Pallavi: Explanation of Treatment

Pallavi visits Dr. Kusum to learn about Sexual Reassignment Surgery.

Note from Indian Cross-dressing Novel: This story has been contributed by our reader Pallavi Desai. All the rights to this story belongs to her. We are merely the publishers of this story.

Disclaimer: Due to our lack of expertise in the medical domain, Indian Crossdressing Novel cannot ascertain the claims made in this story. If you need any further clarification about things discussed her, please contact Pallavi Desai on facebook.

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Dr.Kusum is not happy with progress of mine. She told masi, the breast area has become soft but proper development is not there. You take a final decision so that I can increase female hormone dose. At this rate it will take another two and half to three years to develop breast of proper size.

Masi discussed with me and informed Dr. Kusum to increase dose to go for final stage to prepare for sex change operation.

Dr.Kusum: I want to discuss various issues related to sex change operation. It will require 2/3 sessions each of about 1 to 2 hours duration with Pallavi. It is better that you also remain present.

Masi: Tell me when can I bring Pallavi to you?

Dr.Kusum any time in next week, preferably in afternoon.

Masi: Is it OK on next Wednesday around 2 P.M.?

Dr. Kusum: Yes, fine. Should I fix the appointment?

Masi: Yes. We will definitely come.


When they arrived at Dr. Kusum’s clinic, they were informed that Doctor is waiting for them and you can go directly in her consulting room.

They entered room and Dr. Kusum greeted them.

Dr. Kususm: Pallavi we are going to take some major decision which is going to affect your entire life from now on so I want both of you to understand clearly what it all means to go for sex change operation.

Pallavi: Yes, I understand. Please explain to me.

Dr. Kusum: Pallavi, do you know what those persons feel after going through sex change operation?

Pallavi: Utter joy and feeling of completely becoming woman.

Dr. Kusum: There is more than that. Let us see what research says:

Most of the patients tracked down some years after their surgery were contented with what they had done and . . . only a few regretted it. But in every other respect, they were little changed in their psychological condition. They had much the same problems with relationships, work, and emotions as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled. We saw the results as demonstrating that just as these men enjoyed cross-dressing as women before the operation, so they enjoyed cross-living after it. But they were no better in their psychological integration or any easier to live with

Pallavi: OK. I will try my best to adapt to the situation.

Dr. Kusum: Do you really know how the (SRS) sex reassignment process for male actually works?

Pallavi: No, only some vague idea.

Dr.Kusum: Sexual reassignment surgery is only one step in a long and expensive process.

For men it involves dressing in public as a woman and undergoing electrolysis to remove facial hair, hormone treatment, electrolysis to remove hair on the genitals and prepare the genital tissue to be used to create a pseudo-vagina, removal of the penis and testes, creation of the pseudo-vagina, creation of an opening for the urethra, and cosmetic surgery—to decrease the size of the Adam’s apple, insert breast implants in some cases, change other features, and insert silicone implants in the hips and buttocks.

Some men present themselves in public as women but have not yet chosen to have surgery below the waist. These are sometimes referred to as “she-males,” since with breast implants and cosmetic surgery above the waist they appear female, but below the waist they are physically male. Some she-males work as showgirls in clubs that specialize in this kind of entertainment or as prostitutes in order to save up the money needed for genital surgery. Certain men seek out the sexual services of she-males.

Dr. Kusum: What do you know about Gender Identity Disorder (GID)?

Pallavi: Nothing.

Dr. Kusum: There is general agreement that it first manifests itself as childhood GID. Because the symptoms of GID appear very early in childhood, some assume that the condition is biological in its origin—either genetic or hormonal, and therefore unchangeable.

The boy, who is highly sensitive to maternal signals, perceives the mother’s feelings of depression and anger. Because of his own insecurity, he is all the more threatened by his mother’s anger or hostility, which he perceives as directed at him. His worry about the loss of his mother intensifies his conflict over his own anger, resulting in high levels of arousal or anxiety.

When anxiety occurs at such a sensitive developmental period, the child may choose behaviors common to the other sex, because in his mind these will make him more secure or more valued.

Most heterosexual transvestites remain content to engage in cross-dressing while others desire SRS. According to research, that a man who can “satisfy his urges by periodically cross-dressing in private or in the company of others” he probably will not seek surgery, while a man “whose primary fantasy is having a vulva” eventually will.

Dr. Kusum: How much do you know about Physical pain and psychological disorders associated with Sex Reassignment Surgery (SRS)?

Pallavi: Nothing.

