Saturday, July 11, 2015

Hijras – The Third Sex

The word hijra is an Urdu word meaning eunuch or hermaphrodite. However, in reality, hijras are very diverse and most join the community as young boys. Hijras consist of hermaphrodites, as well as women who are unable to menstruate and lead the “normal” female life which consists of getting married and producing children. However, a great number of hijras are men who identify themselves as more feminine than masculine, mostly because their sexual desire is for men and not women.

The hijras are an ancient community in the Indian subcontinent with members in Pakistan and Bangladesh. They are classified as the third sex and have their own gender role. Serena Nanda describes them as “man minus maleness” and “man plus woman”. They are not considered either because of their inability to reproduce. In the Indian subcontinent, great emphasis is placed on one’s ability to have children. Someone who is unable to have children is not considered a true man or woman. Therefore, hijras are a separate identity, who fit into neither category, with aspects of both genders.

The population of hijras in India is estimated to be between 50,000 and 1.2 million. There is a huge disparity in the numbers because population censuses only give space to define either males or females. There are no reliable statistics.

The traditional occupation for hijras consists of begging for alms when bestowing blessings on male babies and at weddings. They are notorious for knowing when a baby boy is born and arriving at the right house to sing and dance and demand alms. Most of their songs are about pregnancy and their dances are mostly parodies of pregnant women. They also demand to inspect the baby to check if he is a “normal” boy or an intersexed baby, in which case they might start demanding that the child be handed over to them as it is a hijra. It seems ironic that the hijras, who are unable to reproduce, have the power to bestow fertility blessings on brides. The power to do so comes to them through Bahuchara Mata who is a version of the Mother Goddess. The Mother Goddess plays the role of the mother, who is the creator and nurturer, as well as the destroyer. Hence, she has the power to grant fertility or take it away. However, because of increasing westernization, the traditional roles of hijras are no longer in as much demand as they used to be. Hijras have a hard time accessing houses and apartment buildings because of security, and with an increasing middle class that has access to other forms of entertainment such as cinemas, hijras are no longer required for diversions. A great number of hijras are turning to prostitution which goes against the hijra ideal of asceticism. Ideally hijras are meant to renounce sex and be the devotees of Bahuchara Mata.

All “true” hijras are required to undergo an emasculation operation called nirvan. Nirvan means rebirth and most hijras see this operation as their rebirth into the hijra form from the male. It consists of the complete removal of the penis and testes and is essential in transforming them from men to women. Only after this are they granted their special powers of blessings and curses. The operation consists of three stages: the preparation, the operation and the recovery. All stages consist of various complex rituals. The preparation stage involves praying to Bahuchara Mata and waiting for a good signal from her. One such gesture is the breaking of a coconut, and unless the coconut is broken in half, the hijra-to-be does not go through with the operation because it is seen as a sign that Bahuchara Mata does not want this person to be a hijra just yet. Once the operation has been granted to a hijra, she is given a period of rest where she is not allowed to work or be involved in any sexual activity. This can vary from a week to a month. The actual operation is done by a hijra called a dai ma who is granted the power to do the operation by Bahuchara Mata. On the day of the operation, the dai ma lets herself into the room of the hijra to be operated on and prays to Bahuchara Mata. Then she awakens the hijra to be operated on and encourages her to pray and repeatedly chant Mata, so that she falls into a trance like state. Then the assistant holds the hijra back and encourages her to bite on her hair while the dai ma ties up the penis and testes, makes two diagonal cuts in them and pulls them out. The severed genitals are then buried under a tree and a tube is placed in the urethra. The blood coming out is allowed to flow because it is seen as the bad “male” blood and getting rid of it will get rid of the male inside the hijra. This is one of the reasons why hijras do not get proper doctors to operate upon them since they would stop the blood flow. The time when the blood is flowing is considered the most important time where the hijra, who has just been operated upon, is battling between life and death. Many prayers are said for her, but the blood is never stopped. The recovery period also involves many rituals which include forty days of rest (similar to that for a woman who has just given birth) and vomit inducing foods to get rid of the “maleness”. This operation is against the law in India; therefore, it is done behind closed doors.

Although most hijras dress as women, they engage in activities that would be considered inappropriate for Indian women such as dancing in public. They almost seem to be a caricature of women because hijras wear their hair long and wear saris and other traditional female dresses, whereas, in modern subcontinental society, the upper and middle class women cut their hair and wear western “male” clothes. Hijras also sing and dance and sway their hips in public, which women do not do.

