Transgender

Transgender is an umbrella term indicated for people who possess gender expression, gender identity and behaviour that does not conform to the specific characteristics of the sex assigned to them at birth. In contrast, the term cisgender is used for people with a conformation between sex and gender identity. A transgender female is male sex at birth but carries a gender identity of female. Similarly, a transgender male is female sex at birth but carries a gender identity of male. Some people have both male and female components in terms of gender identity. These are known as non-binary or genderqueer. 

Gender dysphoria

A person may have a mismatch between their gender identity and biological sex. Such people have dissatisfaction or uneasiness to the extent that they suffer from anxiety and depression. This effect on the overall quality of life due to this mismatch is known as dysphoria. 

Gender identity and sexual orientation

Gender identity is defined as the identity of the person reflected in their behaviour according to their gender. For instance, a person of the male gender behaves and feels like a male. Similar is true with females. People who behave and feel according to their gender have binary identities. However, some people feel that their gender identity does not match the assigned sex. For instance, people with facial hair and male genitals do not feel masculine. Such people are often termed as non-binary.

Gender identity is different from sexual orientation. Sexual orientation is indicated as the person’s personal preference for having a sexual relationship with women, men or both sexes. Heterosexuals are attracted to people of the opposite sex while homosexuals are attracted to people of the same sex. Transgender people may be gay or lesbian, straight or bisexual.

Transgender is an umbrella term that comprises the following categories:

1. Transexual: These people have a different gender identity different from their assigned sex. Generally, these people desire to change their bodies through hormones, surgeries or other methods to make the body aligned with gender identity. 
2. Cross-dressing: People who cross-dress wear dresses assigned to the other sex in their culture. Such people do not have a desire to change their sex and are comfortable with their assigned sex.
3. Drag queens and drag kings: Drag queens are men who dress like women to entertain others at clubs, bars or other events. Drag kings are women who dress like men to entertain others.
4. Genderqueer: Such people define their gender out of the boundary for men or women. 
5. Other categories: The other transgender categories include a multi-gendered, third gender, androgynous, gender nonconforming and two-spirit people.  

What are the Stages of Transition for Transgender?

The transgender individual experiences the following stages of transition:

Stage 1: In the initial stage, the person consults with psychologists or mental health providers. These should be experts in gender issues. During the consultation, the doctor will diagnose gender dysphoria or gender identity disorder. Once the condition is confirmed, the doctor will provide risks associated with the gender reassignment procedure. Further, the doctor will also discuss in detail with the patient hormone therapy and surgery to allow the patient to make an informed decision. After the 2-3 visits, the psychologists may refer the patient to endocrinologists.

Stage 2: Hormones play an essential role in developing sexual characteristics. Men who desire to transition into women take female hormones. These hormones increase breast tissues, reduce muscle mass and strength, and slow the growth of body hair. Women who desire to transition into men require to take male hormones. These hormones increase muscle mass and strength, deepening the voice and enhancing the body and facial hair. It has been recommended that the person must undergo hormonal therapy before opting for surgery.

Stage 3: Approximately three-fourths of transgender undergo gender reassignment surgery. One of the important hurdles is cost, as the patient has to undergo multiple surgeries. Further, the insurance coverage may be different. Both the surgeon and the patients must be certain about surgery. There are risks and complications associated with the surgery, including urethral narrowing, abnormal connections, and tissue death.

There are several surgeries available for a transwoman. These are:

