December 3, 2014
KATHMANDU, NEPAL – Pinky Gurung’s black heels click as Gurung strides down a crowded street in Kathmandu, Nepal’s capital, wearing a blue polka dot dress and subtle makeup.
Gurung, 36, knew when she was about 8 years old that she was different from other boys, she says. She wanted to wear dresses and skirts but refrained.
“I was afraid, and I bottled my feelings,” Gurung says. “I did not understand who I was.”
Gurung came to understand her gender identity in 2001, she says. Seven years later, she began dressing as a woman.
And because she wanted to develop more feminine characteristics, she started using hormone replacement therapy – medication that changes the user’s balance of sex hormones.
Without consulting a doctor, Gurung bought over-the-counter drugs recommended by other transgender women, she says. She saw results quickly. She did not realize the drugs had to be taken under medical supervision; her pharmacist did not ask her for a prescription.
She took a combination of three estrogen-based drugs daily, Gurung says. She used to spend about 15,000 rupees ($150) a year on her medication. These hormones gave her smoother skin and more feminine facial features, she says. They also enlarged her breasts.
“Not only did my appearance change, but psychologically too, I felt like a woman,” Gurung says. “That felt good.”
But by 2010, Gurung started having health problems. She was diagnosed with diabetes and hypertension. She went into depression. She lost her confidence, became nervous and developed a sleeping disorder.
“Although I knew the harm it was doing to my body, I continued taking HRT (hormone replacement therapy) because I wanted to look feminine and beautiful,” she says.
Many transgender men and women say appearance is important to them. To achieve their ideal body image, they often undergo surgeries or take HRT drugs. Some take drugs without medical supervision or knowledge of the side effects.
Although a doctor’s prescription is legally required for most HRT drugs, they are easily purchased over the counter. To limit the harm done by HRT and other drugs, the government plans to enact stricter regulations in 2015.
There are an estimated 15 million transgender people in the world, according to a 2011 study by researchers from the University of Hong Kong and the University of Michigan.
No one has conducted a survey to estimate the number of transgender people in Nepal, says Gurung, who is president of the Blue Diamond Society, a nongovernmental organization that advocates for sexual minorities in Nepal.
About 900,000 lesbian, gay, bisexual and transgender people have visited the Blue Diamond Society offices since the organization was founded in 2001, she says.
Many transgender people who use HRT in Nepal do so without a doctor’s supervision and monitoring, Gurung says.
Dr. Dina Shrestha, an endocrinologist at Norvic International Hospital in Kathmandu, confirms Gurung’s impression.
“HRT is not bad,” says Shrestha, who has treated a few transgender patients. “It is only harmful when it is unmonitored.”
Common long-term risks of HRT include heart disease, stroke, blood clots and breast cancer. Side effects during usage include mood swings, nausea, headaches and water retention.
Simran Sherchan, 29, realized her true gender 10 years ago, she says.
“I have always felt like a female, but I didn’t know to what gender I belonged,” she says.
She started taking hormone replacement therapy around the end of 2011, Sherchan says. Because the drugs could be purchased without a prescription, she was not aware that they had to be taken under medical supervision. Initially, she accepted the risks.
“I know these pills will harm my body, but I have to take them to look like a woman,” Sherchan says.
Gurung says that while some transgender people take hormone replacement drugs without knowing their side effects, many who know about the effects nonetheless use the drugs without medical supervision.
“They will continue to take them because they want to look beautiful,” she says, waving her hands expressively as she talks, her perfectly manicured fingers painted the same light shade of pink as her lipstick.
“There is unhealthy competition among transgender women,” she says. “Some take more than seven capsules in a day to look more beautiful and to attract partners.”
Gurung, however, ultimately decided that the ill effects of HRT outweighed the benefits.
In 2011, a doctor advised her to stop taking the hormone treatment because it could be causing her health problems, Gurung says.
Upon following his advice, she came out of her depression, she says. She now sleeps soundly and feels confident.
