On a Saturday night two years ago, Stann Fransisco was driving back home to New Mexico after visiting their parents in Connecticut. Crossing through Texas, they were just reaching the small, well-lit town of Stratford when they knew they were too tired to keep driving safely, so they pulled off the highway to rest their eyes for a bit. As they hopped into the back seat to join their service dog, they suddenly saw flashing police lights. Officers approached the car.
“One officer said, ‘It smells like you’ve been having a party in here. Is that right?’” Fransisco, a white nonbinary person in their 30s, told Filter. “He said, ‘Well, if you haven’t been having a party, you won’t mind if we check your car.’”
Moving quickly, the officers violently handcuffed Fransisco, took their keys and called animal control to confiscate their dog. Then they searched the car.
“One yelled, ‘Show me your track marks, you fucking junkie! We found your needles and drugs,’” Fransisco said. The cop held up their prescription bottle of testosterone. “I said, ‘Those aren’t drugs, that’s my medication. I’m trans.’”
“The second it went out of my mouth, I think ‘Oh, fuck’ … I’m sitting there in a sundress and they see male hormones after they’ve been waiting to get me alone because they think I’m a girl.”
Fransisco was jailed overnight, with two cisgender women who’d also been detained for drug use, but was fortunate enough to have friends and family able to help release them the next day on a $2,500 bond.
Fransisco does not inject drugs, nor do they use any psychoactive substances besides weed. But their experience — of someone outside the gender binary being harassed by police and accused of drug use because they inject hormones — is a common one.
It is also why syringe service programs (SSP) often keep 21 to 25-gauge needles in stock even though they’re too large for almost anyone injecting drugs to request — they’re for gender variant participants who need them for hormone injection. Whether or not these participants also use drugs, SSP are often the safest way for them to access syringes — a marker of how, in police harassment and disenfranchisement from lifesaving, humanizing medical care, gender variant people and drug users often share a common struggle.
Testosterone and Transgender Health Care
Testosterone is an anabolic-androgenic steroid, meaning it’s composed of synthetic variations of the sex hormone testosterone. “Anabolic” refers to muscle building; “androgenic” to increased male sex characteristics.
Transmasculine and gender variant people have used synthetic testosterone for nearly a century. The first documented prescription to a trans man was obtained by Michael Dillion in 1939. In the mid-20th century, it started becoming popular among certain professional athletes, like weightlifters. By the 1980s, it was being used by young cisgender men looking to bulk up.
In 1990, the Anabolic Steroids Control Act classified testosterone as a federally controlled Schedule III substance. This puts it in the same category as buprenorphine and ketamine. Lawmakers intended for this to curb steroid “abuse” among young cisgender men. But its deeper impact has been to criminalize health care for trans men, intersex people, nonbinary people and other gender variant people on testosterone replacement therapy, in a cisheteronormative society that already disenfranchises them from care. (Estrogen is not a federally scheduled substance, but people on estrogen replacement therapy still face health care barriers due to transmisogyny.)
The contemporary US approach to transgender health care is two-fold. Originally, the only route available to people seeking transgender care was what’s colloquially referred to as the “gatekeep model” — a mental health evaluation or referral required on the basis that trans people are mentally ill or “confused.” This model still applies to anyone under 18.
In the 2000s, an alternative began gaining traction: the informed consent model, which permits access to gender-affirming care, including surgeries and hormone treatments, without a mental health professional’s authorization. Those under 18 years old require consent of a parent or guardian. While still flawed, this model facilitates greater patient autonomy.
But “unless you go to Planned Parenthood, it’s difficult to access a provider who does informed consent-based prescriptions, especially without insurance,” TJ Burton, a transmasculine health care clinic coordinator in Kansas City, told Filter. “Even after I went to PP and got prescribed on informed consent, it’s still a time consuming and costly process.” Often that process involves lab fees — which aren’t always covered by insurance even for those who have coverage — and inflexible time windows in which people can refill their prescriptions.
Pharmacies, like all other health care settings, typically aren’t well versed in serving LGBTQ people. Many gender variant people, including myself, have experienced discrimination and hostility at the hands of pharmacists.
“Criminalization has made it easy for pharmacists to deny my [testosterone] prescription, which has happened to me many times,” Artemis McGettigan, a trans student in Dearborn, Michigan, told Filter. “[Pharmacists] have told me in the past that ‘It’s corporate policy, they’re not allowed to fill that type of prescription … but I knew that was false because other CVS locations, for example, were able to fill it.” A CVS media representative told Filter that its policies “do not prohibit our pharmacies from filling testosterone prescriptions.”
