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Doctors Who?

Radical lessons from the history of DIY transition

Fifty years ago, a small group of women of color boarded a bus in Southern California bound for Tijuana, Mexico. They may or may not have stuck out in the crowd of Americans who crossed the border daily for the cheaper rates on goods and services. Once in Mexico, these women, who had journeyed all the way from San Francisco, walked into a pharmacy, bought out its entire stock of estrogen, and then carefully hid it inside their luggage. Back home, they made straight for the Tenderloin.

These women were trans—poor, many unhoused, and most sex workers who faced unending street harassment from the police, clients, and other Tenderloin residents. They were also the self-appointed doctors of their community. In hotel rooms, shared apartments, and sometimes the back bathrooms of quiet bars, they resold and administered the estrogen to their friends—other trans women who could pay in cash for injections. At the turn of the 1970s, this group of ad hoc smugglers and lay doctors were part of a vast and informal market in hormones that stretched along most of the West Coast. Similar networks no doubt spanned other regions of the country, though few left obvious traces behind.

Decades later, the story reads a little like something out of a heist film. What’s not obvious from today’s perspective on trans health care is that smuggling and reselling hormones was once quite normal, verging on unremarkable. Now, in an era of moral panic and shallow journalistic punditry dramatizing trans people as exceptional and mysterious, transition is conventionally narrated as an individual journey into the medical establishment. This form of institutionalized care is also under threat. In April, Alabama became the first state to successfully enact a ban on gender-affirming care for trans people under the age of nineteen. The law was soon challenged in federal court. Yet only a few months later, after the Supreme Court overturned Roe v. Wade, Alabama updated its legal reasoning in the case. If there is no constitutional right to abortion in the United States, then by analogy the state reserves the right to stop anyone it pleases from transitioning. “No one,” argued state Attorney General Steve Marshall, parroting Justice Alito in Dobbs v. Jackson, “has a right to transitioning treatments” because such a right is not “deeply rooted in our Nation’s history and tradition.” The political winds are fast blowing in this direction: Alabama’s law is one of over one hundred anti-trans bills that have been introduced across the country this year.

There is, however, a long history of medical transition in the United States—though it mostly unfolded outside the confines of the medical establishment. There was either no doctor to visit, or the gender clinic was a place that only the white middle class could successfully navigate. Instead, trans people—like the women in the Tenderloin in the 1970s—provided care to and for themselves. This kind of DIY, or do-it-yourself, transition sits at the heart of trans history, though you wouldn’t know it from reading today’s headlines in so-called papers of record. As the liberal principles of bodily autonomy and the right to privacy are eviscerated, the history of DIY transition offers one path out of the quagmire of zero-sum legal arguments and toward what might come after, or in the place of, state-sanctioned care.

Alternative to What?

Institutional trans health care came about in the late 1950s and early 1960s, when a cohort of endocrinologists, psychiatrists, surgeons, and social scientists in the United States and Europe united around the diagnostic term transsexuality to describe those asking for hormones and surgeries to transition. Although trans people were hardly new, and neither were the medical procedures they were requesting, they faced almost universal hostility for asserting themselves. The medical establishment, unwilling to fathom why people without any medical conditions would want to transition, viewed them as sexual deviants—in the words of endocrinologist Harry Benjamin, “among the most miserable people I have ever met.” Doctors thus styled the provision of care as a paternalistic errand of mercy.

The history of DIY transition offers one path out of the quagmire of zero-sum legal arguments and toward what might come after, or in the place of, state-sanctioned care.

The diagnosis of transsexuality came with a particularly cruel twist: it was explicitly designed to restrict access to transition. By establishing extremely narrow diagnostic criteria, doctors were able to reject the vast majority of potential patients from their clinics: either they did not perfectly “pass” as generic women or men; they were not heterosexual enough; they did not dress in a conservative fashion; or they weren’t white, didn’t have blue- or white-collar jobs, and were therefore broadly undeserving. While clinicians pretended outwardly that their self-appointed role was to make sure no one who wasn’t really trans made a decision they might later regret, in private they admitted to one another that there was no test that could determine who was or wasn’t trans. By making transsexuality an exceptionally difficult diagnosis to qualify for, Benjamin and his cohort were protecting themselves from patients who might regret the poor quality of their care, particularly when it came to surgery. This regime of medical gatekeeping made transition through official means inaccessible to most and miserable for the few willing to attempt it.

