How Medical Institutions Drive Trans Women Underground

June Amelia Rose was a teenager the first time she tried to medically transition. She was already presenting very femininely in high school, wearing girls' clothes from Hot Topic. She had even confided in a few girls she dated that she was trans, but never came out publicly, fearing that her family and friends might not believe or support her. She figured that if she could begin hormone replacement therapy -- a combination of a generic testosterone blocker called spironolactone (or spiro, colloquially) and estradiol -- she could more easily convince loved ones to accept her transition. But in order to get those medications, she would need a prescription. So at 15, Rose convinced her parents to let her start seeing a sex therapist, without explaining the full scope her intentions. By going through these appropriate channels, Rose hoped she would be able to transition according to her plans. Instead, all she got was resistance.

"My therapist kept saying he wanted to push it off, maybe as late as 18," Rose recalls. "He wouldn't even consider recommending me for any of it [until I was older.] The hormones were a big deal for me, and he held them over my head, just out of reach. He insinuated I had too many doubts. I wore girl jeans and had long hair -- what more did he want?"

Three years can feel like a long time for anyone desiring to transition, but for a teenager in the midst of a puberty she didn't want, it was an eternity. By delaying her prescription until after high school, Rose felt like her therapist was closing the door on a life she wanted to live -- one that actually felt worth living. She was already reluctant to publicly identify as a girl, and the treatment her therapist provided pushed her further away from doing so, undermining her confidence with skepticism and leading questions. "I was hoping something immediate could be done, but it couldn't," she says. "After that, I kind of fell off that train." Three years into treatment, she stopped seeing that therapist and trying to transition altogether.

Though the door on transitioning had been closed, the internet allowed Rose to catch glimpses of what may lie on the other side for her. She spent her middle and high school years bonding with other trans people on message boards similar to those found on Reddit and 4chan. (Out has chosen not to name any trans-specific online spaces out of respect for its users' safety and privacy.) It was through one of these platforms that she learned there were trans people who were self-medicating with the help of online pharmacies based outside of the United States, or by borrowing medications from their friends who had their own prescriptions. It became apparent that some teenagers begin their transitions through these alternative avenues. Rose didn't, but she kept it in mind as she grew older. She had tried to transition through institutional means, and it had led her nowhere. She began to believe that if she ever tried to transition again, she'd need to do it herself.

"It was the only option," she thought.

Rose's therapist might not have explicitly refused to ever write her a prescription for hormones, but by continuously delaying it, he might as well have. Her therapist is what many trans people refer to as a gatekeeper -- a medical professional who holds the power to decide whether a client will get the treatment they need in order to physically, socially, and legally transition. In her 2007 manifesto, Whipping Girl, writer and biologist Julia Serano writes that, beginning in the 1960s, gatekeepers have sought to "regulate and limit the availability of hormones and sex reassignment procedures only to those trans people who would successfully blend into society as 'normal' women and men." As medical professionals, they could argue that they're simply following the Hippocratic Oath to "do no harm" -- withholding transition care until they are absolutely certain that it's what is best for their patient. But for Rose, and countless other trans people denied care despite going through the appropriate channels, it is nearly impossible to argue that no harm was done.

Gatekeeping practices are not the only barrier trans people face when seeking care -- in fact, some trans people might consider it a privilege to even be able to get one-on-one time with a therapist at all, regardless of the outcome. Money is an obstacle to care for anyone trying to navigate the United States' private health care system, and this is no less true for trans people, who, per the National Center for Trans Equality's 2015 survey on trans Americans, are already dealing with disproportionate poverty rates. Location is an obstacle, as well; the farther one lives from a metropolitan area, the more difficult it is to find a trans-affirming medical provider or a community of other trans people who'd know where to go. Then there's the matter of insurance, since it is difficult to get "health coverage for transition-related care, and costs can be prohibitive" out of pocket, as journalist Alex Verman wrote in a 2018 piece about transitioning outside of medical institutions for Briarpatch. And if they're underage, a trans person will likely need their parents' support to seek that care in the first place. In short, with so many hurdles in place, transitioning through the system can become insurmountable. Doing it independently through non-traditional routes -- ordering hormones from online pharmacies, seeking out surgery from unlicensed practitioners -- can feel like the only option. For a lot of trans people, it is.

Los Angeles-based model and social media influencer Eden the Doll uploaded a video to her popular YouTube channel last August, revealing that she owes her hourglass frame to silicone injections -- that is, free-floating liquid silicone injected directly into the hips to create a more traditionally feminine silhouette. Liquid silicone is not approved by the U.S. Food & Drug Administration for use in hip augmentation procedures, unlike solid silicone implants. Eden followed that video with another in January, where she discusses complications she experienced as a result of these procedures, including leakage and temporary paralysis.

