Lack of expertise and government oversight endangers transgender people’s gender affirmation

Nandana Suresh was numb when she heard about the suspected suicide of the transgender activist Ananya Kumari Alex, reportedly following a failed gender-affirmation surgery. Suresh told us she immediately thought back about her own botched gender-affirmation surgery, and how many others like her would have had to suffer the pain and other post-surgery complications that had plagued her for the past 20 months.

In 2019, Suresh underwent the surgery at Saravana hospital in Tamil Nadu’s Madurai city. For the next year, she struggled to urinate. We met Suresh at her partner’s residence in Mararikkulam village, in Kerala’s Alappuzha district, on the afternoon of 22 September. She had already changed her clothes twice that day due to bleeding, as she had to insert a catheter tube for urination a day before. “I had barley boiled in water to make urination smooth but still the quantity of urine was tiny,” Suresh said.

Suresh’s experience is common for transgender people in Kerala who underwent gender affirmation surgery in the state. While the state claims to help fund such surgeries, the transgender people are only reimbursed after the surgery, barely reducing the struggle for a community that has been economically marginalised. Trans-rights activist told us that the state does not offer such surgeries in government facilities and medical staff at government hospitals can be hostile to the needs of the community. The lack of guidelines or clear protocol has also meant that private hospitals can conduct such surgeries without the transgender person being prepared for the procedure or giving informed consent. This has led to several transgender people suffering severe medical complications following the surgery. Trans-rights activists argue that the issue is exacerbated by the Transgender Persons Act, 2019, because it makes surgeries a necessity to access welfare schemes meant for them, forcing many reluctant transgender people to undergo unsafe surgeries.

Following Ananya’s death, there was an outpouring of accounts by transgender people about their own uncomfortable and often debilitating experiences with gender-affirmation surgeries in private hospitals in Kerala. The accounts spoke of surgeries often conducted without following established medical protocols for such procedure, and by doctors who lacked the requisite expertise. Suresh too wanted to share her account, because she reasoned, “If enough of us speak up, maybe something like this will never happen in the future.”

“My longing for the surgery is 21 years old,” Suresh told us. Growing up in a Malavedar tribal colony in Kollam district’s Punalur village, she could identify her gender identity, during her school days itself. She went to school wearing girls’ clothes and told the school’s authorities that she can only dress in this manner demanding that they accept her the way she was. After her secondary education, she left home, doing odd jobs in Karnataka, Tamil Nadu and Maharashtra, to collect money for her surgery.

“I had stayed in transgender communities in Bombay and Bengaluru. We collect money for the community we live in, and the elderly would sit at home,” Suresh said. “We first had to collect the money for our food and room rent. There would be almost nothing as savings. Finally, I realised that it would be impossible to get my surgery done if I continue there.” After about a decade of hardship, Suresh managed to save Rs 1.8 lakh and decided to get her gender-affirmation surgery done as soon as possible. The high cost of gender-affirmation surgeries, Suresh told us, is often the biggest inhibiting factors in helping transpeople transition.  

In India, accessibility and legal recognition of gender-affirmation surgeries came after a 2014 judgment by the Supreme Court on a petition by the National Legal Services Authorities. The judgment declared that transgender people—who were termed “third gender” in the judgment, a term widely condemned by the queer community—were equally deserving of constitutional rights. The judgment further recognised that gender identity did not refer to biological characteristics but rather referred to it as “an innate perception of one’s gender,” following which it asked state governments to frame policies to end the marginalisation of transpeople, including aiding corrective surgery when the individual requests it. “The NALSA judgment in 2014 said the transgender persons have the right to do surgeries on their body in the way they want their body to be,” Sundeep Vijayaraghavan, a clinical professor at the Centre for Plastic and Reconstructive surgery in Amrita Institute of Medical Science a private medical college in Kochi, told us. “In 2017, this order was contested. The court reinstated the order in 2018. In 2018, we began to do the surgery.”

Kerala was among the first states to unveil an official transgender policy, in 2015, which covers all categories of transgender people and “emphasises attaining a just society for such marginalised groups.” The policy includes many programmes which safeguard the rights of the community in law and also extended several welfare schemes to the community including educational scholarships, self-employment programmes, shelter homes and financial aid. In 2018, the state government extended the policy to include financial support for gender-affirmation surgeries. Under the financial-support scheme, trans men are reimbursed up to 5 lakh rupees, while trans women can only claim up to 2.5 lakh rupees, for gender affirmation surgeries. According to a report in the online portal Behanbox, the government has spent 1.26 crore rupees since 2018 for reimbursement of such surgeries in private hospitals, financially supporting 86 trans women and 42 trans men over the same period.

