Gender Reassignment in India at Columbia Asia Hospitals

Columbia Asia Hospital- Mysore has a robust gender reassignment program for management of gender dysphoria (meaning unhappiness with one's gender) and people who wish to change their gender referred to as "Transsexuals".

Trans-sexualism is "a gender identity disorder in which the person manifests, with constant and persistent conviction, the desire to live as a person of the opposite sex and progressively take steps to live in the opposite sex role full-time for life."

The team of plastic surgeon, endocrinologist, psychiatrist and psychologist are specially trained in some of the premier institutes in India and abroad and follow management protocols accepted internationally. The precision with which the various stages of surgeries are to be done has been acquired by the plastic surgeon through performing many surgeries of this kind.

Steps for enrollment in the gender reassignment program

  • Discussion with patient giving details of various steps, criteria for selection and steps in surgery, including irreversibility of the surgeries.
  • An evaluation by a psychiatrist for a period of 18 months, followed by a second psychiatrist’s opinion
  • If medically permitted and cleared by the psychiatrist, a trial of continuous hormone therapy under the supervision of an Endocrinologist for a minimum period of 12 months
  • If an individual has significant medical or mental health issues, they must be reasonably well controlled before enrollment is considered.
  • Documentation of the completion of a minimum of 12 months of successful continuous full time real life experience in the new gender, across a wide range of family and social events.
  • Regular psychotherapy during the period of psychiatric evaluation and trial continuous hormone treatment
  • Continuous hormone therapy
  • Evaluation of successful behavioural and medical outcomes
  • Clearance by the hospital ethics committee
  • Clearance for surgery
  • Signing an indemnity bond, informed consent as required

Criteria for sex reassignment management including surgery

  1. Person shall be above 18 years of age
  2. Shall have the mental capacity to make fully informed decisions
  3. Person shall not be married and if married, shall be legally divorced or spouse shall also be counselled and assessed for willingness to accept the gender reassignment.
  4. Person shall not have any minor children
  5. Person shall meet criteria for the diagnosis of "true" gender dysphoria, including:
    • A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant; and
    • A desire to live and be accepted as a member of the opposite sex and wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • A stable transsexual orientation evidenced by a desire to be rid of one's genitals and to live in society as a person of the other sex for at least 2 years, that is, not limited to periods of stress; and
    • Absence of physical inter-sex of genetic abnormality; and
    • Does not gain sexual arousal from cross-dressing; and
    • Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and
    • Not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and
    • Clinically significant impairment of social and occupational functioning

Person has completed a program of transgender identity treatment as evidenced by the following:

  • A qualified psychiatrist* who has been acquainted with the person for at least 18 months recommends sex reassignment surgery documented in the form of a written comprehensive evaluation; and
  • For genital surgical sex reassignment, a second concurring recommendation by another qualified, independent psychiatrist * must be documented in the form of a written expert opinion**; and
  • For genital surgical sex reassignment, person has undergone a urological examination for identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex reassignment includes the invasion of and the alteration of the genitourinary tract (urological examination is not required for persons not undergoing genital reassignment)
  • Person has demonstrated an understanding of the proposed male-to-female or female-to-male sex reassignment surgery with its attendant costs, required lengths of hospitalization, likely complications and post-surgical rehabilitation requirements of the planned surgery; and
  • Psychotherapy is not an absolute requirement for surgery unless the psychiatrist initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real-life experience (usually a minimum of 3 months);
  • For genital surgical sex reassignment, the person has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real-life experience), without periods of returning to the original gender; and
  • For genital surgical sex reassignment, person has received at least 12 months of continuous hormonal sex reassignment therapy recommended by a psychiatrist and carried out by an endocrinologist (which can be simultaneous with the real-life experience), unless medically contraindicated.

* At least one of the two psychiatrists making the favourable recommendation for surgical (genital) sex reassignment

** Either two separate letters or one letter with two signatures is acceptable. One is from the treating psychiatrist. The other can be from a psychiatrist who does a document review of the process and does one final patient assessment and thereafter signs the form. All counselling sessions need to be video recorded. If one of the psychiatric opinions is conflicting, then the patient shall be referred to a third psychiatrist and the majority decision shall prevail.

Evaluation by a psychiatrist

Psychiatrists working with gender identity disorders shall have a degree recognized by the Medical Council of India and have special training on handling gender dysphoria cases.

A psychiatrist shall assess patients and has the following responsibilities:

  • To accurately diagnose the individuals gender dysphoria
  • To accurately diagnose any co-morbid psychiatric conditions and to ensure their appropriate treatment
  • To counsel the individual about the range of treatment options and their implications
  • To engage in psychotherapy
  • To ascertain eligibility and readiness for hormone and surgical therapy
  • To make formal recommendations to the endocrinologist and surgeons
  • To document all relevant findings and recommend or reject the process, giving reasons
  • To educate family, employers and institutions about gender identity disorders
  • To be available for follow up as prescribed

The assessment and continued support shall be done for a period of 18 months. Thereafter the report either recommending or rejecting the case, citing reasons, shall be prepared. The opinion of another psychiatrist shall be obtained.

