title: Non-Prescribed Hormone Use and Barriers to Care for Transgender Women in San Francisco.
abstract: OBJECTIVE
  Inconsistent access to healthcare represents a barrier to transgender patients receiving hormone therapy through a licensed provider. Inability to access care leads many transgender people to buy hormones from unlicensed sources and transition without medical supervision. Little is known about the factors predisposing people to rely on this method of transition. It is critical to understand what leads to non-prescribed hormone use to better support safe medical transitions for transgender people.
  
  
  METHODS
  We conducted an analysis of a study with 314 transwomen in San Francisco from August-December 2010, using Respondent Driven Sampling (RDS). The study collected information on demographics, hormone use, gender identity milestones, violence and trauma experienced due to gender identity, substance use, sexually transmitted infections, law enforcement contact and sexual behaviors. We evaluated whether these demographic and behavioral characteristics were correlated in the following outcomes: taking hormones not prescribed by providers and taking hormones consistently without interruptions.
  
  
  RESULTS
  Data demonstrate that 68.7% of transwomen were currently on hormone replacement therapy (HRT) but only 41% reported being on hormones consistently. In addition, 49.1% reported taking hormones for HRT not prescribed by a clinician. Consistent hormone use was independently and positively associated with being born in the United States, having contact with a health care provider, and currently living full-time as a female. Those who reported ever being forced to have sex or having been raped had 60% lower odds of being consistently on hormones. We found greater odds of non-prescribed hormone use among participants who had gender confirmation surgery and among those who had experienced verbal abuse due to their gender identity and presentation.
  
  
  CONCLUSIONS
  Non-prescribed HRT in transwomen is a common and poorly characterized phenomenon. Increasing access to healthcare (with culturally-competent, affordable, and accessible providers) is crucial to assuring trans people are able to have safe, consistent access to the hormones they need.
authors.affiliation: 1 School of Medicine, University of California San Francisco , San Francisco, California.
authors.forename: Gene
authors.initials: G
authors.lastname: de Haan
authors.affiliation: 2 Center for Public Health Research , Population Health Division, San Francisco Department of Public Health, San Francisco, California.|3 Community Health Systems, School of Nursing, University of California San Francisco , San Francisco, California.
authors.forename: Glenn-Milo
authors.initials: GM
authors.lastname: Santos
authors.affiliation: 2 Center for Public Health Research , Population Health Division, San Francisco Department of Public Health, San Francisco, California.
authors.forename: Sean
authors.initials: S
authors.lastname: Arayasirikul
authors.affiliation: 2 Center for Public Health Research , Population Health Division, San Francisco Department of Public Health, San Francisco, California.|4 Epidemiology and Biostatistics, University of California San Francisco , San Francisco, California.
authors.forename: Henry F
authors.initials: HF
authors.lastname: Raymond
mesh_terms: D000293:Adolescent; D000328:Adult; D015914:Estrogen Replacement Therapy / Q000706:statistics & numerical data*; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D012495:San Francisco; D012725:Sexual Behavior / Q000706:statistics & numerical data; D012749:Sexually Transmitted Diseases / Q000453:epidemiology; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000453:epidemiology; D063106:Transgender Persons / Q000706:statistics & numerical data*; D014754:Violence / Q000706:statistics & numerical data; D055815:Young Adult; D008297:Male
keywords: access to care; health care disparities; hormone replacement therapy; medical transition; trans health; transgender