All hijras are part of one community. The community consists of households where all the members contribute to run it like an Indian subcontinental joint family system. All hijras are part of one of seven houses which function as a family unit. Each house has a chief who represents them at meetings with all the other houses in order to discuss important issues. Being part of any specific house does not mean having an advantage or disadvantage over anything. They came into being in order to organize the community. Anyone wishing to join the hijra community must be sponsored by a guru whose house she will join. The guru functions as a teacher, as well as a mother. In fact, hijras refer to their guru’s guru and other members of their household with feminine relative names such as grandmother (nani for the guru’s guru) and aunt (khala for their guru’s sisters). Hijras, whose gurus have more than one disciple, refer to each other as their sisters.
Although most hijras identify with Islam, they do not seem to have a conflict with being part of a community that worships the Mother Goddess instead of Allah. Most of them fast during the Muslim holy month of Ramzan, get buried instead of cremated, and if they get married, they have a Muslim wedding called a nikkah. Some hijras do get married and live with their husbands, but by doing so, they are not cut off from their community. They live apart from them but still work with them. Most of them also adopt Muslim female names.

The hijras acceptance into Indian society is due to Hinduism more than Islam. Many Hindu deities are linked to the hijras such as Arjun (who lives for a year as eunuch), Vishnu (who transformed himself in to the most beautiful woman in the world in order to defeat a demon by seducing him), Shiva (who is both male and female and whose image is represented by a phallus in a vagina), and Krishna’s son Samba (who was a homosexual and cross dresser). “What is noteworthy about the hijras is that the role is so deeply rooted in Indian culture that it can accommodate a wide variety of temperaments, personalities, sexual needs, gender identities, cross-gender behaviours, and levels of commitment without losing its cultural meaning.” (Nanda, Neither Man nor Woman: The Hijras of India 19-20). Because hijras are able to identify with different figures in Indian mythology, they are tolerated and were traditionally much respected as the third sex. Also, as Serena Nanda points out, hijras do not have to conform to one set of norms since they are a very diverse group and have room for such diversity in their community.

The British rulers in India stripped the hijras of the laws that granted them the protection they received under Muslim rulers and regarded them as a menace to society. Because the hijras did not fit the category of male or female, the British passed laws that required the hijras to wear turbans in order to distinguish them from women.

Hijras in India are actively involved with raising awareness on issues, such as the problems related to discrimination against hiring hijras for certain jobs because of who they are. All official documents require that the sex of the individual be stated as either male or female, leaving no space for hijras. Hijras are not allowed in most restaurants, even when they have the money to eat. The treatment of hijras in hospitals is an issue of great concern because whenever a hijra is admitted in to a hospital, the doctors never knows whether to place her in the male ward or female ward. Some hijras are actively involved in raising awareness about AIDS because it is estimated that one in three hijras in Bombay is HIV positive.

Q: Do the hijras leave the penis and take out the testes only?
A: In order to become a “true” hijra they have to remove both so that they are as close to being a woman a possible.

Q: Hasn’t hijra prostitution been around for a very long time?
A: Not to the extent it is today. Earlier, hijras used to sell sex at certain temples for religious purposes. However, today some gurus encourage young hijras to become prostitutes because that brings them more money than other jobs do.

Q: Are hijras incapable of reproducing biologically?
A: Yes. One of the most important tests for joining the hijra community last century was proof of impotence. Potential hijras were made to sleep next to a prostitute for a number of days.

Q: Do hijras marry within the hijra community, or do they marry men or women?
A: They marry men and refer to them as their husbands.

Q: How are hijras treated in Pakistan and India?
A: They are viewed with different attitudes. Some people regard them as a menace whereas others feel sorry for them. Because Pakistan is a Muslim country, hijras do not have the same kind of respect as they would get under Hinduism. They are harassed and do not have much protection.

Q: Did the concept of hijras come to the Indian sub-continent from the Muslims?
A: They probably brought a different attitude with them which must have merged with what the hijras are today, especially since most of them identify with Islam. However, the concept of hijras is in Hindu literature and is part of the Hindu religion.

There were two major sources used for this presentation:
Nanda, Serena. Neither Man nor Woman: The Hijras of India. 1999, Belmont, Wadsworth Publishing Company.
Herdt, Gilbert, ed. Third Sex, Third Gender. 1994, Zone Books, New York.

