers may also receive counterfeited products and, therefore, using compounds that may be toxic or even lethal


The main reason for such behaviours seems to be due to the difficulty in accessing gender reassignment/gender affirmation treatments, leaving a significant part of the TGNC population in a condition of discomfort that make them more vulnerable to the onset of psychiatric illnesses (depression, anxiety) as well as other unhealthy conditions or practices (e.g., smoking, drug intake)

Furthermore, as their need for medical assistance may grow, trans individuals often experience problematic accesses to healthcare in terms of professionals’ education and discriminatory practices

This is also due to the length of the waiting lists (up to three years) that pushes TGNC individuals into obtaining hormones online

Gender affirmation is not the treatment of an illness but is a procedure that improves the wellbeing of TGNC and non-binary individuals and, therefore, should be appropriately funded and supported by every clinician