Abstract
Purpose: The purpose of this study was to determine the prevalence and correlates of nonprescription hormone use among Brazilian trans women.
Methods: This study is a cross-sectional survey of trans women in São Paulo, Brazil, recruited by respondent-driven sampling in 2017–2019.
Results: Of 790 trans women, 36.8% were taking nonprescribed hormones. Nonprescribed hormone use was higher with younger age, lower education, homelessness, and using estrogen plus progesterone. Lower use was associated with accessing health care and having trans-specific health needs met.
Conclusion: Marginalized Brazilian trans women exhibit high use of nonprescription hormones, which may have health consequences and requires further examination and research.
Keywords: Brazil, health care access, hormones, nonprescription drugs, transgender persons
Introduction
In Brazil, trans women (i.e., those who self-identify as transgender, woman, or travesti, among other terms, and were assigned a male sex at birth) are a marginalized group with limited access to transition-related health care.1–3 Transition-related medical treatment has been a practice of transgender persons for more than a century.4 Gender-affirming hormone use (hereafter “hormone use”) among trans women is a common method for feminizing body characteristics due to ease of accessibility and relative low cost compared with surgeries.3,5,6 Hormone use is recognized as a necessary, often life-saving practice5,7,8 that can help trans women improve their self-image and address gender dysphoria.7,8
Trans women have made major strides in social movements to recognize their human rights, which, in Brazil, are interpreted to include access to transition-related health care.9,10 Gender transition medical services in Brazil are currently offered free of charge by the unified health care system, or SUS.2,11 SUS provides multidisciplinary care to transgender people, including hormone therapy, surgeries, psychological care, and clinical follow-up.11 Still, there is a considerable shortage of resources, centers, and medical staff to meet the demand for transition-related procedures and care.2,3,12 These shortages create long waiting lists and overworked and underpaid staff, which in turn limit access to and reduce quality of services.3,12,13 Trans women also face considerable gender identity-based stigma and discrimination in SUS, resulting in unwillingness to seek services to avoid confrontation.2,3,12,14,15
Many trans women use nonprescribed hormones due to barriers in accessing prescribed hormones through SUS.13,16 Gender-affirming hormone therapies for trans women are typically antiandrogens and estrogen-only drugs at low dosages.6,8,17 Studies have found that trans women in Brazil use nonprescribed hormones at high dosages, which may result in health risks for noncommunicable diseases.17–20 Few data exist on the prevalence of nonprescribed hormone use and characteristics of trans women who access and use hormones outside the medical system.16 Our study examined nonprescribed hormone use among Brazilian trans women with a focus on the types of hormones used and the profile of users versus nonusers to identify disparities in access to transgender health care and potential future health risks.6,17–20
Methods
Participants and recruitment
We conducted an analysis of a cross-sectional survey that comprised the baseline enrollment data collected from trans women enrolled in the Trans*National Cohort Study in São Paulo, Brazil, from 2017 to 2019. Recruited through respondent-driven sampling (RDS), 790 participants were interviewed. Inclusion criteria were being assigned male sex at birth, self-identifying as a woman, trans woman, or travesti, and being 18 years of age or older. An incentive of R$40 (∼US$10) was given.
Ethical considerations
The protocol was reviewed and approved by the Institutional Review Board (IRB) of the Faculdade de Ciências Médicas da Santa Casa de São Paulo (CEP-CRT DST/AIDS), the Brazilian National Ethics Review Board (CONEP-CNS, #1880217), and the University of California San Francisco IRB (#15-17775). All participants provided written informed consent.
Procedures and measures
Trans women were interviewed face-to-face by trained staff, using tablets to record answers. The questionnaire included demographic characteristics, access to and use of transition-related care, and use of nonprescribed hormones. Most questions were mutually exclusive, except current hormone types where multiple responses were allowed.
