The Gender Identity Clinic (GIC) and Gender Reassignment Surgery Clinic were set up at the National University Hospital in the early 1990s, two decades after Singapore's first sex change operation was done at Kandang Kerbau Hospital in 1971 by pioneering O&G surgeon and head of the Department of Obstetrics and Gynaecology, National University of Singapore, Prof. S Shan Ratnam. The GIC was headed by Ratnam himself until his retirement in 1995, after which leadership passed to his nephew and protege, Dr. C Anandakumar. Owing to the existence of these clinics and the skills of their staff, Singapore was one of the world leaders in gender-affirming surgery for 30 years, performing more than 500 such operations. This gave a new lease of life to many transgender individuals whose bodies did not match their gender identity. As one consequence of this, Bugis Street and Johore Road started to become populated with a range of transgender people from transvestites to iatrogenic intersex individuals to fully transitioned women.
Closure and reopening[]
In the early 2000s, the National University Hospital's Gender Identity Clinic (GIC), the offshoot of the Department of Obstetrics and Gynaecology at Kandang Kerbau Hospital formed a decade ago, was the only facility for sex change operations in Singapore. Although it helped to build Singapore's reputation as a top destination for sex reassignment surgery over the past 30 thirty years[1], its exact location within NUH and the services it provided were kept confidential because of the sensitivity of the more vocal religious fundamentalist segments of Singapore's population to sex reassignment surgery. Since 1971, when the late Prof. S Shan Ratnam performed Singapore's first sex change operation, there had been 500 such procedures, an average of 17 a year. But the GIC had done no male-to-female operations since 2001. Since September 2001, it had performed only four female-to-male operations.
This was because the Ministry of Health had asked hospitals to phase out sex-change surgery in the late 1980s for fear that hospital staff might be exposed to HIV. It was also reported then that the Ministry had not considered sex-change surgery as a life-saving procedure. These objections were lifted in 2001.
The general public could not find any information on the GIC on NUH's website and it was extremely difficult to interview its then consultant, Dr. Arunachalam Ilancheran. Dr. C Anandakumar, who was the specialist-in-charge at the GIC from 1995 to 2001, recounted how, during his time, consultations with transgender patients could only be done on Saturdays and after office hours, as NUH had very little interest in encouraging sex reassignment surgery. Transsexuals would also need to book themselves into single-bed wards after the operation as Dr. Anandakumar claimed "the hospital did not want the transsexuals to mix with other patients". This would push up the cost of the operation, prompting many transsexuals to head to Bangkok for more affordable treatment. However, he conceded that the situation may have changed and added that the clinic had served its purpose well.
In reply to queries from The New Paper, an NUH spokesman said, "All our patients are important to us and we care for them with respect and sensitivity due to any individual. The Gender Identity Clinic operates at the usual hours, as per all other hospital clinics. Patients stay in single room as per MOH regulation since the seventies."
Transwoman Leona Lo completed her psychiatric assessment in Singapore but elected to have her surgery performed in Bangkok. She felt that the lack of information about the GIC deterred transsexuals like herself from having the operation done here. She said, "Many of us can't be bothered to find out more about the GIC as it's so secretive about its services. It signals the clinic is not interested in helping and is ashamed of us. There's always the Bangkok and the surgeons there have done so many operations. The more operations they perform, the better they get. So we're happy to go there." But not all transgender patients were flocking to Thailand. Transwomen were still seeking help from the GIC.
In April 2001, the Gender Identity Clinic at the National University Hospital, which was the last hospital in Singapore where sex change operations were performed, closed without any fanfare. The official explanation was that the gynaecologist in charge, Dr. C Anandakumar, had left for private practice, and without him, the clinic did not have the skills to perform SRS. However, as early as 1987, the Ministry of Health had been directing hospitals to stop doing such operations on foreigners. It also discouraged them for Singaporeans, saying, "the increased danger of AIDS with such patients poses unnecessary risk to hospital staff". However, some believe that the increasing number of Christian doctors filling the administrative ranks of Singapore hospitals over the past decades had a part to play in its shutting down as cross-dressing and sex reassignment are proscribed in the Bible.
This dismayed transgender people seeking to have their operations performed locally. The online edition of the now-defunct newspaper Project Eyeball carried out a survey in June 2001 asking, "Should sex change operations be resumed in Singapore?" 39% of respondents said, "Yes, they are people with valid medical needs, like infertile couples" and 35% said, "Why not? It is legal here, as are transsexual marriages". The results showed that Singaporeans were generally quite supportive.
In June 2001, a petition organised by Jael[2], the founder of the transgender group "FTMs in Asia", urging the re-opening of the Gender Identity Clinic garnered 60 signatures[3]. When asked by The New Paper about the GIC's services, an NUH spokesman replied: 'The NUH Gender Identity Clinic reopened in September 2001 to provide a service to those who request it."
The transgender community's petition was successful, with the clinic discreetly and fully resuming it services in 2003, helmed by Dr. Arunachalam Ilancheran. However, owing to the discrimination against transgender people in Singapore even within some segments of the medical community, the high financial outlay involved and the necessity for psychological clearance, many preferred to have their operations performed sans the hassles in Bangkok, which had by then become the premiere centre for sex reassignment surgery (SRS).