Courtesy: "–-the-third-sex/"

Eunuchs not always born but made

They gatecrash weddings and childbirths, sing lewd songs and make extortion demands that are quietly acceded to due to the accident of their birth.

But a recent study by the All-India Hijra Kalyan Sabha (AIHKS) reveals that only 1 per cent of society's invisibles are born eunuchs, while the rest have joined the community under duress or for money.

Khairali Lal Bhola, Sabha president, says most eunuchs in the country are not transvestites or hermaphrodites. They are actually castrated men or chibbras.

The study indicates that Delhi alone has 30,000 hijras. Putting a number to the growing population, it says about 1,000 youths are converted into eunuchs in Delhi every year.

As per estimates, only one in a lakh is born a eunuch. Arun Kumar from Sahara Group, an NGO that works with eunuchs, says what the statistics don't reveal is how kids and youths are kidnapped for sex work.

"Eunuch gurus and their paid agents get these kidnapped youngsters addicted to opium and then initiate them into homosexuality. Eventually, they are castrated in a gory and risky operation."

Indira, general secretary of the Hijra Kalyan Sabha and victim of a kidnapping, hit out at eunuch gurus. "These gurus have become millionaires by making eunuchs service homosexuals," says Indira, formerly known as Rajendra, who was castrated.

"I can never return to my wife and two daughters. My life has been destroyed forever." Alka, 45, is fair and lighteyed but he's grown to resent his looks.

"I lost my parents and siblings to communal strife in Kashmir, but a worse fate was in store for me. Eunuchs picked me up and brought me to Delhi.

In no time, I was introduced to hashish and brown sugar (an impure form of heroin)," says Alka, a sex worker who's now quite popular with the gurus for the money he brings in.

Kirpal,who was sold to eunuchs by his employer at Old Delhi railway station, was luckier. Though he did have to work as a sex worker, the sabha saved him from castration.

The Supreme Court intervened to order that Kirpal be provided full protection. He is now working for the Hijra Kalyan Sabha.

But the sabha president admits this is the only rescue that his organisation has managed. "Others will probably have to wait for the eunuch-police nexus to end," says a dispirited Bhola.

Friday, July 10, 2015

How were Eunuchs castrated?

The magnitude of the question runs from at least the Assyrians (probably earlier) until now, and covers many major civilizations. Add on to this, many societies had more than one way to skin a cat, some societies having more than one variety of eunuch on top of that, and a general taboo about the procedure leading to a muddled mess of 3rd party rumor-reports and outsider travelogues as our main basis of information on how to make a eunuch. This is also probably the most boring aspect of eunuchs to me to be honest! It's like you study the history of steamships and everyone asks what iron they used.

There are two basic types of eunuchs in history, “clean-cut” (no penis or testicles) or just a removal of the testes. A simple removal of the testes is historically the most common sort. There’s a third type where the penis was removed but the testicles left, but it’s only referenced in a few places for Islamic eunuchs and seems to have been a very limited thing, and there’s really no reason to do it like this other than punishment.
For clean-cut eunuchs there was basically only one method, cutting it all off in one go which has been described for the Ottoman black eunuchs, and here’s the Chinese version from G. C. Stent who is probably our most reliable Western reporter:

When the operation is about to take place, the candidate or victim--as the case may be--is placed on a kang in a sitting--or rather, reclining position. One man supports him round the waist, while two others separate his legs and hold them down firmly, to prevent any movement on his part. [...] with one sweep of the knife he is made a eunuch.
The operation is performed in this manner:--white ligatures or bandages are bound tightly round the lower part of the belly and the upper parts of the thighs, to prevent too much hemorrhage. The parts about to be operated on are then bathed three times with hot pepper-water, the intended eunuch being in the reclining position as previously described. When the parts have been sufficiently bathed, the whole,--both testicles and penis--are cut off as closely as possible with a small curved knife, something in the shape of a sickle. The emasculation being effected, a pewter needle or spigot is carefully thrust into the main orifice at the root of the penis; the wound is then covered with paper saturated in cold water and is carefully bound up. After the wound is dressed the patient is made to walk about the room, supported by two of the "knifers," for two or three hours, when he is allowed to lie down.
The patient is not allowed to drink anything for three days, during which time he often suffers great agony, not only from thirst, but from intense pain, and from the impossibility of relieving nature during that period.
At the end of three days the bandage is taken off, the spigot is pulled out, and the sufferer obtains relief in the copious flow of urine which spurts out like a fountain. If this takes place satisfactorily, the patient is considered out of danger and congratulated on it; but if the unfortunate wretch cannot make water he is doomed to a death of agony, for the passages have become swollen and nothing can save him.

