The High Price of Looking Like a Woman

James Estrin/The New York Times
TRANSITION Zaira Quispe, a transgender woman, was determined to get curves, so she paid for injections of silicone.
By LAURA RENA MURRAY Published: August 19, 2011 Reposted at keystothecloset.blogspot.com

ZAIRA QUISPE, 42, said she knew as a child that she was a girl, though she had been born male. She picked up a photo that she kept on the windowsill above her bed and held it out as proof. It’s a picture of herself as a smiling baby, naked and with legs crossed, concealing genitals. “Look,” she said, “even then I was trying to hide it.”

TREATMENT Dr. Anita Radix of Callen-Lorde with a patient.
Ms. Quispe, an Ecuadorean immigrant who came to New York at age 9, was determined to get the curves that would make her look more feminine. But she lacked health insurance or the money to pay for surgical procedures that would provide them; they can cost as much as $70,000. So she tried something else: she went to a so-called pumper, a person who illegally injects silicone to modify the body.

For her first injections, she said, she went to the Upper East Side, to an apartment with a view of the East River. In a small room she lay down on a narrow massage table, having paid $1,200 to get four cups of silicone injected into her hips and buttocks — without anesthesia.

When she slid off the makeshift surgical table, she saw bright red drops of blood staining the white sheet. The pumper, she said, dabbed Krazy Glue over each puncture — there were six on each side — to stop the bleeding. Then the pumper covered them with gauze and wound plastic wrap over the wounds before telling Ms. Quispe to get dressed.

Ms. Quispe was ecstatic with the results. Photos propped up on her desk depict a glowing young woman swathed in colorful dresses to showcase her new hourglass figure. Ms. Quispe smiled at the youthful images of herself surrounded by friends.

She has paid a heavy price for her joy. In time, the silicone in her body calcified and began to migrate, causing her a seemingly endless series of hospitalizations. At the beginning of July, she was hospitalized for an infection. Her body has been left scarred and misshapen. The skin on her buttocks and legs is discolored, and a lump of hardened silicone the size of a golf ball hangs behind her left knee.

“I knew she didn’t have any training, but I couldn’t go to a doctor to get the implants,” she says of the pumper and what drove her to get the injections. “I just wanted to look beautiful.”

PUMPERS and their desperate transgender clients operate in an underground world rarely glimpsed by most New Yorkers. But the practice is commonplace, especially among immigrant and poor women, according to dozens of transgender women, social-service providers and doctors interviewed in recent months. Although there are no reliable statistics on the number of transgender people in the city, a recent study prepared by the health department estimated it at 12,500. And according to the same study, 22 percent of transgender women have had silicone injections.

For these women, yearning to appear more feminine, and unable to afford gender reassignment surgery, pumping can seem like a relatively cheap and easy shortcut. The names of pumpers travel by word of mouth, handed down from older women to younger ones just beginning the process of transition. Some operate in teams, renting a hotel room and holding a pumping party to inject 10 or 20 women at a time.

It is a dangerous, and sometimes fatal, practice. Most plastic surgeons say silicone is safest when used as enclosed implants, but pumpers use loose silicone, which can migrate and cause disfigurement or significant scarring. Because medical-grade silicone can be hard to come by without hospital connections, some pumpers even inject cooking oil or industrial-grade silicone intended for cars and airplanes, said Dr. Anita Radix, a physician at Callen-Lorde Community Health Center in Manhattan, which primarily serves the lesbian, gay, bisexual and transgender community.

Cutting medical-grade silicone with baby oil, Crisco or other substances makes it cheaper. Although a number of pumpers say they have been trained as nurses, most have no medical training and are not licensed to perform surgical procedures, said Dr. Paul R. Weiss, a plastic surgeon and professor at the Albert Einstein College of Medicine of Yeshiva University. They often operate in rooms that are not sterile, increasing the risk of infection, Dr. Weiss said.

If silicone is injected into the bloodstream in error, it can cause a laundry list of serious medical problems, including acute respiratory distress, severe autoimmune or connective tissue disorders, pulmonary embolism or death, Dr. Radix said. Because of the underground nature of pumping, it is impossible to know exactly how many women have died from it, though deaths have been reported across the country.

Among the most recent was a case in Philadelphia, where in February, a 20-year-old woman who had flown in from London for injections died shortly after receiving them. In July, a transgender woman named Gabrielle Aguilar died at Elmhurst Hospital Center in Queens, days after visiting a pumper, said her cousin, Sheyla Gomez.

