By Brynn Tannehill

Cyprus and the Republic of Vanuatu are, literally, a world apart from each other. Cyprus is one of the largest islands in the Mediterranean, and Vanuatu is a tiny chain of South Pacific islands. Cyprus has been at the center of world affairs and great conflicts dating from the legendary battles between the ancient Myceneans and Persians. Vanuatu, not mapped by Europeans until 1768, didn’t even get caught up in the Pacific campaigns of World War II. Cyprus is arid with diminishing water reserves. Vanuatu tries to not to drown from 15 feet of rainfall per year. Cyprus is cosmopolitan. Vanuatu relies on agriculture and tourism to boost a limping economy with negligible natural resources.

What do these places have in common? In short, the answer is drugs, the kind transgender people desperately need for transitions but often are unable to obtain through normal channels. Because of a lack of laws governing requirements for prescriptions and lax regulations on what can be mailed overseas, these two island nations are the source of most mail-order hormones obtained by people trying to transition. As a result, online pharmacies have become a cottage industry in both these nations.

Trans people trying to get Hormone Replacement Therapy (HRT) through normal channels have to jump through many hoops. The World Professional Association for Transgender Health (WPATH) publishes the Standards of Care (SOC) for people who transition. Because the SOC recommends psychotherapy and referral prior to a physician prescribing HRT, the few doctors who handle transgender patients are often hesitant to make a prescription for HRT without said therapy. Doctors who work with trans patients are so uncommon, wait time for an appointment can be six weeks. Few therapists are familiar with gender dysphoria, and few insurance policies cover gender dysphoria-related medical and psychological expenses anyway.So, you can get a prescription for HRT if you can run this course of hurdles:

• You can find a therapist who knows about gender dysphoria;
• Your insurance covers months’ worth of sessions or you’re wealthy enough to pay for them yourself;
• Your insurance company will pay for the workup labs or you can afford to pay $800 for them;
• You can find a doctor willing to work with you;
• Your insurance company will cover the doctor’s visits or you have the money to pay for the visit; and
• Your insurance covers the cost of the drugs at the pharmacy or you can pay for them out-of-pocket.

If you get through all of this, the process can take three months to a year and cost close to $2,000 if you don’t have insurance that covers trans-related care.

Or, you can go online for five minutes and place an order with one of the pharmacies in Cyprus or Vanuatu to get a three-month supply for $200 if you’re a male-to-female trans person, and about $350 for a female-to-male. Shipping time is about two weeks. FPOs and APOs are treated like any other address inside the United States—folks are self-medicating on the front lines out of desperation.

Hormone regimens for male-to-females and female-to-males differ in the particulars. Male-to-female transsexuals typically take one medication to suppress testosterone production plus provide some form of estrogen. Some take a bio-identical form of progesterone in addition to the estrogen and the androgen blocker. Female-to-male individuals generally only take testosterone as part of their HRT regimen.Both the testosterone and estrogen can be delivered as injections. Many doctors prefer injections because it reduces both the cost of the regimen and the strain placed on the liver. However, injectable testosterone or estrogen is not available from the mail-order market due to refrigeration requirements. For female-to-male trans people, the testosterone gel or dermal patch alternatives available online are typically 10 times more expensive than the injectable version. Still, most trans people will go to almost any length to align their bodies and minds and will bear almost any cost burden.

What makes the online, no-questions-asked option even more attractive is that some of the drugs used as part of HRT everywhere else in the modern world, are not approved by the U.S. Food and Drug Administration (FDA). The costs of getting FDA approval versus the small market for these particular drugs don’t balance out for the manufacturer. In the United States only one drug is available for suppressing testosterone as part of HRT. That’s because this drug, spironolactone, is also used to lower blood pressure, and its anti-androgenic effects are ancillary.

If you’re a runner (like me) and you take enough spironolactone to significantly reduce testosterone, you often suffer the pesky side effect of passing out cold every time you stand up too quickly. This leaves you with three options: stop HRT, keep fainting at work every other time you get up from your desk, or use one of the newer and better drugs available online, cyproterone acetate, which has far fewer side effects. Unfortunately, the last option carries risks.

Obtaining drugs from Cyprus and Vanuatu is something of a legal grey area. People can theoretically be prosecuted under civil law for ordering drugs from overseas, with or without a prescription. However, since 2006 customs and the FDA have rarely gone after people importing low-risk medications in quantities normal for personal use.
Many trans folk in the military who start transition prior to getting out of the military and use online pharmacies also face civil and UCMJ article 92 risks. Being in one of these countries that sells these legally does not help either; the FDA prohibits importing drugs by mail or on your person, and the UCMJ does not allow seeking medical care outside the DoD system without authorization.

The penalties for using hormones, even those obtained legally, can be severe. What follows are true stories. One trans woman Sailor bought estradiol in Spain, where it can be purchased without a prescription. Her vial was found during a drug sweep, they made her take a urinalysis, and it detected the presence of synthetic estrogen. She was given an otherthan- honorable discharge. A current case involves a trans man who obtained testosterone via a legal prescription from a doctor in the U.S. He was hospitalized for a condition unrelated to gender dysphoria, and his lab work revealed the presence of synthetic male hormones. He has been relieved of duty, had his clearance revoked, and is also facing a potential discharge.

Another risk is counterfeit or low-quality drugs. Some estimates place the value of that illegal industry in the United States at $75 billion. A constant source of discussion on transgender forums is the reliability of different websites, the reliability of the drug manufacturers whose products are being sold on those websites, and where each drug is manufactured. Do you trust the estrogen made in New Zealand or the much cheaper but supposedly identical brand made in India? Which sites are more likely to have their merchandise confiscated by customs?

Some vets will be eligible for Department of Veterans Affairs benefits that cover therapy, labs, and prescriptions for HRT. Others don’t meet the somewhat byzantine requirements for eligibility. The Affordable Care Act doesn’t mandate coverage for transgender-related care, most corporate-provided policies don’t cover transrelated care, and individual policies that cover trans-related care are prohibitively expensive.

This whole sordid story has many lessons. It demonstrates the power of free market economics and the terrible risks trans people will take to transition. It highlights the foolishness of our own medical system and the funny way drugs have of finding their way to demand.

I would sort of like to see where my money went for all those years. Going to Vanuatu seems like it would be something of an adventure.

For more information on hormone replacement therapy, Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines is a good place to start. It is both informative and moderate in tone.

Editor’s Note: OutServe Magazine does not endorse the illegal use of hormones.