Anannyah Kumari Alex was not new to the camera, or afraid of public speaking. She was a model, the first transgender radio jockey in Kerala, even a contender in the state elections, before she died by suicide on July 20 this year. Days before her death in the city of Kochi in Kerala, she had spoken to one media portal about the trouble she had been going through. Her pain was very visible to anyone watching… The agony she went through every time she sat down or stood up, or simply stretched out, stemmed from a botched gender affirmation surgery (GAS) she had undergone in 2020. And yet, she could not convince the people who treated her to help, she could draw no sympathy from the authorities. Anannyah deserved a chance to live life being true to herself – as everyone does – but she lost it at the mere age of 28.
“The outcome [of Anannyah’s surgeries] looked horrible, and even worse, caused her physical pain which she experienced till the day she died. There is always a huge risk in GAS and the one she underwent was a complicated surgery for which one needed to be mentally prepared for. Anannyah wasn’t,” wrote Vihaan Peethambar, a known trans activist in Kerala, on Facebook.
Vihaan wrote in detail about gender affirmation surgery which can go wrong due to multiple reasons. Most importantly, trans people going through the surgery should be physically and mentally prepared for it, which is not something hospitals providing the surgery in Kerala ensure.
Even after Kerala became the first of the states in India to formulate a transgender policy in 2015, there still is no government hospital doing gender affirmation surgeries. Trans people rely on a few private hospitals in Kochi – mostly the Renai Medicity, followed by Amrita and Sunrise Hospitals.
Trans people face a lot of discrimination and social prejudice, which makes them more vulnerable to mental health issues as well. Some opt for gender affirmation surgeries as a means to better align their body to their self-identified gender. However, many are left worse off if the procedure is not done properly. A trans man talks of the terrible experience he has had in a hospital after his surgery.
“I spoke to a psychiatrist at the hospital for a few minutes. He asked me what the problem was, and I told him. He prescribed a blood test and within a week I began my hormone treatment. There wasn’t much counselling during this time. I didn’t know it had to be done either. A year later, I had my mastectomy. All they asked was if I wanted a keyhole surgery or a ‘flat surgery’ (double mastectomy). I chose the latter, without properly being explained what either would result in. After the surgery and after my second dressing, I don’t have nipples anymore,” he says. He never went back to the hospital.
In a 2019 study by research scholar Shilpa Menon on gender affirmative healthcare in Kerala, one of the first cases of a trans person going through a gender affirmation surgery is discussed. The study, done for Kerala-based LGBTQIA+ organisation Queerala, noted that the surgery happened in 2017 at the Thiruvananthapuram Medical College. "Despite initial celebratory reports about a first-of-its-kind medical procedure in Kerala, it was later revealed that the trans man's health was in a dire condition, and that he had been inadequately informed about his options and the risks involved," Shilpa's study says.
In 2018, another trans person died by suicide when he was repeatedly denied the surgery, citing the lack of his parents' consent, even though he was an adult, aged 22 years.
"Most transgender individuals continue to suffer because of lack of access to gender affirmative procedures, or because of medical malpractice by doctors," says the study from two years ago. Unfortunately, not much has changed still.
In Anannyah’s case, Vihaan alleged that she did not know the nature of the surgery would be so complicated. “The doctor never prepared me for this… he only explained what he had done to my body after the surgery, when I asked him in pain," she had told Vihaan, he writes. He adds that she had even asked the doctor to reverse the surgery, or do something to stop the distress she was experiencing.
The doctor who had operated on Anannyah offered to do corrective surgeries. But after hearing stories of other trans people who went through multiple corrective surgeries at the hospital and ended up worse than before, she did not want to trust the same doctors. She wanted to have corrective surgery done elsewhere, and asked for her medical records from the hospital. According to Vihaan’s post, she also asked for a fund from the hospital to facilitate the same. However, her demands were never met.
Kerala government's 2015 policy for transgender people mentions the need for funds for those who wish to undergo gender affirmation surgeries; but most trans persons in the state are yet to get any financial help from the state. Amid limited possibilities for jobs and abandonment by families, many trans people find it hard to save up enough money for the surgeries. The government policy says that an amount of Rs 2 lakh will be reimbursed for trans people who have undergone the surgery, in addition to furnishing Rs 3,000 a month for a year for post-surgery care.
Shilpa's study says that while 52% of the trans people surveyed felt a need to undergo the surgery, only 9% have done so, "indicating severe limitations in accessing gender affirmative procedures."
