Official vs Unofficial Medical Channels
Understanding the tradeoffs for both
No longer daily posting, but trying to keep some reasonable cadence. More focused on transfeminine medicine as I know much more here.
If you are trans, you need medical care to achieve the outcomes you need. Depending on your situation, you should consider carefully whether you want to go through official channels vs gray-market sources, or you can try informed consent pathways, or you can also do some combination.
Official Medical Channels
This is the de-facto default. Most people throughout their lives interact with an established medical system in their country, and thus it can make sense to continue to do this for trans healthcare too. But there are some considerations.
Additionally, this depends a lot on what country you are from.
Pros
The main advantage of official medical channels, is that you can be very certain that you are very certain what you are getting. Medications will be exactly as labelled, healthcare workers will be risk-averse in providing care, and so you are unlikely to receive medicine that has significant unknown side-effects.
Theoretically, it also means that you don’t personally need to have good knowledge on how effective different medications are.
For many procedures (e.g: surgical procedures like FFS/FMS, VFS, etc. or more modern medicines like estrogen pellets and long-lasting GnRH agonists) going through official medical channels is the only choice.
In some countries this can be provided for free (some European countries). In others, it can be expensive but covered by insurance (USA). In some other still, the only reasonable option can be to pay without having access to insurance.
It is also generally easier to get other treatment in your country, such as surgery and in some countries, name change recognition, if you have been going through official channels.
Cons
A key disadvantage, is that medical workers are very often risk-averse. They avoid potential side effects or less-known medicine, at the detriment of side effects that are not as visible to them (effects on mental health, etc.)
Many workers can be subtly or blatantly transphobic, and either refuse to prescribe, or to placebo-dose (to provide such low-level doses of medication that any reported effects are likely due to placebo, though it could be sufficient for a very small portion of the population).
For example, in medicine there is often some preference to know what the “minimum possible dose of estrogen to get desired effects.” While there are non-zero risks, the current guidance is directionally misguided (see footnotes1), but it can be difficult to convince medical workers otherwise.
While there are a few health workers who can be excellent and know the latest research and best regimens. Many, however, continue to follow the weakest form of HRT permissible in WPATH SOC 8 guidance2 as coded by downstream UCSF guidance. Standard clinical procedure is to start with oral estradiol typically 2–6 mg/day, and spironolactone 100–300 mg/day, and typically starting at the lowest dose for both, and titrate up. This is too risk-averse for most people, and for most is a waste of time.
There is also aversion to giving longer-lasting medicines. Even when giving injectable HRT (the best form), the only pharmaceutically available form in the US for example, is to prescribe Estradiol Valerate. Other forms such as Estradiol Cypionate or Estradiol Enanthate, can be more practical, even if not strictly leading to different results.
This is more of a borderline con, but more experimentally useful medicines such as pioglitazone3 typically are avoided overall until there are larger academic publications on it’s efficacy, while being adopted earlier in less-regulated settings form weaker forms of evidence.
Lastly, many countries have particularly terrible medical systems and bad laws very often. Some countries do not have injectable HRT as an option. Some don’t have any surgeons for most trans-related procedures. Some ban basic anti-androgens such as Cyproterone Acetate4. Some countries have a 12-year waiting list as the only option. And these are examples in countries where things are “particularly good”. Some do not prescribe progesterone for later-stage feminization. Many require you to jump through hoops and questionnaires and committees. Many countries or states may be better or worse than this on any individual question.
It can be worth trying to move somewhere the medical options are better suited to you, but this is not always an option.
Other thoughts
If you have a functioning medical system, financial access to the system, and are lucky with doctors, and don’t have privacy concerns with your government, then going through the normal medical system can be a great option.
If not all of these are true, then it can still be worthwhile to engage with the system (to gain access to things such as surgeries via insurance or for legal sex change, etc. - depends on jurisdiction), but it can be beneficial to seek some assistance outside the medical system in your country, either by changing country or by using grey-market channels.
Informed-consent Pathways
In some countries, it is possible to get access to some medications without strictly needing to go through the whole medical system. This is called informed consent.
Depending on your jurisdiction and location, this can be a reasonable middle-ground for people who have sufficient knowledge about what medications they need, while not needing to necessarily jump through as many hoops.
This alleviates some (but not quite all) of the cons above, and is worth pursuing if it’s an option in your area.
Unofficial Medical Channels
There are also unofficial channels for obtaining medication. These have their own pros and cons too. All else being equal with standards of care, this is a worse option. But all else is not equal, and so it can be worth engaging with grey-market channels.
Pros
Grey-market channels tend to be much more specialized for dealing the problems you are dealing with. Often some of the best forms of medications (Estradiol Enanthate injections, Progesterone, and more experimentally useful Pioglitazone5) are only accessible via grey-market channels in most countries, or from highly specialized medical professionals.
They tend to be able to offer no-judgement medicine if you know what medicine you need. They will not attempt to placebo-dose you or gaslight you, or tell you your estrogen levels are too high for being slightly above the normal female range.
