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In China, gender reassignment is still a taboo topic, and gender reassignment surgery can be prohibitively expensive and restricted. A 2010 report from the International Gay & Lesbian Human Rights Commission on China describes the level of discrimination faced by transgender Chinese citizens:

Transgendered people face serious levels of police harassment in China. The transgendered community also faces particular difficulties in obtaining employment. The Chinese authorities are currently consulting on new rules on gender realignment surgery. In certain aspects these rules fail to meet international standards on individual autonomy and privacy.

The government implemented guidelines in 2009 for restricting gender reassignment surgery. According to the new guidelines, a person must apply with the police to change the gender on their official registration before undergoing gender reassignment surgery. A person must also live openly as the gender with which they identity for a number of years before the surgery. They cannot have a criminal record, must be over the age of twenty and unmarried, and must have gone through a considerable amount of therapy. The candidate also must tell their immediate family about their plans for surgery.

For many, these guidelines have made the surgery completely unattainable. Han Bingbing is a Chinese woman who underwent gender reassignment surgery in 1999. She said in a 2009 interview, when asked about the new guidelines that:

I would not be able to have the surgery if there was such a guideline in 1999 ... mother died when I was seven and I was not able to speak to my father about my feelings until I returned to my hometown after the operation ... Most transsexuals are not on good terms with their family. That is the reality. They sometimes change their names and move far away. What happens if their family refuses to let them have the surgery?

Even for others who fit the guidelines, the surgery can be prohibitively expensive. Han spent almost 200,000 RMB (about $32,000) on the procedures in 1999. There are no recorded statistics regarding the number of Chinese citizens who have undergone gender reassignment surgery.

Culture also plays a role: Dr. Howard Chiang, a professor of History at Warwick University, wrote in his essay Transgender Studies and the 'C' Word that instead of using ideas and frameworks for transgender studies developed in the West, China's transgender issues may be better understood in the context of the country's own culture and history.

There are many instances in Chinese history in which a third gender or variations on a gender are apparent -- eunuchs being the most obvious example of this. When Manchurian women did not bind their feet in the early Qing dynasty, they were seen as masculine compared to Chinese women with bound feet. Chinese men were not attracted to "large-footed" Manchurian women, as the small bound foot was seen as a gender marker. Feminine men played women on stage for centuries in Peking Opera, even living as women as noted in the semi-fictionalized M. Butterfly.