Surveillance and Control
Prescription drug monitoring programs (PDMP) are electronic databases through which medical professionals and law enforcement can track someone’s prescription history. Initially designed to combat “diversion” of controlled substances with potential for addiction, they are often used to monitor testosterone prescriptions and the people who receive them. Many in the trans and gender variant community, especially those who aren’t fully public about their gender identity, fear being listed on PDMP — they could be outed by anyone with access to the database.
L. Lanzillotta, a Virginia-based trans man and Filter contributor, recalled meeting with a psychiatrist who didn’t know he was trans and to whom he had no plans to out himself. But that decision was made for him as soon as the psychiatrist pulled up what he strongly suspects was the state’s PDMP.
“She knew I was on testosterone after checking something on her computer, even though I hadn’t said anything,” Lanzillotta told Filter. “Naturally, she quickly deduced why.”
While not everyone on testosterone is transgender, it’s certainly a clue, especially for those who still have a female gender marker on legal documents. Such surveillance costs gender variant autonomy, outing people without their consent.
In July, Phillip Cooper*, a trans man from Santa Fe, New Mexico, was required to sign a patient agreement form regarding controlled substances. “[I] was told it’s a clinic policy for all controlled substances,” he told Filter. “I’ve been getting T from this clinic for almost two years now and this had never been asked of me before.”
Cooper does not use any state-banned drugs, so he was taken aback. “To be clear, the thing I found intrusive wasn’t having to sign the form. It was being required to undergo a drug screening [and] submit a urine sample as though using testosterone, which doesn’t get you high and isn’t addictive, and is only a controlled substance because of sports doping, made me more likely to be using illegal drugs!” He added, “It’s nothing to do with monitoring safe T levels, which has to be done via blood test.”
Gender variant people, along with those of any marginalized identities, experience disproportionate rates of substance use disorder. This isn’t a moral failure — of an individual or a community — but rather a systemic one. It’s a symptom of the trauma associated with living in an ostracizing, capitalist society rooted in (among other things) the gender binary, patriarchy and colonial gender roles.
“It was humiliating and infuriating,” Cooper said of being presumed to use illicit drugs on the basis of his gender identity. “I don’t think either the clinic or my provider was being deliberately transphobic — rather, T being a controlled substance, and the policy being inflexible, led to a transphobic result.”
Ending This Injustice
There are a few ways testosterone criminalization could be abolished. It could be federally rescheduled to IV or V category. It could be descheduled from the CSA entirely, though it would still be subject to some type of government regulation.
If rescheduled, T could be accessed similarly to other over-the-counter medications — like birth control, which is also a fundamental human right. Descheduling would allow trans and gender variant people greater access and agency, but would likely be perceived as too “radical” by much of our transphobic society, which already micromanages our everyday lives even down to the bathrooms we’re permitted to use.
And while descheduling would mean gender variant people are less likely to be criminalized for accessing T, it still wouldn’t solve the larger problem: that we do not receive equitable health care.
The use of testosterone without medical supervision, including regular blood level monitoring, can potentially lead to health complications (such as high blood pressure or overproduction of red blood cells) that are otherwise easily avoided — and among people already unlikely to have access to decent care. Transgender care in the US is gatekept even for gender variant people who have societal privileges like whiteness or wealth.
Descheduling wouldn’t fix health care, but it would remove barriers for gender variant people already receiving care, and theoretically protect them from experiences like what Fransisco endured in 2019. And criminalizing testosterone isn’t any more effective at curbing recreational use by cis men than criminalizing psychoactive drugs is at reducing their use, either.
“In my opinion, any medication you’re put on should be monitored by a doctor, but that gets into how crappy our healthcare is in the US,” Burton said. “I would imagine there are bigger fish to fry [since] testosterone doesn’t get you high. It doesn’t have any immediate gratification effects. It just seems silly, for lack of a better term, to classify this the way we do. It’s an unnecessary, gate-keepy thing to do, especially when the majority of patients I see scheduling HRT are elderly and need it or are trans and need it.”
Any non-cisgender person faces discrimination and overall antagonism from the medical industrial complex. We are frequently mistreated by providers, experiencing verbal harassment; misgendering; denial of hormone therapy; denial of treatment unrelated to gender; and having to educate providers about our identity and needs. People of additional marginalized identities and experiences — like race, disability, mental illness, higher weight or drug use — face compounding barriers to care.
Gender variant people should be more than acknowledged in drug policy reform; we should be prioritized.
*Name changed at source’s request.
This article was originally published by Filter, an online magazine covering drug use, drug policy and human rights through a harm reduction lens. Follow Filter on Facebook and Twitter, or sign up for our daily or weekly email newsletters here.