(Amy King/The Washington Post; iStock)

By age 32, Teagan Beal had become convinced of two opposing facts: She needed a prescription for gender reassignment hormones, and there was no doctor whom she could ask.

So, two years ago Beal resorted to a route that a growing number of transgender people appear to be taking: She logged online and bought a year’s worth of estradiol injections from an unregulated pharmacy in India.

“There is still gate-keeping and laws that can prevent trans people from getting the help they need,” Beal said. The Indian pharmacy, on the other hand? “They never even asked for a prescription.”

That the Internet has a profitable hustle in shady prescription drugs is, of course, not breaking news — public health experts and advocates have decried it for years. But more dangerous, even, than the murky trade in Viagra or Xanax is the booming black market for trans people desperate to “DIY” their transitions.

On Deep Web marketplaces like Valhalla, prescription drug-dealers have begun to stock medications like Kryptocur in addition to their usual opioids and benzodiazepines. An underclass of unlicensed online pharmacies markets to U.S. and European customers from locations in India, Russia and the Philippines.

Even mainstream marketplaces like eBay and Amazon.com dabble in DIY hormone therapy. On both websites one can find dozens of “feminizing supplements” for men, though they conspicuously make no promises “as to their efficacy.”

Disclaimers like that hardly matter to buyers — many in the trans community are desperate for these meds, explains Madeline Deutsch, the director of clinical services at the University of California’s Center of Excellence for Transgender Health.

The process, called hormone replacement therapy, is perhaps best known for reversing some secondary sex characteristics, like body fat allocation or body hair. But HRT has also been shown to combat anxiety and depression and dramatically increase quality of life. Far from an optional or cosmetic procedure, the World Professional Association for Transgender Health categorizes it as “medically necessary” and “essential to achieving well-being.”

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Despite that qualification, trans people frequently struggle to find health-care providers who can oversee their HRT. In the United States, an estimated third of all trans people say they’ve faced discrimination in a doctor’s office, and half say they’ve had to educate their own doctors on the therapy. The problems are compounded for patients who don’t have health insurance, live in rural or conservative areas, or are younger than 18 — which many are.

“I want to start hormones, but I can’t get a prescription right now due to me living with my highly transphobic parents,” one user posted in the Reddit forum r/asktransgender earlier this year. “Where can I get some HRT pills online? I want them shipped to the house that I currently live in.”

“I apologize for the sketchy nature of this post, but I am pretty desperate,” a 17-year-old wrote in the subreddit r/washingtondc six months later. “I started HRT in April. The issue is that my doctor has me on a very, very low dose. … Thus, I’m turning to Deep Net sources.”

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The Deep Net — an almost mythical place, in the public imagination — has certainly risen to meet the demand. This part of the Internet is not indexed by search engines and can only be accessed via an anonymous browser like Tor, which makes it attractive to prescription drug-dealers. An analysis by the cybersecurity analyst Paolo Stagno, commissioned by The Post, found dozens of sellers offering common HRT medications in Deep Web marketplaces like Hansa and Valhalla, typically for $1 to $2 per pill.

One German Valhalla vendor, who spoke to The Post on condition of anonymity, said that he hadn’t seen much demand for the drugs, but stocked them anyway. Sex-change hormones aren’t controlled substances in Germany, which means he gets them pretty easily. Plus, he’s convinced there’s a market, particularly among teenagers. In Germany, as in other parts of the world, “you effectively can’t start [HRT] without having reached the age of 19,” he said.

Surprisingly, illicit pharmacies also proliferate on the regular Web or “clearnet.” According to a report out this month from LegitScript, an online-pharmacy monitoring firm, more than 30,000 online stores sell prescription drugs — and of those, only four percent are licensed or regulated. The remaining sites are largely based in places like India and the Philippines, though they market themselves to Western consumers in English-speaking countries.

Thanks to a tangle of overlapping national and international regulations, the U.S. agencies that oversee pharmaceutical sales don’t usually have power or jurisdiction to shut these sites down; they also don’t have the resources or the precedent to pursue individual buyers, particularly when they’re buying uncontrolled substances. As a result, it’s common knowledge on trans forums and message boards that hormones can be bought, with little legal consequence, on sites like All Day Chemist and InHouse Pharmacy — which are based in India and Vanuatu, respectively.

That doesn’t mean there aren’t other risks that come with shopping in the pharmaceutical black market. Most online pharmacies don’t guarantee privacy or securely process their transactions. And like any medical procedure, HRT comes with significant potential side effects, including blood clots, stroke, heart attack, heart disease and diabetes. That’s just when you know for sure what it is you’re swallowing or injecting: Sites like All Day Chemist explicitly disclaim any guarantee that the drugs they advertise are what you’ll actually receive.

“I understand people are desperate, particularly when it comes to hormone replacement therapy, but it’s like playing a game of Russian roulette,” said Libby Baney, executive director of the Alliance for Safe Online Pharmacies, an industry group. “You have no idea what you’re getting. It might be a legitimate medication diverted from another market. It might be counterfeit. It might be mixed with chalk or boric acid — and if it doesn’t kill you, it’ll make you sick.”

Given those risks, advocates like Deutsch, of the Center of Excellence for Transgender Health, urge patients to seek any and all other alternatives. Organizations like the World Professional Association for Transgender Health and the Gay and Lesbian Medical Association maintain databases of trusted providers; most LGBT community centers also offer medical referrals and other resources. That said, not everyone lives in a city with an LGBT clinic, and not everyone can afford the high cost of an above-board transition. Given that “significant lack of access to health care,” Deutsch fears many in the trans community can do little more than buy from InHouse Pharmacy and cross their fingers. 

Beal took that route for roughly 12 months, then, after several orders of Indian estradiol and spironolactone, she decided to “go legit.” She circled the block a dozen times before working up the courage to enter a Los Angeles LGBT clinic, where — a year later — she remains a patient. Beal acknowledges that she’s relatively lucky. She has a job at a trans-friendly company that provides good health insurance, and she lives in a large city with plenty of knowledgeable health-care providers and LGBT advocates.

“I will urge others to go legit because of the health risks,” she said. “[But] I will not shame anyone for self-medding — because so many of us in the trans community depend on it.”

Amazon.com chief executive Jeffery P. Bezos owns The Washington Post.