Transgender Clinic

AHAM, Amrita’s Transgender Clinic is a holistic centre offering medical, psychosocial and surgical intervention to individuals with gender incongruence. It includes team of doctors & medical workers from Endocrinology, Psychiatry, Plastic & Reconstructive Surgery, Clinical Psychology, GI surgery, Urology, Gynaecology, Maxillofacial Surgery, Dermatology, Fertility Clinic and ENT.

Treatments offered include:

• Mental health evaluation and management
• Hormone therapy and endocrine management
• Assistance with social and legal issues and referrals to community resources
• Sexually transmitted infection screening and pre-exposure prophylaxis (PrEP)
• Voice therapy
• Electrolysis and laser hair removal
• Hair transplantation
• Gynecological care for transmen
• Feminizing surgical procedures:
  • Top surgery for transgender women
  • Facial feminization- Surgical & Non Surgical
  • Body-contouring procedures
  • Orchiectomy
  • Bottom surgery – Penile inversion vaginoplasty
  • Colon vaginoplasty
• Masculinizing surgical procedures:
  • Top surgery for transgender men
  • Body-contouring procedures
  • Hysterectomy and oophorectomy
  • Metiodioplasty
  • Phalloplasty
  • Fertility preservation

Surgical management is a part of the comprehensive management of trans persons and helps in alleviating gender incongruence. Not all patients require every surgical procedure. The surgical care of these patients needs to be customized to the individual patient’s requirements

1. Top Surgery (Breast augmentation): Breast development occurs once the patient initiates feminizing hormone therapy. But usually, this enlargement is hemispherical and conical, and without distinctive feminine curves or natural ptosis. Therefore, many transwomen opt for surgical breast augmentation. There are two common methods for breast augmentation.
   • Breast augmentation with implant- Most common method of breast augmentation. Cohesive silicone gel implants are used for augmentation, commonly via inframammary approach. Transaxillary approach is also possible.
   • Autologous fat grafting- In this procedure, fat is harvested from an area in which there is excess- such as abdomen, love handles, thighs etc. under low suction pressure. The purified fat infiltrate is then injected into the appropriate area on chest wall for breast development. Two or more sittings may be required.
2. Bottom Surgery (Creation of new vagina) – (orchidectomy penectomy ,vaginoplasty, clitoroplasty, labiaplasty, vulvoplasty, corporectomy and feminizing urethroplasty): Vaginal reconstruction is of major importance for the psychological and sexual well-being and quality of life in transgender women. The goals of the procedure are to create a perineo-genital complex, which is aesthetic and as feminine as possible, a vagina of adequate depth and dimensions and to make the urinary stream downwards in a sitting position. The new vagina is created between urinary bladder and rectum, avoiding injury to these important organs. This cavity then needs to be lined by a skin flap or skin graft to prevent its collapse. The 2 methods that we perform bottom surgery are:

a). Penile Inversion Vaginoplasty-use of penile and/or perineoscrotal skin flaps for lining of Neovagina. Post operatively we advise self- dilatation of NV cavity by the patient three times in a day, for a year. After she starts to have regular vaginal intercourse the number of dilatation may be decreased. Most commonly performed type of bottom surgery with least complication. In case there is a lot of hair in the donor area, preop laser hair removal is done.

b). Colon Vaginoplasty- Here a segment of the sigmoid colon is used to created the cavity of new vagina. The advantages of intestinal vaginoplasty are that it provides sufficient vaginal depth, is self-lubricating, and has a  lesser tendency to shrink. We prefer to do colon vaginoplasty over small bowel vaginoplasty because colon has less secretion.

3) Facial feminization- Surgical & Non Surgical

Surgical:

• Rhinoplasty
• Cheek implants
• Forehead correction,
• Jaw correction,
• Hair transplantation (for male pattern hair loss and receding hair line)
• Body contouring with liposuction, abdominoplasty
• Thyroid chondroplasty

Non Surgical –   Fillers used for aesthetic correction of face.

