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Answering Questions About Hormone Therapy And Gender Affirmation Surgery

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Written by: Uma Sathwika Manda

Yay, it’s Pride Month! And we should learn about Gender Affirmation Surgery on this occasion. Well, I didn’t know much about this until recently when I read a lot about it. For the layman, this is the surgery that transgender people undergo to ‘change genders.’ Unfortunately, due to the underrepresentation of the trans community by the media, most of us are ignorant about this process. I personally had many questions, and after extensive research, I am to answer all your queries about Gender Affirmation Surgery.

Gender Affirmation surgery is for people that don’t associate with the sex assigned to them at birth/ transgender people undergo to confirm their gender. It is also addressed as Gender Confirmation. There was a discussion about this with the team. After talking to someone belonging to the trans community, we decided upon sticking to the term Gender Affirmation since they were comfortable with the same. Also, changing Genders is another term used to refer to the same, and this implies that one’s gender changes after the surgery have been performed (which isn’t true). Many are unaware of the process, and your questions concerning Gender Affirmation shall be answered in this article.

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Firstly, Why Do People Undergo Gender Affirmation Surgery?

Gender Dysphoria is the reason behind people opting for gender affirmation surgeries. According to Mayo Clinic, Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their assigned sex at birth or sex-related physical characteristics. It is often described as a feeling trapped in the body of the wrong sex. Although every trans person does not experience this, some people might be at ease with their bodies.

On that note, it can also be overcome through medical intervention (Gender Affirmation Surgery). The surgery helps trans people by improving their mental health, boosting self-image and self-esteem, paving the way for a better quality of life, and the ability to ‘blend with society.’

What Exactly Is Transition?

According to Trans EqualityTransitioning is the time period during which a person begins to live according to their gender identity, rather than the gender they were thought to be at birth. This can look different for different people. This may (or may not) include things like changing names, pronouns, appearance, etc. Some get their name and gender changed on official documents (passport, license, bank accounts, credit cards, birth certificate, medical records, etc.). This is because they might be subjected to harassment if their appearance and gender don’t match with the one mentioned in the documents. Some others opt for hormone therapy, while others also go for gender affirmation surgery. However, not every transgender person necessarily needs to transition, but most do.

What exactly Is Hormone Therapy?

Hormone therapy helps trans folx deal with gender dysphoria that has been haunting them for years. In this, individuals that have been Assigned Female at Birth (AFAB) are administered Androgens to develop ‘secondary male sexual characteristics’ such as beard and chest hair. Those individuals that have been Assigned Male at Birth (AMAB) are given Estrogen and anti-Androgen hormones to make their bodies look more ‘feminine’ with a decrease in body hair. Hormone therapy helps trans people feel better about themselves since their physical features align with their gender.

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How Is The Surgery Performed For People Assigned Female At Birth?

A person first receives testosterone replacement/hormone therapy. After this, they can undergo the following procedures based on how they want their body to be:

1. Hysterectomy (partial/total)

  • Performed when having a uterus and fallopian tubes causes discomfort.
  • Also, hormone therapy doesn’t help stop menstruation, but a hysterectomy is performed.
  • In partial hysterectomy, only the uterus is removed, while in the case of total hysterectomy, the cervix is also removed.

2. Vaginectomy-

  • The vaginal mucosa is removed during this procedure.

3. Mastectomy- 

  • The breast tissues are removed.
  • Nipples’ position and appearance are changed.
  • There will be the growth of chest hair due to hormone therapy.

4. Metoidioplasty-

  • Makes the clitoris penis-like.
  • This is the process of constructing a new penis (neopenis/neophallus) out of the clitoris.
  • The urethra is lengthened to position it through the neopenis.
  • Tissues from other parts of the vagina are used to lengthen the neopenis.
  • Neopenis, constructed through this process, is not usually long enough for penetrative sex, though it can become erect.

5. Phalloplasty-

  • Skin from the abdomen, arm, back, forearm, or thighs is used in penile construction.
  • This neopenis can’t become erect on its own but is long enough for penetrative sex.
  • For erections, there should be a penile implant after recovery.
  • The cost of this procedure is quite high and also demands a lot of visits to the doc.

