An injectable testosterone shortage in Canada and the U.S. has left some trans men and gender nonconforming people worried and depressed as they scramble to fill their prescriptions. Many have no idea as to when they can expect to be able to access their medication again.
“What was really worrying was the complete lack of information,” says Thomas O’Donnell, a trans man in Vancouver who has been using testosterone since the beginning of 2020. “Nobody explained to me when it was going to end. One of the pillars of medically transitioning, one of the most important drugs you can take, can just sort of disappear, and there’s nothing you can do about it.”
O’Donnell had gone to his pharmacy on Aug. 31 to pick up his regular supply of testosterone, only to be told, “It’s really weird, we didn’t fill it for you.” The next day, his pharmacy called and told him there was a shortage, and that they might be able to get him some by the next week. But they didn’t, nor the following week, and they weren’t able to tell him when it might be back in stock.
“At first, I thought this was a big deal for me but not for anybody else,” O’Donnell says. “But I looked on a Facebook page for FTMs in B.C., and quite a few other people were talking about it. It put me on edge. I spent all my time calling around to other pharmacies and doing as much research as I could. I emailed my old doctor, I emailed Trans Health BC. Nobody had any information.
“It got to the point where, medically, I was nervous. I was scared my gender dysphoria was going to come back. I was taking my vials and trying to draw the very last amounts out of them.”
The shortage, which began this March, has affected both of the leading manufacturers of injectable testosterone, Bausch and Pfizer. Bausch—which makes testosterone marketed as Delatestryl—says its shortage is due to supply chain issues, which began on May 31 and ended on Sept. 10. Delatestryl is now available again. Pfizer—which manufactures Depo-Testosterone—says its shortage, which began in March and will be ongoing until early 2022, is due to the company’s focus on manufacturing COVID-19 vaccines.
Previous shortages, while not uncommon, have only affected one product at a time. While many people can use either type of testosterone, a significant number cannot switch their prescriptions due to allergies or the fact that Delatestryl is stronger.
Trans men say nobody, including Health Canada and provincial health authorities, has kept them updated about the situation.
O’Donnell—who injects testosterone weekly and refills his prescription every three months—had experienced a similar problem with Delatestryl last year, but was able to find it at another pharmacy. This time, he had no such luck.
On Sept. 20, O’Donnell says he was only able to inject himself with one-third of his normal dose. Fortunately, he was able to refill his prescription at his pharmacy again three days later, but he says he was definitely feeling the effects. “For two weeks or so, I was probably the most exhausted I’ve ever been,” says O’Donnell. “I was so totally lethargic, very moody, complaining to everybody. I felt a little bit off and a bit dysphoric. It made me feel very powerless and sad, and it made me feel alone.”
He says he was also worried about having to explain to co-workers unfamiliar with the realities of living as a trans man how he was suffering emotionally and physically.
“I didn’t feel like having to explain the situation to cis people.”
According to Amy Bourns, a family physician at Toronto’s Sherbourne Health clinic with a focus on LGBTQ+ health, O’Donnell’s reaction to going without testosterone was to be expected. She says that if a trans person has had their ovaries removed, then stopping testosterone for several months could bring on symptoms of premature menopause. For those who still have ovaries and a uterus, stopping testosterone could mean a resumption of menstruation, which can be particularly distressing. These can lead to changes in mood and energy levels.
Bourns says that stopping testosterone can also lead to the reversing of some masculinizing effects, including changes in muscle mass and fat redistribution. If testosterone is stopped for a longer period— years rather than months—then trans masculine folks could begin to see a loss of bone mineral density.
Some or all of these could lead to “depression, anxiety, intensified gender dysphoria and potentially unhealthy coping strategies like substance abuse,” says Bourns.
Bourns says she was able to guide her patients to a generic form of injectable testosterone called Taro-Testosterone, which has only been available since November 2020. However, the accessibility of Taro-Testosterone varies across Canada, especially for those on provincial drug benefit plans. While the drug is readily available in some provinces, it requires special authorization to be prescribed for those on provincial health plans in Ontario and B.C.
“The biggest problem was the delays,” says Bourns. “I had to co-ordinate going to different pharmacies, submit approval for patients who are on public plans—it actually needed a new prescription, since pharmacies do not substitute generic testosterone automatically. For me it was a lifesaver. There were logistical hurdles, but with proper legwork and administrative headaches, we were able to ensure none of my patients went without.”
