New Delhi: What are gender affirmation surgeries, how does it help LGBTQIA+ community, what is the process of getting the treatment – to understand all about it and how it can help make life easy for transgenders, team Banega Swasth India speaks with Dr Bheem S Nanda, Senior consultant and Vice -chairman, Department of Plastic and Cosmetic Surgery, Ganga Ram Hospital, New Delhi. Dr Bheem started his journey of treating transgenders patient back in 2013. Recounting the initial phase, he said, “When I first got a transgender patient, I was very sympathetic to learn about his journey. I realised, in India there are very few people in healthcare for them. Even in hospitals, even within doctors, there was a stigma related to transgenders. By the time it was 2014 and 2015, and my patients count increased, my hospital staff also made fun of me for doing the surgeries. I remember people asking me what am I doing and why I am doing these surgeries. Somehow, that made me even more passionate about this path and I never looked back. I realised the issue in India and I decided to dedicate my surgeries towards the LGBTQIA+ community.”
Here are the other things we discussed:
NDTV: What is a gender affirmation surgery and why is it done?
Dr Bheem S Nanda: Gender Affirmation Surgery is a procedure done for people who suffer from gender dysphoria. When people face constant distress with their sex which was assigned at birth, as it does not match the person’s identity, it is termed as Gender dysphoria. To help such people, doctors do a series of procedures/surgeries that help people transition to their self-identified gender. The surgery is done so that their physical body matches their gender identity.
NDTV: Take us through the journey of the gender transition, what is the first step?
Dr Bheem S Nanda: When a transgender person comes to me, the first step is to make them comfortable, know their current status and understand their requirements, which here means what all surgeries they want to undertake. The first step is to make them understand that if they want to undertake any kind of surgeries for their transformation, they need a Gender Reassignment Surgery certificate from a Psychiatrist or physiologist. The certificate basically states that the person is suffering from gender dysphoria and not any other disease and is fit to undergo transformation surgeries. Usually, I tell my patients to be under a Psychiatrist treatment for at least six months so that they can assess the patient thoroughly and they themselves can also be sure of surgeries, as once the surgery is done, it is done, these surgeries are irreversible.
NDTV: What are the different types of surgeries involved in Gender Affirmation Surgery and what is Hormone Replacement Therapy (HRT)?
Dr Bheem S Nanda: Before surgeries are done, LGBTQIA+ community is put on Hormone Replacement Therapy, which means a trans man (transitioning from female to male) will start getting male hormones and a trans woman (transitioning from male to female) will start getting female hormones. HRT usually helps the person get secondary desired characteristics like for trans men beard will start coming, voice will become heavy, in trans women, there will be some natural formation of breast, unwanted hair growth will stop, to name a few. But in trans women, through HRT, voice will not get mild, they will have to undergo a voice transformation surgery. Nor through HRT trans women will experience menstruation.
The problem is that HRT studies around the world are still lacking. We still don’t know answers for many questions like what will be the long-term impact of this therapy. Can it cause cancer in such patients in next 10-12 years or not, we are still unaware.
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LGBTQIA+ Community can kick-start surgeries in between their HRT treatment or after its completion, it is upto them. Some patients will go only for top surgery, which is called Mastectomy (a procedure in which the entire breast is removed), this is usually done for trans men. For trans women, top surgery means an implantation of breast. Some patients will go for bottom surgery for the complete transition, in which, genitals of by birth gender are removed, followed by reconstruction of the desired gender genitals. And then there are facial characteristic surgeries to make facial features more masculine or feminine.
NDTV: What is the consenting age for these surgeries for anyone from the LGBTQIA+ Community?
Dr Bheem S Nanda: It is not just these surgeries alone, for any surgery the consenting age is 18 years. But what happens is that in normal surgery, parents can give the consent. In trans people, there is lack of family support as a result they will have to wait till 18-years of age to get started with the treatment.
NDTV: Is gender affirmation surgery the only treatment for gender dysphoria patients?
Dr Bheem S Nanda: No, these surgeries are not important at all. A person, who is gender dysphoric, can also live without getting these surgeries done. It all depends on a person and at what level his or her gender dysphoria can settle. It can even settle after taking HRT, which increases masculine or feminine characteristics or just by going to a Psychiatrist or physiologist, or when they come out to the world openly and start living in their desired gender. People who want to socially transition to their true gender with or without surgery, usually adopt a new name, choose different pronouns, start presenting themselves as their desired gender identity by wearing different clothing or changing hairstyle. So, surgeries are not at all necessary. It all depends on person’s personal mental health and at what level their gender dysphoria settles in.