6. Scrotoplasty-

  • A scrotum is created through this procedure.
  • The labia majora is hollowed out and repositioned to form a scrotum.
  • Silicone testicular implants are placed.

How Is The Surgery Performed In The Case Of people Assigned Male At Birth?

The procedure begins with the individual undergoing estrogen/hormone therapy alongside supportive counseling. Later, they sit for other surgeries (the first three in the following list are quite easy).

1. Facial Feminization Surgery (FFS)-

  • The face usually depicts the gender of a person, and changes in the same can be very comforting to many people.
  • Based on the requirements of the person, surgeons customize the plan.
  • FFS involves brow lift, nose reshaping, tracheal shave, lip lift, cheek implants, face/ neck lift, cheek softening, and blepharoplasty (makes eyelids look more aesthetic).
  • Adam’s Apple is also shaved down so that it is less prominent.

2. Breast Augmentation-

  • Hormone therapy helps in the growth of breasts in trans womxn, but some opt for breast augmentation surgery.
  • Based on one’s preferences, the process is carried out.

3. Body Feminization Surgery-

  • Includes buttocks augmentation and trunk liposuction.
  • Fat is removed from the abdomen, lower back, and waist regions (Trunk liposuction).
  • This fat is used to make the buttocks look more ‘feminine’ (Buttocks augmentation).

4. Gender Affirmation Surgery-

  • Penile inversion is performed to turn the penis inside out to form the walls of the vagina.
  • The clitoris (neoclitoris) is created from the head of the penis.
  • The urethra is made shorter and repositioned.
  • These changes help in urination, penetrative sex as well as in experiencing orgasms.

What are the risks involved in Gender Affirmation Surgery?

  • Bleeding
  • Infections
  • Reaction to anesthesia
  • Spouses, friends, and family might not be welcoming this, unfortunately

Also, according to a study by Karolinska Institute, people have a risk of suicidal tendencies, deaths, and psychiatric morbidity. Besides this, one might not be pleased with the results after the surgery has been performed (though this is not the case with most people).

What about recovery?

  • The person needs to stay at the hospital for a few days.
  • Recovery time varies from person to person based on one’s lifestyle.
  • In the case of a person who smokes or uses nicotine in any other form, recovery takes quite a long time. As a result, such people are usually considered ineligible to get the procedure done.
  • For about 6 weeks post-surgery, one needs to take maximum rest.
  • Trans womxn must use a catheter for approximately a month post-surgery.

How beneficial is a gender affirmation surgery for one’s mental health?

According to a Yale School of Public Health survey, trans people who undergo this procedure are less likely to seek therapy for mental well-being. According to WebMD, trans people are more likely to seek care to overcome anxiety and anti-anxiety medication about 6 times and 3 times, respectively (before surgery). Though gender affirmation isn’t the panacea, the study found out that people who underwent surgery were 8% less likely to seek help for mental well-being. Undergoing the procedure isn’t an easy thing, and it is important to analyze if it would be beneficial because the physical appearance of an individual doesn’t define their gender!

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How much does the surgery cost?

The surgery is expensive, and this discourages many from opting for it. A ‘male to female’ transition can cost anywhere between Rs. 2-5 lakhs and a ‘female to male’ transition ranges from Rs. 4-8 lakhs in case of a private hospital. The one year of compulsory therapy costs around Rs. 50,000 to 70,000. In the case of government hospitals, the procedure is performed for free, but the staff there are reportedly highly insensitive. Also, this procedure is not encompassed by Ayushman Bharat. As a result, people wishing to undergo surgery are forced to approach private hospitals only. Another reason people prefer going to private hospitals because there is this taboo surrounding transgender people that makes them choose privacy. Many also get this done in Thailand since the costs are way less there.

A few pointers to remember:

  • A gender confirmation surgery can be reaffirming, but it just helps change your body the way you experience your gender.
  • Your gender isn’t defined by your body but by your experience.
  • The way you experience your gender is completely valid!

