Vaginoplasty Part 1: Prep

Congratulations! You’re on the path towards getting gender affirmation surgery. In this case, you’ve chosen to get a surgery to create both an internal vagina and external genitals called a vulva. This is called a vaginoplasty, and it is a long process to get one.

A picture of a strawberry that looks suspiciously like a vulva
Strawberry via Wikimedia Commons © Jeff Kubina (CC BY-SA 2.0)

In this series we’ll walk through how to get a vaginoplasty (Part 1), how the surgery and hospital stay work (Part 2), and how to recover effectively (Parts 3 and 4).

What needs to be prepared?

There are a lot of moving parts to planning for surgery. On the other hand, there is also a lot of time to do so. It took me about 4-5 years (depending on how you count) of deliberate effort before my surgery day came. Partly because prepping takes time and partly because the waitlists are long. This is the first thing to prepare for: the waiting.

This will give you an opportunity to create your social support network, which is the single most important factor in any of this working out. You will need others to get through this. You’ll need emotional support as you wait and get closer, physical support as you recover, and much much more help in ways you won’t be able to predict.

Five people holding hands in a circle
five person holding hands via PickPik

I can not stress enough: Your support network is your lifeline. You will not get through this on your own.

Once you have assembled people who will support you in the ways you need there are three major categories of prep you will need to address: paperwork, body, and environment.

Paperwork

In the United States, typically surgery can cost thousands of dollars. There are many strategies to be able to afford this, but the most common one is by using health insurance.

You can get health insurance through your parents if you’re under 26 years old, your job, purchasing your own, or getting governmental assistance if you make under a certain amount. Every plan is different and covers different things to different degrees. To find out if a plan you’re considering covers gender affirming surgery, you may need to call their customer service line or ask for a Summary of Benefits and Coverage. To learn more about health insurance in general, visit this link. Also, if you have a low income level, consider looking into free medicaid coverage in your state.

A zoomed-in picture of the signature line of some paperwork

Typically, insurances that cover vaginoplasty require two letters from medical professionals indicating that you understand the risks and have a medical need for the surgery. There may also be a requirement of living a certain amount of time publicly out as your current gender, often up to 12 months. These can be frustrating hurdles to overcome, but continue to chip away at these requirements one at a time.

Prepping the body

Your body will also need to be ready for this surgery. This typically includes three factors: hair removal, weight control, and pelvic floor health. As always, please take this with a grain of salt as I am not a doctor. Consult a medical professional with any questions.

Typically your doctor will set up several appointments in advance of surgery. For instance, they may meet you and discuss next steps in an appointment called a consult. As your other prep continues and a surgery date is chosen, you may have several other pre-operative appointments to discuss expectations and final preparations. But before we get ahead of ourselves, let’s discuss another obstacle in getting ready for surgery.

Hair removal

In most cases, vaginoplasty uses the skin of the penis and scrotum to create the inside of the new vagina. Which means skin that is outside you now will be inside you later. This makes it very important to make sure that the skin that will be inside you does not grow any hair since it can not be easily addressed once it is inside the vagina.

Some surgeons offer to use burning techniques during the surgery that in theory destroy hair, but others feel this is not effective or impedes healing. Most surgeons agree that removing or reducing hair through other ways is a better strategy. The most common methods being laser hair removal and electrolysis.

Laser Hair Removal

Laser hair removal is typically an option for people with light skin and dark hair. It uses high intensity lights that are absorbed by the dark hair follicle, destroying the follicle in the process so that it can not grow hair.

A technician uses their laser to remove hair
Laser hair removal on the legs, Copyright Alice Pien, MD (CC BY-SA 4.0)

It can be relatively painful, especially on sensitive skin. I describe the sensation as a combination of holding a hair drier too close to your skin while at the same time snapping a rubber band hard against your skin. You can ask if you may use lidocaine cream to lessen the pain or a cold roller to put on immediately after to soothe the heat.

