Patch-worked Access to Hormone Replacement Therapy in Philadelphia

Those seeking gender-affirming care in Philadelphia use a patchwork of options, as a primary method has yet to be established. Across the US, twenty-two states enacted limitations on gender-affirming care. This includes a Pennsylvania bill that would allow minors to bring a civil action against clinicians for gender-affirming treatment. However, even within states where gender-affirming care is available, factors such as time and cost delay many from seeking care. These compounding factors leave patients with a patchwork of options.

In-Person Care: Mazzoni Center

Within Philadelphia County, patients can receive hormone replacement therapy from several sources, including Planned Parenthood, Philadelphia FIGHT, Penn Medicine, Jefferson Health, Temple Health, and Mazzoni Center. 

“The whole purpose of Mazzoni Center is to serve the LGBTQIA+ community, although you don’t have to be part of that community to seek care here,” Dr. Billie Swiggard of Mazzoni Center said. “There are other places where one can receive gender-affirming care, but here, the program is highly developed.”

Founded in 1979, Mazzoni Center is a medical clinic explicitly created to treat queer patients in Philadelphia. The center is currently staffed with about fourteen physicians, with nine on the floor daily. In their 2020 annual report, Mazzoni Center saw 6,443 patients, resulting in 14,433 visits at the health center, (460 patients to one provider or 1,030 visits to one provider) with 1,136 trans and gender non-conforming (TGNC) patients of all ages. A 2021 report by Penn Medicine revealed a ratio of 637 visits to one provider (when looking at outpatients). Despite this disparity, Mazzoni Center puts patients at the forefront of care.

“What’s the most important part of gender-affirming care? What is the single most important factor?” Dr. Swiggard asked. “It’s learning what the patient wants. There is no algorithm here. No guideline says what’s right and wrong to do. It is deeply personal and deeply individualized.”

Dr. Swiggard estimates that about a third of her patients are seeking gender-affirming care (GAC), primarily hormone replacement therapy (HRT). Beginning her medical career at 44, she has worked at Penn Medicine and an affiliate location of Massachusetts General Hospital. Now, at Mazzoni Center, she specializes in HIV/ AIDS treatment and GAC. 

“I’m in the business of bringing joy and happiness into people’s lives,” Dr. Swiggard said. “Mazzoni Center is the happiest place I have ever worked. [After burning out in Massachusetts] I’ve recaptured the joy of medicine. I had lost my way. I was in a very toxic and bad place, but this has made medicine fun again.”

Gender-affirming care offers a myriad of benefits outside personal joy. The Trans Pulse Project reported that those with access to GAC in adolescence report higher life satisfaction, higher self-esteem, better mental health, including less depression and suicidality, and adequate housing compared to those without such access. Moreover, hormone replacement therapy and medical transition allow trans people to avoid transphobic violence due to “passing” (the process in which a transgender person “passes” as a cisgender person). According to the Williams Institute, transgender people are victimized over four times more often than cisgender people and one in four transgender women who were victimized thought the incident was a hate crime, compared to less than one in ten cisgender women. 

It should be noted that “passing” is not a required step in transition, nor is it even a goal for some pursuing transition. However, it cannot be denied that those perceived as cisgender face far less violence in society. 

As a trans woman, Dr. Swiggard can connect on a much deeper level with her patients. Employing trauma-informed care, Mazzoni Center staff understand that for many, this process is all too scary and unknown. 

“It may be difficult to get them to trust you, and it may take more than one visit,” she said. “The other thing to note is that gender-affirming care is health care. Much of it doesn’t have to do with hormones and haircuts. If you treat the person with courtesy and respect, use their preferred pronouns, use the preferred names, you’ve done a great deal to facilitate the process. If you blow it in those first steps, you’ve lost them.”

Issues such as cost and long wait times delay many deciding to transition. Mazzoni Center offers a plethora of payment options. The clinic accepts several forms of Pennsylvania-based insurance. For uninsured patients, special funds are available, allowing for a sliding scale where they are charged based on their current income. These patients can expect to pay between $25-$95 for a medical care appointment. Mazzoni also works with patients to obtain insurance or any applicable benefits. Despite previous wait times of almost a year, Dr. Swiggard said that Mazzoni has drastically reduced this period to a matter of months. 

“We have a new medical director, Dr. Stacy Trisken, who has been on an aggressive campaign of bringing this place up, including hiring more providers,” Dr. Swiggard said. “Most of us got raises that brought our salary into the competitive range for other similar institutions.”

Despite these obstacles, Dr. Swiggard said that those who do receive care are grateful.

“For most people, [they are relieved] at finally connecting to somebody who’s going to help them achieve their goals,” she said. “I don’t hear a lot of complaints about how long they had to wait. I hear complaints about I wish I’d done this earlier in life. You don’t have to beat yourself up because you didn’t do this when you were 16. It is, however, too late when you are dead.”

