So… you’re thinking about transfeminine bottom surgery, part 2 — process

So, you’ve gotten through the previous article, and you can probably already see that there is a lot of choice. That choice then gets compounded by just the sheer number of surgeons out there, which I haven’t especially gotten into yet. What goes into the time between “I decide I want to do this” and “I have a vagina now”? I’m going to walk you through the process I personally used, please do take or leave my specific advice, but I’m at least trying to show one way that one could narrow down this process, which is obviously intensely personal.

Step 1: do I want this surgery at all?

This is itself a pretty fraught thing. I personally started out pretty firmly in the “non-op” camp. When **looks around** started happening, and the threat of forcible governnment-sponsored detransition started staring me in the face, making myself physically non-detransitionable became a priority. So, approximately a year and a half ago, I got the orchi done. And the result of this was just immediate relief. I found a new happiness and rightness with my body, and was just completely caught off guard by what was a very practical logistical decision for me. Behind THAT, though, was a pile of new bottom dysphoria, showing up slowly at first, and then gradually screaming more and more loudly. Before long, it was pretty clear that I needed the old thing gone, and found myself doing internet searches for bottom surgery stuff more and more often.

The takeaway, here, I think is that this is an intensely personal process. What does your body want? What feels good when you query it? You can probably add stuff like “is passing in locker rooms and the like a transition goal for you?”

Step 2: Which surgery, though?

Now, in Part I, we listed a lot of various procedures, and why we did was for a very specific reason — getting an idea of what is out there can be used to then go and inform what you actually want. There are a lot of surgeons out there, and they have a lot of procedures that they offer. If you just exhaustively go through EVERYONE, you’ll be researching for a long time. One fast way to narrow the space down is to then step back and say “what do I want?” Typically, every vaginoplasty surgeon will do penile inversion, but as you get into the more specialized procedures, they will require more certifications and equipment (PPT requires a secondary laproscopic surgery and robotic assistance, for one example), and fewer surgeons will offer those procedures.

This is also the period where it is good to think about whether you are considering keeping the phallus or doing zero/minimal depth. Some thoughts I’ve heard women talk about here are:

1. Do you want to engage in receptive vaginal sex? How about recieving dildos, strap-ons, etc? Do note, here, after a vaginoplasty, that the canal will be placed in-between the prostate and the rectum, so, the prostate will be basically where a cis woman’s g-spot would be, and will not be accessible the other way anymore, though practical results vary a lot
2. How bothered are you by the idea of dilating, starting from frequent daily dilations and tapering down to lifelong weekly dilations over the first year (noting that penetrative sexual activity counts as dilation once in the maintenance phase)? This can be an emotionally draining thing for some women, for some it’s not an especially big deal
3. Is the shorter recovery time of zero depth attractive?
4. Does your dysphoria include a lack of an internal canal?
5. How big a deal is hair removal? A lot of surgeons will require permanent hair removal on any surgical areas, with PIV having the most extensive requirements, and min depth often requiring no hair removal

For me, the answers to these were 1. yes, 2. not a ton, 3. yes, 4. extremely. 5. it sucks, but I’ll deal. And really point 4 was the sort of definitive thing that pushed me over to seeking traditional full-depth vaginoplasty. As for choosing between the various types of full-depth procedures, concerns about self-lubrication, recovery time (the more sites you harvest tissue from, the bigger the surgery is), surgeon availability, and post-operative heath (harvesting from the colon can affect colon health, for example) are the things that came into play. If various preexisting health conditions are present, or certain matter is insufficient to do the surgery (notably, if a trans woman went on puberty blockers and/or HRT previous to puberty, she might not have enough of a penis to then repurpose to a canal, precluding PIV alone as a viable choice), it might limit the choices of procedure, too.

OK, so how do I find a surgeon?

So, step one, especially (in the USA) if you plan on using insurance to pay for surgery (though this is part of WPATH, so I suspect most single payer systems will mandate this, too, but I know nearly nothing about using non-USA national insurance to do trans surgeries), before you go hunting super hard: get a HRT note from your HRT provider stating that you’ve been on hormones for at least a year. Any primary care doctor should be able to write this, so if you’re on DIY hormones, you’re going to have to find a doctor to write to for this step. Similarly, you are also going to need at least one letter from a therapist or social worker diagnosing you with gender dysphoria and recommending vaginoplasty. If you plan on getting other procedures, I’d highly recommend just getting every condition you’re even thinking about on both of these letters so you don’t have to go begging for them again. Typically, for trans bottom surgeries, you will need two therapist letters, but most insurance requires that the second letter come within a calendar year of surgery, so I’d kind of recommend waiting until you have a date before getting therapist letter #2, so you can guarantee it’s not stale. But having your letters in order will definitely make hunting for surgeons easier.

Armed with your letters and the knowledge of what you want, it is now time to go to the internet and start looking around. I plan on having part 4 of this series be a simple annotated research list, but I will say that the wiki at r/Transgender-Surgeries on reddit is at least a good way to get a pretty comprehensive list of surgeons. This is also the phase where you should start asking yourself about your secondary priorities:

1. How willing are you to travel? Most procedures will require at least some extended stay within driving distance of the operation, and by most accounts “time in the passenger seat post-op” is a quite unpleasant thing
2. How are you paying? If you are using insurance, this is where you start cross-validating with your insurance’s website to figure out who is in-network. Some surgeons either are out-of-pocket only or only do reimbursements. If you are considering going to Thailand to have it done, in the classic transfeminine way, then you likely will be paying completely out of pocket.
3. If you care about having a trans woman do your vaginoplasty, your three choices as of this writing are Marci Bowers, Christine McGinn, and Ellie Zara Ley
4. How long are you willing to wait to get the surgery done? Wait times as of this writing vary from 9-ish months to “2 years to consult, and then another year or two to surgery”. Note that if you are doing hair removal that you should definitely budget at least like six months to a year to get that finished. Electrolysis is both slow AND fun! (bottom prep electro does go faster than face, though)

Now, it’s time to get surgeons names, and to start investigating them. I recommend going to their websites and seeing them talk about their surgeries. I REALLY recommend looking for results photos, noting that there are biases in pretty much every source for results photos. The surgeons’ sites themselves are obviously going to be biased toward “good” results, and various forums will have cultures toward complaining about results to a sort of “showing off the new pussy.” Different surgeons will definitely have their own individual sort of aesthetic. This is also where you will find out more about their individual techniques — some surgeons do vaginoplasties in two phases, some have different stitching techniques, some default to various techniques, they will all have different dilation schedules and different recovery timetables. A lot of them will even straight up have their pre- and post-op instruction packets just free for download, whcih can be really informative. This phase of research definitely was the one that took the longest for me.

By the time you’ve spent some time (for me, this was several months) reading through all of this, it is time to start scheduling consults. The surgeon’s website will usually tell you how. The wait lists are long, so it’s usually better to get in line for consult sooner rather than later, and then drop off if you don’t need the consult later. It’s also not the worst idea in the world to get multiple consults, just to see if you mesh with a different office better than another.

For me, I went through this process, and I kind of valued recovery time, minimizing risk, and especially minimizing time to surgery. After looking online, I meshed with his general aesthetics, and have opted for a PIV with John Henry Pang at Align Surgical.

So now, congrats, you have a consult. Part 3 will be a discussion about what happens next, and part 4 will be a list of resources for research. Thank you for reading