Self-injection experiences among transgender people on injectable gender-affirming hormone therapy: A narrative review

Abstract

Background

Transgender and gender-diverse (TGD) people may self-administer injectable estradiol or testosterone therapy for gender-affirming hormone therapy (GAHT). Knowledge about injection-related safety and injection adherence for TGD people remains to be determined.

Objectives

To determine the types of injection-related safety issues and medication adherence issues reported in the literature for TGD people on injectable GAHT. Our secondary objective was to identify opportunities for pharmacists to enhance the self-injection experience for TGD people on injectable GAHT.

Methods

We examined the literature to determine the types of issues TGD people experience when prescribed injectable GAHT. We searched for English language publications in PubMed and Google Scholar from inception to 5 August 2024 (e.g., “transgender,” “nonbinary,” “self-inject∗,” "estrogens,” and “testosterone”) and included original research publications that assessed 1 of 3 injection-related domains: Safety (injection site-related reactions or pain, psychological safety around injections), injection-related medication administration (individual self-injection practices and preferences including family or caregiver support administering injections, access to appropriate injection supplies, continuation of injections, patient-reported comfort) and teaching and assessment of injection practices by a pharmacist or other health care provider (clinic- or pharmacy-based injection counseling or follow-up assessments). We excluded articles that did not describe whether GAHT was self-injected and publications about long-acting injectable testosterone undecanoate, as trained providers administer this medication.

Results

Seven publications discussed at least 1 of the 3 injection-related domains. Investigators used various methods for assessing these elements across publications. Although self-injected GAHT was well-tolerated overall, most publications reported injection site reactions that were managed while continuing self-injected GAHT. Gaps included comprehensive teaching and assessment of individual self-injection practices long-term.

Conclusion

Based on the types of injection-related challenges identified, pharmacists, as one of the most accessible health care providers in the United States, are well-positioned to intervene and improve the experience of patients using injectable GAHT.