In early August 2001, Singapore's pioneer sex reassignment surgeon and co-author of the book "Cries from within", Prof. S Shan Ratnam, passed away from pneumonia[4]. His death prompted his nephew, Dr. C Anandakumar to relinquish leadership of the GIC to Assoc. Prof. Arunachalam Ilancheran and to leave for private practice. Anandakumar subsequently to head SSR International Private Limited at Camden Medical Centre, an O&G centre of excellence named after his late uncle.
Final closure[]
The Gender Identity Clinic at the National University Hospital drew its shutters for good in 2008. When asked by The Straits Times in 2014 about the Ministry of Health's stance on sex-change surgery, its role in overseeing the procedure, and why public hospitals had stopped offering it, an MOH spokesman would only say that "sex reassignment operations are not subsidised and are performed with...safeguards".
Demand, however, had not shrunk, according to private psychiatrist Prof Tsoi Wing Foo. Since 1971, Tsoi had seen over 2,000 transgender patients, half of whom went for surgery. A psychological assessment is needed before sex reassignment surgery can be carried out on a patient in Singapore. During the 1970s and 1980s, he had roughly 30 cases a year. From 2007 to 2014, he had seen an average of 40. He did not know why surgery options here were dwindling, but speculated that it could be due to public policy changes or the personal preferences of the few doctors who had undertaken such surgery. Dr C Anandakumar, who was the gynaecologist in charge of the GIC until 2001, declined to speak to press when queried.
Despite the fact that many male-to-female transgender patients were flocking to Thailand for their surgeries because of the lower cost and less stringent psychological requirements, female-to-male transsexuals were still seeking help from the GIC. Such operations are more complex and cost SGD$15,000 or more here. But psychiatrist Prof Tsoi Wing Foo believed that many female transsexuals would head to Bangkok as well once the operation was available there.
Other clinics for sex reassignment surgery in Singapore[]
A 28 December 2014 article in The Sunday Times by Hoe Pei Shan (hpeishan@sph.com.sg) revealed that sex change operations were dwindling in Singapore[5].
In the 1970s, Singapore had become a global destination for sex change surgery, with public hospitals dealing with hundreds of cases every year. Such operations in public hospitals ceased since 2013, forcing transgender people wanting sex reassignment surgery to look to Thailand and South Korea. The National University Hospital (NUH), believed to be the last public hospital to perform sex change surgery, said it no longer offered the procedure. It did not give a reason, and the Ministry of Health (MOH) also did not reply specifically when asked about the issue.
The only known surgeon still performing sex change surgery in private practice - Dr Colin Song of Cape Clinic (Cape Plastic Surgery Pte Ltd) which opened in the middle of 2013 - said that "one known concern" surrounding sex change had been the spread of HIV. The authorities had asked hospitals to phase out sex change surgery in the late 1980s for fear that hospital staff might be exposed to the virus. MOH did not considered sex change surgery as a life-saving procedure. The objection was lifted in 2001.
When asked about the ministry's current stance on sex-change surgery, its role in overseeing the procedure, and why public hospitals had stopped offering it, an MOH spokesman would only say that sex reassignment operations were not subsidised and were performed with... safeguards. Demand, however, had not shrunk, according to private psychiatrist Tsoi Wing Foo, who co-wrote a book on transsexualism here with Singapore's pioneer sex-change surgeon, the late Dr S Shan Ratnam.
Since 1971, Dr Tsoi had seen over 2,000 transgender patients, half of whom went for surgery. A psychological assessment was needed before sexual reassignment. During the 1970s and 1980s, he had roughly 30 cases a year. From 2007 to 2014, he had seen an average of 40. He did not know why surgery options here were dwindling but speculated that it could be due to public policy changes or the personal preferences of the few doctors who had taken on such surgery. Dr C Anandakumar, who had worked with his uncle, Prof Ratnam, declined to speak to The Sunday Times.
Prof Colin Song of Cape Clinic specialised in female-to-male operations and had previously worked at Singapore General Hospital. A male-to- female operation at Cape cost $55,000, with the reverse being slightly more expensive, said Prof Song. While NUH declined to reveal its most recent rates, such operations used to cost between $8,000 and $15,000 in 2018.
Prof Song said he had yet to see a patient for full reconstruction since setting up Cape. Most sought partial reconstruction, such as removing breast tissue, as it changed the outward appearance and is more economical. The adjunct professor at the Duke-NUS Medical School, who had been performing sex change surgery since the early 1990s, said high facility costs were the main reason he could not match the rates public hospitals used to offer. 8 in 10 patients whom Dr Tsoi had referred to him for surgery chose to go to Thailand, "mainly because of costs". In Thailand, a full sex change cost around $20,000 in 2014.
Those who went overseas for surgery might have to do without the immediate support of family and friends right after surgery, while cultural and language differences might affect the quality of post-operative care, said Oogachaga Counselling and Support deputy director Leow Yangfa. Oogachaga provided support for the LGBT community.
Transman activist Joe Wong, who underwent a gender affirming operation in Bangkok, said doctors there were "only concerned about performing the surgery and provided little or no information on post- operative care and follow- up". The then 30-year-old said he knew the risks in having surgery overseas, but with scarce options in Singapore, he had little choice.
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Acknowledgements[]
This article was written by Roy Tan.