Facing hormone shortages, South Africa’s trans men try black market

South African tech adviser Josh Stols felt a wave of euphoria when his doctor handed over his first testosterone prescription, allowing him to finally start his physical transition as a transgender man after a year of psychiatric assessments.

He was looking forward to starting a new chapter until he discovered that testosterone supplies often ran short – an issue that has worsened during the COVID-19 pandemic – pushing him and other desperate trans men to seek risky, black market hormones.

“These shortages mess with our sense of self,” 29-year-old Stols told the Thomson Reuters Foundation in a phone interview from Johannesburg.

“It is like someone with mental health issues not being able to get their meds. (Testosterone) is what we rely on to look in the mirror and see ourselves – without it, it’s like walking around blind. The risk of not getting this is suicide.”

In South Africa, trans men and doctors say that widespread testosterone shortages began around 2015, and can last for a few months at a time.

Similar shortages of the male hormonal drugs have been seen from Canada to Spain, health reports say, leaving a trail of derailed transitions in their wake.

“Without testosterone, breast tissue can form again, fat redistribution could return to more female areas and periods can start again,” said Stols, all of which carry devastating mental health impacts as trans men see their new bodies sliding away.

Reasons for disruptions include shortages in the compounds that form the medication, transport issues such as shipping container shortages, or lack of manufacturing capacity due to heavy demand for other products such as COVID-19 vaccines.

Depo-Testosterone, the affordable, injectable hormone used by many South African trans men and gender non-conforming people, is produced by Pfizer, which has had to pivot resources to meet huge demand for its COVID-19 vaccine.

Production of some drugs including testosterone has been “temporarily impacted” as a result, said Zogera Kara, director of policy and public affairs at Pfizer’s Sub-Saharan Africa office, over email.

Pfizer said it is “actively working to mitigate any supply interruptions” but did not respond to specific questions about when the current shortage is expected to end.

BLACK MARKET

While some trans men can afford to turn to more expensive testosterone prescriptions when their normal brand runs out, those who cannot are forced to seek black market supplies from gyms, dealers or other illegal suppliers.

The illicit market is largely driven by men who use it for its muscle growth effects, but it carries health risks and side-effects such as increased anger levels or thromboembolism – obstruction of a blood vessel by a dislodged blood clot.

Trans people using black market testosterone report side effects such as dizziness, exhaustion and nausea.

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