7th of January, 1994, was a happy day for my family, a son was born after quite a while. I often hear from my mother, the day I was brought home from the hospital was, according to her, a queer day of unlikely winter rains in Kolkata. From then till now, there has been multiple revisiting of this story, from gleeful family time bonding, sharing the joy of a son being born, to distress of knowing that I am not their son, to acknowledging that I am their daughter. My birth and all that I got with it, has been a constant battleground for me, my family, the world I live in. The gender I was assigned at birth has defined my life of what I am not, and what I could be. I have heard from many trans* people that we live parallelly in two worlds, of truth and of imagination, the truth of who I am, the imagination of me by the world I live in, therefore to me transition in the context of trans* lives means the articulation of the fact that the gender assigned at birth to me is not my gender. Transition is the movement towards embracing my authentic gender. It does not necessarily mean any visual, social, medical or legal change. Transition does not always mean change.

Kriti (name changed), a trans* feminine person, in their early 20’s defines transition, as saying that they are not a man, for them the movement from being seen as a man to stating that they are not one is a complete transition for them. Shamin (name change) a trans* woman in her early 30’s feels a high amount of distress with her body, as she states “ I want to get rid of my male parts.” For her transition is the movement from a body that is perceived in a certain way in the world she lives in, to a body that is perceived to be her truth, her authentic gender.

Transition is a personal journey and there is no one reality. For many trans* people, transition is having the language to define who they are, their true gender, for many of us it is the transformation of the body and for many of us it is being perceived in our true gender by the world. In a world, that reduces trans* identities to just transitioning, it is equally important to put it out there that trans* people are more than their bodies, their gender. The complete human-ness of us may not be defined by our gender journeys. For many of us transition is not even a part of our trans* lives.

However this does not take away the discomfort one may experience due to gender dysphoria, and gender incongruence, which is often triggered by misgendering, and multitudinal denial of rights that trans* people around the world continue to experience. From not being able to use a bathroom that affirms to one’s true gender, because of being perceived in a certain way to denial of entry in public spaces to refusal of healthcare and legal aid for not presenting in adherence to societal gender norms. Therefore transition often is a tool for survival, and hence in the context of transfeminine individuals a profound guide is helpful to ease navigation. Even though each trans* person may define their discomfort and comfort about their own gender identities, following are some widely agreed definitions.

• Gender: A social construct used to classify a person as a man, woman, or some other identity. Fundamentally different from the sex one is assigned at birth.
• Sex: A medically constructed categorization. Sex is often assigned based on the appearance of the genitalia, either in ultrasound or at birth.
• Transgender: An umbrella term for people whose gender identity and/ or expression is different from cultural expectations based on the sex they were assigned at birth. While transgender may refer to a woman who was assigned male at birth or a man who was assigned female at birth, transgender is an umbrella term that can also describe someone who identifies as a gender other than woman or man, such as non binary, genderqueer, genderfluid, no gender or multiple genders, or some other gender identity.
• Trans*: The term trans* acts as a more inclusive term than transgender for gender non-conforming and non-binary folks. The asterisk refers to all non-cisgender gender identities like trans women, trans men, gender non-conforming, genderqueer, gender non-binary, etc.
• Cisgender: A term used to describe a person whose gender identity aligns with the sex assigned to them at birth.
• Dysphoria: Clinically significant distress caused when a person’s assigned gender at birth is not the same as the one with which they identify.
• Gender incongruence: This is used to describe when one’s gender is different to the one assigned to then at birth. People with gender incongruence may describe themselves as transgender (trans*) or gender diverse. Every person experiencing gender incongruence may not experience dysphoria. 
• Transitioning: Transitioning is the process of taking steps to live as one’s true gender identity. Transitioning is different for each individual and typically includes social transition, such as changing name and pronouns, medical transition, which may include hormone therapy or gender-affirming surgeries, and legal transition, which may include changing legal name and sex on government identity documents. Some people may not choose to transition in certain ways for a variety of reasons. The extent of someone’s transition does not make that person’s gender identity any less or more
• Misgendering: Attributing a gender to someone that is incorrect/does not align with their gender identity. This can occur when using pronouns, gendered language (i.e. “Hello ladies!” “Hey guys!”), or assigning genders to people without knowing how they identify (i.e. “Well, since we’re all women in this room, we understand…”).
• Affirmed Gender: The gender by which one wishes to be known. This term is often used to replace terms like ‘new gender’ or ‘chosen gender’, which imply that an individual’s gender was not always their gender or that the gender was chosen rather than simply in existence.
• Tucking: Tucking refers to the practice of putting the penis and testicles between and behind the legs so they are no longer visible from the front. 
• Padding: Process of using products externally such as silicone or clothe to enhance breast shapes and size.  This can also be done by using padded bras.
• Neo Vagina: A vagina which is acquired through surgical intervention.
• Natal Vagina: A vagina which is acquired by birth.
• Pronouns: Linguistic tools used to refer to people’s gender in conversation – for example, ‘he’ or ‘she’. Some people may prefer others to refer to them in gender-neutral language and use pronouns such as they/their and ze/zir.

