...I could have told you that π€·
Source: https://x.com/BriannaWu/status/1984574165643403370
Not my usual kind of source (Xitter), but I want any centrists out there who ask trans people to "just get along" / compromise with actual hate groups that want them eradicated to know that it doesn't work.
There is no such thing as a reasonable bigot, by definition.
I'm going to push back on OTC HRT because of the health risks. Supraphysiologic estrogen and testosterone can both have lethal side effects, so correct dosing and monitoring for health complications are essential components of trans healthcare.
Both are already OTC in most of the world, specifically most developing countries.
More importantly, you are applying an insane and bad-faith standard when assessing medication. ANY medication can have lethal side effects. Down a bottle full of Tylenol and you'll condemn yourself to a slow agonizing death of liver failure. Yet you can buy that shit at gas stations.
You answered the wrong question. You asked, "can HRT be dangerous?" Any rational person trying to form an unbiased opinion about it would ask, "is HRT of comparable risk to existing OTC medications?"
In countries besides America, Tylenol comes in blister packs of maybe 20 total pills per package in a lower dose than the American variation. The drug and marketing regulations here are not a good example and I think a lot of medications that are currently OTC need to be much more closely regulated or have things like the inconvenient packaging and MUCH better warnings on them for patient safety.
That being said, poorly managed (or un-managed) HRT has more potential for significant harm than most OTC medications. There are many complications that can come from exogenous hormone treatment for both trans and cis patients, and the risks need to be adequately assessed and managed. Estrogen significantly increases the risk of blood clots and strokes, and Testosterone drastically increases the risk of heart attack and organ failure if not dosed appropriately.
In no way do I intend to restrict trans healthcare, but most medications on the market in America need to be much more closely regulated than they are now because of the risks of harms that can vastly outweigh the benefits, especially when not dosed or monitored accurately.
You're spreading anti trans FUD. The risks are extremely modest. The risks you cite, like heart attack risk on T, are just from moving an FTM person from a female to make heart attack profile. Men have a greater risk of heart attack than women do. Having a male hormone profile gives you male health risks. But people like you like to spread fear by citing this as an effect of HRT.
You're portraying hrt as this crazy substance, but we're talking bioidentical hormones here. They are the same exact molecules that are produced naturally.
You are shamelessly spreading anti trans propaganda. Or take estrogen for example. Trans women raise their E levels to the 100-300 range, the normal female E range. Yet cis women, when pregnant, experience E levels 10-20 times those levels. The human body can handle very high levels of estrogen quite well. You can take 10x the recommended E dose and still be extremely unlikely to have any adverse effects from it.
Show me one single person that has died from the misuse of modern bioidentical hormones. Find me one. Because hrt is absolutely far safer than almost every otc medication out there. You can literally take 10x the recommended doses. That's how safe it is. It's safe because we're talking the exact same molecules that are made by the body.
There's a reason diy is so common among the trans community. Even most doctors are comically ignorant and repeat long disproven myths like the ones you repeat here.
HRT is extremely safe when dosed appropriately. As I said in another comment, I'm less worried about trans folks getting the HRT wrong than cis people taking a bunch of extra hormones because some influencer convinced them that more estrogen or more testosterone will fix all their health problems. Making something OTC makes it available to everyone, not just the people that need it. Trans people need HRT, cis people very rarely do.
And yet, other countries where HRT is OTC don't have an epidemic of cis kids dead from taking T and E. Your concern is purely hypothetical. Meanwhile we have real world data showing the risks of OTC HRT are minimal. And even cis people taking it have very low risks, comparable to other otc medications.
Social media leads people to do all sorts of stupid things. We don't ban bleach because someone might try and drink it to cure covid.
It isn't the cis kids I worry about. It's the menopausal woman in the emergency department with a DVT and PE from the estrogen she got online on the advice of her chiropractor. It's the man in his 50's that thought testosterone would fix his lost libido and fatigue that now has to get coronary artery stents because he got his dosing recommendations from body building influencers.
