What We Don’t Talk About After Gender Confirmation Surgery

There are a lot of taboos when it comes to talking about trans medical care. Talking about something that goes wrong is one of the biggest. For me, it was minor complications, but the lack of discourse on the healing process made them feel a lot worse than they were.

First, a note about this article: I’ll be referring to body parts by medical names, talking about some of the more difficult parts of my healing after gender confirmation surgery (“bottom surgery”), and including some highly stylized diagrams of anatomy.

Photo by Kristina Flour on Unsplash

The Expectation vs. Reality

When I had gender confirmation surgery (“male-to-female bottom surgery” or, crudely, “the surgery” in some people’s eyes), I expected that my healing would follow the standard narrative: A few weeks of intense healing, followed by some routine, relatively simple, after-care for a few months. I expected that life would become normal again after those few months. Sure, some people talked about having complications or needing to return for a second surgery (also known as a “revision surgery”). But, I thought, that won’t happen to me.

Well, it did. And I want to talk about that.

When I started talking to other trans women about my healing process, and the need for a second surgery, I was shocked by how many other post-op trans women had similar issues during their healing process but wouldn’t talk publicly about it. For a group of people who have fought social stigma to be who we are, this is a stigma we haven’t yet overcome. I think this stigma hurts our community.

What This Article Isn’t

This article isn’t proof that we shouldn’t have access to this life saving medical procedure, and I hope nobody tries to use it that way. Having surgery was the best thing I’ve done in my life, medically. Nothing I’ve experienced since surgery would have changed my decision, had I known it would happen in advance. I’m happy about my body and my journey to arriving in a body that fits me properly. It is a body I can thrive within.

There is always a bit of an unknown.

I also want to make it clear that I received outstanding medical care from my surgeon and would recommend my surgeon without any reservations. These medical procedures are complex, and even the best surgeons can’t predict entirely how your body will heal. There is always a bit of an unknown. But, as someone who has dealt with dysphoria, the initial surgery, and a revision, I think my opinion on this has weight. So here it is: I regret nothing!

My Experience — First Surgery

After some stresses with insurance (a last-minute insurance denial two days before surgery, despite pre-approval by my insurance company!), I had a fairly uneventful time in the hospital. The operation seemed to go well, and I remember waking up very happy! It ranks up there with the day I was married as one of the happiest of my life.

My first memories after waking were mostly how little anything hurt. Sure, I could feel that something happened, and it wasn’t comfortable, but it didn’t hurt. This lack of pain would be a theme throughout my recovery — I experienced very little pain. I know some people experience a ton, but I’m thankful that at least this part of recovery was easy.

Sick, sick, sick.

But, a few days after release from the hospital, I had some problems — they felt major at the time, but in the scheme of things weren’t that big of a deal.

During recovery, just after leaving the hospital, I got quite nauseous. All I can say certainly from that time is that throwing up is no fun after this surgery. What was going on? So many people who went through this surgery said they were just fine and were mobile at this point. I was in bed trying to get puke into a bedpan rather than all over my bed and me. My surgeon had told me not to move, to be very careful even if I lay on my side, and to rely on my wife for anything I needed, so I was doing that (and I owe my wife a ton for this). But my experience didn’t seem to match what I’ve heard from others! Was it embellishment by others, or was I just this unlucky? I don’t know the answer to that, but it certainly wasn’t feeling as easy as I hoped it would be.

Fortunately, this nausea passed relatively quickly, thanks to being prescribed a fantastic drug. I started feeling better, almost immediately. I left my concerns about my recovery in the past and was enjoying that I would be back to normal in no time.

What do you mean, “It’s dying?”

Then, a day or two after that, during one of the daily house-call visits by my surgeon, I was told that I was likely experiencing some necrosis. Some of the exterior grafted skin was, essentially, dying. Sure enough, a few days later, the skin in one area was falling off — and my surgeon removed the remaining dead skin. The cause was eventually determined to be swelling that cut off a blood vessel that was providing blood to some of the newly placed skin.

I was terrified. At the time, with an open wound, I couldn’t see how I could heal from this, and I was worried about being disfigured for life. I reassured myself that I’d rather have disfigured parts that fit who I am than the original parts I had before surgery. Even with that complication, I was happier now than I was before the surgery. But, it was still terrifying.

I asked myself, at each point, if I had to live with this the rest of my life, would I be happy? I always answered, “yes.”

But, at this point, I had an open wound. I would be applying dressings to this wound while healing for at least several weeks (it took about two months).

I’d repeat this process several times during my healing from surgery. I asked myself, at each point, if I had to live with this for the rest of my life, would I be happy? I always answered, “yes.”

