Cutting through the red tape

While Dan was able to successfully access gender affirming mastectomy, they said that many nonbinary folks find it extremely challenging to make it past the first stage of medical transition. 

The National Portal for Transgender Persons states surgery, hormone replacement therapy (HRT), mental health counselling, and laser treatments as the types of gender affirming care available in India. Aritra detailed how these services work in stages for those seeking traditional binary medical transitioning in India. 

First, a person who needs it is required to get a gender dysphoria (GD) diagnosis that their gender assigned at birth doesn’t match their gender identity and a document certifying this from a mental health professional, who must either be a psychiatrist or a licensed clinical psychologist. 

Next, the individual has to visit an endocrinologist to start hormone replacement therapy (HRT), which helps with the development of secondary sexual characteristics such as hair growth redistribution, voice change and fat redistribution. And if the person wants, they can opt for gender affirming surgeries. Additional treatments, like laser therapy, facial feminisation, and speech therapy—that are also part of gender affirming medical transition—can occur at any stage.

Aritra said nonbinary people often get stuck at the stage of getting a gender dysphoria certificate because nonbinary identities challenge the medical notion of linearity—that only two forms of transitions exist: male to female, and female to male. 

According to WPATH, the lack of understanding in the medical community about nonbinary identities can put a pressure on nonbinary people to identify as either transgender men or women to access gender-affirming medical care. 

Dan recalled how one of their nonbinary friends seeking gender affirming procedures had to not just conceal that they were trans nonbinary but also lie to the psychiatrist that they were a trans man to get a GD certificate.

Aritra has accessed gender transitioning, and has had extensive conversations about nonbinary transition experiences with her nonbinary friends and the medical fraternity. In the absence of reliable quantitative and qualitative data on nonbinary transitions in India, people like Aritra, Dan and others members rely on lived experiences of their queer-trans community to understand what goes on in medical spaces and what to expect while accessing gender affirming care.

With this understanding, Aritra painted a picture of the environment in some psychiatrists’ offices. “The moment you enter a psychiatrist's chamber, the way you present yourself can dictate what they [psychiatrists] perceive your gender to be,” she said. “If a trans woman enters the chamber wearing cargo shorts and a tee instead of what is perceived to be conventionally feminine attire—say a saree or dress, some Indian psychiatrists may be unconvinced of the trans woman’s desire to transition. That's why many trans people say they have to present in a certain manner to legitimise their identity [to the psychiatrist].” 

This can be a tricky experience given the mental health professionals hold so much power, deciding whether or not to grant a GD certificate, said Aritra. 

Aritra noted that some psychiatrists employ subdued tactics such as repeatedly asking their nonbinary patients ‘Are you sure you are nonbinary?’ and insinuate that there is still scope to opt for binary transitioning. 

Distrust in the doctor’s clinic and reclaiming agency

Even if nonbinary individuals manage to cross the hurdle of securing a GD certificate, the following steps are no less excruciating for them. For example, Mumbai-based Blue (their name has been changed in the story to protect their identity), who is a 26-year-old nonbinary musician, didn’t quite have a clear vision of their gender transition journey. What they knew though is that they didn't want to look like a man.

"I had dysphoria about my chest, so I wanted a mastectomy," Blue told me. "But I never aspired to look very masculine. When these feelings surfaced, I came out as nonbinary "

Fortunately, their psychiatrist in Mumbai, affirmed their nonbinary identity and helped them obtain a GD certificate. Blue desired some specific physical changes that make them look slightly muscular but not a lot. For example, they didn’t want a full beard or facial hair, and didn’t want their voice to deepen or masculinise, which is a common occurrence for transmasc people if they undergo testosterone therapy. So, Blue decided to take a lower dose of testosterone, known colloquially as “microdosing”, and planned to try it for six months to see how their body responded to this kind of HRT. 