It's the real patients I have seen and treated that concern me when these hormones aren't even that freely available. It's not a hypothetical for me, it's real people that have suffered real harm even if they didn't die from it.
You can get lethal effects from nicotine, alcohol, bleach, ammonia, and many, many combinations of chemicals that are available with, at most, age verification.
I'm all for people educating themselves as much as they want, from whatever sources they trust, but bodily autonomy DEMANDS someone be able to direct their own medication, including gender affirming medication. Doctor-as-gatekeeper is, IMO, not as good a model as Doctor-as-confidant-and-educator.
As a soon-to-be physician that has sought training in trans healthcare, I do not see my role as gatekeeper, but the role of educator includes teaching about and monitoring for the risks and complications that can come from HRT. Estrogen and Testosterone are both powerful and potentially dangerous hormones and I do not want to see my trans patients dying from strokes or heart attacks that could have been prevented with more careful dosing of their HRT.
No one imagines they are the bad guy. But, if a patient asks for a drug and you deny it to them, you are being a gatekeeper. I imagine you are only doing this for "good reasons", but you are still violating their bodily autonomy.
To be clear: I am not saying this about HRT specifically because, most of the time, HRT is safe when dosed appropriately.
That being said, if I think a medication is going to be dangerous, harmful, or lethal to a patient and I prescribe it anyways, I am legally and morally liable for any harm that comes to them from that medication. I have had conversations with patients about weight loss drugs that they really want, but that would be extremely dangerous based on other comorbid conditions like heart problems or pancreas issues. If a patient asks me for something that I think is unsafe, I engage them in a discussion about why they want that medication, the risks and benefits of it, and possible alternatives that could be safer. If a patient is dead-set on getting a medication that is very likely to harm them, I'm not going to write that prescription because if the worst happened, their blood is on my hands.
It is very uncommon that physicians refuse to prescribe something that a patient is asking for specifically. The much more common situation ends up being that the physician can write the prescription, but insurance won't pay for it. There are obviously some physicians out there that refuse to prescribe things like birth control based on their personal beliefs, but they are obligated to refer that patient to a provider that will give them the prescription.
Then, you don't value bodily autonomy as much as I do, and will deny it to some of your patients, gatekeeping -- no matter what you "think" you are doing.
Does my ethical autonomy count for nothing? Am I really obligated under your worldview to harm my patients by acquiescing to their demands carte blanche?
Even as a medical student, I have had patients die in my care from things I couldn't do anything about. I had no way to save them because the medicine to fix the problem simply does not exist. As an ER tech, I have had multiple times where the physician running the code called the time of death while I was the one doing compressions on the patient. Most of those were children. I am already haunted by the patients I have lost through no malpractice, negligence, incompetence, or malice of my own. I refuse to intentionally add to my nightmares by doing something that I truly believe would harm my patient, even if it is what they are asking for.
In my worldview, the drugs would not have a gatekeeper. They would in available OTC. You should not have your "ethical autonomy" compromised at all. (And yes, it does count for nothing compared to bodily autonomy.)
If your reason (for not providing the drugs) was only protecting yourself or others from State-backed violence, it could be justified. But, you claimed you would do it because you know better how to manage a patient's body than themselves.
I think you are severely underestimating how much education is actually required to fully understand how medications work and how they can interact with each other. The internet is full of quack grifters like the "Hims" and "Hers" sites that will give people unregulated compounded semaglutide (that doesn't undergo actual health inspections) to people that are likely to be seriously harmed by it because they don't do their due diligence of actually screening for comorbid conditions that could lead to serious health consequences.
I just got home from a shift at the hospital where two medical students, two resident physicians, and an attending physician couldn't find the information on how to adjust dosing for a couple of medications to prevent dangerous interactions so we had to go ask the pharmacist. She responded with more questions about the patient's clinical condition so that she could give us appropriate recommendations. If we had gotten that medication combination wrong, our patient could have easily ended up with a pulmonary embolism or a stroke.
Point being: even physicians have to phone a friend to figure out medication safety sometimes and I do not think it's reasonable to put the responsibility of medication safety on patients who don't have over a decade of study and training to know what the risks are.
