CONJOINED TWINS AND SEX CHANGER SURGERY IN SINGAPORE

FIRST SEX CHANGE SURGERY, IN SINGAPORE IN 1971

Chan Meng Choo wrote in Singapore Infopedia: “The first sex change surgery in Singapore was successfully performed on 30 July 1971 at the 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. [Source: Chan Meng Choo, eresources.nlb.gov.sg/infopedia]

The patient was a 24-year-old Singaporean citizen of Chinese heritage. Her name was kept secret, but her background was later made public in a book. 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. S. Ratnam, a 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 surgeons from the University of Singapore’s Department of Obstetrics and Gynaecology, Associate Professor Khew Khoon Shin and plastic surgeon R. Sundarason. Photography of the operation was not permitted. Ratnam later described the three-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 her successful operation, the patient went on hormone treatments and was 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.

In the years following the operation, a number of legal issues arose for transsexuals who had undergone a sex change. By 1973, the government allowed sex change patients to have their new sex reflected on their identity cards. The Registry of Marriages implicitly recognised marriages involving a sex change patient, as it required only an identity card to prove the different genders of the couple. However in 1991, a marriage between a sex-change transsexual man and a woman was declared void from the beginning by the High Court, officially making such marriages illegal in Singapore. It was only in 1996 that the government amended the Women’s Charter to allow transsexuals to legally marry.

Shan Ratnam: Singapore’s Sex Change Operation Pioneer

Professor Shan Ratnam (1928 – 2001), a gynaecologist and sex change doctor at University of Singapore, pioneered gender reassignment surgery. According to fridae.asia, Singapore’s main gay website, “Singapore became a top Asian destination for sex change operations in the 1970s and 80s after he pioneered a technique that led to Singapore's first sex change operation in the 1970s. The late professor who performed both female-to-male and male-to-female reassignment surgery is believed to have operated on as many as 500 transsexuals between 1971 and 1991. [Source: fridae.asia, August 7, 2001]

The author of several books including Cries from within and medical texts on obstetrics and gynecology was also responsible for several fertility breakthroughs. He gave Asia its first test-tube baby through the in-vitro fertilization process in 1983 and in 1987, the first baby in Asia was born from a frozen embryo. Prof Ratnam received several awards including the Singapore Public Administration Gold Medal in 1977 and an ASEAN award for his contributions to Reproductive Medicine in 1991.

Shan Ratnam was of Ceylonese Tamil descent, and was born in Jaffna where his mother came from, although his father's family had lived in Malaysia for three generations. From the age of six months he lived in Kuala Lumpur. Ratnam's father was ordered to be beheaded by the occupying Japanese in 1942, but was saved by a Japanese woman married to an Indian man. His mother died at age 38 during the Occupation from rectum cancer, as did his youngest sibling from tuberculosis meningitis. This inspired him to become a doctor. [Source: zagria.blogspot.jp]

He trained at the Singapore General Hospital from 1959, and began teaching at the University of Singapore in 1963. He studied at the Royal Postgraduate Medical School in London where he earned MRCOG and FRCS in 1964. He then became Professor and Head of the Department of Obstetrics and Gynaecology at the University of Singapore in the new Singapore independent of the UK and then in secession from Malaysia.

In 1969 Ratnam was pestered by Shonna who was desirous to have sex change surgery. He became intrigued by the possibility, read the literature and finally practised the operation on two cadavers in the mortuary. He had Shonna evaluated by a team of psychiatrists who confirmed that she was indeed transsexual. Legal clearance was sought from the ministry of health and granted. Surgery was performed 30 July 1971 at the Kandang Kerbau Hospital. This was the first such operation in east Asia.

A Gender Identity Clinic was set up headed by Prof Ratnam, who ran it until his retirement in 1995, when it was passed to his nephew, Dr. Anandakumar. In 30 years more than 300 sex change operations were performed. In 1972 Ratnam's gynaecology department was recognized by the World Health Organization as one of 13 outstanding research centres in human reproduction. In 1983 Ratnam did the first Asian In-vitro fertilization. In 1987 the first Asian live birth from a frozen embryo. In 1989 the world's first live birth after microinjection, and in 1991 the world's first infant born via human ampullary coculture. He published 596 research papers in internationally refereed journals, 396 in local and regional refereed journals, 138 chapters in books and 795 presentations at conferences. In 1996, Ratnam was appointed as Emeritus Professor. In 2000, the Shan S. Ratnam Professorship endowment was set up to award internationally recognised O& G specialists annually.