Laser hair removal isn’t an option for everyone. Also, theres some controversy over whether it is truly a permanent hair removal tool. As such, it’s usually called a “hair reduction” technique in medical literature. I used laser because it was cheaper and the individual treatments were shorter than electrolysis, but your milage may vary. It took me eight sessions spread out over about a year to get the results I needed.

Electrolysis

Electrolysis is a process that uses an electrical instrument to zap each hair follicle, one at a time, to destroy it so it can not produce hair. Since this treatment requires individual attention to each follicle, it typically results in longer sessions than laser. However, it is widely considered permanent and can be used on people who don’t have fair skin and/or dark hair.

While I haven’t personally had electrolysis the general consensus is that it can also be painful, though it depends on the person. Some say it’s not any worse than a mosquito bite while others say it feels like a rubber band being snapped against your skin. Like with laser, you can discuss pain management with your technician to find solutions if it hurts too much.

Similar to laser, it will take a number of months to fully remove all the hair needed for surgery. Whatever method you go with, you will need to be prepared for it to take several sessions over a long period of time.

Weight control

This author does not feel weight is a reliable way of determining physical fitness and believes it can be a damaging and arbitrary concept. However, many surgeons may use weight or Body Mass Index (BMI) to determine whether someone should be allowed to have surgery. Be sure to ask your surgeon if they have any restrictions around weight or BMI and be mindful of your relationship to those restrictions.

Your worth is not based on how much you weigh. Please don’t let this define you. However, you may have a difficult journey ahead of you to meet the requirements of this surgery. And if you’re serious about this, you’ll have to figure out the best way to address it. Be sure that whatever you do is healthy. Resources for healthy weight loss can be found here.

Pelvic floor health

Your pelvic floor is the group of muscles sitting in your pelvis at the bottom of your abdomen that hold up your internal organs and control the flow of urine, feces, and gas. If you’ve ever done kegels, you were engaging the muscles of your pelvic floor.

The vagina, both of those born with them and those who have one from surgery, pass through the pelvic floor. As such, you will need to learn to control these muscles to be able to dilate (more on dilation in Part 3). You will likely meet a physical therapist who specializes in the pelvic floor before you have your surgery. They will give you exercises to stretch and strengthen your pelvic floor, as well as learn to have finer control over tensing and relaxing those muscles.

Other considerations

This may vary between surgeons, but mine had strict rules about not taking nicotine or smoking (including marijuana) a certain amount of time before surgery. You may want to discuss that with your doctor if that is a concern. There are also some additional concerns if you have diabetes, which you should follow up with your doctor on as well.

Environment

While you’re putting things in motion, it’s good to get ready for what you’ll need when you get home from the hospital. Being ready now will save you endless suffering later on. Some things are absolutely necessary, and others will save you so much pain and discomfort.

The Necessary

There are some things you need to have to be able to recover. A place to stay. Someone to look after you for the first couple days. Folks to run errands and do chores for you while you’re bedridden (I’d recommend planning for at least four weeks). Rides to appointments. There are also some supplies that you will need.

A menstrual pad on a pink background
Sanitary napkins pad life by SookyungAn

(Note: I have provided amazon links to some of these things for the sake of having permanent links that specifically explain what I’m talking about. If you can afford it and have the resources, please consider shopping from independent retails or–even better–locally.)

