Born in the wrong body: The fight for transgender surgery in SA

South Africans diagnosed with gender dysphoria can wait up to 25 years for an operation. Ziphezinhle Msimango speaks to transgender patients and their therapists about this tough journey

On January 16, Soweto's Karabo Richards*, 29, posted the following status update on his Facebook profile: "Today marks 365 days since I took the shot that leads to my truest self. It has been the longest, funniest, most challenging and blessed journey I've ever taken. I had to let go of the person I grew up knowing as myself, the one person I hated and grew to love before letting her go. She housed this man in her body. I thank you for all your love and support. I am the happiest man alive."

Richards underwent his transformation at Joburg's Chris Hani Baragwanath hospital public-sector transgender clinic after being diagnosed with gender dysphoria, a recognised medical condition treated by a procedure that changes the patient's gender.

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Human rights are enshrined in South Africa's constitution and we are part of a global community taking the transsexual agenda seriously. But to many in South Africa, the idea of transitioning remains taboo. Some doctors refuse to perform the procedures as a matter of personal principle.

In spite of this, people with gender dysphoria still choose to transition in order to gain that which those who have never questioned their identity take for granted - the freedom to express who they really are.

Richards wrestled with feelings of confusion for years before addressing them. "As a child, gender was something I never understood," he says. "Growing up [as a girl] I would collect empty toilet paper rolls and create a makeshift penis. In high school I became a lesbian and really started examining the concept of gender. The way I felt confused me. When I became a gender activist people around me said I was 'trans', which was scary because I thought the Creator made you this way and you can't change it. I went home and thought about what I wanted my kids to call me one day."

Richards remembers crying because he knew unequivocally that he wanted them to call him Daddy. "I just couldn't bring myself to admit it." Finally he began to connect the pieces of his behaviour. "For the first time in my life I knew who I was. I understood why all my life in a relationship I would always naturally take on a male role and would get angry when I was treated as a girl."

South Africa doesn't have any statistics on the size of its trans community (people choosing to live as a different gender). Katlego Sepokotele, co-ordinator of the Gender Dynamix Advocacy NGO, says: "Perhaps the number of individuals who are on waiting lists in the public health system for gender reassignment surgeries and hormonal replacement therapy could give an indication ... but not all trans people want to access hormonal replacement therapy or gender reassignment surgery."

Sepokotele says another layer of complexity is the issue of self-identification, which makes quantification difficult. Not all people perceived as trans identify with the label. A man who lives as a woman may not want to be called "trans". Not everyone has access to the vocabulary of transgender.

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Caitlyn Jenner may have made transitioning look glamorous when she gazed at us from the cover of Vanity Fair, but in South Africa people have to fight to get access to the means to transition. They face innumerable challenges before they even make it to their first doctor's appointment.

The biggest obstacle is finance. For patients with no money, transitioning becomes a search for help. Gender Dynamix co-produced a report on the relationship between health service providers and the transgender population in South Africa, which found that "access to informed and trans-friendly healthcare providers remains a struggle ... forcing transgender individuals to seek expensive, far-removed and often extremely delayed services".

Transitioning in Thailand, considered one of the cheapest places to have the surgery done, can cost roughly R200,000. In a 2011 article titled "Transgender patients sidelined by attitudes and labelling", published in the South African Medical Journal, Chris Bateman said that private-sector transition surgery in SA cost roughly R250,000, but patients who earned R1,000 or less a month could pay R75 at a state institution.

The report quotes a surgeon who commented on the reluctance of some doctors to openly perform such procedures. "We need to demystify and destigmatise, encourage people to open their minds and see this as part of being a doctor helping relieve human suffering," he said.

The standards of care set by the World Professional Association for Transgender Health say patients must receive psychotherapy as part of the diagnosis. A therapist's referral of a patient diagnosed with gender dysphoria allows them to get hormonal treatment. They then have to live publicly as a member of that opposite sex for a year before they can have surgery.

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From his extensive research, Richards knew transitioning was not going to be easy. The help he received from Chris Hani Baragwanath came as a surprise. A Facebook contact told him to see psychologist Ethelwyn Rebelo. "We had a one hour and 45 minute session which was holistic and looked into a lot of my issues."

Rebelo has years of expertise in transgender and intersex fields and is currently completing her PhD on the subject. She is part of the team at Bara's Luthando Clinic (which also assists those affected by HIV) helping patients with gender dysphoria, along with psychiatrist Dr Greg Jonsson and psychologists Kim Zamparini, Garret Barnwell and Najeebah Noorbhai.

"It started because Ethelwyn had been collecting a cohort of patients that used to come in needing endocrine and hormonal treatment but required therapy beforehand," says Jonsson. "At first it was very ad hoc but we realised the need to formalise the service.

