Balancing benefits and harm: chemical use and bodily transformation among Indonesia's transgender waria.

BACKGROUND: Members of Indonesia's diverse male-to-female transgender community often describe themselves as waria. Waria do not equate being feminine with being female. They do not want to be women; they aspire to be like women. It entails cultivating mannerisms and wearing make-up and women's clothes, shaving one's legs and styling one's hair. But some go further in their practices of self-administered, chemically assisted bodily transformation.
METHODS: Field research took place in Makassar, the capital city of South Sulawesi; in a smaller town in the regency of Bulukumba on the south coast of Sulawesi; and in the special region of Yogyakarta in Java. Data were collected through repeated in-depth interviews with ten waria youths aged between 18 and 26 in each site; interviews with pharmacists, drug and cosmetics store clerks; three focus group discussions at each site; and participant observation.
RESULTS: Our respondents saw their bodies as 'projects' they can manipulate with pharmaceutical products and cosmetics. To lighten their skin, they experimented with different brands of exfoliating liquid, whitening cream, powder, foundation, face soap and skin scrub. To grow breasts and reduce muscle mass, they experimented with different brands and dosages of contraceptive pills and injections in order to get faster, better and longer-lasting results.
CONCLUSION: Harm reduction programs often neglect chemicals that are not narcotics, not related to sexually transmitted infections, and which are legally and freely available. Safety issues arise when otherwise safe products are used off-label in large quantities. Drug policy-makers are paying insufficient attention to the safety of cosmetics.

Introduction

Studies of transgender men and women have often focused on their gender identities and how societies differ in their acceptance of gender ambiguity (Besnier & Alexeyeff, 2013; Graham-Davies, 2010; Johnson, 1997; Koon, 2002; Nanda, 1990, 2000; Sinnott, 2004). These studies, which often focus on how transgender individuals ‘perform’ gender, have generally portrayed transgenders as stigmatized and disempowered groups in heteronormative societies.

A number of recent studies have addressed non-heteronormative subjectivities in Indonesia (Blackwood, 1998, 2005; Boellstorff, 2005, 2007, 2008; Wieringa, 1999, 2012). Blackwood (1998) has focused on the construction of masculinity and erotic desire among tombois in West Sumatra; Blackwood (2005) has examined how lesbi in West Sumatra access and appropriate the discourses of the global queer movement to shape their gendered and sexual subjectivities. Boellstorff (2005) has addressed how transvestites in Indonesia experience dissonance between their male bodies and female jiwa (souls), while Wieringa (2012) has discussed some of the major symbolic forms of subverting heteronormativity in Indonesia.

Members of Indonesia's diverse male-to-female transgender community often describe themselves as waria – derived from the words wanita (woman) and pria (man). Waria are “male bodied individuals who act like women and take men as lovers” (Blackwood, 2005, p. 233). Although waria usually have sex with ‘real’ men, they are not seen as gay (Boellstorff, 2005). Bodily presentation appears more important than sexual acts in asserting femininity (Boellstorff, 2005). Most waria begin identifying as such while they are (young) children.

“Warias do not equate being feminine with being female” (Boellstorff, 2007, p. 92). Our research in three urban sites in Indonesia confirms that – like the travesti Kulick (1998) studied in Brazil – waria do not want to be women. They instead aspire to be like women (seperti perempuan). This entails cultivating mannerisms as well as ‘covering up’ masculine traits, here associated with the notion of dandan – to be made up, wearing women's clothes, shaving one's legs and styling one's hair (see Boellstorff, 2008). And as we found out in the course of our research, some waria go further in their practices of transforming their bodies.

Before the 1970s, waria could only strive to feminize their bodies through the use of ‘traditional’ medicines and by inserting padding under their blouses. Nowadays, more permanent means of bodily transformation are available (cf. Sanabria, 2013), including the ingesting and injecting of female hormones, surgical interventions involving silicone, and in the rarest of cases, sex-change operations (Boellstorff, 2007, p. 94). The current article is an in-depth exploration of contemporary practices of self-administered, chemically assisted bodily transformation among a group of 30 waria youths, spread across three sites in Indonesia.

The ideal mark of femininity in Indonesia, many have claimed, is to have well-formed breasts and light skin, for which women use a variety of chemical products. Indeed, having smooth, fair skin and beautiful breasts emerged as major preoccupations among the waria we interviewed in all three of our field sites. To achieve these ends, they experiment with various contraceptive hormones (both pills and injections) and skin-whitening products (including those containing potentially harmful ingredients), finding the dosages and products that work best for them. While most of our informants were fairly happy with the immediate results, they continuously experience severe side-effects. And while they develop strategies to minimize the side-effects, at least some of our informants did not expect to live long (cf. Suja, Sutanyawatchai, & Siri, 2005).

Following a brief outline of our methods, we turn to the detailed description of the practices of body-shaping and skin-whitening that we observed in our field sites, focusing on the products used by our informants and their pervasive experimentation to find the (combinations of) products that are most cocok (compatible) with their individual bodies. This is followed by reflection on how these practices spread, pointing to the social contexts of chemically assisted bodily transformation in our field sites. In the conclusion, we touch upon what our findings imply for existing harm reduction programmes in Indonesia and beyond.

