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Megha*, a transgender woman from northern Kerala, got her transgender ID card in 2020, five years before undergoing gender affirmation surgery. Esha Kishore, another trans activist based in Kerala, got hers in 2015, also before undergoing gender-affirming procedures.
The card is the legal document that certifies an individual’s gender identity under the Transgender Persons (Protection of Rights) Act, 2019, and neither had to undergo surgery to get it. They could apply based on their self-identification, with any medical procedures they choose to undergo coming later.
Megha spent roughly Rs 3-4 lakh on her gender-affirming care, including surgery, hormone therapy, doctors' fees, tests, travel, accommodation, food, and medication. She still spends over Rs 2,000 a month on medicines, a cost she will have to shell out for decades to come, since doctors advise most trans individuals to stay on hormone therapy until their 50s. Esha too spent a comparable amount on gender affirmation procedures, which she began a decade earlier than Megha.
For many like them, legal recognition did not depend on whether, when, or how they chose to medically transition. But that has now changed.
The Transgender Persons (Protection of Rights) Amendment Act, 2026, which came into force in May, removes statutory recognition of self-identification and requires a medical board to certify a person’s transgender identity. It also narrows the definition of who can be legally recognised as transgender, covering certain socio-cultural identities such as kinner, hijra, aravani, and jogta, as well as people with specified intersex variations. A heavily criticised provision also includes a separate category of people whom the law says have been compelled to adopt or present a transgender identity “by force, allurement, inducement, deceit or undue influence.”
The amendment effectively excludes people whose identities are based solely on self-perception, including self-perceived trans-masculine, trans-feminine, and gender-non-binary identities.
The change has left transgender persons, activists, and lawyers concerned about who will now be able to obtain legal recognition, and what the new medical-board process will require.
For those who already have ID cards, however, there is some clarity. During a hearing on August 17, the Union government told the Supreme Court that transgender identity cards issued before the 2026 amendment would continue to remain operational, subject to the outcome of the petitions challenging the law.
But for those seeking an ID card under the new system, the process could carry a significant medical and financial burden. Experts told TNM that requiring certification by a medical board could function as a surgery mandate in practice, even if the amendment does not explicitly say that surgery is compulsory. That could make expensive medical procedures and the costs of follow-up care a barrier to obtaining legal recognition, marking a significant departure from the earlier system, under which self-identification was enough to apply for a transgender ID card.
What the amendment changed
The Transgender Persons (Protection of Rights) Amendment Bill, 2026, was introduced in the Lok Sabha on March 13 and passed by the Lok Sabha on March 24 and the Rajya Sabha on March 25. It received presidential assent on March 30.
The amendment makes three significant changes to the process of legal recognition. It removes the statutory right to self-identification, narrows the definition of a transgender person, and introduces a medical board as the authority responsible for certification.
To understand why these changes matter, it helps to look at how the process worked earlier.
Under the 2019 Act and the 2020 Rules, a person could apply to the District Magistrate for a certificate of identity as a transgender person by submitting an affidavit declaring their gender identity. The Rules specifically said the application was to be processed without a medical or physical examination.
Surgery was therefore not required to obtain an initial transgender certificate. Medical intervention came into play if a person who already had a transgender certificate subsequently underwent surgery to change their gender to male or female and sought a revised certificate under Section 7 of the 2019 Act. Rule 6 of the 2020 Rules used the broader term “medical intervention” for this process, defining it to include counselling, hormone therapy, and surgical intervention, if any.
The 2026 amendment changes the process for obtaining the initial certificate. The District Magistrate must now examine the recommendation of a designated medical board before issuing a certificate, although the amendment itself does not specify what medical tests, examinations, or criteria the board must use.
A Tamil Nadu-based lawyer, who wishes to remain anonymous, told TNM that the new system could function as a surgery mandate in practice, even if the law does not explicitly say that every applicant must undergo surgery. “Until we get the rules under the amendment, we won’t be sure. But so far, surgery is mandatory. The 2019 Act also said surgery is mandatory, but the rules watered it down to ‘medical intervention’. The 2020 rule said the same. But now, with the 2026 amendment, they’ve restored the language of surgery.”
While the lawyer’s interpretation goes beyond what the amended law expressly states, it points to the central concern raised by activists: a process that once began with an individual’s own declaration of their gender identity will now involve medical scrutiny by a state-appointed body.
“What this amendment essentially does is shift that power into the hands of the government,” the lawyer said.
That shift is significant in light of the Supreme Court’s 2014 landmark National Legal Services Authority (NALSA) judgement, which recognised transgender people’s right to self-identify their gender without making medical or surgical intervention a prerequisite.
