Not many know that gender reassignment surgeries are conducted in a few hospitals in Kerala. Unfortunately, it took a recent controversy to bring this topic to the public discourse. At least some people still believe that complex surgical procedures like the gender reassignment surgery are unnatural or immoral. This article discusses, in detail, the background of the surgery, the various methods and techniques that are used in it and also about the post surgical complications.

What is gender reassignment surgery? Isn’t it an incorrect treatment for a mental ailment?

The mental cognizance of ‘self’ is an extremely complex one. The main reason for that are the unique changes that have been caused in the brain by hormones and neuro transmitters, during the fetal stage. In most instances, these changes might be related to the anatomical structure of the body. For example, those who have a male body would have the consciousness that they are males. Individuals would begin exhibiting these gender traits as soon as they turn two. However, in some people, the gender identity would be different from their physical gender or body. A trans woman would possess the gender identity of a woman even though that person would have the body of a male. This happens vice versa in the case of a trans man. (More intricate details about this have been published in the article titled ‘Gender, Gender Identity, Transgender).

It must be noted that even though males and females are genetically opposite, gender identity is something that cannot be properly discerned. A male might possess female psychological traits to certain extend and vice versa. However, the extent of it might differ in different individuals. So, modern science deems transgender persons as a normal variation. They are normal individuals who have the right to lead normal lives.

Why would anyone undergo surgery to change their gender? Will these surgeries have validity if society changes its attitude and accept transgender people?

The greatest challenge that the transgender community faces is the apathy by society. However, that is not the only issue. Transgender individuals live with the feeling that they are trapped in the wrong body. It is their natural desire to transition into the gender that they identify with. Most of them are willing to take the risk too. If the surgery is a success and they transition into their desired gender, then trans people could lead a normal and healthy sex life too. It is necessary to understand that such transitions or surgeries are unavoidable for at least some people.

How did the practice of gender reassignment surgeries begin?

It was about a century ago that gender reassignment surgery began in modern medicine. Alan L Hart, an American physician and writer was the first trans man to undergo gender reassignment surgery in 1917. Born as a woman, Alan desired to live as a male, upon reaching adulthood. Alan underwent hysterectomy or the surgical removal of female organs. By 1920’s male hormones were available in the form of injections. He then began hormone therapy to completely transition into a male.

Meanwhile, German Dora Richer is the first person to undergo a gender reassignment surgery to transition from male to female. She was one of the transgender people in the care of noted sexologist Magnus Hirschfeld who is hailed as a pioneer in sex research in Germany. In 1922, Dora underwent a surgical procedure to remove his testicles. This was followed by another surgery to remove penis in 1931. By this time, the Nazis were gaining strength in Germany. Dr. Hirschfeld’s institute was attacked by the transphobic Nazis and Dora is presumed to have been killed in that attack.

Some babies are born with ambiguous genitalia. Will the surgery that is done on them come under gender reassignment procedures?

It is a rare condition, in which an infant’s genitals don’t appear to be clearly either male or female, due to genetic reasons or hormonal abnormalities during pregnancy. Usually, ambiguous genitalia are recognized by the medical team soon after the birth. However, in some cases, it is found out only at a later stage. This condition is found in five out of ten thousand infants. An anatomical gender would be suggested by the medical team (depending upon the presence of testicles or ovaries) and a surgical procedure would be done to change the other organs to that gender. This surgery is not called gender reassignment surgery; but it could be termed as a surgical management of ambiguous genitalia in order to determine gender. However, there have been instances where kids who had undergone such surgeries later identify with the opposite gender. So, the ethical feasibility of such surgeries has been questioned. But it must also be noted that many surgical procedures could become complex and risky when it is done on adults. Besides, people undergoing such treatments at a later stage in life might face discriminations or other societal pressures.

WPATH is a word that is often associated with gender reassignment surgery. What exactly is this?

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World Professional Association for Transgender Health is an organization that is devoted to the treatment and understanding of gender dysphoria. The guidelines issued by WPATH are globally accepted when it comes to transgender health and complex surgical procedures. Professionals working in medicine, psychology, law, social work, counseling, psychotherapy, family studies, sociology, anthropology and sexology take membership in this organization. Those who are not part of these professions or fields of studies too could become members by paying a membership fee. However, many European countries and the United States have their own laws and guidelines, other than the ones suggested by WAPTH, to regulate gender reassignment procedures and promote transgender health.

Meanwhile, IPATH is a similar organization that functions in India. It was recently that the organization had issued guidelines that suit the Indian situations. However, all sex reassignment surgical teams that are led by authorized plastic surgeons in India usually follow the WAPTH guidelines.

In India, the WAPTH guidelines do not have any legal validity. Each country requires separate guidelines that are formulated by taking into account their unique practices, culture and resources too. WAPTH offers a general structure which could guide individual countries to come up with their own guidelines and instructions.