Statistical analyses
Descriptive statistics for trans women overall and by hormone use are presented. Bivariate logistic regression analysis was used to identify correlates of current nonprescribed hormone use. The outcome variable was a “no” response to: “Are the hormones you are now taking received from and used under the supervision of a doctor or other health professional?” Variables significant in bivariate analyses at p < 0.05 were entered into a multivariate model. Those remaining significant at p < 0.05 were retained in a final model that also included gender identity and race as confounders of other correlates. Statistical analyses were conducted using STATA version 13.0.21
Results
Overall, 52.7% participants identified as trans women, 32.4% as travestis, and 14.1% as women (Table 1). The sample was young, with 38.4% being 18 to 25 years old. A majority (51.0%) identified as mixed race (“parda”), followed by 26.7% as White and 19.3% as Black. The majority, 62.5%, did not complete high school; 61.7% were living on less than minimum wage, R$1039 (∼US$250) per month.
Table 1.
Demographic and Behavioral Characteristics of Trans Women Interviewed, São Paulo, Brazil, 2017–2019 (N = 790)
| Variable | Overall (N = 790) |
Currently not on hormones (N = 389) |
Currently on prescribed hormones (N = 110) |
Currently on nonprescribed hormones (N = 291) |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | |
| Gender identity | ||||
| Trans woman | 416 (52.7) | 169 (43.4) | 72 (65.5) | 175 (60.1) |
| Travesti | 256 (32.4) | 162 (41.6) | 7 (6.4) | 87 (29.9) |
| Woman | 111 (14.1) | 54 (13.9) | 29 (26.4) | 28 (9.6) |
| Others | 7 (0.9) | 4 (1.0) | 2 (1.8) | 1 (0.3) |
| Age (in years) | ||||
| 18–25 | 303 (38.4) | 134 (34.4) | 26 (23.6) | 143 (49.1) |
| 26–35 | 280 (35.4) | 133 (34.2) | 42 (38.2) | 105 (36.1) |
| 36–45 | 158 (20.0) | 88 (22.6) | 34 (30.9) | 36 (12.4) |
| 46–55 | 38 (4.8) | 24 (6.2) | 7 (6.4) | 7 (2.4) |
| 56 or older | 11 (1.4) | 10 (2.6) | 1 (0.9) | 0 (0.0) |
| Race/ethnicity | ||||
| White | 211 (26.7) | 88 (22.6) | 44 (40.0) | 79 (27.1) |
| Black | 152 (19.3) | 77 (19.8) | 22 (20.0) | 53 (18.2) |
| Mixed race | 403 (51.0) | 212 (54.5) | 42 (38.2) | 149 (51.2) |
| Indigenous person | 15 (1.9) | 8 (2.1) | 2 (1.8) | 5 (1.7) |
| Asian | 9 (1.1) | 4 (1.0) | 0 (0.0) | 5 (1.7) |
| Education level | ||||
| Less than high school | 491 (62.5) | 273 (70.4) | 35 (33.0) | 183 (62.9) |
| High school | 265 (33.8) | 107 (27.6) | 61 (57.5) | 97 (33.3) |
| College graduate | 27 (3.4) | 8 (2.1) | 8 (7.5) | 11 (3.8) |
| Postgraduate | 2 (0.3) | 0 (0.0) | 2 (1.9) | 0 (0.0) |
| Income (monthly, reaisa) | ||||
| <1039 | 481 (61.7) | 249 (64.8) | 62 (56.9) | 170 (59.4) |
| 1039–4999 | 270 (34.7) | 128 (33.3) | 40 (36.7) | 102 (35.7) |
| ≥5000 | 28 (3.6) | 7 (1.8) | 7 (6.4) | 14 (4.9) |
| Ever taken hormones | 738 (93.4) | 337 (86.6) | na | na |
| Ever taken nonprescribed hormones | 687 (87.0) | 326 (83.8) | 91 (82.7) | na |
| Age when first took hormones (in years) | ||||
| 6–12 | 80 (10.1) | 40 (10.3) | 13 (11.8) | 27 (9.3) |
| 13–18 | 452 (57.2) | 214 (55.0) | 55 (50.0) | 183 (62.9) |
| 19–25 | 157 (19.9) | 74 (19.0) | 20 (18.2) | 63 (21.6) |
| 26–35 | 32 (4.1) | 6 (1.5) | 12 (10.9) | 14 (4.8) |
| 36–45 | 15 (1.9) | 2 (0.5) | 9 (8.2) | 4 (1.4) |
| 46 or older | 54 (6.8) | 53 (13.6) | 1 (0.9) | 0 (0.0) |
| Current hormone type (multiple responses allowed) | ||||
| Estrogen | 86 (10.9) | na | 45 (40.9) | 41 (14.1) |
| Progesterone | 76 (9.6) | na | 20 (18.2) | 56 (19.2) |
| Combination of estrogen plus progesterone | 228 (28.9) | na | 33 (30.0) | 195 (67.0) |
| Testosterone-blocker | 90 (11.4) | na | 52 (47.3) | 38 (13.1) |
| Intermittent hormone use | 543 (68.7) | 255 (65.6) | 79 (71.8) | 209 (71.8) |
| Visited a health care provider in the last 12 months | ||||
| Yes | 492 (62.3) | 232 (59.6) | 95 (86.4) | 165 (56.7) |
| No | 298 (37.7) | 157 (40.4) | 15 (13.6) | 126 (43.3) |
| Ever been discriminated against when seeking medical care | 317 (40.1) | 157 (40.4) | 56 (50.9) | 104 (35.7) |
| Health care meets trans-specific needs | ||||
| Yes | 353 (45.3) | 175 (45.0) | 66 (62.3) | 112 (39.3) |
| No | 427 (54.7) | 214 (55.0) | 40 (37.7) | 173 (60.7) |
Categories do not always add to the total due to missing data.