NDTV: What is the ideal duration for the full body transition for someone undergoing Gender Affirmation Surgery?
Dr Bheem S Nanda: The ideal duration for the overall transition one cannot say as it depends on many things, even money. But, the ideal gap between each surgery should be minimum of 3 months, but it may increase depending on person’s recovery time as well. In case of trans men, who opts for bottom surgery, after reconstruction of the private parts, we have to wait for the sensation to start on its own, which can go upto 12 months. After that we put an artificial implant and then is the recovery time.
NDTV: Explain the pre and post-surgery care that is needed after these surgeries.
Dr Bheem S Nanda: Every surgery is different and requires a set of pre-post-surgery care. Generally, we ask our patients to stop HRT 10 days before the surgery as we don’t know what complications it may have. We also recommend patients to quit smoking 10 days before the surgery. For people opting for top surgery, the minimum duration of hospital stay is 24-hours and for bottom surgery it is 7 days. If the patient is not from the same city as their hospital, then a minimum of one month stay is required within the city for bottom surgery and 10 days stay is required for top surgery.
NDTV: What is the cost of these surgeries. Is there a way the financial burden can be reduced?
Dr Bheem S Nanda: If we talk about the top surgery, the price range ranges anywhere between 1,20,000 to 1,30,000 and it may go up for people opting for an implant. For trans men who opt just for vaginal removal, the price is between 50-60 thousand and for genitals reconstruction it takes anywhere between 4 to 5 lakhs. Implant cost may again vary in such cases. And depending on what surgery the person is opting; the cost will increase.
In India, government of India has decided to include these surgeries cost under Ayushman Bharat, but the waiting is huge.
NDTV: How common are the gender affirmation surgery in India?
Dr Bheem S Nanda: Most of the patients only go for top surgery, only 1 to 4 per cent opt for the bottom surgery. Reason being one it is costly, secondly, the rate of success in such surgeries is not much. If I am doing a surgery for 10 patients and reconstructing genitals, out of 10, 6 might come back with issues in such cases they might have to undergo a surgery again.
NDTV: What are some of the things someone should keep in mind before going for Gender Affirmation surgeries?
Dr Bheem S Nanda: There are a few things which the community should understand:
– These surgeries are irreversible
– You cannot become a biological parent ever
– The legal age to undergo such surgeries is 18, before that, people are only allowed for Puberty Blockers, this is only after the certificate from the Psychiatrist
– Gender Dysphoria issues are much for trans men because till the age of 13 such people think that they are male and suddenly when they start getting female like features for example when breast gets formed or menstruations start, it may become too much for them to accept. In such cases, puberty blockers should be taken. Puberty blockers are basically hormones that help delay these things so that a person can become of a legal age and decide if they want to undergo for a surgery or not
My message for the community is that their goal should be realistic. They should realise, we doctors are not god, but we will try and give them the best possible results. They have to be patient; accept the way they were born as and know that the transition process will take time.
When it comes to healthcare, I wish there are more and more doctors to help the community. I also urge the healthcare staff that they should undertake such surgeries only if they are experienced and have trained many to handle such cases. They should not take on these patients for their experiments.
NDTV – Dettol have been working towards a clean and healthy India since 2014 via the Banega Swachh India initiative, which is helmed by Campaign Ambassador Amitabh Bachchan. The campaign aims to highlight the inter-dependency of humans and the environment, and of humans on one another with the focus on One Health, One Planet, One Future – Leaving No One Behind. It stresses on the need to take care of, and consider, everyone’s health in India – especially vulnerable communities – the LGBTQ population, indigenous people, India’s different tribes, ethnic and linguistic minorities, people with disabilities, migrants, geographically remote populations, gender and sexual minorities. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign will continue to raise awareness on the same along with focussing on the importance of nutrition and healthcare for women and children, fight malnutrition, mental wellbeing, self care, science and health, adolescent health & gender awareness. Along with the health of people, the campaign has realised the need to also take care of the health of the eco-system. Our environment is fragile due to human activity, which is not only over-exploiting available resources, but also generating immense pollution as a result of using and extracting those resources. The imbalance has also led to immense biodiversity loss that has caused one of the biggest threats to human survival – climate change. It has now been described as a “code red for humanity.” The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene. Banega Swasth India will also be taking forward the dream of Swasth Bharat, the campaign feels that only a Swachh or clean India where toiletsare used and open defecation free (ODF)status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and the country can become a Swasth or healthy India.