Telehealth: FOLX Health

While in-person care may be ideal for some, some patients find telehealth a much more manageable option. The biggest providers of transgender Telehealth care are Plume and FOLX Health. While both providers vary in pricing, they offer roughly the same services and both are available to Pennsylvania patients. Nikki Edwards and Robin Swanhart spoke about their experiences with FOLX Health. 

“It was just so easy, and that was appealing to me because I didn’t want to wait,” Swanhart said. “I had been in the closet for [almost fourteen years]. I [didn’t] want to be on the waitlist. I’ll pay the money, it’s fine.”

FOLX offers transfeminine patients oral or injectable estradiol, estradiol patches, testosterone blockers, and DHT blockers (hormones specifically to prevent hair loss) in varying doses. Patients of FOLX will also receive bloodwork, access to support groups, and letters of authorization for gender-affirming surgery. Edwards described her first time receiving hormones from FOLX; saying that as daunting as it was, it was a necessary step forward. 

“I remember being alone,” she wrote. “My entire family was out, and in all senses, I was not. I waited all day for the hormone delivery. I remember being scared of the size of the needle, as intramuscular injections are thick and painful. I remember the pain as I injected myself for the first time, but also a newfound alleviation knowing that I finally made it to such a monumental point.”

FOLX CEO Liana Guzmán said that the online clinic serves over 12,000 patients with over 40 clinicians (roughly 300:1). “It [felt] personal,” Edwards wrote. “I recently switched to a PA provider. It’s still great, but I’m still getting to know my newest [nurse practitioner] and he’s great.”

FOLX currently offers monthly and yearly payment plans. FOLX advertises prices of  $39.99 per month plus a first visit co-pay if insured, or $39.99 per month plus a first visit cost of $159, if uninsured. However, this does not cover pharmacy expenses, which FOLX estimates at $80-$95 per month. Yearly plans start at $299 per year. Swanhart said that even without insurance, she can afford these services with her job. The online clinic also offers grants for those who qualify; Edwards received a two-year FOLX subscription through these funds. 

“I’ve been with FOLX Health for a year since I started,” Edwards said. “I chose them because I received a grant for free hormones. It opened in June or May. I just applied. It was supposed to be a year, but they renewed my grant, I didn’t think that was going to happen.”

Access to hormones has allowed both women to begin living more authentically.

“If I did not have access to HRT, I would have [killed] myself,” Edwards said. “[Now], I feel confident, I feel the desire to do things, to live, to be perceived. I feel the desire to do things that make you human.”

Swanhart echoed this sentiment. “After having been in the closet so long, it feels very freeing to go party and feel good and look good,” she said. “All those other times I did it, it wasn’t the same because I wasn’t who I was meant to be.”

Those Without & Mutual Aid:

When first trying to access gender-affirming care, many are overwhelmed by a lack of affordable local care. Luci Canfield explained how despite seeking care for almost two years, she has yet to receive it. 

“There’s a lot of hoops to jump through right now and not everyone’s got time for that,” she said. “I have school to worry about right now. Then I’m going to have to focus on my job for a bit until the money starts rolling in.”

Canfield applied for care at Mazzoni Center and Planned Parenthood but was discouraged by wait times, and as a student of Pennco Technical School she cannot afford Telehealth services. 

“I don’t have much of an income right now,” she said “I can’t go out with friends as much as I want to. I can’t go and grab a drink at a bar. I can’t go into the city because that takes money for public transit. So it’s just that everything requires money. When you don’t make money you’re not free.”

Canfield has not given up, knowing that this type of care would provide comfort in herself: “HRT would improve my life a lot. I’d feel comfortable in my body, like there’s unity. Right now it just feels like I’m controlling a meat suit. It’s not terrible, it gets the job done, but it’s not ideal.”

With obstacles such as cost, time, and fear of discrimination or violence, some seeking gender-affirming HRT may go outside of a prescription. “DIY HRT” refers to any hormone therapy or supplies obtained outside a doctor. This form of care is uncommon, but leads those accessing it to rely on help from others. While not supplying hormones, Orchid N. aids in this search for care by providing free hypodermic needles. 

“When I first started injections, I was getting needles from the pharmacy. That was expensive and annoying because they would only give you three,” they said. “Then I was talking with friends and [I discovered] you can just buy it on Amazon.” 

Due to a quickly expiring Health Savings Account through their brother’s girlfriend, Orchid purchased 300 syringes of 18 and 25-gauge sizes from Amazon (18-gauge to extract hormones, and 25-gauge to inject them). Since May 2023, they have disturbed over 200 syringes via word of mouth or social media, namely Lex. Lex is a queer-centered community app where users can see posts from others in their area.