How a New Drug Law, Old Attitudes, and Persistent Health Care System Shortcomings Threaten China’s Transgender Community

When a father in the city of Cixi in the eastern Zhejiang province of China discovered that his 13-year-old had been secretly self-administering androgen inhibitors and estrogen tablets for months, he told local media that he was aghast. His child, whom he referred to as his son, had developed breasts and was “ruined.” The father complained that the teen was able to buy these drugs without a real prescription, and the story made the rounds on Chinese social media.

The incident reflects China’s pervasive black market for hormone replacement therapy (HRT) drugs, which is fueled both by the country’s troubled medical system and conservative societal attitudes around gender.

In the U.S., access to gender-affirming care, especially for minors, has increasingly been attacked, as the Republican Party has made rolling back transgender rights a touchstone of its so-called culture war. Rising anti-trans rhetoric at the national level as well as numerous pieces of state-level legislation have prompted pushback and protest from LGBTQ advocates and allies. Across the Pacific, the situation for transgender people is much less visible. In China, there is limited research on public attitudes toward transgender people or rights, and Chinese law avoids the specific topic altogether. For Chinese transgender people, some of whom seek surgery overseas, getting gender-affirming care domestically largely comes down to finding the right combination of pills.

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But when it comes to prescription medicine, China’s health care system suffers from a fragmented pharmaceutical industry and regulatory system, substandard drug quality and a proliferation of counterfeit medications, and inconsistent verification of prescriptions exacerbated by a severe shortage of clinical pharmacists. Last year, amid rising concerns of general drug abuse and misuse, not just of HRT drugs, the government’s National Medical Products Association promised a five-year plan to improve safety.

On Dec. 1, 2022, China officially opened the pharmaceutical market to online sales, which had been a legal gray area. During the pandemic, consumers increasingly turned to e-commerce giants like JD.com, Taobao, and Alibaba to buy medicine. But as part of officially legalizing that practice, the government tightened regulations on the industry, banning completely the online sale of certain pharmaceuticals, including the most common HRT drugs, even with a prescription.

Many transgender people in China are aware of the dangers of self-medication and welcome efforts to improve safety. But in the three months that the new law has been in place, several transgender people in China have told TIME that the new regulations cracking down on the purchase of HRT drugs online simply add to the many hurdles the community already faces in getting adequate care. And rather than protect them from the risks of self-medication, the new rules may actually be driving more transgender people deeper into the black market, potentially putting their lives further in danger.

Limited options

A 28-year-old transgender woman from the eastern province of Shandong, who goes by the pseudonym Chen, tells TIME that the new regulation simply forces her to look more carefully for the remaining online sellers of tablets of estradiol valerate—a hormone that regulates the female reproductive system. Chen asked TIME to withhold her real name out of fear of police harassment. She, like many other transgender Chinese people, utilizes private groups on local social messaging app QQ, as well as Twitter, which is blocked by China’s Great Firewall though often accessed via VPNs. “I also get my hormone medication through local friends in Japan and Thailand who buy it at regular pharmacies and send it back to China via courier,” she says.

Chen says the number of remaining online retailers that stock HRT drugs for Chinese buyers has decreased following the crackdown. Those that remain are now selling the medication illegally, and prices have been jacked up as a result—with certain drugs sometimes nearing double their original cost. Out of concern of a dwindling supply, some of Chen’s transgender friends have asked her to buy pills on their behalf, but Chen says she has had to decline because she can barely get enough for herself. “This is necessary for me,” she reasons.

Before the new rule took effect, many HRT drugs could be bought on e-commerce platforms like JD.com and Taobao, as long as buyers presented prescriptions. China’s government reasons that true prescription holders can simply go to their local pharmacy to obtain the same drugs now. But getting legitimate prescriptions is easier said than done: a rare study on transgender people conducted by Peking University and the Beijing LGBT Center in 2017 found that up to 71% of respondents who sought hormone therapy said they had difficulty accessing it.

To start, those who need HRT drugs must be over 18, or receive parental approval, and must first secure a “certificate of mental illness.” Though the World Health Organization declassified it as a mental disorder, gender incongruence or gender dysphoria is typically defined as the persistent distress a person experiences if their sex at birth does not match with their expressed gender.

Further, in some cases, even patients over 18 will still be asked for their parents’ approval before doctors will prescribe HRT drugs, says Felicity Huang, a non-binary transgender activist from Guangdong province. Involving parents can cause problems for young adults seeking gender-affirming care; in modern Chinese society, as in many Asian cultures, family ties are at the center of daily life. But among older generations especially, patriarchal and conservative beliefs dominate.

“Sometimes [transgender people] even face domestic violence,” Huang tells TIME. “Their parents will forbid them from buying [HRT drugs] and will lock them inside their house, and even send them to some schools for conversion therapy. It’s very common.”

