Ruby Corado never expected to live past her 30s.
A transgender woman from El Salvador, she moved to Washington, D.C., in the late 1980s to escape the country's civil war. It was a time when AIDS was already devastating an entire generation of gay men and transgender women in the United States. Homophobia and transphobia were part of everyday life, from finding housing or landing a job to facing all-too-real threats of violence.
"Growing up in an environment where your friends are dying, they're getting killed, it's just a matter of, like, 'When is my time?' " she says. " 'When am I next?' That was the whole thing."
Corado quickly got involved in community activism — while also navigating both her transition and learning she was HIV-positive.
"I survived a civil war," she says. "So a part of me was like, 'Well, I survived bullets. Bombs. I can survive this. I can survive the intolerance.' "
Because of complications from her HIV medication, she developed a condition that affects how the body stores and distributes fat tissue. She says it was like her butt was "erasing." At the same time, she was already contending with the pressures of conventional beauty standards. Meeting those standards can be a boon to a trans woman's self-esteem; breaking them can put a target on her back.
But then the first talk of "pumping" slipped into her circles — a procedure where someone will, for much cheaper than a licensed surgeon, inject you with silicone. "Pumping parties" began making their way down from New York to Washington. Everyone in Corado's circle, it seemed, was getting it done.
"So I'm thinking to myself: 'Well, I'm gonna give it a few years,' " she remembers. " 'And if they die — I'm not getting a butt,' " she laughs.
Years went by. The people who had gotten pumped seemed fine. And Corado found herself thinking, "You know what? Maybe I won't die."
So she decided to do it. She got pumped in a hotel room near Washington's Dupont Circle neighborhood.
"There's a point where you get in your mind, where you're like: 'I just want to heal from some of this pain,' " she says.
"And I'm not gonna lie to you," she says, her voice breaking. "In my new body, I felt so beautiful. I felt so together. I felt like I fit in. And even though I was one of the most educated people in my circle, I still went ahead and gave in."
She pauses, tearing up. "And I ended up with a very high price to pay."
Nearly two decades later, Corado is sharing her story on a couch at Casa Ruby, the organization she founded to help queer and trans people around the greater D.C. area. She's 49 now, an age she'd never imagined she would reach.
Her organization is led almost entirely by black and brown trans women. They help people find housing, navigate immigration services or get the medical care they need.
But more than that, the women who run Casa Ruby are a lifeline for the youth in their community, an adoptive network of aunts who help young people avoid the tough lessons they had to face on their own — including the complications that come with pumping.
"There are people who are still getting it done," Corado says. "I think the [question] is not: 'Can we stop it?' It's: 'Can we give people options?'
"And the difference between them today and us before is that we didn't have options."
"It's about surviving"
"Pumping" refers to a kind of underground plastic surgery. While cisgender people also get silicone injections, pumping in trans communities is largely done to help address gender dysphoria — a community-preferred term for the anguish of feeling a disconnect between the sex a doctor determined for you at birth and the gender you truly feel you are. Being unable to address dysphoria is linked with increased risk of mental health problems and suicide. (Linguistically, the word is an inversion of "euphoria," meant to capture the same powerful emotional experience but on a negative scale.)
"Having access to an illegal treatment allowed me to have the body that I saw in my mind," Corado says. "Allowed me to address my deep mental health issues with gender dysphoria."
There's a Gordian knot of factors that contribute to why some trans women get silicone injections. Dysphoria. Impossible beauty standards. Economics. Physical safety.
Pumping is often turned to when licensed medicine isn't accessible — typically because of a combination of social, financial and discriminatory barriers in health care.
If a woman doesn't pass as cisgender — or if someone finds out she's trans — she risks discrimination in getting a job, finding housing, going to the doctor's office. In a 2015 survey of transgender Americans by the National Center for Transgender Equality, 53% of respondents reported being harassed in public in the past year.
About 1 in 5 trans people in the U.S. has faced discrimination when seeking a home, according to the survey. And more than 3 in 4 have experienced some form of workplace discrimination.
"We didn't know what dysphoria meant [growing up]. We just knew that we wanted to look in the mirror — I didn't wanna see those boy hips anymore," Consuella Lopez, the director of operations and housing at Casa Ruby, remembers. "The more passable your body was, the less bullying you'd get, the more chances of you getting a regular job at a regular place without somebody clocking you.
"There were all these stipulations that came along with having to have this done in order for you to feel like you were gonna have a better life: from looking better, people telling you that you look better, being able to stop doing survival sex work and getting a job."
Then there's another critical aspect: the risk of physical violence against transgender people — especially black trans women.
In that same 2015 survey, the largest poll of its kind, 22% of black trans respondents reported being physically assaulted in public in the last year.
According to the Human Rights Campaign, at least 16 transgender people in the U.S., all but one being black women, have been killed in 2019. For a community where hard data are limited, it's an alarming number — and one that activists agree is almost certainly underreported.