$1 USD = ∼R$3.90 Brazilian reais.
na, not applicable.
Nearly all participants (93.4%) had used hormones for feminization at least once in the past, and most (87.0%) had used nonprescription hormones at least once in the past. The age range of 13–18 years was when the majority of trans women (57.2%) reported their first use of hormones; 10.1% reported that their first use was at age 6–12 years. The most common nonprescribed hormones used were a combination of estrogen plus progesterone, accounting for 67.0% among those on nonprescribed hormones. In the overall sample, 28.9% used estrogen plus progesterone (both prescribed and nonprescribed). Intermittent hormone use was reported by 68.7% of trans women. More than one-third of trans women (37.7%) had not visited a health care provider in the last 12 months and 40.1% had experienced discrimination from a health care provider. More than half (54.7%) reported that their current health care did not meet their trans-specific needs. Nearly half, or 389 (49.2%), were not currently taking hormones. Current prescribed hormone use was reported by 110 trans women (13.9%), while 291 (36.8%) reported current use of nonprescribed hormones.
In bivariate analyses, nonprescribed hormone use was significantly associated with younger age (between 18 and 25 years), non-White race, lower education, homelessness, using a combination of estrogen plus progesterone (compared with other hormones), not visiting a health care provider in the last year, feeling that their health care did not meet their trans-specific needs, and not experiencing discrimination by a health care provider (Table 2). In multivariable analysis, in the model adjusted by gender identity and race, independent correlates of nonprescribed hormone use were younger age, from 18 to 25 years (adjusted odds ratio [aOR] 3.03, 95% confidence interval [CI] 1.67–5.56), less than high school education (aOR 2.81, 95% CI 1.59–4.94), being homeless (aOR 2.72, 95% CI 1.18–6.53), and using a combination of estrogen plus progesterone (aOR 4.82, 95% CI 2.73–8.51). Trans women who visited a health care provider in the last year (aOR 0.25, 95% CI 0.12–0.51) and those who felt their trans-specific needs were met by their health care (aOR 0.50, 95% CI 0.27–0.82) were less likely to use nonprescribed hormones (overall model F(8, 400) = 152.28; p < 0.01; R2 = 0.33).
Table 2.