Methods

Our field research took place in Makassar, the capital city of South Sulawesi; in a smaller town in the regency of Bulukumba on the south coast of Sulawesi; and in the special region of Yogyakarta in Java. NGOs were involved in the recruitment of our informants: Yayasan Gaya Celebes in Makassar, Wakerba in Bulukumba, and Kebaya in Yogyakarta. Waria in Makassar are more loosely organized and were harder to contact. The fact that we were often introduced to our informants through self-organized groups of waria introduces the possibility of significant selection bias. We do not claim our findings to be representative for waria in South Sulawesi or Yogyakarta, much less for waria across Indonesia. We pursued research in these three sites to see if the chemical use practices that we observed were localized or geographically widespread.

Data were collected through repeated in-depth interviews with ten waria youths aged between 18 and 26 in each site (30 in total); interviews with pharmacists, drug and cosmetics store clerks; three focus group discussions at each site; and participant observation. We began our focus groups with drug recalls to obtain data on the chemical products consumed over the preceding four days, dosages, costs, length of use, desirable and adverse effects, and any perceived long-term risks.

We used NVivo 10 to analyse the data. We began by identifying themes in the interview transcripts to make a coding scheme. Subsequent text-search queries using NVivo facilitated the iterative analysis of the data.

All participants in our research gave their voluntary written consent after we explained our research objectives. We received ethical clearance from the University of Amsterdam as well as official letters from provincial and local authorities to conduct research in their jurisdictions. All names in this article are pseudonyms. Although we recognize that other scholars have used different terminology, we have chosen to use “she” and “her” when referring to gender transgressing individuals.

Body shaping

Many of our waria informants took contraceptive hormones meant for women to reshape their bodies. By ingesting or injecting hormones directly into their chests, thighs and arms, they sought secondary beneficial effects such as smoother skin, the elimination of visible veins and reduced muscle mass. Unlike the Brazilian travesti studied by Kulick (1998) who sought to physically transform their chests, buttocks and thighs, our informants mostly wanted to have breasts like women. This first entailed creating a base (dasar) containing hard tissue (batu) for our informants in Makassar and Bulukumba, and a pocket (kantong) to form their breasts for our informants in Yogyakarta.

Contraceptive pills and injections were the favoured means to form breasts among our informants in Makassar and Bulukumba. Their initial concern was to form the base containing hard tissue so that their breasts would grow in the right place. They then turned to high dosages of injected hormones to grow their breasts, followed by lower dosages of contraceptive pills or injections to maintain them. Many of our informants in Yogyakarta, sick of taking regular pills or injections, favoured silicone breast implants. But regardless of whether they used hormones or silicone, our informants all stressed that they first needed to use hormones to form a pocket to position their breasts. Becoming more feminine was thus a gradual process (Fig. 1).

Fig. 1

The most popular brands for pills and injections. Photographer: Nurul Ilmi Idrus.

Our informants experimented with Andalan, Marvelon, Microdion, Microgynon and Trinordiol brand contraceptive pills as well as Andalan and Cyclofem injections. Andalan and Marvelon were the most popular pills; Cyclofem was the most popular injection, though Andalan (on the market for breastfeeding women) was also seen as highly effective. The popularity of these brands was confirmed by a number of chemists whom we interviewed. Many said that contraceptive pills work faster than injections (but see Sanabria, 2013). Most began with brands mentioned by their waria peers, by a midwife (bidan), or more seldom, by family members. Some pills were prescription only; others were not. Either way, they were freely available over the pharmacy counter. Table 1 shows the products used by our informants along with their manufacturers, chemical content and product information.

Table 1

Contraceptive products used to feminize bodies.

Product	Manufacturer/licence	Content	Product information
Andalan pill	Marketing: DKT Indonesia	Each tablet contains:0.15 mg Levonolgestrel0.03 mg Ethinylestradiol	Begin taking on the first day of menstruation
	Manufacturer: PT Sydna Farma, Jakarta, Indonesia		Indication: low dosage oral contraceptive for breast-feeding mothers
	License: NV Organon, Netherlands		By prescription only
Marvelon 28 pill	Marketing: DKT Indonesia	Each pack consists of 21 large tablets, each containing:0.150 mg Desogestrel0.030 mg EthinylestradiolNo active ingredient in the small tablets	By prescription only
	Manufacturer: PT Sydna Farma, Jakarta, Indonesia
	License: NV Organon, Netherlands
Trinordiol pill	Manufacturer: Wyeth, Germany & Republic of Ireland	Each light brown tablet contains:0.03 mg Ethinylestradiol0.05 mg Levonorgestrel	Synthetic oestrogen and Levonorgestrel is a synthetic form of progesterone
		Each white tablet contains:0.04 mg Ethinylestradiol0.075 mg LevonorgestrelEach ochre tablet contains:0.03 mg Ethinylestradiol0.125 mg Levonorgestrel	Each 21-day pack contains three types of tablets (six light brown, five white, ten ochre), each with a slightly different hormone dosage
Microgynon pill	Manufacturer: Schering do Brasil Quimica Farmaceutica Ltda, Sao Paolo, Brazil	21 Sugar-coated tablets, each containing:0.15 mg Levonorgestrel0.03 mg Ethinylestradiol7 Sugar-coated tablets, each containing 48.25 mg Lactosa	By prescription only
	Importer: PT Bayer Indonesia
Microdiol 30 pill	Manufacturer and distributor: Kimia Farma Indonesia	Each small tablet contains: 0.150 mg Levonorgestrel 0.030 mg EthinylestradiolNo active ingredient in the large tablets	By prescription only
Cyclogynon pill	Marketing: PT Tunggal Idaman Abdi, Indonesia	Each tablet contains:0.15 mg Levonorgestrel0.03 mg Ethinylestradiol
	Manufacturer: PT Sunthi Sepuri, Indonesia
Andalan Laktasi pill KB	Marketing: DKT Indonesia	Each tablet contains:0.15 mg Levonorgestrel0.03 mg Ethinylestradiol	By prescription only
	Manufacturer: PT Sydna Farma, Indonesia
	License: NV Organon, Netherlands
Andalan contraceptive injection	Manufacturer: Harsen, Indonesia, incorporated under DKT Indonesia	Each 1 ml contains: 150 mg Medroxyprogesterone acetate	By prescription only
		Sterile suspension of Medroxyprogesterone acetate in water
Cyclofem contraceptive injection	Manufacturer: PT Tunggal Idaman Abdi, Indonesia	Each vial contains:25 mg Medroxyprogesterone acetate5 mg Estradiol USP sterilized micronized	By prescription only
	License: Concept Foundation, Thailand