Nepali SiameseTwins Separated After Five-Day Operation in Singapore

In April 2001, doctors at Singapore General Hospital were able to separate the fused skulls and intertwined brains of 11-month-old Nepali girls in a four day operation. Associated Press reported: “Eleven-month-old twins Jamuna and Ganga Shrestha were in different rooms for the first time in their lives after doctors successfully separated the girls, who were born joined at the head. A wide-eyed Jamuna, the more bashful sister, was wheeled out of the operating room wearing a tiny surgical cap after the grueling, five-day, marathon surgery doctors are calling a success. The feistier sister, Ganga, finally left the operating room at Singapore General Hospital at 4 p.m., 96 hours after entering. Dr. Keith Goh, who lead the medical team, said Ganga's operation took longer because she needed more "complex reconstruction." [Source: Associated Press, April 10, 2001 ==]

“The Nepalese twins shared the same skull cavity. Their brains were partially fused, making the separation surgery extremely difficult. "Happily, we had no adverse events throughout the entire five days" of surgery, Goh told reporters at a news conference after the surgery. "We are cautiously optimistic." Goh said it was too early to tell if the twins would suffer brain damage or other neurological defects, and that the next few days would be crucial for the girls. "Thank God, now I will be able to see my great-grandchildren and I hope they come back soon," Devkumari Khatri, 84-year-old great-grandmother of the twins, told The Associated Press in Nepal by telephone. ==

“Surgeons began operating on the twins at 4 p.m. Friday, initially hoping to finish within 40 hours. Twenty doctors worked in shifts around the clock to separate the girls. Anesthesiologist Claire Ang said the mood in the operating room "varied from euphoric to hysterical." To close the wound left by the surgery, doctors used the synthetic material Gortex to replace parts of the girls' dura, a fibrous tissue layer covering the brain. They mixed bone material with polymer to help rebuild the girls' tiny skulls. Goh and other members of the medical team said the surgery took so long because they had to deal with hundreds of interwoven blood vessels in the girls' brains. ==

“Siamese twins joined at the head are very rare, occurring once in 2 million live births, according to Goh. Successful separations are even more uncommon. Surgeons in Brisbane, Australia, last year successfully separated six-month-old Tay-lah and Monique Armstrong, who were joined at the backs of their heads. A similar operation was successfully performed in South Africa in 1997. ==

“Ganga and Jamuna, the twins in the Singapore surgery, are the only children of a poor couple from the remote Nepalese mountain village of Khalanga, where Maoist guerrillas are active. The girls' mother, Sandhya, is a kindergarten teacher and their father, Bushan, helps his father in a small business. The couple, who are in their 20s, kept almost constant vigil at the hospital during the operation with brief breaks to pray at a Hindu temple. A surgeon in Nepal referred the family to doctors in Singapore, a wealthy Southeast Asian city-state known for its advanced medical facilities. ==

“Before the surgery, doctors rehearsed the procedure in virtual reality using a three-dimensional imaging system developed in Singapore. The system, called VizDExter, was first used in 1998 by doctors at Johns Hopkins University in Baltimore, said Dr. Luis Serra, a Singapore-based researcher who helped develop the technology. Serra said the doctors used the images to consult with a Johns Hopkins' Siamese twins expert, Dr. Benjamin Carson, before separating Ganga and Jamuna. Singaporeans have donated $358,000 to help the twins. The hospital has waived many of their charges, and national flag carrier Singapore Airlines paid for the girls and their family to make the trip from Nepal. ==

“Goh said the girls would likely return to Nepal when they are well enough to travel, which could take months. In Nepal, relatives had been waiting around the one phone shared by their neighborhood for news on the twins. "We had only 50 percent hope that they would survive," Abhaya Shrestha, the twins' uncle, said. "Now this is a miracle and we just can't describe how happy we all are to hear the news." “

Singapore Doctor Says Operation on Nepali Conjoined Twins Was a Mistake

In 2005, four years after the surgery, the Scotsman reported: “An operation to separate two Nepalese twins with conjoined heads was widely hailed as a triumph of medicine, but a prominent neurologist said the surgery was a mistake. Ganga and Jamuna Shrestha, whose conjoined heads were separated in an unprecedented 97 hour operation in Singapore in 2001, now lie sick and virtually immobile in a cramped apartment in Nepal’s capital, Kathmandu. They will be five years old next month. [Source: Scotsman, April 13, 2005 |::|]

“The girls do not have a hard cover on the tops of their heads, which are protected only by skin and hair, according to the Straits Times newspaper in Singapore. Singapore doctors had planned a second operation to install a protective lining in the twins’ heads, but no date has been fixed. They are cared for by their mother and grandparents. Their father went back to their home village two years ago and has not returned. Jamuna can only pull herself along the ground with her left arm and leg because her right limbs are weak. Her sister, Ganga, is unable to sit up, lift her head or talk. |::|

