Are you planning on (or just thinking about) having bottom surgery (sometimes called sex reassignment surgery, gender confirmation surgery, or vaginoplasty) as a trans woman? I expect you did a lot of research already, so I won’t talk about the basics of the surgery, but instead some of the things which may surprise you. This won’t be “Trans Woman Bottom Surgery 101!”
Note: I’m going to talk frankly in this article — I’m going to use proper names of body parts, and I’ll mention sexuality briefly as well. In addition, not every trans person desires surgery, there are multiple paths to surgery, and there are few true universals. So please forgive any generalizations below that don’t apply to you.
There isn’t a “standard” bottom surgery
You likely already know that there are a lot of variations — penile inversion or colorectal, for instance. Penile inversion “inverts” much of the skin from the penis, sometimes with other grafts, to form a vaginal cavity, using scrotal skin for the labia. When this isn’t possible, there are other techniques, such as using a part of the colon.
There are other surgeries as well — using skin grafts (Macindoe vaginoplasty) or peritoneal vaginoplasty (an experimental procedure currently).
Most surgeries performed today are called “penile inversion” and done by using penile and scrotal skin to form the vagina and labia, relocating (and shortening) the urethra, and creation of a clitoris using part of the glans penis. But there is no standard here — some surgeons use only the scrotal skin for the vagina (yet, confusingly, call this a penile inversion!), some use only the penile skin, some use both. There are advantages and disadvantages to all of these, and some may be more suited to your existing anatomy. If you’re looking at a particular surgeon, ask them to draw out exactly what tissues come from where, as well as where tissues will be stitched together (each of these places is a potential problem spot during healing, so it is wise to know where your stitches will be).
“Zero Depth” is not “Zero Complication” or “Zero Aftercare”
One variation on bottom surgery is a zero-depth variant. In this variant, the introitus (opening) of the vaginal cavity is typically created, but the cavity itself is not. Thus, externally the genitals look like any other vulva, but there is no capability of having vaginal sex. For someone who doesn’t like the idea of vaginal sex, this might be attractive because it does not involve dilation protocols after surgery to maintain width and depth of the vaginal cavity during the healing process.
This choice is fine — but there are a couple things someone should know. First, all other complications that may occur — incisions not healing well, necrosis (death) of tissues forming the labia or clitoris, poor sensation, infection, urethra stenosis (narrowing of the urethra), and lack of sensation are still all possible consequences of this surgery, although the risk of a fistula or prolapse is greatly (or entirely) reduced. And, yes, there are less post-surgical care requirements.
One other difference with this surgery is that with a zero-depth procedure, if a post-surgical woman wanted her g-spot (the tissue that would be a prostate in a man) stimulated, it would be done through the front wall of the vagina (the same way a cis-woman’s g-spot is stimulated) if there is a vagina, rectally otherwise. One possible complication of bottom surgery is difficulty achieving orgasm, so you may want to consider what activities you might enjoy in addition to clitoral stimulation (I.E. if you think you might enjoy the g-spot stimulated through the vagina, but not through the rectum, you might not want the zero depth procedure), to maximize your chances that some method will “get you there.”
Hair Removal is Worse Than You Think
Most surgeons require hair removal, and you should certainly talk to your surgeon about these details — well in advance of your surgery date. The scrotum contains a surprising amount of hair! You can always have external hair removed after surgery (after you’ve healed), but it is difficult or even impossible to remove interior hair permanently after surgery.
There are some surgeons that claim hair removal is not required, but sometimes patients of those surgeons report they wish they had removal done. If your surgeon says hair removal is not required, you may wish to talk to some of their former patients to make sure their experiences match this. I know of some people who were told they wouldn’t need hair removal, only to later regret not having hair removed. Remember that many trans women don’t follow up with their original surgeons, so the surgeon may not realize that their methods are not as effective as they expect.
It takes a long time to remove the hair. Hair growth is on a cycle. At any given time, only about 1/3rd of your hairs are in the active growth phase, able to be killed via laser or electrolysis. If you only do laser or electrolysis for a few months, you will have regrowth, even if the hair removal actually killed every hair that was active (it’s thus not actually regrowth, but just dormant hairs during hair removal that activated later). It can take over a year to complete the entire hair growth cycle (and this only gives you the chance to kill each hair once, assuming you are doing full clearings starting at the beginning of the one year), so if you want to have surgery, contact your surgeon and obtain their hair removal diagram (the surgeons all have different requirements) and get started. And, yes, it hurts. Just remember many of your sisters have done this before you, and they aren’t any tougher than you are. You can do it.