Our informants experimented with dosages to see what works best, consuming anywhere between 1 and 21 contraceptive pills per day. Imas from Bulukumba began by taking one pill a day, the prescribed dosage for ‘ordinary women’. After finishing a strip of pills and experiencing pain in her breasts and penis, she changed to monthly contraceptive injections, three times the normal prescribed dosage (Table 2).

Table 2

Contraceptive dosages.

	Women (prescribed)	Waria (off-label)
Pills	One per day	1–21 per day
Injection	Once a month or every three months	Twice a week to once every three months

Some of our informants experimented with much heavier dosages. Anti from Bulukumba took five Andalan pills twice a day for almost two years. Her friend Nindi took seven pills three times a day, while Mince from Makassar had six contraceptive injections over a period of three weeks. The belief is that the higher the dosage, the greater and faster the effect. Problems ensued, however, when our informants lowered dosages to maintain their breasts; their breasts then shrank, necessitating higher dosages again. Citra experimented with weekly injections which provided quick results, but had to continue injections at the same dosage to maintain the shape of her breasts.

Our informants believed that in the process of growing breasts, certain foods and drinks had to be avoided so that the hormones would have their full effect. Cece from Yogyakarta avoided drinking cold water and soft drinks. Anti from Bulukumba was warned by her peers not to eat spicy or sour food, while Ade from Yogyakarta was advised not to consume alcohol. Growing and maintaining breasts was not just a question of taking hormones, but concerned brands, dosages, modes of administration, and diet.

Switching and combining hormones

Our informants often switched between or combined hormonal products. Some stayed with one brand; others experimented with different brands to see which were most cocok with their individual bodies. How the products influenced their outward appearance was a major consideration; negative side-effects were often tolerated if outward appearance was not adversely affected. Others stopped using certain products when they could no longer tolerate their side-effects.

The effects of hormones differed between individuals. The beneficial effects reportedly included the growth of breasts, hair fall-out (i.e. body hair), smoother skin, the reduction of muscle mass, the elimination of pimples, a glowing face and firmer buttocks. Among the adverse effects, our informants reported nausea, dizziness, drowsiness, pimples, red facial spots, constipation, diarrhoea, feeling sluggish and bloated. Table 3 shows the desired, beneficial and adverse effects of each brand mentioned by our informants.

Table 3

Effects of hormones.

Product brands	Desired effects	Beneficial effects	Adverse effects
Andalan pill	Growing breasts	Growing breasts, thinning body hair, smoothing skin, eliminating visible veins	Continuous diarrhoea, sleepiness, feeling limp and dizzy, feeling like vomiting, gaining weight, lacking sexual desire
Marvelon pill	Growing breasts	Growing breasts, glowing face, good skin	Pimples, feeling dizzy, hair fallout, gaining weight around nose, red facial spots, shivering
Microdiol pill	Growing breasts	Growing breasts	Red facial spots
Microgynon pill	Growing breasts	Growing breasts, eliminating muscle, eliminating visible veins	Red facial spots, feeling limp
Cyclogynon pill	Growing breasts	Growing breasts	Gaining weight
Trinordiol pill	Growing breasts	Growing breasts, eliminating pimples	Nausea, constipation
Andalan Lactacy pill	Growing breasts	Fast growing breasts	Watery breasts, hair fallout
Diane 35 pill	Growing breasts	Growing breasts, smoothing skin, eliminating muscle	Feeling lazy, becoming fat, increased appetite, headache, lacking sexual desire
Andalan contraceptive injection	Growing breasts, eliminating visible veins	Shrinking muscle	Nausea, constipation, feeling dizzy, gaining weight, feeling limp
Cyclofem contraceptive injection	Growing breasts, eliminating muscle	Shrinking muscle, beautifying body, growing breasts, lifting up behind	Pimples, deafness, hair fallout, red facial spots, pain

Some of our informants reported no side-effects. Citra from Makassar noted that Andalan pills made her breasts grow without adverse effects. Others switched between pills and injections to see what best fit their individual bodies. Mince from Makassar began with pills, shifted to injections, then reverted to pills again. Andalan pills made her dizzy, nauseous, sleepy and lazy; she gained weight and could not work. She then tried Cyclofem injections. When she achieved her desired results – less muscle mass, firm buttocks and growing breasts – she reverted to pills, this time Marvelon, explaining that once the body is shaped, pills can effectively maintain the results. Though she experienced muscle pain, she stayed with Marvelon. Pain that did not affect her appearance was acceptable; weight gain was not. Anti from Bulukumba reported that even though Andalan pills made her breasts grow, eliminated visible veins and made her skin smooth, she turned to injections because she could not tolerate the nausea. She finally also stopped with the injections because they made her fat.

