BIRGUNJ, NEPAL — Thanks to advice from friends, Sanju Mahato crossed Nepal’s border into India, walked into a pharmacy and left minutes later with hormone therapy drugs.
Nobody asked any questions. No one gave him advice on dosage.
It was easy — and for Mahato, it was a welcome change from his hometown of Birgunj, where pharmacies don’t stock hormone therapy drugs for transgender people who want to body transition.
Mahato started taking drugs. Every day, her body got closer to the one she wanted. Her breasts grew bigger. The veins in his arms softened. His confidence also increased.
Then came the complications: nausea, vomiting, fatigue. She gained about 25 kilos (55 pounds) and began to forget things. She had kidney stones and needed surgery, but because her veins had thinned from hormone therapy, the operation would cause excessive bleeding, a doctor told her.
In 2007, Nepal’s Supreme Court ruled that a third official gender self-identification option would be possible — a change specifically designed for transgender people — but the real-world transition process remains a struggle. Gender-affirming surgeries are illegal, and there is a shortage of hormone therapy medications, as well as doctors qualified to prescribe them.
Ultimately, transgender people – especially transgender women – rely on self-administered hormone treatment, often purchased from pharmacies across the border in India. (For transgender men, access to masculinizing hormones is difficult, even in India.)
These treatments facilitate gender transition, but they carry significant health risks, including life-threatening complications.
A network of friends, risky advice
The Global Press Journal interviewed six transgender women in Birgunj, all of whom purchased hormonal drugs in Raxaul, crossing the open border easily and without consulting a doctor. They relied mainly on the advice of their friends who were already taking hormone treatment.
These friends told them what to buy, where to buy, and what side effects to expect.
This is a problem, says Madhusudan Kafle, Kathmandu’s public health officer. Unsupervised use of hormones can lead to serious health risks, including cardiovascular disease, blood clots and even cancer. And some people take the wrong medications or mix different types of medications.
“Transgender people already struggle mentally with discrimination and stigma,” he says, “and random hormone use adds even more complications.” »
Selina Chaudhary, a transgender woman from Birgunj, started taking Diane-35, a hormone blocker, on the advice of an Indian transgender friend. Chaudhary bought the medicine from Raxaul and began taking what she thought was the right dose every day.
At first everything seemed fine. Afterwards, Chaudhary says his mental health deteriorated. She later developed diabetes and thyroid problems. She made no connection between these complications and her hormone use. One day she had severe pain in her leg and it started to turn blue. She had it examined in India and doctors discovered a blood clot, which they believed was due to her unregulated use of Diane-35.
Now 40, Chaudhary says the negative effects of hormones forced her to rely on medications to treat the illnesses she developed – diabetes, low blood pressure – for the rest of her life.
Diane-35, which is used in low doses to treat acne, can cause bodily changes quickly at certain doses. But its excessive use carries risks, says Dr Sunil Pokharel, an endocrinologist based in Kathmandu.
“People want overnight transformation,” he says.
The pharmacy in the world
India describes itself as the “pharmacy of the world”. It supplies around 20% of the world’s pharmaceuticals, including a quarter of the UK’s medicines and 40% of the US’s generic medicines.
Nepal relies heavily on India for its supply of medicines. Both countries have regulations regarding the sale of medicines, but implementation is often lax. Indian law requires a pharmacist to be present in pharmacies, but this is often not the case. The availability of low-cost generic drugs in India means that the border market is particularly saturated with cheaper options and it is easy to buy drugs without a prescription.
Prasad Tiwari, owner of a pharmacy in Raxaul, says the demand for hormones has increased over the past seven years. Sellers deliver medicines without a prescription and without information on side effects. They are primarily traders, he says, and the Diane-35 is in high demand.
Narayan Prasad Dhakal, director general of Nepal’s Department of Drug Administration, says there are hormonal treatments available in Nepal for transgender people, but the government does not monitor their side effects.
Dr Prakash Budhathoki, spokesperson for Nepal’s Ministry of Health and Population, says the government is trying to manage the situation. “We try to control its use because there are a lot of negative effects,” he says.
He did not provide details of the government’s regulatory plans.
“Easy access is necessary”
For Sona Gupta, the desire to transition outweighs the risks. She wanted the soft hair and skin her friends promised her if she took hormonal medications. She ignored their warnings that it could lead to medical problems.
A few months after buying the hormonal drug in Raxaul, she said, she had a more feminine voice, less body hair and glowing skin.
But like Mahato, she suffers from nausea, fatigue, increased hunger, low blood pressure – and even passes out sometimes. She works as a dancer and avoids taking medication before her performances due to dizziness and exhaustion. She has considered seeing a doctor in Kathmandu to get a proper dosage, but she worries about discrimination – and not just from doctors, but also from other patients at the hospital.
For her, going to India to take medicine and self-medicate is the safest option.
Mahato says she spent four years mixing drugs, including Sunaulo Gulaf, Ovral G and Nilocon White. At one point, she even switched to injections, although she doesn’t remember the type. She did all this without consulting a doctor. She then switched to Estradiol tablets and stayed there for another five years.
There was a time when taking hormones for transition meant everything, she says, but as a result, she had to deal with too many health complications.
At the time of this interview, she had stopped taking them altogether. But she still believes they are important. “Easy access is necessary.” But some accountability is necessary, she says. “If the hormone causes a complicated disease, who will take responsibility?
