The Kerala Health Minister on Wednesday ordered a probe into the death of Anannyah Kumari Alex, a 28-year-old trans woman who allegedly died by suicide this week. Anannyah had undergone gender affirmative surgeries last year, after which she experienced “excruciating” pain that hampered her day-to-day life.

Anannyah was the first trans woman contesting as an elected representative in the state.

“I’m standing before you as a victim of gross medical negligence,” she said in an interview recently. Speaking to the News Minute, Anannyah’s father alleged that she was denied her treatment records and follow-up checkups when she experienced illness and pain after the surgery.

A trans rights organization submitted a complaint to further investigate the matter. The Health Minister said that a committee to study issues pertaining to “sex reassignment surgery” would be formed.

“The state needs to frame a protocol for conducting such surgeries and also put in place an ethics committee to monitor and evaluate sex reassignment surgery,” said Anil A., a member of the Kerala State Transgender Justice Board.

The incident raises concerns about the lack of quality gender and trans affirmative healthcare in India. Gender confirming or affirming surgeries for trans people are highly inaccessible due to high cost and stigma. But even when they are, surgeries are rarely performed with the requisite care and attention.

“It’s a combination of problems — no acceptance of trans bodies because there is no knowledge… Acceptance can only come at a later stage when the health care service is there. But it’s not,” Amrita Sarkar, a trans woman activist, told The Swaddle in a previous article.

Trans people are more vulnerable to medical neglect and are also stigmatized even in primary healthcare settings, which impacts the quality of healthcare they receive. This has persisted despite the progressive NALSA judgment of the Supreme Court in 2014 that recognized the right of gender self-determination for trans people.

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The issue highlights the health disparity between cis and trans people. Health disparity is defined as “groups who have persistently experienced social disadvantage or discrimination—systematically experience worse health or greater health risks than more advantaged social groups,” according to an article in the Annual Review of Public Health. Doctors and medical staff who are not trained in gender affirmative or inclusive medicine, therefore, tend to pathologize trans people as having “gender identity disorders,” in addition to denying or providing inadequate treatment for various health issues.

A 2019 study found that government facilities for gender affirmative healthcare in Kerala were “rare or non-existent” — leaving trans people at the behest of private hospitals that largely evade accountability and are prohibitively expensive. The access barrier can also imply that gender-affirming surgeries are a “luxury” rather than life-saving procedures, according to the study.

Medical bureaucracy also furthers the marginalization of trans people. Due to the stigma and secrecy associated with gender affirmative surgeries, many hospitals do not provide a bill for the costs of the surgery and, therefore, are no longer liable to provide post-operative care.

“SRS [sex reassignment surgery] is not a simple one-time surgery. It requires all medical professionals involved to be non-judgmental, post-operative care, and proper pain alleviation. So it can’t involve just one surgeon, but all the professionals who are necessary to make the process possible have to be on board,” said Sameera Jahagirdar, a trans woman who developed a protocol for gender affirmative surgeries.

Sappho for Equality, a rights group, also created a guide to address the “lack of multi-disciplinary collaborative teamwork… [that] has resulted in miscommunication and subsequent complications and ineffective outcomes” in health care. The document emphasizes the need for standardized guidelines, consent procedures, sensitization of medical workers, and the formation of multidisciplinary teams of health professionals experienced in trans healthcare, among others. However, many practitioners do not follow any of this or other global “Standards of Care” guidelines — with the exception of a few.

Moreover, such efforts — that are led by trans people themselves — are few and far between. At present, the Kerala police have ordered the hospital to stop performing any further surgeries. But the issue goes beyond gender affirmative surgeries — the incident is a marker of how trans bodies are often neglected and treated with apathy by the entire healthcare system.