Some Good News This Pride Month

The Madras High Court, on 7th June 2021, issued an order (do give it a read) which is expected to pave the way for mainstreaming the people belonging to the LGBTQIA+ community. It aims to increase awareness by educating parents as well as students about sexuality. Every single individual is entitled to the ‘right to privacy’ and the ‘right to lead a dignified existence,’ and that these rights have been protected through the Constitution.

Justice N Anand Venkatesh, who gave this judgment, said, “I have no hesitation in accepting that I too belong to the majority of commoners who are yet to comprehend homosexuality completely. However, ignorance is no justification for normalizing any form of discrimination.” Also, in any cases involving two consenting adults from the LGBTQIA+ community, the police must close the case without harassing them.

Conclusion

I would have never guessed” is a common phrase that trans people often get to hear. This is because there’s this notion that trans people look ‘visibly trans.’ The truth is that trans people are everywhere- even if you don’t think you know of one, you will most probably do! On this note, a small reminder to everyone who doesn’t identify themselves as trans people – IT’S NOT A SIN FOR ONE TO BE THEMSELVES! Also, never ask a trans person about their surgical status (or genitalia) or birth name. Let them bring these up if they wish to. Please let others define themselves. Be a safe space for them. This is how you will become a better ally to the community as well.

Finally, HAPPY PRIDE MONTH!

Graphic design by: Ruta Shelke

Feature image is for representational purposes only

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An ambassador and trained facilitator under Eco Femme (a social enterprise working towards menstrual health in south India), Sanjina is also an active member of the MHM Collective- India and Menstrual Health Alliance- India. She has conducted Menstrual Health sessions in multiple government schools adopted by Rotary District 3240 as part of their WinS project in rural Bengal. She has also delivered training of trainers on SRHR, gender, sexuality and Menstruation for Tomorrow’s Foundation, Vikramshila Education Resource Society, Nirdhan trust and Micro Finance, Tollygunj Women In Need, Paint It Red in Kolkata.

Now as an MH Fellow with YKA, she’s expanding her impressive scope of work further by launching a campaign to facilitate the process of ensuring better menstrual health and SRH services for women residing in correctional homes in West Bengal. The campaign will entail an independent study to take stalk of the present conditions of MHM in correctional homes across the state and use its findings to build public support and political will to take the necessary action.

Saurabh has been associated with YKA as a user and has consistently been writing on the issue MHM and its intersectionality with other issues in the society. Now as an MHM Fellow with YKA, he’s launched the Right to Period campaign, which aims to ensure proper execution of MHM guidelines in Delhi’s schools.

The long-term aim of the campaign is to develop an open culture where menstruation is not treated as a taboo. The campaign also seeks to hold the schools accountable for their responsibilities as an important component in the implementation of MHM policies by making adequate sanitation infrastructure and knowledge of MHM available in school premises.

Read more about his campaign.

Harshita is a psychologist and works to support people with mental health issues, particularly adolescents who are survivors of violence. Associated with the Azadi Foundation in UP, Harshita became an MHM Fellow with YKA, with the aim of promoting better menstrual health.

Her campaign #MeriMarzi aims to promote menstrual health and wellness, hygiene and facilities for female sex workers in UP. She says, “Knowledge about natural body processes is a very basic human right. And for individuals whose occupation is providing sexual services, it becomes even more important.”

Meri Marzi aims to ensure sensitised, non-discriminatory health workers for the needs of female sex workers in the Suraksha Clinics under the UPSACS (Uttar Pradesh State AIDS Control Society) program by creating more dialogues and garnering public support for the cause of sex workers’ menstrual rights. The campaign will also ensure interventions with sex workers to clear misconceptions around overall hygiene management to ensure that results flow both ways.

Read more about her campaign.

MH Fellow Sabna comes with significant experience working with a range of development issues. A co-founder of Project Sakhi Saheli, which aims to combat period poverty and break menstrual taboos, Sabna has, in the past, worked on the issue of menstruation in urban slums of Delhi with women and adolescent girls. She and her team also released MenstraBook, with menstrastories and organised Menstra Tlk in the Delhi School of Social Work to create more conversations on menstruation.

With YKA MHM Fellow Vineet, Sabna launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society. As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Read more about her campaign. 

