By Beverly Cosgrove, Revision 16, November 7, 2020
For AMAB trans people who take estrogens, the best combination of safety and effectiveness is to use self injection of estrogen, particularly in the form of estradiol valerate, and this is what I suggest patients request from their doctors. In the case of AFAB trans people taking testosterone in oil, the need for self injection is even more obvious. The biggest problem is that doctors and nurses usually advise their patients to use the WRONG syringes and needles for the purpose. So, here is a quick startup guide on the subject of:
First, just to be clear: Self medication is not for everyone, in particular those who have heart disease, history or risk of cancer, diabetes, and other conditions which can only be judged by a medical professional. However, we live in a world trying to prevent some of us from getting appropriate treatment, and some patients have felt forced to take pills secretly. It’s bad enough that a patient is self treating, but doing so with pills is usually the worst choice. Injection (self injection or otherwise) is in most cases the choice for best safety and effectiveness, whether you are “DIY” or have a legitimate medical provider. And you will want to save money, and may be surprised to find that ordering your own supplies online can save you a lot of money even if your insurance already covers your supplies. For AMAB trans people, the costs can be as low as about $19 a month in the US, using cash only, no insurance needed. Surprised? See this summary. Note that the information I give here also applies to AFAB trans people injecting testosterone.
There are THREE basic injection methods for transgender people (both AMAB and AFAB). Before reading on, you will need to decide which of the three is your choice. The equipment needed for each method is different from the others. The three methods are Long-needle Intramuscular (LIM), Two Needle Subcutaneous (2S), and One needle Subcutaneous (1S). The LIM method is generally most effective, doses being equal, but complicated since there are 3 parts, and seems awkward to those who have not done it before. (Do it 10 times and you will feel like an expert, though.) The “2S” method (2-needle subcutaneous) is usually least painful, and least distressing for those with needle phobias; I now use the 2S method myself. The “1S” method (1-needle subcutaneous) is simple but slow to do; it can also hurt more than the 2S method; my partner uses this method.
I am listing links to sources on this page. Feel free to leave a message if the link is broken, inaccurate, or there is a better link you think should be included — but don’t expect me to do an update every day.
LINKS FOR THE LONG NEEDLE INTRAMUSCULAR METHOD
First, the Long Needle IM method. In this method, you use a 1CC syringe, and attach a 22G needle to draw the hormone/oil medication into the syringe. Then you remove and discard the 22G needle, and attach the long needle, and do the injection into the upper outer quadrant of the Gluteus Maximus (buttocks). Because the injection site requires the needle to pass thru the smaller Gluteus Medius into the large Gluteus Maximus, the needle needs to be long enough to penetrate, at least 1.25 inches. A shorter length is not as effective, probably because it risks the needle expelling the dose into the boundary between the Maximus and Medius, where the dose is quickly picked up by the system and dissipates, failing to make a long lasting depot site. Because the needle is long and thin, the syringe MUST be a 1cc (1 ml) size, for hydraulic reasons. (For you science fans, force times throw is inversely proportional to the ratios of the cross sectional areas. Think of how automobile brakes work.) Do not attempt to use a 2.5 ml or a 3 ml syringe. Do not attempt to use a “Luer Slip” syringe – make sure it says “Luer Lock”.
LIM 1ml Syringe sources.
(Above: the BD 1ml syringe. BD does not have the full displacement plunger that some syringes feature, which pushes out the last drop of the hormone dose and reduces waste. In the list below I have indicated the syringes with a full displacement plunger with the initials “FDP”. Also note that BD syringes are in shortage and their price is about 4x normal, which is ironic because the other syringes are FINE. I have personally tested each of these except for the Air-Tite. I presently use the Global Easy Glide, which I ordered in quantity 1000 and got an extremely low cost for a 20 year supply.):
The above is an example of an Ebay listing. These listings change rapidly, but as long as the syringe is 1ml, and is Luer Lock, then it is probably suitable. However, be warned that some sellers use Ebay as a place to dump ruined stock, which may have heat or water damage, so be sure to check Ebay feedback and return any product which shows packaging damage.
LIM draw needle, 22 Gauge 1 inch sources:
LIM Injection needles. The needle should be 25 or 27 gauge, and at least 1.25 inches long. This gives 3 sizes: 25G/1.5, 27G/1.25, and 27G/1.5 (Nipro needles are recommended for best comfort, but Nipro does not make the 27G/1.5 size.)
LINKS FOR THE TWO-NEEDLE SUBCUTANEOUS METHOD
Second, there is the Two-Needle Subcutaneous method. In this method, you use a 1CC syringe, and attach a 22G needle to draw the hormone/oil medication into the syringe. Then you remove and discard the 22G needle, and attach the 30g 1/2 inch long needle, and do the injection shallowly at an angle into the fatty layer of the abdomen. See my main article on this subject. Because the needle is very thin, the pain level is very low, but as with the LIM method the syringe MUST be a 1cc (1 ml) size, for hydraulic reasons. (For you science fans again, force times throw is inversely proportional to the ratios of the cross sectional areas. Think of how automobile brakes work.) Do not attempt to use a 2.5 ml or a 3 ml syringe. Do not attempt to use a “Luer Slip” syringe – make sure it says “Luer Lock”.
2S 1ml Syringe Sources
Use the same syringe as in the LIM method, above. See the list here.
2S draw needle, 22 Gauge 1 inch sources:
Use the same draw needle as in the LIM method. See the list here.