To be sure, there have been developments in domestic transgender healthcare. In 2021, the country’s first ever clinic for transgender children and adolescents was opened in Shanghai’s Fudan University Children’s Hospital. State news outlet Global Times reported that the goal of the clinic was “to safely and healthily manage transgender minors’ transition.”

But Chen from Shandong says such clinics remain unavailable in smaller, less cosmopolitan areas. When she worked in Beijing in 2021, Chen went to a clinic that recognized her gender dysphoria. She has since moved back to her hometown due to the pandemic, but the local physician that she went to there did not understand gender dysphoria, she says.

Self-medicating

Because of the scarcity of transgender medical resources in China, transgender people regularly engage in “high-risk” activities to access care, such as self-medicating hormones, which medical professionals have warned is complicated and dangerous.

Dr. Greg Mak, a veteran psychiatrist in Hong Kong who chairs the Asia Professional Association for Transgender Health, says those born with male sex characteristics, for example, who take the hormone estradiol will experience feminizing effects, such as enlargement of breasts. But without proper check-ups and management, Mak says those using estradiol may experience serious side effects like breast cancer, endometrial cancer, and deep-vein thrombosis.

Estradiol is one of the HRT drugs included in the list of drugs banned from being sold online. Another is cyproterone, which counters the body’s production of androgen, the male sex hormone. Mak says that for those born with male sex characteristics, that drug stops male sexual response and prevents erections. But too much of it may result in fatigue, depression, and in some cases, liver toxicity. (In July 2018, a doctor diagnosed Chen with mild liver damage after she had been taking HRT drugs for years; she has since recovered after treatment).

“There are quite a lot of misunderstandings with respect to the choice of drugs to use, their expectation, the possible medical complication without medical assessment or follow-up,” Mak tells TIME.

Mak says China, unlike other parts of the world, does not have comprehensive sex education, especially about transgender identities and gender dysphoria, so many people are misinformed about these drugs. Sex education in the country has historically languished, in large part due to conservative values and ideologies espoused by the state.

In Jiangsu, 28-year-old Wang, who identifies as a non-binary transgender person with male pronouns and who requested to use a pseudonym for his safety, says he sought drugs that would help regulate feminizing hormones and boost male sex characteristics last year. But Wang tells TIME that the local doctor—concerned about abuse of testosterone, which can be used for doping in sports—would only prescribe him medicines typically taken by transgender women—the opposite effect he needed. “There’s not much guidance among hospitals and doctors on receiving hormone therapy,” said Wang, who ended up getting the HRT drugs he wanted from cisgender male bodybuilders, who regularly take them as performance-enhancing drugs.

Weighing risks

Limited legitimate accessibility to HRT drugs has led to transgender support groups—often cloaked in the nickname yàoniáng (medicine ladies)—forming on social platforms like WeChat, Weixin, and QQ, to exchange medical recommendations with peers. In some of these groups, drug sellers will use code words, like “candy,” for HRT drugs to avoid getting busted. Others use VPNs to circumvent Chinese internet censors and access sites like Twitter and Telegram to try to learn more about hormones and acquire them.

Resorting to the black market—whether online or offline—has obvious risks. Wang says transgender people know they may be purchasing counterfeit products or imported products that may be below China’s health standards. Amnesty International affirmed in a 2019 study that the lack of oversight poses risks for the quality of the HRT drugs available. The Globe and Mail reported in 2019, for example, that in some instances people took hormones meant for animals.

In Guangzhou, Shia Majer, 29, says that, even as a transgender woman, she understands why the Chinese government is imposing regulations on these online sales: because anyone, even those as young as 13, can buy the drugs without a real prescription, and improper usage can have dangerous consequences to their health. “You see a lot of people, a lot of teenagers talking and sharing medical information that they have no idea [about],” Majer says. “They think they know. They don’t.”

Yet despite knowing the risks of self-medicating and of unchecked availability to buy HRT drugs online, many transgender people—adults and children alike—insist that the alternative is worse. Majer recalls how she felt after the first time she was able to take HRT drugs, which she acquired on the black market. “It was the first time that I actually felt at peace.”

Chen from Shandong also says the toll her liver has taken from self-medication was less harmful to her than the hardship she has experienced from missing her regular HRT doses.

“If you stopped taking the hormone, the mental health issue will be even bigger,” Chen says. She says she knows of several transgender people who have died by suicide just in the past few months. When people have limited options to feel at home in their body, she says, they feel hopeless about their future. The latest regulation limiting access to online HRT drugs has only exacerbated that, and Chen and her peers worry things are only trending in the wrong direction. “There is a lot of concern that more restrictive laws will emerge.”