“Dr Lee Wei Ling, daughter of Singapore elder statesman Lee Kuan Yew, said in a letter to the Straits Times that the surgery should not have happened because the children were left with expected disabilities, and their family faces a tremendous burden in caring for them. “The operation put Singapore on the world map, and the members of the surgical team were hailed as heroes,” wrote Lee Wei Ling, senior consultant of paediatric neurology at the National Neuroscience Institute. “But at the end of the day, to me and to the family, the operation was a mistake.” Lee was not involved in the surgery at Singapore General Hospital, and said she advised her neurosurgeon not to participate. “I advised him against it on the basis that even if the operation were a technical success and he gained worldwide fame, his responsibility was the ultimate welfare of the patients,” she said. “They would have died soon if the operation was not carried out, and the young parents, after a period of grieving, could have carried on with life and probably would have more children who are normal,” Lee wrote.

Iranian Siamese Twins Die After Four Day Surgery in Singapore

In July 2003, Singaporean neurosurgeons performed marathon surgery to separate Ladan and Laleh Bijani, a pair of 29-year-old Iranian Siamese twins who were joined at the head. A team of 28 doctors and about 100 medical assistants participated in the landmark operation that took almost four days. Just cutting through their skulls took six hours because their skulls were denser than previously thought.

The $288,000 cost of the operation was underwritten by Raffles Hospital, where the surgery was performed. The doctors waived their fees. They often worked through the nighr, occasionally drinking coffee and juice and eating rice, noodles and sandwiches.

Singaporean doctors were able reroute a shared vein as thick as a finger and separated their brains (the female Siamese twins had separate brains that touches within a single skull) and ultimately separated the twins but both sisters died shortly after the operation due primarily to a loss of blood that resulted from the separation of the brains. A spokesman for the hospital said, the sisters brains had “to be teased apart very slowly. Cut. teased apart. Cut. In the process you encounter a lot of blood vessels and other tissues.”

S. Korean Conjoined Twins Separated in Singapore Hospital

In July 2003, two weeks after the operation on the Iranian sisters, doctors at Raffles hospital were able to separate a pair of 4-month-old South Korean sisters conjoined at the back. Voice of America reported: “Four-month-old South Korean twins joined at the pelvis were separated Tuesday at the same Singapore hospital where Iranian sisters died in a similar operation two weeks ago. Doctors have expressed optimism for the babies' recovery. The separation of Min Ji Hye and Min Sa Rang took place after only one hour and 40 minutes of surgery at Raffles Hospital. Dr. Prem Kumair Nair said the team of surgeons then proceeded with another several hours of corrective surgery aimed at enabling the girls to develop normally. [Source: Voice of America, July 22, 2003, updated October 30, 2009 ||||]

“The team of specialists was led by Dr. Yang Ching Yu, and included Dr. Keith Goh. Dr. Goh is the neurosurgeon who headed the international surgical team that recently tried unsuccessfully to separate 29-year-old Iranian twins fused at their heads. Fourteen days after the Iranian women's deaths, Dr. Nair expressed optimism over the prospects for the Korean babies, and spoke of the complexity of the operation. "Members of the team include specialists in the field of neurosurgery, pediatric surgery, plastic surgery, obstetrics and gynecology, urology, orthopedic surgery, pediatrics and anesthesia," he said. "Separation surgery is essential to enable the girls to walk and to develop as normal children." ||||

“Dr. Nair said the Korean twins were fused at the lower end of the spine, in the colorectal region and at the end of the genital tract. Dr. Yang, a colorectal surgeon, said the babies had to be separated at this stage to prevent possible skull and spinal deformities. This was the third operation on conjoined twins for Dr. Goh. He also led the team that successfully separated Nepalese sisters fused at the head in April of 1991. ||||

“The Korean twins' parents had consulted experts at Raffles Hospital before the operation on Ladan and Laleh Bijani, the two Iranian women. The parents also sought a second opinion at a London hospital, and were in London when the Iranians died, but they eventually decided to have the surgery done at Raffles. Dr. Nair said the surgeons on his team were waiving their fees. A fundraising effort has been underway in South Korea to help pay more than $28,000 in hospital costs. ||||

Image Sources:

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, Singapore Tourism Board, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Foreign Policy, Wikipedia, BBC, CNN, and various books, websites and other publications.

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© 2008 Jeffrey Hays

Last updated June 2015

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