Hormones to aid gender transition are easily available online and inexpensive, and there is concern that in places where people suffering from gender dysphoria have to wait a long time for referral for advice, they may opt for this method of obtaining treatment.

In the UK, for example, particularly for children and young people with gender dysphoria, average wait times for referral to transgender clinics are currently around 18 months, highlighting the need for greater provision of such care.

The situation echoes that seen in the United States a few years ago, which has since been largely resolved with many more medical specialists trained in transgender care and support more forthcoming, says one expert.

But according to a recent investigation by the UK's Daily Mail newspaper, cross-sex hormones are easily available from online "pharmacies." The newspaper carried out an investigation whereby they sought out estrogen and testosterone online and purchased them with "no age checks and no questions asked, for as little as £25 ($32)."

The article gives an example of a mother who discovered her teenage son had obtained estrogen from a US website and was starting to develop breasts. And investigators from the newspaper sourced similar cross-sex hormones, as well as puberty blockers, from online sites based in Thailand and India.

The article stresses there were no age checks on purchasers and there were plenty of online chat rooms for buyers to seek advice on how to order the drugs and which "pharmacy" websites to use.

Indeed, with a few clicks of a mouse, Medscape Medical News was also able to find websites that advise on how to obtain hormones on the Internet without a prescription and how to self-medicate, with advice given on the legality of this practice in different countries.

However, a spokesperson for Mermaids, a UK-based charity that supports transgender youth, told Medscape Medical News that they have little reason to believe that children and young people in the UK are actually accessing hormones online.

Little Published Information on Self-Prescribing/Use of Hormones

There are, in fact, very little published data that provide any reliable estimate of how widespread the practice of online sourcing of transgender hormones is.

One study (J Sex Med. 2014;11:2995-3001), which surveyed adults attending for initial assessment at a gender identity clinic in the UK, found that 23% of individuals were self-administering hormones mainly bought online (70%).

The behavior was found to be more common among transwomen, with 32% already using hormones at the time of referral.

And an article published last year in Brain Sciences describes seven patients referred to psychiatric services in the UK who had self-sourced hormones and gave permission for their cases to be described in detail.

"Self-prescribing of sexual hormones for gender affirmation is a potentially widespread and poorly studied phenomenon that many clinicians are unaware of. The uncontrolled use of hormones poses significant health hazards, which have not been previously reported in the literature," the authors observed.

"The main reason for self-administration of hormones seems to be the lack of access to specialized care due to discrimination and long waiting lists," they emphasized.

"We advocate for clinicians to be aware of the phenomenon and proactively help transgender and gender nonconforming individuals by enquiring about self-prescribing of hormones, providing information, and referring to the most appropriate treatment center, as well as encourage a public debate on the discrimination and the stigma" this population suffers from, they concluded.

Endocrinologist Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery, New York City, and spokesperson on transgender issues for the Endocrine Society, explained to Medscape Medical News some of the risks involved with purchasing cross-sex hormones online.

"The product might not be what you believe it is, or it might be something different entirely, or there might possibly be no active medication in the product so the buyer is effectively paying for nothing."

"Without monitoring, if someone needs to change dose or stop medication there is no professional to manage that. There's a risk of over-dosing and of under-dosing, and with respect to the latter, people look for an effect and when they see none it can be distressing," he noted.

Online Purchasing in US Resolved With Greater Access to Good Care

But, according to Safer, the situation in the United States has now shifted away from people sourcing hormones online.

"In the past, more transgender people needed to work around the fact that they either couldn't find knowledgeable providers or their insurance did not pay for their care. People resorted to these alternative strategies, which are really just an extension of when people bought hormones on the street, largely before the Internet," he pointed out.

The United States has seen an increase in the number of transgender care providers available and there is a more established medical community for these individuals, with optimal treatment approaches to gender dysphoria, added Safer.

So "people are having an easier time receiving the support they need, and people prefer a conventional and trustworthy source."

However, the current shortage of providers in the UK relative to the large number of young people seeking referral for gender dysphoria reflects the situation in the United States some years ago.

This situation also still persists in some US states, noted Safer.

"Previously, I practiced in Boston, and now in New York where access has improved a lot. We clearly observe that, as access improves, use of the Internet as a source of hormones decreases," he said.

What Is the Evidence That Kids in the UK Are Buying Hormones Online?

In the UK, Tavistock's Gender Identity Development Service (GIDS) in London is one of only two National Health Service (NHS) funded gender dysphoria services for children and young people (under-18s) in England and Wales.

The service has seen the number of people seeking treatment balloon over the past 10 to 15 years, as described by Sarah Davidson, PhD, consultant clinical psychologist at GIDS, who spoke with Medscape Medical News last year. There were approximately 50 referrals in 2006, which surged to 2500 referrals in 2017, for a clinic that serves a 13 million-strong UK population of those 18 years and younger.

And with this surge, there has been a dramatic switch in terms of cases. Over 70% of referrals are now for females who want to transition to males, whereas previously it had been the other way around (at least in those over aged 11 years).

Susie Green, chief executive officer of Mermaids, a UK-based charity that supports transgender children and reports 7000 contacts per year with individuals, professionals, and/or family members concerned about gender dysphoria, believes there are multiple explanations for the dramatic increase in the number of young people putting pressure on limited services.

"These reasons include a mix of high-profile celebrities coming out, more knowledge about being transgender, schools and other organizations becoming more trans-friendly, the production of guidance from the Department of Education, and the Equality Act now providing support for transgender people."

"The current media furor is a repeat of where gay people were 25 years ago," she told Medscape Medical News.

With respect to the long wait times because of the surge in numbers, Green pointed out that her organization will always recommend the NHS pathway: "Ideally, we would like people to access the care on the NHS," but many families seek private healthcare, and this "has been exacerbated by the waiting times of 18-plus months."

And regarding the purchase of cross-sex hormones online by young people, Green said: "We haven't seen much evidence of it at all."

"I think older transgender people do take these routes to access hormones sometimes, as it's easy to do, and to find online advice from other transgender people."

"We probably get asked about this issue by young people or their families a handful of times per year, but we always advise not to go online for these drugs," she continued.

"Our main concern with online purchases, if it happens, is harm. Adults, with full knowledge and understanding of the risks, can buy other medications such as slimming pills online. Why wouldn't they buy hormones if they want?" she remarked.

"But most young people don't have this knowledge or the money to do this. How would they keep it secret from their parents?"

However, when asked about the availability of online hormones by the Daily Mail, a spokesperson for the Tavistock GIDS told the newspaper: "We are concerned about the online purchase of trans drugs by youngsters because it is completely unregulated. They don't know what they have been taking."

"It is incredibly dangerous to buy these online," the spokesperson told the newspaper, pointing out that many young people later change their mind about changing sex. "By getting drugs off the Internet, adolescents may start on a path they don't want to tread later on."

The Tavistock GIDS now runs an online advice service for youngsters on its waiting list, which it hopes will help those who might otherwise be tempted to turn to the web to buy hormones. "We are also trying to get the wait to see us down," said the spokesperson.

Safer and Green have declared no relevant financial relationships.

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