Recovery and Healing
There Are Unplanned Costs
How will you do follow-up care with your surgeon? Will it involve travel? Time off work?
In addition to routine follow-ups, surgery doesn’t always go perfectly. There are far too many variations among our bodies to have any guarantees. In fact, it’s more likely than not that some part of your surgery won’t be perfect. If this happens, you may need additional surgeries — for instance, to correct a urinary flow issue, touch up incisions that don’t properly heal, or to correct a major issue like a fistula or prolapse. This will involve time off, and, even if your surgeon doesn’t charge for their time, there will be hospital and anesthesia fees, a need to arrange for a companion again, and possibly travel.
You also cannot predict accurately how long you’ll need to spend during recovery. You might plan to spend two weeks near your surgeon after surgery, only to find out you have complications that make it unwise to return so quickly, meaning you may have additional travel costs (assuming you traveled for surgery). Likewise, you may need more time to heal before returning to work, which means you won’t make your full salary for longer than you might have planned.
You Probably Won’t Heal Faster Than Average
Sure, you’re young, healthy, active, don’t smoke, not overweight, and whatever else. That’s good and will help your healing time. Or maybe you aren’t, but working with your doctor you’ll be fine, even if your healing might be a bit longer than it would be otherwise.
But you’re not going to want to run marathons, go back to work, take a long car ride, or anything else for several weeks after surgery, even if you are that perfect candidate for surgery. Because of the gatekeeping, most people that have this surgery are darn-near perfect candidates. So what is average for recovery time is average for that perfect candidate, not for a person that has exceptionally long recovery times. So plan on not taking the average time, you very well may need longer. Even a healthy, young, fit person might take longer.
Most surgeons require you to stop some or all of your HRT before surgery (there is debate on this, but right now most require you to stop). But even if you don’t stop your HRT, when you have bottom surgery you lose the tiny amount of testosterone your testes were producing (even if you were suppressing your testosterone with medication and those organs were atrophied from estrogen), and losing that suddenly can be a pretty rough ride.
You’ll be tired and weak from this, and the hot flashes suck. If a companion is staying with you after surgery for a bit, you might want a two room place to stay, with separate air conditioning in your room.
Your catheter will be removed a few days, maybe a week or two, after surgery. You’ll be happy to see it removed, but if you are like many people your happiness will turn to frustration quickly. It can be really difficult to pee when your groin is numb (the trauma of surgery tends to numb a lot of things) and you’re very swollen. It fairly common not be able to pee and end up with the catheter re-inserted for a few more days. That sucks, but you’ll get through it! One nice thing: Since you’re post-operative at this point, catheters are much easier than they were before surgery.
For a while, you’ll probably pee in all sorts of directions you don’t want, thanks to all the swelling. It’s almost a post-op woman right of passage to sit on the toilet, relax your muscles, and watch as a stream of urine inexplicably decides it can exit between swollen lady parts and go horizontal, passing right between the toilet seat and bowl, and ending up right on your shoes! Learn to laugh at the absurdity of not being able to get a stream of urine into the damn bowl consistently, while you are still swollen. It does get better!
Also, your surgeon might not tell you some simple tricks to help with this— try peeing with your legs in different positions, such as spread apart, pressed together, etc. Like cis women, we are all different, and, like cis women, we might find some positions work better than others!
Getting Follow-Up Care is Tough
After having surgery, once your mostly healed, you’ll have the same body parts other women do. You’ll be, anatomically, very similar to a woman who has had a total hysterectomy. Like her, you can get vaginal infections and urinary tract infections (more common in women than men because of the shorter path for bacteria to enter the bladder). You may have granulation tissue where your healing (just as a woman who recently had a hysterectomy might have). These things are treated the same way they would be treated in a cis woman, but a lot of gynecologists are worried about seeing trans patients, and you may experience outright discrimination.
You may want to consider scheduling a check up with a gynocologist to happen about six weeks or so after your surgery. But you’ll want to find this gynocologist before surgery, as the few that will see a recent trans surgery patient will often have significant waiting lists, particularly for new patients. It also helps to deal with the stress of scheduling while you are not going through a hormonal roller-coaster!
It’s disgusting (for the first couple of months!)
Healing is kind of a disgusting process. Expect that for at least a few weeks, you’ll be overall pretty gross to be around. You won’t be able to properly shower for a bit after surgery, you’ll be bleeding and having discharge, and you’ll be (more often than you like) ruining whatever clothes you put on your lower body. Just accept that people who recently had major surgery are not supposed to look and feel their best!