The 2019 Act subsequently gave statutory recognition to this principle. Section 4 recognised a transgender person’s right to be recognised as such and to a self-perceived gender identity. The 2026 amendment removes that statutory recognition of self-perceived gender identity and introduces medical-board scrutiny into the certification process.
A system already struggling to work
The uncertainty is not limited to the law’s language. It is also visible in the machinery meant to implement it. As the new system is being put in place, the National Portal for Transgender Persons has been throwing technical errors.
“When we ask about the site, the authorities say it is under renovation. Usually the site renovations take two weeks; now it's taking months. This means they are changing the complete process,” said Sanjo Steve, a trans man and activist from Kerala.
Under the earlier system, applicants could submit a self-declaration and supporting documents as required under the rules. Medical documentation could be relevant when a person sought a revised certificate reflecting a change in gender.
It remains unclear what the new medical board will require from applicants.
“We don’t know what the new medical board will determine as mandatory. Some people choose not to undergo surgery based on the severity of their gender dysphoria. The current amendment undermines these choices regarding bodily autonomy,” Sanjo pointed out.
Esha was more critical.
“How can a medical team determine whether a person is transgender? Some people identify as transgender but have not undergone any surgeries; the current change can affect them significantly. The situation for transgender individuals has improved compared to the humiliation we faced in public in the past. Now things will go back, as they don't have any evidence to prove that they are transgender,” she said.
“We have fought hard to achieve the positions we currently hold; now we face the challenge of going back decades,” she added.
Even if one overcomes financial and other difficulties, getting surgery is not an easy task.
A doctor in Delhi told TNM that a hospital known for gender-affirming surgery cancelled her surgery four days before it was scheduled, stating they needed her father’s consent letter to move forward. “They are asking what if I experience social regret or what if I have been forced to do surgery. So they have postponed the surgery till my parents offer consent,” she said.
The cost of gender affirmation – what the bills say
For transgender people who choose to undergo medical transition, surgery is often the largest single expense. But it is only one part of a process that can begin more than a year before surgery and continue for months or years afterwards.
The costs vary significantly depending on the procedure, city, hospital, doctor, and individual’s healthcare needs. Community members and activists gave TNM the following approximate figures.
For trans men
Mastectomy, involving the removal of breast tissue and chest contouring through techniques such as the keyhole or double-incision method, is commonly referred to as “top surgery”. The procedure can cost between Rs 2 lakh and 4 lakh. As per an activist in Delhi, the cheaper options exist there for Rs 60,000–80,000, but often come with poor results. But in parts of south India, activists said, the cost may come down to below Rs 1 lakh.
“These surgeries have both expensive and cheaper versions. People try to save up and go for the expensive version of the surgery because that offers better results,” said Goutam Yadav, an LGBTQIA+ rights activist.
The cost of metoidioplasty or phalloplasty can range from Rs 5 lakh to Rs 6 lakh. These procedures can involve several stages and may include procedures such as hysterectomy, vaginectomy, and construction of a scrotum.
Metoidioplasty and phalloplasty are gender-affirming procedures used to construct male-typical genitalia. Depending on the procedure and individual’s needs, they may involve hysterectomy, vaginectomy, and scrotum construction, among other procedures. Often referred to as “bottom surgery”, they can cost Rs 5-6 lakh. Complications, including infections, can require additional corrective surgeries.
“These corrective surgeries often happen three to four times. So, the total cost goes above Rs 15 lakh,” Goutam explained. These procedures also have comparatively lower success rates, prompting some people who can afford it to travel to the UK or US seeking better outcomes.
For trans women
Breast augmentation using silicone or saline implants costs between Rs 2 and Rs 4 lakh, priced higher than the equivalent procedure for cisgender women. In parts of south India the cost may come down between Rs 1 lakh to 2 lakh. Vaginoplasty, often performed alongside orchiectomy, can cost up to Rs 7 lakh, rising to about Rs 10 lakh in Delhi and other large cities. In parts of south India, activists said, the cost may come down to anywhere between Rs 2 lakh and 3 lakh.
The costs nobody counts
Surgery is often the biggest expense people cite, but it is only one part of a long process that can begin more than a year before the procedure and continue for months afterwards. Consultations, tests, hormone therapy, travel, accommodation, and post-operative care can add significantly to the final bill, but are often left out when estimating the cost of gender-affirming care.
Based on the experiences shared with TNM, these are the approximate costs:
Endocrinology consultation: The first consultation for hormone replacement therapy (HRT) can cost around Rs 500.