Either two separate letters or one letter with two signatures is acceptable. One is from the treating psychiatrist. The other can be from a psychiatrist who does a document review of the process and does one final patient assessment and thereafter signs the form. All counselling sessions need to be video recorded. If one of the psychiatric opinions is conflicting, then the patient shall be referred to a third psychiatrist and the majority decision shall prevail.

Gender reassignment surgery for male to female (feminizing surgery)

Before undertaking sex reassignment surgery, important medical and psychological evaluations, medical therapies and behavioral trials should be undertaken to confirm that surgery is the most appropriate treatment choice for the individual.

Medically necessary core surgical procedures for male to female persons include: penectomy, orchidectomy, vaginoplasty, clitoroplasty, and labiaplasty.

Note: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic.

Gender specific services for transgender persons:

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include: 

  • Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.

Surgery 1 MTF augmentation mammoplasty

Risks associated with augmentation mammoplast

  • Post-operative bleeding/ hematoma
  • Infection
  • Seroma
  • Wound healing problems
  • Asymmetry
  • Capsular contracture
  • Implant extrusion
  • Implant failure

Surgery 2: Complications following MTF genital reconstruction

  • Post-operative bleeding/hematoma
  • Infection
  • Wound healing problems
  • Recto-vaginal fistula
  • Partial or complete flap necrosis (loss of clitoris)
  • Vaginal stricture or stenosis
  • Urethral stricture or stenosis
  • Swelling/irregularities of urethral meatus
  • Prolapse of the neovagina
  • Intravaginal hair growth
  • Hypertrophic scarring

Surgery 3: Complications following MTF facial feminizing surgery

  • Infection of the wound or implants, sometimes necessitating removal
  • Numbness due to edema (transient)
  • Nerve damage (potentially permanent)
  • Dissatisfaction with the aesthetic results
  • Following rhinoplasty there may be a mild scleral hemorrhage and edema around the nose which typically resolves spontaneously after several weeks.

Surgery 4: Revision surgery

Typical revisions in breast augmentation include, but are not limited to:

  • Exchanging implants for those of a different size
  • Exchanging implants for those of a different type
  • Placing the implants in a slightly different location
  • Scar revisions

Revisions in vaginoplasty may include:

  • clitoroplasty: adjusting the size, shape, location or hooding of the neo-clitoris
  • labiaplasty: adjusting the size or shape of the labia minora or majora
  • commisuroplasty: narrowing the superior aspect of the labia majora (the anterior commissure)
  • deepening the neo-vagina: occasionally the neo-vagina will not be long enough or will contract in size. This is usually the result of inadequate dilating.

Gender reassignment surgery for female to male

Before undertaking sex reassignment surgery, important medical and psychological evaluations, medical therapies and behavioral trials should be undertaken to confirm that surgery is the most appropriate treatment choice for the individual.

Medically necessary core surgical procedures for female to male persons include: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty and placement of testicular prostheses and erectile prostheses.

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

  1. Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;

Limitations of hormone therapy

  • There may be no change in voice or hair growth
  • There may be change in the quality of body hair and redistribution of body fat

Expected outcomes of surgery

  • Cosmetic/aesthetic effect
  • Psychological outcome - happiness and satisfaction to be able to live with the gender inclined by the person
  • Social outcome - ability to work, maintain relationships and contribute to society

Surgery 1: Hysterectomy/oophorectomy

This is a routine gynecologic procedure, where the uterus and the ovaries are removed. Complications/risks are no different in the female-to-male patient than the non-transgender female patient.

Surgery 2: Breast surgery

The aim of chest surgery in the FTM is not just to remove the breast tissue, but also to re-contour the chest to create a masculine appearance.

Patients with larger breasts or poor skin quality have a higher chance of requiring revision surgery. Typical revisions include, but are not limited to:

  • liposuction to improve contour abnormalities
  • scar revisions
  • excision of skin excess, wrinkling or puckering
  • adjustment of nipple-areola complex position or size

Management of complications following FTM chest surgery

  • Post-operative bleeding
  • hematoma Infection
  • Seroma
  • Wound healing problems
  • Mastectomy flap necrosis Nipple necrosis (loss of nipple)
  • Contour abnormalities
  • Nipple asymmetry

Surgery 3: Management of complications following FTM genital reconstruction

After phalloplasty revision surgery may be necessary to correct urinary dysfunction, a common complication of urethral lengthening.

  • Post-operative bleeding/hematoma (all sites)
  • Infection (all sites)
  • Seroma (recipient site)
  • Wound healing problems (all sites)
  • Partial or complete flap necrosis (loss of phallus)
  • Compromised sensation/function of hand and wrist (donor arm)
  • Urethral fistula