Less political, more personal: The many struggles of China’s transgender population

From the window of her room on the sixth floor, Shia Majer peered out over Yanhee International Hospital. The buildings spread out under a dark evening sky. It was a humid Monday in July 2019, and Shia had just woken from a six-plus-hour-long procedure. Shia was unsure about the outcome of the surgery, specifically “the shape of it,” she said. But mostly she felt happy, empowered, and liberated, a state of mind that she had been craving her entire life.

Shia, 28, who asked to be called by her nickname rather than her Chinese legal name, was born biologically male. For as long as she can remember, she was vexed by the social and parental expectations of how she should behave and express herself. As a child, she was drawn to toys and games traditionally associated with girls. In high school, she had no male friends, which was a source of concern for her mother. “Every time I went out, she would ask who I was going to meet,” Shia said. “I thought I was completely normal because I was just hanging out with friends who I got along with. They just happened to be girls instead of boys.”

In her adolescent years, Shia didn’t really know what transgender meant. At college, she felt “uncomfortable” seeing her male roommates’ naked bodies in the dorm, but she couldn’t pinpoint what exactly was bothering her.

Then, in 2015, when she moved to Guangzhou to study fashion design, things began to change. One day, she discovered YouTube and immediately went on a binge of documentaries and first-person testimonials by transgender women, where they described taking hormone treatments, appearing more feminine, and restoring a sense of authentic self. Suddenly, Shia had an explanation for how she felt — and what she wanted.

The possibilities of living a different life fascinated her, but the excitement didn’t immediately translate into action. Burdened by loneliness and the pressure to make ends meet, Shia had suicidal thoughts. “I felt like I wasn’t going to live the next year if I didn’t do something. At that point, it was either transition or suicide,” she said. “Once I came to that realization, I couldn’t hold myself back anymore.”

In 2016, Shia began looking into hormone replacement therapy (HRT) and devoured whatever information she could find online. By the time she arrived in Thailand for her gender reassignment surgery, three years on estrogen had given Shia a feminine voice and breasts.

“The surgery allowed me to fully be myself and now I can interact with the world as who I truly am,” said Shia.

Desperate for meds

There’s no accurate count of how many people in China are like Shia, identifying with a different gender than what they were assigned at birth. A 2012 study published by the United Nations Development Programme estimated that roughly 0.3 percent of the entire population of the Asia-Pacific region are transgender. If that proportion were applied to China, there would be as many as 4.2 million trans people among the country’s 1.4 billion citizens.

In China, the appearance of transgender television stars like Jīn Xīng 金星 and Chāo Xiǎomǐ 超小米 may convey the illusion of a culture at ease with gender fluidity. But it is also a country where transgender people must undergo mental health screenings in order to legally transition, and where transgender people routinely struggle to obtain medical care, finish school, or hold jobs.

“Consumed by a whole set of real-life struggles and inconveniences, trans people in China barely have time to advocate for policy-level changes or think about issues like visibility and representation,” said Alex, a 23-year-old genderqueer student from Suzhou, who prefers to use a pseudonym for privacy reasons. Having volunteerd in multiple civil groups serving the transgender community, Alex said that officially transitioning in China can be a frustrating process.

While policies vary from hospital to hospital, Chinese citizens generally have to take psychological assessments and be diagnosed with gender dysphoria — a medical condition resulting from a conflict between one’s sex assigned at birth and one’s gender identity — before being granted access to HRT. Most evaluations involve the SCL-90-R and the Minnesota Multiphasic Personality Inventory, two psychometric instruments devised to assess personality traits and symptoms of certain mental disorders.

Because transgender people are at high risk of mental health challenges due to the effects of social discrimination and their own internal struggles associated with self-worth and self-esteem, the screenings usually result in not only diagnoses of gender identity disorder, but also prescriptions for depression and mandates of an “observation period,” which, in some cases, can last up to two years.

“There are so few trans-friendly psychiatrists in the country, and most doctors would put trans people on antidepressants or anti-anxiety medications before suggesting therapy,” Alex said. “To make a gender dysphoria diagnosis required for hormone treatment is inherently stigmatizing and pathologizing.”

But even for those who are willing to go through the process, success is far from assured. Wǎntóng 宛瞳, a 24-year-old trans woman in Guangzhou (whose name has been changed to protect her privacy), said that after obtaining two letters from psychiatrists attesting that she had gender dysphoria, hospitals in her city still refused to prescribe her hormones. Fed up with obtuse excuses and delays, she traveled to Beijing’s Peking University Third Hospital, home to China’s first gender dysphoria clinic, for treatment.