What has long been overlooked, at least outside of trans circles, is that there were always other options—and most trans people tried every avenue at their disposal. But the history of DIY trans care doesn’t leave behind the written records, research data, and publications that form conventional medical science, forcing researchers to rely on community newsletters, personal archives, and interviews to reveal the punk sensibility and medical ingenuity of those determined to provide care for themselves and their community.

One of the most democratic forms of DIY has always been the self-administration of hormones, which are identical to the hormones prescribed to non-trans people. Today, they are also chemically equivalent to endogenous hormones, making the management of their effects and health risks predictable and straightforward. Synthetic hormone medications were first developed and brought to market in the 1940s, and trans people were among their earliest adopters, though they were mostly purchased by middle-class American homes, promising a chemical solution to every conceivable problem. In the burgeoning trans print culture of the 1960s and 1970s—the same time the women from San Francisco were making their trips to Tijuana—we get a sense of both the popularity of DIY hormones and the class conflicts they raised.

In 1963, rumors sourced from “the grapevine” swirled in the newsletter Turnabout that some trans women were obtaining the livestock hormone diethylstilbestrol “by ordering them from Sears Roebuck’s animal nutrition department.” To the middle-class writers of Turnabout, this veterinarian “scheme” was “foolish” not only on medical grounds but because it ran afoul of the Food and Drug Administration. “Don’t try to be your own doctor,” warned Virginia Prince, a prominent transvestite—a term that predates transsexuality and often referred to people who did not want to medically transition—a year earlier in her newsletter Transvestia. In a 1971 column for the newsletter New Trenns, Sally Ann Douglas, a trans woman embedded in an especially well-connected social network, remarked that “everywhere I go these days, I bump into gals who seem to be getting hormones from somewhere”—somewhere other than a doctor’s office, that is. Calling it a trend, she wrote that “most of them seem to be pursuing a ‘do-it-yourself’ program of experimentation with various formulations” of estrogen on the market. Trans women often wrote into such newsletters looking for advice on this subject, but Douglas, like many of her peers, dismissed DIY approaches as reflecting a lack of courage—being too “shy” to go to a doctor—rather than problems of finances and gatekeeping.

Birth control pills, which were flooding the U.S. market by the end of the 1960s, became an attractive alternative because of their availability—even though their hormonal composition proved mostly ineffective for trans women and came with a high risk of blood clots (as they did for non-trans women) because the dosage was quite high. In the newsletter Empathy Forum, columnist Jessie Collins summed up the risks in 1975: “There’s not any reason to take more chances than necessary, so stick to ‘nature’s own’ estrogens!” by which she meant hormones like Premarin, the most common estrogen then prescribed, which was derived from horse urine. In 1978, when Douglas was serving as an editor of All the Social Femmes, she replied to a letter from a reader asking about the pill: “I don’t have access to un-prescribed hormones myself, and I wouldn’t put you in touch with the underground, even if I knew who the girls were . . . because they all cheat.” By “cheat,” Douglas may have meant that the “underground” stood to profit off desperate trans women—but that was the central worry about most legitimate doctors, too.

The Transsexual Action Organization saw gender clinics as crass opportunists out to make money off desperate people instead of prioritizing good surgical outcomes.

It was easy for Prince, who publicly maintained she did not want to transition through surgery, or Douglas, who had the means to navigate the transsexual medical model successfully, to chastise anyone who found DIY more practical or the only option within reach. The written historical record skews in favor of DIY’s critics; the trans women of color who ran the black markets didn’t have newsletters in which they could publish their side of the story. (And considering what they were doing was to varying degrees illegal, they had little reason to leave traces of their work behind.) Yet DIY was straightforward and unapologetic in neighborhoods that relied on it. Angie Xtravaganza, one of the New York City ballroom performers made famous by Jennie Livingston’s documentary Paris is Burning, started hormones that way at fifteen. The “doctor” selling them went by Jimmy Treetop, and he hung out at the clubs where drag queens and femme queens gathered, offering syringes of estrogen and vitamin B-12 for $15 a pop. Xtravaganza supplemented these injections with progesterone in the form of birth control—a savvy molecular combination that many doctors still fail to recognize when providing hormone replacement therapy.

