China lowers minimum age to 18 for gender reassignment surgery

Society & Culture

China is taking steps to bring itself up to international medical standards when it comes to trans healthcare.

Demetrius Freeman/Reuters

Welcome to our new China LGBTQ Column — Queer China — a fortnightly round-up of news and stories related to the sexual and gender minority population in Greater China.

On April 20, the National Health Commission of China updated (in Chinese) its regulations on gender reassignment surgery (GRS). Last updated in 2017, the new edition lowers the minimum age for receiving the surgery from 20 to 18, simplifies mandatory operative procedures, and scraps previous conditions that required recipients to go through a year of psychological counseling or psychiatric treatment pre-surgery. 

“Many trans people I know reposted the news on WeChat. The community was applauding the change,” said Āwǎn 阿婉, a Shanghai-based medical practitioner and active volunteer in the trans community, who requested to use a pseudonym for privacy reasons. Several LGBTQ blogs and social media accounts praised the new policy (in Chinese) as moving toward a more supportive and inclusive medical environment for transgender people. 

According to Awan, the simplification of operative procedures will have a particularly positive impact on trans individuals. In China, going through GRS is a necessary condition for the change of gender mark on one’s national ID and other legal documents. The 2017 version stipulated that one could receive a validation document from the surgeon only after the completion of two separate surgeries: genital removal and reconstruction. In contrast, the new edition specifies that the removal operation alone can suffice. This move will likely streamline the process of changing gender identity on legal documents. In addition, chest reconstruction has been removed from the list of mandatory procedures for trans men (a rule that has never been imposed on trans women).

Awan remarked that these revisions were not only symbolically meaningful in recognizing trans people’s diverse bodily expressions and medical demands, but they would also make the process more financially accessible. For trans women in China, removing their male genitals usually costs 10,000 yuan ($1,500), but the price tag for the transition can climb to over 60,000 yuan ($9,000) with reconstruction surgeries included. The combination of two surgeries also entails a longer recovery period with a whole new set of expenses involved. This would make surgical treatment more affordable for young and lower-class people, especially when their financial situations are exacerbated due to discriminations they encounter in seeking job opportunities, and lack of family support. 

Another noticeable change is in medical terminologies. While the psychiatric diagnosis of “transsexualism” (易性症 yìxìng zhèng), a stigma-laden evaluation one must fulfill to be eligible for the surgery, is preserved, two other labels — “gender dysphoria” (性别焦虑 xìngbié jiāolü) and “gender incongruence” (性别不一致 xìngbié bùyīzhì) — have been added as equivalents. The two terms were respectively used in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) and the ICD-11 (International Classification of Diseases, 11th edition), both of which are internationally recognized handbooks for diagnosing mental disorders. 

The new terms intend to stop pathologizing the feeling of mismatch between one’s sex assigned at birth and their gender identity, while recognizing the need to provide medical care to resolve the distress faced by certain transgender or genderqueer people, said Ms. Xiāo 肖女士, a U.S.-based Chinese trans researcher. She commented that although the use of “transsexualism” retains the pathological and stigmatic connotations on trans people and GRS (which is known as “sex change surgery” [变性手术 biànxìng shoushù] among the Chinese public), the inclusion of the two new terms signals that Chinese policymakers are starting to accept international protocols and language on trans issues.

The only new limitation added to the regulations pertains to the eligibility of psychiatrists who prescribe diagnoses. Previously, there was no restriction relating to the rank of medical institutions, but now only prescriptions from doctors in top-tier (三甲 sānjiǎ) hospitals are acceptable. Awan reckoned this restraint as having a light impact, given that there’s a limited number of doctors in China right now who have the knowledge and awareness to prescribe the diagnosis, and most of them work at sanjia hospitals already. Moreover, the trans community has assembled and regularly updates a list of trans-friendly doctors and clinics, which is used by many as a guide to access medical instructions and services.

Existing challenges and obstacles

However, several prerequisites are preserved in the new edition, which may continue to exclude certain trans people from accepting surgical treatment. For instance, it is stipulated that candidates shall “voice continuous demand for GRS for at least five years,” and their legal status must be unmarried. Moreover, a clean criminal record is required, which perpetuates the “unfriendly condition for those who engage in sex work for a living,” said Ms. Xiao. 

In China, where sex work is outlawed, transgender sex workers are among the most marginalized and vulnerable populations. According to a 2015 survey of 70 female trans sex workers from Beijing and Shanghai, 64% of them had been arrested by the police; those with a male gender mark on their IDs were jailed with men. Many reported experiences of being physically and verbally abused by the police due to the mismatch between their gender expression and legal identity. 25% of the respondents intended to undergo GRS someday.  

Another retained prerequisite is the notarized consent requirement from an “immediate family member” of the candidate, which usually refers to their parents, even in cases where the candidate is an adult. Ms. Xiao said the actual implementation of the rule often varies between surgeons. However, certain doctors can be so strict that they even request the parents to be physically present, adding another layer of obstacles for trans people. Awan opined that this policy is very likely a preemptive act to protect the medical professionals and institutions from possible disputes waged by the parents, or yīnào 医闹. Roughly translated as “medical ruckus,” the term refers to incidents where aggrieved patients and their families disturb the hospital or violently attack doctors for what they consider as mistreatment. In the case of GRS, however, a rule meant to protect the doctors might in fact institutionalize parental authority and weaken trans people’s autonomy of their own body, Ms. Xiao added.

In a recent interview (in Chinese), Pān Bǎilín 潘柏林, a Beijing-based surgeon and leading figure in introducing more integrated and accessible medical care system for trans people in China, also discussed the question of parental intervention in trans healthcare. Pan recalled meeting a young trans woman whose parents once sent her to a psychiatric clinic, where her hormone replacement therapy was suspended and the staff forced her to take antidepressants. Similar stories of parental violence against trans youth have been reported in the past few years, illustrating the cruel reality that “trans medicine is more than a medical issue,” as Pan said.

Despite these challenges, the new regulations nevertheless send some positive signals. Ms. Xiao attributed the progress to a convergence of factors: media coverage that promotes public visibility of trans issues; medical professionals who display an increasing interest in the field and have begun to join international dialogue; more assertive voices demanding change inside the trans community; and NGO activists who persistently push for a low-profile but effective social change. 

Other LGBTQ topics in the news:

A Taiwanese queer film made in the 1980s was rescreened in the U.K.
Girls’ School: Taiwanese queer gem is hopelessly devoted to teenage passions / The Guardian
The Taiwanese film Girls’ School 女子學校 (dir. Lee Mi-Mi 李美彌) was re-screened on the Queer East Film Festival in London on May 24. Originally released in 1982, the film revolves around the intimate, homoerotic relationship between two students in a girls’ school, and showcases school life and social attitude toward homosexuality in 1980s Taiwan.

Beijing Queer Chorus released a musical video to observe IDAHOTB 2022
IDAHOTB | Sing, dance, right now! You will find your power and love yourself more / Beijing Queer Chorus
On May 16, the day before International Day Against Homophobia, Biphobia, and Transphobia (IDAHOTB), Beijing Queer Chorus (北京酷儿合唱团) released a musical video titled “This Is Me.” Featuring chorus singing and vogue dancing, the video “tells a story about how a group of ordinary people break up constraints and make their true self flourish.”

Trans Brotherhood celebrates its three-year anniversary
I stopped wearing feminine clothes at work, then this happened… / Trans Brotherhood
May 11 was the anniversary of the establishment of Trans Brotherhood (飞天猫兄弟团), a network for transgender men in China. A comic strip was published on its WeChat platform that narrates the founding story of the network.