This article is the second in TNM’s ‘Access Denied’ series, which dives into the issues and needs of certain sections of society that are confined to the margins and denied access to the mainstream..\r\tTW: Mention of suicide, violence.Ousted by her family for asserting her identity as a woman, Padma (name changed) was all of 18 when she realised ‘transgender friendly’ Kerala was not going to be kind to her. There were not many ways forward, the few trans women she knew at the time had advised her. No one would employ a trans woman, and she did not even have a degree. If she wanted to survive, let alone one day undergo the surgeries she hoped would finally allow her to be comfortable with her body, she had but two options — turn to sex work, or beg on the streets..So at the age of 19, Padma made her choice. She became a sex worker..“Life has been a struggle, as one would expect,” she says. “Many people are uncomfortable, even angry, with how we don’t conform to their concept of a rigid gender binary. In addition to that is the shame associated with sex work and begging. Due to this dual stigma, people often do not even think of us as humans who deserve respect.”.One day, Padma hopes to undergo a gender affirming surgery. A distant dream, she says. “As of now, I am struggling to make ends meet. I do not have the funds for a surgery. But I am slowly learning to love my body in small ways, through my clothes and how I express myself.”.The Kerala Social Justice Department has a scheme in place to provide financial assistance to trans persons undergoing gender affirmation surgery, which should have ideally come as a solace to many like Padma. As detailed in its website, the government will provide a maximum amount of Rs 2.5 lakh as financial assistance for the surgery, in addition to another Rs 1 lakh for breast implantation and Rs 36,000 for postoperative care (Rs 3,000 per month for 12 months)..But the problem, trans activists point out, is that this amount is paid only as a refund. “Most trans women are disowned by their family and live their life stranded on the road. A majority of us don’t have access to education or jobs. Yet, we are expected to arrange lakhs of rupees for the surgery by ourselves, and apply for a refund only after the procedure is completed,” says Raji (name changed), a trans woman. “Even the refund is provided in instalments, that too after a year or so,” she adds..Besides, postoperative money is not provided to individuals aged above 40 years, as the age limit for availing funds is between 18 and 40. Padma doesn’t understand why. “Do our needs stop to matter after a certain age?” she asks..Thiruvananthapuram-based trans activist Sreemayi suggests that a more viable option would be for the government to tie up with a hospital and provide the money for the surgery directly. “This way, we at least won’t be forced to turn to sex work or begging to save money,” she says..But according to Vasuki, a trans rights activist based in Thrissur, what the government needs to do first is set up a facility equipped to conduct gender affirmation surgeries. “As of now, trans persons have no option but to get the surgery done in private hospitals and submit the bills to the government, and then wait for years to get a refund,” she says..The primary reason gender affirmation surgeries are not carried out in Kerala’s government facilities is simple — the lack of trained healthcare personnel. Reconstructive surgery is indeed a complicated procedure, says Dr AK Jayashree, professor and head of the department of community medicine at Kannur Government Medical College Hospital. “But if government doctors are provided adequate and rigorous training, it can be accomplished,” she says..Private hospitals in the state, meanwhile, have reported multiple failed surgeries, which often leave trans women with excruciating physical pain, additional mental trauma, and little to no support to hold on to. “This is what pushed Anannyah over the edge,” Krishna (name changed) says, as she recalls the young trans woman radio jockey with bright eyes and a vivacious voice. Less than a week before her suicide in July 2021, Anannyah Kumari Alex had alleged in a media interview that she had faced gross medical negligence during her surgery at a private hospital in Kochi..“After Anannyah realised the surgery was botched, the doctor’s response was that they would ‘try again’ to fix what went wrong. Was that what a doctor was supposed to say?” Krishna asks..Read: Anannyah’s story isn’t new: Kerala lacks support for trans persons undergoing surgery.Even if the surgery is ‘successful’ at the outset, it usually comes with an additional set of health problems, says Tara (name changed), a trans woman sex worker. “Some of us face urinary continence, and some have issues with their intestines. There are people who struggle with back pain all their lives due to breast surgery. This is in addition to the pain we go through during hormone therapy and laser treatment for hair removal,” she says. “It is also not uncommon for us to see deaths, during and after surgeries.”.Viji, a queer activist and Malappuram District Transgender Justice Board member, says incidents such as this happen due to the non-existence of a uniform protocol while performing surgeries. “Each hospital does it in a different way. We even have three different types of surgeries that can be performed based on the amount of money we can provide. Not all of them would give us a functional vagina,” adds Viji, who is also the president of Karma, an NGO for queer persons..