It’s Scary, and (hopefully minor) things will go wrong
You’ll feel you did everything right — you got healthy enough to have surgery, you stopped doing things that are bad for you, and you’re probably healthier than you’ve ever been in your life. You set yourself up for success. You only have one shot at this, after all, you told yourself.
So, a few weeks later when you experience a complication, whether it is difficulty peeing, it’s nausea from the pain medications (throwing up after this surgery really, really sucks), or pieces of your new genital skin literally falling off, it’s terrifying. It’s even more terrifying if you feel alone. Having a companion is really important during these times, to help calm yourself down. Text your friends. Put your therapist on speed dial. This is a roller coaster ride you’re about to go on. But trust your surgeon! They see this every day and knows when it is just a minor bump in the road and when it’s something that is actually significant. You won’t be the most objective judge of that when it is your body!
You Didn’t Know How You’ll Look, but That’s Okay!
One thing I can guarantee: the first time you see yourself in the mirror (well, that part of yourself), it won’t be what you expect to see! You’ll be swollen, bruised, possibly bloody. But more significantly, a few months later you’ll still not see what you expected to see. All women are different “down there,” and you’ll be no exception. You’ll be different too. And that’s okay.
I’ll add that some of the more typical aspects of trans woman genitalia (such as how post-op labia minora often look) are normal — even desirable — in the eyes of other women (I’m amazed at the number of cis-women who have vaginoplasty to essentially look just like many post-op trans women already look). For most post-op trans women, their genitalia is indistinguishable from that of a cis-woman, but it probably won’t look like your high school girlfriend or a porn star, either. Just like most women won’t.
Prostate & Women’s Health Exams
Typically the prostate is not removed — there is little upside to removing it, and lots of downside. So, yes, you need to still have that exam. However, a lot of doctors seem to lack an understanding of anatomy and try to examine the prostate in a post-op trans woman by touch through the rectum, which is not optimal. Being that the prostate is around the urethra, and the urethra is in front of the vagina in people with a vagina, a doctor trying to feel it should do so via the vagina, not the rectum (as through the rectum, the doctor would need to feel it through three walls — the rectal opening, the back of the vagina, and then the front of the vagina, greatly reducing the ability to, well, feel the prostate). You’ll want and need to advocate for yourself when you see a doctor for this exam — most won’t know the proper way to do the exam until you explain it!
Also, in case you are curious, you don’t need a pap smear — you don’t have a cervix. Still, it is a good idea to ask a doctor about what routine examinations you should have with your new body. At the very least, you should do the same types of exams any post-hysterectomy woman would have.
Yes, your sex life is probably going to be different. Your parts are different, and they work different ways. You won’t be up to this for quite some time after surgery, but when you are, it will be different than before surgery (obviously!). Lynn Conway wrote about this a while ago, and I’ll simply refer you to her outstanding work (noting that terminology has changed in the decades since she wrote this).
One fear a lot of trans women have is that they’ll need to use lubrication to have sex if they don’t have a mucous membrane lining in their vagina (I.E. if they have a penile-inversion type of procedure). Let me clear up a few things. First, many doctors recommend all women use lubrication during sex, so a trans woman using it is not unique here. Second, there is nothing wrong with using lube and most women find lubrication helpful (not just women with “dryness”). Third, if you’re worried about another person touching you there and not feeling a waterfall, fear not — you’ll have moisture down there no matter what when you’re turned on, no matter what procedure you had. You’ll probably still want (and, frankly, need) to use lube, but that’s no different than any other woman. And, forth, even if you have a mucous membrane lining, you still should use lube — it’ll be better for everyone involved! Just like it would be with any woman.
You might still want therapy
This is a tough process, and the difficulties don’t suddenly stop with a medical procedure. You may have things you want to talk about — there will be major changes in your romantic life, there may be surgical complications to deal with, and it might be time to address some of the less-urgent-but-still-important things about your life (you know, the stuff that isn’t about gender!).
Nothing Changes. And Everything Changes.
For the most part, nobody will know you had surgery. Your genitals won’t be apparent to the cashier at Wal-Mart. If you were misgendered before surgery, you’ll be misgendered after surgery — but likely frustrated that even after you did all this, it wasn’t enough. Be prepared for that.
At the same time, the confidence of knowing your own body is what you want to be can help others see you as you are, even when they won’t have any idea what genitals you have! I know several trans people that say that they are seen more often as their proper gender since surgery, and I think a lot of that is simply being more comfortable in their body — and that confidence helps others see it too.