When Bhumika Shrestha travelled overseas holding a passport with her gender marked as ‘O’ for ‘other’ for the first time in October 2015, she made international headlines as the face of Nepal’s third gender movement. Although it came after years of campaigning and advocacy, Shrestha said she acquired the changed passport, correctly identifying her gender, through self-identification, and without any court papers or medical proofs.

But that may change—if the draft bill to amend the Citizenship Act in Parliament is not revised.

The new bill registered by the Home Ministry demands proof of gender transformation to obtain new citizenship. The queer community has strong reservations about the clause, which according to them is vaguely worded—and can result in further discrimination against sexual minorities.

“The ‘requirement of evidence’ definitely suggests submission of proof of a sex change operation to obtain citizenship with a changed gender, and it is undoubtedly a regressive step,” said Pinkey Gurung, chairperson of Blue Diamond Society, an advocacy organisation working for the rights of the LGBTIQ community.

According to Gurung, there are many layers to how this provision can be discriminatory towards the queer community. First, it undermines an individual’s “right to have one’s own identity” and pushes them farther from self-identification. Second, it only caters to those who can afford to have sex reassignment surgeries; and third, it asks for evidence of such medical procedure that isn’t even available in Nepal.

Shrestha, who underwent a breast enhancement surgery in Thailand in 2011, agrees with Gurung. “I travelled to Bangkok for my breast surgery because the procedure wasn’t available in Nepal at that time. Even back then it cost me around Rs300,000. It must have become more expensive now,” she said.

Although she successfully underwent the top surgery, she said she has never visited a counsellor or undergone hormone therapy till date.

No team for transition

The internationally approved medical procedure for the transition of transgender individuals is to have their psychiatric evaluation by a psychological counsellor, after which they undergo hormone therapy. Then, with further consultation with medical professionals, they undergo top and bottom surgery to avoid possible side effects.

But these numbers and types of interventions applied may differ from person to person as explained by the World Professional Association for Transgender Health in their clinical guideline ‘Standards of Care’. According to the protocol, many health professionals have recognised that many individuals need psychotherapy, hormone therapy and surgery, while others may only need one of these treatment options—the treatment has become individualised.

Dr Ansumali Joshi, an endocrinologist at Alka Hospital, said that although there should have been a standard procedure, there are none available in Nepal. When a trans patient visits him for hormone therapy, his team makes them sign a consent form in order to avoid any legal consequences.

“There is no clear law in Nepal about these procedures. As an endocrinologist, I am aware of these issues, but I agree that due process has not been followed,” he says.

Pratik Thapa, a transman who is undergoing hormone therapy with Joshi, said he came to know about the possibility of hormone therapy in Nepal through Rukshana Kapali, another transgender activist.

“When I realised that I want to transition, I went to Dr Joshi and he prescribed testosterone dosages. I did go to the counsellor but it was post the hormones, and that too the counselling was more for my parents,” Thapa said.

As Thapa started transitioning, his physical attributes started to change significantly—from his appearance to the pitch of his voice. In order to adjust to the new look and new identity, he felt that it was important for him to take his parents into confidence. That is when he went to Bijaya Bijukchhe, a psychosocial counsellor at Abbal Women Entrepreneurs Pvt Ltd, a psychosocial counselling centre.

Like Dr Joshi, Bijukchhe does not specialise in transitioning individuals or does not deal with cases of gender dysphoria. But Bijukchhe said they cater to such individuals as they are initially diagnosed with depression or anxiety.

“People who come to me rarely identify themselves as a transgender in the beginning. Most people visit us in reference to their deteriorating mental health and through multiple therapy sessions on emotional and behavioural cycles, they are able to recognise their issues, which for some is related to gender issues,” said Bijukchhe.

Her role, she said, is only assuring them of their gender. Seeking further procedure is purely an individual’s decision—she, or her team, does not prescribe them any kind of treatment.

