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CC BY-NC-ND 4.0 · Indian J Plast Surg 2022; 55(02): 127-128
DOI: 10.1055/s-0042-1755452
Editorial

Gender Incongruence: A Progressive Approach for Transition

Dinesh Kadam
1   Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India
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We are happy to present this special issue on Gender Incongruence, comprehensively covering surgical, medical, and legal aspects by renowned authors. The field has evolved rapidly through innovative surgical procedures and protocols, and much progress has been made in India and internationally in the care of transgender people.

Gender dysphoria or incongruence occurs when gender identity and expression do not conform to the biological sex assigned at birth, resulting in marked physical and psychological distress. The World Health Organization (WHO) has adopted a progressive approach to depathologize the condition. The latest version of the International Classification of Diseases (ICD-11), published in February 2022, has replaced the term Gender Identity Disorder with Gender Incongruence, characterized by a marked and persistent incongruence between an individual's “experienced gender” and the assigned sex.[1] Though the condition is not considered pathological anymore, there is often an intense desire for “transition” to live and be accepted as a person of the experienced gender. The role and benefits of gender affirmation or confirmatory procedure to align with the experienced gender are well documented and constitute an accepted standard of care.[2] With gradual social acceptance in the last two decades, favorable legislation, and emerging support groups, transgender people are more open to their desires for transition and seeking gender-affirming surgeries.[3] [4]

Historically, the transgender community has been marginalized and treated as pathological ill-offenders. During the British colonial domination of India, they were prosecuted under the Criminal Tribes Act, 1871.[5] The LGBTQ+ community continues to be the victim of discrimination and deplorable social and economic conditions. According to a 2017 National Human Rights Commission study, over 90% were denied jobs, deprived of the right to participate in economic activities, and forced to take undignified work for livelihood.[6] Reliable data on their population is unavailable, although the 2011 census with binary male–female format recorded 4.88 lakh transgender people in India.[7] This is a gross underestimation, as many do not disclose their identity because of stigma and fear of discrimination. The lack of data and documentation indeed deprive them of the privileges of ordinary citizens and social safety nets.

Globally, the protection of transgender rights and the promotion of equality are gaining ground with affirmative action from the judiciary, government, and NGOs. Different countries such as the United Kingdom (2004), USA (2009), South Africa (2003), Argentina (2012), Germany (2013), Australia (2013), and several members of the European Union have enacted laws to recognize gender identity.[5] In 2014, the Supreme Court of India gave a landmark ruling recognizing the third gender to safeguard their constitutional rights.[5] It grants full right to decide and declare their gender identity, such as a male, female, or third sex, without having to undergo any sex reassignment surgery. The judgment makes an unambiguous observation that the test to be applied to transgender individuals is not the “Biological test” but the “Psychological test”; thus, the freedom of choice to align their gender lies with them.

Several professional organizations, NGO groups, and communities are working to support and protect transgender and gender-diverse persons. The World Professional Association for Transgender Health, Inc. (WPATH) has published a standard of care and best practice guidelines for the professionals.[8] The Indian Standards of Care for Persons with Gender Incongruence was published by the Association for Transgender Health in India (ATHI) following its first International Conference on Transgender Healthcare, IPATHCON 2019, held in New Delhi.[9]

The Govt. of India enacted the Transgender Persons (Protection of Rights) Act 2019 and formulated rules recently.[10] These enumerate details for the issue of identity cards following the change of gender surgery and various welfare measures in education, social security, and health. Further, the Ministry has constituted the National Council for Transgender Persons with representations from the community. Its overall functions include formulating policies, programs, legislation, and projects concerning transgender persons and redressing their grievances.

Gender-affirming surgery is evolving rapidly with innovative techniques in a patient-centered decision-making environment addressing their specific needs. These procedures are available mainly in private hospitals, self-financed by the patients. Due to the lack of easy access, affordability, and the absence of government or private insurance, many transgender people are drawn into unethical procedures in unregulated places. Recently the central government has announced a plan for a special package for gender affirmative surgeries and medical therapy under the Ayushman Bharat Yojana health benefit scheme.[11] To avail this, registration under the national portal and obtaining identity cards are mandatory. Currently, ∼8000 transgender persons have been given ID cards.[10]

While much of the literature emerges from various international groups, little is known about the number of people undergoing affirmative gender procedures in India. It is essential to understand the specific issues of patients, the protocol, and legislation and maintain a registry of interventions performed. Plastic surgeons, the core multidisciplinary team member, have a crucial role to play in ensuring the standards of care and adoption of protocols.

I am thankful to Dr. Richie Gupta for being the Guest Editor of this special issue curating a wide range of topics by renowned authors. I trust this will generate much interest among plastic surgeons and provide a ready reference on this topic, which is nonetheless a surgical challenge but with social and legal implications. Our responsibility remains to facilitate the social integration of individuals seeking transition with honor and dignity.


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Conflict of Interest

None.


Address for correspondence

Dinesh Kadam, MS, DNB, MCh
Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences and Research Centre
Mangalore 575004, Karnataka
India   

Publication History

Article published online:
23 August 2022

© 2022. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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