Dr. Kusum: One researcher writes, thse who opt for surgery suffers the immense amount of physical pain that surgery entails. Generally, this fact is totally told. Anyone who has the slightest degree of medical knowledge knows that penectomies, mastectomies, hysterectomies, vaginoplasties, mammoplasties, and the like cannot be painless for those who undergo them.

The suffering of persons who desire SRS cannot be denied. In many cases, it began in early childhood. Many have been victims of various forms of abuse or neglect and of peer or parental rejection. These persons are strongly desires for acceptance and love.

At the very least, health professionals should evaluate the role that strong anger toward oneself, with self-destructive impulses and intense anger toward others, depression, self-pity, childhood trauma, addiction to masturbation and fantasy, and envy, plays big role in the development of becoming a woman.

Persons who desire SRS typically experience serious emotional conflicts, often complicated by sexual self-rejection and depression. Because many therapists are not skilled in uncovering and addressing these serious conflicts, SRS is put forward as the best available solution—if not the only solution. Some therapists too readily accept a patient’s “I feel trapped in the wrong body” explanation and do not probe at all.

Pallavi: I think we should stop now and let me digest the information. Please don’t think I am going to change my idea of cancelling sex change but I want to understand all above aspects so that I will be more comfortable afterwards.

Dr. Kusum: I understand it. I am happy you want to consider all aspects of what lies ahead. When can you come next?

Pallavi: If possible tomorrow same time.

Dr. Kusum: It is fine but please think for two days to understand, ask me again for clarification. We will discuss more about transition after two days.

Pallavi: Sure.


Dr. Kusum: Any doubt? Any more clarifications?

Me: No. I refered some content on the subject written for non medical and I am clear of what to expect.

Dr. Kusum: Today we will discuss effect of hormone on health and risks associated with it.

Hormones are special chemicals responsible for male and female characteristics in male and female.

While there is some health risks involved with hormone therapy, it can have positive and important effects on Trans people’s quality of life.

Knowing what you can expect will help you work with your Doctor to maximize the benefits and minimize the risks.

It may also be a helpful resource for partners, family, and friends who are wondering how hormones work and what they do.

How Hormones Work?

Hormones are chemical messengers produced by one part of the body to tell cells in another part of the body how to function, when to grow, when to divide, and when to die. They regulate many functions, including growth, sex drive, hunger, thirst, digestion, metabolism, fat burning and storage, blood sugar and cholesterol levels, and reproduction.

Sex hormones regulate the development of sex characteristics – including the sex organs that develop before we are born (genitals, ovaries/ testicles, etc.) and also the secondary sex characteristics that typically develop at puberty (facial/body hair, bone growth, breast growth, voice changes, etc.).

There are various types of medication that can be taken to change the levels of sex steroids in the body. Changing these levels will affect fat distribution, muscle mass, hair growth, and other features that are associated with sex and gender.

For Male To Females this can help make the body look and feel less “masculine” and more “feminine” giving satisfaction to person taking treatment for transition.

PLEASE NOTE THAT I AM NOT GOING TO DISCLOSE THE EXACT NAME AND DOSAGE OF HORMONES/MEDICINES. Please always be under the observation of consultant. I will just explain its effect on you.

Various kinds of medication can be used to change the levels of sex hormones in your body. Some work on the part of your brain that stimulates sex hormone production, some work on your testicles (which produce testosterone), and some work directly on the cells in your body that respond to sex hormones. Some of these medications are also hormones, and some are another type of chemical.

Typically Male To Female hormone therapy involves estrogen, medication to block testosterone, or a combination of the two.

  1. Estrogen: Estrogen is the main hormone responsible for promoting “female” physical traits. It works directly on tissues in your body (e.g., makes breasts develop) and also indirectly suppresses your testosterone.
  1. Anti-androgens (also known as androgen blockers or androgen antagonists) Anti-androgen drugs work by blocking the effect of testosterone. This reduces “male” physical traits and has a mildly “feminizing” effect.
  1. Progestagens: Doctors use progestagens:
    • To supplement estrogen if estrogen isn’t working even at the maximum dose, or
    • As a replacement for estrogen if there are concerns about estrogen’s side effects or health risks, or
    • Because they believe that progestagens help with nipple development

In prescribing a particular medication and dosage, your doctor should consider your health, including any other medications you are taking. Every person is different in terms of how their body absorbs, processes, and responds to sex hormones. Some people have more changes than others; changes happen more quickly for some people than others.

 Taking more hormones than the dose you were prescribed is not a good way to try to speed up changes. Taking more than your prescribed dose also greatly increases your health risks. You will need to stay on estrogen or another form of medication for the rest of your life to preserve bone strength.