Bourns wrote the provincial guidelines for hormone therapy for trans patients on the Ontario Drug Benefit (ODB) plan, in which she suggested that doctors apply for both the Pfizer and Bausch forms of testosterone, because shortages are not uncommon.
“We apply for exceptional access to ODB because we know at some point one will be on backorder.”
Now, she says, she will recommend doctors apply for Taro-Testosterone as well.
But while Bourns has the experience to help her patients, many doctors do not. Refilling a prescription may be easy, but navigating a shortage can be tricky for a doctor not used to dealing with trans patients.
“When barriers occur, if you have a doctor who works more closely with trans communities and has a better understanding, as opposed to you being the sole trans patient in their practice, there are definitely going to be benefits to the former,” says Bourns.
The shortage has also pointed to some clear discrimination against trans men in the ODB, says Bourns. While the plan covers testosterone creams or patches for cis men, it does not do so for trans men, meaning that during a shortage, trans men on the plan are unable to switch to creams or patches, which are significantly more expensive than injectable testosterone. According to Rainbow Health Ontario, the cost without insurance for four weeks of testosterone ranges from $13 to $29 for injectable testosterone; from $76.50 to $315 for patches; and from $62 to over $300 for gels.
“Gender dysphoria isn’t covered. It’s a clear discrepancy.”
Bourns believes that the needs of trans men may often be overlooked by the health care system. “There’s no question that transphobia and discrimination have played a significant role in the lack of visibility of all trans populations,” she says. “This is reflected in research and policy. There is improvement in recognizing the importance of supporting and meeting the medical needs of trans and non-binary people, but there’s still often the idea that trans people are really rare. It creates further issues of where resources go.
“There’s still a lot of work to be done to create an equitable health care system that considers the needs of trans and non-binary people at every level.”
Neither Pfizer nor Bausch acknowledged the particular importance of testosterone to trans men in their explanations of the shortage.
“Unfortunately, shortages do occur from time to time with many pharmaceuticals because of API [active pharmaceutical ingredient] availability issues encountered by suppliers,” says Bausch spokesperson Boyd Erman in an emailed statement. “We work diligently to ensure that any shortages are as brief as possible, because we know how important our products are to patients.”
“We understand and regret the challenges that these issues pose to patients,” says Christina Antoniou, the director of corporate affairs for Pfizer Canada, in an email. “Pfizer fully realizes the importance of our medicines to our customers and patients. Ensuring continuity of the supply of our medicines is paramount.”
Health authorities were no more expansive in their replies.
“An interview is not possible at this time,” wrote a spokesperson for Health Canada in an email. “Drug shortages are a complex global problem. Health Canada recognizes the negative impact of drug shortages on patients, health care professionals and the health care system, and works together with stakeholders to build a more open and secure drug supply system. Everyone has a role to play in addressing drug shortages.”
And Justine Ma, the manager of communications and stakeholder engagement for B.C.’s Provincial Health Services Authority—which includes Trans Care BC—wrote only, “Shortages of testosterone happen quite routinely as it does with other types of injectable medications.”
Bourns is not ready to attribute the shortage to transphobia, at least not entirely. She points out that most patients prescribed testosterone—including in her own practice—are cis men. “I’m reluctant to say this is about discrimination. The bulk of [pharmaceutical companies’] business comes from cis men.”
The American College of Physicians, at the beginning of 2020, released guidelines suggesting that testosterone should only be prescribed to cis men for sexual dysfunction, and not for concerns about energy, vitality or hair loss.
“I see a lot of demand for testosterone from cis men in my practice, and it’s not always medically warranted,” Bourns says. She believes it’s possible that over-prescribing of testosterone to cis men has contributed to the current shortage.
O’Donnell says he’s feeling back to normal now, but that the shortage cost him a month of stress and depression. Whatever the reason, the fact that testosterone shortages could be a chronic problem is hugely worrying.
“I’m not that far into the medical process, and this has already happened twice in 21 months. Every year, will I have to take a month off?”
He says he’s going to investigate the use of creams or gels, despite their higher cost, so he can be prepared if he’s unable to obtain injectable testosterone in the future.
“When your prescription is out, there’s nothing you can do about it. It makes me want to double-check my employer’s insurance policy to see if I can get the other kinds of testosterone.”