Due to the difficulty of accessing the medical resources they need and the barriers to getting sex reassignment surgery in China, the country's transgender people are turning to online pharmacies and going overseas for operations. An almost total lack of expert medical guidance poses major health risks, but activists are working to change things.

Liu Siyu, 31, a transgender woman, performs at a pub in Taiyuan, capital of North China's Shanxi Province, in August last year. Liu underwent surgery to change her sex in Thailand four years ago. She has since become a successful entertainer. Photo: CFP

Almost every day, Pipi (pseudonym), a 37-year-old transgender woman living in Northeast China's Liaoning Province, receives medical questions from other trans people in need. 

Their questions include how to get prescription hormones, how to use them on their own, whether it is possible to find a friendly doctor to prescribe the drugs and how to deal with the side effects of surgery.

As there is a lack of medical resources for trans people in China, Pipi, co-founder of Trans-Life, an NGO dedicated to helping them, plays the role of medical expert.

"I can only tell them my own understanding and experience as a reference. But my understanding of hormones keeps changing. I used to tell them not to take hormones because they damage one's health but now I know that if they're used properly, the side effects are controllable," said Pipi.

In the broad sense, being transgender means that one is not content with the gender one is assigned at birth. Some people undergo surgery to change their sex, or use hormones to change their appearance, while some choose to do nothing.

Pipi started to use hormones to change her appearance more than 15 years ago when the Internet first became widely available in China.

Back then, she could still buy prescribed hormones in pharmacies and administer the drugs on her own. Due to her lack of expertise, Pipi says she developed diabetes from taking the drugs - she claims to have since recovered. After developing diabetes she tried to stop taking hormones, but explains that this made her very unhappy.

In 2011, without telling her son or parents, she decided to use all the means and connections at her disposal to find a doctor willing to remove her testicles to make her less reliant on drugs.

"Transgender people have very limited channels to seek medical help in China. It's hard for us to access medical resources. Communication between doctors and transgender people is totally lacking and most doctors have no clinical knowledge about trans issues," said Pipi.

Asia Catalyst, a US-based NGO, once estimated that there are about 4 million trans people living in China.

Chaotic medicine market

As many trans people are either unable or too shy to contact doctors who will prescribe them hormones, they often turn to online pharmacies and self-administering hormones, said Pipi.

A search on China's largest e-commerce platform taobao.com for medicines including spironolactone tablets, a drug that suppress the male hormones known as androgens, and Progynova, a drug that increases estrogens, yields dozens of results.

Sprionolactone tablets are sold for between 11 and 28 yuan ($1.62 to $4.12) per bottle of 100 pills on taobao.com

On those pharmacies' taobao.com pages, it says that a prescription is needed to buy the medicines.

Buyers can't just buy prescription medicines like buying other products, either online or in brick-and-mortar pharmacies. They are required to leave their contact number first and a pharmacist will contact them later to check they have a valid prescription.

Searches for Androcur, a popular hormone which suppresses androgens, return no results on e-commerce websites.

Linlin (pseudonym), a trans woman who buys Androcur online, refused to tell the Global Times how she gets the drug.

"If I tell you, it will bring trouble to the online pharmacies that sell the drugs to us. They will be shut down. Then what can we do?" said Linlin, 24, who lives in Nanjing, capital of East China's Jinagsu Province.

Pipi revealed that some trans people fabricate prescriptions and some disguise themselves as pharmaceutical professionals to directly buy drugs from those pharmacies.

In order to guarantee the authenticity of those medicines, Lin said she is very careful with the descriptions and certifications that the online shops display. But there are no other practical ways she can use to verify the medicines.

Taking fake drugs or using incorrect doses can damage people's internal organs, especially their kidneys, and in serious cases the side effects can be fatal.

After obtaining the drugs, dosing poses a big obstacle. There are many questions asked online concerning doses.

"How much should be used each time depends on different people's physical condition," said Linlin. She refuses to give people advice on doses as she believes "it's a dangerous thing."

Although she administers drugs to herself on her own, Linlin pays regular visits to hospitals to take hormone tests and check on her health.

