Hormone self-medicating: A concern for transgender sexual health services

Discrimination, marginalisation and stigmatisation of transgender people has been associated with poorer healthcare outcomes. The transgender population is not homogenous; clinical services need to adopt a bespoke, holistic and practical approach to service development and delivery. As demand for specialist gender identity services (SGIS) increases, we have observed an increasing trend in hormone selfmedicating, with patients obtaining treatment from internet pharmacies, friends or illicit sources. This raises concerns about adverse effects, suboptimal treatment outcomes, drug–drug interactions and unsafe injecting practice. We have a large trans population locally, and the health needs of this population are increasing. Hence, we developed a specific sexual health service for trans people. Brighton is a city on the South East coast of England with a large population of men who have sex with men and transgender people. We audited electronic patient records from patients attending our open access specialist transgender sexual health service over 12 months between 2015 and 2016. Eighty-one attendances were recorded (56 unique patients). Twenty-nine (51.8%) patients were trans-men, 15 (26.8%) were trans-women, 9 (16.1%) identified as non-binary (assigned female at birth [AFAB]) and 3 (5.4%) identified as non-binary (assigned male at birth [AMAB]). Overall, AMAB patients were significantly older than AFAB – median age 39 years vs. 29 years (p1⁄4 0.03). Three (5%) of these 56 patients were known to be HIV infected. Only 47/81 (58%) attendances were for sexually transmitted infection (STI) screening or genital health issues such as testosterone-associated vaginitis or post-surgical genital pain. Six patients (7.4%) attended for psychosexual issues and assessment and 31 (38.3%) attended for endocrine advice and monitoring of hormone therapy. Thirteen (23%) were selfmedicating, with eight patients using intramuscular hormones. Only two of the patients who were selfmedicating had discussed their hormone use with another healthcare professional. Eleven patients were subsequently referred to medical services (SGIS, endocrinology or primary care) for ongoing treatment, with two patients choosing to continue self-medicating without any other medical input. There was no difference between those people self-medicating by country of origin or ethnicity. A large number of transgender people attend our dedicated sexual health service for non-STI-related issues, particularly hormone therapy concerns and management of self-medication. Interestingly, there are more AFAB than AMAB attending our service which may reflect access to our service or our local population. It is important that hormone selfmedication is discussed with patients, and appropriate links between SGIS, primary care and endocrinology are formed. Moreover, it is vital for health care commissioners and health care providers to work together to measure need and provide dynamic, patientfocussed, collaborative and joined-up health services.