Josh Stols (@jd_justjosh on Instagram) is an aspiring community activist, visiting classrooms across Johannesburg to teach students about what it means to be a South African trans man in 2022. Stols, along with a countless number of transmasculine people, also recently stopped taking depo-testosterone, the most common form of hormone therapy for masculinization. More and more people are starting to hear that a shortage of depo-testosterone has hit South Africa, but the media doesn’t usually tell the whole story – that story started in 2015. According to Stols, shortages of depo-testosterone have been a systemic problem since 2015, the root of which is the lack of local manufacturing on the part of Pfizer, the only company that produces depo-testosterone. “Pfizer’s been promising for years that they’re going to start manufacturing locally,” explained Stols, “and it just…never materializes.” This September, Pfizer completely cut off its supply of depo-testosterone to South Africa, leaving patients and doctor’s scrambling: “Doctors can only prescribe…according to what’s available from pharmaceutical companies.” Still, doctors do bear some of the responsibility, said Stols, who found in his search for new HRT options besides depo-testosterone, “that our doctors don’t educate us on what options we have available…They prescribe hormones but only keep prescribing depo. Now, because of this shortage, most of us have switched to Fagron. Currently, that’s manufactured here.”
Stols clarified that while there are alternatives to depo-testosterone, access to them depends on a lucky combination of finances, opportunity, and knowledgeable doctors. Because of this, a not-insignificant portion of the transmasculine community has turned to the black market, a perilous option. Using black market testosterone, according to Stols, causes an “[increased] risk of blood clots. Increased risk of heart attacks. Aggression like you’ve never seen. Overdosing. Testosterone toxicity. Your emotions go haywire.”
“Have you watched ‘The Fosters?’” Stols asked. “There’s a trans guy on it who gets black market hormones and nearly dies because he doesn’t know the dosage to take. All of our dosages are given according to our blood tests, and if that’s not done, then we run into a whole host of problems.”
It cannot be understated how desperate people are to access testosterone therapy. Though the intricacies of trans medical care are likely foreign to cisgender people who happen to see a headline about South Africa’s testosterone shortage and think little of it, Stols wants them to know that without testosterone therapy, many transmasculine people wouldn’t survive. “It’s our lifeline,” said Stols. “For people with mental health [issues], it’s like taking away their antidepressants…Why is [producing depo-testosterone locally] not a priority of pharmaceutical companies? Their excuse is that they’ve had to prioritize COVID vaccines, but then what happened for the last six years that there was a shortage? They’re really quick to downplay it and really quick to come up with excuses that suit their narrative.”
A sudden lack of access to hormone therapy is more than a disruption to mental health; it’s a disruption to the patient’s treatment process. Depending on where a patient is in the process of receiving hormone therapy, the effects of testosterone can start to reverse. Stols is part of a national social media network of transmasculine South Africans whose main “topic of conversation for the last eight or so months” has been these potential reversals: “For the guys that haven’t had hysterectomies, if they don’t have access to T, periods start again. Fat redistribution starts going back to more female…It’s extremely, extremely dysphoric. It’s been an absolute nightmare. The number of guys that are reaching out and asking for help because they’re feeling suicidal is astronomic.”
Another topic of discussion is the general state of trans healthcare in South Africa, into which the recent shortages have invited a closer inspection. “For example,” said Stols, “there are only two government hospitals in the entire country that offer free top surgery. They do something like four a year. There’s a 25-year waiting list. As for bottom surgery, only two doctors in the entire country even perform it. That waiting list is more than 50 years.” Stols’ revelations show that upon closer inspection, the tapestry of trans wellbeing in South Africa, both medical and legal, has been coming apart at the seams for years.
Stols wanted to emphasize that medical problems are not the only problems for trans people in South Africa because despite its constitution, which states that “equality includes the full and equal enjoyment of all rights and freedoms,” trans people still face a myriad of struggles. “The government is the institution that [supposedly] gave us the protections we’re trying to have, but we still have things like corrective rape. [And] our criminal justice system is…I don’t feel like we really have one, to be honest. So that’s why when I see a case in America, I’m like, ‘you guys have no idea how good you’ve got it.’ [Sure,] our constitution says that they’ll protect us, but that’s easy to say and harder to put into practice.”
Things don’t have to be this way; according to Stols, trans wellbeing in South Africa can be improved right now with some key actions. First, depo-testosterone needs to be consistently accessible in South Africa, and for that to happen, it “Needs to be manufactured locally instead of relying on imports.”
Second, Americans need to take a step back to put their own issues in perspective. “I know America has its own issues in terms of trans healthcare and all the bills that are going around (you know, funnily enough, the one thing that’s not an issue here is the bathroom thing). I would say, though, that it’s easy to look at what you don’t have rather than appreciating what you do have. And I would just say to appreciate the healthcare options that you do have rather than complaining about what should be done. Just put the shoe on the other foot.”
Third, the media needs to consider how it portrays South Africa: “You know, when the Omicron variant came out, people were very quick to label it as a South African variant. It wasn’t. We just discovered it. It wasn’t our variant. It came from outside of our border. Everything that happens in the media that relates to South Africa it’s negative [or it’s about Omicron.] But these people need your help. Why isn’t [this shortage] being made as important [as South Africa’s supposed variant]? Very few people know about this. If they do, it’s only because people like me are speaking about it.”
And if nothing else, said Stols, trans people need to stay true to themselves, stay proud, and stay visible. Stols does this on Instagram, explaining that “one of the reasons I will always keep my Instagram page open is because if it weren’t for public Instagram accounts when I was struggling, I wouldn’t be here. So if I can touch one person, just one kid sees my Instagram and says ‘there’s hope for me’ then I’ve done what I need to.”