Getting a vagina is a pain. 

Luckily, you can score some good drugs to help fight the discomfort of surgical recovery, but there's no prescription for the pain of navigating the multi-step, labyrinthine process you must complete before donning that gown. Until now, that is. 

Below you’ll find a step-by-step guide to help you plod your way out of the mire.

We’ll be dropping a similar guide for phallo-seekers (and metoidioplasty) and a general gender-affirming guide soon. But this guide is for the transfemmes in Seattle and in Washington state. Much of the advice applies if you live elsewhere, and it should be pretty clear which tips are for the locals and which are more universal. 

Looking for something specific? Use these links to jump around the guide.

To Crowdfund or Not to Crowdfund? • Prepare to Battle Insurance Companies • Public Insurance Options (and Doctors Who Take It) • Private Insurance Options • How to Fight a Discriminatory Health Insurance Plan • How to Appeal a Denial of Service • More Options for Financial Help • Get Three "Letters of Readiness” from Therapists • Get a Letter of Medical Necessity • How to Pick a Surgeon • Planning for Before and After Surgery • Coda: A Short Neovaginal History 

To Crowdfund or Not to Crowdfund? 

We won’t sugarcoat it. Insurance companies suck, applying for coverage sucks, and it sucks to talk to insurance agents and their robotic counterparts. But an insurance plan has serious utility, especially if you know the playbook.

Of course, you don’t need an insurance plan for surgery. You can pay out of pocket, and it is reasonable to believe that crossing your fingers and crowdfunding care beats fighting a formidable medical bureaucracy. But why not do both?

If you’ve never had your own plan, there are two big numbers to consider: monthly premiums and a plan’s out-of-pocket maximum. Premiums are the baseline monthly payments to your insurance company, and the out-of-pocket maximum is the most an insurance company will charge for covered services in one year. Once you hit that magic number, you’re pretty much home free.

Bottom surgery can cost about $25,000 dollars or more, not including air travel, hotels, food, medical supplies, unpaid time off work, and anything else. The sedan-sized sum dwarfs monthly premiums and yearly maximums. Just having good insurance can save you money, and there’s nothing stopping you from crowdfunding your insurance payments. A strategic combo could reduce the total you’ll need to raise by thousands and thousands of dollars. Lowering the ceiling can help; a paper published in Transgender Health found most campaigns don’t reach their goal.

Also, it is worth thinking about how many crowdfunds there are–many for people fleeing persecution from hostile state laws–and how little money the trans community has to pass around.

An old friend and I often joke that the trans community passes the same $5 around in a giant circle over and over again. If it is accessible to you, then using insurance and Washington’s equality protections to your benefit is an extension of that altruistic devotion to community care. Making insurance companies pay for medically necessary surgeries–like they should–is worth pursuing.

Point of Pride, a trans health care organization that raises money for its annual trans surgery fund, asks its applicants to deeply consider their access to health care before applying for their financial aid. Do you have trans-inclusive health insurance? Do you qualify for Medicaid? Are you employed and able to save for surgery? Are you documented? Are you able-bodied? Are you white? These are great questions. 

That said, there’s absolutely nothing wrong with crowdfunding or grants, which this guide discusses below. To the contrary, they are lifelines, especially for folks contending with additional racial, financial, and legal barriers to care beyond transness.

Yeah, the process still sucks, but there are resources that make selecting an insurance plan (and getting your surg covered) marginally easier.

Prepare for Battle: The Hell of Insurance Coverage

For this story, I contacted nearly every insurance carrier in the state of Washington. Those who answered gave some version of the same meaningless response praising their inclusive, compassionate practices for trans customers. Yeah, right.

A word to the wise: insurance companies are sharks. If they can deny a claim, they will deny a claim–for anyone, and for anything–cis or trans. 

Expect an adversarial relationship. Insurers are not your friend, despite whatever LGBTQIA+ platitudes they’ve plastered on the gay-friendly part of their website. There are certainly individuals within insurance companies that will help you. Go them! But be on guard.

Treat conversations with your insurance company like a deposition for a case you might have to build. Every time you pick up the phone, note the time, the date, and take detailed notes of everything said. Ask customer service representatives for their name, employee ID, and the reference number of the conversation you’re having. Then save it to your computer and back it up. Be kind but firm. Get a little terse if you absolutely have to, but keep in mind the person on the other line probably isn’t your enemy. Their boss’ boss’ boss’ boss’ boss’ boss is.