 Dr Kusum Now I will discuss what changes Can you expect, and how soon? (Benefits)

“Feminizing” hormone therapy has important psychological benefits. Bringing the mind and body closer together eases gender dysphoria and can help Trans people feel better about their bodies. People who have had gender dysphoria often describe being less anxious, less depressed, calmer, and happier when they start taking hormones. For some people this psychological change happens as soon as they start taking hormones, and for others it happens as physical changes happen.

The degree and rate of change depends on factors that are different for every person, including your age, the number of hormone receptors in your body, and how sensitive your body is to the medication. There is no way of knowing how your body will respond before you start hormones.

Typical changes from estrogen (vary from person to person)

Average timeline effect of estrogen 1–3 months after starting taking hormones:

  • Softening of skin starting estrogen
  • Decrease in muscle mass and increase in body fat
  • Redistribution of body fat to a more “feminine” pattern
  • Decrease in sex drive
  • Fewer instances of waking up with an erection or spontaneously having an erection

 Estrogen affects the entire body. It’s not possible to pick some changes and not others.

Breast and nipple growth starts early but is usually gradual – sometimes  it can take two years or more for breasts to reach their maximum size.  If breast are not developed as per expectation, breast implants will inserted by surgery.

Most of the effects of hormones happen in the first two years. During this time, the doctor who prescribes your hormones will want to see you one month after starting or changing your dose, then 3–4 times in the next year, then every six months.

Most of the effects of hormones happen in the first two years.

 At appointments in the first two years, your doctor will likely:

  • look at your facial/body hair and ask how fast your hair grows back after you remove it
  • measure your breasts, hips, and testicles, and examine your breast/nipple development
  • ask about changes to your sex drive, erections, or other sexual changes
  • order a blood test to see what your hormone levels are
  • ask how you feel about the changes that have happened thus far

After two years have passed, you will likely just be asked if you notice any further changes from the hormones

Pallavi: Are These Changes Permanent?

Dr. Kusum: Most of the changes brought on by “feminizing” hormone therapy are not permanent. If you stop taking the medication, most of the changes will reverse themselves. There are two types of changes that will be permanent: breast growth with nipple size increase and sterility.

Pallavi: What Won’t Change?

Dr. Kusum: The list includes following:

1. Hormone therapy won’t solve all body image problems.

The point of hormone therapy is to feel more comfortable with your body by bringing physical characteristics closer to your internal sense of self. This relief can increase self-esteem and make you feel more confident and attractive. However, you will find that there are also attractiveness standards after hormone therapy, and you may not fit them.

2. Hormone therapy won’t make you into somebody else.

Whatever things you think of as your strengths and weaknesses will still be there. Hopefully, you will be happier, and that is good for anyone. Hormone therapy may help you to be more accepting of yourself. But if you are expecting that all your problems will pass away, and that everything is going to be easy emotionally and socially from here on in, you’re probably going to be disappointed.

This extends to mental health concerns as well. Tran’s people who were depressed because of gender dysphoria may find that taking hormones greatly alleviates their depression. However, if you have depression caused by biological factors, the stresses of transphobia or unresolved personal issues, you may still be depressed after you start hormones. Likewise, if you are having problems with drugs or alcohol, hormones will not necessarily get rid of those problems.

3. Hormone therapy won’t provide you with a perfect community.

Making physical changes is a way to bring who you are to the rest of the world so other people can see it. This process of self-emergence can be very liberating but it does not guarantee that you will find acceptance or understanding. Being realistic about the likelihood that you will at times feel lonely and alone after you start taking hormones is part of emotionally preparing for hormone therapy.

4. Hormone therapy won’t remove all “male”/“masculine” aspects of your body

Some physical characteristics aren’t changed by hormone therapy, or are only slightly changed. This includes aspects of your body that develop before birth (penis, sex chromosomes, etc.) and also physical characteristics that developed from the increase in testosterone at puberty. Hormone therapy may make facial and body hair grow more slowly and be less noticeable, but hair will not go away completely. You will have to either use Electrolysis or Laser for permanent hair removal.

“Feminizing” hormone therapy does not change voice pitch or speech patterns Speech therapy can help change pitch and other aspects of speech associated with sex/gender. Some Male To Females have surgery on their vocal cords or the surrounding cartilage to try to further raise voice pitch.

Once your bones have stopped growing after puberty, feminizing hormone therapy won’t change the size or shape of your bones. Facial feminizing surgery can be used to change the shape of the skull and facial features, and to reduce a prominent Adam’s apple. There are no treatments you can take to reduce your height or the size of your hands/feet.

