The cosmetic surgeon began his presentation with an apology: “I could have used pictures to explain my point better, but I cannot share pictures of my patients. I did so once, showing pre-operative photos of a patient who had transitioned from being a man to a woman. She was in the audience and later came to me in tears. Her current partner had never seen her pictures as a man, and they traumatised him. That day I realised that before preaching to society, we doctors must first become more sensitive ourselves.”
The speaker, Manish Mukul Ghosh, is a consultant plastic reconstructive and cosmetic surgeon with over 30 years of experience. He was at Swasthya Bhavan for a seminar to sensitise healthcare professionals on transgender persons. It was organised by the department of Psychiatric Social Work, Institute of Psychiatry-centre of excellence (IPGME&R – SSKM Hospital), National Institute of Social Defence (transgender division), ministry of social justice and empowerment, in collaboration with the state government’s Institute of Health and Family Welfare.
Transphobia
“Transphobia has increased in the last five years,” said Ghosh. “Some famous people —American President Donald Trump, author of the Harry Potter books J.K. Rowling — have been picking on them. Thirty years of our efforts have been undone by their uninformed nonsense. One only needs to spend time with transgender people to realise they are regular folks.”
He explained that transphobia often stems from the belief that transgender persons are hypersexual and a threat to social morality. “People think being transgender is restricted to the elite, such as late filmmaker Rituparno Ghosh, but that’s not true either. I’ve had patients who waited till their children were grown up before going in for gender-affirming surgery. Others wait till their parents pass away, as they don’t want to upset their families. This is a big issue in India,” Ghosh explained.
Who needs surgery
The doctor gets many patients who come and declare they will commit suicide unless he operates upon them. “Such patients need to be counselled, and surgery should be done only when the person is calm, informed and prepared,” said Ghosh, adding that out of 100 people interested in surgery, 90 do not actually need it. “Many are relieved simply to be allowed to dress as the other gender.”
The decision to go under the knife must be thought out carefully, as there is no such thing as minor surgery. “I know of people who died getting their nails cut. Some transgender people are the only earning members of their family, so the risk has to be weighed. And schemes like Swasthya Sathi don’t cover such surgeries,” said Ghosh.
The next point to consider is how many surgeries to undergo. “Male-to-female transition is fairly simple. I once had a male patient who wanted to change his gender and enter a beauty pageant. So he needed work on the jaws, nose and hips to make them more feminine, breast augmentation, Adam’s apple reduction, voice pitch changes, laser hair removal, hairline work…. And I’m proud to say she won the pageant!”
Breast augmentation is relatively easy to but the implants carry the risk of cancer. “So one patient in his 40s came back years later asking to remove his implants; he said he’d manage the rest of his life by stuffing his brassiere,” Ghosh said.
But female-to-male transition is tough. “Women have to be given supramaximal doses of testosterone that can affect the heart and liver. The injections are painful and may cause abscesses. For male-to-female transition, estrogen tablets are usually enough,” he shared.
Patients may also opt for genital surgery, but it is irreversible, so one has to be sure. “I ask what it is they seek from this surgery. Psychological fulfilment or sexual function? Much of the sexual function is in the mind, as trans men often find it difficult to achieve orgasm and reconstructed vaginas have no sensation either.
The joy of the patients after successful transition is unparalleled. “For someone who is forced to enter the male ward in the hospital, it means the world to be able to leave from the female ward,” said Ghosh, asking people, however, to choose their doctors carefully. “These services are mushrooming in Delhi; they are cheap but are poorly done. I get many patients who come to me later with complications. The patients can’t tell anyone else about it, as families will retort: ‘Who asked you to do all this in the first place?’”
Legal angle
The three-day event featured multiple speakers, including Bappaditya Mukherjee, secretary of Prantakatha, a body that works for marginalised communities.
“How many here have heard of the Transgender Protection Act 2019?” he asked. When only three hands went up, he went on to explain how the Act prohibits discrimination in healthcare, education, employment, and provides legal recognition of a person’s gender identity.
“Since the time of Ballal Sen (the Sena dynasty ruler of the Bengal region in the 1100s), transgender people have had land rights. Even in the Mughal era, ‘khwaja sira’ or the third gender held high positions in royal courts,” recounted Mukherjee. “All that changed during British rule, especially when they criminalised homosexuality in the 1800s.”
“Today, the law says that gender is self-perceived. Doctors cannot impose their own idea of someone’s gender,” said Mukherjee, whose wife, Anuprabha Das Mazumdar, a trans woman, was at the seminar too.
“In a hospital, the trans community faces discrimination from the receptionist to the doctor, and this makes many of them avoid seeking medical help at all,” shared Anuprabha. “I myself got dengue in 2022 while transitioning – my documents were still in the process of changing my gender – and they wouldn’t let me into the general female ward. I had to hire a separate cabin for myself. Doctors still use regressive and archaic terms like “victim” to refer to trans people and DSD (Differences in Sex Development) disorder. How will doctors know better since the MBBS curriculum does not teach gender-affirming care?”
Final word
“Due to ignorance, many parents still believe a transgender child is a curse of God and consider handing them over to transgender communities. This superstition has to be removed with knowledge of new procedures, as well as sensitisation programmes not just for parents but also doctors,” said Dr Kaustav Nayak, director of the Institute of Health and Family Welfare, Swastha Bhavan.
“The objective of this event was inclusive care,” said Mayank Kumar, project head and assistant professor, department of Psychiatric Social Work, IOP-COE. “We explained affirmative communication, such as asking for pronouns and avoiding assumptions based on appearance. Creating a safe, non-judgmental, and welcoming environment is central to ethical healthcare. This event involved many stakeholders, and a large team worked hard to make it possible.”