SHANGHAI — If there is one ritual that Lanya, a 26-year-old transgender woman in eastern China, has kept sacrosanct over the past decade, it’s taking pills — or “candy,” as it’s known among China’s trans community.

“Estrogen, anti-androgen — you have to take these during your adolescence or your physical characteristics will be hard to change,” she says, naming two essential components of hormone replacement therapy, or HRT.

But with its potentially debilitating side effects, the candy isn’t always sweet. “The problem is that neither professional medical advice nor prescribed hormones are readily accessible in China,” Lanya tells Sixth Tone, adding that in the absence of reliable information, the risk of improper use is compounded. Like all of the trans women Sixth Tone interviewed for this story, she has been given a pseudonym to protect her privacy.

Lanya began taking estrogen in 2008, when she was 16 years old. Unlike her trans counterparts in certain Western countries, who can receive puberty blockers and other prescriptions under a doctor’s watchful eye, Lanya resorted to buying long-acting oral contraceptives — with only the vague knowledge that they contained estrogen — from local pharmacies, claiming they were for her parents. Without any guidance or supervision, she began taking once-per-month pills every day.

Unexpectedly, her breasts began to grow: After a few months, she was up to a B-cup. But her budding breasts were also painfully swollen. “I would cross my arms to protect them — and occasionally there would be a milky discharge,” she says. By Lanya’s account, her body grew flabby, and her mood became increasingly unstable. Eventually, she decided to take a break from contraceptives and look for other options.

A transgender woman prepares to undergo a sex reassignment surgery in Dehui, Jilin province, Sept. 22, 2015. VCG

Ziye, another trans woman from eastern China, followed a similar course. While attending high school in Zhejiang province, she took the same long-acting contraceptives daily for around two weeks until a routine health check revealed damage to her liver. Shocked and afraid, Ziye stopped taking the pills, leaving her body in the throes of a severe hormonal imbalance. “I guess breast growth can be difficult when it doesn’t happen naturally,” she tells Sixth Tone with a sigh. “But I’m not giving up — I want to be a girl. As long as they get bigger, I don’t care how gradual it is.”

What Ziye didn’t realize until she got to college was that she also needed to suppress her male sex hormones, or androgens. Initially, she started doing this with domestic drugs, then turned to hormone suppressants imported from Germany. But instead of larger breasts, she observed a handful of troubling symptoms: nausea, depression, and a persistent pain around her abdomen.

Try. Get hurt. Stop for a while. Try again. This is the cycle that defined Lanya’s and Ziye’s teenage years. For fear of having her secret revealed, Ziye never once went to the hospital to speak with a doctor about transitioning. “They would have thought I was a pervert,” she says.

“Most of our pills come from gray areas,” Lanya explains, referring to markets that aren’t quite black but can’t operate openly either. “Why? It’s affordable and accessible.” Lanya explains that to get such hormones prescribed by a doctor, one must first be diagnosed with yixingbing — a term that equates being transgender with a mental illness.

Even if trans people are willing to go through the humiliation of being diagnosed, it doesn’t necessarily mean they’ll be able to get what they’re looking for. “For reasons that are both opaque and complicated, not all hormonal drugs manage to get registered by the National Medical Products Administration — which means they can’t enter the market,” Pan Bailin, a doctor specializing in transgender medicine and surgery at a Peking University-affiliated hospital, tells Sixth Tone. Meanwhile, Ziye laments that some of the domestic drugs that have been approved cost nearly twice as much as imported ones.

Over time, these expenses add up. Lanya, for example, says she has spent over 70,000 yuan ($10,000) on pills. “Counterbalancing your masculine traits becomes a lifelong commitment,” she says with a hint of resignation.

Varieties of hormonal drugs used by Chinese transgender women, Shanghai, Nov. 22, 2018. Wu Huiyuan/Sixth Tone

According to a 2012 report by the United Nations Development Programme, an estimated 0.3 percent of the population in the Asia-Pacific region is transgender. Applied to China’s population of nearly 1.4 billion, this ratio suggests there could be 4.2 million transgender people living in the country — which does not keep its own statistics for LGBT demographics.

A lack of financial resources and available medical treatments can lead to perilous self-medicating regimens similar to Lanya’s and Ziye’s. According to a survey from the Beijing LGBT Center and Peking University published last November, 66 percent of the 2,060 transgender respondents said they had obtained HRT drugs from so-called online pharmacies — unlicensed vendors on social platforms like WeChat, QQ, and Zhihu — and 51 percent reported having obtained such drugs from friends. All of the 11 trans women Sixth Tone interviewed said they had purchased hormonal drugs through online vendors at least once.

“No one is helping us, so we have to help each other,” says Lanya, referring to the many trans women who try to assist their peers by procuring hormones for them. Her own foray into HRT was cut short when Xiasl — perhaps China’s best-known online resource for transgender people, and the source of her do-it-yourself treatment guidelines — was abruptly shut down. Though Lanya says she can’t be sure when Xiasl went offline, other trans women told Sixth Tone they had accessed the site as late as last year.

By around 2010, the sometimes-pejorative term yaoniang, or “pill girl,” was being used online to refer to trans women who take pills to feminize themselves. Around the same time, more forums where trans people could share advice on self-medicating and body contouring, as well as discover and nurture kinships they rarely experienced in real life, began popping up. But such resources for China’s trans community — from yaoniang-related websites to forums on the Reddit-like Tieba — have been shut down in recent years to comply with “relevant laws, regulations, and policies.” In particular, authorities have increasingly applied China’s cybersecurity law, which prohibits the dissemination of sexual or otherwise obscene “information,” to any content it deems morally inappropriate.