Blue's psychiatrist recommended an experienced endocrinologist at Mumbai's Kokilaben Hospital to consult about HRT, and particularly, microdosing. In May 2022, Blue met the doctor and explained their nonbinary identity and desired changes. However, according to Blue the doctor dismissed their nonbinary identity and the physical changes they wanted, saying, “Nonbinary people do not exist. Decide if you are a man or a woman. You can't be midway.” Blue told me that the doctor then started talking about detransitioning (cessation or reversal of gender transition, whether temporarily or permanently, through social, legal, and/or medical means) and cited examples of patients who had regretted their transitions. 

Feeling overwhelmed, Blue left the hospital in tears. "Maybe if I had simply stated that I wanted to transition to a man, I wouldn't have faced this ordeal," Blue reflected. Later, they consulted their psychiatrist to prescribe them microdosing and began their HRT process with him. In medicine, there is some debate about whether or not psychiatrists can prescribe HRT. 

I reached out to Kokilaben Hospital to discuss Blue’s experience and whether their doctors have had any training regarding gender transition procedures, but didn’t receive any response at the time of publishing. 

In August 2022, Blue proceeded with a mastectomy from a surgeon at a private clinic in Mumbai. To avoid being subjected to dismissive behaviour again, Blue chose not to disclose their nonbinary identity. Blue said that the surgeon there referred to them as ‘Mr,’ assuming they were a trans man. Though they were annoyed by the assumption, Blue was relieved to be receiving the treatment they desired. 

Like Blue, Nin Kala, a 28-year-old nonbinary transfemme fashion model from Mumbai, also didn’t reveal their nonbinary identity while accessing gender transition at the Kokilaben Hospital in 2019. She wanted to go through HRT and an orchiectomy—a procedure to remove one or both testicles.

Growing up in the slums of Dharavi, Mumbai, Nin had limited knowledge about being queer, trans, or nonbinary and didn’t know anyone who had undergone a medical transition. Despite this, they said they had a clear vision for their own transition. Nin experienced dysphoria about their testicles and was certain they wanted them removed, but didn’t desire a vaginoplasty—a surgery that creates a vulva and vagina—as they didn’t feel dysphoric about their penis.

Starting their medical transition in November 2019, Nin’s HRT included oestrogen, testosterone blockers, and briefly, progesterone. When they learnt that progesterone accelerates feminization—resulting in faster breast growth, fat redistribution, softer skin, and changes in hair patterns—Nin decided to stop progesterone after a few months, as the effects did not align with their goals. She said her endocrinologist supported her decision.

Nin told me that there was an expectation from friends and medical professionals that, being transfemme, she might also aspire to have larger breasts. However, Nin did not share this desire. "Being assigned male at birth I express myself in a feminine way and often pass as a cisgender woman, but I still am nonbinary," Nin said. 

Affirming nonbinary aspirations

The understanding about non-binary transition in the medical fraternity seems to be so little that before meeting Dan, Barua, the Assam-based endocrine surgeon, himself had not heard about it. But Barua was keen to understand the experiences of his nonbinary service seekers. Dan felt that Dr. Barua really listened to them, was professional in his approach and polite in his curiosity. 

Dan was able to openly discuss their concerns and aspirations with Barua. "He acknowledged that I knew more about the surgery than he did, which meant a lot to me. It was significant that he recognized trans individuals' valuable knowledge about their own gender identity and body."

Dan recalled that on the day of the surgery—May 31, 2023— in the large operating room, Barua, wearing a light blue scrub, drew markings with a felt-tip marker on Dan’s chest to indicate incision markings to Dan. He wrote ‘NO NIPPLES’ in big letters to re-emphasize Dan's request. 

“When I told him I didn't want to keep my nipples because I didn't want to look like a cis man, he was surprised. He raised his eyebrows and asked, 'Are you sure?'” Dan recalled. Barua asked for written confirmation from Dan before proceeding with the procedure. 

"I was intrigued,” Barua recalled while speaking to me. “Dan showed me pictures of other nonbinary Asian-American, South Korean people who had gone through similar procedures." 