DIY doctors who weren’t trans were viewed with suspicion by their customers, but for Black and brown trans women already facing chronic police violence, becoming an entrepreneurial smuggler or ad hoc doctor was not always an appealing alternative. Stonewall veteran Miss Major, who came of age in Chicago in the late 1950s, remembered a doctor like Xtravaganza’s who cornered the DIY market for Black trans women across the upper Midwest at a time when racism precluded getting a legitimate prescription. “He used these shots,” she told historian Susan Stryker in an interview in the 1990s, “his shots were so potent, that after he shot you in the arm you went out to sit in his waiting room and would just fall asleep.” Although she and her fellow customers were skeptical of the safety, she explained that “at the time you didn’t ask questions . . . And to this day I don’t know what was in it, but I know that at the time it made me feel like a femme fatale!”

What I have been able to reconstruct of the seriousness of this lay medical expertise has come through these sorts of personal testimonies. When I asked one trans woman of color who participated in this underground in the 1960s and 1970s to reconstruct the medical knowledge possessed by DIY practitioners, she put it as common sense born of necessity: “Everybody knows. Everybody knows. We knew more than our doctors.” My follow-up questions about the types of estrogen, dosage, and the effects went unanswered because, as I learned in the interview, that just wasn’t what mattered to her. Or perhaps I had come across too critical, like I was more interested in the risks than the rewards of DIY. My interviewee reminded me that the one doctor in town offering hormones was, in her words, “making money hand over fist. He was so cheap he, instead of the regular medical scale, he had a bathroom scale. Instead of ashtrays in his waiting room, he had coffee cups. Instead of furniture he had, like, you go to the drugstore and get cheap lawn furniture. Plastic furniture, that’s what he had.” It’s not hard to imagine why trans women would have trusted one of their own with DIY hormones over a doctor preying on their vulnerability for maximum profit, with little regard for medical ethics.

The TAO of Liberation

Do-it-yourself hormones are in many ways the focal point of DIY transition, but the history of DIY surgery adds another dimension to the story. In the mid 1950s, after former soldier Christine Jorgensen’s trip to Denmark for surgery made the front page of the New York Daily News, rumors began to circulate in private correspondence among trans women that some were willing to do anything to get what Jorgensen had. On paper, there was nowhere in the United States to get surgery because it was considered legally dubious to perform, although a few cavalier surgeons, like Elmer Belt in Los Angeles, tried until peer and financial pressures built up and local hospital boards blocked procedures. In 1956 a transvestite in Southern California named Edythe Ferguson remarked in an amateur “dissertation” on her community that she had heard a story of someone who “recently has induced emergency treatment by self-mutilation—i.e., calling the ambulance just before slashing off his organs!” Like the newsletters warning against DIY hormones, Ferguson’s sensationalism should be read through her middle-class suspicion that surgery wasn’t necessary to be a successful woman. (She had a long career as a lawyer before transitioning to full-time life as a woman after retirement. For many transvestites of her generation, the practical limitations on when they could live as women were incorporated affirmatively into their identities, meaning they were skeptical of the transsexual emphasis on a true inner self.) At the time, gender-affirming surgery was still new in the United States and not something all trans people saw in a positive light. Many from the generation that had come of age before World War II, like Ferguson, greeted the prospect of surgical transition with suspicion, even as they were fascinated by it. They weren’t sure about the motives of doctors and what they would demand from patients in return.

Trans medicine as we know it today should be judged in its efficacy and ethics against DIY.

Behind the rumors of self-castration, or the occasional report like one from a 1974 activist newsletter that “two men” in San Francisco had been arrested for performing “ersatz sex change ops,” lies a fascinating but much less dramatic story. Although many gender-affirming surgeries are too technical to attempt outside of a hospital setting, an orchiectomy (the removal of the testes), which is a procedure that many trans women decide to undergo (either on its own, or as a step towards vaginoplasty), is not particularly complicated. In fact, it’s likely one of the oldest surgical procedures, dating back thousands of years both in the Mediterranean and on the Indian subcontinent. And while there are no official medical records to consult, there are stories held in tight-knit trans communities, corroborated by oral histories, that begin to sketch the contemporary trans surgical tradition that developed at some point between the late 1950s and 1970s.