Top surgery for transgender men:

1. Reduction mammoplasty (the top surgery)- Here the breast is excised to give a masculine chest. In small and moderate sized breast, periareolar incision helps to hide the scar. In larger breast, double incision mastectomy with a nipple areolar graft is done. Nipple size is also reduced whenever required usually in a separate sitting.
2. Hysterectomy and bilateral salpingooophorectomy- Removal of the uterus and ovary. Many a times a single ovary is preserved to avoid hormonal imbalance for calcium etc when both ovaries are removed. (Preservation of ovarian follicles can be done if the patient wishes to do so).
3. Vaginectomy- Removal of the female external genitalia. It is usually combined with urethral reconstruction. Part of the vagina is used for the urethral lengthening.
4. Penile Reconstruction- ( phalloplasty with scrotoplasty & urethroplasty) – – to construct or reconstruct genital organs, which aesthetically match the biologic male genitalia, allow the transman to easily micturate in standing position in a male washroom without soiling himself, and to enable him to function as a male partner in penetrative sexual intercourse. This is the most complex among these surgeries, in which penis is reconstructed most commonly from a) the tissues of forearm (free Radial artery forearm flap or fRAFFp), b) thigh (pedicled Anterolateral thigh flap or pALTp) flap. Placement of testicular prosthesis and placement of an erectile implant/ penile prosthesis is also done.
5. Metaidoioplasty with scrotoplasty & urethroplasty- Alternative to penile reconstruction in patients who do not opt for complete penile reconstruction (phalloplasty), and instead opt for enlargement of clitoris (Metaidoioplasty). In this procedure, the natural enlarged clitoris (after hormone replacement for atleast a year) is lengthened and urethra is advanced to the tip of clitoris. Though this procedure does not enable the patient to engage in penetrative sexual intercourse in most cases, it allows for excellent erogenous sensation and orgasm, and in some cases, allows the patients to micturate in erect position.
6. Body Contouring- High definition Liposuction & Fat Grafting-  for 6- pack appearance of abdomen & pectoral masculine definition
7. Hair Transplantation (moustache & beard)

The Transgender clinic of Department of Clinical Psychology works in conjunction with the team of experts to provide a range of services for Transgender persons. The clinic caters to needs of Transgender persons providing gender reaffirming therapy, counselling and psychoeducation regarding medical and legal procedures for gender reassignment. Along with a detailed case work-up, evaluation of co-morbid psychiatric conditions, sexuality exploration, minority stressors, congruence to their appearance and gender identity acceptance are done.

Based on clinical observation and evaluation results, the necessary steps for clearance for gender reassignment surgery are done. Some clients are advised to seek gender affirmative psychological intervention and re-evaluation subsequently. The psychotherapy services provided for transgender persons focus mainly on addressing common mental disorders seen in LGBTQ+ community like gender dysphoria, trauma, besides personality disorders, mood disorders, eating disorder and anxiety disorders. During case work-up, their understanding about the legal procedures and side-effects relating to the surgery and hormone replacement therapy are also assessed. The clients are psychoeducated about possible risks and psychological difficulties they may have. Further, their current level of support from family, friends and community are also evaluated. Individuals are also given referrals to supportive communities and NGOs that provide support to them.

Apart from these services provided, the department has partnered with programs conducted by other departments in the hospital as well as with external NGOs like Sahayatrika. These programs have been platforms for psychoeduating general population about mental health concerns of LGBTQ+ community, societal stigma and discrimination faced by them, and regarding how society can extend their support to the community

1. Assess and diagnose gender concerns according to the criteria and see that they are addressed.
2. Assess and diagnose any coexisting psychopathology and see that it is addressed, provide ongoing mental health services.
3. Assess eligibility for treatment (hormonal, surgical) by collaborating with other professionals.
4. Assess capacity to give informed consent for hormonal and surgical treatments.
5. Ensure that eligible individuals are aware of full range of treatment options and their physical, psychological and social implications including risks, benefits, and impact on sexual functioning and reproductive potential.
6. Ensure adequate psychological and social preparation for transition treatments.
7. Ensure continuity of mental health care as indicated throughout and beyond.

Understand person as a whole, support them throughout from understanding their emotions, helping family members to understand the concept of gender incongruence, deal with family emotions.

Voice (and speech) is the identity of human beings. This uniquely human faculty is many things to many people; a means of communication, a means of livelihood, a means of our very existence. To be recognized by one’s voice is a satisfaction in itself. And when this is lost, or is affected, it is often a huge blow to one’s psyche, apart from all the potential social handicaps.

People with transgender issues would be very familiar with this distressing situation. Whether it is a male in a female’s body, or vice versa, the mismatch between perceived gender and heard voice leads to difficult situations in the individual’s life. Even after all other surgeries for sex reassignment have been done, the last bridge to be crossed is often the trickiest one. This is the process of change of voice, especially male-to-female. The pitch, voice quality, intonation, all tend to remain of a masculine nature.

Here is where the Voice personnel come in. Therapy, surgery, along with psychological counselling are all available to help the trans person attain her/his voice. A team of dedicated voice care professionals take care of the assessment and management of the voice aspect related to gender affirmation, the need of the hour.

Welcome to Aham Trans-Form: transform into your real self, and let the world hear your true voice.