You have provided us with really good information about hormones and surgery.
So as of now in our country how much does it cost if a transgender person wants to go through transitioning? Either hormonal therapy, or SRS or gender reassignment surgery.
How much does it approximately cost to do it correctly? Are there any subsidy that the government is giving for this, or not.
As in, how is the situation? For the time being, the situation.
I can say that in medical fraternity itself, there are not many experts available till now in our country.
For that there should be more understanding and more encouragement.
There should be betterment in training and education of doctors regarding this.
If this happens then definitely, centre by centre development can take place about this.
People have slowly begun thinking about it.
You talked about cost effectiveness.
Unfortunately, the major.
I want to talk about transwomen surgery first.
The surgery that happens for transwomen takes place through stages.
In one stage there is genital surgery.
And in the rest of the stages, there are.
I would not say cosmetic surgery, but other gender enhancement surgeries such as breast augmentation, facial feminisation, voice change or tracheal shaving, body contouring etc.
All of these procedures, plastic surgeons have been doing to some extent for females.
But specifically, the understanding and knowledge about the level of practice for gender assignment surgery for transwomen, is very low.
So because of this reason, the number of doctors available for doing surgery in India is very less.
The ones who do these, whether they are available in government set-ups or not there is a huge question mark about it.
The ones who do or are available, their exposures are at a very primitive level, meaning at a primitive stage – emasculation surgeries in which the genitalia is removed just externally.
Actually, what is called vaginoplasty, that is, the creation of a functional vagina, which requires little bit of expertise, all these things have not really come up to any level.
So definitely, if the government takes initiatives, such as in the 2014 NALSA judgement, there is an enforcement about this.
That medical health systems also should look into these things apart from just other issues related to discrimination or health benefit.
Even the benefits related to gender assignment surgeries too should get enforced through government.
The government can organise training at subsidised rates, the experts who are already there in India who have, through their own efforts, gone abroad to the WPATH Society's workshops; the experience that they have gained.
If that experience is used for the benefit of the community to organise workshops, train different surgeons through it, then definitely there will be huge benefits.
But then funding is required for this, right? So if this is implied through the government as a health benefit scheme, then definitely it is going to be.
Transgender persons will be greatly benefited.
This I was talking about transgender women.
Surgeries for transmen are extremely complex.
I can say that it is more challenging for them.
It is not only in the first level in which surgery is completed, but they may additionally need 2 to 3 steps more even.
And all these steps go for quite a long duration – their wound healing, post-operative recovery, etc.
And then at the end of it, the expected result.
So the success rate about that is also very much "under the bracket".
So our transmen brothers who are there, definitely it is very challenging for them.
The development that has happened up till now, that has happened to some extent for surgery of transwomen, but surgery for transmen is still somewhere lagging behind.
It is going at turtle's pace.
So if the government takes all these issues seriously, and takes a very organised approach, so then there is no go for this.
Right, so like this you are informing that such and such is the cost.
Now the kind of SRS that you are doing in Pondicherry, can you share something about that? So the institute that we have in Pondicherry is Mahatma Gandhi Medical College and Research Institute.
rather, the first transgender clinic was introduced there.
One of the transgender activists, Ms Sheetal and Prof.
Ambuja, who is the professor of dermatology and venereology, the two of them, with the management's support, opened the transgender clinic.
The initial function was related to trans community and HIV/AIDS, works related to trans community, MSM and HIV were started with.
So I am talking about this established in 2006.
So these two ladies started with the initiative in 2006.
Gradually, a surgeon came who expressed an interest in helping transwomen to some extent, by doing emasculation.
Okay so few girls accepted and slowly it began.
But unfortunately administration had to stop those operations because of some legal setbacks.
Then during that time the management came to know that they have a transgender doctor, who is doing transition, so they took my advice – how to go about it, what to do.
So together we formed a collective, which is now the Gender Care Team, where Ambuja Madam is already there and Sheetal too.
And administrative representative, Dr Swati, who is also the chairperson of the Gender Care Team.
Along with us, there are two psychiatrists of the professor level, surgeon, as well as legal advisers.
We involved all of these people in the Collective.
We discussed and then formed and established protocol.
And whatever the standard international guidelines were, according to those we formed and developed protocol that will help to think about our system, how to give care, and culturally blend in the Indian context.
So we don't have funding for surgeries from the government, or any agency or NGO.
So we started off at a minimum set level, like consumables only they will pay for it.
The equipment required for operation, only those consumables should be used.
And so for basic hospital use, and basic minimum cut-off charges they were allowed to operate for trans patients.
So we are running that program quite successfully now.
So far now the concentration is on genital surgeries, but slowly and slowly, surgeons are looking forward so that other gender enhancement surgeries are also incorporated.
So, not only transwomen surgery, even transmen surgeries have been carried out by plastic surgeons.
Development is thus going on.
Inshallah, there are plans of more development such as, we are thinking that the international protocols that are there already, those are to a large extent suitable for international levels, and not for our community.
So how to recognise and establish that.
When the government will form rules as per the requirement of the community, and so certain things should be there accordingly.
We want the government to look at us and see how this set-up is running, what we are doing, what are the step-wise approaches to deal with patients.