  • Gauze – You will need to make peace with the fact that you will bleed. A lot. So having gauze around is important, especially if you find yourself with a steady bleed and need to apply pressure to stop it.
  • Menstrual pads – These are absorbent pads that are put into your underwear to catch the blood and discharge that will occur as you begin recovery. You will go through a lot of these, especially if you need to change them multiple times a day.
  • Loose clothes – It will be difficult to put on clothes at first, but loose fitting clothes will not only be more comfortable but easier to put on. Especially if you end up needing to take a catheter home (see Part 3). Make sure you have lots of underwear, preferably the kind you don’t mind getting blood on.
  • Towels – Have several on hand. I had to take two showers a day, so having multiple bath towels was useful. I also put towels down on anything I would sit or lay down on for the first week or so, just to protect surfaces from blood that got around the pad. Similarly, you will need either towels you can clean or bed pads to catch any blood or lube that comes from dilating.
  • Water-based Lube – You will need lubricant to dilate. A lot of it. Like, think of a silly amount of lube and then get more than that. You will need to dilate for the rest of your life, so if you can get a better deal in bulk, please do. Ask your doctor what kind of lube is best for you, but this is the kind I used.
  • Ice packs – Have a couple of these so you can keep them in rotation. Ice helps with pain and swelling. Just having some temporary relief from the pain while in between pain killers can be critical to your sanity and wellbeing.
  • Cleaning supplies – Have plenty of toilet paper, paper towels, soap, and disinfectant. You may drip blood or discharge on the toilet seat while going to the bathroom, spray a little bit while peeing at first, or have various other accidents along the way. Be prepared and have plenty of stuff to clean up.
  • Medications – Your doctor may tell you to buy over-the-counter medications such as miralax, ibuprofen, and tylenol to prepare for recovery. Ask if there are specific dosages or forms (tablets vs gel capsules for instance) that they recommend.

The Lifesavers

These things aren’t strictly necessary, but if you can afford them, I highly recommend them. I have listed them from most to least necessary in my opinion, but they are all good to have if you can get them.

  • Bed rail – If you can afford it, invest in this. Bed rails help you get in and out of bed, reposition yourself in bed, and provide support while dilating. This was the best purchase I made in this whole process.
  • Orthotic pillow – This is a donut-shaped pillow you can sit on that takes the pressure off of your surgical site. It is invaluable on long car rides or whenever you need to sit up.
  • Lap desk – These are handy because they allow you to have a working space to set something down, whether that be a plate, laptop, or notebook. Also, if you have a pet that likes to walk or jump onto your lap, you can leave this above your surgical site to protect yourself. I had this positioned above me almost constantly for this reason.
  • Pillows – For moments where you need to sit up in bed, it can be useful to have either many pillows or a large one to act as a backrest. Also, pillows are extremely helpful while dilating.
  • Peri bottle – This is a little squeeze bottle that allows you to spray your vulva with water or saline solution for cleaning. Since it can be painful and awkward to have a shower head directly spraying onto your vulva at first, this can be very useful. A handheld shower head can also be useful for cleaning hard to reach areas, although not as gentle.
  • Phone stand – During bedrest, entertainment will be important. If you watch a lot of things on your phone, I recommend having some way for it to stand up on its own. Both so that your arms don’t get tired and also because you may have IVs in your hands at the hospital and hands-free entertainment will be very important.
  • Squatty Potty – You can use any stool for this, but a squatty potty is designed to put your feet up on while having a bowel movement to elevate your legs and make pooping easier on your muscles. This is especially important right now as you want to avoid bearing down after surgery, which puts pressure on your surgical site.

Final Thoughts

After surgery you will spend a few months not being able to do everything you used to do. As such, do everything you can to prepare yourself and your environment for that time. Deep clean your home, freeze meals (preferably in individual servings for ease of reheating) to eat, and have any prescription medications filled before surgery. If you have pets, consider stocking up on food, litter, and whatever else you might need. Be mindful of the things you use on a daily basis, remember frequently bought items from your grocery lists, and make sure you have those things in abundance.

an empty checklist
Checklist via NeedPix

Lastly, have a plan for who will do what and when. I recommend having an online document or spreadsheet outlining exactly who will drive you to each appointment (include when and where it is), who will help with errands and/or chores, and who will be on call in case of emergencies. Make spare keys if needed and give directions to everyone of exactly what you need from them. The more you communicate now, the easier it will be later, even if unexpected things happen.

Alright. This is a lot to do, but again, you will have a lot of time to do it. Take things one step at a time. In the next post, we’ll talk about the day of surgery itself and the hospital stay afterward.

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