However, several transgender people we spoke to said this scheme did little to help, as the state government did not give the money ahead of a surgery, but as reimbursement after the completion of surgery. Dev, a 34-year-old trans man who is studying a urology technician course, told us he was previously a part of the Kerala Transgender Cell. The cell was set up by the state government’s social justice department in 2018 to mainstream the transgender community and uphold their rights. “When I was a member of the cell, I raised the issue of reimbursement,” Dev said. “The government is saying first you submit the bills and then you will get the amount. I don’t agree with that. First of all, transgenderpeople will not have any money, which is why they need support in the first place. If they have money, why do they come to the government?”

He said while working with the cell, he had also suggested alternate financial support models. “If you are giving money, give money to them or to the hospital,” he told us. “If they give the estimate of the bill or something like that, you ask them the date of surgery and give the money to the hospital’s account or any other means. If you give it only post surgery, I don’t know where they will get the money.” He said his suggestions, however, were largely ignored by the cell. Raga Ranjini, a trans rights activist in Ernakulam, told us that unlike the state’s Women’s Commission or the SC/ST Commission, the Transgender Cell has no legal powers. “The Transgender Cell has no power on its own. It does not have the power to file a case on someone,” she said. “It is a functionary under the social justice department which mostly informs and updates the community about the state’s welfare schemes.” 

This has meant that transgender people, who are economically marginalised, still struggle to pay for the surgery as they did before. According to a study conducted by the Kerala-based LGBTQIA+ organisation Queerala, in 2019, gender-affirmation healthcare was not available in the state’s public healthcare system. This is a violation of the Transgender Persons (Protection of Right) Act, 2019, which mandates the government to ensure public healthcare facilities for transgender persons including free of cost gender affirmative healthcare.

“If the government hospitals provided gender-affirmation surgery facilities, it can be done at a cheaper, more subsidised, cost,” Vihaan Peethambar, a board member of Queerala, told us. “If they invest the money to train the doctors in Mumbai or Thailand where gender-affirmation surgeries are known to have greater success rates, in the long run, it would work out much cheaper to ensure proper trans healthcare than providing funds to transgender people for sub-standard gender-affirmation surgery facilities in private hospitals.” According to Vijayaraghavan, in private hospitals in the state, a trans woman’s top surgery costs Rs 80,000, vaginoplasty approximately Rs 1.5 lakh and follow-up surgeries around Rs 2.5 lakh in his institute. For a trans man, top surgery will cost around Rs 50,000 and the three stages of bottom surgery around Rs 4 lakh.

In comparison, the Tamil Nadu government provides gender-affirmation healthcare for free within the state’s own health system. “In 2019, an exclusive transgender clinic was set up at Rajiv Gandhi Government General Hospital in Chennai and at the Government Headquarters Hospital in Madurai,” L Ramakrishnan, the vice president of the NGO Solidarity and Action Against the HIV Infection in India, told us. “The doctors and staff from the government hospital were sent to Mahatma Gandhi Medical College and Research Institute in Puducherry, a popular place since 2006 for gender-affirmation surgery, for exposure.”

Sameera Mahamud Jehagirdar, a former assistant professor of critical care medicine at MGMCRI Puducherry, told us that for successful systems for gender affirmation surgeries a medical protocol that was instilled with the values and morals of the transgender community was necessary. By consulting international guidelines regarding gender-affirmation surgery, Jehagirdar, with the help of SAATHI, formulated a set of protocol, policies and set up a multi-disciplinary Gender Care team. Jehagirdar’s own gender-affirmation surgery was conducted by the Gender Care team.

“Till September 2020, the MGMCRI Gender Care team conducted at least 200 gender-affirmation surgeries,” Jehagirdar told us. “We charged around Rs 35,000 for transwoman’s bottom surgery. For transman’s top surgery, the cost is around Rs 50,000.  Few complications were there related to surgeries but we conducted detailed audits about that. We analysed what went wrong and how things could be improved. Every four months the whole team will meet and discuss all problems we are having and how to improve them. These systems are followed in all other forms of medical care and should be done with gender related healthcare too.” Jehagirdar said that the national health mission has visited MGMCRI’s Gender Care teams to study the functioning and protocol followed.