As we delve further into unpacking transitioning in the lives of transfeminine individuals, it is important to come face to face with the battle of finding acknowledgment from the world that there is more than what one can see, the expansive experience of gender goes beyond bodily appearance, the cis-het world sees a limited view of gender expression and identity and traps us in it. We are not breaking the norm, there is in fact no norm at all, the cis-patriarchal society has created a handbook of do’s and don’ts, and often our dysphoria stems from questioning those rules. I have been often asked this question, that when did I come to know that I am not a man, I find this question ridiculous since I never knew that I was one, it is the world that told me and reminded time and again that I am one, my battle has been to prove to the world that they are wrong, therefore for me transitioning has been a process of establishing my womanhood. Transitioning can be of different kinds, for example, social, legal, and medical, however, in this piece, we will delve into social and medical transitioning for trans* feminine people.

Social Transition

Social transitioning is the movement from one’s sex assigned at birth to socially expressing one’s true gender identity. This can look very different for different people, quite often, it begins with letting the world know one’s correct pronouns, wearing clothes that affirm their authentic gender, and using the correct bathrooms. For many transfeminine individuals, social transitioning feels like full and complete transitioning to express their truth.  There is no definite step or standardized process towards this, however following are some simple accommodations one may do to mark social transitioning 

• Coming out to friends, family, colleagues, and people who are a part of one’s social circle 
• Wearing clothes and make-up that are seen as feminine, growing hair to longer lengths, removing body hair and wearing jewellery that are perceived as feminine.
• Using names and pronouns that affirm feminine gender identities.
• Many trans* feminine individuals use tucking to feel more aligned with their affirmed gender.

It is important to remember the transition is not an individual responsibility but a social one, the onus of adjusting to new pronouns and presenting an authentic self, is stress-inducing in a world that constantly advocates for strict gender rules, therefore families, both natal and chosen, friends, organisations and systems must use correct pronouns, not dead name, ensure safety with regards to using correct bathrooms and so on. Organisations ensuring gender-neutral policies on workplace harassment including sexual harassment is important, to be inclusive of trans* people’s needs, along with a profound equal opportunity policy which ensures that discrimination does not happen due to reasons such as transition and enough opportunities are provided to ensure growth at the workplace. 

In order to ease the process of social transitioning, the following few things may help in easier navigation.

• Identifying queer-trans* collectives, groups and organisations locally are important for seeking any support in case of a situation of distress.
• Knowing clothing and lingerie shops that will not ask intrusive questions will ease navigation. Relying on peer and community support will help in identifying affirming shops. Finding the right bra might be hard and may feel dysphoric, many transfeminine people find it difficult to find a band size and cup size that fits. Bras are made mostly in a way where larger the band size, bigger is the cup, however many of us have larger body structures and smaller breast size. Therefore finding ‘A’ or ‘AA’ cups on 38 band size becomes a hazard. What often helps is finding cross-over cup sizes, for example, cross over size of 36 A could be 34 B, these are easily available online. It is important to know that band size is the measurement around the ribcage, where the bra underband sits, and is a number (like 34 or 36). Then the cup size, which is a letter, represents the difference between the underbust measurement and the one around the fullest part of the bust. This is describing the volume of the bra cup
• A lot of trans* feminine people use tucking and padding to feel affirmed, the following are definitions of these terms and some safer ways to do these
  1. Tucking:
  Using tapes specifically meant for tucking is safer to use instead of transparent sticky tapes. Tucking tapes are easily available on Amazon in a price range of Rs 200 to Rs 500 per kit. In case tucking kits are not available sports tapes can be used, these cost between Rs 700 to 1000 per tape. A gaffe is an underwear specifically designed for tucking and can be used without tape. Using a gaffe will also allow easy use of the bathroom. These underwear might cost slightly high, starting from Rs 1500 per underwear. When tucking, it is important to do so gently. If experiencing pain and discomfort, tucking may not be advisable.
  2. Breast padding:
  Using padded bras often helps in creating the required silhouette, however, there are silicone prosthetics that are also available which stick to the skin and can be worn under dresses and bras. These costs are slightly higher starting from Rs 2000, but can be used over a period of 6 months to a year. 

