Threatening notes. Physical assaults. False accusations. In his years dealing with the families of young transgender people in Beijing, Doctor Poon has seen it all.

Since 2016, Poon has been running one of China’s first specialist medical units for transgender individuals. Based inside a public hospital, it supports patients through every stage of their transition: from counseling to hormone therapy and gender affirmation surgery.

In China’s trans community, Poon — who spoke with Sixth Tone using a pseudonym to protect his privacy — is widely regarded as a hero. His clinic has already treated more than 3,000 people, and the number of patients is growing by over 60% each year, he says.

But his work is also highly controversial. In many parts of China, conservative social attitudes remain dominant. Patients’ families are often determined to prevent them from transitioning — and willing to take extreme measures to stop Poon helping them.

Over the years, multiple parents have threatened Poon. Several have reported him to his employer, accusing him of “poisoning teenagers” and being “influenced by foreign forces.” One even broke into the outpatient department and stabbed Poon’s colleague.

Across China, widespread social intolerance toward the transgender community is exerting a powerful influence over the health system, creating barriers that prevent trans Chinese from securing the care they need.

Doctors offering treatment to transgender patients frequently become targets of abuse. This is leading other health workers to avoid dealing with trans patients, as they fear encountering similar blowback.

Transgender Chinese describe trying to overcome these obstacles as “traumatizing.” Several told Sixth Tone they had suffered severe mental health issues after being unable to access treatment. Many had resorted to buying medication on the black market. Suicides are worryingly common, social workers say.

Chinese authorities have taken some steps to make treatment easier to access, such as by reducing red tape for trans people wishing to undergo gender affirmation surgery. But a recent ban on the online sale of several hormone drugs risks exacerbating the situation unless the medication is made easier to access via legitimate channels.

Hidden barriers

In theory, completing a gender transition via China’s health system should be relatively straightforward. 

A patient must first consult a psychologist and obtain a diagnostic report confirming they have gender dysphoria. This diagnosis allows them to begin hormone replacement therapy, which is the first step of the transition process for most people.

Once the course of HRT is complete, the patient can obtain permission to undergo gender affirmation surgery. They must also be over 18 years old, and have a clear criminal record and a valid diagnostic report. Surgery is usually followed by further HRT and counseling.

In practice, however, clearing each step can be extremely challenging. For many trans Chinese, the problems start as soon as they try to find a psychologist willing to provide a diagnostic report.

In Beijing, Poon’s staff can connect patients with psychologists who are experienced at working with the transgender community. But such specialist clinics are “extremely limited” in China, Poon says. 

There are only a handful of similar facilities in the entire country, concentrated in the major cities. In the rest of the health system, the transgender community is “practically invisible,” Poon adds.

Fan Nan, a 23-year-old trans woman from southwest China’s Sichuan province, says that it’s common for people in the transgender community to be unable to find a medical professional willing to provide an official diagnosis.

“Although doctors specializing in psychology are more aware of the concept of being transgender than other physicians, few of them are willing to provide a diagnostic report,” Fan tells Sixth Tone.

It took Fan years to find a psychologist willing to help her. She first realized that she was transgender in 2017, when she was 17 years old. At the time, however, there were very few doctors willing to treat transgender patients outside of Shanghai and Beijing, she says.

Things got even harder a year later, after Fan “accidentally” came out to her family. One day, her mother walked in on Fan wearing a dress. Her parents reacted badly. They not only refused to support her during her transition; they also cut her off financially to make it harder for her to do so.

“It was a nightmare,” Fan told Sixth Tone. “I was forced to change back to what they wanted me to be. It was like finally seeing the light at the end of the tunnel, but then the light being covered up … I was hopeless.”

Throughout college, Fan went through several mental health crises. These culminated in a severe depressive episode during her final year, when she twice tried to take her own life.

Those incidents finally pushed her parents to change their attitude. They agreed to support Fan with her transition, and she was referred to a psychiatrist at the Sichuan Mental Health Hospital.

Luckily, the psychiatrist had a reputation for helping trans people, and was willing to sign a diagnostic report allowing Fan to begin her transition. But many others were not so fortunate. Soon after, the psychiatrist stopped providing diagnostic reports, after the families of several young transgender people filed complaints to the hospital, Fan says.