Hormone therapy doesn’t decrease the risks of HIV and sexually transmitted infections. Depending on how you have sex, you may need to consider condoms, gloves, or other latex barriers.

 Pallavi: What are the Possible Side Effects/Risks of “Feminizing “Hormones?

Dr. Kusum: The medical effects and safety of “feminizing” hormones are not fully understood. There may be long-term risks that are not yet known.

Many of the known risks of “feminizing” hormones can be reduced by creating a hormone combination that is tailored to your specific situation.

Prevention includes periodic blood tests to keep an eye on potentially risky conditions, and minimizing other health risks. Stopping smoking is the number one thing you can do to reduce your risk of blood clots and heart disease (and also make it possible to increase the amount of estrogen that can safely be prescribed).


1. General risks

The medications taken in hormone therapy are processed by the liver. There is a possibility that taking hormones over a long period of time can put strain on the liver, possibly leading to liver disease. It is generally recommended that Male To Females taking feminizing hormone therapy get their liver enzyme levels checked periodically to monitor liver health. This is especially important if you have Hepatitis B or C, are a heavy drinker, or are otherwise at risk for liver disease.


Being visibly Trans in a trans phobic society has social risks. While it is possible to stay closeted if you’re taking small doses of anti-androgens (as the changes aren’t highly visible), estrogen causes changes that can be visible, including breast growth. Some visibly Trans people experience violence, harassment, and discrimination, while others have lost support of loved ones. If you are worried or stressed about these possibilities, or unsure of how to tell a loved one that you are thinking about taking or planning to take hormones, peer and/or professional counselling can be useful.

2. Side effects/risks of estrogen

Taking estrogen increases the risk of blood clots. Blood clots can cause death, permanent lung damage (clot in the lungs), permanent brain damage (stroke), heart attack, or chronic problems with the veins in your legs. The risk of blood clots is much higher for smokers, especially those who are age 40 or higher. The risk of blood clots may be reduced by taking estrogen via skin patch, cream, or gel (rather than pill/injection) and also by using a lower dose of estrogen.


Taking estrogen changes the way your body metabolizes and stores fat.

Taking estrogen can increase deposits of fat around your internal organs, which is associated with increased risk for diabetes and heart disease.

Estrogen also increases the risk of gallstones, which can block your gallbladder.

If you have chest or abdominal pain, you should see a medical professional right away.

Estrogen can cause increased blood pressure. There are other changes that can be tried, including other types of medication, exercise, and changes to diet.

In some Male To Females estrogen causes nausea and vomiting, similar to morning sickness in pregnant women. Estrogen can also cause headaches or migraines. If you are getting frequent headaches /migraines or the pain is unusually bad, or if you are vomiting for more than a couple of days, talk to a health professional.

It is not known if estrogen increases the risks of breast cancer.

3. Side effects/risks of anti-androgens

It affects the balance of water and salts in the kidneys. If the proportion of water and blood salts gets out of balance, you can have problems with low blood pressure or, rarely, high levels of potassium in the blood (this can cause changes to heart rhythm that may be life threatening).

The doctor who prescribes you hormones should check your potassium levels and kidney function on a regular basis if you have a history of kidney problems

Before taking medication that can raise blood potassium please ask your doctor.

Pallavi: When there are so many risk factors involved how should health checkup plan be made while taking hormone?

Dr. Kusum:

As long as you are taking hormones (possibly the rest of your life), you need to have regular physical exams and lab tests to monitor your overall health. The first year after starting hormones, the prescribing doctor will want to see you at least every 3–4 months; after that, you will have appointments at least every 6 months. At each of these appointments, the doctor/nurse will likely:

  • To ask questions about your overall health
  • To check your blood pressure and your weight, and listen to your lungs
  • To look at your arms, legs, hands, and feet to check your overall circulation as well as any signs of swelling, fluid retention, or pain
  • To check for early warning signs of health problems that can be caused by hormone therapy or made worse by hormone therapy (e.g., blood clots, heart disease, diabetes)
  • To recommend blood tests to check your blood sugar, blood fats, blood cells, and liver health
  • To recommend other tests (e.g., bone scan, heart stress function test) as needed, depending on your health history, age, and any signs of possible health problems

 Pallavi: We will stop it here. We will continue tomorrow.

Dr. Kusum OK Same time.

Pallavi: yes, sure


Pallavi: How much important it is to have a real life experience?

Dr. Kusum: It is very important.

The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that the patient’s wants to live with life time.