Many trans people desperate for hormones turn to alternative means. A 2017 report (in Chinese) from the Beijing LGBT Center that surveyed nearly 2,100 trans Chinese found that only six percent of respondents reported no difficulty in obtaining hormones from hospitals. Ignored or turned away by doctors, 33 percent of the respondents said they resorted to the black market, where they risked taking counterfeit and unsuitable medications with little information on dosage or side effects.

Particularly at risk are minors who are afraid to come out to their parents or face objections at home, said Āshū 阿书, a transgender woman in Beijing, who requested to use a pseudonym. While she primarily uses legal drugs, the 22-year-old college student, who has been on HRT for nearly three years, still gets hormones outside her prescription because they are “cheaper and more accessible,” she said.

“For transgender teens, they can buy hormones from doctors online as long as they get their hands on adult women’s national IDs, such as their mothers,” Ashu said. “Safety and accessibility is a tradeoff that many of them have to make. I’m not in a position to judge them because this gray area has to exist when transgender medical resources are so scarce.”

According to the aforementioned report by the Beijing LGBT Center, of the 1,640 participants who have come out to their families, only six said they never suffered any form of domestic abuse. Cutting off financial support and psychological abuse such as belittling and humiliation were among the most common forms of abuse.

China’s anti-domestic violence law, which went into effect in March 2016, should be applied to these situations, said Darius Longarino, an expert on Chinese law at Yale University. “But it’s hard for law enforcement officers to get rid of the habit of just being like, ‘Oh, no, this is a family matter, we don’t get involved,’ even though a person’s rights are being violated or forcibly taken away,” Longarino said. “Parents often think their children are deviant and need to be molded into the correct form when they come out as transgender. There needs to be messaging from authorities telling them that that is not true, and that the kids are totally fine.”

Systemic failures

The first time Ashu cross-dressed in public was a pure accident. While she was growing up, she said she experienced “inexplicable feelings” that she was trapped in the wrong body, but she never had the desire to try on women’s clothing. At 18, to celebrate high school graduation, Ashu and her friends organized a trip to Japan, where they made an appointment with a local shop to rent Yukatas, a type of traditional Japanese robe popular with tourists.

At the store, a girl in the group suddenly changed her mind, insisting on wearing the male attire that Ashu had booked. Granting her wish, Ashu took the girl’s costume and spent an afternoon in it. “This was unexpected but it felt nice,” Ashu recalled.

At college, when Ashu met a transgender woman in her department, she had a flash of recognition. “Before that, I didn’t know people like her existed. Seeing her being comfortable in her own skin inspired me to start self-exploration,” Ashu said.

In her junior year, after being on HRT and living entirely as a woman for almost two years, Ashu came out to her family — a hasty decision that ultimately led her on a different life path. “I was pressed to tell my parents because I wanted to have the surgery and make the gender marker on my diploma match who I really am,” she said. “I was told by many transgender friends that if I had the wrong gender marker on my diploma and decided to have the surgery later, it could take years to get it changed.”

In recent years, gender self-identification has become the law in a handful of countries, including Ireland and Denmark, where transgender people are allowed to change gender legally without a medical diagnosis or hormone therapy. Last year, in a decision widely hailed as a major step for transgender rights in Taiwan, a high administrative court in Taipei ruled against a law requiring transgender people to provide proof of sex-change operation before altering their legal gender.

But in China, to apply for a gender revision on official documents such as identification cards and diplomas, trans people are still required to fully transition through irreversible surgery. Complicating matters, China’s most recent policy on gender affirming surgery (in Chinese), published by the National Health Commission in 2017, stipulates that the operation is restricted to unmarried people over 20 who must have a clean criminal record and consent from their immediate family.

“Some trans people see surgery as a critical part of their transition process, but not everyone does. Some can’t have surgery due to medical reasons. Some can’t afford it. And some simply don’t want to,” Alex said. In Chinese hospitals, costs for bottom procedures can range from 60,000 yuan ($9,400) to 80,000 yuan ($12,500); for patients who select multiple surgeries, such as breast augmentation and facial feminization, the combined costs can reach six figures.

Alex added, “They end up having to carry identification that says they are a different gender to how they appear and identify. The mismatch can cause lots of inconveniences when they access medical care, apply for jobs, or travel — basically every aspect of life.”

