Rise of theThird Gender

Sumithra Sathyan | 01-June-2014

Detailed News

Sex and gender are two different entities, which are often confused and misunderstood to be the same. Sex is a physical feature of having male or female anatomical structures or organs whereas gender is a psychological phenomenon

By Sumithra Sathyan

When a child is born,the baby is assigned as male or female on the basis of physical sex characteristics which are immediately apparent at the time of birth or investigations during pregnancy. But there are no tests or investigations to ascertain the gender of the baby at the time of birth or before.

In most other cases, anatomical sex and psychological gender are in congruence, this means a male child develops with characteristics of male, likes to play with cars, rough sports and male ambitions, and at appropriate times develops attractions to the opposite sex and vice-versa. In rare cases, there will be discordance between anatomical sex and psychological gender.  

A baby born neither male nor female is a transgender. They are known as Hijra in India and forced to lead an unaccepted life in the society. They are a happy lot today as a Supreme Court verdict in April recognized them as the third gender for the first time giving the social acceptance. The verdict of the Apex Court has in fact opened a new chapter for about two million people in India who qualify for the third category of humanity.

In the wake of the historic Supreme Court verdict,

Sumithra Sathyan, Co-ordinating Editor of Future Medicine, looks into the murky world of transgenders and also talks to two eminent doctors in the US who have specialised in transgender surgery, Dr Sherman Leis, Surgeon, Professor, Lecturer and Founder of Philadelphias Center for Plastic and Reconstructive Surgery, and Dr Jayaram BN, a well known plastic and reconstructive surgeon, who has worked in some of the best institutions in the US.

The above is a famous letter from a reader (name withheld) to Chuck Klosterman, The New York Times Ethicist, which reflects the pain and anguish of the reader who seeks a sexual transition.

The journey of transition

There are a number of such cases across the world. It is believed that sexual transitioning is a journey that is touched on by a myriad of factors: surgical, psychological, hormonal, aesthetic, legal, and more.  Each transition is an intimate, distinct experience, so our patients will have many unique questions and concerns throughout the process. Therefore, we have created a more personalised experience, says Dr Sherman Leis.

We personally support the patient emotionally by being available to discuss all aspects of the transition with the patient and by answering all the questions in a realistic and honest manner. We clarify and objectively provide correct, balanced information, dispelling unrealistic or erroneous concepts prevalent in public sources and addressing fears and anxieties. Patients are guided to obtain counseling from a mental health professional specifically trained in gender identity concerns. This could be a psychologist or psychiatrist with training and experience in this field. 

Mental and physical transition

Best practices for hormone therapy are reviewed with the patient in order to help with the many levels of mental and physical transition. Hormones will change the body as well as the personality in both subtle and, sometimes not so subtle ways, toward the desired gender. 

‘‘We offer guidance and advice to our patients before, during and after the entire process and hope to provide support years after the surgeries. I believe there is no type of surgery or any other field in or out of the medical world which creates such a profound and positive change in both the physical, emotional, and mental status of a person as with transgender surgery. After many years of surgical experience, I have never observed a more positive improvement in self-image as I have seen with my transgender patients. This is what gives me such a strong feeling of self-purpose and satisfaction in work every day, knowing that I am helping another person to have a happier and more fulfilling life,’’ says Dr Sherman.

Main concern of psychologists and psychiatrists

The main concern of psychologists and psychiatrists is that these patients who seek sex reassignment surgery are normal in all other aspects of psychological personality. Their main task is to evaluate and study these patients thoroughly for an extended period of observation to rule out psychosis, personality disorder not related to G I D.

Transgender surgery is performed on otherwise perfectly normal healthy people other than GID. Therefore, psychiatrists take all the responsibility in recommending this type surgery for a patient.

Without his unequivocal opinion, these patients will not be accepted for surgery. It is a rule to have these patients evaluated by more than one psychiatrist and only on the concurrent opinion of psychologists and psychiatrists, the patient is accepted for surgery. There are other equally important requirements the patient has to fulfill before undergoing sex reassignment surgery,’’ says Dr Jayaram.