Some of our informants turned to padded bras because they could not tolerate the adverse effects of hormonal products. Lili, a sex worker from Makassar, stopped using injections as she experienced great pain in the hard tissue forming under her breasts, especially when clients squeezed them. Cantik, Cece, Yeni and Ade from Yogyakarta likewise preferred padded bras to contraceptive pills or injections. Both options, they said, are in any case fake. They instead desired silicone injections, which they saw as a more permanent solution. While Cantik, Cece and Yeni dreamed of silicone, Ade had already injected 250 cc into each breast. She was too impatient to wait for the effects of the Microgynon pills which made her feel limp and sleepy. Waria who are growing breasts enjoy greater respect and legitimacy; the padded bra remains the object of jokes and derision.

Other informants tolerated the side-effects of taking hormones, believing them to be signs of efficacy. Imas from Bulukumba shifted from contraceptive pills to injections as she experienced pain in her breasts, one of the noted side-effects of Lynestrenol contained in the Andalan pill. It was commonly believed, however, that pain in one's breasts means they are beginning to grow. Pain is thus evidence of transformation. Although Imas was afraid of injections, she continued with them in the hope of having larger breasts in the future.

Some of our informants combined pills and injections. Tenri from Makassar took pills twice a day and an injection once a week to speed up the growth of her breasts. Since she felt shivery when she took the pills, she usually took them with a hot cup of coffee. Susi from Bulukumba said she began with pills to grow her breasts and later combined pills with an injection every three months to eliminate her visible veins.

Others experimented with even more aggressive regimes, switching brands to find which was most cocok, increasing dosages and combining pills with injections that targeted specific parts of their bodies. Oci from Makassar began with Marvelon pills and then switched to Microdion, Trinordiol, Microgynon and Andalan, each having a different effect. She finally chose Trinordiol because its side-effects – nausea and constipation – are invisible, while other brands led to pimples or red spots on her face. She started by taking three pills a day; after a week she increased the dosage to five pills. Feeling that pills were cocok, she increased her dosage to seven pills a day, which became her regular dosage combined with a weekly injection (she believes injections on their own provide slow results). Tenri from Makassar confirmed the efficacy of pills: ‘When we took pills, the hormone accumulated in our chest (terkumpul di dada)’.

Does size matter?

Some of our informants stopped taking hormones because the growth of breasts was minimal. Uci from Yogyakarta told us she wants breasts but does not use contraceptive hormones. The latter do not lead to beautiful breasts, she said, but to ‘grandmother breasts’ like hanging saucers. Though she knew that taking hormones can have other benefits such as eliminating visible veins, she was afraid of their side-effects. Uci wanted breast implants instead. But since she cannot afford them, she wants to find a Western partner who can. Imas from Bulukumba told us that high dosages of injected contraceptives only had a minimal effect, giving her the breasts of a 12 year-old girl.

Yeni from Yogyakarta discontinued taking Microgynon pills after six months. Even though she attained her desired effects (reduced muscle mass and visible veins), her breasts grew only slightly. Yeni was afraid of trying injections because she was told they have strong adverse effects; she turned to a padded bra instead. Though breast size was important, it was never specified just how large they had to be. None of our informants aspired to have very large breasts. The most important thing was to have breasts at all – a sign of having a feminine body.

Mimi, a 50 year-old head of a boarding school for waria in Yogyakarta and a beauty salon owner, disagreed about the dangers of using hormones. As long as they are used cautiously and cheap products are avoided, she said, there will be no problems. She pointed to her own well-developed breasts which she has had for over 20 years; she first used contraceptive pills to form the kantong and then travelled to Jakarta for silicon injections. Although she disapproves of surgical breast implants due to her friend's failed experience, she had plastic surgery for her nose. In Surabaya we met Pretty, a beauty salon owner with breast implants. We heard stories that both Mimi and Pretty not only sell cheap silicon products behind the scenes, but also inject them for their clients. Nevertheless, Mimi and Pretty blamed those who failed to attain well-developed breasts for wanting good and instant results with cheap products. Beauty is expensive, they said.

Hormones and sex-related effects

Kosenko (2011) has found that taking hormones has a noticeable impact on the sexual thoughts and behaviour of both male-to-female and female-to-male transsexuals. Among male-to-female individuals, hormones tend to diminish sexual appetite. In our group discussions, our informants discussed how taking female hormones affected the functioning of their male organs. Nindi from Bulukumba switched from pills to injections when she could no longer achieve an erection. Susi from Bulukumba explained that before using hormones, her penis would erect whenever she saw a man. Though she is no longer taking hormones, she can no longer achieve a full erection, though this has not affected her desire to have sex with men. She believes taking contraceptive pills has ‘turned off’ her testosterone, though she can still have orgasms.

