How Transgender Amendment Act hinders medical care

CHENNAI: Ask any trans person about gender-affirming care in Tamil Nadu, and you’d be shocked the obstacles they would have to overcome to access it – an irony considering TN is famous for medical treatments for the marginalised.

P Ranjan (25), a trans man from Chengalpattu, had his gender-affirming surgery at the Rajiv Gandhi General Government Hospital (RGGGH), Chennai, on August 7. However, the journey was nothing short of a nightmare.

To begin with, he had to visit RGGGH multiple times to finalise a surgery date. “Every time I visited the hospital, doctors and nurses would give me a new test to be taken. They did not give me a reason or explain any of the complications,” he recalls.

He stopped taking his hormones in June, and the surgery should have been in the second half of July. The date was continuously delayed with requests for multiple tests without explanations.

Loss of pay

Ranjan, because of the lack of family support, works in a garment store in Chengalpattu. For every visit to the RGGGH in Chennai, he had to lose a day of pay for over eight months of his transition process. “My monthly salary is Rs 12,000. Every time I had to go to the hospital, I had to take leave. You do the math on how much I lost,” he rues.

Also, he had to pay close to Rs 1 lakh from his pocket as the Chief Minister’s Health Insurance Scheme only covered his surgery expense. After the surgery, he had to visit the hospital in Chennai multiple times a week because there is no government-aided gender facility in Chengalpattu. 

Doctors at RGGGH say that the repeated tests could be due to health complications that he was at risk of. However, Ranjan was never informed about those health complications; only that he had to take those tests.

Activists opine that delays are a norm at government hospitals. Often, trans men would choose to procure hormones themselves; those who had the money would buy from private hospitals. “A surgery in a private hospital would cost somewhere between Rs 3-5 lakh,” says trans woman Jaya, the co-founder of Sahodaran, (NGO).

Additionally, he was asked to produce a letter from any of the associations for trans persons in Chennai, or an NGO, a practice that came up only after the bill was passed.

Act changed it all

The letter was not mandatory up until a year ago; however, after the Transgender Persons (Protection of Rights) Amendment Act, 2026, came into place, doctors have started asking for the letter again.

“They had stopped taking it last year, after multiple sensitising sessions; however, the Act has reactivated that,” says Fred Rogers, activist, transgender rights. Many places have also been demanding parental consent as well. 

The amendment, which came into force in March this year, removes self-identification as a valid recognition of trans persons, and requires a medical board to certify a person’s gender identity. It also narrows the definition of who can be legally recognised as trans, covering certain socio-cultural identities such as kinner, hijra, aravani, and jogta, as well as people with specified intersex variations. This leaves out other people in the community like trans men and intersex people.

Further, it criminalises those who aid people to adopt or present a trans identity “by force, allurement, inducement, deceit or undue influence”. This last clause has triggered panic among doctors who have been seeking letters and consent from parents. 

“My friend who had surgery was never asked for a notary certificate. If I were educated, I would have known, but I studied only until Class 7,” laments Ranjan. Later, he was helped by others in the community to secure a certificate. 

TG card

If getting a gender-affirming surgery was a Herculean process, availing an insurance card is next to impossible. Karthik (30) knows that very well.

Waiting is not new to this trans man, as he had to wait for months to apply, and then some more, to receive the Transgender ID (TG). Though it was mostly an online process, he couldn’t even apply for a TG card as the portal did not work most of the time.

The Trans ACT has stalled the process of getting a transgender ID card. The application processes have slowed down considerably.

When Karthik approached RGGGH for gender-affirming surgery, he was turned down, as he did not have a TG card – a legal requirement for his treatment. Now that he has received the TG card, he still needs a health insurance card.

Karthik, originally from Kancheepuram, had been travelling back and forth to the GH until he was finally turned away. Every week, he begins his journey from Kancheepuram at 4.30 am, so he can get all the tests done. “But even after the test, we cannot meet the doctor; I have to go again next week,” he says. Each day he misses work, he misses Rs 1,500 of his pay too. 

Karthik, who works as a parotta master for daily wages, disclosed his gender identity to his parents in 2021. “I was assigned female gender at birth. So, when I came out as trans to my parents, they got me married to a man. And, now I have a five-year-old boy,” he begins.

Feeling miserable with the identity assigned to him, he separated from his partner two years ago. Since then, he had been mulling over transitioning. “I’ve lost almost 6 years of my life to society; now I want to live for myself. I feel transitioning is right for me. But the delays have been stressful and heartbreaking,” he says.

Due to the delay in acquiring the insurance card, Karthik began the transition process at a private clinic, after getting a recommendation letter from RGGGH. After Chief Minister C Joseph M Vijay announced an increase in the insurance amount from Rs 5 lakh to Rs 25 lakh, there has been a delay in processing new applications. His application is caught in the melee.

Gender erasure

The new Act removes self-identification as a valid way of identifying oneself as trans. With this, the trans community has been pushed into a limbo. The amendment also leaves out trans men, erasing them further in the system.

“Across India, the terminology T is being equated only as trans women. We’re marginalised of the marginalised. This Act erases us by refusing to recognise us, include us and protect us through law. Our entire community of trans men (assigned female at birth) and gender-queer communities – the Act does not see us as belonging to the transgender umbrella,” explains Fred. 

There are two types of TG cards: one from the State and another at the National level. For the State-level card from Tamil Nadu, only an Aadhaar is sufficient for the application. A national card requires an affidavit as well. Following the amendment a few months ago, the national TG card portal is not active,” says Jaya.