2S injection needle, 30 Gauge 1/2 inch (12mm) sources (Nipro recommended):
You probably noted that I recommend the Nipro needle — especially over the BD needle. This is because the Nipro needle is so sharp that it significantly reduces injection pain. I can attest to this, after using many different brands of needles, many years, hundreds of times, I am convinced that the Nipro really are superior. Nipro says: “The FLOMAX needle wall is ultra-thin compared to a conventional needle, permitting rapid and efficient drug delivery. A proprietary grinding process results in an exceptionally sharp lancet point able to penetrate tissue smoothly and with minimal trauma.” Furthermore, Nipro needles are among the lowest cost ones available. You will not be offered Nipro needles in any US pharmacy — you must buy them online.
LINKS FOR THE ONE-NEEDLE SUBCUTANEOUS METHOD
Finally, we come to the 1-needle subcutaneous method. This uses one of several “Insulin syringes” which may come in three volumes: 1 ml, 0.5 ml, or 0.3 ml, but all of them have a fixed needle which acts as both as your draw needle and your injection needle. These combos have some disadvantages: (1) the needles tend to be thicker wall ones with a higher pain factor, (2) since you must draw with the same needle as you inject with, the needle becomes dulled and thus more painful from being forced thru the rubber seal, and (3) the thin needle can be VERY slow to draw up the oil. Despite these drawbacks, the combo needle is popular because it is so simple and compact. In choosing the combo for you, buy only the smallest volume that fits your injection amount. The 0.3 ml size is much easier to inject with than the larger sizes, so if you can set your injection volume to less than 0.3 ml, that should be your choice.
3/10 ml size:
5/10 ml size:
1 ml size:
SOME COMMON QUESTIONS
“I inject into my thigh. Can I use a 1 inch needle?” First, I recommend you do NOT inject into the thigh. Thigh injection causes surges of hormones in the system, and may not reliably form a slow release depot, which is the object of the IM injection. Thigh injection is fine for many things such as vaccinations, antibiotics, etc but NOT for hormones in oil. The results may tend to be weaker and last fewer days, requiring injections every 3, 4 or 5 days. Many doctors and nurses are unaware of this, but ask a hormone specialist if you want an expert opinion. Finally, the needle: I can’t really say if a 1 inch needle will degrade the results of a thigh injection, which is already giving poor results anyway. It certainly can’t help. Long needle injection into the gluteus is the high performance method.
“I’m small and thin, so can I use a 1 inch needle for gluteus injection?” If you are a normal adult, the 1.5 inch needle is really the needle considered the “gold standard”. The 1.25 inch 27G Nipro needle is fine also. The 1 inch needle is getting too short. If you are a child, that’s different. But if so, I think you should have your parent give you your injection.
“My nurse says that she discourages patients from gluteal self injection because they might hit their Sciatic nerve, and hurt themselves.” The nursing profession has lately taken this stance, possibly due to student nurses using bad technique, perhaps on children. The chances you will hit the nerve is zero if you use the right location and follow instructions — that nerve should be at least 4 inches away, at the closest, from the injection site, and MUCH deeper than 1.5 inches. Talk to your doctor and nurse about this. I have coached and worked with many thousands of trans people for over 30 years and never once has anyone hit the nerve. But if you run into implacable resistance from your medical providers — switch to subcutaneous injection.
“Isn’t it ok to inject into the Deltoid (arm)?” No. For oil-based hormones, this is as bad as thigh injection, maybe worse — and my answer above for thigh injection applies. While you may get some depot action, it will likely be very poor efficiency. Deltoid injections of oil-based hormones are a way to waste a lot of hormones. Use gluteal injection instead, and you may get the same effectiveness with a third the dose. Subcutaneous injection is also usually more efficient than deltoid or thigh, so consider that instead.
“Needles scare me.” Honestly, I understand. But injection has significant health advantages over pills, and it is really worth it. You’re going to have to get over your phobia, and perhaps this is the time to tackle it. Remember, you are going to need to get blood tests while taking hormones too. Not to mention electrolysis of facial hair, for some. Try to determine if it is the size of the needle that scares you. If it is, then subcutaneous injection with the tiny 30G 1/2 inch needle is the way to go — nearly painless and almost always bloodless. Take it one step at a time.
“Luer-slip syringes are easy to buy and are cheap! Can I use them?” Stay away from the Luer-slip style. These syringes are meant to be pressed into the needle, and are a “lance fit”. However you cannot change the needle without contamination from the oil. This can cause them to “pop off” just when you are doing your injection, leaving a mess of spilled hormones all over you. Luer-Lock syringes exist for a very good reason!
“I draw my hormones from glass ampules, not rubber-sealed vials. Should I use a different draw needle?” Good question. Yes, instead of the 1 inch needles I listed, you probably should get a 1.5 inch needle, so that you can reach the bottom of the ampule easier. There are also some needles which have a built-in filter, meant to make it impossible for tiny glass fragments to be drawn into the syringe. I personally don’t think they are important but I’ll leave this up to you. Filter needles are more expensive. If you use good technique in opening your ampules, the chances of glass particles should be minimal.
“One of the sites you listed will not ship to my state for legal reasons. What can I do?” The easiest thing to do is to buy from Ebay or Amazon, where these restrictions generally are not a problem.
There are many myths about injections. See my article here, where I try to debunk a few of them.
Feel free to leave comments, with your favorite links, and I’ll try to include them.