Medical Transition

Medical transition is getting desired changes in one’s body using gender-affirming medical procedures and interventions. These changes might help with distress and discomfort caused by gender dysphoria. Medical transitioning includes a variety of surgeries, therapies, and other procedures. To initiate the medical process, a trans* person will need to be certified with a Gender Dysphoria Letter by a psychiatrist. The procurement of this letter may take multiple sittings as the doctor has to ensure that they have a persistent and consistent gender identity that does not align with the sex assigned at birth. For this, all confounding mental health conditions are addressed and it is ensured that one has the capacity to make informed decisions. However, the certificate is not required for obtaining hair reduction services. 

1. Feminizing Hormone Therapy or Hormone Replacement Therapy (HRT)

Feminizing hormone therapy is used by transwomen, transfeminine persons, and non-binary people to get secondary sex characteristics that help them align their physical features with their gender identity. The therapy includes taking oestrogen supplements, also called female or feminizing hormone, to develop physical characteristics that are considered to be feminine. The oestrogen, depending on your tests and doctors’ advice, can be taken with or without anti-androgens that suppress and bring down hormones such as testosterone that give the body masculine characteristics. Each body is different and that’s why it is important to go through the tests that will help your doctor plan therapy, your dosage, etc. Remember, that hormones affect different bodies differently and the changes that take place in the body and the speed and extent of them vary from person to person. Please note that it is important to do follow-ups with your doctor to better handle side effects (if any) such as hot flushes, allergies, alteration to blood compositions. Long term intake of feminizing hormones will reduce testicular size and may cause infertility. In case, one wants to reproduce through biological means it is advised to cryopreserve their sperm. 

The average cost of HT in India ranges from Rs. 500  to Rs 2000 to per month, depending on the brand of the . This includes the cost of hormones, injections, blood tests, doctor visits, and follow-up appointments.

2. Puberty Blockers

These can be used at the pre-puberty or early puberty stage to block the hormones and delay puberty. Blockers can help in stopping and suppressing the undesired changes that can be caused by masculinizing hormones in transfeminine kids. 

The average cost of puberty blockers in India ranges from Rs. 2000 to Rs. 5000 per month. This includes the cost of hormones, injections, blood tests, doctor visits, and follow-up appointments.

3. Gender-affirming Surgeries

Gender-affirming surgeries include surgical procedures that can help a trans person align their body with their identified gender. People may and may not opt for surgery depending on several factors. The following gender-affirming surgeries are considered by transwomen, transfeminine, and non-binary people.

• Chest Surgery or Top Surgery:

Also known as breast augmentation or mammoplasty, is a surgical procedure that is used for the reconstruction of breasts, increasing their size and giving them a more feminine appearance. WPATH guidelines recommend 12 months of HRT before going for a mammoplasty. 

As has been already pointed out the effects of HRT are different in every person, hence, some trans women get significant and satisfactory breast growth after taking hormones and may not go for surgery while others may choose surgery to get desired shape and size.

• Genital Surgery/Bottom Surgery

Genital surgeries or Bottom surgeries in transwomen include various surgical procedures that help alleviate dysphoria and can help some people align their body with the gender they identify as. Surgical procedures are complicated and require a lot of after care. It is Important to make an informed decision and understand each and everything involved in it. 

• Vulvoplasty: This involves construction of a vulva without a vaginal cavity or canal. 

• Vaginoplasty: The procedure is similar to vulvoplasty but here the person also gets a vaginal canal.

• Orchiectomy: With this surgery, testicles are removed. 

• Scrotectomy: This surgery is done to remove the scrotum.

Cost gender affirmative surgeries for trans* fem folks range from 2 lakhs to 7 lakhs depending on the medical facility.

4. Gender-affirmative cosmetic surgeries.

• Facial Feminization and Cosmetic Surgeries and Procedures

Facial feminization and cosmetic surgeries include a variety of surgical procedures, which help reshape and redefine the features of the face such as the nose, cheekbones, forehead, jawline, etc. to give them feminine appearance. Facial feminization is not limited to surgeries and can also include non-surgical procedures such as laser hair removal Botox, fillers, liposuction, etc. 