Pipi said that some teenagers who can't get hormones turn to taking huge doses of contraceptive pills, which contain female hormones.

"Some people even eat a whole bottle of contraceptive pills at one time. This does great damage to their health," she said.

Lü Xiaoquan, a lawyer with Beijing Qianqian Law Firm, told the Global Times Tuesday that "the sellers of hormones violate the law as they illegally sell prescription drugs."

Sellers without legal certifications face criminal charges and could end up in jail depending on how serious the consequences are, he noted.

Going abroad

In 2012, the American Psychiatric Association eliminated the term "gender identity disorder" from its diagnostic manual. In China, the CCMD-3 - the most recent edition of the Chinese Classification of Mental Disorders that came out in 2001 - still states that transsexuals, or people who want to change their sex, have gender dysphoria and recommends they receive psychiatric treatment.

According to a guideline released by China's health authorities in 2009, patients who want to undergo sex reassignment surgery need to get approval from their direct relatives.

This year, a doctor surnamed Tian in Sichuan Province faced charges of intentional assault for giving a teenager such surgery without the approval of their parents.

Facing these restrictions, many trans people choose to go abroad, as the barriers for surgery are lower in other countries and regions.

"Thailand is the hottest destination for the surgery," said Sisi (pseudonym), who had male to female sex reassignment surgery in Thailand in 2014.

Sisi, a Christian, lives in Beijing. She learned about overseas surgery online and through her trans friends.

It took three years of saving until Sisi had enough money for a sex reassignment operation in Thailand, which cost her about 70,000 yuan in total.

"Besides the obstacle of obtaining parental consent, medical techniques in China in terms of sex reassignment operations lag behind Thailand," said Sisi, who spent more than 20 days in Thailand.

Sisi still relies on online platforms for prescription hormones and she said the pills and injections sold online "are cheaper than in hospitals."

She added that unlike in China where transgender people often face discrimination from medical stuff, in Thailand they can enjoy good service.

According to Pipi, there are also a handful of trans people undergoing sex reassignment surgery in countries like Germany.

"These people are oversea students. Their surgery fees can be paid for by the government there," she claimed.

Mixed future

At a meeting for trans people hosted in Beijing this month, Xin Ying, director of the Beijing LGBT center, pointed out that trans people face many difficulties in society. They face different problems from transgender celebrities like Jin Xing.

Jin, a trans dancer who came into the public eye in 2011, now hosts her own talk show and has millions of followers.

Last year, famous sociologist Li Yinhe openly said that her current partner is a trans man, which aroused national attention.

But still, discrimination is everywhere and it is unseen by most people. Unlike gay people, trans groups are virtually invisible, said Xin.

Last April, it was reported that a trans man was fired one week after being hired at a health service firm in Southwest China's Guizhou Province for wearing men's clothes to the office, people.com.cn reported.

In China, people can only change the gender listed on their ID card after surgically changing their sex. This also brings them other problems as important files and documents like their university degree certificate are all linked to their ID card. If a person changes the gender on their ID card, the person still has to change the gender on all related documents, a complicated bureaucratic process that can take a long time.

"They don't want to be seen by the public. Those still struggling with their gender identity don't like to speak out. Those who have finished surgery mostly want to be forgotten and live their own life," Sisi said.

Sisi said that she is afraid that negative media reports - many of which involve transgender people and sex work - will make the group even more marginalized. But at the same time, she agrees that "publicity is important for the public to see the group and to understand them."

Despite negative coverage, Pipi revealed that her organization is now trying to set up a parents' network where parents of trans children can talk and share their stories to facilitate understanding among parents.

Lü said that trans adults have full capacity for civil conduct. "They should have the right to access reassignment surgery on their own," he said.

The CCMD-3 is outdated and being trans shouldn't be listed as mental disease any more. China's Constitution protects minority rights and it's illegal to discriminate against trans people, he added.

According to Lü, it's better to make it clear in the Constitution that LGBT groups should be protected by law.

To provide more practical help, Lin is now trying to find doctors who are friendly to trans people in the country and will set up a doctors' network in the future.

"So far it is going well," she said.