The exposed urethra would form a standard stoma. Scrotal tissue healed with some cicatrix formation but really nothing too dramatic. There are some historical drawings and photographs of this but I do not link to them in here as they were obtained non-consensually. Google “stoma” if you really need to know though, they all form the same looking thing really.
For removing the just the testes, you’ve got a few more options.
  • Crushing the testes inside the scrotum with no cutting, most likely used for Assyrians (through some context clues I can go into), reportedly used for young boys and infants in the Byzantine empire, and also reportedly used for Italian castrati.
  • Cutting the scrotum open and removing the testes. This is rather finicky but one method reportedly in use in Italy during the heyday of the castrati.
  • A full removal of the scrotum with testes inside. I don’t suppose you do any livestock farming? This is the method in which the “castrator” tool was for, which are still used for livestock. It would often be heated to cauterize the wound right off, which prevented infection.
 Courtesy: ""

Thursday, July 9, 2015

The eunuchs of India: An endocrine eye opener


There are established guidelines for the endocrine and overall treatment of transsexual persons. These guidelines provide information about the optimal endocrine management of male-to-female and female-to-male transsexual persons. India has a large community of eunuchs, also known as hijras, who are men with gender identity disorders. While this community has been studied from a social and medical point of new, no endocrine work has been done in them. This exploratory article tries to discuss the endocrine status, health, and management of the eunuchs.


The eunuchs or hijras have been an integral part of Indian society since time immemorial.[1] Eunuchs were prized as guards of harems, and as companions, by kings and emperors.

An estimated 5–6 million eunuchs live in India.[2] In modern day India, eunuchs often live a ghetto-like existence, in their own communities. They make a living by dancing and celebrating in births and marriages but often have to resort to other means to make both ends meet. Yet, the community is beginning to make a mark in the national mainstream as well. A member of the eunuch community, Shabnam Mausi, was elected as a member of the legislative assembly in 1999. Others have been elected as mayors and municipality presidents.[2]

Eunuchs are given a homogenous social identity, irrespective of their physical or endocrine status. The Sanskrit term “tritiya prakriti,” or third nature, is used to classify them.[3] They are considered infertile persons, with a female gender identity, with masculine secondary sexual characteristics, with or without male external genitalia, with feminine gender role, with predominantly homosexual identity. While the sexual identity of eunuchs is considered homosexual by the general public, no work has been done to assess their sexual orientation or endocrine status.

The eunuchs can therefore be termed as male-to-female (MTF) transsexuals. The etiology of transsexualism or gender identity disorder is controversial. MTF transsexual persons may have abnormal hormonal imprinting, genetic makeup, or psychological attitude toward gender. They constitute a heterogenous group of people, rather than conforming to a single genotypic or sexual stereotype.


Although the community appears a homogenous monolith to outsiders, Indian eunuchs include a wide variety of medical, psychological, and endocrine conditions and variants.

The vast variety of terms used to translate the Hindi word “hijra” makes things confusing for the outsider. Eunuchs, transvestites, homosexuals, bisexuals, hermaphrodites, androgynes, transsexuals, and gynemimetics are some of the words used to describe the community. They are also called intersexed, emasculated, impotent, transgendered castrated, effeminate, or sexually anomalous or dysfunctional.[4]

Some eunuchs are born with intersex disorders of sexual differentiation and are handed over to the community leaders by their patients.[5,6] Other MTF transsexuals choose to join the community of their own free will, and undergo crude, yet radical, gender reassignment surgery. Yet others are coerced into doing so because of a multitude of factors.[2,6,7] A case report of two eunuchs, from north India reports: “Young boys were allegedly kidnapped and kept under illegal custody for months together. After demoralization had set in due to prolonged confinement, surgery was done on their private parts and female hormones were given to the persons. The converted person were made to wear female garments and performed in groups as a female dancers and earned money while in captivity.”[7]

Physical intersex and gender identity disorder are two different conditions. The management of intersex is well documented in endocrine texts and journals. Ample work has also been published on the sexual, psychological, legal, cultural, and anthropological aspects of the eunuchs.[8,9] However, it is surprising that not a single publication is available which focuses on the endocrine status or management of the eunuch community. This brief communication will focus upon the potential role of endocrinology in the management of eunuchs with gender identity disorder.