“Besides, the hospital is supposed to assess the person undergoing the surgery for at least six months before the procedure. This is a precaution most facilities overlook,” says Dr Jayashree..The government should consider introducing unified guidelines on how to perform vaginal reconstruction surgery, Sreemayi agrees. “If the surgery is done properly, the touch sensation of the nerves there can be retained without fail. An informed system has to be implemented to ensure this,” she says..Shyama S Prabha, former Transgender Cell project officer under Kerala’s Department of Social Justice, says the government is currently working on implementing a uniform protocol for gender affirmation surgeries. “This was one of the hurdles that had come up while the government was discussing the provision of financial assistance for surgeries. The other was the difficulty in making surgery expenses uniform,” she says..When asked about the age bar for surgeries, she says the 18-40 age range was fixed when the Government Order was first released. “However, there was an application to remove this bar and the plan is currently under negotiation,” she adds..\r\tBeyond the surgery.But of course, this does not mean every trans person wants to undergo a surgery. Gender affirmation is simply a process through which an individual recognises and affirms their gender identity, Raji points out..There are several other affirming procedures that trans persons depend on to overcome their gender dysphoria, explains Viji. “This can range from resorting to conventional dressing styles of the gender one aligns with, to surgically altering their sexual anatomy. Some undergo breast surgery alone, some bottom surgery, and others both. There are also individuals who wish to exist on a continuum, a spectrum that gives space for their own expression of gender,” she says..Raji adds that while there are a number of medical procedures such as hormone therapy and laser treatment besides surgeries, social interaction is also an important aspect of gender affirmation. “Using the right pronouns of an individual and not discriminating against them, ease of access to legal procedures such as changing names in documents, and being included in welfare schemes are all important,” she adds..\r\t‘Imagine PMS, but every day’.Then there are the significant mental health costs that accompany procedures such as hormone therapy, says Viji. “The recurrent hormone administration is often accompanied by depression, mood swings, and suicidal tendencies. Imagine experiencing severe premenstrual syndrome (PMS), but on a daily basis,” she says..Dr Jayashree is of the opinion that while depression and suicidal tendencies are rampant among trans persons, hormone therapy alone is not to be blamed. “The lion’s share of mental health issues faced by the trans community is due to the social isolation and ostracisation they face,” she says. But of course, hormonal changes and the multiple surgical procedures trans women undergo are also factors, she adds..Several trans women TNM spoke to say they often do not receive any familial or societal support, let alone appropriate physical and psychological treatment facilities. They also experience more body shaming than cisgender women, both in public life and on social media..Reeling from depression and the trauma of ostracism, Vijaya (name changed) had once attempted to end her own life. “I was taken to a counsellor, but they did not have anything to say to me. They just stared at me, with a puzzled look on their face.” After that, she stopped going to counselling. “Not to mention the cost of therapy. There is no way people like us can afford it on our own,” she says..Vasuki has another experience to share, shining light on the ignorance of Kerala’s health personnel when it comes to trans women. “I once went to a primary health centre because of a stomach ache. The staff there asked me if I was on my periods. I had to sit down and explain to them that trans women don’t get periods,” she says..Though we claim that Kerala and its institutions are trans friendly, the outlook of most Keralites on the ground is very different, Vijaya says. “We have a long way to go, and a lot of awareness to create, before there is a change in the judgemental lenses through which most people here look at us.”.Read: How transphobia and ignorance of doctors drove a Kerala trans man to suicide.\r\tHelpless childhoods.Most trans persons’ problems start right from their childhood, says Viji. “Once the realisation about our gender sets in, we begin to experience severe dysphoria. This is especially hard because as we grow up, society ingrains the idea of gender binaries into our heads. At that age, most children are unlikely to be even privy to the existence of transgender persons. So eventually, when a child starts to feel ‘different’, they have no clue how to handle it. It is a mental struggle too harsh for a child to deal with,” she says..The Kerala government has introduced a scholarship scheme for transgender students, as per which eligible students from Classes 7 to 10 receive an amount of Rs 1,000 per month for 10 months. But Viji thinks the scheme is impractical and uninformed..