Fortunately, I did heal. New skin grew, something called “healing by secondary intention.” Healing by primary intention would be healing using the original graft that closed the wound, the graft that partially failed in my case. Healing by secondary intention is when the skin grows over new “granulation tissue.” Granulation tissue is, essentially, a dense network of blood vessels, a red, bumpy surface you might see in a wound if you lose some skin. The doctor showed me how to use silver nitrate sticks to treat excessive granulation tissue, something I continued doing for weeks after my return home. It wasn’t painful or complicated, but it was scary waiting to see how the healing would be complete when I couldn’t picture the end state.

The worst part of this? I jokingly say the worst part is that I couldn’t soak in the tub, an essential part of my way of dealing with life’s stresses. I knew going into surgery that I wouldn’t be able to do that for a few weeks, but the necrosis (and resulting open wound) made that wait a lot longer. But this did have a happy ending — eventually, I wasn’t able to differentiate the parts healed by primary intention from the parts healed by secondary intention. In other words, the only lasting effect was a longer healing timeline.

I can’t pee!

While I was dealing with the beginning of the wound healing, the rest of my recovery wasn’t on hold. At about one week after my surgery, it was time to get rid of the catheter I had lived with since surgery! On that day, the surgeon visited me and removed the catheter. He told me to let him know when I was able to urinate.

Ha!

I tried. And I failed. I couldn’t squeeze out even a drop.

I drank a bunch of water — still no go (quite literally).

So, with tears in my eyes at the end of the day (I hated that catheter), I told my surgeon, during his return visit that evening, that I still couldn’t pee. If you don’t urinate, you die, so I had no choice but to have the catheter replaced for a few days. I was still too swollen to be able to urinate correctly without it. But, having it back was somewhat a relief, as it was stressful to worry about peeing all day.

Then came the big day to remove the catheter again. I decided I was going to pee this time, no matter what! I was determined! It would happen! My surgeon removed the catheter, and I did everything I could to be sure to pee this time. Running the sink tap after drinking a lot didn’t quite do the trick, so I tried to relax when I was taking my shower later that day. The shower was the trick, and, as disgusting as it was, I was able to relieve myself there. I was so happy — I came running out to my wife (okay, I very slowly and cautiously walked out, careful not to fall or hurt myself) and excitedly told her how I peed. I think she said something along the lines of, “Uh, okay, I’m proud of you, I guess.”

Photo by Kevin Baquerizo on Unsplash

Fortunately, the need to pee standing up (kind of what the surgery was supposed to take care of) went away fairly quickly, and I was soon urinating on the toilet properly. I don’t even remember what I thought was so hard now, but, of course, I’m not swollen like I was then, either.

Unfortunately, that wouldn’t be the last of the problems with peeing…more to come later.

Back Home

I made it back home, able to pee. Mostly things seemed to be going well, other than the wound I was still taking care of (due to necrosis). The post-op care (dilation) wasn’t a big deal, and I felt I was progressing as I should be for that.

Things were going so well…

While taking care of post-op chores, I noticed something hanging down from my vagina, a piece of flesh.

I freaked. I was 1,500 miles away from my surgeon.

It was a narrow strip of tissue, not very long, but it was definitely there in the 3X magnification mirror I was using to look at myself. I took a picture and sent it off, along with a panicked note to my surgeon — basically, “HELP!”

He responded and said it was one more piece of dead skin, and that if I sanitized some scissors I could snip it off, that it was dead skin, there was no blood flow in it, there were no nerves in it, and this wasn’t a big deal, but also that it would almost certainly fall off on its own in a day or two.

After cutting a piece of my genitals off, things seemed to be going reasonably well. I can definitively say that I never knew I would have to be brave enough to take scissors to my lady bits.

Dilation

About a week after my surgery, before I came home, I was shown how to dilate. Basically, during the first year or so, your body is adjusting to the new configuration — and your body must adapt to having the new vagina. You’re training your body to realize this new configuration is the new normal, fighting against scar tissue that will tend to contract while it heals. Dilation is a progressive thing, at least the way my surgeon does it, starting with a small dilator (about 7/8” diameter) and, after weeks of dilation, progressing to a large dilator (about 1 3/8” diameter) in 1/8” steps (so there are five dilators). The dilators I use are straight (not curved).

The Small and Large Dilator (the middle three sizes are not shown)

At first, I was dilating four times per day, which does take some time — you get everything set up, so you don’t make too big of a mess, then you dilate, then you have to clean up. I’ll admit, I was a bit scared to do this at first, worried about the pain.

It turns out this was one of the least challenging parts of recovery. It is not enjoyable, and certainly can it be time-consuming, but it wasn’t all that difficult.