As there is considerable variation among different eunuchs, a customized, tailor-made approach to endocrine management will be required. Comprehensive psychological, medical, endocrine, genetic, and laboratory assessment will be necessary before beginning endocrine therapy.

Lack of communication between health providers (specially, endocrinologists) and eunuchs, lack of awareness about potential endocrine treatment among eunuchs, a keep distrust of the modern medical system, and a desire to preserve their privacy are some of the reasons why Indian eunuchs do not seek endocrine help.[10]

It is our responsibility, however, to share our knowledge with those who need it. A beginning can be made by discussing the topic of transsexual endocrine management at medical education forums and disseminating information among other medical colleagues. This will certainly stimulate researchers to study and improve the endocrine health of eunuchs.


Diagnosis of transsexualism needs to be made by an endocrinologist and a psychiatrist or psychologist. The endocrinologist is best placed to rule out disorders of sexual differentiation, while the mental health professional decides if the eunuch fulfil the criteria for gender identity disorder.[11] In virtually all Indian eunuchs, however, the person has already been living a female gender role, with a female gender identity. A formal diagnostic assessment, therefore, may just be a formality. However, it should still be done to rule out cases of intersex, with male gender identity, who may have been coerced to join the community.

Adult, transsexual eunuchs are eligible for cross-sex hormonal therapy if they fulfil DSM-1V-TR or ICS-10[12,13] criteria for transsexualism or GID; do not suffer from psychiatric comobidity that interferes with workup or treatment; know and understand the risks, benefits, and outcomes of hormonal treatment; and have lived as male-to-female transsexuals for at least 3 months.[14]

Adult transsexual eunuchs demonstrate readiness for therapy of their female gender identity consolidated by real-life experience or psychotherapy, if they have stable mental health, and if they are likely to take hormones in a responsible manner.[14] Before beginning therapy, eunuchs with functioning testes should be informed about the potential for cryopreservation of sperms for future use.


It is extremely rare to encounter prepubertal boys in Indian eunuch communities. Occasionally, however, a prepubertal male-to-female transsexual may request induction of puberty.

In India, this is an issue with grave ethical, moral, and legal implications. Until clear consensus is generated about the ability of adolescents to give consent for major medical decisions, this is an area best left untouched. Other guidelines, however, do specify protocols for induction of female puberty in biologically male transsexuals.[11]


The aims of hormone replacement therapy in eunuchs are to minimize endogenous androgen levels, suppress masculine secondary sexual characteristics, and use exogenous female sex steroids to achieve feminine characteristics.[11]

The principles applied are the same as those used in treatment of female hypogonadal patients. The patient should be made aware about the risk of thromboembolic disease, macroprolactinoma, hepatic dysfunction, breast cancer, coronary artery disease, cerebrovascular disease, and migraine, with exogenous estrogen. The patient should also understand the need for regular medical follow-up and investigations.

Management is usually done with an antiandrogen, prescribed concurrently with estrogen. The antiandrogens reduce endogenous testosterone, ideally to levels found in biological women, and allow exogenous estrogen to demonstrate full effects.

The antiandrogens of choice are spironolactone,[15] cyproterone acetate,[16] and the gonadotropin-releasing hormone against, goserelin.[17] While spironolactone is used in a dose of 100–200 mg/day, cyproterone acetate should be prescribed as 50–100 mg/day. For comparison, commercially available oral contraceptives contain 2 mg of cyproterone per tablet. The dose of goserelin is 3.75 mg SC monthly.[11]

Estrogen therapy can be administrated orally (estradiol, 2–6 mg/day), transdermally (estradiol patch 0.1–0.4 mg twice a week) or intramuscularly (estradiol 5–20 mg every fortnight).


Monitoring is done by testosterone and levels. If synthetic or conjugated estradiols are used, serum estradiol will not be able to indicate feminization status accurately. Target testosterone and estradiol should be the midrange for adult biological premenopasual women.[11]

Synthetic estrogens are linked with a higher incidence of venous thromboembolism. Many eunuchs consume oral contraceptives regularly, in a (partially) misguided attempt to achieve feminine features, without monitoring.