While various factors are at play, being able to pass as cisgender can, in some cases, be a matter of life and death, Corado says: "It isn't just about acceptance. It's about surviving."
What's used in pumping?
Transgender people in the U.S. have turned to pumping for decades. And it has particularly affected trans women of color and those living in poverty, according to several sources NPR spoke with.
The procedure is most often associated with liquid silicone. One medical professional likened the substance used in pumping to what you might buy from a hardware store to caulk a bathroom.
But it can be cut with other substances, too — and it's impossible to know what someone is injecting each time. One 2013 study of illicit silicone in Brazil found that it sometimes also contained olive oil, paraffin wax or even transmission fluid for a car.
By comparison, what a licensed plastic surgeon puts in someone's body is pure silicone, Zil Goldstein explains. She's the associate medical director for transgender and gender nonbinary health at Callen-Lorde Community Health Center in New York City.
Medical-grade silicone is implanted in one cohesive, encapsulated unit, rather than as a free liquid that can move around over time. And it's biologically inert — meaning it flies under the radar of your immune system, and your body is less likely to attack or reject it.
A persistent phenomenon
Experts say it's tough to know how common pumping is. Available federal data don't even say how many transgender people there are in the U.S. — let alone who might be accessing underground procedures.
"We can't really give statistics on how common something is when we don't have any idea what the common denominator is," Goldstein says.
But advocates and health providers say it's a persistent phenomenon across the country. NPR found reports of complications from silicone injections all over the U.S., not just in New York City and Los Angeles — but in Atlanta, Dallas, Miami, New Orleans and Salisbury, N.C.
"I can tell you that it's much more common in poor communities," Goldstein says. "Just because of the level of access to services to transition is so much lower, that people are more likely to turn to alternatives to the medical system."
"This isn't something I've read about in a book," says Lopez, of Casa Ruby. "I sat there ... in the same room where a guy would sit there and pump everybody — back to back, back to back, back to back, back to back — and I was in line."
Lopez, 45, says the majority of her friends growing up now have silicone. Some have had complications, and some haven't.
And that itself is part of the problem: It can take 10 to 15 years to experience serious health issues from pumping, making it difficult for health experts to track — and tough for people getting it done to know if anyone else has had complications.
'I have concrete hips'
In Corado's case, she says she knew something was wrong within a year of getting pumped.
In the winter, she couldn't stay outside for long, concerned that her silicone might freeze. In the summer, she worried about sitting on pavement and getting it too close to heat. She says she's had to go to the emergency room because of complications.
Now, years later, she tosses and turns at night, unable to sleep on her side for longer than a few hours.
"I have concrete hips," she says. "I have problems with my cheeks ... because some nerve is going on, and sometimes my face jumps. I can't walk a set of stairs."
In pumping, the worst-case scenario is that silicone hits a person's bloodstream, where it can cause a clot or travel to the person's vital organs. The person can be dead in minutes. But Goldstein says the effects of pumping can vary widely.
"I've had patients who've had chronic open wounds in the area that they had silicone injected, because their body sort of tries to expel it and can't actually heal up," she says. "I've had people who have been disfigured as injected silicone has shifted. People who are in chronic pain because of silicone. And I've seen some bone damage and kidney damage."
And it isn't just health concerns that people have to contend with. Pumping, especially for those who perform it, carries some legal risks. In one case, a North Carolina woman was charged with second-degree murder — and pleaded guilty to involuntary manslaughter — after a 17-year-old girl she had pumped died. The woman spent about 15 months in prison.
A patchwork of policies
In much of the country, there's a dearth of culturally competent care for trans patients. And even if you do happen to live somewhere with access to care, that's only the beginning.
"There's really a patchwork when it comes to insurance policies and coverage for transition-related care," says Sarah McBride, the national press secretary for the Human Rights Campaign. "For a while, it was the reality that almost no transition-related care was covered by most insurance plans."
Today, more plans are covering at least some transgender care, like hormone replacement therapy and some reconstructive surgeries, McBride says. And 19 states and D.C. have implemented bans on insurance exclusions for trans health care.
But some aboveboard alternatives to silicone injections, like facial feminization surgery, are too often not covered, McBride says.
"It varies based on the plan, it varies based on the state, it varies based on the employer," she says. (The fact that employer-based health care is often the norm in the U.S. only compounds the effects that employment discrimination has on trans women's lives.)
After Lopez noticed lumps forming and her skin becoming discolored, she decided to look into getting her silicone removed. In 2009, she says, at least three major insurance companies denied her for the surgery. For one of them, she says, the reason for her rejection was listed as a preexisting condition: "gender disorder."
"It was a slap in the face," Lopez remembers. "I'm working a steady job. I have a steady income. I am in the best financial position of my life. And all I wanted was health insurance. And I was denied ... like, flat-out: no."
"Can you imagine how that feels?" she says. "What happens if I got sick? What happens if something really bad happens to me that I need medical attention — what happens?"
