“I have something to tell you,” my chosen sister said, lowering her voice conspiratorially. She dropped gracefully onto the bed of my motel room, lounging back against the pillows. Her long, black braids fanned across the comforter and shone in the light of the sun. How does she always manage to look so beautiful? I wondered. 

I arched my eyebrows at her in the mirror from across the room, where I was applying a fresh coat of liner. “Girl, enough with the drama,” I said. “Just spit it out.” 

She laughed. “Well, I think I’m ready to go back on hormones.” 

“Oh my god!” I squealed. It was the early 2010s, I was 24 years old and I had just started taking estrogen a year prior. A lot of trans women in my life were doing the same. It was exciting. It was a little scary. I spun around and jumped onto the bed alongside her.
 

“Congratulations,” I said, hugging her tightly. Tears shone in both our eyes. We were both young, but transition had already been a long journey for both of us. 

When I asked if she had a doctor, she shook her head. “Not yet,” she said, wrinkling her nose. “It’s so hard to find one. Do you know anyone?” 
 

“Just mine, and she’s full,” I said. “Plus, she’s not great. Last time, she told me that I’m lucky because Asian men make better women. Or I think that’s what she said. She was speaking French, and it was kinda fast for me. But don’t worry, we’ll figure something out for you.” 

I reached over into the duffle bag beside the bed and pulled out a bottle full of estrogen and another full of Spironolactone, a testosterone blocker—my own prescriptions. I rattled them at her. “In the meantime, wanna try some of these?” 
 

The world of trans women and transfemmes is full of stories like this: stories of care, emotional intimacy, mutual support and disregard of standard healthcare procedure. I’m told the world of trans men and transmascs is similar. 
 

For most of trans history, gender-affirming care (that is, things such as access to hormones, body-hair removal and surgery for trans people) has been largely inaccessible, gatekept by a medical industry that has long held trans people in contempt. In more recent years, our care has been politically attacked by anti-trans lobbyists who claim that trans healthcare harms children. Many of these same actors advocate for the “eradication” of trans identity from public life. Is it any wonder that many of us end up taking matters into our own hands? 
 

Despite some gains in accessibility and recognition made over the past decade, legal restrictions on trans healthcare are an increasing threat to trans lives and well-being. Bans on gender-affirming care for youth have been implemented in jurisdictions around the world, including the U.K., Canada and the U.S., and there are currently 161 bills that seek to limit healthcare for trans youth and adults actively being considered in the U.S. today. 

In this current social, political and cultural moment of intense transphobia—which has been named by some human rights experts as the early stages of a genocide—it is becoming increasingly important for trans communities to take ownership of our own healthcare, in as many ways as possible. It is equally essential that we start to envision and fight for a future in which transition is understood as a naturally occurring process (and not an illness) in human development. While medical intervention may be necessary for some—but not all—people who transition, empowered choice and autonomy should remain at the centre of gender-affirming care models. 

In other words: Trans healthcare belongs in trans hands. 
 

For many, DIY care is the only or best option. 
 

There are many healthcare professionals, some of whom identify as “allies” and some of whom may even identify as trans, who might gasp in horror at the paragraphs above. For decades, conventional medical wisdom has warned of many terrible risks of do-it-yourself (DIY) approaches to hormone therapy in particular (hair removal being classified as a cosmetic rather than medical procedure and DIY surgeries being, for obvious reasons, rather less common). And indeed, significant medical risks do exist, and in a perfect world, perhaps every trans person would have access to a competent doctor or nurse practitioner to oversee their care. As it happens, however, we are not living in a perfect world, and for many, DIY care is the only or best option. 
 

Community-based, DIY approaches to gender-affirming care are common among many communities of trans people for a wide variety of reasons. Chief among them, however, are a lack of access to mainstream healthcare due to financial barriers, a lack of providers willing or competent to provide gender-affirming care and fear of harm from transphobic professionals. Recent data from the PTP Pink Paper on health, for example, found that more than half of trans respondents reported experiences of discrimination in healthcare settings. 

There are also many different forms of DIY gender-affirming care, which include but are not limited to, sharing prescriptions, buying and selling hormones extralegally and “cooking” or chemically synthesizing hormones at home. 
 

Though the risks of DIY hormone care are not to be minimized, it must be said that risks also exist within a supervised medical environment and most healthcare training institutions provide little or no education on gender-affirming care. Among trans people, it’s a known and much-lamented truth that it’s often easier to find a self-taught local doll or masc who’s memorized every medical journal article on hormone dosing published since 1987, as well as the molecular structure of estrogen and testosterone, than it is to find a family doctor who can coherently describe what to expect from the first six months of gender-affirming treatment. 
 

When culturally competent healthcare can’t be found, or when it’s outright criminalized, people find ways to do it on their own, and not just trans people. A striking and important parallel to trans communities’ use of DIY hormone therapy can be found in radical approaches to pregnancy, contraceptive and abortion care—for centuries, underground networks of birth-care providers have resisted both the over-medicalization of childbirth and crackdowns on birthing parents’ right to choose whether to carry or end a pregnancy. 
 

In her seminal text Witches, Midwives, & Nurses: A History of Women Healers, feminist writer and journalist Barbara Ehrenreich writes of cis women and pregnancy that, due to patriarchal structures underpinning reproductive care, “We were not supposed to know anything about our own bodies or to participate in decision-making about our own care.” She goes on to point out how gatekeeping the knowledge and practice of healthcare is a powerful tool through which men and the patriarchy exercise control over women’s bodies, and therefore domination over women.

The same can be said about the gatekeeping of gender-affirming care: Trans people’s existence is deeply threatening to the patriarchal, colonial and capitalist social order. Our very lives threaten the ways that sex and gender roles are used by the ruling class to maintain control over the population. By limiting trans people’s autonomy of our experience of transition, the patriarchy keeps its control over us as well. 
 

Today, many trans people continue to organize and practise community-based forms of gender-affirming care, while also advocating for legal access to traditional medical care. The point isn’t that one should replace the other, but rather that we need and deserve access to both, just as cis women and other birthing parents need and deserve a wide range of options for pregnancy care. 
 

Where institutional medicine fails us, there will always be a need for community-based innovation and mutual aid. When I offered my chosen sister my hormones nearly fifteen years ago, it wasn’t because I wanted to play at being a medical professional, it was because we lived in a world without enough medical professionals who were safe for us. 

It was because the only way I made it through my own transition experience was thanks to the kindness and ingenuity of other trans women who gave me guidance, offered me tips and taught me how to attend to and advocate for my own needs in the face of doctors who downplayed my concerns, put me through bizarre psychological tests to “prove” I was trans, even sexually harassed me. It was because of other trans women, not doctors or nurses or psychotherapists, that I became the woman I am today.
 

Perhaps it’s because of experiences like this that for me, even in a perfect world, gender-affirming care wouldn’t belong to doctors or nurse practitioners. In my perfect world, it would belong to trans communities. For most of human history, midwives attended the miracle of birth, until their practice was criminalized and nearly erased by the emerging profession of contemporary physicians while pregnancy and birth themselves were heavily medicalized. Yet midwifery endured and is now flourishing in many countries, as is a de-pathologized understanding of birth. Why can’t the same be true for transition? 
 
What if there were a whole new class of healthcare providers, rooted in trans community but trained to accompany individuals and families holistically through the physical, mental, social and spiritual aspects of transition? What if these providers were empowered to prescribe and oversee hormone therapy and maybe even assist at gender-affirming surgeries? How would that change the experience of trans healthcare? How would it change society? 

In my perfect world, everyone has the right to autonomy over their own body—and really, is that so much to ask?