Once Fan was ready to begin HRT, she ran into another obstacle: a hospital administration system that was unable to accommodate transgender patients. Fan described the experience of trying to get a prescription for the anti-androgen drug estradiol at a local hospital in Sichuan as “embarrassing.”

“I was prescribed estradiol, which is only available at the endocrine unit for women,” Fan recalls. “However, at the time, I still held an ID with a male gender identity, which cannot be used to register at the women’s unit. And no doctors from the men’s endocrine unit were willing to prescribe estradiol. There was no way for me to get a prescription.”

“This is commonplace, as the understanding and acceptance of transgender people domestically remains low,” says Poon. 

This is why Poon considers it so vital that Chinese hospitals set up more specialist clinics like his own, which can provide transgender patients with a “consistent and all-inclusive service.” This would save people from having to rely on other parts of the health system — which often struggle to accommodate the transgender community — to access treatment, he says.

“It would avoid duplicated work when setting up diagnostic profiles and simplifying the circulation of individuals’ medical records,” says Poon. “At the same time, it allows us to ensure a closed loop when offering counseling, which provides the best protection for privacy.”

However, it is difficult to motivate hospitals to set up such clinics, Poon says. Transgender treatment presents a complex organizational challenge, as it requires coordination between a wide variety of medical disciplines, including pediatrics, psychology, and endocrinology. And few doctors are willing to be associated with transgender units, as they worry doing so could harm their careers and potentially put them in danger, he adds.

“This discipline still doesn’t appeal to medical professionals, which is also a result of the wider social intolerance toward the transgender community,” Poon says. “Plus, there are the risks of being reported or even attacked by the families of transgender teenagers.”

‘Very concerning’

Facing these barriers in the health system, transgender Chinese are being forced to seek out alternative — and, in some cases, dangerous — sources of treatment. Among the most common: black market hormone therapy medication.

Fan began buying unlicensed anti-androgen pills when she was 17, contacting dealers via several Chinese online platforms. Often, the drugs would arrive concealed inside a notebook.

She knew buying the drugs online was potentially unsafe, but she viewed it as her “last resort.” In hospitals, HRT drugs were not only difficult to access; they were also double the price, Fan says. At the time, she couldn’t have afforded the licensed drugs, even if she’d been able to get a prescription.

Fan is far from alone in doing this. In 2021, Poon’s team conducted a nationwide survey of more than 2,000 transgender individuals, which suggested that the majority of trans Chinese source their HRT pills outside the health system. Of the respondents, only 10% had consulted a doctor and received regular health checks while taking their medication.

“This is very concerning, although within expectation,” Poon says.

The potential health risks of self-administering HRT drugs are severe, Poon says. In some cases, the medication can cause liver damage and other side effects, which might go undetected without proper health monitoring.

“This could be even more dangerous for individuals who have underlying health conditions,” Poon says. “It could lead to irreversible consequences for them.”

Then, there is the added risk of being sold fake drugs. The only way to protect yourself when buying medication online, Fan says, is to rely on word-of-mouth recommendations from other members of the trans community.

“Some agents get called out by other queers who had taken fake drugs, and get banned. Otherwise, you just have to test them on yourself,” she says, with a resigned shrug.

The Chinese government has grown increasingly concerned about the health dangers posed by unlicensed HRT medication, and is now taking steps to curtail the trade. In December last year, it banned the online sale of several “high-risk” drugs, including estradiol and cyproterone.

But the ban also risks causing issues for trans Chinese who were dependent on black-market channels for sourcing their HRT medication.

There is still a lack of clinical evidence on the mental health risks associated with pausing HRT medication, Poon says. But the doctor adds that, in his experience, the risks are real. Some teenagers suffer a decline in their mental health after they stop taking the drugs, as the sexual characteristics they have rejected re-emerge, he says.

Han Lianyi, a 22-year-old volunteer social worker, agrees with this assessment. For the past five years, she has been working with trans teenagers in China struggling with mental health issues. 