They tend to be quite inexpensive for the most standard medicines. They are often (but not always) reselling identically produced medicines from different countries.
While it is harder to verify, many actors in this space are incredibly good willed. If you are in really dire financial circumstances, some unofficial channels can sometimes provide you with subsidized or free medical care too.
Cons
With things being often more underground, it can be much more difficult to verify authenticity or safety of any products sold. Yes, the number of reported negative incidents is very low, and yes, are various organizations that try to test and verify. But even with this, standards are not to the same level as exist in pharmaceutical settings where you have multi-billion-dollar market caps and very high levels of legal liability. Batch variance can be much higher. Sanitation and sterility can be much worse.
Secondly, there is a much higher chance of user-error. Most know that if one is taking feminizing HRT or masculinizing HRT, that some drugs need you to monitor your blood levels for different things (e.g: bicalutamide has very rare liver complications that need to be monitored, and could lead to fatalities otherwise, CPA has risk for elevated prolactin, Spironolactone has risk for elevated potassium). Most people who have the information and knowledge to pursue grey-market medicines, also do have the knowledge to monitor blood levels for liver function and other things. But it is also much easier to neglect. The traditional medical system this is forced upon you, which makes catching edge cases more likely.
Third, if one only relies on grey-market channels, then it can be more difficult to get access to things such a surgery through one’s medical system. Thus it can be worthwhile to still interact with an official medical system even if one doesn’t use it for official medications, but given this, it might be sometimes easier to just use the medical establishment medications anyway.
Fourth, while there are reasons to believe that anecdotal evidence and small scale observational evidence can be superior, some of the more experimental medicine tends to have significantly less academic literature or certainty on the effectiveness of less standard medication. There is more tolerance for taking medicine that may have less upside and more risk of downside, though this can be avoided if one sticks to grey market medicine that is pharmaceutical-grade and more standard.
Lastly, there are also sometimes practical and legal risks. Estrogen is a very legally safe substance, even if requiring a prescription in many places, while testosterone tends to have much more legal risk. Reported incidents for these tends to only target people who are selling and distributing large amounts of these, and not for personal use, but the legal risk is non-zero.
Conclusions
I think most people understand the potential risks of grey-market medicines. Being denied medical care through official medical channels also has it’s own risks. My impression is that people who have no knowledge of grey-market channels tend to significantly overestimate the risks of the former, while people who use grey-market channels tend to slightly underestimate these same risks.
In a few places, official channels can be the best option. In others, informed consent can be a reasonable option. For yet other places, grey-market channels can be the only option for reasonable care. I wish it were the case that grey-markets were not needed, but in the current world, it seems important that they continue to exist.
Footnote: There are non-zero risks from higher estrogen levels, but these are generally small and considered fine for most, and, in my opinion, are significantly overblown compared to risks from not being having sufficiently controlled HRT regimens.
The main risk is not from high estrogen levels per-se, but form oral estradiol intake, which has more side effects. But I will name a few of the main risks for completion:
Blood clot risks: Higher estradiol levels may be a concern, but a relatively minor one (if not orally administered). There is a lack of evidence (likely safe but more evidence needed) that high levels of non-orally administered estradiol in trans women elevates risks noticeably beyond those of cis women (~1 in 10,000) and it likely lower than for women on hormonal birth (~1 in 1,000) or pregnant women who have 10x-100x estradiol compared to non-pregnant women (also ~1 in 1,000)
Breast cancer risk: There is plausibly an increase in breast cancer risk, which may depend on estrogen levels, but also on breast size and other factors. The risks of this are usually still low (especially since most trans women typically do not gain much breast growth). The absolute risks are typically higher than cis-male but less than cis-female.
Infertility risk: There is also potentially some long-term risks to infertility being irreversible if one has long-term high estrogen levels (~for a few years), though this is not one that doctors really care about. If this is a concern, I would recommend storing gametes prior to starting HRT.
For the most part, the risks to physical health are much smaller in size than the continued mental health risks of not having high enough estrogen levels and seeing continued masculinization.
The standard argument for titrating up, is that for feminization, the sole determinant seems mostly from having some threshold sufficient level, and that beyond this there is not much benefit. And there may be potential long-term risks from elevated E. But if potential long-term risks are the concern, this doesn’t really explain why one needs to titrate up and suffer months of masculinization, instead of starting high and titrating down if desired.
They do also recommend trans-dermal or injectable HRT, but many clinicians fall back to oral estradiol as it is also allowed by WPATH SOC 8 guidance
Pioglitazone has some relatively weak published evidence, and a moderately good combination of anecdotal evidence. See feminizing HRT.
CPA has some risks, which is why it was not FDA approved, but at typical doses used for trans women, (~12.5mg per 2 days) these risks are much less significant. Spironolactone is relatively a much weaker and less effective anti-androgen though.
See previous footnote on pioglitazone, or feminizing HRT.