“How is it possible for children to just come out and reveal their gender identity? When children play games or wear clothes conventionally aligned with a gender they weren’t assigned at birth, families typically overlook it assuming ‘it will pass’. When this tendency persists through puberty, the family begins to admonish them for continuing these ‘childish games’. They are never even going to consider that this might be the child’s way of expressing their gender, because they simply don’t have the awareness for that,” she explains. Instead of implementing generalised schemes, the government should aim to provide support to transgender children as and when they realise their gender identity, she adds..Dr Jayashree suggests that the government focus on providing intensive gender sensitisation training to its own education and health departments. “Only with proper training can those dealing with children handle such issues sensitively, without traumatising the child or putting a halt to their education. Also, along with the child, parents should also be provided with proper counselling by teachers and counsellors,” she says..School can oftentimes be a traumatic period for trans children, who face abuse and ridicule from other students for ‘being different’. Many trans children eventually drop out due to the ostracisation they face..The government is conducting gender sensitisation workshops and seminars in schools more often now, many of which she has taken part in, Viji says. “It is necessary to make children aware of the fact that gender, as well as sexuality, is not a rigid structure, and that it is not something to be ashamed of. This will help change the future generation’s attitude towards gender minorities.”.\r\tLayered stigma.It is pertinent to understand that a trans person’s life does not revolve around their gender, says Tara. “We struggle to find a place to stay, pay the monthly rent, and often even to buy food. In fact, if we need to put food on the table today, we have to step out onto the streets. It is a hand-to-mouth existence.”.Engaging in sex work for a prolonged period of time also triggers an array of health problems, from anal fissures to sexually transmitted infections (STI) including AIDS. Besides, trans sex workers are paid less for their services and are vulnerable to more violence — whether it be from family, friends, customers, partners, or society and the system as a whole, says Tara..“We lose most of our health earning money for the surgery, after which we return to work and lose our remaining health as well. We cannot afford to take much rest after the procedure because it would incur substantial expenses. There is no way we can survive without our daily earnings,” says Viji..Some trans women are able to avail other odd gigs, such as making deliveries for Swiggy or Flipkart, etc. But many end up taking these jobs without adequate rest after the surgery. “Reconstructive procedures can be traumatic for the body. Riding a two-wheeler for very long periods soon after undergoing such physical trauma can create problems of its own, including intense discomfort and back pain. This forces them to depend on painkillers, which in turn becomes an addiction they have to struggle with,” says Raji..“Kerala society’s negative attitude towards trans persons extends to all aspects of their life — from healthcare and housing to education and employment,” says Ajitha (name changed), a trans woman residing in the coastal region of Malappuram. She shows us around her ‘house’ — two small rooms and a passageway converted into a kitchen, located on the first floor of a two-storeyed building dedicated for shops. At around 2 in the afternoon, the room is blazing hot..Ajitha and her family of trans women, which includes her adopted daughter Siji (name changed), had earlier rented another house in a more prominent location in the village, but were forced to move out due to constant harassment. “At times, people would randomly show up at our doorstep and demand sex. Someone once threw a firecracker into our compound. We could not take it anymore,” she says..The day trans women start expressing their gender identity, they are stripped of their dignity, says Binni (name changed). “Our families, neighbours, and then random strangers shame us. If we beg, we get chased away from shops, people utter obscene words at us, and we walk till our legs can’t take it anymore. Our hands start stinging after a point. We go through all of this for food, and for that one surgery we hope to undergo,” she says..“People think we are taking the easy way out by resorting to begging. Wherever we go, we end up facing condescending comments asking us if we are not ashamed; if we can’t work and live. They don’t realise, or care, that no one employs us for money,” Binni adds..\r\tTrans welfare in Kerala.Until a decade ago, trans persons in Kerala used to routinely migrate to cities such as Mumbai or Delhi, where they would spend the rest of their life doing sex work or begging, Viji says. “Now, after some trans friendly policies were introduced in Kerala, more and more trans persons are beginning to stay back. Of course, but not without our own struggles,” she adds..On November 12, 2015, Kerala had created history as the first Indian state to unveil a policy for transgender persons — the ‘State Policy for Transgenders [sic] in Kerala 2015’. The development had come in the wake of a 2014 Supreme Court judgement that granted legal recognition to all transgender and other gender non-conforming persons. The apex court had held that “all persons have the constitutional right to self-identify their gender”, further directing the government to provide reservation to trans persons in education and employment..The state has since gone on to implement several welfare programmes for trans persons, such as Sakalyam for vocational training and Karuthal for emergency assistance, among other schemes to aid their education, marriage, and skill development..However, due to lapses and limitations in the implementation of most such policies, the lived realities of trans women remain far from the utopian dream of a ‘trans friendly’ Kerala. In 2023, nearly nine years after the SC judgement, Siji with her postgraduate degree and teacher training still works as a sex worker. “There