Sunita Neupane, GPJ Nepal
Alisa Chaudhary started self-medicating with Diane-35, a hormone treatment she bought in Raxaul, a border town in India near her home in Nepal, without medical supervision. She soon experienced symptoms like weakness, nausea and loss of appetite. Doctors warn that incorrect dosing can lead to critical conditions, including blood clots.
BIRGUNJ, NEPAL — Thanks to a tip from friends, Sanju Mahato crossed Nepal’s border into India, walked into a pharmacy, and left minutes later with hormone therapy medication.
No one asked questions. No one gave her advice on dosage.
It was easy — and for Mahato, a welcome change from her hometown of Birgunj, where pharmacies don’t stock hormone therapy medicine for transgender people who want to transition their bodies.
Mahato began to take the drug. Every day, her body shifted closer to the one she wanted. Her breasts grew. The veins in her arms softened. Her confidence grew, too.
Then came the complications: nausea, vomiting, fatigue. She gained about 25 kilograms (55 pounds) and started forgetting things. She had kidney stones and needed surgery, but because her veins had thinned due to hormone therapy, the surgery would lead to excessive bleeding, a doctor told her.
In 2007, the Supreme Court in Nepal ruled that a third official option for gender self-identification would be possible — a change specifically made with transgender people in mind — but the real-world process of transitioning remains a struggle. Gender-affirming surgeries are illegal, and there’s a short supply of hormone therapy medication, as well as doctors skilled to prescribe them.
In the end, transgender people — transgender women especially — rely on self-administered hormone therapy, often bought from pharmacies across the border in India. (For transgender men, access to masculinization hormones is difficult even in India.)
These treatments help with gender transition, but they carry significant health risks, including life-threatening complications.
A network of friends, risky advice
Global Press Journal interviewed six transgender women in Birgunj, all of whom bought hormone medicine in Raxaul, easily crossing the open border, and without consulting a doctor. They relied mostly on advice from their friends who were already on hormone therapy.
These friends told them what to buy, where to buy and what side effects to expect.
This is a problem, says Madhusudan Kafle, a public health official from Kathmandu. Unsupervised hormone use can cause severe health risks, including cardiovascular disease, blood clots and even cancer. And some people take the wrong medication or mix various types.
“Transgender [people] already struggle mentally from discrimination and stigma,” he says, “and haphazard hormone use adds more complications.”
Selina Chaudhary, a transgender woman from Birgunj, started taking Diane-35, a hormone blocker, on the advice of a transgender friend from India. Chaudhary bought the drug in Raxaul and began to take, every day, what she assumed was the correct dose.
At first, everything seemed fine. Then, Chaudhary says her mental health deteriorated. Later, she developed diabetes and thyroid issues. She did not make any connections between these complications and her hormone use. One day, she had severe leg pain, and it started turning blue. She had it examined in India, and doctors found a blood clot, which they said was caused by her unregulated use of Diane-35.
Now 40 years old, Chaudhary says the negative effects of hormones have forced her to rely on medications to treat the conditions she developed — diabetes, low blood pressure — for the rest of her life.
Diane-35, which at low doses is used to treat acne, can bring about body changes quickly at certain doses. But it carries risks when used excessively, says Kathmandu-based endocrinologist Dr. Sunil Pokharel.
“People want the transformation overnight,” he says.
Pharmacy to the world
India describes itself as the “pharmacy to the world.” It supplies about 20% of the world’s pharmaceuticals including a quarter of the drugs in the United Kingdom and 40% of generic drugs in the United States.
Nepal relies heavily on India for its supply of medication. Both countries have regulations around the sale of medication, but implementation is often lax. Indian law requires that a pharmacist be present in pharmacies, but that’s often not the case. The availability of low-cost generic medication in India means that the market at the border is especially saturated with cheaper options, and it’s easy to buy drugs without prescriptions.
Prasad Tiwari, a pharmacy owner in Raxaul, says there’s been a spike in demand for hormones in the last seven years. Sellers dispense medication without prescription, and without information about side effects. They’re primarily traders, he says, and Diane-35 is in demand.
Narayan Prasad Dhakal, director general of Nepal’s Department of Drug Administration, says there are hormone treatments available in Nepal for transgender people, but the government doesn’t monitor their side effects.
Dr. Prakash Budhathoki, spokesperson for Nepal’s Ministry of Health and Population, says the government is trying to handle the situation. “We are trying to control its use as there are a lot of negative effects,” he says.
He did not provide details on the government’s regulation plans.
‘Easy access is necessary’
For Sona Gupta, the desire for transition outweighs the risks. She wanted the soft hair and skin that her friends promised she’d have if she took hormone medicine. She brushed off their warnings that it could lead to medical problems.
Within months of buying the hormone medicine in Raxaul, she says, she had a more feminine voice, less body hair and glowing skin.
But like Mahato, she has nausea, fatigue, increased hunger, low blood pressure — and even faints at times. She works as a dancer and avoids taking the medication before her performances because of the dizziness and exhaustion. She has considered consulting a doctor in Kathmandu for a proper dosage, but she worries about discrimination — and not just from doctors, but other patients at the hospital too.
For her, going to India for pills and self-medicating is the safest option.
Mahato says she spent four years mixing medications, including Sunaulo Gulaf, Ovral G and Nilocon White. At one point, she even switched to injections, although she can’t recall the type. All of this she did without consulting a doctor. Then she moved to Estradiol tablets and stayed on them for another five years.
There was a point when taking hormones to transition meant everything, she says, but she has dealt with too many health complications as a result.
At the time of this interview, she had stopped taking them entirely. But she still believes they are important. “Easy access is necessary.” But there is a need for some accountability, she says. “If the hormone causes a complicated sickness, who is going to take responsibility?”
