As I sit in Dr. Narendra Kaushik’s office at the Olmec Cosmetic Surgery Centre, in Pitampura, he recalls a story about a very successful sex-reassignment surgery (SRS) he had performed.
“Once we make the vagina – using a part of the intestine – you have to wait for the air to come outside through the anus,” he explains. “This is called peristalsis, meaning your gut is moving and you can now eat orally.” And the patient on whom he had performed this surgery was able to do it on the first day itself!
“Passing the flatus is compared to saying ‘You have become a woman!’ or ‘You have delivered a baby!’,” he adds.
This is just one of roughly 8,000 sex-reassignment surgeries (SRS) that have happened at the Olmec Centre in the last decade. And Dr. Kaushik remarks how for many patients the day of the surgery either coincides with their birthday, or how they choose to make it their birthday because of the importance it holds in their lives.
But despite the successes of medical advancement, and increasing social acceptance (even legal) many Indians still choose to see transgender people as “unnatural”.
To that, the doctor has a sharp response: “That way, all breast reconstruction in Hollywood and Bollywood is unnatural! There are so many females who don’t have vaginas, and we make the vaginas. There are many people with small penises, we correct the penis. You cannot say this is unnatural.”
A similar view is echoed by Dr. Anubhav Gupta, whom I meet later. He sees between 10 and 20 SRS cases, annually, at the Sir Ganga Ram Hospital in Rajendra Nagar. To him it is a simple question of health.
“Health is a state of physical and mental well-being. It’s quite logical to say that unless the patient is comfortable with themselves, and their body, they are not ‘healthy’! We are just helping them achieve what they want, and to be strong in front of society.”
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About the sort of patients they see, the two doctors have different experiences to share.
Dr. Gupta tells me that most of the Female-to-Male (FTM) patients he sees come with their parents, and surprisingly do not want ‘complete’ surgeries. “Most of them are very uncomfortable with their menses, and just want to get rid of their genitalia. In my experience only half of them do genital reconstruction.”
In Dr. Kaushik’s experience with Male-to-Female (MTF) cases, on the other hand, things are a little different. “Many people don’t opt for breast augmentation because they can’t disclose themselves to their family, so sometime they go only for genital reconstruction.”
What These Surgeries Involve
Sex-reassignment is a grade, made up of various procedures. For MTF candidates, there’s breast augmentation (which involves implants), vaginoplasty, and orchidectomy (removal of the testicles). Then there’s face feminisation surgery (FFS) – narrowing the jaw, rhinoplasty to streamline the nose, and laser removal of facial hair.
For FTM candidates, there’s a whole other set. Mastectomies, or ‘top-surgery’, remove the breasts. The vaginectomy and hysterectomy remove the vagina, ovaries and uterus. Then there’s phalloplasty, to create a penis: “We take tissue, nerves, vessels, along with the fat from other parts of the body, and we join all the nerves to the recipient site, so that it becomes a sensitive and functional penis.”
And for elderly FTM candidates who cannot handle bigger surgeries, there’s the metoidioplasty, or the creation of a small penis.
Risks And Doubts
While SRS isn’t advisable for minors, there is no upper age limit as long as the candidate is physically fit. “With meticulous planning, expertise, the advancement of anaesthesia, and an overall understanding of the subject, the risk is practically zero,” says Dr. Kaushik.
And if there are risks, Dr. Gupta says it’s with hormonal treatment: “If a person takes oestrogen for a long time, there is a risk of the blood becoming thicker, and chances or thromboembolism, for example, increase. Just like with taking contraceptive pills.”
But as with all surgeries, SRS candidates have several questions. Dr. Kaushik says that the first thing clients from remote places ask is whether it is even possible. Then they want to know if people will be able to recognise whether they were male or female before the surgery. Many MTF candidates ask if they will be able to have penetrative sex. And yet another question is whether they can have children. Unfortunately, the answer to that last one is no.
The Legal Side Of Sex-Reassignment
While in some respects, SRS is like any other surgery, in others it is not. Surgically transitioning from your assigned gender actually involves a number of legal steps.
Apart from facial surgeries or hair transplants, candidates have to be diagnosed with Gender Identity Disorder before SRS. Dr. Kaushik explains that a candidate needs clearance from two mental health professionals and an endocrinologist. Then they have to take hormones for six months, before they can proceed with the surgery.
“Interestingly there are no clear guidelines in the Indian law,” says Dr. Gupta. “We are following the American law. Before we do any such surgery, we need an affidavit in the court of law, with a witness and the doctor, describing to the patient that this is permanent.”
A version of these steps also appears in India’s newly passed Transgender Persons (Protection of Rights) Bill 2016, but has also been criticised on many counts – like subjecting trans people to a long-drawn, and potentially dehumanising sex determination process. But the approach to the subject itself is undergoing review.
Health Care For Transgender People
Dr. Kaushik tells me that SRS terminology is in the process of being changed. For example, Dr. Kaushik prefers ‘Gender Dysphoria’ (distress caused by not having your body match your gender identity) to ‘Gender Identity Disorder’, as the former is more mindful of the struggles of trans people.