The fear of being misgendered and having no legal ground to dispute was exactly what drove Ashu to come out to her parents in 2021. Her mother, who divorced her father when she was little, reacted with a mix of shock, anger, and disappointment. Soon after, she blocked Ashu on all messaging platforms. Although Ashu’s father appeared to be more accepting of her trans identity, he felt unable to consent to the surgery. Looking for a way out, Ashu started applying for study opportunities abroad and got accepted by a university in Canada.

“My mind is all over the place right now when it comes to surgery. I’m looking into options in Thailand or Canada,” Ashu said. However, she didn’t hold any grudge toward her father, as she attributed her predicament to “systemic failures.”

For trans people without imminent plans for surgery, telling families about their gender identity isn’t any easier. In February, after living a double life — male at home and female outside — for six years, Wantong revealed her secret to her parents. “At that point, I was fully comfortable with presenting myself as a woman in my social life and felt that living authentically was critical for my happiness,” she said. “I was tired of pretending to be someone I wasn’t when I was with my family. So I came out.”

The rejection was immediate. Her mother, who is a Christian, implored Wantong, who has been an atheist all her life, to read the Bible in the hope that she might reflect on the “sins” of being transgender. “She thinks that I have a mental illness that can be ‘cured’ once I find strength in God,” Wantong said. Fearing for her safety, Wantong has told some close friends where to find her in case she disappears one day, whether under home confinement or sent by her parents to somewhere remote for “conversion therapy,” a harmful and discredited practice intended to alter sexual orientation or gender identity.

Wantong’s concerns are not unfounded. In a case that was closely watched by the Chinese transgender community, Zhāng Xiǎoqián 张小乾, a trans youth from Weifang, Shandong Province, vanished in the winter of 2020 after her parents discovered her use of hormones and confined her at home. The last time she was reachable, Zhang cried for help in a series of text messages to friends, saying that she had been taken away by strangers who “claimed to be police officers.” Volunteers who tried to track down Zhang believed that she had been sent to an underground “behavior correction” facility for “troubled youth” in Jinan, the capital of Shandong. The illegal clinic, they said, is notorious for using abusive measures like electric shock and physical punishment to “cure” homosexuality and gender dysphoria. Until this day, Zhang remains out of contact.

Legal battles

For most people in China, Jīn Xīng 金星, a 54-year-old television host often compared to Oprah Winfrey, is the reference point for their perceptions and expectations of transgender people. A former male ballet star and army colonel, Jin became the first public figure in China to openly undergo transition surgery in 1995 and went on to carve out a respected career as a television personality. Her program, The Jin Xing Show, is one of China’s most popular talk shows, drawing in an estimated 100 million viewers every week.

The riveting, glamorous life of Jin, however, is far from representative of the socially and economically disadvantaged trans community that continues to face discrimination at school and in the workplace, partly as a result of lagging legal protection.

Employment discrimination is a harsh reality for many transgender Chinese. After returning to China from her gender-affirming surgery in Thailand, Shia found that her trans identity was the focal point of many job interviews, and she was judged and picked apart for her appearance. The most humiliating experience, she recalled, was when she was called in to be interviewed by a panel of four managers at a renowned design firm. After she handed out her résumé and sat down, what she expected to be a professional conversation quickly degenerated into an interrogation, with her being run over by a barrage of personal questions like if her boobs were natural.

“The most upsetting thing about this interaction is that none of them looked at my résumé, as if my skills meant nothing to them. In the end, the design director told me that they couldn’t hire me because I was ‘too special for the team,’” she said. It was a breaking point for Shia, who later launched her own branding agency. “When I got home, I was like, ‘Fuck this society. Fuck everyone. Fuck everything.’ I decided to stop proving myself to people who don’t like me or respect me.”

While it’s hard to pin down precise numbers, the 2017 survey by the Beijing LGBT Center revealed that 11.87% of its trans respondents were unemployed, compared to 3.97% of the general population. Nearly 25% of trans people with jobs said they faced a “hostile work environment,” with things particularly bad in conservative settings such as government agencies. To avoid prejudice or discrimination on the job, almost half of the trans female respondents chose to hide their identity at work.

On the bright side, Chinese transgender employees have scored a string of legal victories in recent years. In July 2017, a court in the southwestern city of Guiyang ruled in favor of a transgender man, known as Mr. C, determining that he was unjustly fired from his job because of his gender identity. The landmark ruling, believed to be the first of its kind, showed protections for LGBTQ individuals in China on the basis that workers cannot be discriminated against “based on their ethnicity, race, gender or religious beliefs,” the court said.

