by Dr. Rixt A.C. Luikenaar, MD FACOG

Within the United States there are currently several transgender surgeons well known for GRS surgery (vaginoplasty-phalloplasty/metoidoplasty with urethral lengthening, vaginectomy and scrotoplasty). These include Dr. Curtis Crane (and partners), Dr. Sherman Leis, Dr. Toby Meltzer, Dr. Joanna McGinn and Dr. Marcy Bowers. Together these physicians have performed thousands of transgender surgeries.

Several other surgeons are known for top surgery, breast augmentation, and a few for facial feminization surgery and tracheal shaving. Most gynecologists perform hysterectomy although few are informed of the WPATH Standard of Care requirements are for Gender Dysphoria. Insurance companies also give a list of requirements, some of them very outdated (one insurance requires living in the desired gender for one year). Most want you to have been on hormone therapy for four months (orchiectomy) to one year (GRS surgery).

The 10 questions I get asked most frequently by transgender people who are considering transitioning are:

1. How do I get started?

The WPATH Standards of Care currently require two letters from mental health professionals with the diagnosis of Gender Dysphoria and the conclusion that you are “ready” for GRS surgery. For a hysterectomy that is one letter if the procedure is done under the diagnosis of Gender Dysphoria (not if it is for pelvic pain, bleeding issues or endometriosis). For top surgery one letter is requested by most insurance companies that have a transgender inclusive policy.
Insurance plans that currently cover transgender healthcare are Aetna, United Healthcare, Blue Cross Blue Shield Federal and out of state (some states such as California, Illinois, New York, Maryland), University Health plans (including market place plans) and some multi-plans. Always call your insurance company (or your parents’ insurance company) to find out details. After Jan. 1, 2017, some plans may now cover transgender health care where they did not before so check frequently.

2. How long does the mental health stage take?

This depends on the mental healthcare therapist you see and on the comorbidities (other mental diagnoses on the DSM) you have been given.
Some therapists see you have been on hormones and have socially transitioned and are comfortable quite quickly providing a letter, others want to get to know you first. For patients with little income this can become expensive depending on the amount of visits a therapist desires. Consider asking a therapist at the first visit what they usually do. Surgeons don’t typically deny you surgery if you take antidepressants or antianxiety medications and you should continue taking them as there is a condition called postsurgical depression. Like any stress factor in your life that can trigger depression, surgery is one of them. Especially if you have little support.

3. What is the time requirement for being on hormone therapy?

The WPATH Standards of Care requires patients to be on hormone therapy for at least a year for GRS surgery. There are no guidelines for gender nonconforming patients that desire surgery but do not desire to be on hormone therapy. These patients should discuss with their surgeon what they desire and if the surgeon is comfortable with it. The surgeon should discuss risks and benefits with you and also be honest about their comfort level performing your surgery. Many surgeons don’t get the fact that Gender is an Infinity or spectrum and are still very binary. Most insurances also require a year of hormone therapy.

4. Is there a weight limit for candidates?

This depends on what the surgeon is comfortable with. Some GRS surgeons do not (for example, Dr. Leis), others definitely do (Dr. Bowers, Dr. Crane). Of course you recover and heal quicker if your BMI (body mass index measurement) is normal. In general surgeons want you to be both physically and mentally healthy. Chronic conditions like diabetes, hypertension and thyroid disease should be well managed. Patients who have had weight loss surgery (gastric bypass for example) should not have other surgeries within the first year due to rapid weight loss and loss of important minerals and vitamins.

5. How long am I in the hospital after surgery?

Several surgeries are “outpatient” which means you go home the same day or the next morning. These are surgeries such as orchiectomy, tracheal shave, breast augmentation or top surgery. Even after a hysterectomy can you go home the same day or the next morning. Patients who have GRS surgery are inpatient for usually at least three days because their recovery process is more complicated, especially if you have had other surgeries such as facial and chest surgeries at the same time. GRS surgeons often practice in facilities that have on-site recovery suites or a hotel nearby so the surgeon can check on your progress several times a day after surgery.