Ramakrishnan however pointed out that the reach of the teams was still limited, restricted to only two institutes in Tamil Nadu. He added that other problems also arose at some of the government centres. “The functioning was a bit arbitrary,” he said. “Most of the doctors were not aware or exposed to trans man gender reaffirmation. The doctors were also demanding the consent of parents for conducting surgery. It is totally unessential.”

In Kerala’s public-sector hospitals, gender-affirmation surgery had been attempted a couple of times. In 2017, the Thiruvananthapuram Government Medical College conducted a gender-affirmation surgery on a transman named Sagar. He alleged to the media that his body was taken for experiments and the surgery was not done according to protocol. “Most of the doctors lack the expertise for gender affirmation surgeries and many of the public hospitals do not even have a urology department,” Vihaan said. “Importantly, most of the government hospital employees are not sensitised to deal with transpeople. They use the most derogatory terms and objectionable questions while dealing with transgender people.”

Dev said that when he was in the state’s Transgender Cell, he had tried to push for ways to make government hospitals more welcoming to trans people. “Every government hospital must have a department for transgender persons with a well-known surgeon and a well-known team of doctors,” he told us. “Without any hesitation, people will have to be able to go for hormone therapies, with all transgender persons around. They will feel comfortable. They will not feel hesitant about talking to the doctor. They feel when there is one of them, they are at the right place.”

Grace Banu, a trans-rights activist from Tamil Nadu, told us that access to safe healthcare for transgender people could not exist as long as the government failed to give the community the same access to education, particularly medical education, as the cisgender community. “The governments are only giving us welfare schemes, not our rights,” she said. “They haven’t done anything to protect our rights and to stop conversion therapy of LGBTQTIA+ persons. Education rights, employment rights, self-care rights, these all are our rights but they are denied to us. Only providing our rights, providing for the upliftment of the community can be a solution. Welfare schemes don’t give any upliftment for the community. Our rights will mean liberation.”

Jehagirdar told us that in terms of the expertise required for trans healthcare, both the private and government hospitals were severely lacking. “No matter if the surgery is done in the public or private sector, what matters is that care is given properly in a stepwise manner,” she said. “It should be patient-oriented care. If complications develop, adequate financial compensation must be given and need to ensure complications are managed properly. It is not about giving money. It is about ensuring that the person is safe.”

The Transgender Persons (Protection of Right) Act, 2019, recommends that state governments publish a health manual for gender-affirmation surgery following the guidelines issued by the World Professional Association for Transgender Health—commonly called the WPATH protocol. The Kerala government is yet to publish such a health manual. “Currently the state of Kerala does not have a protocol on its own,” Sheetal Shyam, a member of Kerala’s Transgender Justice Board, said. The board was set up by the Kerala government in 2017 to monitor violence and discrimination against trans people. “In 2018 itself, transgender justice board members, including me, had demanded the government to set our own surgery guidelines, but there was no result. We suggested that the private hospitals should stop conducting gender-affirmation surgeries for now, but we do not have an effective mechanism which can ensure this.” R Bindu, Kerala’s social justice minister, M Anjana, the director of the state’s social health department and Veena George, the health minister, did not respond to emailed questions about surgery protocols, transgender healthcare policies, advanced training for public health practitioners or welfare schemes for queer communities.

In the absence of a state health manual, Vijayaraghavan told us that his hospital and others tend to follow a set of guidelines issued by the Indian Professional Association for Transgender Health—called the IPATH protocol. According to both protocols, the process for gender-affirmation surgery needs to include endocrinologists, psychiatrists, psychologist, plastic surgeons, gynaecologists, urologists, and gastrointestinal surgeons.

Even these protocols can often be misunderstood by doctors. Vijayaraghavan told us, “The first thing to do is to confirm this person is a Transgender person, not having a psychiatric problem because there will be persons who have psychiatric problems.” This understanding of the psychiatric evaluation that protocols require can easily feed into bigotry and the denial of gender affirmation services to many transgender people. “That doctor should update himself, it is a patriarchal comment,” Banu said. “This is why I said specialisation is needed, they need to know how to deal with transphobia and how to handle a trans person, they should know completely about a transgender person. Being a transgender is not a psychiatric condition, it is natural.” Vijayaraghavan told us that after the psychiatric evaluation, transgender people wishing to undergo gender-affirmation surgery would be given six months of hormone therapy. Only following that is any surgical procedure done.