Since Shilpa’s study, there have been hundreds of surgeries, with many of them ending up badly. Anannyah spoke of several trans people confiding in her of similar experiences but everyone was too scared to speak about it openly. As it is, they are shunned by a lot of people, they didn’t want to add to their alienation, says another trans man.
The hospital where Anannyah went to had trans-friendly doctors, he says. This easily buys the trust of trans people who are met with medical gatekeepers and discrimination. However, the same friendly doctors turn a blind eye when their patients come back in distress, upset at what the surgery has done to their bodies.
All of this calls for the need of government facilities which are affordable to the community, and which comes with sensitive and approachable doctors and staff.
The Kottayam Medical College was set up as the pilot clinic for transgender persons in 2017. However, apart from offering general health services and counselling, the hospital is not equipped to do gender affirmation surgeries.
Despite the much-appreciated transgender policy, government hospitals still lag in trans-friendly services or provision for surgery, found Shilpa’s study. "Many of the transgender persons consulted for this report indicated that transgender persons avoided government hospitals, even for general healthcare needs, because of lack of privacy and discriminatory behaviour by doctors and other staff members which can be deeply traumatic."
A government facility for gender-affirmative healthcare is also highly desirable since that will reduce the stress of finding the money for the surgery for the economically backward members of the community.
While stressing the need for private-public partnership, Shilpa’s report talks of several cases of transgender people suffering lifelong complications and health issues because of botched up surgeries – not unlike what Anannyah went through. And, doctors extract "more cash from clients for corrective surgeries."
"There is an absence of proper discussion on how improper surgery can affect one's sex life and mental and physical health," the report adds.
The WPATH (World Professional Association for Transgender Health) SoC (Standards of Care) recommends one year of hormone replacement therapy and living in their self-identified gender role before a surgery is performed. While some mental health professionals agree to this, others say that the surgery can be carried out with minimal preparation, if the trans person is willing and cleared through psychiatric evaluation. In Anannyah's case, a gap of one year was not needed since she was already living her gender for years.
Dr CJ John, a psychiatrist at Medical Trust Hospital in Kochi, says that those who go through the surgery should be emotionally prepared. "This is a surgery which is reconstructive as well as mutilating – the process by itself can cause a lot of trauma. It’s a procedure which extends up to one or one and half years, sometimes two years, including reconstructive surgery. Mental preparedness is important."
The procedures are not without any side effects or complications, he says. "When that happens, one will need emotional strength to go through the remaining procedure to attain their final objective. Usually, mental health support is given in the initial phase to help them decide whether they really want to undergo the procedure. Once the procedure begins, they need sustained mental health support – through hormone replacement therapy, surgery and even during rehabilitation. There could be many adjustment issues related to societal acceptance, coming to mainstream society etc."
Support is needed at the level of state infrastructure as well, but there is no such system, Dr John adds.
Thrissur-based ayurvedic practitioner, Dr Priya VS, who is reportedly one of Kerala's first doctors from transgender community says that it is significant to educate the people undergoing the surgery about the protocol and procedures that they will be undergoing. "Most of the people from the community undergo a lot of hardships and struggles on a day-to-day basis. When issues regarding the surgeries arise, it topples the lives," Dr Priya adds.
Dr Priya VS
Dr Priya also stresses it is important for the government to proactively engage in the matter in a step-by-step manner. "Earlier, the government had started clinics for trans persons. But they are not yet equipped to conduct these surgeries. The need of the hour is to conduct studies on the matter and equip our government health sector for gender affirmation surgeries," she says.
The first stage begins in preparation of the surgery, which is an assessment to determine if the potential beneficiary is mentally ready for it. "There are cases where the main motivational factors are the partners of the trans people. However, that is not enough – the primary motivation should come from the self. It should not only be an emotional decision but a rational and intellectual one. They should reach a frame of mind where they think they can face any adversities that may arise," Dr John says.
Trans people should also have realistic expectations. "For instance, trans women should very clearly know that even after surgery they cannot get pregnant,” says Dr John, adding that both the person considering a gender affirmation surgery and their partner should know that the surgery will not change sexual pleasure drastically either, and the “feel good factor” will be more emotional than anything else.
The next crucial stage where counselling support is needed is after the surgery, which is mostly lacking. "In the case of Anannyah, considering the trauma she was going through, she was at risk (psychologically). And this is not only the case with Anannyah. A lot of people who undergo this procedure are at risk of depression and other mental health issues. Foreseeing this, they should be given healthcare. The Social Welfare Department has much to do," Dr John says.