By June of this year, almost all transgender-related content had been purged from Zhihu, a formerly important resource for the transgender community as well as concerned or curious parents. In the absence of such online support networks, young trans women are often left to fend for themselves in hostile home and school environments.

A transgender woman tries on a pair of heels at a shoe store in Guangzhou, Guangdong province, April 6, 2015. VCG

Yuanlin, an 18-year-old trans woman from a small village in central China, sought companionship in cyberspace to combat the isolation she felt in real life. She was afraid to buy hormonal drugs from local pharmacies. “People are closely connected in our town,” she tells Sixth Tone. “If I bought those drugs at a store, the entire village might find out.”

By Yuanlin’s account, her hometown in the countryside was too traditional to accept a “sissy boy” in its midst. In October of last year, she began taking anti-androgens that made her feel tired and depressed. Meanwhile, the violence she suffered both at school and at home made life unbearable: As a small, slender, effeminate “boy,” Yuanlin says she was physically and even sexually harassed by her classmates. Her bullies would cup their hands on their chests to mimic breasts — “They’d ask me if that was what I wanted,” Yuanlin recalls.

During this year’s Chinese New Year holiday, Yuanlin’s parents found her pills hidden in her closet. “They came and got me from school, and my father beat me,” she says. “They said I had shamed the family name. Our holiday ‘celebration’ turned into a nightmare.” Feeling shunned by her family and her peers, Yuanlin became depressed and failed the gaokao, China’s ultracompetitive college entrance examination. Then over the summer, she ran away from home and attempted suicide.

Three months later, she returned to her high school to repeat the semester and retake the gaokao. Yuanlin says that by that point, she had vowed to stop pursuing “girly stuff” — at least until she made it to the relative safety of university. “My friends online assured me that I wasn’t mentally ill,” she says, “but sometimes the thought would become stuck in my mind anyway: Why does everyone else seem ‘normal’ except me?”

According to research, the violence Yuanlin was subjected to as a teenager may be just the tip of the iceberg. The 2017 survey from the Beijing LGBT Center found that 70.8 percent of trans respondents reported experiencing violence at school. Over 46 percent said they had considered suicide, and around 1 in 8 had attempted it at some point.

Wu Huiyuan/Sixth Tone

Though the World Health Organization stopped classifying transgender people as mentally ill in June, the Chinese term, yixingbing, continues to carry the connotation of pathology. And to gain access to HRT through official health channels, a clinical diagnosis is still required. “To my knowledge, this can only be obtained from a few hospitals in Beijing and Shanghai,” says Pan, the Peking University doctor.

“I understand that some kids wish to de-pathologize what they’ve got, but in my professional opinion it comes down to their brains sending different instructions,” Zhao Yede, one of the few surgeons in China who specializes in sex reassignment surgery, tells Sixth Tone.

“When I heard the word ‘illness,’ I didn’t want to have the surgery in China,” says Yuyu, a trans woman who works as a programmer in Shanghai. But Yuyu gives Zhao — a revered figure in China’s trans community — the benefit of the doubt, acknowledging that performing surgeries that run counter to China’s “traditional values” must carry with it a considerable amount of pressure. “It’s too early for a society like ours to pursue the topic of gender equality on this level,” she says, referring to the medical community’s lack of tact in treating trans people. “We need people who are trying to help.”

Having performed over 1,000 sex reassignment operations throughout his career, Zhao says he gets harassed from time to time by parents demanding that he make their children “normal” again. “Sometimes the whole family — even old folks in their wheelchairs — shows up and begs me to talk their kid out of it.” Pan, too, once received an anonymous letter threatening a lawsuit if he continued prescribing hormones to his patients.

Yuyu, the programmer, says that even compared with other LGBT communities in China, the situation is especially grim for trans women. “Society is becoming less tolerant of ‘sissy men,’ let alone us,” she says. “To them, we’ve betrayed masculine norms — I feel like our very existence is sometimes viewed as morally wrong.”

A transgender woman prepares to undergo a sex reassignment surgery in Dehui, Jilin province, Sept. 22, 2015. VCG

For Yuyu and the perhaps millions of other trans people in China, hormones from online vendors are usually obtained too late to be effective. To achieve an ideal outcome, medical intervention should come before puberty, explains Pan. But because of the risks of HRT, the treatment is only recommended for people aged 16 or older. In countries with more societal and medical acceptance of trans people, puberty inhibitors are often introduced during adolescence to bridge the gap until their mid-teens. “More than half of my patients are adults — it’s almost impossible for them to change their secondary sex characteristics once they’ve developed,” says Pan.

When 25-year-old Yuyu started taking hormones two months ago, she worried about whether it would be possible to have sex reassignment surgery at her age. After being bullied through three years of middle school, she had cut her hair short, hoping to lead a brand-new life as a “boy” in high school. And for the most part, she succeeded.

Yuyu’s high school years passed smoothly until her graduation, when students were finally allowed to cast their dull uniforms aside. She remembers tears welling in her eyes at the sight of other girls rehearsing for a dance performance in their vibrant sundresses. She then glanced at her own reflection in the mirror, only to see a boy in a somber, dark suit. Her appearance appalled her. “To this day,” she says, “I feel so ashamed for burying the real me.”

“It costs tens of thousands of yuan to have the surgery and maintain a feminine body,” says Yuyu. “But I have forever lost the chance to spend my golden youth as a beautiful girl.”

In China, the Beijing Suicide Research and Prevention Center can be reached for free at 800-810-1117 or 010-82951332. In the United States, the National Suicide Prevention Lifeline can be reached for free at 1-800-273-8255. A fuller list of prevention services by country can be found here.

Editor: David Paulk.

(Header image: Wu Huiyuan and Ding Yining/Sixth Tone)