Surgical procedures

The surgical procedures include facial feminisation- Alteration of facial features and/or structures (nose, brow, jaw, etc.), breast augmentation - Placement of breast implants, buttock enhancement or reduction - Shaping buttocks to more feminine contours and thyroid cartilage reduction - Reduction of Adams apple, vaginoplasty Bottom surgery; conversion of genitalia from male to female, and vaginoplasty methodology.

Facial feminisation

It includes surgical procedures that alter the face to create more classically feminine characteristics, such as a higher brow, a more refined feminine nose, less pronounced Adams apple, and others. For the transsexual woman, facial feminisation greatly enhances the socialisation process as a woman.

Breast augmentation

This surgical procedure involving the placement of breast implants to increase the size and improve the shape of the breasts. According to the American Society of Plastic Surgeons, breast augmentation is one of the most commonly performed cosmetic surgeries in the United States. Those who desire a larger breast than hormones produce should explore having breast augmentation surgery, in which a breast implant (prosthesis) is inserted under the existing breast through an incision.

Buttock enhancement or reduction

Both male-to-female (MTF) and female-to-male (FTM) transgender patients schedule buttock enhancement or reduction surgery if they desire shaping their buttocks to achieve a classically feminine or masculine look. The classical feminine form features buttocks that are rounder and fuller. Some hip shaping may be necessary as well. Classically masculine buttocks are smaller, angular, and firmer.

Thyroid cartilage reduction

People who are undergoing a male-to-female (MTF) transition consider having chondrolaryngoplasty or thyroid cartilage reduction surgery to reduce the classically male characteristic, the Adams Apple. Having thyroid cartilage reduction surgery, more commonly known as a Trach Shave, reduces the prominence of the Adams Apple to provide a more feminine appearance.


It is a surgical procedure that essentially converts penile and scrotal tissues into a vagina, clitoris, and labia. This procedure is usually combined with labiaplasty that further refines the labia and external vaginal area, giving it a classically female appearance.

Vaginoplasty methodology

This one-stage procedure is done under general anesthesia in the lithotomy position (legs elevated and separated in stirrups). All incision sites are infiltrated with zylocaine containing epinephrine, which constricts blood vessels and reduces bleeding.

Health hazards

Challenges:mental and physical

The health hazards of transgender people are not much different from the health problems of any normal people, except for the psychological stress of possessing genital features that are opposite to their gender identity. This causes serious stress and anxiety in lifestyle, and when this disparity between anatomical sex features and psychological gender becomes intolerable, they seek correction through surgery to change their sex organs in accordance with their psychological gender.

I have been doing surgeries for 40 years, but mostly transgender surgeries for the past 10 years and have done 3000 to 4000 surgeries during this time. The challenges of living life in your desired gender are not difficult if you feel comfortable in your desired gender,’’ says Dr Sherman.

The need for post transition support

People have been focused on transitioning for so long in their own private thoughts and the process is so involved that very often the individual and perhaps their therapist are not as focused on what happens afterwards. The gender dysphoria has been such a problem in ones life that transitioning comes to be seen as the solution. Many other problems, emotional and otherwise, are understandably not addressed because of the overwhelming nature of gender dysphoria, and so it can be something of a rude shock to find these issues emerge after transition.

The verdict

The transgenders who don’t identify themselves either male or female and are known as ‘Hijra’ in India are jubilant after the Supreme Court verdict last April recognizing them as the “Third Gender”, ending a struggle for decades for recognition and social acceptance.  The verdict has in fact opened a new chapter for about two million people in India who qualify for the third category of humanity. 

The Supreme Court order is a turning point in the struggle of transgender people and other sexual minorities in India. The landmark ruling grants them, who are born male and live the life of a female; or who are born female, but live the life of a male, but not recognised as a male or a female, the right to choose a gender. They are given three options to be identified in the society as “Male, Female or the Third Gender.”

