Mail-order hormones for children?

Emelie Schmidt first thought about being male in 2015, the year Bruce Jenner publicly came out as a transgender person named Caitlyn and TLC launched I Am Jazz, a reality show about a then-14-year-old boy who had identified as a girl since early childhood. Schmidt, then a sophomore in high school, struggled with social situations and considered herself a tomboy. She found online transgender forums where others welcomed her and even sent her a free chest binder. Before long, teachers complied with her request to go by male pronouns.

By 2017, Schmidt was done with high school—and with identifying as a male.

Now 25, she’s grateful she never pursued physical changes with drugs like cross-sex hormones. But still she wondered—would it have been easy to get testosterone mailed to her? This past February, she posed as someone with gender confusion and set up a 30-minute telehealth appointment to request a high dose of testosterone. She said she showed the provider her driver’s license, took a 10-minute general health survey, and chatted with a doctor over Zoom. No lab work was needed, and nobody suggested alternatives, like talk therapy. She paid about $300, and within two days, vials of testosterone arrived outside her door.

Currently it is illegal in 23 states for doctors to prescribe drugs or procedures that could alter the sex traits of anyone in their state under age 18, according to the pro-LGBTQ Movement Advancement Project. A minor who lives in a state with laws protecting children from cross-sex hormones could physically visit a doctor in another state without those protections. But with a growing telehealth industry and a debate about the legality of mail-order abortion pills pitting states against each other, could an underage teenager book a virtual appointment to get transgender drugs from an out-of-state doctor without leaving home?

In Schmidt’s state of Texas, adults can legally get cross-sex hormones via telehealth, and Schmidt did not pretend to be underage during her telehealth appointment. But if an underage girl wanted testosterone in her state, Schmidt said, based on her experience the teen could easily circumvent state laws using telehealth. Schmidt said the telehealth provider asked for her driver’s license and location, but she didn’t have to prove she lived in Texas.

WORLD reached out to FOLX Health, the telehealth provider Schmidt used, but it neither confirmed Schmidt’s account nor addressed our questions.

Some experts I spoke to agreed that teenagers could get cross-sex hormones via telehealth but added a few caveats. Jonathan Alexandre is an attorney and legislative counsel for the Maryland Family Institute. He said that, if a minor lived in a state such as Utah—which protects minors from cross-sex hormones—and wanted to get the drugs from a state like Colorado that doesn’t have similar protections, he or she would have to find a doctor who is licensed in both states. Federal regulations allow providers from a different state to provide telehealth services if they share a border.

Even if that hypothetical teen found a doctor who was licensed in both states, he or she would also have to find a telehealth provider that serves minors. Most won’t provide gender services to anyone under 18. This includes Planned Parenthood and niche transgender telehealth centers like FOLX and Plume.

Izzy Lowell, a doctor who works for QueerMed, said her center will. “We cover 46 states and we treat minors in all states where it is legal,” she told me in an email. When I asked her whether providers in states that shield doctors could hypothetically prescribe cross-sex hormones to underage patients in states where it’s not legal, Lowell told me, “I have no idea, but I expect not.

Jamie Reed, a former case manager for a pediatric gender center in Missouri, said her center fielded telehealth calls during her employment. Some providers, she said, might not verify patient locations as strictly as others. “We simply asked at the start of a telehealth call for the patient to tell us their location,” Reed wrote in an email. “If the telehealth services make no effort to actually verify, then yes, minors can circumvent state bans by using telehealth.” The center where Reed worked no longer prescribes puberty blockers or cross-sex hormones to children.

Because state laws surrounding telemedicine are confusing and still evolving, it can be not only easy for minors to circumvent state laws but also difficult for providers to know if they are following the law.

Ten states, for example, prohibit telehealth prescriptions of testosterone because it is considered a controlled substance. As a result, neither Plume or FOLX offer it in those states. But QueerMed said it does, citing a federal agency extension of a pandemic-era policy. When I asked Lowell about it, she said QueerMed hosts “pop-up clinics” so patients can get testosterone in those states.

Making things more complicated, 11 states have laws shielding doctors from liability if they prescribe transgender treatments to children who come from other states. This month, Maryland lawmakers passed a bill barring other states from investigating Maryland doctors who provide gender treatments to anyone, including children. Gov. Wes Moore is expected to sign the bill into law, which would make Maryland the 12th state to protect doctors who prescribe cross-sex treatments—but not the children who receive them. Alexandre, the Maryland Family Institute attorney, says it’s a chilling move.

“If a state’s attorney general realizes that this is occurring to the children within their state, certainly the parents and that state, even that governor, should have the responsibility to protect the citizens within their state,” said Alexandre.

Weak scientific evidence and a scathing independent review of the pediatric gender industry published in England last week undermine recommendations made by American professional medical organizations that puberty blockers and cross-sex treatments are safe and effective for children. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” the report said. But the American Academy of Pediatrics and the Endocrine Society still support puberty-blocking treatment and cross-sex hormones for children who identify as transgender.

Former case manager Reed argues that in-person care should be the standard for patients who identify as transgender and telehealth the exception. Too often it’s the reverse.

“Patients are treating these telehealth platforms as primary care or otherwise foregoing primary care,” Reed wrote in an email. “Even if hormone prescriptions via telehealth are totally safe (it is not), it is not safe for patients to only receive medical care from their telehealth hormone provider. Underlying health concerns are going to be missed.”

Reed said telehealth providers will not pick up on signs of homelessness, self-harm, or mental illness, things she witnessed at her in-person center. And when it comes to prescribing cross-sex hormones, patients benefit from in-person follow-up. She related the story of one patient who was instructed to attach one estrogen patch on a different part of the body each week, and to avoid attaching the patches on the chest. 

“If we never saw the patient in person, we would never have found out that they had 11 patches still on and all were on their chest,” Reed said.

So far, there have been no publicized cases of children or parents using telehealth to circumvent state laws on cross-sex treatments. Emelie Schmidt’s experiment showed that it is possible for adults to misrepresent themselves over telehealth and still be prescribed cross-sex hormones. 

I asked Queer Med’s Lowell if adults could request cross-sex hormones for themselves but then administer them to a teen. “Theoretically, yes,” Lowell responded. “But we do treat people under 18 directly.”