"We will interview the patient as a panel and then make a decision as to the type of therapy they need. Endocrine requires six months of therapy, after that we'll write them a letter of referral, then they go into the big world of Bara. Unfortunately the hospital is still functioning in silos ... so we've got a good psychiatry team but thereafter the hormones and surgery happens on an ad hoc basis, if it happens at all."

The sad reality is that South Africa already has an overburdened healthcare system.

"It's been especially difficult, obviously, with the resource problem at Bara," says Jonsson. "Not only the human resource shortage but also with theatre times - the surgical components have been a bit of a battle".

The team currently sees one new patient a week and runs a support group consisting of eight patients. They hope that one day Bara will have a cohesive transgender team - consisting of experts in therapy, endocrinology and surgery - servicing patients with gender dysphoria.

Bara's obstacles made Richards look to other places for completion of his transition.

"I want to get my top surgery done, which is removal of the breasts. Hopefully I can have it done at Steve Biko academic hospital in Pretoria. Then I'm going to store my eggs and remove the womb."

In addition to Bara, Cape Town's Groote Schuur and Pretoria's Steve Biko have transgender clinics. Both have very long waiting lists. Limited operating times mean that only about four surgeries can be performed a year.

Alaric Jacobs, communications officer for Groote Schuur, says: "We offer full transition, from psychiatric to hormone manipulation and gender affirming surgery. We treat between 10 to 15 new patients a year ... We have a 25-year waiting list for surgery."

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Amber Greggorio Lallu, 42, is a transgender patient who will be grateful to Bara for the rest of her life. Lallu has recently had an orchiectomy (removal of the testes) at the hospital. She says: "When I realised I could have this done I celebrated. Finally I found ease in myself. I could start accepting myself.

"Before the surgery the nurses and doctors kept asking if I was sure I wanted to have this done. The op is done under local anaesthetic and the needles injected into the scrotum are extremely painful. During the surgery there was a moment where it felt like the doctor was pulling my intestines. I got through it by closing my eyes and meditating."

Christened Ambrose, Lallu started dressing as a woman from the age of 16. After watching Michael Jackson and Boy George music videos, she started experimenting with make-up. "I remember looking at myself with the make-up on and thinking, 'I love this feeling'."

Her mother accepted her unconditionally and even bought her women's clothing, but her father was a different case. "There I am, his eldest child and I'm dressing in Foschini women's clothes. He just wanted to die. But I couldn't see myself getting in a suit. The only time I wore one was once at a lunch with extended family and when I had my first holy communion in church."

For years Lallu struggled with depression and suffered public humiliation. She was once shamed in front of her school. "During assembly the principal announced that the boys who wear eyeliner and gold eye shadow must follow him to his office immediately. That was so embarrassing, to have the whole school looking at me being escorted to the principal's office. It was hectic. I got to Standard 9 and dropped out."

Having gone through such tough times makes the fact that he finally has a referral letter to see a plastic surgeon at Bara even more unbelievable, says Lallu. "The doctor will check the size of the penis. The scrotal skin is important because that makes the vulva for the vagina, so you can imagine how excited I am. All I dream about is the plastic surgeon saying, 'Yes, let's do it'. I'm only going to start living when this is done."

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Roderick Lechuti, 25, is transitioning into a man with the assistance of the therapy team at Bara's Luthando Clinic. Born Lebogang, he was raised by his mother in Dobsonville and has been dressing as a male for most of his life.

"My mom and I had a strained relationship because she insisted on buying me dresses and skirts which I refused to wear. If she wanted to punish me she'd hide my pants."

Lechuti always felt uncomfortable about being female and is excited to be on his way to becoming the same person on the outside as he is on the inside. He's been on hormone treatment for 50 days. "Hopefully soon I'll be going for the hysterectomy, and then I will go for top surgery."

The toughest part has been explaining it to his mother. His parents thought he was lesbian because that's who he socialised with. "After school I met this trans guy. I then went for therapy for personal reasons and in those sessions the gender issue came up. That's when I got the courage and knowledge to actually come out and tell people that I'm trans."

His mother still struggles with the concept. "You know sometimes with black parents it's tough. When I came out to her the first reaction was she would understand if I stayed being a lesbian ... but now this: 'Kemothlolo, that thing. I don't know what you're talking about.' I had to sit down with her and watch documentaries on trans people. She still calls me Lebogang."

Every day South Africans face tremendous challenges to get decent primary healthcare. But the trans community, even though they remain largely unseen, also have legitimate needs. Legitimate enough to at least warrant more debate on how the limited services that exist can be improved.

* His name has been changed at the subject's request

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