Richie Gupta, senior consultant and director, Department of Plastic, Cosmetic and Reconstructive Surgery, Fortis Hospital, Shalimar Bagh, who headed the team that performed the gender affirmation surgery on Taksh and Kritika speaks to The Hindu about gender dysphoriaHow long does the entire gender affirmation take? Can you break it down step-wise?Physical sex is assigned at birth based on appearance of external genitalia, while gender refers to innate and personal sense of being male or female. Normally, sex and gender are in alignment. These are out of alignment in certain individuals, thus resulting in a feeling that they are trapped in the wrong body. These individuals suffer constantly as they are in conflict with their body, family and social groups such as school and office. The discomfort arising from this conflict is known as GD [gender dysphoria]. Some GD persons are so severely affected that they wish to get rid of the wrong body type or organs, and are sometimes depressed or think of or may attempt suicide unless their GD is somehow relieved. This subset of individuals is known as transsexuals. These individuals are candidates for hormonal and gender affirmation surgery, which results in alleviation of GD. While gender is hardwired into the brain and cannot be changed, the sex of an individual can be changed. Hence, such surgery is known as ‘gender affirmation surgery.We follow a protocol for treatment of transsexuals, which is largely based on the 7th Standards of Care [SOCs], published by the World Professional Association for Transgender Health [WPATH] in 2011, and modified by our experience. It encompasses a multidisciplinary approach for management of such patients with involvement of specialities like plastic surgery, psychiatry, psychology, endocrinology, gynaecology, etc. We have a multidisciplinary team — the Gender Identity Clinic [GIC], at Fortis Hospital, Shalimar Bagh.Surgery or hormone therapy is not offered to anyone who walks into the GIC claiming to have GD. It is important to first diagnose GD and differentiate it from other conditions like schizophrenia. This is done with the help of psychometric analysis and diagnosis by a mental health professional. As for any genital surgery in GD, two psychiatric opinions are required. We take one opinion from Fortis GIC and the other from an outside mental health professional competent in diagnosing GD. Psychiatrists also treat underlying neurosis such as depression, facilitate the patient’s assimilation in society, and encourage role-playing and real-life experience [living in the patient’s true gender role in society]. Generally, a real-life experience of at least two years is required before undergoing the surgery. Once the conditions mentioned above are met, the patient can start hormone therapy and later undergo surgery.For male-to-female transsexuals [transwomen], generally one surgery is required for removal of the penis, scrotum and testes, and reconstruction of the vagina, labia and clitoris. Also, the urethra is recessed to a female position. This costs around ₹1.8 lakh. Since breast enlargement occurs on hormone therapy, breast augmentation is usually deferred till 18 months and most transwomen do not require it. Breast augmentation is undertaken if desired by the transwoman before this period. Other optional surgeries include facial and voice feminisation surgeries, trimming of the Adam’s apple, hair transplants to produce a feminine hairline, rhinoplasty, liposuction, etc.What is the cost of gender affirmation surgery? For female-to-male transsexuals [transmen], generally three surgeries are required. These are: top surgery [reduction of breasts] which costs around ₹1.25 lakh; removal of female internal organs such as the uterus, ovaries, fallopian tubes and vagina, which costs around ₹1.8 lakh; and reconstruction of the penis, scrotum and urethra, which costs around ₹2.5 lakh to ₹3.5 lakh. Implantation of a penile erectile device [Indian implant] costs approximately ₹80,000. Optional surgeries include voice masculinisation, liposuction, rhinoplasty, etc. We usually plan an interval of three months between surgeries. The surgical process in transmen takes nearly a year.What is the follow– up required?After the surgeries, we recommend a follow-up once in six months for patients on hormone therapy to assess for any adverse effects.What are the complications associated with these surgeries?Like any other surgeries, complications such as bleeding and infection can happen. In penile reconstruction surgeries, there may be urinary leak or partial blockage. This may require further intervention. At what age can someone opt for these procedures?Hormone therapy in the form of puberty-delaying hormones can start at stage II/III of puberty [11 to 14 years]. Surgery is carried out after the age of legal majority [after 18 years]. Are there any support groups in India for persons who undergo gender affirmation surgeries to help assimilate them in society?We have started a support group called Khem, which includes GD individuals who have undergone the procedures, some parents and a few health professionals. We connect trans individuals to this group, if they so desire.