Video Producer/Editor: Akanksha Pandey
In July 2021, Kerala's first trans woman radio jockey Anannyah Kumari Alex was pushed to take her life, allegedly due to medical negligence during her gender affirmation surgery. Anannyah had publicly voiced her discomfort and dissatisfaction over the surgery performed at a private hospital in Kochi, but received no support.
This is why the Delhi Health Department's circular, directing government hospitals to provide free sex-reassignment surgeries (SRS), is much-needed. But it is also something that needs to be treaded with caution, say medical activists.
The circular mentions that all government hospitals with burn and plastic wards, along with the facility of a surgeon, must begin providing transgender people free sex-reassignment surgeries.
But do government hospitals in Delhi, or anywhere else, have what it takes to perform these crucial surgeries? Can it actually be implemented, or is it simply a policy that will exist on paper?
Does Free SRS Include Pre & Post-Surgery Care?
As per the Transgender Persons (Protection of Rights Act) 2019, at least one state government hospital should offer SRS to those who identify as transgender persons. However, this has not been followed by most states, Dr Aqsa Shaikh, a community medicine expert, who also identifies as a trans woman, told The Quint.
"Last year, the Centre announced that TG Plus card will be issued to transgender persons to avail healthcare facilities, up to Rs 5 lakh, under the Ayushman Bharat scheme. Therefore, only when government hospitals provide services for gender-affirming healthcare that one can use these benefits. Not everyone seeking these services can go to government hospitals, and not just that, there are no enforceable guidelines in case of a mishap."Dr Aqsa Shaikh to The Quint
Dr Shaikh explained that gender affirmation treatment can come in many forms, and there needs to be clarity on whether the Delhi government means only surgeries. To break it down, a transgender person, who wishes to undergo a gender affirmation surgery, would first:
Consult a mental health professional
See an endocrinologist or gynaecologist who would put them on hormone replacement therapy (HRT)
Laser-induced hair removal
Surgeries like breast augmentation, in cases of transgender women, or mastectomy (removal of breasts), in cases of transgender men
Vaginoplasty or phalloplasty
'Should Not Be Experimenting on Bodies'
Dr L Ramakrishnan, public health professional from NGO SAATHII, in Chennai, explained to The Quint that some gender-affirming surgeries can be performed at government hospitals, provided they are gender-sensitised and equipped with the required skills.
For example, he explains, a surgeon may have the skills to perform a mastectomy (removal of breasts) or oophorectomy (removal of ovaries) – but they should not be experimenting with the bodies of patients by performing vaginoplasty when they have no training for it.
"Caring for trans men and women, ensuring that they get the best of healthcare, requires a lot of training. It is not like performing appendicitis, where any surgeon can perform the surgery. If not given the needed training on how to decide on what's best for the patient, it may lead to a botched up surgery that can turn deadly."Dr L Ramakrishnan
Tarun, a medical counselor and man of trans experience, points out that performing a mastectomy on a cis-het body, and on the body of a person who identifies as trans, requires different skillsets. Speaking to The Quint, he said:
"Many doctors in government hospitals do not understand the gender spectrum umbrella. These are life-saving surgeries, but doctors do not really understand what is going on in the person's mind. Imagine that you are a trans man undergoing mastectomy and the doctor misgenders you, or does not understand why you take HRT. I cannot put into words the trauma that the person will go through."
Need for Guidelines, Skill Training for Complex Surgeries
A surgery like phalloplasty is very rarely performed in India – as it requires a high level of skill. It is also much more expensive than vaginoplasty.
"Any genital reconstruction must absolutely be performed only by highly trained and skilled professionals. To start with, doctors can start providing all the other healthcare services, and those interested must be trained in these surgeries," Dr Shaikh told The Quint.
Dr Ramakrishnan agrees.
"Those doctors who are gender sensitive can be sent abroad to train, to watch and learn from other doctors specialised in performing these surgeries."
However, if gender-affirming surgeries are going to take place regularly in government hospitals, then the ICMR and National Medical Council (NMC) guidelines, which are followed across the country, need to be in place.
"The surgeons in some government hospitals that are already providing these services, do not have the time to stick to a timeline. For example, a person already on HRT will have to stop treatment for a surgery, but then, will be told that the surgery is being pushed. There need to be proper guidelines, which all medical professionals adhere to. Right now, we just follow other countries when it comes to guidelines for these surgeries."Vignesh Dhananjayan, medical student who identifies as a trans person
Dr Shaikh added that many doctors who have the skills do not perform gender-affirmation surgeries due to the threat of a legal case – but government guidelines can help overcome this barrier.
But First, Basic Sensitisation, Please
None of these guidelines or suggestions can be effective if hospitals lack respect that people from the queer and trans community deserve, say both doctors and activists.
1. Gender-Neutral Wards & Washrooms
According to Vignesh, hospitals need to consider a separate ward for transgender persons undergoing SRS to ensure their safety.
"There are some government hospitals in Chennai that has a separate ward for transgender persons undergoing SRS. But if this is not possible, one must consider a gender-neutral ward and washrooms. All these things seem small, but they matter," he says.
2. IDs for All
Dr Shaikh claims that less than 2 percent of trans persons in India have a community card, and the rest do not have access to even basic services due to a lack of identification cards. "Government should address at the earliest the red-tapism."
3. Sensitise Everyone
But most importantly, ensure respect, says Dr Shaikh.
"Don't make transgender persons turn away from healthcare services they deserve and need, because of transphobia."
"Everyone needs to be sensitised, right from the chairperson of the hospital to the ward staff. If this is not done, people will not turn up for better healthcare services, and these will remain policies on paper," Tarun added.
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