In a country with a per capita income of $700, some transgender people refrain from using hormone replacement therapy because they can’t afford it.
Bhakti Shah, 29, a transgender man, wears a tight vest under his clothes and carries a jacket to conceal the shape of his breasts.
He lives with his partner and mother in a two-bedroom apartment in Kathmandu and works as a human rights regional coordinator at the Blue Diamond Society. His family supports his quest to fulfill his gender identity.
But hormone replacement therapy drugs are unaffordable, he says. A six-month supply costs 4,500 rupees ($45) – more than Shah can afford on his monthly salary of 15,000 rupees ($150).
Shah also wishes he could have surgery.
“If I could afford a surgery, I would have removed my breasts,” he says.
The most popular destinations for sex reassignment surgery are Thailand and India; the latter option is cheaper.
Going to Bangkok, the capital of Thailand, for surgery on both the upper and lower body costs upwards of 500,000 Nepalese rupees ($5,000), including air travel and accommodations, Gurung says. In India, such a procedure costs about 400,000 rupees ($4,000).
“I want a muscular body,” Shah says. “I want to get rid of my jacket and wear a T-shirt, but I don’t know when that will happen.”
The surgery he wants, a double mastectomy that could be performed in Nepal, would cost at least 100,000 rupees ($1,000), Shah says.
Although Nepalese law requires a prescription for most hormone drugs, these medications are easily purchased from pharmacies without one.
Akftar Ali, owner of the Green Pharmacy in Kathmandu, sells hormone replacement drugs to one or two customers a day, he says.
“I sell HRT without a doctor’s prescription,” he admits candidly. “I am not aware of the law regarding selling HRT. I don’t think there is a law for the sale of HRT. I do know the laws regarding other drugs. I don’t know that I am breaking the law.”
Laying down the law and requiring prescriptions for HRT and other drugs would be bad for business, Ali says.
“If I sell HRT only with a doctor’s prescription, then no one will come to my shop to buy the medicine,” he says.
Enforcement of laws restricting the sale of HRT drugs is lax. But while hormone treatment is easily obtainable, “it should be prescribed by a doctor,” says Hari Phuyal, managing partner of Pacific Law Associates of Kathmandu.
Phuyal knows of no lawsuits filed over adverse effects of unsupervised use of HRT drugs.
Lacking complaints about the unauthorized sale of HRT drugs, the government’s drug enforcement agency, the Department of Drug Administration, has difficulty tracking down offending pharmacies.
Department agents conduct spot checks at pharmacies across the country to assess compliance with the law, says Bharat Bhatrai, a drug administrator at the department.
These inspections are comparatively rare. In the fiscal year that ended in July 2014, agents checked 1,332 pharmacies, Bhatrai says. The department aims to inspect 2,000 pharmacies this fiscal year.
In addition, the department will introduce a code of ethics for pharmacies, Bhatrai says. It plans to promulgate the code by next fiscal year, which begins July 15, 2015.
The Department of Drug Administration hears consumer complaints about defective drugs or problems with pharmacies, Bhattarai says. It has not received any negative feedback about hormone replacement therapy drugs.
“To my knowledge, we have not received any complaints on HRT,” he says.
Transgender people in Nepal need to learn more about how to make a safe, effective transition, Gurung says.
“Awareness programs have to be conducted on surgeries and HRT so that transgenders do not abuse their bodies,” she says.
The Blue Diamond Society plans to roll out a program to raise awareness of the dangers of hormone replacement drugs, Gurung says. It has not scheduled a launch date.
Gurung does not plan to take HRT drugs again, nor does she intend to undergo surgery, she says.
Sherchan, on the other hand, dearly wants a sex change operation, including getting breasts implants and having changes made to her facial structure, but she cannot afford such surgeries now.
Transgender women want to make a thorough transition, she says.
“Looking like a woman is very important to us,” Sherchan says. “We were born in a man’s body. So to modify our body, we need the help of HRT and surgery.”
Some interviews were translated from Nepali.