The focus groups revealed differences in sexual expectations among our informants (cf. Winter, 2012). Some thought the ability to sustain erections was crucial, with the ability to satisfy partners through penetration and be satisfied through oral sex remaining an important part of their sexual lives. Indah, a sex worker, had stopped using pills because her ‘Mr. P’ could not turn on for her own and her client's sexual pleasure. Hetti felt that hormones make her body ‘boneless’: her penis had ‘shrunk’ and ‘could not stand up’. In contrast, one of the participants in a group discussion in Bulukumba was proud of her ‘dead penis’, which she invited us to touch. Still others proudly proclaimed lebih besar mama dari pada papa (my penis is bigger than my partner's).

Our informants were aware that ingesting hormones has long-term effects. Many feared that they would die young. Nevertheless, to become like women was more important than their health so the risks were worthwhile. Yuli from Yogyakarta was perhaps exceptional. She did not want to use hormones, believing that products for external use were safer. Her preference to use a padded bra, she felt, did not diminish her waria ‘soul’.

Whitening beauty

In addition to growing breasts, our informants also expressed a general desire to have lighter complexions. Having ‘white skin’ was assumed to be more attractive than having dark skin, and was associated with femininity. ‘Whitening’ their skin was thus one way to become ‘like women’. All of our informants saw skin-whitening as a way to attract or maintain male attention; they clearly believed that men – potential boyfriends, partners or clients in the case of sex workers – prefer women with light skins (see Idrus and Hardon, under review; cf. Ashikari, 2005).

Our informants used many different skin-whitening products. The strongest were exfoliating products containing Tretinoin and Hydroquinone. Twenty-seven products containing Tretinoin and 20 containing Hydroquinone are registered as medicines in Indonesia, most of them manufactured by Indonesian companies. According to Informasi Spesialite Obat Indonesia (AIA, 2012), some of these products require prescriptions. The product labels state that Tretinoin and Hydroquinone are skin whitening exfoliants and anti-acne depigmenting agents.

Our informants also reported using skin creams containing Vitamin E, Ginseng, Aloe Vera, Hydrolized Pearl and Allantoin as well as various powders, foundations, soaps, hand and body lotions and scrubs. Powders and foundations were used to cover their faces; hand and body lotions and scrubs to whiten their bodies. Some even used foundations and creams to cover the dark skin on their arms and legs.

Perhaps due to their geographical proximity, our informants in Makassar and Bulukumba reported using the same products. They also reported using more aggressive products than our informants in Yogyakarta, where we came across fewer exfoliating products and creams, and only relatively mild face soaps, lotions and scrubs. Table 4 shows which products were mentioned where, the potential harmful ingredients in each product, and their potential adverse effects.

Table 4

Popular skin-whitening products.

Brand of exfoliating liquid and facial cream	Makassar	Bulukumba	Yogyakarta	Potentially harmful ingredients	Potential adverse effects
RDL	√	√	–	Hydroquinone, Tretinoin	Decrease production of melanin, increase exposure to UVA and UVB, increase risks of skin cancer
Maxi Peel	√	√	–	Hydroquinone, Tretinoin	Decrease production of melanin, increase exposure to UVA and UVB, increase risks of skin cancer
Maxi White	√	√	–	Hydroquinone, Tretinoin	Decrease production of melanin, increase exposure to UVA and UVB, increase risks of skin cancer
Diamond cream	√	√	–	Not provided	Feeling hot on skin, drying, exfoliating
UB ginsara herbal pearl cream	√	√	–	Allantoin	Irritation, stinging, redness and burning
SJ day and night cream	√	√	–	Triethanolamine	Itching and burning
				Methylparaben	Increase skin aging and DNA damage
				Isopropyl myristate	Cracks and fissures
SP cream	√	√	–	Petrolatum	Feels hot on skin
Maxi Peel bleaching pearl cream				Not provided	Redness
Quina ginseng pearl cream	√	√	–	Propylparaben	Skin irritation, itchiness and redness
Quint's-yen cream	√	√	–	Propylparaben	Skin irritation, itchiness and redness
				Methylparaben	Increase skin aging and DNA damage
Kelly pearl cream	√	√	√	Isopropyl myristate	Cracks and fissures
				Propylparaben	Skin irritation, itchiness and redness
Krayolan cream	√	√	√
Walet 2 in 1 super whitening cream	–	–	√	Dimenthicone	Skin irritation, burning, stinging, redness
Ling Zhi day and night cream	–	–	√	Tocopheryl leukocyte extract	Skin irritation, redness, rashes, allergic reaction

Our interviews revealed exfoliating products and creams to be the strongest and mostly commonly used skin-whitening products. A cosmetics store clerk in Bulukumba explained that these products give ‘instant’ results but have strong side-effects. In contrast, other popular products such as Ponds have no side-effects, but are slow to show results.

A cosmetics retailer in Makassar reported that alongside papaya soap and Bali scrub, SJ, Diamond and UB are the most popular creams sold in her store (see Table 4 for product contents). She said that some of the creams are palsu (fake), merely re-labelled versions of cheaper products. The retailer sells them at similar prices, given that there is demand and customers report that they are cocok for them. A shopkeeper in a Yogyakarta cosmetics store told us that products such as Ling Zhi and Walet creams are not placed in the glass showcase because ‘they are too small’. We suspect they were hiding non-registered products in anticipation of sudden inspections by Badan POM, the Drug and Food Control Agency (Fig. 2).

