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Transgender people in China are performing highly dangerous surgery on themselves and buying unsafe hormone treatments on the black market because it is almost impossible for them to access the health care they urgently need, Amnesty International said in a new report.

I need my parents’ consent to be myself- Barriers to gender-affirming treatments for transgender people in China reveals that prevalent discrimination and stigma, restrictive eligibility requirements, and a lack of information, leave transgender people to seek unregulated and unsafe gender-affirming treatments.

“China is failing transgender people. Discriminatory laws and policies have left many people feeling they have no choice but to risk their lives by performing extremely dangerous surgery on themselves and to seek unsafe hormone drugs on the black market,” said Doriane Lau, China Researcher at Amnesty International.

“The authorities and medical profession must stop classifying transgender people as having a mental illness. The highly-restrictive requirements for accessing gender-affirming surgeries and lack of health-related information needs to change so people can access the health care they need.”

The transgender community in China is largely invisible, and faces entrenched discrimination at home, school, work and in the healthcare system. Despite the challenges, 15 transgender people from across the country were willing to share their experiences with Amnesty International.

Many spoke of the emotional distress caused by the mismatch of their gender and sex characteristics.

Zijia*, a 21-year-old a transgender woman, told Amnesty International why she started to use hormone treatment: “I was anxious to change my body. I felt disgusted with my male sex characteristics. The medication brought changes gradually, but I felt much better right away. I could finally start being myself.”

However, in interviews, Amnesty International found an alarming lack of knowledge about how transgender people can access gender-affirming treatments in the public health system. This, combined with stringent and discriminatory eligibility requirements, means transgender people are often not supported to access the health care they need.

In China, transgender people are classed as having a “mental illness” and gender-affirming surgeries require the consent of families. This is a major barrier in accessing safe treatment. Due to the fear of rejection, many transgender people choose not to tell their families.

Many other criteria to qualify for gender-affirming surgeries – such as not being married or having a clean criminal record – also create significant barriers to accessing this treatment.

Dangerous self-surgery

Let down by the health system, transgender people have taken the highly dangerous step of attempting to perform surgeries on themselves. Two people told Amnesty International of their traumatic experiences, including Huiming, who became desperate to align her male sex characteristics with her female identity after the onset of puberty.

The 30-year-old began to self-medicate while still in university, buying hormone drugs via the online black market – but stopped after only a month due to suffering extreme mood swings and significant impact on her mental health.

Accessing gender-affirming treatments at a hospital was not an option as she feared her family would reject her when she asked for their consent. In 2016, she took the desperate decision to attempt surgery on herself.

Huiming was rushed to the emergency room. She asked the doctor to lie to her family and say she had an accident. Her parents remained unaware about their child’s desperate act to remove her male sex organs. In 2017, Huiming traveled to Thailand for gender-affirming surgery. Before she went, Huiming came out to her mother who accepted her for who she is.

Unsafe medication

Due to the failings of the health system, transgender people who have an urgent need to align their body with their gender identity told Amnesty International that they have had little choice but to resort to the unsafe and risky black market to obtain hormone medication.

This includes buying medication through social media chat groups, online shops, and via overseas surrogate shoppers, often at inflated prices compared to the legal market. None of the transgender people Amnesty International interviewed had accessed advice from medical professionals when they started taking these drugs.

Without any regulation and oversight, there is a real risk the drugs purchased on the black market are unsafe and counterfeit. Without knowing the required dose, side-effects, or quality of the drugs, many told Amnesty International how they experienced different levels of mood swings, with some even plunging into depression, with no medical supervision or access to a doctor to address these conditions.

People were prepared to risk buying unsafe medication as they wanted to escape the distress triggered by living in a body that did not align with how they see themselves.

Shanshan, a 21-year-old transgender female from Beijing, hated her male sex characteristics. “My greatest anxiety is being a man. Sometimes it felt so bad I wanted to commit suicide,” she told Amnesty International.

Unable to live with the anxiety, Shanshan began buying hormone medication on the black market.

Lack of adequate information

The transgender people Amnesty International interviewed did not get any advice or guidance on gender-affirming treatments from their doctors when they first started using hormones, and instead learnt about treatment options from friends and by searching for information on the internet. They did not feel that doctors in the public health system were able to support them.

Health care facilities specializing in gender-affirming treatments are not common. There is only one multi-disciplinary clinic in the whole of China that specializes in a range of gender-affirming treatments. The multi-disciplinary medical team for gender-affirming care opened in September 2018 at Peking University Third Hospital and is the first of its kind in China.

The current guidelines for medical professionals on gender-affirming treatments are not fit for purpose. These guidelines combined with a lack of adequate information means transgender people face significant barriers and challenges to access the care they need.

In March 2019, the Chinese government accepted recommendations by the UN Human Rights Council to legislate to ban discrimination against LGBTI people.

“The Chinese government can show it is serious in addressing discrimination against the LGBTI community by removing the barriers transgender people face when trying to access safe gender-affirming treatments,” said Doriane Lau.

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