On April 2014, in a historical ruling — the Indian Supreme Court (SC) recognized transgender people as a “third gender” – creating a bureaucratic category which acknowledges non-binary gender identities. Widely known as the National Legal Services Authority of India (NALSA) judgment – it was been hailed by many as a step in the right direction. And indeed, the NALSA judgement has provided the political climate in which a variety of transgender friendly health policies and programs have bloomed. Most notably a marked increase in gender affirming medical facilities, particularly for trans masculine people. Several states – including Kolkata and Kerala – have began the process of providing free sex reassignment surgeries. As India hurtles towards an aggressively medicalized vision of transgender rights, it is useful to understand the existing reproductive trans health context and its driving forces.[pullquote align=”full” cite=”” link=”” color=”” class=”” size=””]Idea that trans people do not want to, cannot or should not bear children is pervasive.[/pullquote]
During arguments before the Indian SC , justices for the NALSA judgment repeatedly asked questions related to a hypothetical trans individual’s capacity to have “normal sex” and bear children. The petitioners for the case – a third party group – agreed that transgender people cannot have “normal sex” and cannot have children as they were a “third gender”. Along with the transphobia, what is worth noting about this story is how fertility and pregnancies are explicitly dissolved into the category of (cis) “womanhood” (from which then trans women are automatically denied entry). It’s an example of how transgender people must maintain their (sexual) citizenship – by being produced as sterile and reproductively static.
This idea that trans people do not want to, cannot or should not bear children is pervasive. Trans people biologically producing children becomes coded as radically subversive, and more often shamed and mis-gendered. It not only reinforces cis-normative violence, but also abets a form of gendered genocide. Well-meaning conversations about trans communities bearing children often defaults to adoption protocols and rights. While these discussions surely has its place and are relevant, they are also not the only conversation possible when talking about trans reproductive rights. The self-determination that is profoundly at the core of cis women’s reproductive health movements – for some reason – do not get applied to trans bodies.[pullquote align=”full” cite=”” link=”” color=”” class=”” size=””]There is also a longer, more known history of (physical) gender transitioning among Indian trans femmes through the ritualized, non-medical removal of reproductive organs, practiced among the Hijra community[/pullquote]
Trans and gender non-conforming people face high levels of violence (as repeatedly corroborated by multiple studies all over the world). A particular form of violence that trans men (and queer cis women) face is an explicitly stated threat of impregnation along with the sexual violence – intended to “cure” gender nonconformity (and/or sexual orientation). In India, the relative invisibility and subsequent isolation that so many trans men face must also be located within the hetero-patriarchal institution of marriage. In light of the frequently violent ways in which trans people encounter sexual and reproductive health needs, it becomes ever more urgent to move towards a reproductive justice paradigm.
Understanding Gender Affirming Surgeries through Reproductive Justice
As is true in many other parts of the world, in India medical gender transitions have both legal and health components. They include legal affidavits, psychiatric gate-keeping, and finally proof of intention either through lived experience or further certification prior to beginning the process. However, there are many contexts that are unique and particular to India that are important to underline. India’s deeply privatized and minimally regulated health care infrastructure (private care makes up for as much as 80% of health care provision) – means that costs and procedures vary greatly regionally and between public and private hospitals. Anecdotally, we know that the length of time for obtaining documentation and also surgical staff’s commitment to operate can vary from weeks to months to even years. For the vast majority of Indian citizens, health service provision is fee-for-service and out-of-pocket (including in public hospitals). Consequently and unsurprisingly, health care shocks are a well-documented driving force plunging the poor and the working class into poverty, and further draining any capital accumulation that might occur. Privatization always reinforces unequal, differentiated, class and caste marked encounters with a system – including the health care system. Those who can afford to assess, choose and buy better health care, do. Trans people who are able to buy medical care that is non-coercive, supportive and safe, do.
For a variety of reasons, the bureaucratic steps described above vary wildly and are sometimes not enforced at all for trans femmes. There is also a longer, more known history of (physical) gender transitioning among Indian trans femmes through the ritualized, non-medical removal of reproductive organs, practiced among the Hijra community – called Nirvaan. In India, trans femmes have a particular religious and caste marked legibility that is not as clearly translated or evident for trans masculine people. To be clear, the health care violence that trans femmes face both within and outside the system, are profoundly under-examined. Thus far, the (often sensational, lurid and offensive) focus on the cultural practices of the Hijra community wrongly conflates gender affirming surgeries among trans femmes with Nirvaan. Because of its meaning within a religious and caste-marked axis of which gender is just one component, many activists do not consider Nirvaan to be part of gender reassignment surgery. The hyper visibility of HIV programming among trans femmes in India has further pathologized an entire community as diseased and in special need of public health and medical intervention.