• Tracheal Shave or Chondrolaryngoplasty

A lot of Trans women and non-binary people who feel dysphoric about the size of their Adam’s apple opt for a tracheal shave to reduce the size of Adam’s apple and get a more feminine appearance. 

Facial feminization processes costs start from Rs 2 Lakhs and may range up to 7 Lakhs depending on the procedures incurred.

5. Post Operative Care

To ensure that the newly constructed vagina maintains the desired depth and width, the patient will have to begin using a vaginal dilator as soon as the bandages are removed. Ensure that the patient understands how critical compliance with dilation is to keep the vagina patent and functional.

Dilation Instructions:

Inserting the dilator for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed. Furthermore, regular douching and cleaning of the vagina is recommended.

Vaginal Deepening:

It is possible to experience loss of depth or width of the vaginal canal after vaginoplasty. This can be due to a variety of factors, including inconsistent dilation and individual outcomes from healing. An additional surgery using full thickness skin grafts can be used to help increase the width and/or depth of the vaginal canal. The skin grafts are generally taken from the lower abdomen, back of the arm, or the inner thigh. Frequent dilation is required after this surgery, similar to the frequency of dilation required after an initial vaginoplasty.

Please note that it is important to use lubricant as the neo vagina will not produce its own lubrication

6. Hair Reduction

• Laser hair reduction:

Laser hair removal can be an effective treatment of gender dysphoria for patients who have unwanted hair on their face or body, and it can be used to remove hair follicles for any transgender person who wants bottom surgery. Many patients choose laser hair removal because it offers long lasting (and in most cases, permanent) results. It’s important to know that multiple sessions will be needed to achieve desired results, and the result is hair reduction (the hair follicles become lighter and finer), not complete hair removal.

Cost of laser hair reduction will vary depending on the area of skin that needs treatment. It typically costs between Rs. 2000 to 4000 for facial hair per session, and Rs 4000 to 6000 per session for chest and upper body. Most individuals require 8 to 10 sessions.

• Electrolysis:

Electrolysis is a permanent hair removal method. Medical electrolysis destroys the growth center of unwanted hair using electric current. A very fine probe (a stainless-steel wire about half the thickness of a strand of hair) is inserted through the surface of the skin at each unwanted hair follicle. The hair is then carefully removed with tweezers. The disadvantages of electrolysis are that it’s time-consuming and expensive. Multiple sessions will be necessary to remove all unwanted body and chest hair.

Cost of electrolysis is between Rs 2000 to 4000 per session. The full process may take 8 to 24 months, depending on the amount of hair.

It is 2023, I walk the streets with glittery eyes, cheeks flushed red with my favourite blush, walking my stride in high heels. Transitioning for me has not been an easy journey and it continues to often be filled with fear as there is frequent lack of information and support. As I continue to walk, collecting my pride in every step, I realise that there wasn’t much I could find to help me ease my journey. So perhaps, the above guide aims to serve the much realised knowledge gap that has remained undocumented, unimportant in conversations of main-stream health and mental well being. 

Trans* lives are important, our joy needs to occupy space. Though this piece is not the bible, however it sums up perspective that many trans* people have found value in. Our bodies, our lives hold years of knowledge that needs to be spoken about to ground our reality to ensure a sense of community that we so heavily rely on. I hope you too, find your much needed euphoria while trying on your favourite lipstick with pride and wear that exquisite bra with glee. 

Do You Have Any Question? #AskQueerLips

Acknowledgments

We would like to extend our gratitude to United For Transgender Health for providing resources for the article. Queering Healthcare: A Step Towards Inclusive Health® (First Edition), Dr Sakshi Mamgain for UTH-United for Transgender Health, 2022.  https://linktr.ee/unitedfortransgenderhealth

About the Author: Riju (she/they) is an intersectional trans* feminist working in the space of gender justice, sexual and reproductive health and rights and inclusive education. She is passionate about writing on themes of pleasure, sex, sexuality of trans* lives.

Note: We do not endorse or guarantee the accuracy, completeness, or usefulness of any information provided. Consult your healthcare provider before making any healthcare decisions or changes to your treatment based on information obtained from this platform. In case of a medical emergency or urgent situation, please seek immediate medical attention or contact your local emergency services.