After a week or so at each size, I was able to add the next size dilator. Once I was using the large one, I could then start to cut back on the frequency of dilating, to the point where it was only necessary once a week. I use this as “me” time — I watch a TV show I enjoy and relax as I’m doing it. It’s not pleasurable, but it’s not horrible either. It’s just mostly dull.

My surgeon tells me that being able to use the large size is a bit unusual for my surgeon’s work, and that I am fortunate to have a bone structure that allows this — I’m also told it is okay if you don’t have this structure and can’t make it to the biggest dilator. I’ll say this as delicately as I can: I was told (by my surgeon and by other trans women) you’ll still be able to be ‘fully functional.’

Getting Back to Life

I started easing back into work at about three weeks after surgery, which, frankly, was too soon. Working just a few days a week, laying down, was a bit much. When I went to my first full day of work at the office, at five weeks post-op, it was tough. I’m glad I can mostly work from home.

One surprising thing I found as healing was that the type of seat I sit on mattered a lot more than I expected. It turned out the best kind of seating for me to use for work was a cheap folding plastic chair — with absolutely no padding. With a hard chair, nothing pressed into the wrong part of my body. Instead, the weight of my body, when sitting on a hard chair, rests on parts of my body that weren’t healing. I still spent plenty of time standing or laying down (both of which were more comfortable than sitting).

But, Not Everything was Perfect

Three months after surgery, I flew back to see my surgeon for a post-op checkup. This visit was a routine checkup that was optional, but since I could make the arrangements to do so, I figured it was a good idea, just in case some things might not be going as well as I hoped.

So, I flew the 1,500 miles to see my surgeon, flying in during the morning and back home that evening. At the visit, the doctor took a look at my healing and let me know that externally things looked perfect. However, internally, I was developing some granulation tissue that could be an issue later. It didn’t hurt or bother me but could cause full healing to take longer or could become a bigger problem if enough of it developed. My surgeon treated the granulation tissue with the same silver nitrate sticks I was shown to use on the granulation tissue on the outside, but did so on the inside, using a speculum to be able to see.

The doctor then wrote down instructions for an OBGYN to follow back home to continue these treatments. I was told to do this every two to three weeks until there was no more excessive granulation tissue.

OBGYN office: “We don’t have the equipment to treat you.”

Joelle: “You only need a speculum!”

My first stop was my GP. I knew she did some OBGYN work, but she wasn’t interested in doing this. So I started calling around to local OBGYNs. Several doctors flat out refused to even talk to me about this — they were not comfortable with this work. I was surprised since these OBGYNs provided care for patients who had recent hysterectomies (which can have the same complication, have it in the same place, and which is treated in the same way). One OBGYN office, an office that advertised “transgender health care” in addition to OBGYN services, informed me that they didn’t have the equipment necessary to provide the treatment. I pointed out that I could bring the silver nitrate sticks with me (my surgeon previously provided these to me), so all they would need is a speculum, and, besides, this is the standard treatment for granulation tissue at the vaginal cuff, regardless of why the vagina is closed at that end. I was told again, “We don’t have the equipment to treat you.” I found that a bit hard to believe. I’m still not sure what that OBGYN considers “transgender health care.”

This rejection took quite an emotional toll on me. Up until now, I did not have any problems getting basic medical care. But now it seemed clear that some doctors didn’t want to provide this care for people like me. I cried to my friends, who helped me not only find a trans-friendly OBGYN, but find one that could see me on short notice (that was the problem I anticipated — not that I would have trouble getting in at all, but rather that they would take a while to be able to see a trans patient).

It was wonderful to walk into an OBGYN clinic and be treated not only as a woman in need of medical care but also to be treated by trans-informed providers. I saw two different providers there for the next month and a half, and both were knowledgable about trans health care, asking relevant questions (“How are you doing with dilation?”), and skipping the irrelevant ones (“When was your last period?”). In the end, it was more than I dared hope for — I just wanted someone to look into my vagina, note the granulation, and touch it with a silver nitrate stick. Instead, I found providers that understood the procedure I underwent and could ask questions that informed their care. That was far more competence than I expected! I saw them twice for treatment, and one more time to confirm that no more treatments were necessary.

More Trouble with Peeing

Around this time, after a few months of recovery, it was clear that I was having an issue with urination. Rather than sitting on the toilet and having the stream go down into the bowl, it tended to leave my body more horizontally.

What happened when I urinated

Unfortunately, this meant sometimes urination was messier than I would like — sometimes, the stream would try to exit in that small gap between the toilet seat and the toilet itself. It’s not fun to pee on your pants. But, still, I could live with this if needed. I discovered ways of using a toilet without making a mess. Inconvenient? Yes. Worse than having the wrong body? No. I was still happier than I was before surgery with my body, and if I had to live like this for the rest of my life, I’d manage and be pretty happy about it.

