Early sex reassignment surgeryEdit
Singapore's second President, Benjamin Sheares, was a well known and distinguished O&G surgeon who headed the Department of Obstetrics and Gynaecology at Kandang Kerbau Hospital in the 1940s and 50s. One of his main contributions to medicine was a technique to create an artificial vagina for patients born without one. A modification of Sheares' vaginoplasty technique was later used by pioneering gynaecologists in the same department like Prof. S Shan Ratnam to perform male-to-female sex reassignment surgery (SRS). Ratnam later trained other younger surgeons like Assoc. Prof. Arunachalam Ilancheran and Ratnam's nephew, Dr. C Ananda Kumar to undertake the procedure. The first such operation in Asia took place here in July 1971. However, before patients could go under the knife, they first had to subject themselves to an exhaustive battery of tests and be given a clean psychological bill of health by Singapore's chief academic psychiatrist Prof. Tsoi Wing Foo of the Department of Psychological Medicine, National University of Singapore. Psychiatrists in Singapore required transgender patients to live and dress as a member of the opposite sex for at least a year before certifying them suitable for sex reassignment surgery. Half of those seen by Prof. Tsoi were not deemed suitable for the operation. His counselling sessions also helped to make transsexuals aware of the difficulties they might face after they have had the operation performed.
First sex-change operationEdit
The first sex-change surgery in Singapore was successfully performed on 30 July 1971 at Kandang Kerbau Hospital. The operation involved a 24-year-old man and was the first procedure of its kind performed in Singapore and in Asia. There had been previous “sex-change” operations performed in Singapore, but these mostly involved patients who had both male and female genitalia (hermaphrodites) and the removal of one set of genitalia. The 1971 operation was regarded as a first because it involved a surgical conversion aimed at functionally changing a person’s sex.
Patient and diagnosisEdit
The patient was a 24-year-old Singaporean citizen of Chinese heritage. Her name was initially kept secret, but her background was later made public in a book, which also revealed her name as "Shona". The eldest son in a family of five with two younger sisters, her father was a dentist who was often physically violent with his wife, which caused the patient psychological trauma. As a child, the patient was raised by her grandmother, who dressed her as a female. In her teenage years, she associated with other cross-dressers before frequenting the transsexual and transvestite scene at Bugis Street as an adult.
From the age of 16, she worked as a sales assistant, a housemaid, in a bank and as a public relations officer. She later won second prize in a beauty contest and became a model. While working as a part-time model, she joined a cabaret and was known as “Mama Chan”. She also ran a social escort service.
Having lived as a woman for some time, she first consulted Professor S Shan Ratnam, then senior lecturer in the University of Singapore’s Department of Obstetrics and Gynaecology, in 1969. She had been suffering sexual and emotional problems, which had led to two suicide attempts. Ratnam explained to her that he had no experience in sex-change surgery, but she continued to visit his clinic weekly. After researching the subject of transsexualism and sex reassignment surgeries, Ratnam familiarised himself with the surgical techniques by practising on cadavers.
The patient underwent a psychological analysis by a team of psychiatrists who confirmed that she was a transsexual who required surgery. A diagnosis of transsexualism requires that the patient possesses a continuous sense of inappropriateness about his or her anatomic sex, a desire to discard his or her genitalia and live as a member of the opposite sex, and the absence of physical intersex symptoms or genetic abnormalities. As well, his or her gender confusion (gender dysphoria) must not be caused by other disorders such as schizophrenia. The patient was also cautioned that the surgery would be irreversible, potentially involved a number of complications and required a prolonged follow-up period.
Legal clearance for the operation was then sought from the Ministry of Health and granted. After consideration of the patient’s psychological profile, the medical expertise involved and the approval of the Ministry, the decision was taken to proceed with the operation.
The operation was performed by Ratnam and two other top surgeons from the University of Singapore’s Department of Obstetrics and Gynaecology, Associate Professor Khew Khoon Shin and plastic surgeon Mr. R Sundarason. Photography of the operation was not permitted. Ratnam later described the 3-hour operation as a success, with an uneventful post-surgery recovery. He later founded the Gender Identity Clinic specialising in sex change surgeries at the National University Hospital.
After the operation, Shona felt fine and was to leave hospital for home because she had marriage plans. Speaking from her Kandang Kerbau Hospital bed, she said she was engaged to an executive who worked in the same office building as herself. Reclining on her hospital bed and peeling an apple, she said she was feeling fine and waiting to be discharged “very soon."
The 24-year old stenographer also said she would be going back to work on her discharge from hospital. Shona was subsequently put on hormone treatments and became functionally a woman, with the exception of being unable to conceive or menstruate. She later married a French man and owned a travel agency in Paris, before moving to England.
The July 1971 operation paved the way for sex change surgeries in Singapore and in the region. Singapore’s first sex change operation on a woman took place three years later, between August 1974 to October 1977 (female-to-male conversions are a more complex process and involve several surgical stages). In the 1970s and 1980s, hospitals in Singapore accepted numerous sex change patients from other Southeast Asian countries, with foreigners making up around half of all surgeries performed."
Second sex-change operationEdit
Singapore's second sex reassignment surgery was also performed successfully at Kandang Kerbau Hospital by a team of doctors — which included a psychiatrist — headed by Prof. S Shan Ratnam of the University of Singapore’s Department of Obstetrics and Gynaecology. The second patient was a 25-year-old bachelor, who was said to be working in the hotel industry. Like his predecessor, he had been using a woman's name and had dressed as a woman for many years.
