Gender Confirmation Surgery - Part Three (before)

Very soon, I’m scheduled to have a surgical procedure designed to alter my physical appearance as well as certain functions of my existing sexual characteristics. The goal of the surgery is to make my body more in line with my desired gender.

If you’ve read any of my earlier posts, no, you’re not experiencing Déjà vu. I’ve already undergone some gender-confirming surgery (GCS), and you can check out what I had to say about the surgery before and after: Gender Confirmation Surgery and Me – Part 1 (before), or Gender Confirmation Surgery and me – Part 2 (after). 

Consequently, this upcoming surgery is Part Three – with Part Four to come soon!

Here is where I’d normally go into detail about being transgender female, the types of medical transition, and my overall journey. However, I discuss all of that in detail in my other surgery-related posts – go read them, then come back here. Cool? Oh, and if you’re turned off by discussion of genitals, or you know me personally, and it’s weird reading about what’s in my pants, you probably shouldn’t read further. And hey, if I do know you personally: “Hi! I hope you’ve been staying safe and sound! Drop me a line sometime – we’ll catch up.” 🙂

The procedure I have scheduled shortly (assuming COVID doesn’t mess things up – 2020, oof!) is a limited-depth vaginoplasty. Also sometimes called a shallow (or zero) depth vaginoplasty. 

Basically, this involves a talented surgeon reforming my penis into the look and function of a vagina. Since I’ve opted for the limited-depth vaginoplasty – there will be very little depth to my vagina.  

I didn’t know this was an option until I started looking into it a year ago – I was (like many others, I think) under the impression that any vaginoplasty procedure resulted in a full-depth vagina.

“Why wouldn’t you want the full-depth procedure?” I hear you ask. Well, many reasons – and since you asked, I’ll go into some basic details: 

 - Longer and much more difficult recovery time.
 - Requires years of vaginal dilating – with dildo-like devices.
 - Much more expensive.
 - Requires scrotal skin to turn into the vaginal canal – which I no longer have (see my post about my first surgery). Or requires skin grafts from the inner thighs.
 - Only required if I desire vaginal intercourse – which I do not.

These reasons are all fairly clear, but the motivations behind my choice for the limited-depth procedure are more complex. Suffice it to say I’m making the correct choice for myself. Any trans person who chooses to pursue any kind of medical transition has complex reasons, thoughts, and emotions behind their unique choice.

Friendly reminder it’s NEVER ok to ask a trans person about their medical transition! Not all trans people choose or need to have surgery or take hormones – that doesn’t make them any less than the gender with which they identify. Remember: Trans women are women, trans men are men, and non-binary genders are valid.

Ok, now that that’s out of the way, let’s discuss insurance, World Professional Association for Transgender Health (WPATH), therapists, and getting ‘permission’ to have gender surgery. (I’ve touched on these issues in posts about my previous gender surgery – but I’ve focused on different elements/issues here, so it’s worth reading.

Anyone who has had any kind of surgery knows it isn’t cheap. (For-profit healthcare in America, right?) Many people are able to get life-saving surgeries covered under some form of health insurance, but gender confirmation surgeries are trickier. Long considered ‘cosmetic surgery’ (and thus not covered under insurance) it wasn’t until semi-recently that many gender surgeries could be justified as ‘medically necessary’ by insurance companies. There’s a catch, however. In order for a gender surgery to be considered ‘medically necessary,’ there are hoops that must be jumped through vis-à-vis WPATH’s Standards of Care for Transgender Individuals (version 7). The hoops (aka ‘requirements’) are different depending on the procedure desired. The requirements for vaginoplasty in MtF patients are (with my comments in parentheses):

 - Persistent, well-documented gender dysphoria; (This is a big one. It involves obtaining TWO letters from two different ‘mental health professionals’ that document the patient’s gender dysphoria. I have a lot to say about this, so more about it below…)
 - Capacity to make a fully informed decision and to consent to treatment;
 - Age of majority in a given country; (18 for this procedure, possibly 16 for hormone replacement therapy – information online varies.)
 - If significant medical or mental health concerns are present, they must be well controlled; (Interesting fact – identifying as transgender was classified as a mental health disorder by the World Health Organization [WHO] all the way up to 2018! wtf)
 - 12 continuous months of hormone therapy as appropriate to the patient’s gender goals; (I’ve been on hormones for 4+ years. Being approved for hormone replacement therapy, HRT, was a huge stepping stone in my personal gender transition.) 
 - 12 continuous months of living in a gender role that is congruent with their gender identity; (This is an insidious and outdated concept. Men, you go be construction workers and tech bros. Women, go take care of the children and cook your man a tasty dinner cause he’ll be hungry after all that ‘man work’ when he gets home.
Curse you stereotypical ‘gender roles’!)

While most of the larger insurance companies adhere to the WPATH’s Standards of Care for determining treatment coverage of transgender individuals, some have additional or different requirements or will not cover certain procedures under any circumstances. Also, a person can choose to simply pay out-of-pocket for their surgery, and all they have to do is sign ‘informed consent’ paperwork – bypassing the Standards of Care (though not all surgeons will do this). Gender surgery is very expensive, and if you have that kind of money – send some my way, and I’ll build you a piece of furniture… deal? 🙂

It’s also worth mentioning that the Standards of Care cover other aspects of a transgender person's healthcare – including hormone replacement therapy (HRT). If you somehow haven’t checked it out yet – please do (it’s surprisingly legible and approachable for non-medical people – like me).