On the other hand, when I've worked in emergency departments I've seen patients that have been severely harmed by medications that they got on their own. A perfect example was the man that thought he had a rare parasite from a continent he had never been to because Chat GPT told him so and it also told him that the treatment for that parasite is Ivermectin. He went and got the horse paste version from Tractor Supply and turned up in our emergency department with fulminant liver failure because he didn't know how to do the dose conversion correctly (and didn't know the safe human dosing anyways).
Your model of "total bodily autonomy" with every medication being OTC would drastically worsen the Darwinian hell caused by medical misinformation. I don't want to see my patients harmed by dangerous medications even if I wasn't the one that prescribed it.
I'm all for a person educating themselves before making a decision to ingest some material, but the final decision MUST BE THEIRS, and not someone else's.
Yes, the decisions are often difficult, and I personally know I'm an idiot with a bias NOT to ingest something. But, I refuse to deny someone else their freedom based my judgements, or even the judgements of "experts". I think there are a LOT of good reason to, so I will almost universally defer to an expert, but I refuse to DEMAND everyone else make that same decision.
Citation needed. ESPECIALLY around HRT.
Elsewhere in this thread I talked about a couple patients I have actually treated. One was a woman in her 60's that got mystery doses of estrogen from implanted pellets that now has to take blood thinners for the rest of her life because she got a DVT and pulmonary embolism because of the excessive estrogen. She's also at much higher risk for uterine and breast cancer too. Another was a man in his 50's that had to get coronary stents and start a pile of medications to try to mitigate his heart and liver damage from taking the doses of testosterone recommended by body building influencers. I actually care about HIPAA, so I won't be giving you any more specific information about these cases.
It really isn't the trans folks I'm worried about when it comes to HRT, but if it's freely available to trans folks, that means it's also freely available to cis folks that are more likely to do it wrong and suffer severe consequences.
I am concerned for the population at large, and unfortunately, safety regulations have to account for the lowest common denominator unless you think that uneducated or gullible people deserve to suffer. Prescriptions are a way to make sure that people are getting the medications they need in the appropriate doses for the correct indications. There's enough trouble with people hurting themselves with the medications that are already OTC. I don't think more OTCs (HRT or otherwise) are a particularly good fix for the disaster that is American healthcare.
Data is not the plural of anecdote. As has been pointed out elsewhere in the thread, many countries have OTC HRT and do not have significantly higher morbidity or mortality rates associated with those materials. Your experiences, in the form you've shared them, are NOT citeable. So, we're still at "Citation Needed" stage.
I think that uneducated or gullible people deserve full bodily autonomy, even if that means bad results from their choices.
Certainly, educated and sophisticated people can also get bad results from their choices; I see no reason to deny them to anyone else.
There is a difference between safety regulation and paternalism that I think you are failing to parse. As a society, we share a collective responsibility to build safeguards and fail-safes into the structures of our environment for the protection of those among us that need help. Unfettered freedom and rugged individualism with "full bodily autonomy" is a recipe for disaster.
And many of those countries have wildly different healthcare systems and health culture. The American population is so utterly bombarded with misinformation (including from our own government and regulatory bodies now) that I don't see phenomena or results from other countries as fully applicable to Americans. There are tons of studies about vastly different outcomes of treatments or interventions in other countries (especially Scandinavian countries) that I do not apply to my clinical practice because a lot of those results are heavily confounded by factors that the study doesn't account for like cultural diet, healthcare access, amelioration of poverty, and genetics that would skew the results into uselessness in America. So, I'd love to get a list of these countries you're talking about because if they're civilized countries with accessible healthcare, it's not even an apples to oranges comparison; more like apples to chunks of concrete.
There is a fundamental right to bodily autonomy that you aren't valuing.
You can call it whatever you want, if you prevent a person from self-administering any substance, you are violating their human rights.
On top of that, many, many OTC substances are much more lethal than HRT, so the risks of HRT cannot be great enough to justify them not being available OTC.