A student from Delhi School of Social work, Vineet is a part of Project Sakhi Saheli, an initiative by the students of Delhi school of Social Work to create awareness on Menstrual Health and combat Period Poverty. Along with MHM Action Fellow Sabna, Vineet launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society.

As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Find out more about the campaign here.

A native of Bhagalpur district – Bihar, Shalini Jha believes in equal rights for all genders and wants to work for a gender-equal and just society. In the past she’s had a year-long association as a community leader with Haiyya: Organise for Action’s Health Over Stigma campaign. She’s pursuing a Master’s in Literature with Ambedkar University, Delhi and as an MHM Fellow with YKA, recently launched ‘Project अल्हड़ (Alharh)’.

She says, “Bihar is ranked the lowest in India’s SDG Index 2019 for India. Hygienic and comfortable menstruation is a basic human right and sustainable development cannot be ensured if menstruators are deprived of their basic rights.” Project अल्हड़ (Alharh) aims to create a robust sensitised community in Bhagalpur to collectively spread awareness, break the taboo, debunk myths and initiate fearless conversations around menstruation. The campaign aims to reach at least 6000 adolescent girls from government and private schools in Baghalpur district in 2020.

Read more about the campaign here.

A psychologist and co-founder of a mental health NGO called Customize Cognition, Ritika forayed into the space of menstrual health and hygiene, sexual and reproductive healthcare and rights and gender equality as an MHM Fellow with YKA. She says, “The experience of working on MHM/SRHR and gender equality has been an enriching and eye-opening experience. I have learned what’s beneath the surface of the issue, be it awareness, lack of resources or disregard for trans men, who also menstruate.”

The Transmen-ses campaign aims to tackle the issue of silence and disregard for trans men’s menstruation needs, by mobilising gender sensitive health professionals and gender neutral restrooms in Lucknow.

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A Computer Science engineer by education, Nitisha started her career in the corporate sector, before realising she wanted to work in the development and social justice space. Since then, she has worked with Teach For India and Care India and is from the founding batch of Indian School of Development Management (ISDM), a one of its kind organisation creating leaders for the development sector through its experiential learning post graduate program.

As a Youth Ki Awaaz Menstrual Health Fellow, Nitisha has started Let’s Talk Period, a campaign to mobilise young people to switch to sustainable period products. She says, “80 lakh women in Delhi use non-biodegradable sanitary products, generate 3000 tonnes of menstrual waste, that takes 500-800 years to decompose; which in turn contributes to the health issues of all menstruators, increased burden of waste management on the city and harmful living environment for all citizens.

Let’s Talk Period aims to change this by

Find out more about her campaign here.

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

A Gender Rights Activist working with the tribal and marginalized communities in india, Srilekha is a PhD scholar working on understanding body and sexuality among tribal girls, to fill the gaps in research around indigenous women and their stories. Srilekha has worked extensively at the grassroots level with community based organisations, through several advocacy initiatives around Gender, Mental Health, Menstrual Hygiene and Sexual and Reproductive Health Rights (SRHR) for the indigenous in Jharkhand, over the last 6 years.

Srilekha has also contributed to sustainable livelihood projects and legal aid programs for survivors of sex trafficking. She has been conducting research based programs on maternal health, mental health, gender based violence, sex and sexuality. Her interest lies in conducting workshops for young people on life skills, feminism, gender and sexuality, trauma, resilience and interpersonal relationships.

A Guwahati-based college student pursuing her Masters in Tata Institute of Social Sciences, Bidisha started the #BleedwithDignity campaign on the technology platform Change.org, demanding that the Government of Assam install
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Bidisha was selected in Change.org’s flagship program ‘She Creates Change’ having run successful online advocacy
campaigns, which were widely recognised. Through the #BleedwithDignity campaign; she organised and celebrated World Menstrual Hygiene Day, 2019 in Guwahati, Assam by hosting a wall mural by collaborating with local organisations. The initiative was widely covered by national and local media, and the mural was later inaugurated by the event’s chief guest Commissioner of Guwahati Municipal Corporation (GMC) Debeswar Malakar, IAS.

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