Ok, I promised to discuss the first requirement in more depth: “Persistent, well-documented gender dysphoria.” While I have a lot to say about gender dysphoria, I’m going to focus on the bane of many surgery-seeking transgender people: gatekeeping therapists.

When I talk about therapy and therapists, I usually say, “Oh, therapy can be beneficial for everyone – we all have issues we’re working on, and discussing them with a mental health professional is always a good idea. Mental health is important and shouldn’t be stigmatized.”

I really believe all that!
However… if I (and other trans people) have been profoundly annoyed by any one step in my (our) long gender transition, it has been the therapists.

Above, I called the therapists ‘gatekeepers.’ This refers to their ability to control the speed and outcome of a transgender person’s journey. For example, the first letter discussing my ‘well-documented gender dysphoria’ had to be written by a therapist with whom I had an established relationship. This means different things to different therapists; some require relationships of as little as three months – while some require at least a year. This is an appreciable amount of time (not to mention money) spent pursuing permission to go through this ‘gate’ of gender surgery permission. The second letter was slightly easier to obtain and typically only requires a couple of ‘evaluative’ visits – and does not require a long-established relationship. However, I still had to find a therapist who would fit me into their schedule and write the letter (more time and money). 

I’ve had to obtain therapist letters for every stage of my gender transition: One letter to start HRT. Two letters to have my first surgery. Two more letters (nope, I can’t use the letters from my first surgery) for my upcoming surgery.

Adding insult to injury, I had difficulties obtaining one of my current letters due to the uncommunicative and unprofessional nature of my established ‘therapist.’  This delay pushed back my potential surgery date – and caused me much anxiety and depression.

In case you couldn’t tell, I’m still pissed about the whole thing. And while it’s easy for me to say ‘it’s all well that ends well’, I bet even Shakespeare would support some kind of elaborate revenge – perhaps after pointing out the similarities between me and the character of Helen and the similarities between my uncaring therapist and the character of Bertram. If that doesn’t make sense, read the play or support your local theatre company. (Have I mentioned I have a theatre background?  no?) 

In case anyone thinks I’m overreacting – I’m not alone in my opinions of gatekeeping transgender people: see here, and here, and here.

As I said above, I still feel therapy is a valuable tool for people – but its use in determining whether a transgender person really ‘needs’ gender-affirming procedures needs to be reevaluated.  Not to mention all those people who do not have the resources (time, money, insurance, distance) to pursue long relationships with therapists. Does that mean they don’t deserve the care and procedures they need to feel complete as the person they know themselves to be? It doesn’t, and of course they do!

Obtaining the letters to satisfy my insurance company was a big part of the whole process. It allowed me to get pre-approval from the insurance company and schedule a date with my surgeon. Yay!

In case anyone is wondering how much this kind of procedure (Limited-depth Vaginoplasty) costs, it’s pretty expensive. I won’t go into specific numbers, but well above $10,000. Thus, if you can, it’s worth taking the time and effort to get insurance to help pay for it.

I’ll give you an idea of what the surgery and recovery will involve (as I understand it): The surgery itself will take about three (blissfully anesthetized) hours and involves a night in the hospital. I’ll be fitted with a catheter and will have to wear it constantly for the first week or so – not something I’m looking forward to. I’ll also have to wear fashionably tight bike shorts (compression shorts) for, oh, about eight weeks and change my bandages fairly often.  Once I have the catheter taken out (ouch), I’ll have to relearn how to urinate. (And I thought potty training was over!) No heavy lifting for me for a few months (not great for a furniture maker), and to top it all off, I’m technically not allowed to sit down for 6 to 8 weeks… I thought that was a typo when I saw it printed in bold and red ink on my pre-surgery documentation, but no, no SITTING for 6 to 8 WEEKS. Fun.

Of course, the most important outcome of all of this is that I’ll be able to wear stretch pants without a penis-related bump in the front! Yessss!

Ok, I’m joking (kind of) – the most important outcome is that my body will finally conform to my desired gender identity.  *Pow!* Take that, gender dysphoria!

If this all sounds like a lot to go through for a part of my body few people see, you’re not wrong. But unless you’ve experienced something similar, it’s hard for me to explain just how incredibly important it is for me. I’m trying to figure out how to use the expression ‘soul-crushing’ to help describe what I feel about my penis, but it sounds a bit awkward, amirite??

While I’ve become a bit anxious and nervous as the surgery date approaches, I’m trying to be more pragmatic about it than I was last time. While this surgery is different than my last one, the overall process is similar: same surgeon, same hospital, same surgery time (6 am, yay.), etc.

I also have the love and support of my wife, Elena. (I can’t write enough about what she’s done to help me figure out and accept the person I really am.) She will, thankfully, be taking care of me after the surgery – for which I will be forever grateful. Having a solid support system is so very important for trans people (whether they are having surgery or not)!

The reason I wrote this post is to educate others about my experiences as they relate to medical transgender issues. I’m very open about my transgender journey and status – so feel free to ask questions!

Meanwhile, I’m looking forward to writing the sequel to this post: ‘Gender Confirmation Surgery and Me – Part Four (after…again)’ – where I’ll discuss how the surgery and recovery went.

That’s all for now – I’ll see you after the anesthesia wears off!