The role of state and private orphanages can only be understood in the context of the broader social, cultural, and economic forces that shape the lives of their resident children. In China’s strongly familial culture, there is a particular poignancy and significance to the separation of a child from her birth family. Such separation is commonly caused by parental relinquishment—researchers believe that the majority of “orphans” in institutional care in China have one or both parents living, but have been abandoned. This chapter considers the two most prominent risk factors for abandonment in China, sex and disability. By exploring the coercive structural conditions that impact parental decision-making and contribute to sexist and ableist abandonment patterns, the “unwanted baby girl/disabled child” narrative that often dominates the discourse on abandonment is challenged. The chapter also considers the norms, structures, and processes by which new families are formed, including adoption, before turning to the state’s response to the problem of “left behind“, unadopted children: primarily institutionalisation, supplemented more recently with foster care. China’s state orphanages gained international notoriety in the 1990s in the wake of a number of damning exposés, but have also been the subject of various state initiatives aimed at improving the welfare of resident children, with mixed results.