Ellen Borakove, a spokeswoman for the city’s medical examiner’s office, said Thursday that test results to determine the cause of death were still pending, but that an investigation was under way.

“Pumpers are preying on desperate people who are poor,” said Pauline Park, president of Queens Pride House, an organization that provides services to lesbian, gay and transgender people. “They’re basically killing people and profiting from it.”

The process of transitioning from one gender to another is a long and complicated one that can take years and cost tens of thousands of dollars in hormones and surgical procedures; it is hard enough for people who have the money to pay for it. The majority of transgender women don’t. They are either enrolled in Medicaid, which does not cover the transition process, or are uninsured, as Ms. Quispe was.

Dr. Radix has been treating transgender women since 1989, and at least a quarter of her patients have had silicone injected into their breasts, buttocks and faces, she said. Most believe the trade-off is worth the risk, she added, “for all the years that they had the body they want to have.” They also feel shut out of the medical establishment, a situation that heightens the appeal of pumpers. “If folks had access to medical care, they wouldn’t have to go for the silicone,” Dr. Radix said.

That was true of Ms. Quispe, who said she desperately wanted to possess curves but could not afford to see a plastic surgeon.

Ms. Quispe decided to build her buttocks and hips incrementally, visiting a pumper whenever she could afford a liter of silicone. She estimated that she was injected 10 times by three pumpers from 1989 to 2000, spending close to $20,000.

“If I collected all the money I used for silicone,” Ms. Quispe said, “I would have enough money to do my sex-change operation.”

Six months after receiving her last two liters of silicone, in 2000, Ms. Quispe began to experience chronic stabbing pain in her legs and stomach, she said. The silicone turned hard and began to migrate down her legs and through her body.

Many share her experience, said Ronica Mukerjee, a nurse practitioner who does medical outreach in Queens with transgender women. “Silicone isn’t always deadly, but injecting free loose silicone is very dangerous in large quantities,” Ms. Mukerjee said. “Silicone drifts. I’ve seen silicone injected in their hips end up in their ankles.”

In 2002, Ms. Quispe’s primary-care doctor referred her to a plastic surgeon at Beth Israel Medical Center who, she said, told her the last injections she received had been industrial oil rather than silicone. Trying to remove it surgically could be life-threatening because the oil was embedded in the muscle tissue and the entire muscle would have to be excised from her buttocks and hips. Removing the tissue would leave her with massive cavities, altering her body weight and metabolism drastically, and increase her suffering.

He advised her, she said, to take medication for the pain instead of risking surgery. Since then, she has visited several other plastic surgeons with the hope that one might have a different answer — but none have. Five of her friends were injected by the same pumper, she said, and are experiencing similar problems.

Now, Ms. Quispe spends most of her time in her tiny apartment in Vinegar Hill, Brooklyn, in the Farragut Houses. Ms. Quispe’s home is decorated with miniature Buddhist statues and several plastic Chinese tapestries tacked on the wall for good luck. The front door opens to a small kitchen with a narrow table and two chairs squeezed next to an old refrigerator. A short corridor leads to her bedroom, most of which is dwarfed by a queen-size bed, where she spends most of her time safely removed from the jeering comments of strangers.

“I’d rather be inside my place because everyone looks at me like I’m an alien,” she said, wincing and shifting uncomfortably on the chair. “I’m a human being just like everyone else.”

STORIES like Ms. Quispe’s wouldn’t be possible without women like S., a pumper who agreed to be interviewed only on the condition that she be identified by her first initial because what she does is illegal. Born male, S. said, she ran away from home at 15. She met an older transgender woman at a nightclub who helped her begin her transition. The same woman also introduced her to prostitution, and S. used that money to pay for female hormones when she was 15 and for silicone injections that she began receiving at 24, in 1985, from Dr. David R. Wesser, a New York surgeon then well known in the transgender world.

S. said she learned to inject silicone herself 17 years ago by informally training with an Upper East Side doctor from Spain who performed surgical procedures without a license in New York. S. said she worked out of his office for a year, but began injecting women without his supervision because she did not like having to split the profits. When he realized she was pumping on her own, the doctor agreed to sell her equipment and silicone, she said. She continues to buy supplies from medical distributors because of the relationships she developed through him and Dr. Wesser, who died in 2008.

Sometimes, S. said, she buys silicone abroad; sometimes she gets it from hospital connections. She currently pays $2,700 for a half-gallon of loose-flowing medical-grade silicone, which she can use to inject 10 people, charging $400 to $1,000 for each treatment.

SHORTCUT Zaira Quispe has been hospitalized after receiving injections from an untrained woman called a pumper.