Pre-HRT workup: A full-body health checkup can cost approximately Rs 8,000. A psychologist’s consultation may cost around Rs 500 for the certificate required to begin HRT, while a psychiatric consultation can cost another Rs 500 for a second certification.
Travel, food, and accommodation: People who need to consult doctors outside their home district may incur significant additional costs. Megha estimated spending around Rs 5,000 per visit to Kochi, with similar expenses for visits to Coimbatore.
Hormone therapy: For trans women, medications such as Progynova (supplies exogenous estrogen) and Aldactone (acts as an androgen blocker and potassium-sparing diuretic) can cost around Rs 3,000 for three months, although the cost can double if twice-daily doses are prescribed. Some also undergo laser hair reduction, which can cost Rs 4,000–7,000 a month for around six months, before hormones take over naturally.
For trans men, injectable hormone therapy can cost around Rs 1,000 a month for two injections.
Follow-up testing: Another full-body health check may be required around three months after starting treatment, often alongside an increase in dosage increase.
Teleconsultations: These can cost around Rs 750 every three months.
Post-surgery recovery: Recovery can require one to three months of rest, sometimes with paid caregiving. Many trans people instead rely on community support instead to save money.
Ongoing medication: Hormone therapy can be a long-term expense. The people TNM spoke to said doctors had advised continuing hormone therapy into later adulthood, making it a recurring cost over several decades.
Post-surgical complications add another layer of cost, since many trans individuals say they can't safely go to a hospital near their homes and must go back to the hospital or doctor who performed their surgery.
“It’s another expense that we need to come back to the hospital where we underwent the surgery for any kind of discomfort or infection,” Megha said.
Esha described repeated trips back to her surgeons to seek treatment for pain, bleeding, and unfamiliar post-op symptoms.
Sanjo attributed this partly to gaps in medical education. “Gender-affirming surgery and broader transgender health care are generally not taught in the medical curriculum. Doctors study transgender health care in a separate course. So, not all doctors are aware of the surgery. Hence, patients are asked to go to the same doctor who did the surgery, because only that doctor knows the history and the procedures,” Sanjo said.
States offering aid
Some states provide financial assistance or free gender-affirming healthcare.
Kerala's Social Justice Department offers financial assistance for gender-affirming surgery, with reimbursement of up to Rs 2 lakh towards hospital bills. The state, which was the first to introduce a transgender welfare policy, also provides Rs 3,000 a month in post-surgery support for up to 12 months. Applicants must have a Transgender ID card and submit address proof, a medical report, a doctor’s declaration confirming the surgery, original bills, proof of age, and a self-declaration.
“We need to submit the hospital bills to the transgender person’s cell, and it will take six to seven months to get the refund,” Megha said.
Tamil Nadu’s Social Welfare Department offers free gender-affirming surgeries at select government hospitals and support through its welfare board.
In Maharashtra, Mumbai’s state-run GT Hospital has introduced the state’s first specialised, dedicated transgender ward, including free voice change (feminisation) surgery. In Karnataka, the government policy also suggests free gender-affirming surgery, apart from counselling and hormone therapy.
At the Union level, Ayushman Bharat TG Plus provides transgender individuals with health insurance coverage of up to Rs 5 lakh a year.
A right to health
The cost of gender-affirming healthcare is also tied to a broader problem: the lack of standardised medical protocols.
Researcher and activist Anagh said India does not have a standardised medical protocol for gender-affirming surgery. The World Professional Association for Transgender Health (WPATH) has published standards of care, but activists say they have not been consistently implemented in India.
“The right to health is still not available to many transgender people. One of the major issues is that surgeries are performed differently at different centres,” Anagh said, calling for standardised pre-operative, post-operative, and intermediate-procedure counselling protocols recognised across the medical fraternity.
Without a standard protocol, there’s also no standard price, and what fills that gap is a pattern of hospitals charging trans patients more than cisgender patients for the same procedure.
Goutam laid out the comparison directly. “A chest tissue removal procedure known as laparoscopy costs a cisgender man Rs 50,000 to Rs 60,000, but a trans man is charged Rs 2 lakh to 3 lakh for the same mastectomy. Similarly, a hysterectomy costs Rs 60,000 to Rs 70,000 for a cisgender woman but around Rs 1.2 lakh for a trans man. Breast augmentations for trans women are also priced much higher than reconstructive surgeries for cisgender women who have had breast cancer,” he said.
Even before the 2026 amendment, gender-affirming healthcare in India could involve high, variable, and largely out-of-pocket costs. The option of self-identification is gone, and the paperwork meant to formally recognise years of spending and years of care has never been less certain.