In the videos, which together have been viewed more than 320,000 times, the 23-year-old says that she wanted a fuller figure with hips a la Kylie Jenner. It wasn't just a vanity thing; it was a safety issue as well. "I couldn't even walk out of my house without being clocked because of my body -- the way it was shaped," she shares in one of the videos. "I could not leave the house unless I had hip pads on."

Eden says that she got her injections over the course of six months, visiting two different unlicensed practitioners for nearly half a dozen sessions in total. She first received injections while visiting a friend in Florida. One of her friend's co-workers mentioned that she was getting pumped that week, and Eden begged her to let her do it, too. The woman who administered the injections, also trans, came to Eden's friend's apartment. She had Eden lie facedown on a massage table and injected her hips with silicone drawn from milk jugs she'd brought with her. She sealed the injection sites with Krazy Glue and cotton balls, without providing any anesthesia or pain killers.

"It was the most excruciating pain of my entire existence," Eden says in one of the videos. "[I was lying there asking myself,] Why am I risking my life? Like, is it worth it? Everything you're thinking now, I was thinking it, too. [But then I looked] at my friend's body with no hip pads, and I [knew I] just had to do it. I had no choice."

At the end of the video, Eden says that she doesn't want to get any more injections, as she's no longer willing to "risk my life to look better." Still, she doesn't regret getting them done. She echoes that sentiment in a subsequent phone interview with Out, explaining that she tried to augment her body legally but was unable to do so for reasons beyond her control. "I did reach out to doctors before getting injections," Eden explains.

The doctors she spoke with presented two options for augmenting her hips: fat transfers or implants. Her slender frame ruled out the first option; she simply had no fat to transfer. The second option, the implants, proved cost-prohibitive. "They were asking for $10,000," says Eden, who -- like many others -- couldn't afford such an expense out of pocket. "It just wasn't gonna happen for me."

Most of the women interviewed for this story shared similar experiences: their decision to transition without going through a medical institution felt like the only choice they had. Raven Ovah, a two-spirit woman from New Jersey, says it all comes down to the price tag: Silicone injections are dangerous, she says, but they're cheaper and more accessible than other options. Donna Sarandon, a New York-based trans woman who spoke under a pseudonym, says that when she first thought about transitioning, she didn't know what to say to a doctor in order to get a prescription for hormones. Even if she did, what if he didn't believe her? She was broke at the time, so she knew she couldn't expect to throw money at him until he did. Instead, she turned to a friend, who gave her 10 bottles of spiro that were ordered off the deep web. Some of them had expired.

After six months, Sarandon felt confident enough to visit a medical provider. She now goes to her local Planned Parenthood, which offers trans-affirming care including hormone prescriptions on a model of informed consent. (This option is available at select clinics nationwide.) There, a licensed practitioner is able to monitor her health in ways that Sarandon wouldn't easily be able to do on her own. Despite inviting supervision into her transition, Sarandon retains agency over the process, changing her doses as she sees fit without waiting for a provider to give her the green light. "My providers have really embraced my DIY punk ethos when it comes to medicating myself," she says. "I'll be like, 'Listen, I spiraled off of spiro three months ago,' or, 'I upped my estrogen,' and they'll say, 'Great! Why don't you come in for blood work?'"

This is the best way healthcare providers can treat a patient who was or is transitioning through non-institutional, underground methods like silicone injections or black-market hormones, says Asa Radix, the senior director of research and education at the Callen-Lorde Community Health Center in New York City. "Telling your patient that what she's doing is bad is not a good way to build trust, especially when she might know more than you do," says Radix. The goal in providing healthcare, trans or otherwise, is to keep people healthy, he adds, not to make patients feel bad for their choices. Doing so risks pushing more people away, just like it did with Rose.

At 23, Rose tried to transition for a second time. Now in her 20s and living on her own with the memory of her therapist still fresh in her mind, she ordered spiro and Estrofem, a brand-name synthetic estrogen often prescribed to cis women who've recently undergone a hysterectomy, from an online pharmacy based outside of the U.S. After about a month of ordering online, she felt confident enough to set up an appointment with a provider at Callen-Lorde to continue her transition with their assistance.

Though Rose, now a 26-year-old fiction writer living in New York, has a proper prescription for HRT, she says that she doesn't regret beginning her transition via alternative methods. "Self-medicating hormones felt like a life or death situation for me that first month, which I think speaks volumes about how trans people in this country would risk self-medicating [rather than go through doctors]," she says. "Doing my own thing felt good. It felt liberating, like taking control of my destiny, like there was this thing that was going to help me, but no one else was going to give it to me but me."

"Since transitioning, I have had no regrets about it," Rose adds. "My therapist was wrong for doubting me."

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