That said, it was annoying. I talked to a few other post-op friends, including several who told me they had similar issues after I described mine. I had no idea that this was as common as it was until I started sharing about my own body (that’s one of the reasons I’m choosing to talk about this publicly). One person, in particular, told me that she wished she got her body fixed, rather than having lived with it for years. To me, that was the clincher: I didn’t want to have this small annoyance for the rest of my life.

Another Visit With My Surgeon

Being that I could not fix this myself, I needed to find a surgeon. While some local surgeons could do this, I figured the person most equipped to fix this was probably the original surgeon. This surgeon knew my body and the changes made to my body through surgery, and this surgeon wanted to see me anyhow to check on the progress with the granulation tissue. So I made another appointment with my surgeon.

At that time, we were still waiting to see what was going to happen with the urine stream. But now that I knew what was happening, we could talk about fixing it. Importantly, we could set a date to fix this in a few months.

Surgery, Round Two

Unlike the first surgery, this was an out-patient procedure that would take only an hour or so in the operating room. It was still significant, but much less invasive than the first one. So I arrived at the hospital at 7:00 AM, changed into the surgical gown, met my anesthesiologist and some others, and then took my nap while the doctor operated yet again.

Mercifully, this time I didn’t need to go without my hormones or to do the awful bowel preparation that I had to do the first time. Unlike the first surgery, this wasn’t classified as a gender-related surgery, so there were no pre-approvals or letters from mental health providers required this time.

A stylized, non-realistic, definitely not-to-scale drawing showing where the incisions were made for the revision surgery

In this procedure, a bit of tissue between my urethra and my vagina would be removed, and the skin closed over that. To minimize stress on the skin, two cuts were made along the inside of my labia minora to spread the stress over a larger area. This had the effect of pointing my urethra more downward while I was sitting on a toilet. The incisions were tucked into the folds of my body whenever they could be so that they would be hard to notice after healing.

I remember coming out of the recovery room and feeling the need to pee. I, of course, didn’t have to pee (I was catheterized during surgery), but my urethra was irritated by the now-removed catheter, so it sure felt like I did, so I insisted on trying to use the toilet (turns out I didn’t need to go).

I remember removing the bandages and seeing blood dripping down under me onto the bathroom floor. I freaked. I didn’t need the call button to get the nurse’s attention — my voice was plenty loud for that!

The nurse took a look, then called my surgeon — who told her that this is relatively normal and expected. She was instructed to apply pressure and new dressings, and that it would resolve on its own. My surgeon was right — it did. But it was scary! Those few drops of blood felt like pints of blood when I saw them on the floor. I suppose that’s what perspective can do.

Recovery, Round Two

For the next week, I (mostly) only got up from my hotel bed to attend to my bodily functions. I remember being chastised by my surgeon for merely answering the hotel door when my surgeon made a house call to check on me. I was told in no uncertain terms to make my wife do that the next time!

After a week, I was allowed to answer the door, and it was time to return home. Having learned my lesson from the first surgery, I did request a wheelchair this time! But despite that, it was still an unpleasant flight home, and I was glad to see my bed when I got here. After another two weeks in bed, I was ready to return to work.

It was also around this time when I was allowed to resume the dilation (I stopped just before surgery). However, I had to start back with the small dilator, being very careful to slowly work back up to the large one, over two months or so. This caution was required to avoid ripping any stitches holding my body together. Because of this time away from dilation, I was a bit scared. Would my parts lose any elasticity? Was this going to hurt? It turns out that they did just fine — my body is happy maintaining its current state, without the need for much external intervention.

Can I Pee Now?

So far, my hopes have come to pass since the revision surgery — I can comfortably urinate on a toilet without issue, something you don’t realize you should be thankful until you can’t do that!

Would I Do This Again?

The simple answer: yes. I knew from the start that things could go wrong, and they did for me. Fortunately, all of these things were relatively minor. Sure, it stinks to need a second surgery, but the confidence I now have in my body has changed my life.

I’d give my trans sisters two pieces of advice: if bottom surgery is right for you, it is life-changing. Even though nobody but me knows my surgical status in most interactions, it somehow changes those interactions. I think this is a result of being confident in my body. The second piece of advice I’d give is to fix any functional issues that come up after surgery. Do you want to live with it for the rest of your life? Everyone’s circumstances are different, but I’m happy that I chose to have a second surgery.

I also encourage other trans women to talk about this. It is time to end this stigma.

Programmer (🦋, 🐪, & 🐍), Gender Traitor & Shape Shifter ⚧, Geek 📚, Christian ✝, Motorcycle Rider 🏍️ , Puppy Parent 🐾, Wife 👩‍❤️‍💋‍👩.

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