Fig. 2

A shelf in a market cosmetics stall in Makassar. Photographer: Nurul Ilmi Idrus.

Our interviews and focus groups revealed three ways in which our informants whiten their skin: with exfoliating liquids, with skin creams, and with powders and foundations.

Exfoliating products

Exfoliating is the fastest and most intrusive way to lighten one's skin. The use of exfoliating liquids was only reported by our informants in Makassar and Bulukumba, commonly used with night and day creams as well as papaya soap. They began by cleansing their skin with face soap then applying the alcohol liquid, stating that the creams are to counter the liquid's strong side-effects (Fig. 3).

Fig. 3

Exfoliating products. Photographer: Nurul Ilmi Idrus.

Our informants often associated the efficacy of exfoliating products with their side-effects, many of them negative and alarming. These included reddish, painful, hot and burning skin. Participants in a group discussion in Makassar found the exfoliating liquid RDL to be stronger than Maxi Peel. While the end result of using RDL was ‘smooth, clean and white’ skin, the process to arrive there entailed suffering ‘hot, itchy, and reddish’ skin. Oci from Makassar ended up using RDL after discontinuing Diamond cream because it burned her skin and gave her pimples. While RDL solved her pimple problem, her face turns red if she goes out in the sun. Lili complained that RDL is hotter than chilli. These effects, however, were believed to be signs that the desired result was being achieved. ‘Beauty pain’ thus hardly mattered. Transformation literally means peeling away the old (male) skin to reveal the new self.

Many of our informants devised ways to manage the harsh effects of exfoliating products. Titi from Makassar stated about Maxi White: ‘It's very hot, almost every night I rub gently with an ice block… it feels like a knife cutting my face and I usually stand in front of the fan.’ Citra used the products only at night to lessen the heat and to avoid the reddening effect of the sun. Some said they only used exfoliating products occasionally. Cici from Bulukumba used RDL only when she had pimples. Manis used Maxi Peel to ‘refresh’ (menyegarkan) her skin only when it grew dark.

Creams

Creams were another way to lighten one's complexion. Some of our informants used different day and night creams; others switched products until they found the one most suitable for them. Some stopped using products when they had attained their desired result; the effects, however, soon disappeared. Some reported that after stopping with the product, their skins were darker than before. Others stopped because they could not tolerate the adverse effects.

In Makassar, our interviews revealed the popularity of the Diamond brand. This was confirmed by a cosmetics retailer in a Makassar market who told us that she sells more Diamond skin-whitening cream than any other brand. Exfoliating products containing Hydroquinone and creams such as Diamond are registered by Badan POM. Other cream products, such as SJ (containing Triethanolamine, Methylparabon and Isoprophyl Miristate) and SP (containing Petrolatum), can be fake or authentic. The latter have a registration number and the Badan POM stamp on their packaging (Fig. 4).

Fig. 4

Cream products containing potentially harmful ingredients. Photographer: Nurul Ilmi Idrus.

The effects of using creams differed among our informants. Some attained lighter complexions without adverse effects. Manis from Bulukumba reported that Diamond cream worked faster than the other brands she had tried. Anti found that Diamond cream not only whitened her skin, but also made her skin look more natural (alami). Others did not entirely attain their desired result but continued using products due to their positive side-effects. Fera from Makassar stated that although Diamond cream's whitening effect is minimal, its skin-smoothening effect is significant. Endah from Makassar likewise reported that Diamond cream does more than make her face white – it makes her face shine. Its adverse effects could therefore be tolerated.

Yeni from Yogyakarta previously used Placenta cream but could not tolerate its adverse effects, among them inflamed skin. She turned to a facial wash and cream concocted by Dr. Jenong, a dermatologist popular among waria in Yogyakarta. This product also exfoliated her skin but was not as strong as Placenta. Participants in a Yogyakarta group discussion reported Dr. Jenong's krim racikan (concoction cream) to be quite expensive; most could not afford it. Most importantly, such products have to be used continuously. Otherwise, their skins will revert back to their ‘natural’ state. Maintaining one's bodily transformation is thus a continual process rather than a sequence of events leading to a fixed and permanent outcome.

Covering

Covering darker skin is another strategy to ‘become white’. Here we found foundation and loose or compact powder to be the most popular options, commonly used by our informants when they could no longer tolerate the adverse effects of stronger exfoliating or cream products. Whether they used foundation or powder depended on individual preference, the occasion, and/or the price. One advantage of covering foundation or compact powder is that they come in different shades. Kiki from Bulukumba used Kryolan, a heavy foundation to cover up her black spots and applied Double Pixy, a compact powder containing foundation to reduce stickiness and absorb makeup. Sinta from Bulukumba settled with a covering product after her long journey using exfoliating and cream products with various adverse effects. She finally decided to use Kryolan combined with Pixy white powder for her ‘full makeup’ as a singer and beautician. In her other roles as college student, kindergarten and dancing teacher, she only uses loose baby powder. Imas, a beautician and singer from Bulukumba, claimed that she accepts her dark skin and prefers to keep it natural (alami). Nevertheless, she uses Kryolan on her face ‘to cover up’.

