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.