Transgender people we spoke to said that the procedures conducted in private hospitals in Kerala and Tamil Nadu not only failed to follow protocol, but were often botched, causing extreme pain. In November 2019, Suresh was staying with a transgender community in Tamil Nadu Nagercoil city. Over the previous year, she had been able to collect the Rs 1.8 lakh required for her surgery. At Saravana hospital, in Madurai, she was not given psychological counseling, hormone treatments or even an explanation of what was to follow.  “They didn’t make me sign anything,” Suresh said. “They changed my clothes and placed me in front of the operation theatre in a wheelchair. I was taken in around 10 and brought out by 12.”

“I wasn’t given the prescription and receipts in hand,” Suresh continued. “I was discharged on the third day.” Following the surgery, with a catheter bag on her hip, she was expected to do household chores around the community where she was staying. Unable to bear the pain and exhaustion, Suresh left Nagercoil and returned to Kerala.

Suresh said that for the first seven or eight months following her surgery, she did not face any medical complications. “From then, I started facing difficulties,” she said. “I went to the doctors to show my vagina to know what is happening to it. At the Kottayam medical college, doctors told me that a shrink inside my vagina is the reason for the obstruction in urination. I was not sure why it was happening, so I kept cleaning the area hoping it would get better but it didn’t help. I went to Sunrise Hospital in Ernakulam and they carried the case for a while. I didn’t even tell my husband. The doctor told me another surgery is a must, otherwise, there is a threat to life.”

There are only a handful of hospitals in the country that offer corrective surgery. Renai Medicity, a private hospital in Kochi is one of the few that does. But several transgender people we spoke to said that its reputation was dubious. Two months before Ananya’s death, she had undergone a botched gender-affirmation surgery there. On 20 July 2021, she posted a video, through her adopted sister, Heidi Sadiya’s YouTube page. “They exploited my excitement,” Ananya said in the video. “It would be unimaginable for you to use sanitary napkins for 24 hours. Daily I have to use at least eight pads. I’m unable to work, I can’t bend down to apply makeup. Such is the pain and irritation. It can’t be called a vagina. Anyone who sees it would shut their eyes. They just chopped off what was there in between my legs. This is not just my experience, many others did the surgery from the same hospital and got it failed. So many who were reluctant to speak out now have started speaking out. I want to live ahead; I want to live healthily.”

In the video, Ananya claimed that nothing about her operation had been explained to her before or after the procedure. “Dr Arjun Ashok didn’t inform me about the post-surgery care,” she said. “Some patients have done revision surgery more than once. My surgery is done by cutting the stomach open. I can’t properly clean my tongue because of the pain, sneezing or laughing is difficult ... The surgery must be done by an expert doctor.” Vihaan said, “In Ananya’s case. Renai Medicity failed to follow the protocol. They did her surgery within ten days after her first appointment.” We were unable to reach Ashok for comment. This piece will be updated if Renai Medicity responds to questions about the protocol followed for gender affirmation surgery.

On 20 July 2021, Ananya was found dead at her apartment in Kochi. Although the police and the authorities ruled it a suicide, transgender activists and Ananya’s acquaintances expressed their doubts over it. Two days after Ananya’s death, her partner, Jiju Raj, was found hanging inside his friend’s house in Kochi.

Suresh told us that many people were now advising her to go to Renai Medicity for her corrective surgery but she was too scared of the hospital after what had happened to Ananya. “I didn’t have any trust in those doctors,” she said. “What if I face a similar fate to Ananya?” She told us she is still trying to raise funds for corrective surgery as her situation worsens. When we last met her, her urological issues had become so severe she had to begin using sharp objects like pins to be able to urinate. In an attempt to raise funds for her surgery and gain media attention about the lack of proper gender affirmation care, she decided to publish an image of her vagina. It is unclear if the Kerala government will reimburse her for corrective surgery as it is supposed to for the initial gender-affirmation surgery. 

The surgical experiences of other transgender people have been equally horrifying. A transgender person from Ernakulam, who had undergone gender-affirmation surgery from a private hospital in Kerala, and wished to remain anonymous, told us they had faced severe constipation and digestion issues after undergoing intestinal vaginoplasty. “No one has expertise regarding these surgeries, no one has properly studied about it,” they said. “Merely keeping constitutional bodies with transgender persons’ representation wouldn’t do the work. Access to these bodies is still difficult for many of us. The state’s reimbursement of funds for gender-affirmation surgery is a flawed one. Government hospitals must facilitate surgery facilities for transgender persons. Laser treatment at a low and fixed rate must be available.”