According to Joshi, due to the lack of clarity and standard procedure in dealing with trans issues, there are many patients who stop coming. For instance, male hormones work faster than female ones due to which more transwomen opt out of the prescribed hormone therapy. In the absence of the facility of regular counselling and easy over-the-counter accessibility of female hormones, this trend is on the rise.

“Male hormones are only accessible in injectable forms while female hormones can be easily found in oral forms. This has led transwomen to self-medication, which can have grave consequences in the future—from metabolic changes to rise in haemoglobin levels to risk of contracting cardiovascular diseases and even cancer,” said Joshi.

Foregoing groundwork

Many countries around the world have the provision to demand a medical certificate or to limit the validation of the government-issued document. In the United States, the validity of passports (from 10 years to two years) depends on the ‘appropriate clinical treatment for transition’, with the individual’s physician determining the clinical treatment. Similarly in the United Kingdom, an individual has to be diagnosed with gender dysphoria and should have lived in the acquired gender for at least two years to be eligible to apply for Gender Recognition Certificate.

But Gurung believes the policies practised in developed countries may not be applicable in Nepal’s context. “These [developed] countries have appropriate medical services, with a few European countries even providing free surgeries,” she said. “What is Nepal government’s plan or strategy to create a safe space for or provide LGBTIQ friendly medical facility?”

Eshan Regmi, an intersex man, said he has faced discrimination even in the hospitals where it is mandatory to disclose his identity to receive correct treatments. His citizenship mentions his gender as a female whereas he identifies himself as a male. “There aren’t enough medical services that cater to us and even where there are services, the awareness level is very low,” he says.

He is not the only one who has experienced humiliation from people working in the medical sector. It was also difficult for transgender activist Kapali to buy hormonal medication in many pharmacies in the Capital during her early days of transition.

“The pharmacists used to give me a confused and judgmental look even when I used to give them my prescription. They were not at all aware of these issues and I had to explain to them my situation in detail,” she says.

Even medical professionals are not sure how they can testify or certify an individual’s gender identity without a clear law.  “We have been providing hormone therapy to people who have asserted their identity themselves. It is their choice,” said Joshi, the endocrinologist.

Additionally, gender reassignment surgery internationally requires medical professionals to follow certain clinical protocols. But in Nepal, the only medical Act that deals with the alteration of body organs through surgery is ‘The Human Body Organ Transplantation Act 1998’ and it is silent on the issues regarding gender reassignment surgery. And while some hospitals and clinics have started providing top surgery, there is still no provision for bottom surgery at any medical facility in Nepal.

Consent is key

On December 21, 2007, when the Supreme Court of Nepal acknowledged the third gender, the move was commended all over the world not only for recognising the rights of the LGBTIQ community and the umbrella term ‘third gender’, but also for moving away from the traditional binary identity of male and female, creating a much broader space to accommodate even the non-binary community.

More than a decade after the decision was taken in Nepal, a US federal court just recently in February 2019 ruled for the first time that a passport be issued to a non-binary person with a gender marker of ‘X’. In this context, Nepal has been one of the most forward-thinking countries for LGBTIQ rights. But with the proposed bill stating that people need to present a proof of sex change, it seems that the country is taking a step back. On the other hand, while the LGBTIQ community may have gained recognition under the umbrella term of third gender, there are no awareness mechanisms by the government to discuss and demonstrate diversity within the community.

Over the years, many transgender individuals were able to change their gender marker from what they were assigned at birth to ‘other’. But there were many individuals who preferred to change their gender to male or female rather than be marked as ‘other’.

“Within the queer community, individuals may describe themselves as gender non-conforming, unambiguously cross-sexed or genderqueer and mandate for the ‘other’ gender marker. But many may not identify as such—the underlying principle being how the individuals describe themselves,” says Regmi.

Similarly, following the principle of self-determination, the proof of gender change is also not a feasible solution as not all people require or desire medical services.

According to Regmi, not all people within the intersex community need medical attention and it is also an individual’s discretion to seek medical services. It cannot be intrusive but should always be based on consent.

Likewise, according to Gurung, many transgender individuals cannot undergo medical procedure due to their health complications—or simply because they choose not to.