Although our informants in Yogyakarta also wanted to ‘become white’, they were less obsessed with this than their counterparts in Makassar and Bulukumba. They explained that being clean (bersih) and light (cerah) were more important than being white (putih); they had nevertheless all tried products to lighten or at least cover their dark skin. We explored cultural notions of beauty in our Yogyakarta focus group. Many said they strove for putih-putih Jawa (Javanese white) skin, which is not ‘too’ white. They also repeatedly used the term hitam manis (black sweet) to refer to the beauty of darker skin.

Uci stated that she does not want her skin to be ‘too white’. But lighter skin was nevertheless important to attract prospective clients. Indah said she is happy with her relatively dark skin because she thinks it is exotic; she uses a mixture of powder and water on her face, hand and body lotion on her hands, and foundation and powder on her legs to ‘blur her masculine body and dark skin’. Her use of whitening products is to ‘balance’ the colour of her face and other parts of her body as she likes to wear sexy dresses to attract clients. Astri reported wearing heavy makeup and stockings on both her arms and legs when she works as a street singer; this was thought to be more alami (natural) – beauty being an internal state of mind. Yuli, a street singer, preferred Pixy white powder because it suits her ‘Indonesian skin colour’. While she believed that white skin is valued as a commodity (nilai jual), she said she can ‘balance’ her brown skin with her personal traits: being smart, sexy, a tomboy, and easy to get along with.

Changing and mixing skin-whitening products

Our informants switched between techniques and brands as they tried to find those that best ‘fit’ their individual bodies. Rara from Makassar began with exfoliating products containing Hydroquinone; skin-reddening led her to try SJ day and night creams containing Triethanolamine, Methylparabon and Isoprophyl Miristate. Though the SJ creams made her skin itchy (the adverse effect of Triethanolamine), there was no reddening. Her friends suggested that the itchiness was a sign of the product's efficacy; she tolerates the itchiness because it does not affect her outward appearance. Sinta from Bulukumba tried a long succession of products that worked for her friends, finding each to have undesirable side-effects. She switched from exfoliating products to creams and achieved her desired result with the SJ brand. But when she stopped using it, her skin turned from ‘white’ to ‘yellow’.

Others switched products when they could no longer tolerate the adverse effects. Rara from Makassar turned to creams because she felt that her exfoliating product (Maxi Peel) was too strong and smelled like alcohol. Una likewise began with exfoliating products containing Tretinoin and Hydroquinone. While RDL initially whitened her face, her skin reddened in the sun and then broke out in pimples. She tried Diamond cream but without the desired effect. She subsequently tried Cusons baby powder which she uses during the day when she works as a beautician. As a sex worker at night, she uses foundation for her ‘full makeup’ (dandan) which makes her feel beautiful and confident. Mince from Makassar finally decided to cover her face with long-lasting Pixy white powder after using creams that made her skin break out in pimples. Otti from Bulukumba switched from Diamond cream to Pixy white powder; she suspected the adverse effects she experienced with Diamond were due to its being a ‘fake’ product.

Many of our informants combined products. Sari from Bulukumba began her evening ritual with Papaya soap to cleanse her face, then applied Maxi Peel to remove her ‘dead’ skin, and then finally UB cream to soften her skin. Her morning ritual began with Papaya soap before applying Pixy white powder for her daily makeup. Such experimenting was very common among our informants in Makassar, Bulukumba and Yogyakarta.

How practices spread

Alongside the influence of peers, advertisements played an important role in the consumption of skin-whitening products. Skin-whitening is a well-established practice in Indonesia, evidenced by the numerous products sold in market stalls and advertised on TV, the internet and through social media (used by our informants in all three sites). Our informants in South Sulawesi used similar skin whitening products, only some of which we came across in geographically distant Yogyakarta. While the products available in Yogyakarta's department stores differed from those advertised online, our informants reported that they were influenced by online advertising.

There was variety between our research sites in the favoured means to enhance breasts. Practices were again similar in our two research sites in South Sulawesi, where our informants favoured the use of hormones. This was less the case in Yogyakarta, where our informants used contraceptive pills but rarely turned to injections. Some of our informants in Yogyakarta used padded bras; others aspired to have silicone breast implants and mentioned the capital city of Jakarta, the city of Surabaya in East Java or abroad (e.g. Thailand) as the best places to go for such treatments.

Product availability differed between the three sites. In the urban centres of Makassar and Yogyakarta, a broad range of contraceptive and skin-whitening products were readily available in pharmacies and stores. Lili from Makassar simply asked the pharmacist for a contraceptive injection and received it without any questions. This was confirmed when we visited a pharmacy in Makassar. When we pointed out that the package states ‘by medical prescription only’, the pharmacist on duty explained that ‘she was there’. She added that the pharmacy does not stock a lot of contraceptives because they are provided free of charge at the community health centre (puskesmas). In contrast, the regency of Bulukumba has stricter laws on the sale of prescription products, which places a premium on having the right personal contacts. Imas from Bulukumba obtained her contraceptives from her regular retailer in the market, who injected her as well. Susi from Bulukumba, a beauty salon owner, received injections from her friend, a midwifery student, in exchange for beauty treatments. Accessing pills was more complicated for Manis. Chemists do not sell them to ‘men’ so she had to befriend a midwife to get them for free. Those without access to contraceptives through their personal networks thus relied on their luckier peers. Our informants reported that skin-whitening products can easily be found in super/minimarkets, while ‘fake’ products are commonly sold in traditional market stalls.