Three years later, a transgender woman in Beijing won her case against Chinese ecommerce platform Dangdang after the company fired her when she took a leave of absence for her gender reassignment surgery. While Gao had legally changed her gender from male to female, the company misgendered her and blatantly called her “mentally ill” in letters and email exchanges.

Although Chinese employment law doesn’t recognize discrimination against transgender employees as a form of sex discrimination, the court in Dangdang’s case took a “pioneering step,” Longarino said, to specifically point out Gao’s trans identity in a statment accompanying the ruling. The judge wrote, “We respect and vow to protect the dignity and legal rights of transgender people. Our attitude is based on our respect for individuals’ dignity and legal rights.”

Longarino credited the strides made on the legal front in large part to the advocacy work done by nonprofit agencies for LGBTQ people and a tight-knit group of lawyers willing to take on cases involving transgender individuals. But he worried that amid Beijing’s growing restrictions on social activism and civil groups — especially those primarily serving gender minorities, transgender poeple in need of help would “become more cut off from each other, from resources and the community,” he said.

A shift of priorities at nonprofit organizations is already happening, with psychological counseling and community building taking center stage. The website of the Trans Well-being Team, a Guangzhou-based entity founded in 2018 with a focus on offering mental wellness assistance to transgender people, introduces itself as “a network of volunteers,” signaling a departure from traditional nonprofit organizations that are subjected to close scrutiny by Chinese authorities for civil rights activism. The Beijing LGBT Center tries to serve transgender people through mental health therapy and seminars on sexual health rather than raising their visibility outside the community.

“I feel that ‘equal rights’ has become a phrase that these groups try to avoid in their activities and posts on social media,” said Alex. He speculated that their less-progressive agenda was what shielded them from erasure when WeChat shut down dozens of accounts run by LGBTQ university students last summer.

“No one is calling for radical reforms now. But if transgender activists keep retreating and the line keeps moving, they will be in a corner one day — and there’s nowhere else to go,” Alex said. He pointed to Beijing’s crackdown on “sissy men,” where male celebrities deemed too effeminate are banned from television, saying that this reflected the government’s intolerance of gender fluidity. “Basically, authorities want to see you as male or female. Nothing in between is acceptable.” He added that the promotion of such binary thinking could amplify the social stigma of transgender individuals and cause distress for people who are unsure about their gender identity.

With where things stand now, living in a free and fair society is still a pipe dream for China’s transgender population. Wantong, who considered herself a “privileged” trans woman with a well-paid job, stable access to hormones, and a supportive group of friends, said that the challenges of living are so vast and multifaceted for most people in the community that issues like bathroom access can seem less pressing than more immediate concerns.

“I generally prefer using unisex restrooms if there’s any, but I sometimes use women’s bathrooms too,” Wantong said. “Out of fear of confrontation, I carry my diagnosis of gender dysphoria with me whenever I go. It’s an annoyance, but it’s a minor one compared to other problems faced by the community.”

Giving back

“It’s been about five years now since I started my HRT, and I have completed my gender confirmation surgery in 2019…Life after that has been smooth, has been good, has been joyful,” Shia said in a recent video on her YouTube channel. Lounging in her warmly-lit room in Guangzhou, she went on to share details about her personal journey of discovering her trans identity and coming to terms with it. “This video could potentially help some people who are going through #genderdysphoria and related struggles or confusions to sort out some thoughts,” she wrote in the video’s description.

Since 2019, Shia has been uploading videos on YouTube, where she now has over 1,200 subscribers. But documenting her life as a trans woman is not what her channel is all about. In one video, she shows what it’s like to spend Christmas in China. In another, she opens up about her thoughts on the Russia-Ukraine conflict. “I don’t want people to only see my gender identity. I don’t want it to be my primary label. Being trans is part of me but not all of me,” she said.

Shia’s next video will be about her new entrepreneurial endeavor: She’s been building an all-in-one platform where expats in Guangzhou can hire help for everyday tasks and search LGBTQ-friendly establishments. Shia said she plans to foster a positive workplace environment for LGBTQ employees, and vows to donate a percentage of her profits to LGBTQ causes.

“I feel like we really need a role model in China, who starts from zero, works their way up, and earns their place in society. We don’t have someone like this in China now and I would like to be that person,” Shia said. “In the end, it’s not about me. As I get older, I really start to care less about fame and other things. I want to do it for my country, for my people.”