For that we want to discuss these protocols and publish them.
We want to take review of an ethical committee and recognise that there are people in the medical fraternity, who want to consolidate these protocols as a standard for our Indian community, which is culturally blended up.
You are safeguarded if you follow these culturally blended protocols.
So you can take this model in your institute at the national level, and establish it, and train doctors according to it.
This is our next agenda or motto, and we have started working towards it.
All the very best for your work, and best wishes for your success.
Just now you mentioned about the 2014 jugdement which was passed by the highest court, Supreme Court about the third gender verdict.
So through this judgement the Supreme Court established one principle that any transgender person can self-determine her/his gender identity.
According to the principle of self-declaration.
And no one else can dictate that person's gender.
It is also laid down in the verdict that to be transgender is a psychological state, and surgery is not required for it.
So, being a doctor, what is your opinion or thought about it? As a doctor, and as all medical literature now available also says, you can.
that's how the term transgender has come, right? That it is an umbrella term, a spectrum.
You want to keep your gender in which spectrum, in which level.
So male and female are at one end, and in this, whether you want to relate to the two, or don't want to relate to the two, and how you want to represent yourself.
So it's a choice which is being given.
Definitely, if you want to express your choice and those are socially conducive, then it will give immense happiness to that person.
That person's self-acceptance and self-satisfaction will increase and definitely self esteem will also increase.
So definitely I am pro for that, that however you want to express yourself you should do that.
It's a full freedom for you.
It should be a full freedom for you.
So, any boundary should not be kept for that – whether a person has done surgery only then that person is a transgender person, and if that person hasn't done surgery, or has taken cross-hormone therapy or not, that is not a necessary pre-requisite.
You express that you are a transwoman or a transman and you want to live accordingly, so definitely that should be allowed.
Like we talked about the 2014 judgement, during this time, the government has also come with a bill – Transgender Persons (Protection of Rights)Bill, in 2016.
In this Bill there is a clause that there will be a screening committee which will check and examine who is a man or who is a woman.
all these, mainly who is a transgender person.
Yes, criteria that they have put forward.
Right, so what do you have to say about this? To comment on that, the protocols that these people have displayed in the Parliament, I don't agree with that.
Definitely there should be a procedure and way, but you call community representatives.
There are doctors and lawyers in the community also who are educated and can be called.
The ones who are not in the community, call them even, and discuss and do a consensus.
Ultimately what do you want to see? The community should benefit, right? The benefit level should be targeted for whom – obviously for the community.
Your thinking should also be tailored in that way.
Your thinking should get channelised and coned up to serve the transgender community.
So accordingly, the hurdles that are there, positive or negative should be met by taking the opinions of the people who are from the community.
This is more important, rather than putting a paper and declaring that we want to go like this.
That a transperson should meet this particular doctor and get a certificate mentioning all criteria.
Probably the doctor you are talking about, does not relate to anything, or does not have knowledge about these things, or has no interest.
Then it will be an enforcement on that person.
So definitely if the doctor is not interested, then she/he will make a lot of mistakes about it.
Probably she/he will not diagnose correctly.
So you have to first make a structured arrangement rather than putting the rules first – these are the steps 1-2-3 that need to be followed.
Definitely, this is a very wrong thing.
One thing I would like to ask about your own self.
Dr Sameera, you are a doctor, and often what happens.
a transgender woman, who belongs from the working class, who cannot complete education, who does not have alternative means of income, and earns money by begging.
The kind of harassment and discrimination that they face in society.
We have heard a lot about that.
But you are a doctor now, working for transgender persons.
So even at your own level, is there any kind of discrimination that happens? We would like to hear about it.
Meaning, what happens? Surely.
So I am also not an exception for this.
I have also gone through those phases.
Yes to some extent as a doctor, there was a certain safeguard, certain benefits I can say.
But I have passed through all those challenges.
I have also had to face sexual harassment in hospital through patients – molestation, discrimination.
Maybe not to a severe extent that any other transgender person faces at a public level, but definitely to some extent, yes.
This I am talking about within the hospital, within that border.
When I am outside the hospital, I am not a different person.
The sexual harassment and molestation that took place, the molester did not know that I am a doctor.
I am just a transwoman for them.
So yes a lot of times.
Some 2-3 incidents are there where it has put a severely negative impact on me.
At a very open space in front of 200-300 people in a village when I went, I had to once face molestation.
It happened till that extent.
So definitely after that a fear had grown inside me that I cannot got alone.
I need to protect myself and I need to have somebody along with me.
Somebody has to be there to go with me and to a large extent I had stopped socialisation, and stopped traveling.
I did not travel independently.
Traveling by flight was like a big panic attack for me because I had faced molestation during flight journey.
So it creates a negative impact.
Even I am not an exception to all these things; I have also had to face all these challenges.
So transgender person's hormones, SRS, health etc.
, we have discussed in extensive detail.
But often in society there is an idea that because of transgender persons, there is an increase in HIV, they are the reasons for the rise of HIV.
What do you have to say about this? This is a very wrong conception okay.