Trans women could learn the surgical technique for an orchiectomy from a textbook, but more often they had the tacit assistance of a sympathetic doctor. Aleshia Brevard Crenshaw, who got her start as a performer at San Francisco’s famous drag club Finocchio’s in the 1950s, teamed up with her roommate to do orchiectomies on each another around 1960. As Crenshaw put it in an interview decades later, she went to visit a doctor named Styles who was already prescribing her hormones and told him that she wanted to castrate her cat. “Now whether he knew or not” what she was really planning, he drew a diagram of how to complete an orchiectomy for her, step by step. “And while he was drawing it,” she recollected, “I opened his cabinet and stole a syringe and some Novocain.” Having grown up in rural Tennessee, Crenshaw learned how to castrate animals at a young age, so adapting that knowledge felt like a reasonable leap—she would just have to be a good teacher to her roommate. A few days later, she and her friend sterilized their materials with Lysol and a quick blast in the oven, before setting up on a table in their home. Crenshaw took a painkiller, and they followed the doctor’s advice to complete the surgery with the stolen medical materials. After recovering for a day, they went back to the office and informed him what they had done. Styles “acted shocked,” gave the pair some penicillin, and told Crenshaw, “Of course you can’t breathe a word of this, I can’t put this in the record.”

The risk of performing a surgery at home wasn’t lost on Crenshaw. If something had gone seriously wrong, she and her roommate would have had to show up at a hospital, praying for a sympathetic reception. Even though an orchiectomy was relatively simple, and they both had good outcomes, the twenty-four hours after the surgery were scary as they waited to see if there would be any complications. Ultimately the rewards far outweighed the risks. For many trans women who came of age on the streets of the Tenderloin, safety was a complex matter in real life. But looking back, Crenshaw stressed that the whole scene verged on hilarious—in fact, she put on a comedy record while performing the surgery. “If there’s one thing that we learn, from our survival on the streets, [it] is to have a great deal of fun. You laugh in the face of adversity.”

This underground scene of self-taught surgeons was transitory compared to later efforts of activists to found and operate free clinics, most of which never got off the ground. The Transsexual Action Organization (TAO)—based in Miami but with affiliates throughout the United States, the Caribbean, Latin America, the United Kingdom, and Europe—announced in 1974 that it planned to open a pilot clinic in San Francisco. Trans women would be offered gender-affirming surgery “at a cost of around $4,000” based on a new technique that promised much better results than university gender clinics, which despite their long waiting lists and byzantine gatekeeping still claimed to be the proper venue for transition.

Like many trans liberation groups, the TAO saw gender clinics as crass opportunists out to make money off desperate people instead of prioritizing good surgical outcomes. But their dream was never realized beyond the initial stages, in part because the surgeon they planned to hire turned out to have a litany of serious malpractice complaints against him—and later ended up in prison. More importantly, TAO was run entirely on the labor and ingenuity of trans women for whom almost every dimension of life called for urgent activism. TAO spent much of its energy focused on police brutality, especially the police practice of raping trans women in local jails. Although the trans-run clinic lost priority among competing issues, long-term initiatives were always the hardest for a perpetually under-resourced organization to realize. But TAO’s vision for expanding freedom through mutual aid and DIY transition was archived in the pages of their monthly newsletter for future generations.

Autonomous Zones

Today, an internet search for “trans DIY” opens onto vast networks of lay experts who gather everywhere from Reddit to Facebook to Discord to share their expertise. On smaller scales, most trans people share tips, advice, and consult with their close friends, lovers, and social networks when it comes to transition and health care. The motives that bring people from around the world to DIY vary. Some, like youth in Alabama, may soon have their doctors criminalized. Others, in the United Kingdom for instance, face a National Health Service that has effectively sabotaged publicly funded trans health care by extending wait times so far as to make them untenable. Across much of Europe, a eugenic legacy of sterilizing trans people as a condition of legal recognition has characterized state-funded medicine until as recently as the past five years. And in many other places around the world, there are no formal barriers but a dearth of affordable, competent providers. In Thailand, for example, famous for welcoming Western medical tourists seeking gender-affirming care, the average Thai person rarely has the financial means to transition through the same channels.

Institutional trans health care has roundly failed to resolve any of the basic inequities it created so many decades ago.

There are also broader reasons for the popularity of DIY that have less to do with scarcity and more to do with institutional neglect. In light of the longstanding absence of peer-reviewed studies on matters beyond surgery and hormones, as well as a lack of resources for researching what is perceived as a very small population, many clinicians are unable to answer trans people’s basic questions about their health—and use that uncertainty as a reason to withhold care. In other words, doctors punish their trans patients for the legacy of institutional neglect. According to a 2021 U.S. survey, nearly half of trans people reported experiencing explicit discrimination in health care in the previous year. And that, once again, is only among those people who have some access to a doctor in the first place. Institutional trans health care has roundly failed to resolve any of the basic inequities it created so many decades ago—and with the tidal wave of anti-trans legislation sweeping the states, the situation is deteriorating at a breakneck pace.