is no place that would offer her a job with decent pay,” says her foster mother Ajitha..Read: Six years, no progress: A look into Kerala’s much touted transgender person pension.A counsellor working with the government’s Suraksha project, implemented under the Kerala State AIDS Control Society (KSACS) to monitor and create awareness about sexual health, tells TNM that counselling is provided to all sex workers, including trans persons, who come under its scope. “Suraksha’s primary concerns when it comes to transgender women are three-pronged: condom awareness and distribution; counselling; blood tests for HIV and STIs,” she says..However, an insider — a trans woman who was a peer educator at Suraksha for six years — says there are several limitations when it comes to Suraksha’s interventions. “The first issue is that most of the people working with Suraksha are cis women, not community members. They come to us with preconceived notions about who we are, all based on what they have read and heard about us so far, which does not help trans women feel safe with them in any way,” she says..“Secondly, condoms are to be provided to the sex worker based on the number of clients they attend to. This data is completely made up based on assumptions, because nobody will declare the exact number of people they have sex with. Thirdly, the counselling they claim to provide is a non-entity. I worked there for nearly seven years. I never got counselled, nor have I seen anyone else get counselled,” she adds..Moreover, Suraksha’s outreach workers go to the field during the day, with their shift mostly ending by 5 pm, says the former peer educator. She points out that the sex workers, however, start working after 6 pm or so. “It is based on the surveys undertaken by Suraksha and other NGOs that the government plans interventions for us. But all of that data is fundamentally flawed, which in turn leads to improper planning and delivery of policies,” she explains..\r\tThree demands.\r\t1. Healthcare.Most trans women TNM spoke to highlight the absence of a government system that recognises and acknowledges their health issues, in addition to the continuing stigma among the common public, as their primary woes. They also demand a comprehensive healthcare system that will not only focus on their sexual healthcare, but also their mental and general physical health..Viji says that if the government can provide at least laser treatment and hormone therapy to trans persons for free, that would also significantly ease their burden. “While surgery is a choice an individual makes based on several factors, most transgender persons have to routinely undergo hormone therapy and laser treatment for hair removal. We spend anywhere between Rs 2,000 and Rs 7,500 per month on average for laser treatment, and at least another Rs 4,000 for hormone therapy,” she says..According to former Transgender Cell project officer Shyama, the Kerala government is currently mulling providing monthly hormone medicines at a subsidised cost to trans persons and removing the age bar imposed for availing post-operative surgery care. “As of now, the cost of hormonal therapy for the month in which the surgery is held, is being covered by the government. But monthly hormone medicines can cost anywhere from Rs 1,500 to Rs 9,000. The government has received a petition seeking distribution of subsidised medicines through the Kerala Medical Services Corporation Limited, the cost of which should be undertaken by the Department of Social Justice. Discussions regarding this are underway,” she says..\r\t2. Employment.The government can also provide jobs to trans persons in the various institutions that come under the state’s purview, like it did when the Kochi Metro was launched, says Sreemayi..“More often than not, these families’ fear is that their children will turn to sex work — which is considered a dishonourable act. But if the government can provide us an assurance of a job by actually implementing reservations, our lives will improve manifold,” Viji adds..\r\t3. Housing.Access to housing is another important need trans women want to be met, says Vasuki. “As most of our families disown us as soon as we assert our identity, we often end up on the streets with no money or even identity proofs to help us find our footing. Even if we find a place to rent after much struggle, we are forced to pay more money than cis persons. But if we get a decent government job and we start to earn money of our own, this will deter many families from ousting their children,” she says..Shyama says that during a survey conducted in 2014-15, around 3,600 transgender persons were identified in Kerala. “A recent revised survey (the report of which is not out yet) says there are only 1,900 trans persons in the state. The government had planned setting up shelter homes for trans persons, but the survey data indicated that the potential number of beneficiaries would be too low for it to be economically viable for the government. The plan was hence shut down.”.The need of the hour is accurate data to plan and deliver interventions, she says..Note: The image used for representation is from a protest organised by the Democratic Transgender Federation Kerala (DTFK) in Kochi on July 21, 2021, following the death of trans woman Anannyah Kumari Alex allegedly due to negligence of Renai Medicity hospital authorities..This article is supported by the Health Systems Transformation Platform (HSTP), as part of its Health Journalism Fellowship 2022..In the first part of TNM’s ‘Access Denied’ series, we reported on 'How Kerala govt fails sex workers by seeing them only as vectors of HIV'. The story can be read here.