What are the precautions to be taken before a gender reassignment surgery? How are transgender people psychologically analyzed before such a complex procedure?

It is important to correctly diagnose whether the individual really has gender dysphoria, before proceeding with complex treatments like surgeries or other irrevocable procedures. In some cases, people who have been diagnosed with gender dysphoria might back out of their decision to undergo the procedure after knowing about the complications or the risk elements in the surgery or the side effects. Moreover, they have to live for a certain period of time in the desired gender or spend time with people of that gender to determine whether it suits them. Besides, they have to be given proper insight about how they could live a contended life in their respective gender identity, even without undergoing the surgery. Enabling them to take proper decisions about whether they require only the hormone therapy or more complex surgical procedures too is important. They must be offered mental and emotional support before the surgery. Moreover, family counseling and efficient participation of the queer community too is required.

What are the hormone therapies that are done for transgender persons?

In this therapy, sex hormones and other hormonal medications are administered to alter one’s hormone levels to match the gender identity. This would induce physical changes in their body. Pills, injections, implants that slowly release hormones into the body and patches that could be stuck on skin are some of the methods in hormone therapy.

Feminizing hormone therapy

Female hormones like estrogen and progesterone are administered into the body. Besides, medicines are given to block the male hormones like testosterone. This would avoid the male sex characteristics and aid breast augmentation.

Masculinizing hormone therapy

Male hormones like testosterone are administered into the body through intramuscular injections or subcutaneous injections. This would induce male sex characteristics in the body.

Gender affirming hormone therapy could gradually suppress or lower the fertility of the individuals.

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What are the different kinds of gender reassignment surgeries? How effective are they and what are the side effects?

Top surgery

Top surgery is a reconstructive surgery performed on the chest and the breast tissues. In male to female top surgery, silicone implants are used to increase the chest size and make breasts achieve a feminine appearance. Meanwhile, in female to male top surgery, breast tissues are removed and the nipples are grafted on the flat chest. It must be noted that these aren’t simple procedures.

Related surgeries

Our physical gender shows many unique bodily features that usually go unnoticed. The structure and size of the lower jaw, size, length and shape of the nose, heaviness of the skull, shoulder width, Adam’s apple, carrying angle of the hands, structure of the hip bones and the body shape that is formed due to the distribution of fat are some of the examples. From simple procedures to complex surgeries, there are various types of surgical procedures to address these issues. These could be done with the consent of the transgender person. They are also made aware about the risk factors that are involved in such surgeries.

Bottom surgery

This complex surgery involves the removal of the reproductive organs and the sex organs and is altered to resemble the organs that are associated with their gender identity.

Penis, testicles and scrotum are removed in a male to female bottom surgery. However, the glands that are seen on the shaft of the penis, along with the blood vessels and veins are reattached on the part of the clitoris. This procedure involves changing the structure of the urinary tract too. The labia, meanwhile, is fashioned from the skin grafts of the testicles and penis. However, sometimes, the vagina turns out to be smaller or denser. Moreover, it might even reject the skin grafts. In such cases, a part of the intestine is used to create the labia. The parts of the intestines then have to be reattached, in a complex surgical procedure. Besides, secretions might come out from the part of the intestines that are attached on the vagina. Around 30% of people might require more surgeries to fix these.

Vagina, ovaries and uterus are removed in a female to male bottom surgery. The procedure to create penis, testicles and scrotum is far more complex and riskier that male to female surgery. In most cases, muscles and skin from hands and thighs have to be used to create these organs in a complex micro surgery. Such surgeries are riskier as micro surgeries have a failure rate of about 5%. Most people might require more surgical procedures to fix the flaws and side effects. Blocked urethra and urine leaking through the openings are some of the side effects. About 70% people require surgery to fix this problem. After all these, the penis has to regain its sensory abilities before going for artificial implants that enables erection and sexual intercourse.

In male to female bottom surgery, the newly created vagina might not have the required depth. Closure of vaginal opening, body rejecting the skin grafts and difficulty urinating too are some of the common side effects. In rare cases where parts of intestines have been used, these procedures might lead to serious complications.

Some rare cases of female to male bottom surgeries might be total failures. Obstruction of urinary tracts and leakage of urine through openings are some of the common side effects.

It is difficult to achieve or maintain the shape of the organs when they are recreated. So, it is quite natural that the individuals might be disappointed with the end result.

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How can society positively interfere in the lives of transgender persons?

It is significant to understand that being trans is not a mental illness. To ensure social justice for transgender persons, we could make arrangements for them to lead a normal life without any discrimination. Most importantly, the idea of gender mustn’t be limited to the male – female binaries. Society should rethink about assigning specific gender roles so that individuals can freely explore and express their gender identities. 

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