1. Facial Feminizing Surgery: The surgeon performs this surgery to provide a feminine appearance to facial characteristics. As the face represents whether the person is a man or woman, it is an important surgery for male-to-female transition. Severe surgeries are performed under feminising facial surgery customised to the needs of the person. These may include tracheal shave (helps to minimise thyroid cartilage), nose reshaping, cheek implants, blepharoplasty, cheek softening, and neck, face or lip lift. 
2. Breast Augmentation: Full, round breasts are linked with beauty and femininity by some transgender women. The person may undergo hormone therapy that may result in the growth of some breast tissues. However, a transwoman who desires to achieve full breasts is advised to undergo breast augmentation surgery. Breast augmentation surgery can be done over the chest wall (subglandular placement) or under the chest wall (submuscular placement). 
3. Body Feminizing Surgery: The surgeon performs body feminizing surgery for transwomen who desire to have an ideal "hourglass figure". The defining characteristics of the woman include a low waist-to-hip ratio and round buttocks. The surgeon performs surgery on these areas during body contouring. The surgery includes buttocks augmentation and trunk liposuction. The surgeon removes the fat from the abdomen, waist and back and transfers this fat to the buttocks with a procedure called the Brazilian butt lift. 
4. Orchiectomy: Testicles are the organs in the male reproductive system that produces hormones and sperms. Orchiectomy is the procedure through which the surgeon removes the testicles in a transwoman. This surgery reduces the requirement for testosterone blockers and the amount of oestrogen. Orchiectomy is generally done before vaginoplasty. However, some transwoman prefers not to perform any further surgery after orchiectomy.
5. Vaginoplasty: Vaginoplasty is the procedure in which the surgeon creates a vagina. The vaginal canal is prepared by using the skin of the penile shaft and scrotum. Labia can also be surgically created in some cases (labiaplasty). The clitoris is also created using the penile tip and nerves that supply the penis. However, during vaginoplasty, the skin can also be used from other parts of the body.

The surgeon may sometimes remove the hair from the penis and scrotum before using these tissues through laser or electrolysis. It requires a significant amount of time. In other cases, the follicles are destroyed during the surgery.

Following are the surgeries for transwomen:

1. Mastectomy: The surgeon removes the unwanted breast tissues to provide a masculine chest. Sometimes, it is the only surgery that the transman desires. It is the initial surgery in the process of female-to-male transition. There are several techniques used for a mastectomy, the choice of which depends on the desire of the transman. These include adjunctive lateral chest wall liposuction, the periareolar/”keyhole” technique, and bilateral mastectomy with free nipple grafts.
2. Facial Masculinization Surgery: Several procedures help in providing a masculine look to the face. These procedures include rhinoplasty, forehead augmentation, thyroid cartilage enhancement, jaw contouring, and chin recontouring. 
3. Body Masculinization Surgery: The procedure involves contouring the lower and upper body. The male characteristics include broad shoulders, less fat in the lower body, and a trim waist. Diet, exercise, and hormone therapy may assist in providing masculine features to the body. However, surgery is required when there is a challenge in altering fat storage in some body areas. It involves a liposuction technique that targets the upper body, chest, buttocks, and outer and inner thighs. 
4. Uterus, ovaries, and fallopian tube removal: The transman may also opt for removal of the uterus, ovaries and fallopian tubes in case they are causing discomfort. The procedure may also be opted for if the hormone therapy fails to prevent menstruation. 
5. Metoidioplasty: In this procedure, the surgeon creates a new penis. The clitoris is changed into the penis through this procedure. The clitoris is enlarged through hormone therapy before performing metoidioplasty. The vaginectomy (procedure to remove the vagina) is also performed during the procedure. The urethra is lengthened using the tissues of the labia minora, cheek or vagina. It allows urination during standing. The surgeon also increases the penile girth through the Centurion procedure. Metoidioplasty surgery takes around 2-5 hours to complete. In case the transman requires a larger penis, the surgeon performs phalloplasty. However, the disadvantages of this procedure include several surgeon visits and revisions. 
6. Scrotoplasty: The surgeon, through scrotoplasty, creates a new scrotum. The labia majora is repositioned to form a hollow sac where the silicone testicular implants are inserted.

Risks in transgender surgery

Like any other major surgery, transwoman surgeries also have certain risks and complications. These include:

1. Accumulation of fluid below the skin
2. Delayed healing of the wound
3. Formation of a blood clot
4. Loss of sexual function and pleasure
5. Permanent scarring
6. Pelvic floor dysfunction
7. Reduced sensation, numbness, and tingling sensation
8. An abnormal connection (fistula), such as between bladder and vagina
9. Urinary problems, such as urinary incontinence
10. Damaged tissues in the labia and vagina (transwoman surgery)