Our informants generally learnt about different products, dosages and techniques through word of mouth (dari mulut ke mulut), foremost from their waria peers. They hardly ever consulted health professionals prior to using hormonal products. Much of their knowledge thus derived from self-experimentation (cf. Hardon and Idrus, forthcoming; Winter, 2009,2012). Beyond this, there was one significant difference between our research sites in how our informants learnt about products and techniques. In Makassar and Yogyakarta, none mentioned healthcare professionals as a significant source of information. This was in marked contrast to Bulukumba, where information on the use of contraceptive hormones to transform bodies came from a midwife (bidan) employed at the community health centre. As the health centre only caters to heterosexual couples, this advice was given unofficially to the midwife's waria friends and relatives. The midwife advised Susi to take contraceptive pills to grow her breasts and injections to reduce her musculature. Also in Bulukumba, Anti stopped using hormonal products altogether when a doctor warned her about the long-term effects.

Conclusion

This article has examined how members of the waria community in Indonesia turn to hormonal and skin-whitening products to transform their male bodies to approximate the ideals of Indonesian female beauty – to ‘be like women’. We found our informants’ waria self-image to be deeply rooted in and constitutive of their physical bodies. That is, they do not experience their bodies as fixed biological entities, but as ‘projects’ they can manipulate with pharmaceutical products and cosmetics. Breasts, skin and muscle mass were the focus of their body management. The penis was a lesser priority; buttocks were even less on the agenda.

Our research revealed great creativity among waria in experimenting with chemicals to achieve their bodily aims. Their practices were mostly influenced by those of their peers; they shared information and products, jointly assessing their effects and competing with each other in transforming their bodies. To lighten their skins, they experimented (coba) with different brands of exfoliating liquid, whitening cream, powder, foundation, face soap and skin scrub. To shape their bodies, they turned to different brands of contraceptive pills and injections, switching and combining products and changing dosages to get faster, better and longer-lasting results. The use of specific products and brands depended on their compatibility (cocok) with their individual bodies, their intended and additional beneficial and adverse effects, and whether the products influenced their outward appearance, which in the case of the sex workers bore directly on their economic prospects (cf. Irving, 2008).

Our informants had to continuously balance the desired and adverse effects of chemical use. Alarmingly, bodily pain was often accepted even when the desired results were minimal. Pain was even associated with product efficacy; when an exfoliating liquid burnt their skin, this was seen as a sign that it was working. Breast pain was similarly seen as a sign of the efficacy of hormones. Side-effects that did not affect outward appearance were tolerated more readily than those that did. In Makassar and Bulukumba, the attitude to whitening was captured in the phrase biar menderita yang penting putih (as long as it becomes white, suffering is insignificant). Physical pain is an accepted part of bodily transformation.

The products used by our informants generally did not provide permanent solutions. Stopping with their particular regime of chemical use meant that their bodies reverted to where they started. When this happened, they suffered psychologically. Bodily transformation is thus an on-going process that requires continuous work; it is never complete, nor can it ever be stopped. Over time, some of our informants returned to ‘being natural’, turning to padded bras rather than chemicals when the pain or side-effects become intolerable. Others dreamt of silicone injections which they saw as a more permanent solution. We observed that waria in Yogyakarta were less obsessed with both contraceptives and invasive whitening products, often mentioning the ideal of skin that is hitam manis (sweet black).

Our findings have implications for harm reduction programs. The risks here do not concern HIV transmission (although hormones are injected, needles are not shared). Our point is that the focus of many harm reduction programs on narcotics, needle-sharing and sexually transmitted infections has neglected those chemicals that are not narcotics, not related to sexually transmitted infections, and are legally and freely available – though they equally affect the lives and health of those who use them. The risks to health that we encountered concerned unsafe skin-whitening products (Hydroquinone can cause cancer) and the long-term side-effects of hormones in high dosages. While our informants were concerned about these risks and tried to manage them through their own personalized regimes of chemical use, they would benefit from more information on the substances that evidently play such a central role in their lives. Such information should not only deal with the substances, but how they are used. Contraceptive hormones are fairly safe products and hence available over the counter in pharmacies. The safety issues arise when the products are used off-label in large quantities. The side-effects of hormonal drugs used by male-to-female transgenders have been described in a growing body of studies conducted in formal gender care settings which have associated cross-sex hormone therapies with increased rates of cardiovascular disorders, osteoporosis, and cancers (Van Kesteren, Asscheman, Megens, & Gooren, 1997; Wierckx et al., 2012) as well as psychological problems leading to major depression (Nuttbrock et al., 2012).

Our findings on skin-whitening practices suggest that drug policy-makers are not paying sufficient attention to the safety of cosmetics. Though products containing Hydroquinone are officially only available in Indonesia with medical prescriptions, we found them to be freely available. Harm reduction programs which more broadly address chemical harm need to be attuned to the local specificities of chemical use.

Finally, our study revealed our informants to be concerned about long-term risks to health; many did do not expect to live long. The variety of strategies found in our study to bridge the mismatch between male bodies and female ‘souls’ can be discussed in relation to their relative safety for long-term health, enabling waria to live longer and healthier lives.

Conflict of interest

None declared.