For example, Fred removed the term self-identification from the consent form he shares with medical practitioners because it could complicate things. “Earlier, we used terminology like ‘assigned female at birth’ and that the person is ‘self-identifying’ as a man. Since self-identification is no longer recognised, I have removed the term ‘self’ from the form. But the actual scientific reason is gender incongruence. And to address that, a person is sound enough to give consent for seeking medical care as per ICD-11,” he explains. 

Explaining further, Jaya says, “According to the 2014 NALSA verdict (a landmark Supreme Court judgment that recognised transgender persons as a third gender), self-identity was important, and the State had to accept if someone self-identified as trans. There was no need to have a certificate, take hormones or transition,” she says.

However, according to the new amendment, you can only acquire a transgender identity with a medical board certification. But not everyone can afford to transition or wants to. “For example, trans women could have family pressure, family’s health history and other financial issues that prevents them from taking up gender affirmation care,” she says. “There could be physical issues too. Also, for trans men, there is only top surgery in India. Vaginal construction is still not done. So how would the medical board decide?”

Doctors are scared

Dr Gargi, a transgender person from the Kothi community, says that doctors fear giving care to the trans community because of the amended Act. “The Act mentions that you cannot forcibly transition anyone. But when we approach doctors voluntarily, they are scared of giving us hormone replacement therapy (HRT) or gender affirmation services, as they believe families of trans folks could use the Act to incriminate those who assist in transitioning, even if it was to declare anyone as trans. The amendment is unscientific as no doctor can declare someone as trans. In addition to making life difficult for trans persons, it also punishes those who assist us even if they have a medical license,” she laments.  

For those who already have TG cards, there is some clarity. During a hearing on August 17, the Union government told the Supreme Court that TG cards issued before the 2026 amendment would continue to remain operational, subject to the outcome of the petitions challenging the law. But for those seeking an ID card under the new system, the process could carry a significant medical and financial burden.

Doctors across the country have also started demanding parental video consent, or consent from attendees from the community seeking surgery. 

Lakshya Mannar, a trans woman, says that recently, she was asked to give video consent for one of her friends she was accompanying for a breast implant surgery in Pune. Trans women often seek medical care outside of Tamil Nadu because the treatment there is better.

“So, we go to Pune because the surgery and after-care is much better there. I’ve taken three of my friends there, but nobody had asked for a video recording of our consent till now. While one could imagine that the consent video of the care-seeker is needed, why mine? I am just an attendee,” she says.

While Lakshya was attempting to seek gender-affirming care, she has put her plans on hold following this amendment. “I’ve been planning to do my surgery in Thailand, as I’ve heard of many instances of medical complications during and after the surgery. This has deeply scarred me. But now it’s even worse, as the amendment has put so many obstacles before me,” she says. “As per this Act, I need a doctor and then a magistrate to approve my TG card. And that card can get me a passport but only a surgery will give me legal acceptance as a trans person. I do not look like a trans woman, so people suspect me. And, this Act further prevents care to those who do not fit into the norms. It has created undue pressure and mental stress for us. I do not have parents to give me consent.”

The first step in seeking gender affirming care is a TG card, which in itself is discriminatory, claim activists, as self-identification should be enough. Following that, a gender incongruence test is conducted and a psychiatrist would attest to it in a letter. With that letter, you can seek gender affirming hormone therapy or surgery. For surgery, assessments are made by two mental health professionals (psychiatry and clinical psychology).

It’s noteworthy to point out that for any kind of gender affirming care, the World Professional Association for Transgender Health recommends only informed consent.

Fred says after the amendment, multiple psychiatrists doubt as to how their referral letters would help in seeking gender affirming care. And many endocrinologists fear that they could be booked as criminals, as the phrasing of the amendment criminalises anyone helping someone transition. 

“The amendment has undone years of activists, NGOs, and seniors from the community. This could be detrimental to our health, because we’re scared to approach a primary/secondary/tertiary care unit or even disclose to our families that we’re trans,” he adds. “We already face so much stigma and discrimination; now, it will increase as the amendment excludes us from protections, as it makes us vulnerable to sexual violence.”

Swetha Sri from Saathii, an NGO, says that there were a handful of doctors who were providing gender-affirming care. “They were startled by this, and reached out to elders in the community for clarity on the amendment. This resulted in a private clinic in Chennai asking for video consent of parents of trans people even if they are adults,” she says.

Swetha adds that this was an added burden on people who are kicked out of their homes and have to support themselves. “There are literally very few who offer surgery with minimal complaints, and now this amendment has made it more difficult,” she says.

While a letter was sought before, awareness campaigns by such NGOs sensitised hospitals and doctors towards gender affirming care, and negated that.

Jaya says the amendment was brought in so that the schemes for the community are not misused. But the schemes themselves are so few. “How much exploitation could happen by the community? From a free house to people over the age of 40 to shelters and free admissions, there are some things in place. But if someone is taking advantage of these schemes unfairly, we’ll be the first ones to flag it,” she explains.

Their demand to have more gender clinics in TN, other than in Chennai, has also not been fulfilled. Chennai has a gender clinic only in RGGGH. Further, she adds, “The amendment does not add any safeguards to the schemes, or the aid we could access. While if someone violates us, the punishment is 2 years; for supporting someone, we could face rigorous punishment. How is this fair?” she fumes.

RGGGH doctors say...

Meanwhile, when DT Next reached out to doctors at the gender clinic in RGGGH, they stated that they had always sought a letter from the community. “I’ve had experiences where trans folks have sought care, only to come back saying they want to reverse it. What happens if I am implicated in such a case like a crime? What are my safeguards?” asked one of the doctors in the clinic. They are also looking for clarity from the government. However, RGGGH doctors claim that the Social Justice Department has instructed them to continue doing what they have been doing so far.