Once, an MTF patient had questioned him for using the term “sex-change”, saying “I have never been a male. I was a female since birth, but society has forced me to live as male. I have had body parts that are ‘male’ but these were never my parts.”
Also read: ‘I Found The Courage To Do What I’d Been Avoiding. I Came Out As A Trans Man’
As the medical profession evolves to take all of this into consideration, one wonders what role the state might play in the lives of trans men and women. Last March, the state of Kerala announced it would make SRS free for its transgender population, and the 2016 Bill too had an opportunity to address trans healthcare in India.
A single surgery can cost anything between ₹2,00,000 to ₹8,00,000, and the option is only available to only some of the lakhs of trans people in India. Health care is a priority for this group as it is for anyone. And to that end, there must be a dialogue between trans people, lawmakers, and medical practitioners like Dr. Gupta and Dr. Kaushik who do this work because they believe in it.
The Kerala government’s decision to introduce free sex-reassignment surgeries in government hospitals may open a new lifeline to transgenders who feel they are trapped in bodies that are not compatible with their feelings.
No such facility for such surgeries exists, either in government or private sector, in the state at present, says VN Jithendran, director in the social justice department of government of Kerala.
Transgenders blame this on the state still being very conservative in its approach towards gender minorities. “There are only men and women in Kerala. The society doesn’t recognise the existence of transgenders at all,” says 29-year-old Faizal, who fled to Bengaluru in the face of harassment and humiliation in his village near Chavakkad in Thrissur district.
Chilla Anil, executive director of Chilla, a non-governmental organisation in Thiruvananthapuram, points out that at present transgenders are forced to go to Chennai or Bengaluru for such surgeries. This is neither practical nor affordable because these surgeries are a long-drawn and costly process.
Anil said that a male to female surgery costs around Rs 2 lakh to Rs 5 lakh, while female to male surgery costs between Rs 4 lakh to Rs 8 lakh in private hospitals. This is not affordable for majority of the transgenders since they neither have regular income nor the support of their families.
Even those who have the money find it difficult to go for surgery outside the state as the process involves counselling for six months to two years, continuous hormone therapy for at least one year under the direct supervision of a physician and long post-surgery observation.
With this background, Anil said the decision to introduce the facility in government hospitals in the state will be a big boon to the transgenders. A survey conducted among the transgenders in the state last year found that nearly 81% of the estimated 25,000 transgenders wished to change their gender identity.
The survey found that as many as 76% of the transgenders were reluctant to reveal their actual gender identity because of the fear that they won’t be accepted if their gender identity were revealed. Majority of the transgenders who wish to change their identity reported lack of support for the surgery from any quarters.
Anil said that the transgenders in the state have been demanding free surgery facility in government hospitals for a long time now. The demand was raised at the International Conference on Gender Equality held at Kovalam in the state capital of Thiruvananthapuram in November.
Road blocks ahead
But Anil was sceptical about the government decision since it has come from the social justice ministry headed by Dr MK Muneer. The health ministry that has to implement the decision has maintained a mysterious silence on the issue, said Anil.
“We had made several representations to Health Minister VS Sivakumar for providing the facility at least in government medical colleges, but the minister remained deaf to our pleas," Anil said. "We don’t know whether Muneer has made the announcement after taking his colleague into confidence.”
Jithendran added that the department was pursuing the matter with the health ministry. “We will be soon sending a concrete proposal in this regard to the ministry for implementation, Jithendran said. “I hope the facility will be in place at least in medical colleges during the next financial year.”
However, Jithendran admitted that the process was not easy since Kerala does not have trained physicians to conduct sex reassignment surgeries, which require a multi-disciplinary team of urologists, endocrinologists, sexologists and psychologists.
“We have the specialists, but we need to hone their skills to perform the surgery. We hope the proposal will become a reality before the middle of the coming financial year. The government is committed to bring the gender minorities to the mainstream,” he added.
The new initiative is part of the steps being taken by the government to implement the transgender policy announced in November last year. The policy, the first of its kind in India, is aimed at improving the life and living conditions of the transgender community.
Another major step under the policy is a “Gender Taxi” for the transgenders. The taxi service to be owned and operated by the transgenders is aimed at ending the societal stigma towards them. The programme conceived by the state-run Gender Park on the lines of the successful “She Taxi” is proposed to be rolled out later this month.
While the “She-Taxi”, launched in November 2013, is run exclusively by women for female passengers, the “G Taxi” has been envisaged as an “equality taxi” in which all travellers, irrespective of their gender, can avail of the service.
PTM Sunish, chief executive officer of Gender Park, said the “G Taxi” was also intended to ensure interaction between transgenders and members of the other two genders. This, he said, will help in changing the mindset of the people towards the sexual minorities.
Ten transgenders have come forward to operate “G Taxis”. They are now undergoing training. The government is trying to help them procure the cars. This may not be easy since the banks will insist on collateral security, which most transgenders may not able to provide as they do not have family support.
Transgenders have welcomed the initiative saying that it will not only help them in earning a living but also in gaining access to mainstream society. “I am confident that this will be a successful venture,” said Navas, a transgender involved with the “G Taxi”. "Running a taxi is more than a means of living. It gives visibility to the transgenders and that will in turn help them in joining the mainstream."