Thiruvananthapuram: For Deepa Rani, the decision to go for a sex reassignment surgery or SRS was the essential and final step in her efforts to embrace her true identity. A theatre artiste and model, Deepa underwent the surgery at a hospital in Coimbatore in 2019. The procedure did not go as planned and almost took her life. Correctional surgeries at a Kochi hospital took over a year but were ultimately successful. The ordeal left Deepa grateful, but not quite satisfied.
Deepa Rani. Photo: By arrangement.
“There was something missing, I realised,” Deepa says. “I looked like a woman and I walked like a woman. But the moment I spoke, I could see doubt and confusion in people’s eyes. My voice was still a man’s. It left me frustrated,” she says.
In 2021, two years after her SRS, Deepa chose to undergo a voice feminisation surgery. This surgery, introduced in Kerala only in the last decade or so, is typically the last stage of the SRS procedure.
Dr. Jayakumar R. Menon, one of the leading laryngologists in the country, also holds the distinction of being the first doctor to have performed the surgery in Kerala. Laryngologists are doctors who specialise in treating conditions of the larynx or voice box.
“The surgery originated internationally in the 1970s, in Japan. Dr. Nobuhiko Isshiki, a pioneer of laryngology, developed a series of voice alteration and improvement surgical techniques. In India, it took until the early 21st century for the surgery to be implemented along with the SRS,” Menon says.
The surgery is termed so, Menon adds, because almost all the cases involve a male-to-female voice alteration procedure. The 15 such surgeries Menon has carried out have all been a part of the SRS process for trans women. Menon currently practises at a hospital in Thiruvananthapuram.
Dr. Jayakumar R. Menon. Photo: By arrangement.
The basic science behind the voice feminisation procedure can be attributed to string physics, he notes.
“When the mass or length of a guitar string is reduced, you get a higher pitch. Now, apply the same physics to our vocal cords,” he says.
“In humans, the pitch for males falls in the range of 90 to 130 Hz [Hertz]. The female pitch ranges from 180 to 250 Hz. By reducing the thickness or the length of the vocal cord, we can increase our voice pitch. Another way to raise the pitch is to increase the tension of the vocal cord,” Menon says.
Dr. Reshmi M. Nair, a laryngologist based in Kochi, is another one of the few doctors handling voice feminisation surgery in Kerala. She has performed a total of 11 such procedures and started only in 2020. She is part of the SRS team at the Kochi hospital where Deepa was treated.
One of the earliest techniques used was vocal cord stretching, Nair points out. But the problem with that procedure was that it was not always permanent. “In nearly 30% of the cases, the pitch started dropping over time. Thus, more permanent methods to alter the voice by changing the vocal cord, had to be considered.
“The procedure to increase the tension of the vocal cord is known as a ‘Type 4 Thyroplasty’ or ‘Cricothyroid approximation’. In this, the pitch of the voice is increased by moving the thyroid cartilage close to the cricoid cartilage. Reducing the gap between the two in turn stretches the vocal cord, thus increasing the tension, resulting in a higher pitch. It’s similar to how a guitar string’s tension happens,” Nair says.
Type 4 Thyroplasty: surgical steps. Photo: By arrangement.
“An ‘Anterior or Wendler Glottoplasty’ is carried out to reduce the length of the vocal cord. The procedure shortens the vocal folds, thus raising the pitch,” she adds.
Anterior Glottoplasty: surgical steps. Photo: By arrangement.
The mass of the vocal cord can be decreased through LAVA (Laser-Assisted Voice Adjustment surgery), a laser debulking process. A ‘Thyroid Chondroplasty’ is carried out alongside any of the above vocal cord procedures for a reduction in the Adam’s apple, she adds.
Even after these procedures, voice therapy plays a key role in getting the pitch and the diction correct, Nair says.
SRS procedures, particularly those involving genital surgeries, have come under a lot of scrutiny over the years in Kerala.
Dr. Sundeep Vijayaraghavan, the head of the department of plastic and reconstructive surgery at a Kochi hospital says that SRS is increasingly being referred to as GAS – Gender Affirmation Surgery – amongst the medical fraternity.
The first sex reassignment surgery in Kerala, performed at Thiruvananthapuram Medical College in 2017, was in the limelight for the wrong reasons. The patient, a trans man, claimed that the procedure endangered their health drastically and that they had to undergo several rectification surgeries later. Ananya Kumari Alex, who became known as the first trans radio jockey from Kerala, died by suicide in 2021 after allegedly facing serious health issues after their SRS. Only one hospital in Kochi now performs SRS.
