Many transmasculine and nonbinary people need testosterone as part of their transition, to align their gender expression with their identity or alleviate the distress of gender dysphoria. It’s a crucial step for the mental and emotional health of many trans people. Testosterone is also a controlled substance, which means accessing it can be fraught — and the restrictions can leave some without access to their prescriptions.

With that in mind, Sens. Ed Markey and Elizabeth Warren, both Massachusetts Democrats, are pushing federal agencies to loosen restrictions on testosterone to make it easier for trans people to access the hormone. In a letter first shared with The 19th, the senators argue that testosterone should either be descheduled entirely — no longer federally restricted — or categorized as a controlled substance with a lower potential for abuse. 

“Across the country, trans people are being penalized and punished simply for being who they are,” Markey, who led the effort behind the letter, told The 19th. “Testosterone care is not a crime. It’s something that’s important.”

Loosening restrictions on testosterone could enable more trans people to access the hormone legally and safely, said Camden Hargrove, national organizing manager at the National Black Justice Coalition. 

“That would be a very, very useful thing and it could absolutely change many trans men’s lives,” Hargrove said. Many trans people rely on unsanctioned methods — like ordering from online pharmacies without a prescription — when the financial and transportation barriers to access gender-affirming care become too great, he said. 

Quinn Jackson, a trans primary care doctor who practices in Kansas City, Kansas, believes that easing restrictions on testosterone would significantly reduce barriers for trans people — including his own patients. 

“I have patients who can’t fill prescriptions before they go on vacation because it’s too many days before their next prescription is due. So then they go without doing their medication for however long it is before they can come back to the pharmacy,” he said. 

Being forced to skip doses for too long can endanger a trans person’s health, especially if they have pre-existing conditions that put them at further risk. Hargrove knows that from personal experience. As someone with epilepsy, being unable to access his testosterone prescription for four weeks in 2020 — caused by a primary care provider refusing to continue prescribing the drug — caused him to have a seizure. 

“It not being a controlled substance would give a lot more access to a lot more people and it would make the situations that I went through, the struggles, much less likely to occur,” he said.

Lowering the number of doctor’s visits needed to continue a testosterone prescription would also help Jackson’s low-income patients and those without insurance, who are paying visit fees and doctors fees multiple times per year that they otherwise wouldn’t have to pay, he said. 

Testosterone is classified as a controlled substance with a moderate to low potential for physical and psychological dependence. Congress classified the drug that way as part of the Anabolic Steroids Control Act of 1990, after male cisgender athletes and non-athletes abused anabolic steroids. As such, testosterone prescriptions generally cannot be filled or refilled six months after the prescription was issued or refilled more than five times. 

Descheduling the drug would cut the number of doctor’s visits needed to maintain care and lower fees for trans people, many of whom already tend to live in poverty, advocates say. It would also prevent trans people from having to interact as frequently with a health care system that often stigmatizes and mistreats them. 

In their letter, Markey and Warren ask the Health and Human Services Department, plus the Justice Department and Drug Enforcement Administration, what steps, if any, they have taken to reclassify testosterone’s status as a controlled substance — and point out that doing so would align with the Biden administration’s goals to further LGBTQ+ rights and transgender Americans’ access to gender-affirming care. 

The senators also urge U.S. Attorney General Merrick Garland to consider using his authority to adjust testosterone’s status within the Controlled Substances Act or remove it altogether. 

Markey said that states introducing anti-trans bills across the country to ban gender-affirming care for trans youth, which would primarily affect puberty blocking hormones plus treatment regimens of testosterone or estrogen, motivated him to send the letter. 

“There’s clearly efforts that are percolating all across the country. And so I think it’s important for the federal government to stand up,” he said. “Classifying testosterone as a Schedule III drug means that trans people face unnecessary and burdensome restrictions.”

The push to loosen restrictions is coming at an important time for trans people, said Logan Casey, senior policy researcher and advisor for the Movement Advancement Project, which tracks LGBTQ+ policy. 

“The political landscape of these bills targeting transgender youth’s access to gender-affirming care has created an incredibly hostile environment for all trans people,” he said. While most state-level efforts against gender-affirming care have been focused on preventing minors from getting care, Florida is one state where recent policy actions have also affected trans adults. The state has joined eight others in banning Medicaid coverage of gender-affirming care for people of all ages.  

Casey said that he wouldn’t be surprised to see other states trying to disrupt transgender adults’ access to gender-affirming care. But, if more attacks come, advocates are prepared to respond and “sound the alarm” — especially when states implement restrictions on care that have to go through a lengthy regulatory process. 

Markey and Warren are seeking a response to their letter, which was sent to and acknowledged by the agencies on Thursday evening, from the DOJ and HHS by October 7.