The court ruling also ensures reservation for the Third Gender under the OBC category to pursue education or for entering government service. This will no doubt, improve their social status and acceptance. Earlier, they were not chosen for a dignified job. Discriminated everywhere, even by family members, they were forced to do all kinds of illegal works, including sex work, for a living.

Another highlight of the judgment is that they don’t have to undergo a sex reassignment surgery now to prove their gender. On the strength of the ruling, the Third Gender cannot be now denied admissions to educational institutions or employment due to their gender. Now they can seek hospitalisation for treatment, which was denied earlier the confusion over their gender they could not be admitted to either male or female ward.

The court in its ruling also pointed out that “gender identity is one of the most fundamental aspects of life which refers to a person’s intrinsic sense of being male, female or transsexual.” “Discrimination is so large and pronounced, especially in healthcare, employment and education, leave aside social exclusion. Now, it is time for us to recognise the rights of transgenders as a separate category and to extend and interpret the Constitution in such a manner as to ensure a dignified life for them,” observed the Bench of Justices KS Radhakrishnan and AK Sikri, who pronounced the judgement protecting the right of the Third Gender to live with dignity.

Gender dysphoria

It is a fundamental unease and dissatisfaction with the biological sex one is born with (one’s body) which results in anxiety, depression, restlessness, and other symptoms.  The dysphoria often acts as a catalyst to change one’s body and gender expression (how one presents to the world) to be more in keeping with what is felt to be one’s gender identity (the gender that one feels oneself to be).

In simpler terms this means that natal (biological) males, who are gender dysphoric have unease, dissatisfaction and even disgust with their male genitals, body hair, angularity, facial hair, musculature and any other attributes that one typically identifies with “maleness”. Natal females who are gender dysphoric can have similar feelings with developing breasts, fuller hips, long hair, menstruation and other attributes that are associated with femaleness.

For many transgender individuals being transgender is not just about wanting to live in the social role of the other gender (to some degree), but it’s also about a fundamental dissatisfaction with one’s body.

India’s first transgender entrepreneur

A different voice

Kalki Subramaniam grew up with the stigma of a transgender insulted by others in schools and colleges, but that only made her a strong person. She fiercely campaigns for social, political, and economic equality and rights of transgender and inter-sex people.

Kalki is now the founder of Sahodari Foundation, an organisation working for the social, economic and political empowerment of transgenders in India. A transgender rights activist, an actor and a transsexual woman herself, Kalki holds two Masters degrees in Journalism and Mass Communication and International Relations.

Through Sahodari, she works with the entrepreneurship training which can positively change the poor transgender and intersex peoples livelihood choices a life away from begging and a life with dignity. With the public, she advocates against the transgender discrimination and hatred, and voices for inclusion of transgender and intersex people at all levels. She has lectured at numerous seminars, colleges and universities in India and the US.

Basically, Kalki is an actress who makes documentaries. She is also the editor of the Tamil magazine for transgenders called Thirunangai. She also works as an independent media specialist. She develops web-based projects and is a scriptwriter for documentaries and animation. films.

Festival of the ‘Third Kind’

Koovagam, a remote village in the Ulundurpettai taluk in Villupuram district of Tamil Nadu, is primarily known for its annual 15-day festival of transgender and transvestite people, in the Tamil month of Chitrai (April/May).

The festival takes place at the Koothandavar Temple dedicated to Aravan (Koothandavar). The participants marry the Lord Koothandavar, thus reenacting an ancient myth of Lord Vishnu who married Kootandavar after taking the form of a woman called Mohini. The second day of the festival is about mourning the death of the groom by breaking their bangles and singing and dancing ritualisticly. An annual beauty pageant and several other competitions like singing are held. The festival premises are also venues for several seminars to discuss the basic rights and health care issues of transgender and transvestite people. People from different places attend this festival.

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