In the absence of government enforcement of protocols, transgender people have little recourse after botched surgeries. Days before her death, Ananya discussed the possibility of suing Renai Medicity and doctor Arjun Asok for medical negligence with lawyers. Smruthi Sasidharan, a Kochi-based lawyer who is vocal about LGBTQI issues, told us it is very difficult to sue a hospital for medical negligence following botched gender-affirmation surgeries as the “law is not airtight.” She added, “Our health system laws are very flawed. There is no assurance of anything.”

Sasidharan said that even when consent forms are given for medical procedures, it does little to help the patient understand what they will be going through. “Most of us don’t even bother to read the consent letter before agreeing to do a surgery and most doctors will not spare time to explain the content of the letter,” she said. “Most consent letters are in English and many patients can’t understand them. The consent letter absolves the doctor of responsibility for all the consequences a patient had to face after the surgery. On top of this, in my experience, no doctor would come forward and testify against another doctor’s negligence. So, it is almost impossible to win a medical negligence case.”

Trans-rights activists told us that despite the government lacking the expertise or accountability mechanism to manage gender-affirmation surgeries, it continues to push transgender people towards unsafe surgeries even if they did not wish to undergo them. The Transgender Persons Act, 2019, requires transgender people to have a Transgender Certificate to be legally recognised and have access to the welfare schemes that this entails in various states. It also makes the process to get a Transgender Certificate bureaucratic and cumbersome, unless the person has undergone gender-affirmation surgery.

“According to the NALSA judgment, transgender identity is self-declaration,” Naseema Nazrin, a member of Sahayatrika—a Kerala-based organisation for lesbian, bisexual women and trans gender persons—told us. “But in state level and district level, such screening bodies exist and there is a high chance that the identity card is not provided. There is a challenge to pass the district level screening for ID cards to be provided, only in about 90 percent of cases can transgender persons pass through. If in any situation this screening body rejects our application, how will the person approach a hospital for the gender-affirmation surgery? An ID proof is needed at the time of surgery, but they will be forced to give the old name, the old documents, old voters ID, but this person has gone through immense struggles to reach the surgery phase and leave that old life behind.”

Ranjini agreed. “It is after the union government’s transgender bill, the surgeries are increasing,” she said. “The benefits for the identity will only be given if one has done surgery, at least on one part. Those who decide not to do the surgery in life are forced to do it. I know many transgender women who didn’t want to undergo gender-affirmation surgeries finally had to do it.” These rules established by the 2019 law run contrary to NALSA judgment, which clearly established that, “Each person’s self-defined gender identity and sexual orientation is integral to their self-determination, dignity, and freedom, and no one shall be forced to undergo medical procedures or hormonal therapy to obtain legal recognition.”

“Transgender persons express their identity in the coming out process itself, they mostly desire to express themselves,” Shyam told us. “Mentally the identity they have will be reflected in their behaviour and the gender-affirmation surgery was not seen as very urgent. It is a process that takes two years. Some transgender persons just go for the surgery without proper preparation. In the community, many are unaware of medical specificities, but those who are doing the surgery are well aware of the things. They must know how the process goes, how the counselling can be given, how far we can make monetary profit out of it etc. That is a major concern.”

Shyam said that the union government’s approach had been purely medical, without a rigorous understanding of trans identities. “We do not have enough academics and professionals who are aware of gender identities, gender-neutral identities and sexual diversities,” Shyam told us. “There are only very few professionals who have a focused expertise on cosmetic surgery and trans-identity surgery. It is a question even the Indian Medical Association is not providing any sort of training, nor is it included in the curriculum. They must study about this. This is not an interest, and the community is victimised for that. I think that is the problem.”

The transgender person from Ernakulam, who wished to remain anonymous, told us that they had recently gone to get their second dose of the COVID-19 vaccine. “There were a large number of transgender persons gathered to get vaccinated and we talked about several things,” they said. “We spoke about reimbursement for revision surgeries. We asked the officials there why laser treatment and hormone tablets weren’t available at government hospitals. And then, of course, other issues like housing. Transgender persons must be included in housing schemes, having access to adequate housing would lessen the chance that transgender persons choose to do sex work.” They had earlier spoken to us about how access to schemes for the community often required them to have Transgender Certificates and how the surgeries required to get them often left transgender people medically unfit to work well. “It is an endless loop, once you enter it then you can’t get off easily,” they said. “How can this be called pride? If we get no justice when alive, there is no point in seeking it for the dead.”