Many trans femmes tell harrowing stories of what gender reassignment surgeries look like in medical settings. Nearly a decade ago, at a health conference in India I attended, a hijra activist named Sowmya Shri – told the story of visiting her friend who had undergone bottom surgery at a hospital. She described finding her friend’s bed soaked in blood, on which her friend lay without any medical intervention. She survived her experience. A reproductive justice framework understands these stories as violence against women (and not opportunities that trans femmes should be “grateful” exists at all).
Medical Coercion and Gender Panic
It is important to understand that transgender identities are not linked to gender reassignment procedures. However, the decision to gender transition through a surgical process is a reproductive health right unique to transgender communities. Too often then, infertility is presented as inevitable for those who medically transition. Aside from the fact that not all (or even most) transgender people can or want to undergo medical transition — transgender individuals who surgically transition do not always have bottom surgery (surgeries focused on genital alteration, also sometimes refers to uterus-removal). Medical transition procedures such as hormone therapy, for example, among trans men does not guarantee infertility (it only decreases fertility) and is not effective birth control. Sustained hormone therapy does eventually lead to irreversible sterility, but it takes time.
Safe, affordable and informed access to gender affirming procedures is a fundamental human reproductive health right. This basic right extends to self-determining which gender transitioning procedures feel safe, feel affirming (and for how long) within a context that is not medically coercive, manipulative and ultimately harmful. Gender affirming procedures should not be a ‘buy all’ or none privatized transaction. Anecdotally, among trans men, we know that many doctors are making surgical procedures a requirement for continued administration of hormone therapy. In fact, it is considered routine for medical doctors to threaten to cease (hard-won) hormone therapy if surgeries are not consented to and performed.[pullquote align=”full” cite=”” link=”” color=”” class=”” size=””]Self-determination is difficult to locate when surgical procedures are presented by medical authorities as the only alternative to cancer and death[/pullquote]
For trans men, the unavailability of hormone therapy outside the medical system is frequently the gate-keeping mechanism through which patients are heavily coerced to undergo top and bottom surgeries. The risks involved between these very different surgical procedures remain un-clarified, and in its place cancer is presented as a foregone conclusion because of hormone therapy. To be clear, no epidemiological studies currently exist that show any links between gender hormone therapy – specifically testosterone therapy – and cancer. Furthermore, not only has recent large studies concluded that hormone therapy is completely safe – other studies have shown that physical transition (specifically hormone therapy) among transgender youth have significant beneficial effects on symptoms of depression and anxiety. Indian doctors routinely enact violence and harm on transgender bodies when they hold hormone therapy hostage in return for sterilizing surgical procedures. These medical coercions are possible because of the production of trans people as always sterile (or desiring of sterility) and the authoritarianism of medicalized knowledge.[pullquote align=”full” cite=”” link=”” color=”” class=”” size=””]For trans men, the unavailability of hormone therapy outside the medical system is frequently the gate-keeping mechanism through which patients are heavily coerced to undergo top and bottom surgeries.[/pullquote]
Remarkably, despite a perceived increased risk of uterine cancer, medical advice or referrals for gynecological preventive care is unheard of for trans masculine people in India. Pap smears, regular scans for polyps, monitoring abnormal bleeding and discharge or even documenting family histories of cancer should be routine, instead of a rare and/or classed experience. The utter lack of referrals or attempts to implement preventive measures to mitigate cancer risk is both chilling and alarming. Smoking cessation, diet and exercise are all effective, widely recommended and well-documented cancer prevention techniques that doctors simply do not discuss. Instead, uterus-removal is strongly recommended as the only alternative if hormone therapy is to be continued.
Self-determination is difficult to locate when surgical procedures are presented by medical authorities as the only alternative to cancer and death. Self-determination is difficult to locate when hormone therapy is held hostage to coerced sterility. More studies and data is needed and despite the growing visibility of transgender issues, research and data that focuses on transgender populations remain minimal and inadequate. But manipulated discourses of risk and outright misinformation is not an alternative. Anecdotally, I have heard many people in the queer and trans community talk of “female organs” (uterus) that has now become poisonous because of the introduction of “male hormones” (testosterone/hormone therapy). Thanks to medicine, internal organs and molecular constructs now have a gender.
TransHealth and Health Care System
The few studies that are done anywhere (including India) reveal that the health care system is fundamentally under-equipped to manage transgender patients. Not only are trans bodies pathologized, but many are denied care altogether. Trans women tell stories of doctors afraid to touch them to check for the pulse during care; they speak of being ridiculed by health care staff and being denied care. Saikat was an Indian trans woman who went to the hospital after a train accident, and died there because doctors could not decide whether to admit her into the male or female hospital ward .
Under the NALSA judgment, a government order has passed – making it mandatory for public hospitals to provide separate, two-bed transgender wards. This has been hailed by many trans activists as a step in the positive direction, and presumably alleviates barriers to health care access. However, most government hospitals have not followed the order and some have claimed not to be aware of it at all. Since the NALSA judgment last year, there is a portent waiting for rights and equality to flow. The material gains of the judgment hinges on the visibility project, and for transgender communities – it frequently relies on monitoring and segregation. To be literally counted, if not politically.