Since changing one’s gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Change of gender role and presentation can be an important factor in employment discrimination, divorce, marital problems, and the restriction or loss of visitation rights with children. These represent external reality issues that must be confronted for success in the new gender presentation. These consequences may be quite different from what the patient imagined prior to undertaking the real-life experiences. However, not all changes are negative

Pallavi: Thank you very much doctor for sharing highly valuable information with us. Do you have any written material on the topics discussed today?

Dr. Kusum: Yes, I have and prepared a file which I am giving you. She pulled the drawer out and gave the file to Pallavi.

Pallavi: Is everything over or any topic left to understand?

Dr. Kusum: One important topic is still there. It is on Surgery itself and follows up after surgery.

Pallavi: Can we come tomorrow same time? Can we finish both the topics tomorrow?

Dr. Kusum: Sure. Yes, we will finish both the topics tomorrow. You a good student

Pallavi: Thanks and they left.

Session – 4

Pallavi: May I come in?

Dr. Kusum: Why have you come alone? Where is Masi?

Pallavi: She suddenly had emergency so she has not come with me. Can we start?

Dr. Kusum:  I think I will try to avoid medical terms to make it simple.

Sex Reassignment is Effective and Medically Indicated in Severe GID. In persons diagnosed

with transsexuals or profound GID, sex reassignment surgery, along with hormone therapy and real-life experience, is a treatment that has proven to be effective. When it is prescribed or recommended by qualified practitioners, is medically indicated and medically necessary.

Breast Surgery

Breast augmentation and removal are common operations, easily obtainable by the general public Although breast appearance is definitely important as a secondary sex characteristic, breast size or presence are not involved in the legal definitions of sex and gender and are not important for reproduction. The performance of breast operations should be considered with the same reservations as beginning hormonal therapy. Both produce relatively irreversible changes to the body.

Genital Surgery

Genital Surgery for the Male-to-Female Patient. There is a series of surgery and require skilled surgery and postoperative care. Techniques include penile skin inversion or free skin graft to give shape of vagina. Sexual sensation is an important objective in vaginoplasty, along with creation of a functional vagina.

Other surgeries

They may be performed to assist feminization include reduction thyroid suction-assisted lipoplasty of the waist, facial bone reduction and face-lift. These do not require letters of recommendation from mental health professionals.

There are concerns about the safety and effectiveness of voice modification surgery and more follow-up research should be done prior to widespread use of this procedure. In order to protect their vocal cords, patients who elect this procedure should do so after all other surgeries requiring general anesthesia with intubation are completed.

Pallavi: What is importance of post-transition follow-up?

Dr. Kusum: It is equally important as hormone therapy, real life experience and surgery

Long-term postoperative follow-up is encouraged in that it is one of the factors associated with a good psychosocial outcome. Follow-up is important to the patient’s subsequent anatomic and medical health and to the surgeon’s knowledge about the benefits and limitations of surgery.

Long-term follow-up with the surgeon is recommended in all patients to ensure an optimal surgical outcome. Postoperative patients may also sometimes exclude themselves from follow-up with the physician prescribing hormones, not recognizing that these physicians are best able to prevent, diagnose and treat possible long term medical conditions that are unique to hormonally and surgically treated patients. Postoperative patients should undergo regular medical screening according to recommended guidelines for their age. The need for follow-up extends to the mental health professional, who having spent a longer period of time with the patient than any other professional, is in an excellent position to assist in any postoperative adjustment difficulties.


Sex reassignment surgery (SRS) has proven to be an effective intervention for the patient with gender dysphoria. Patient satisfaction following SRS is high and reduction of gender dysphoria following SRS has psychological and social benefits. As with any surgery, the quality of care provided before, during, and after SRS has a significant impact on patient outcomes

SRS is a multidisciplinary Endeavour drawing on plastic surgery, urology, gynecology, reproductive endocrinology, and otolaryngology.

Guidelines for the Recommendation of SRS

For any type of surgery, all patients must meet general criteria:

  • The patient must be physically fit for surgery
  • The patient must be psychologically prepared for surgery
  • The patient must have realistic goals and expectations of the surgery
  • The patient must have a good understanding of the interventions to be performed
  • The patient should be informed of, and understand, any alternative procedures
  • Risks and complications of the interventions must be reviewed and understood
  • The patient must have given their informed consent for the procedures



While preparing this chapter I have researched reputed medical journal and text books. First article was written as I understood and then I have got it checked by my friends from endocrinology, gynaecology and psychiatrist.  Every effort is made to make it as simpler as possible but in my friends opinions the above information is a must in the interest of patient under going SRS.

To be continued …

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