Correlates of Nonprescribed Hormone Use Among Trans Women, São Paulo, Brazil, 2017–2019 (N = 790)
| Bivariate analyses |
Multivariate analysis |
|||||
|---|---|---|---|---|---|---|
| OR | 95% CI | p | aOR | 95% CI | p | |
| Gender identity | ||||||
| Trans woman | Ref. | — | — | — | — | — |
| Travesti | 0.71 | 0.52–0.98 | 0.04 | — | — | — |
| Woman | 0.47 | 0.29–0.75 | <0.01 | — | — | — |
| Others | 0.28 | 0.03–2.39 | 0.24 | — | — | — |
| Age (in years) | ||||||
| 26 or older | Ref. | — | — | Ref. | — | — |
| 18–25 | 2.04 | 1.52–2.78 | <0.01 | 3.03 | 1.67–5.56 | <0.01 |
| Race | ||||||
| White | Ref. | — | — | — | — | — |
| Non-White | 1.82 | 1.14–2.88 | 0.01 | — | — | — |
| Income | ||||||
| More than minimum wage | Ref. | — | — | — | — | — |
| Less than minimum wage | 1.11 | 0.71–1.74 | 0.64 | — | — | — |
| Education | ||||||
| High school diploma | Ref. | — | — | Ref. | — | — |
| Less than high school | 3.56 | 2.23–5.69 | <0.01 | 2.81 | 1.59–4.94 | <0.01 |
| Homeless | ||||||
| No | Ref. | — | — | Ref. | — | — |
| Yes | 3.17 | 1.46–6.89 | <0.01 | 2.72 | 1.18–6.53 | 0.01 |
| Using combination of estrogen plus progesterone | ||||||
| No | Ref. | — | — | Ref. | — | — |
| Yes | 4.74 | 2.95–7.62 | <0.01 | 4.82 | 2.73–8.51 | <0.01 |
| Visited health care provider, last 12 months | ||||||
| No | Ref. | — | — | Ref. | — | — |
| Yes | 0.21 | 0.11–0.37 | <0.01 | 0.25 | 0.12–0.51 | <0.01 |
| Health care meets trans-specific needs | ||||||
| No | Ref. | — | — | Ref. | — | — |
| Yes | 0.42 | 0.27–0.65 | <0.01 | 0.50 | 0.27–0.82 | 0.01 |
| Experienced discrimination by health care provider | ||||||
| No | Ref. | — | — | — | — | — |
| Yes | 0.54 | 0.34–0.84 | 0.01 | — | — | — |
Model adjusted by gender identity and race; F(8, 400) = 152.28; p < 0.01; R2 = 0.33.
aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.
Discussion
A high proportion of Brazilian trans women use nonprescribed hormones for feminization, with structural barriers being associated with nonmedically supervised hormone use. In this study, trans women more likely to use nonprescribed hormones were younger, with low education and unstable housing, and using estrogen plus progesterone (i.e., birth control pills). In contrast, trans women who visited a health care provider and who felt their trans-specific needs were met were less likely to use nonprescribed hormones.
Health care utilization may have been low due to distrust in care providers, past experiences with discrimination in health care, and low expectations in the capacity of the health care system to meet their trans-specific health care needs.2,3 Trans women may have also faced barriers related to a large demand for SUS-issued drugs.12 Limited drug supply, few distribution centers, and an insufficient number of clinics within SUS have resulted in long waiting lists for clinic visits.2,3,12,13,16 Other barriers include health care professionals who exhibit bias or are not trained to be transcompetent,12,13,16 low availability of procedures for gender transition covered by SUS,12 and the high price of estrogen-only and antiandrogenic drugs. Furthermore, estrogen plus progesterone birth control pills can be purchased over the counter in Brazil and are thus easily accessible.
Limitations
We recognize the limitations of our study. First, data were by self-report, which can lead to underestimates due to low recall or gaps in knowledge. Second, social desirability response bias may also result in underreporting of nonprescribed hormone use to research assistants. Third, while RDS is presented as a probability sampling method,22 we cannot verify that our sample is representative of all trans women in São Paulo or Brazil.
Conclusion
To the best of our knowledge, this is the largest study of nonprescription hormone use among trans women in Brazil. This study highlights the need for further research on the prevalence and clinical implications of nonprescribed hormone use among trans women. The consequences of using nonprescribed hormones, unfortunately, can be long term. Based on associations and barriers to hormones for trans women in our study, systems transformation is needed to ensure health equity for trans people, with stigma-free services, and that transition-related care is accessible and consistent with their long-term health goals. There is also a need for outreach and health education on the consequences of and alternatives to nonprescribed hormone use. Alternative models of service delivery that allow a diversity of prescribers of hormone regimens (e.g., pharmacists or nurses) may alleviate pressure on an already constrained medical system and provide trans women with more access to appropriate hormones.
Acknowledgments
We acknowledge the important contributions of Beatriz Paiatto, Aline Rocha, Igor Prado, and Jessica Lin to the implementation of the pilot and parent studies leading to this research.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was supported by the National Institute on Minority Health and Health Disparities (R01MD010678).
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