He had been “unhappy” about his condition and had consulted a private doctor soon after reading about Singapore’s first sex-change operation in July 1971. He was referred to the hospital in mid-October 1971 and the operation, lasting about three hours, was performed a day after he was warded. He was also followed up with hormonal treatment to ensure permanency of the change.
First female-to-male sex-change operationEdit
In October 1974, a team of O&G surgeons from the University of Singapore carried out Singapore's first sex reassignment surgery on a woman at Kandang Kerbau Hospital. The operation was the first-ever performed on a woman in the region. It was done in three stages and was described as “highly complex” by medical specialists.
The lengthy procedure began in about August 1974 and the surgeons from the University of Singapore’s Department of Obstetrics and Gynaecology again led by Prof. S Shan Ratnam successfully completed the first two stages. Two months later, they carried out the final phase on the woman, who was a Singapore citizen and a Chinese, aged 24 and single. Her name address and other details were kept secret.
Prof. Ratnam also opted to remain silent about the operation. A Ministry of Health spokesman said, “Prof. Ratnam is unwilling to discuss any such operation as he to unable to see the reasons for doing so. This Ministry concurs with his views." Ratnam did, in the past, speak on two male-to-female sex change operations and the problems patients faced. The patient, believed to have been educated in a mission school, had a girlfriend. She was to understood to have been feeling very uneasy and desperate for several months. She was taken through a full investigation, including a thorough psychological analysis by at team of psychiatrists, to determine if she was a “true" transexual who could not bear being a woman at all.
It was only after very careful consideration, including a thorough medical study and psychiatric endorsement — and with the Ministry’s approval — that the operation was given the green light. Once the operation is successfully completed, she applied to the Attorney-General's Office for a change in legal status from "Miss" to "Mister."
In a groundbreaking and extremely graphic mondo documentary entitled "Shocking Asia" produced in 1974, transgender women in Singapore revealed the most intimate details about their lives and sex reassignment surgery done by pioneering surgeon, Prof. S Shan Ratnam who also granted an exclusive interview. The operation itself was shown in great detail:
Ratnam is believed to have been unhappy with the final tenor and packaging of the documentary as he was probably led by the producers to believe that it would be a scientific, non-sensationalistic film.
Cessation of sex reassignment surgeryEdit
Sex change operations dwindling in Singapore Tuesday, Dec 30, 2014 The Straits Times By Hoe Pei Shan
Thirty years ago, Singapore became a global destination for sex-change surgery, with public hospitals dealing with hundreds of cases every year.
The National University Hospital (NUH), believed to be the last public hospital to do sex-change surgery, said it no longer offers 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 here in private practice - Dr Colin Song of Cape Clinic which opened in the middle of last year - said that "one known concern" surrounding sex change has been the spread of HIV.
It was reported previously that the authorities here asked hospitals to phase out sex-change surgery in the late 1980s for fear that hospital staff might be exposed to the virus. It was also reported then that MOH had 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 have stopped offering it, an MOH spokesman would only say that "sex reassignment operations are not subsidised and are performed with... safeguards".
Since 1971, Dr Tsoi has seen over 2,000 transgender patients, half of whom go for surgery. A psychological assessment is needed before sexual reassignment here. During the 1970s and 1980s, he had roughly 30 cases a year. In the last seven years, he has seen an average of 40.
He does not know why surgery options here are dwindling, but speculated that it could be due to public policy changes or the personal preferences of the few doctors who have taken on such surgery. Dr. C Anandakumar, who had worked with his uncle, Prof. Ratnam, declined to speak to The Sunday Times.
A male-to- female operation at Cape costs $55,000, with the reverse being slightly more expensive, said Dr Song.
While NUH declined to reveal its most recent rates, such operations used to cost between $8,000 and $15,000 six years ago.
Dr Song said he has yet to see a patient for full reconstruction since setting up Cape.
Most seek partial reconstruction, such as removing breast tissue, as it changes the outward appearance and is more economical, he said.
The adjunct professor at the Duke-NUS Medical School, who has been performing sex- change surgery for two decades, said high facility costs is the main reason he cannot match the rates public hospitals used to offer.
Eight in 10 patients whom Dr Tsoi has referred for surgery choose to go to Thailand, "mainly because of costs". In Thailand, a full sex change costs around $20,000.
Those who go overseas for surgery may have to do without the immediate support of family and friends right after surgery, while cultural and language differences may affect the quality of post-operative care, said Oogachaga Counselling and Support deputy director Leow Yangfa. Oogachaga provides support for the lesbian, gay, bisexual and transgender group.
Mr Joe Wong, who underwent an operation in Bangkok to become a man, said doctors there were "only concerned about performing the surgery and provided little or no information on post- operative care and follow- up".
The 30-year-old said he knew the risks in having surgery overseas, but with scarce options in Singapore, he had little choice.
This article was first published on Dec 28, 2014.
- Sex reassignment surgery
- Transgender people in Singapore
- S Shan Ratnam
- Arunachalam Ilancheran
- C Anandakumar
- Tsoi Wing Foo
- Gender Identity Clinic
- Chan Meng Choo, "First sex change surgery (1971)", Singapore Infopedia.
- Ho Pei Shan, "Sex change operations dwindling in Singapore", The Straits Times, 30 December 2014,.
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- Tan, W. L. (1971, August 31). Man-made woman may not get marriage licence. The Straits Times, p. 6.
- Tan, W. L. (1971, November 11). They’re still ‘misters’ despite sex change. The Straits Times, p. 8.
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- Jeffrey Hays, "Homosexuality, gay life, and sex change surgery in Singapore", Facts and Details, 2008, updated June 015.
This article was written by Roy Tan.