The history of DIY trans care challenges the coerced helplessness of the neoliberal politics of health. It is a story in which normal people, typecast as the most vulnerable, made transition possible for their friends, families, lovers, and neighbors, no matter the barriers. While their motives and beliefs varied, they were all driven by pragmatism: taking care into their own hands was safer, cheaper, and generally more effective than waiting on permission from the state or their doctors, let alone approval from an insurance company. It also meant that gatekeepers and lawmakers couldn’t revoke access on a whim or restrict it until its legality became meaningless. DIY trans history shows how tenacious and expert the most vulnerable have proven themselves to be without any support or legitimation.

But is resilience bred only by tragedy—a cautionary tale akin to the way the story of abortion before Roe v. Wade is told? Certainly, the smuggling, reselling, and administration of hormones by poor trans women of color took place in a context where there were no safer doctors to turn to for a prescription. Likewise, DIY surgeries were the result of a lack of legitimate access. But the presumption that DIY forms only in reaction to scarcity or in opposition to health care is an oversimplification. As many of the stories I’ve encountered during my research stress, most trans people’s lives are characterized by a mix of DIY and institutional health care depending on circumstances. Their relationship is never static. But DIY challenges the monopoly on care through which institutional medicine, and the liberal legal framework derived from the state, together control not just access, but the quality of life that depends on it.

As feminists and trans activists struggle against the liquidation of the right to privacy, digging into the connections between DIY transition and DIY abortion is instructive. Both reject how medicalization and the state collude to restrict people’s autonomy. And DIY history suggests that one of the core lessons of trans feminism is that you can steal your body back from the state—not to hold it as private property, but because the state power that polices and punishes your body, just like the doctors who execute its arbitrary policies, is fundamentally illegitimate. DIY treats legitimacy as arising from the people whose lives are most affected by resources and care, not from the abstract power of the state or medical gatekeepers.

The trans liberation activists of the 1970s who dreamed of free clinics were part of a political movement that wanted to depathologize transition, so it was no longer treated as a mental illness or a medical condition that required diagnosis and supervision from clinicians with no vested interest in trans people’s happiness. Gay and lesbian activists won a major victory when homosexuality was taken out of the American Psychiatric Association’s diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), in 1973. But the removal of homosexuality was followed by the introduction of new trans diagnoses into the DSM in 1980, which permitted clinicians to retain their authority by shifting focus from sexuality to gender. Medical gatekeeping has expanded, rather than contracted, since then, even if that expansion is also, paradoxically, what makes insurance coverage possible today. Yet as Florida’s recent attempt to publish its own made-up “standards of care” to deliberately exclude trans people from Medicaid reminds us, that coverage is only ever tenuous, no matter how many legitimate scientists or medical associations endorse it.

DIY has envisioned freedom in starkly different terms. Instead of pathologizing people to grant them access to medical resources, or relying on the state’s flimsy blessing, activists imagined community-run clinics where people to whom transition matters most would support one another and distribute the care they needed. In that framework, both abortion and gender transition would be something like resources for personal and collective autonomy—means to a life characterized by abundance, not dramatized medical procedures contingent on bizarre criteria of deservingness.

In DIY, trans people are the experts on their own lives. Alongside feminists who demand that anyone needing abortion be treated as credible, trans people command self-evident respect. And through the lens of DIY, to be trans meaningfully becomes a question of doing, rather than one of identity. When people don’t have to prove that they conform to any external definition, they are free to pursue what they want without fear of reprisal. And this version of autonomous, community-level responsibility could strengthen and maintain continuous, on-demand access to abortion, among many other politicized resources.

The story of DIY transition offers a more complex alternative to the zero-sum game in which today’s highly imperfect version of trans institutional medicine will either be banned or remain technically available but effectively inaccessible to most people. DIY asks us to consider whether institutional medicine is even a viable reference for trans people, or if the truth might be the reverse: trans medicine as we know it today should be judged in its efficacy and ethics against DIY. The latter has left a more meaningful imprint on trans people’s lives over the past century. The women of color who made the journey to Tijuana, many of whom were teenagers when they first arrived in San Francisco seeking a home, would not have benefited from the pediatric gender clinics that exist today; they would have been turned away at the door. Despite that, they were far from helpless, and they didn’t need rescuing. Their vision for unconditional care might be strong enough to ensure that the looming spread of criminalization, suffering, and violence does not define our collective future.