Patients begun to experience desired physical changes in the first 3–6 months of therapy. These changes are accompanied by an improvement in psychological well-being, which makes the exercise gratifying for the treating endocrinologist.

The earliest changes (in 1–3 months) include decreased libido and lack of erections (if the patient has a phallus). Body fat redistribution, decrease in muscle mass, change in skin texture, breast growth, and decreased testicular volume (if the patient has functioning testes) follow within 3–6 months. Decreased terminal hair growth occurs later. There is no change in voice pitch or scalp hair. Maximal changes are achieved in 2–3 years.[11]

Regular evaluation should be done at three-monthly intervals, to assess the status of feminization, and watch for adverse effects. Serum estradist should not be allowed to exceed the normal range for healthy females. The target serum testosterone should be <55 ng%, while an estradiol of 200 pg/ml should be aimed for. Prolactin levels should also be assessed. If spironolactone is being administered, serum potassium should be checked periodically.[11]

Prolactin levels may be elevated in eunuchs on estrogen. This may be because of estrogen per se,[18] or because of concomitant psychotropic medication.[11] A reduction in estrogen therapy is warranted in such cases.[18]

While on hormonal therapy one should not forget that eunuchs are exposed to the same risk of other medical illnesses as the general population. Appropriate screening and care for acute, chronic, and metabolic diseases, as per general practice guidelines, should be provided to patients under one's care.


While Western recommendations recommend genital sex reassignment as a final step of transsexualism, Indian eunuchs have often undergone crude surgery before presenting to the endocrinologist. This may include orchidectomy and partial or complete penectomy.

One can help improve cosmetic appearance and sexual function by advising appropriate sex reassignment, revision, or surgery. Options include complete penectomy and creation of a neovagina while preserving neurosensory supply to the neoclitoris.[19]

Voice therapy, breast augmentation, mechanical therapy for facial and body hair, and plastic surgery are now available for patients who desire these modes of therapy.

Eunuchs should ideally be treated with estrogen and antiandrogens for at least 12 months; have successfully completed years of living with female gender identity in female gender role; and be aware of all practical aspects of surgery, before being considered eligible for gender reassignment surgery.[14]

The readiness criteria for sex reassignment surgery include “demonstrable progress in consolidating one's gender identity,” and in “dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health.”[14] As mentioned earlier, however, surgery is often resorted to by Indian eunuchs, without undergoing hormone modification therapy. This may lead to suboptimal physical, social, and sexual results.


The eunuchs are an important, and integral, part of Indian society. No celebration is considered complete without their participation and blessing.

Yet, they remain a neglected part of our population. Although they have obvious endocrine dysfunction, no systematic attempt has been made to evaluate, assess, and improve their endocrine health. This is in sharp contrast to the yeoman work done by other scientists, from allied disciplines, to destigmatize the eunuchs.

A concerted effort is needed by endocrinologists, and allied specialties, to understand the endocrinology of eunuchs and to optimize it.

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2. Swain S. Problems of third gender. In: Swain S, editor. Social Issues of India. New Delhi: New Vishal Publications; 2006. [Last Accessed on 2011 Aug 5]. pp. 57–9. Available at: .
3. Wilhelm AD. Tritiya-Prakriti: People of the Third Sex. Xlibris Corp. 2010. [Last Accessed on 2011 Aug 5]. Available at: .
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9. Gupta A. Right to sexual identity - Legal concerns of the eunuch community in India. Int Conf AIDS. 2002;14 abstract no.TuOrE1158.
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14. Meyer WJ, 3rd, Bockting W, Cohen-Kettenis P, Coleman E, Diceglie D, Devor H, et al. Harry Benjamin International Gender Dysphoria Association. The Standards of Care for gender identity Disorders, 6th version. Int J Transgenderism. 2001. [Last Accessed on 2011 Aug 5]. p. 5. Available at: soc_2001/index.htm .
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18. Gooren LJ, Harmsen-louman W, Van Kessel H. Followup prolactin levels in long-term oestrogen-treated male-to-female transsexuals with regard to prolactinoma induction. Clin Endocrinol (Oxf) 1985;22:201–7. [PubMed]
19. Monsttrey S, De Cuypere G, Ettner R. Surgery: General principles. In: Ettner SR, Monstrey S, Eyler AE, editors. Principles of Transgender Medicine and Surgery. New York: Haworth Press; 2007. pp. 89–104. RP.

Courtesy: ""