When Dan told Barua they preferred microdosing HRT to slow down masculinising effects, Barua was supportive. Barua mentioned encountering three nonbinary individuals after Dan who sought HRT, specifically requesting microdosing. Following Dan's case, "I took proactive steps to educate myself [on nonbinary transition] by delving into research,” Barua told me. "We're here to inform service seekers about the available options, and it's not my place to make decisions for them." 

Need for clear guidelines

Barua said that the medical fraternity in India needs strict and extensive guidelines that illustrate a clear pathway of the best practices for nonbinary transitioning.

Debmalya Shanyal, the president of the Indian Professional Association for Transgender Health (IPATH), and a professor at the Department of Endocrinology, KPC Medical College, Kolkata said, "For binary transitioning, there is guidance from WPATH, IPATH in India, the Endocrine Society of India, and other Indian position statements.” However, there are fewer clear guidelines for nonbinary transition, noted Shanyal, who has served trans individuals for 15 years.

For the first time in 2022, WPATH in its 8th version of Standards of Care, included a separate chapter for non-binary individuals. It clearly stated: It is the role of the health care professional to provide information about existing medical options (and their availability) that might help alleviate gender dysphoria and increase body satisfaction without making assumptions about which treatment options may best fit each individual person.

According to Aritra, while having these guidelines would provide some framework and support for health professionals, she expressed scepticism about their cultural adaptability to the Indian context. 

She spoke about nirvana as an example, which refers to the castration of genitalia within hijra communities, coupled with an elaborate set of rituals. This historical practice has never been recognised by contemporary medical guidelines. “As a result, such practices are rarely discussed as possibilities or aspirations by trans populations, leading to their marginalisation and the erasure of culturally specific gender-affirming practices,” said Aritra. 

Redefining the ‘expert’ 

The gender transition experiences of nonbinary people call for a conversation on redefining who we call an ‘expert’ on trans nonbinary lives. All the nonbinary individuals I interviewed for this story expressed how they dedicated days and months to researching transitioning, engaging in conversations with health professionals, people who have gone through similar procedures, and investing significant thought into their journey. 

They shared a common notion—in the absence of tangible data on trans experiences in medical spaces and unreliable support in India, they do not rely solely on health professionals for guidance. Instead, they often turn to their trans community for understanding and navigating their desires and medical needs.

There’s a need to recognise that expertise on transitioning exists among both health professionals and trans people. Both bring their experiences and expertise to the table and should work collaboratively rather than in isolation.

Barua seconds this. He said, "There's a tendency [in the medical fraternity] to view medical treatments in simplistic terms without considering new possibilities. There's still much I need to learn. Nonbinary and trans individuals should guide us collaboratively by examining research papers, trends, innovations, and more."

Dan, for example, forwarded a collection of PDFs and research papers to Barua, who took the time to read through them all. Shanyal noted that the lack of collaboration and overall knowledge about transitioning also leads to some nonbinary transition service seekers taking risks. A 2023 study The Third Gender in a Third World Country: Major Concerns and the AIIMS Initiative highlights how the lack of social intolerance and stigmatisation in the medical community often forces over 50% of trans persons to seek treatment with quacks or self-medicate. 

"I know many trans people who have gotten their surgeries botched up because of ignorant surgeons and bad sanitary practices. It's the health professional’s responsibility more than ours to provide enough information, options, and possibilities so that we can make informed decisions," Dan emphasised. 

They further explained how researching and having access to information and resources is possible for only some trans and nonbinary people who might have internet access, understanding of the English language (as most resources are written in English), and access to the medical and queer-trans communities. 

When Dan travelled for the mastectomy, they didn’t receive any support from their natal family. They left their natal family home in 2021 to live independently as an openly nonbinary person. It was their friends and people from the trans community who supported, accompanied, and provided post-surgical care. 

In the face of these vulnerabilities, when trans people turn to medical health service providers, Dan believes that they should offer more than just a service —they should care. In the end, gender affirming care is not just a medical intervention. It is life saving for all trans nonbinary people. 

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