Maybe the medical fraternity does relate to the early medical literature, which tells that AIDS epidemic started in homosexuals in America in the 70s and 80s when the first cases were detected.
It was detected in homosexuals during that time.
So that thinking has percolated just the same.
Mentioned in books that for homosexuals and in the transgender community, it is found in greater number.
Maybe you do more research about that.
But it affects everyone.
AIDS and HIV when it gets transmitted, it does not say you are a gay, lesbian, heterosexual, homosexual and all.
This can happen to anyone.
So then why this discrimination?Why this blaming? So even when the medical literature is written, in the way of writing also it should come in that way only.
Why do you want to explicitly write like this? There are other ways of writing and expressing.
If you do it according to that way, then definitely stigmatisation would be less.
It's after all changing the level or thinking process.
It should be like this.
We have also heard Sameera Ji, that a transgender person's mortality rate is very low.
50 or 55 years, meaning within that age itself, Life expectancy is not beyond that.
So is there any specific reason, or specific theory regarding this? Like I said earlier, using hormones indiscriminately, lack of health facility available to deal with transgender patients because there is so much social stigma.
The trans community does not have acceptance.
When they go to hospital with any problem and here I am not only talking about gender care surgery or hormone therapies.
You and I are humans after all.
We also suffer from cough and cold, fever, diabetes, hypertension, blood pressure, heart attack, all these diseases happen.
Because of this reason, when you go to hospital, you face discrimination, doctors are hesitant to give treatment.
That's how the community does not come in contact with.
health contact does not happen.
Since health contact is not there, there is no benefit, awareness creation does not happen inside the community.
This works both ways – the community's understanding is not there that much, as well as health support from the other direction is also not much.
So somehow this is not gelling up.
So if problem happens, then identification does not happen in the right time, if identification happens, there is no care for it.
So this is the major reason that when a transperson falls sick from diseases, then definitely there is no respect when she/he goes to the doctor.
So why will I go? I will not get the right treatment; I will get rejected from here.
So let me just leave.
that kind of attitude will happen.
So you just keep on tolerating because you don't have the exposure or understanding or the option related to that.
So this is one major aspect.
The second aspect that I mentioned is about the education level.
If understanding is less then you are less likely to make an attempt to identify your problem at a proper level, and accordingly get treatment, if the option of treatment is available, then.
This also does not happen.
So there are such negative aspects in the community.
All these things contribute together for the low life-expectancy.
The changes caused by indiscriminate use of cross-hormone therapies, makes one vulnerable to diabetes, heart disease, hypertension.
The most important disease for our LGBT community is depression.
Mental health is the biggest illness, leave along physical illness.
Tackling mental health is the biggest challenge for the LGBT community.
So for this there is no contact or awareness, no dealing or understanding.
So it starts all from the mind.
If the mind is not alright, then your body will also not function properly.
So in the end I have one question Sameera Ji, as you brought in the conversation around the mind, people often think that the birth of a transgender person is a mental illness or disorder.
To what extent is this, and what is science saying about this? Definitely, science has said it all.
American Association of Psychiatrists that is there, and WPATH.
The international organisations that are doing quite a bit of research on this.
So initially transgenderism was identified as a gender identity disorder.
Why do we keep this as a disorder? We should accept it at some level, and the terminology itself has to change.
It is not a disease because we need to accept it in ourselves.
The ones like this, if life accepts their growth as it is, and let their lives go accordingly, then it is good for them.
There is a positive enforcement; their lives are benefited.
If they are encouraged accordingly, then their lives become successful.
So because of that, why not do away with the aspect of disease, or gender identity disorder, do away with 'disorder' and introduce the term dysphoria instead? So dysphoria.
So for the time being, the psychiatric association now are going to put forward the next generation of changes.
New definition changes, the explanations are about to change now.
So in that, even 'dysphoria', meaning fear of the self, and one's own gender, conflicts, fear, anxieties, that terminology will also now be changed, and proposals are being made for that change.
So the medical fraternity is slowly thinking now when you say that someone is normal, even when you write their diagnosis on paper, so how less discriminative way you put the diagnosis as that.
So that it is not offending.
You are saying it is not a disorder, you write similarly on paper that it is not a disorder.
So what will be the proper explanation or definition of words, accordingly, changes are beginning to happen.
Mid 2018, the ICD XI is going to get displayed so we are all waiting for that.
So let us see what are the changes that are explicitly revealed.
Definitely we will hope that for the entire transgender community, it brings good and hopeful results.
And we are extremely thankful that you came to our TransVision studio, and had a conversation for this long about transgender persons, about the misconceptions in the general public – so much information you shared with us.
We are very thankful for this.
Thank you very much Rachana that you gave me this opportunity through TransVision.
That I could display at a large base, with people of our own community about my statements, my heartfelt desires, and thinkings.
So that people from the trans community can reap its benefits.
And I also convey my hearty words to them during this time.
So definitely I felt really good, really happy to have met you all.
Yes definitely we hope to meet you in the future and have more conversations.
So the journey has now started and definitely this journey will go till long.
Inshallah, thank you.
Thank you very much.
Inshallah, we will meet you again, Sameera, in the sets of TransVision, we hope for that.
Thank you for calling me.