According to Dr. Arjun Ashokan, a senior plastic surgeon in a Kochi hospital, the genitalia (also known as ‘down surgery’) and abdominal procedures in SRS can sometimes lead to infections or other complications. The patients are counselled thoroughly, and made aware of such risks before the procedure.
“But the voice feminisation surgery doesn’t really pose such concerns as there aren’t any risks or long-term side effects associated with the voice surgery,” Nair additionally notes.
“One commonly encountered complaint is that the changed voice doesn’t meet the expectations of the patient. That’s where voice therapy and counselling come into the picture,” she adds.
One of the rare issues they have encountered is with the vocal cord reduction procedure, Nair says. If the sutures within the cord get severed, it can create a dual sound effect, known as ‘diplophonia’.
Another feedback they have received from some patients, she adds, concerns an aspect of appearance. The scar left by an open surgery can bother some, especially if they have undergone other cosmetic surgeries as part of the SRS.
Priya. Photo: By arrangement.
V.S. Priya, an Ayurveda medical practitioner from Thrissur, is a trans woman who had her voice feminisation surgery performed by Nair.
“For many transgender persons, voice feminisation surgery may not be even an important part of their SRS. For me, the voice transformation was something I was very sure about right from the start,” Priya says.
Another reason why patients opt for voice feminisation surgery is that hormonal therapy hardly plays a role in voice transition for trans women, Priya adds. “Modulating your voice through therapy techniques can be a constant and conscious effort, and tires you out eventually,” Priya says.
“The first year after my voice surgery was quite a struggle. It was difficult to hold even a normal conversation without straining yourself. I used to sing rather well before that, and I had my doubts as to whether my singing days were over,” she says.
Priya still feels that out of all the surgeries she got, this has been the most beneficial to her. “The stigma associated with a mismatched voice was much greater than the stigma of having to undergo a procedure and changing my voice entirely,” she says.
But both Deepa Rani and Priya unequivocally point out one thing – the need for a better medical system and public health schemes that make gender affirmation surgeries more accessible. As of now, SRS and related surgeries are available only in the private medical sector in Kerala. Under the current state scheme, trans women can be reimbursed up to Rs 2.5 lakh for such surgeries. But this quite often ends up covering only a small part of SRS procedures. For a socially and economically underprivileged trans individuals, there needs to be better state support.
According to Jayakumar, despite the success rate with the voice feminisation surgeries in the state, the current procedures are still not without flaws.
“For one,” he muses, “we only focus on the vocal cord right now, not the resonance factor.”
“The structure of a male and a female throat are quite different from each other. And the part of the throat above the vocal cord amplifies the sound, thus playing a significant role in how the voice ultimately comes out. Unless we figure out how to make changes to that, we would not be able to alter the resonance, and obtain the result that we really desire,” he elaborates.
Dr. Unnikrishnan K. Menon, an ENT and laryngology specialist at a Kochi hospital, feels that this is exactly why the procedure is increasingly being referred to as “pitch alteration surgery” these days. Unnikrishnan is another one in a list of few medical experts to have performed voice feminisation surgery in Kerala. According to him, laryngologists, who have also specialised in voice surgeries, are a rare class in the country itself.
“So it isn’t surprising that Dr. Jayakumar R. Menon and Dr. Reshmi Nair together make up for the majority of the voice feminisation surgeries in Kerala,” he notes.
All the medical experts I talked to agreed that voice feminisation surgery still seems to be one of the “elite procedures” for the transgender community in Kerala. A key reason they noted was the cost of the procedure, which can fall between Rs 1 lakh and Rs 1.5 lakh rupees, depending on the hospital and the type of the procedure chosen. The lack of availability of the procedure in government hospitals right now is a significant reason for lesser numbers. The number of private hospitals in the state performing voice feminisation surgery itself can be counted on one hand as of now. Since the procedure is carried out as the last step of the SRS – which consists of a series of other cosmetic surgeries – the patients are often short of money.
Secondly, voice surgery is generally not deemed to be an indispensable part of transition by many transgender individuals. The doctors noted that only those who felt that voice transition was necessary in their day-to-day – particularly professional – lives opted for it.
Nair cites her patients as an example – most of them are involved in professions where they have to converse and interact with people face-to-face daily. The numbers largely consist of transgender individuals from urban and middle or upper class backgrounds.
Nair feels that the challenges that we talk about are not just restricted to surgical procedures. While undergoing sex reassignment surgery, a trans person exists in a very complex gender spectrum. “Our healthcare and medical system can be more empathetic and representative of, as well as accessible for, the transgender community,” she adds.
Bharath Thampi is an independent journalist and documentarian based in Thiruvananthapuram, Kerala.