“It could take from three to four treatments before you get a perfect image of a feminine face,” S. said. “You have to do it a little at a time because you don’t want to turn somebody into a monster.” She injects up to 20 people a week, making about $10,000 each week, she said.

The evidence of her success crowds the spacious two-bedroom apartment she rents in Brooklyn. The exterior of her building fits in with the dilapidated neighborhood. The front door is missing a doorknob, and the windows are boarded up and painted a mud brown, concealing the opulent interior. Inside her apartment, gold candleholders, ceramic vases, crystal and gleaming white cherubic angels sparkle under elaborate chandeliers. Thirteen Tiffany-style lamps clutter her shelves, and dozens of porcelain plates hang in rows on her walls.

One corner of her dining room contains 10 bird cages stacked in two columns from floor to ceiling, the sides of the cages covered in tin foil and each cage holding three to six canaries, finches and other small birds.

The living room is crammed with stacks of boxes containing items that she plans to move to a house she said she recently bought in Puerto Rico.

S. sees herself as helping the women she injects. “I try to help the girls because they want to look feminine,” she said, caressing the contours of her face to demonstrate. Her overly plump apple cheeks and smooth pink lips are telltale signs of the silicone injections she has given herself over the years. They dwarf her small, sculpted nose and dark brown eyes, which gleam under the thin eyebrows she carefully draws on. “I try to guide them because the majority of these girls are young,” she continued. “They come to me with holes, dimples; they don’t have no cheeks, and their face is long.”

Indeed, a majority of transgender women begin the process of transitioning, as Ms. Quispe and S. did, while teenagers: 62 percent of the transgender women surveyed by the city’s health department identified themselves as female before the age of 18.

Transgender youth cannot be treated by a doctor without parental consent, and many of them are estranged from their families because of their gender identities. According to a 2011 discrimination report released by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 19 percent of transgender people experienced homelessness because of their gender identity, 57 percent were rejected by their families, and 41 percent had attempted suicide.

S. estimated there were 50 pumpers injecting silicone in New York City. While she acknowledged some dangers, she said the problem lay in bad work by other pumpers. She said all of her clients had been satisfied with her work and she had never had a complaint.

“You don’t have to go to school to be a doctor,” S. said. “It’s a gift from God. Sometimes, people have that gift: how to take something and create it, make it something else.”

BUT Jahaira Gonzalez, a 31-year-old transgender woman from the Bronx, said in interviews in the fall that S. had repeatedly injected her with silicone, to the point of discomfort. Ms. Gonzalez came out at 16 and left her home when she was 17 to begin her gender transition. She met S. at a club and lived with her for two years. During that time, she said, S. sold her bottles of estrogen and injected her chin, jaw line, cheeks, upper and bottom lips, calves, hips and buttocks with silicone. Ms. Gonzalez said that she regarded S. as a mother figure and that S. taught her how to be a woman.

“I wanted to be just like her,” Ms. Gonzalez said. “In the beginning, she created me, something beautiful.”

Ms. Gonzalez said, however, that S. injected her with too much silicone. Now, in the winter, it freezes like a bag of water placed on ice. “If it gets really, really cold, my lips become really hard and my cheekbones become really stiff,” she said. “In the summer time, it’s like I’m melting. I sweat a lot in my face and I can feel the heat heating up my sil.”

Worse, she said, is the unnatural look the injections have left her with. Ms. Gonzalez’s apple cheeks and swollen lips mimic S.’s face, meant to make her nose and chin appear smaller but giving her face a round and constructed appearance. “It’s even more worse when you have all this surgery done to feminize yourself and people still know what you are,” Ms. Gonzalez said. “So it kind of messes with your head mentally ’cause it’s like, ‘Why did I do all this work for if people are still noticing that I was born biological male?’ ”

IN mid-July, Ms. Quispe was released from the hospital. She returned home, although she still felt dizzy and weak. Then her hands, feet and lips began to tingle and she developed a fever. Days later, she was admitted to Beth Israel Medical Center, where nurses injected her with blood thinner daily to prevent blood clots from traveling to her heart. She peered wanly over her bloated stomach and swollen feet at the intravenous drip that was inserted in her vein. Her body is in a constant state of inflammation. Ms. Quispe’s doctors have told her they may have to try surgery to remove the silicone if steroids and antibiotics do not reduce the swelling.

“My life is in jeopardy,” Ms. Quispe said. She looked at the angry purple and scarlet marks that dotted her stomach from the blood-thinner injections, just above the stitches from her recent biopsy. “If I had known I would look like this, I wouldn’t have done it.”

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