6. What is the recovery timeline after surgery?

Typically a patient can return to work or school anywhere from a few days to about two weeks for most facial or chest surgeries. For GRS surgery most surgeons recommend two months off work and three months of recovery before exercise. For a hysterectomy that is anywhere from two to six weeks off work depending on what type of work you do and if you have the money to take the time off. Don’t lay in bed all day after surgery. It is important to move around to prevent blood clots.

7. How do I pay for transgender surgery?

Most patients pay in cash and almost all surgeons want it up front. Ask them about payment plans and loans. An increasing number of patients are covered by insurance, even if it doesn’t cover the entire bill. Always check with your insurance and ask the surgeon if they accept the insurance plan. Even consider writing a letter to your insurance and ask for an exception. Some patients have had their surgeries covered this way. Cost may vary a lot so compare prices. Ask for a discount if you can pay the entire amount up front.

8. Can I schedule my transgender surgery in stages?

Every patient I see has their own journey with their own list of things they want to work on or change during their transition. For some that can be breast/chest surgery, for others facial feminization or hair transplantation or hysterectomy. Some patients schedule facial surgery, tracheal shaving, breast augmentation and GRS surgery.

Dr, Meltzer prefers to schedule a phalloplasty in two stages, as do others.

Sometimes patients prefer this due to cost, although having procedures done at the same time saves you money (you only go under once, less recovery time).

Some patients desire to have all surgeries done as soon as possible, others can’t afford this (most of my patients) and for example start with an orchiectomy first (and maybe later GRS surgery-vaginoplasty).

9. How can I make my voice sound more feminine and what about vocal cord surgery?

Kathe Perez is a speech pathologist from Denver who has been a voice coach for many transgender women (and men). She has a phone app, online videos and you can take a “crash” course in voice feminization with her. Within Utah we (soon) will have two voice coaches, one of them is still working on getting experience, the other is Stacy Cole, a voice coach that works part time and recently brought some cards to Rebirth to hand out. She also helps trans men with their voices since a lot changes within your voice box as you start testosterone. Some of you sing and the impact of hormones on the voice can be significant. It is then certainly a good idea to work with a voice coach. Vocal cord surgeries are becoming more popular but the procedure can be quite expensive and does not always turn out well. I don’t recommend it at this time until we have more data about success rates.

10. How soon can I have sex?

After GRS surgery, with a normal postoperative healing course, you can engage in sexual activity after two to three months. Around that time it is typically that I recommend transgender women to replace the dilator with a dildo or vibrator to stop thinking too “medically” about your new vulva and vagina.

For a phalloplasty that is about the same recommended time (after your last surgery) since you want to let your urethra (the tube your urine comes out that has been lengthened with tissue from your vagina) heal. GRS surgeons require that you have a vaginectomy (removal or closure of the vagina) before you can have a phalloplasty. For a metoidoplasty with urethral lengthening they recommend it too since it closes the vaginal canal quite a bit. GRS surgeons also require a hysterectomy before you can have these procedures since you don’t want to bury the cervix and vagina to allow secretions and blood (not desired but does occur in trans men on testosterone therapy) to come out. If you want to give birth yourself one day, don’t get these procedures either (or ask for a cesarean section). If you have a hysterectomy I don’t recommend penetrative sex for at least six, maybe eight weeks (vaginas on testosterone take longer to heal). If you do, you could tear the scar on top of the vagina and your bowels could fall out.

Please ask us any questions you have about surgeries, our recommendations of where to go have your surgery. We are there to help you. For any of the above mentioned surgeries it does not matter what your current name or gender marker is. We do recommend at this time that you obtain a passport.

Our new administration next year may possibly make this very difficult.

Rixt Luikenaar MD FACOG, is an obstetrician gynecologist and transgender healthcare specialist at Rebirth Obstetrics & Gynecology, rebirthobgyn.com

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