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Transitioning off the grid

31 March 2021
Devran Ibrahimsoy. Photo from the film by Parviz Majidov/Chai Khana.

With little to no access to medical care, trans people in Azerbaijan face a stark choice between living with the pain of gender dysphoria or undergoing hormonal therapy on their own.

‘My menstruation stopped, hair started to grow on my face, my mother figured it out and the family used physical violence because of this. I had to escape to Baku during the night’, recalls Devran Ibrahimsoy, a 25-year-old trans man from Shamkir.

Devran has been on hormonal therapy for 2 years now and suffers from serious side effects that put him through a lot of pain. He gets unbearable headaches during the time he would have got his period.

He says that the hormones have noticeable side effects on their bodies; some add oiliness or a specific smell to the skin, layers of fat in the breasts, buttocks, and thigh areas switch their places.

‘One of my friends was suffering from an excessive smell, another was terribly losing their hair. I got a hyoid bone on the third month of the therapy’, he reflects.

Devran also worries about the effects hormonal therapy could have on his internal organs, including damaging his liver.

Devran, like most of those who choose to transition in Azerbaijan, is doing so without medical supervision.


Black market drugs

Turana Nuri, an LGBTQ+ activist from Azerbaijan who works with the trans community both in the country and outside of it, told OC Media that there are a few doctors willing to work with trans people in Azerbaijan, but they have to hide it. 

‘Endocrinologists in Azerbaijan usually do not want to work with trans individuals’, she said, adding that it was much easier to visit one in Turkey or Iran but that this was not affordable for most people. 

Nuri says that most of the trans people she had spoken to started hormonal therapy on their own. 

‘Hormones are usually obtained from the black market because there is no endocrinologist who would prescribe the right dose, therefore there is a high probability of using the wrong dosage’, she concludes.

There are two such medications sold in pharmacies in Azerbaijan, Testosterone Enanthate and Propionate. Propionate is relatively cheap since the percentage of testosterone in it is small, but it is sold only with a prescription. 

The cost of Testosterone Enanthate varies between ₼15–₼20 ($9–$12) for a single does, which is injected every week. 

Devran Ibrahimsoy.

When Devran cannot find the former, he buys five doses of Propionate and injects all of it in one syringe. 

‘I’m lucky to have a friend who sells those to me over the counter. Yet many people have to bring drugs from abroad’, he says. 

The product description on these medications includes information on the known side effects, which are nausea, vomiting, headaches, skin colour changes, increased/decreased libido, oily skin, hair loss, acne, acceleration of the development of subclinical cancer, the formation of benign and malignant liver tumours, liver or renal failure, heart failure, blood clotting disorders and more.

This, advocates say, has opened space for a grey market for leftover drugs in international warehouses. 

‘Difficult to find physicians ready to prescribe hormonal treatment’

Shota Janjgava, an endocrinologist and andrologist at Georgia’s National Institute of Endocrinology in Tbilisi told OC Media that before undergoing hormonal therapy, someone should undergo mental health examinations and have their hormone levels checked.

He said that many people are eager for hormonal changes to take place rapidly, yet it is important to remember that the extent of, and the rate at which, changes take place depends on many factors like genetics and the age at which they start taking hormones.

According to Janjgava, the risk of things like blood clots, heart attacks, strokes, diabetes, and cancer as a result of hormone therapy were minimal, but can be elevated for those with co-existing health conditions or starting hormone therapy after age 50. 

‘Generally, the extent of the risk for those in good health is small, and may be offset by improvements in quality of life and reductions in stress levels once the hormone therapy has begun’, he said. 

Janjgava considers access to hormonal treatment a staple of trans healthcare. ‘For those who wish to take hormones — not every trans person does — access has a positive impact on wellbeing.’

‘This impact can be cashed out in terms of lower rates of anxiety, depression, and suicidality, but there is more to it than pleasure minus pain’, said Janjgava. 

He said there is an intangible element in accessing transition-related care, an element that relates to bodily autonomy and self-actualisation. 

‘Although it has become ubiquitous in trans health literature and among specialised healthcare providers, it is still difficult to find physicians ready to prescribe hormonal treatment on an informed consent basis.’ 

‘Hormonal therapy is not temporary, it is forever’

For Deveran, however, the problems go beyond not finding a doctor to oversee his transition.

His appearance means it is difficult for him to visit many of the doctors he needs. 

‘When I go for an X-ray, for instance, they can see my ovaries and I never know how the doctor will react.’ 

‘Sometimes I don’t know what to answer to their questions. I do blood tests and they see that I have excessive estrogen in my blood. Then they send me to an andrologist, and again I don’t know how to react when they tell me to take off my pants’, he says. 

Having had many unpleasant conversations with doctors — several have even rejected seeing him outright — he no longer visits a gynaecologist. 

Devran compares the situation to neighbouring Turkey, where trans people are able to get employment and insurance companies cover their operations and medication. 

‘Before the pandemic, I didn’t have any problems, everything was great. Then I didn’t have any income and I had to stop the therapy, I couldn’t do tests, this constrained me’, Devran says. 

For someone transitioning, hormonal therapy is not temporary, it lasts forever. If someone is forced to stop suddenly, due to financial or health reasons, the hormonal levels in the body change and this can have a serious impact on their health. 

When Devran stopped taking his hormones, he said this caused problems with his liver and heart. 

‘My mental health has collapsed and I don’t even recognise myself anymore. But I still hope I’ll be able to get out of it.’ 

[Read more about Devran’s story: Voice | 'I was kidnapped by my family']

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