The suicide rate among this group has been worryingly high for several years, Han says. But her work has become even more difficult in recent months, as a number of the teens she works with have lost access to their HRT medication. While it’s impossible to draw definitive conclusions about causation, Han says that she has seen an “increase in suicide cases” this year.

And although some trans Chinese have lost access to their medication, the ban has failed to eliminate the black market entirely. Fan says she is still buying estradiol online, but she now contacts dealers via Twitter rather than Chinese platforms. Han says many of the teens she works with have found similar workarounds.

For Poon, a ban is unlikely to eliminate the unlicensed drugs problem in the long run. The only sustainable solution, he says, is to make it easier for transgender Chinese to access proper treatment.

“Only when this is achieved will those black markets disappear,” Poon says.

‘Fundamental changes’

Last year, China did make some progress toward that goal. In April 2022, the government released new regulations on gender reassignment surgery that lowered the minimum age threshold from 20 to 18, and — crucially — removed the requirement for patients to obtain parental consent before undergoing surgery.

For many trans Chinese, the parental consent rule had long been an insurmountable obstacle — one that caused years of anguish. Filianore, a 26-year-old trans woman, says she had to wait seven years — and endure many rounds of “verbal and physical abuse” — from her parents before they finally agreed to consent to her surgery.

Like Fan, Filianore came out to her family by accident. She first began taking HRT drugs while she was studying abroad in Japan. When she flew home to visit her parents, they noticed the changes in her physical appearance. Things quickly turned ugly.

“They got suspicious and then found those drugs in my bag,” recalls Filianore, who also spoke with Sixth Tone using a pseudonym for privacy reasons. “My mother couldn’t speak, and was just crying. My father was saying he’d send me to a mental hospital.”

Her father wasn’t bluffing. He threatened to prevent Filianore from returning to Japan unless she went to see a psychiatrist. So, in 2017, Filianore reluctantly let her father drive her to several hospitals in east China’s Zhejiang province, where she had to take a series of tests to assess her personality type and mental health.

In several cases, these tests were “very strange and irrelevant,” Filianore says. At one hospital in Hangzhou, she was hooked up to a brain scanner and shown a series of images of men, some of them naked. 

“There were electrodes stuck to my head,” recalls Filianore. “They asked me to press different buttons while looking at those pictures so that they could see changes in my brain waves.”

In the end, these hospital visits changed nothing. “My parents worried if I continued self-administering drugs, it would have serious health consequences. So, the doctor advised me to pause the medication, suggesting it might just be impulsive,” Filianore says.

Filianore ignored the advice. The main outcome, she says, is that she was left feeling “insulted and treated like a mentally ill patient.” She continued taking HRT medication while she finished college, found a job, and gained economic independence from her family. Finally, in 2021, her father gave his consent to her gender affirmation surgery.

The scrapping of the parental consent rule will undoubtedly make life easier for transgender individuals like Filianore. But Poon stresses that, when it comes to making the health system more accessible to China’s trans community, “there is a long way to go.”

To make greater progress, China’s health authorities need to make transgender health care a higher priority, Poon says. There is an urgent need for more specific regulations, training for health professionals, and the inclusion of more transgender treatments in health insurance policies.

“We need changes from the top to push a healthy and regulated development of the transgender health care discipline, which would benefit both the trans community and medical experts in the relevant specialties,” says Poon.

But the sources who spoke with Sixth Tone all agreed that the biggest changes need to take place in Chinese society. In so many cases, the issues trans Chinese face in the health system — the doctors afraid to provide diagnoses, the willingness to appease angry parents, the administrative Catch-22s — reflect the lack of acceptance toward the community in society at large.

“Only when the overall social environment sees fundamental changes can we expect more people to know and accept us … and, ultimately, more trans-friendly medical services,” says Fan.

Editor: Dominic Morgan.

In China, the Beijing Suicide Research and Prevention Center can be reached for free at 800-810-1117 or 010-8295-1332. In the United States, the National Suicide Prevention Lifeline can be reached for free at 1-800-273-8255. A more complete list of prevention services by country can be found here.

(Header image and icons: Jorm Sangsorn and diane555/VCG)