Besides acetaminophen (Tylenol) which I have already addressed as being problematic in its packaging and advertising, which other OTC medications are you talking about?
Here's a list of medications that are available OTC (and not behind the pharmacy counter) that I think should be more restricted in terms of packaging, quantity limits, or accessibility (i.e. put them behind the counter with the Sudafed so they're available without a prescription, but there's a strict limit on how much you can buy.)
Among many, many others.
There's also a huge list of vitamins and supplements that shouldn't be as freely available in such high doses, and others that shouldn't be allowed at all because of safety risks. Not to mention the fact that a bunch of energy drinks out there contain enough caffeine in a single can to cross the threshold of caffeine toxicity if consumed in under an hour. (Celsius is a good example)
Bleach, ammonia, nicotine, and ethanol were the dangerous substances I mentioned earlier in the thread.
Bleach and ammonia are cleaning chemicals that were never intended for human consumption, not OTC medications. Nicotine should be banned entirely, and ethanol needs to be heavily reined in, but again, they are not OTC medications.
They are materials that can be much more dangerously self-administered. Anything less dangerous can't be justifiably ~~banned~~ restricted solely on the dangers of self-administration.
So we should ban every cleaning product, gasoline, diesel, basically every other fluid that goes into a car, potting soil, fertilizers, every item that can be used as a weapon, every actual weapon, and water because those can all be used to harm oneself?
Your argument here boils down to "either everything needs to be completely freely accessible to everyone with no restrictions or every substance on the planet needs to be confiscated and controlled because people could use something to harm themselves"....and I'm only exaggerating your position by a smidge.
Do you also think the FDA should stop having standards for food and drugs? After all, if people want cheaper weight loss supplements, they're way cheaper to manufacture if they're contaminated with lead and toxic substitutes for the advertised herbal ingredients.
No. They should all be legal to acquire and self-administer.
No. They enforce accuracy of labeling, which is important for people to make informed (consent) decisions about what they self-administer. They should stop making it illegal for a willing recipient to acquire an accurately labeled substance and self-administrate said substance.
Oooooh you're an idiot, never mind my previous reply to you
DIY saved my life. I purchased bloodtests and monitored my own treatment. But it would have been a lot safer had I not needed to order estrogen online from a foreign supplier.
I am very glad that you were able to get your own care and didn't have any bad outcomes. On the other hand, I've had cis-female patients go to naturopaths or chiropractors to get estrogen and/or testosterone pellets for peri-menopause symptoms and they had no idea what the risks were. In the emergency department, I've had cis-female patients on estrogen replacement therapy that was not well managed show up with DVTs. Cis-male patients on supraphysiologic testosterone are at risk for several different kinds of organ failure along with a drastically increased risk of heart attacks.
I don't think that trans patients are terribly likely to harm themselves with DIY HRT, but having hormones available OTC is going to lead to a lot of cis people getting sick or getting killed by taking extra hormones to try to fix their problems because scammers and quacks have convinced them that hormones will magically fix all of their problems.
You're still focusing on risk and not relative risk. You're answering the wrong question. You are addressing whether HRT can have health risks. You're completely ignoring whether its health risks are in any way worse than other OTC medications. That is the question here. You'll die if you drink enough tap water. Do you have any evidence at all that HRT is riskier than other typical OTC medications? Cause I'm not seeing any here. Instead you're treating HRT as its own unique and special category, rather than just assessing it like very other medication.
I also said that many OTC medications need to be more strictly regulated. The American capitalistic approach to marketing drugs is obscene and needs to be heavily reigned in. HRT is not a special category of medication because every substance that has a desired effect also has side effects that need to be considered. Acetaminophen (aka paracetamol or Tylenol) in other countries is regulated similar to how pseudoephedrine (Sudafed) is regulated as in needing to get it from the pharmacist in limited quantities in individual blister packs. It is absurd how poorly controlled dangerous medications are in this country, but it's unlikely that will ever change because of the attitudes of American individualism and pharma lobbying groups.