Eventually, at the suggestion of Corado, Lopez decided to uproot from Maryland and move into D.C., which had more trans-inclusive policies at the time. She finally got insurance through Medicaid, though it covered only hormonal treatment, not the surgery she needed. After weighing her options, she eventually decided to fly to Guadalajara, Mexico, to get her surgery done.
Jody Herman, a researcher with UCLA's Williams Institute, says Lopez's headache with insurance isn't uncommon.
Herman points back to the 2015 survey by the National Center for Transgender Equality. It found that 25% of trans people who sought coverage for hormones in the previous year had been denied.
In the same time frame, more than half of people who sought coverage for transition-related surgery were turned down. And 1 in 3 said they hadn't seen a doctor — for any reason in the past year — because they couldn't afford it.
That's another crucial aspect of why someone might turn to pumping: the money.
"Pumping is usually a few hundred dollars per treatment," Goldstein says. "But then you compare that to $10,000 for breast augmentation, $5,000 to $10,000 for breast augmentation ... and there not really being good procedures for enlarging the size of someone's butt. There's a Brazilian butt lift, where they do a fat transfer from one part of the body into the buttocks. That is $8,000 to $12,000 usually."
High costs aren't the only thing that can make the regulated health care system difficult to navigate for trans patients; they also often have to meet certain requirements before they can get gender-affirming care, like getting recommendation letters from a therapist and spending a certain amount of time living in their true gender (though some states have started to change this by moving gender-affirming care to "informed consent" legal models).
"Even when you get to a place like D.C. where they have transgender-related health care, accessing that in a system that's already complicated will make someone be like, 'This is too much. I'm gonna do what I have to do,' " Corado says.
"Because when you go to one of these underground providers, they're not asking you for a therapist letter," she says. "They're not asking you to be on hormones for a certain time. They're not asking you to live in your truth for a year or two. They're not asking you for a lot of things."
It's a sentiment echoed by Herman and McBride. The lack of coverage "pushes people into the black market and pushes people into access to services outside of the traditional, safe health care system," McBride says.
The providers
Given those difficulties, the idea of going to a licensed surgeon, for some trans women, can seem more like a fantasy than reality.
"Many of us live in a world where you will never lie on the table of a plastic surgeon that will give you the FDA-approved devices," Corado says.
"For the time you're being pumped, you dream that it's a plastic surgeon from Beverly Hills. ... Many of us never had even the remote thought that we could go to a plastic surgeon," she says. "So I think that's why people still do this. That's why the caregivers are still doing it."
Pumping can be done by a person just trying to make a quick buck off someone in a vulnerable position, but the reality is often more complicated.
"There are girls all across the East Coast and the West Coast where the providers, the people who actually pumped, were seen as caregivers," Corado says. "And in the context of ... marginalized people with no options, maybe they're thinking, 'I'm doing some good in my community.' "
She mentions the man who pumped her when she was younger.
"The guy whose credentials were that he used to be a nurse in Puerto Rico, OK," she laughs. "That was his credentials."
"I think the guy ... a gay man, made lots of money. But he's a father," she says. "He's still recognized as the father of a lot of trans women. And when I think about the qualities that he possessed as a person, he's a very caring human being."
The history of trans health care is deeply one-sided. The medical field has long pathologized transness, historically seeking to cure it — and has only recently begun to view it as something other than a disorder. In this context, sympathetic providers working outside the regulated health system were practically a part of their communities.
Often, these providers may have had the best intentions, but intentions and impacts are often very different things.
"Nobody else is doing it for us"
Today, Casa Ruby works with about 6,000 clients. And it's in the process of opening a second location in Southeast D.C. this summer.
"We feed these girls. You know, breakfast, lunch and dinner," says Cecily Pertillar, who works at Casa Ruby, helping victims of hate crimes. "You can take a nice hot shower. You can put on your makeup. You can get your hair done. You can go to sleep. ... You can get everything you need. You can go to school and get a job."
But there's more to the organization than its tangible programs. Casa Ruby is offering young trans and queer people a safe place to stay, ask questions and learn from the women who've been there before.
Lopez leans back in her chair, glancing at the rows of portraits lining the walls of the room.
"I look at those girls [who come in], and they know not to do it," Lopez says. "Those are our nieces who are trans girls who have started at Casa Ruby, who've basically transitioned at Casa Ruby. And here we are — the aunts, the mother — who sit there and tell you, 'Look, don't do that.' "
Lopez and Pertillar say those moments, along with the chance to show young people the tools they need to transition safely, are huge for their community.
"We have a niche," Lopez continues, "where it's trans women of color who helped start [Casa Ruby]. We did it to help more girls like ourselves — more women like ourselves. And it blossomed."
Pertillar says a lot of young women who come in ask her about silicone. And while Casa Ruby can't stop every person from pumping, Pertillar has a simple response for anyone who asks.
"I tell them what I did, the story behind it — and that they better not," she says. " 'Cause you ain't gonna die on my watch.' "
Lucy Diavolo helped edit this story.