If you’re lucky, a person who cares about queer people will answer your call. But you might not get lucky. If you start getting that phobic vibe, hang up, scream into a pillow, and call back. Chances are you’ll reach someone new. Barfing as I write this, but if they stonewall you, then ask for a supervisor. 

Oh, and have your insurance policy in front of you. Take a pen and mark it up. Highlight the salient details. Sometimes, insurance representatives will tell you something that doesn’t align with your policy. Knowledge is your best tool in this situation.

Picking an Insurance Plan (Public Options)

You may qualify for Washington Medicaid, aka Apple Health. Kudos to Apple Health for being the only insurer to provide useful information about their coverage. In fairness, its plan isn’t as convoluted or varied as private carriers, but still.

If you’re reading this, then there’s a good chance you qualify. Trans adults are statistically more likely to earn less than cis adults, and a 2019 report from the Williams Institute found that 152,000 of the 1.4 million transgender Americans living in the US were on Medicaid.

Your first stop should be the Washington Healthplanfinder, which will determine your eligibility through a series of questions. If you’re a state resident between 19 and 65 and you earn $20,121 or less per year as a single person (or $41,400 for a family of four), then you may qualify. Here are the full eligibility requirements for 2023. You can apply for Apple Health any time of year.

Gender-affirming surgeries are covered directly by Apple Health fee-for-service and not by the managed care plan.

To get gender-affirming bottom surgery covered through Apple Health, you’ll need to be on hormone replacement therapy for a minimum of 12 months or have a documented medical reason for not being on hormone therapy.

You’ll also need to be living publicly as a transfemme for a minimum of one year, unless personal safety concerns documented by a mental health professional prevent you from being out. You’ll need two letters of readiness (more on this below) from therapists, a letter from the provider administering your hormone therapy, and a pre-surgical physical and surgery plan from your surgeon.

Here is a list of bottom surgeons who take Apple Health, according to Apple Health. This list is not all-inclusive, but it's a place to start:

  • Dr. Shane Morrison (Plastic Surgery) at the University of Washington Medical Center, Seattle. Call (206) 987-2759. Primary care physician referral required.

  • Dr. Geoffrey Stiller in Spokane. Call (509) 747-5773.

  • Dr. Toby Meltzer at The Meltzer Clinic in Portland, Oregon and Scottsdale, Arizona. Call (480) 657-7006.

  • Dr. Daniel Dugi and Dr. Geolani Dy at the Oregon Health and Science University’s Urology Clinic in Portland, Oregon. Call (503) 346-1500. Dr. Blair Peters at the Oregon Health and Science University’s Plastic and Reconstructive Surgery Clinic, Portland, Oregon. Call (503) 494-6687.

  • Dr. Nick Esmonde at Legacy Health, Good Samaritan Medical Center in Portland Oregon. Call (503) 413-5600.

If you don’t have insurance through your job, and if you don't qualify for Apple Health, then you can still find an insurance plan on Washington Healthplanfinder. The state’s insurance marketplace is easy to use. You’ve got options.

PPO plans (Preferred Provider Organization) are generally more expensive than HMO plans (Health Maintenance Organization), but they come with additional flexibility that comes in handy for specialized care like trans services.

For example, HMOs require you to see your primary care doctor for a referral to see a specialist. PPO plans do not. HMO plans don’t cover any out-of-network doctors, unless it’s an emergency. PPO plans offer at least partial coverage. Aside from that, check how vast a provider’s network is. The bigger the better, in this case.

If you have a specific surgeon in mind, call or email their office to ask which insurance plans they take. (If that surgeon is out of state and contracts with Blue Cross, they’re probably considered in-network on Washington’s Blue Cross plans).

Depending on your income, you may be eligible for federal subsidies, which will cut your monthly premiums by hundreds a month (potentially; I don’t know how much you make). Report any changes in your monthly income (over $150), because if you make more than you expected, then Uncle Sam may ask for some of his money back on tax day. In my early twenties, I learned this lesson the hard way when I switched from one barista job to another with extra shifts.

You can’t exactly sign up for this insurance whenever you want. “Open Enrollment” for coverage in 2024 begins November 1 and ends January 15. If that sounds far away, don’t despair, there’s a lot you can do in the meantime, like secure therapy letters and schedule consultations far in advance, (see below). You won’t know exactly what next year’s plans look like yet, but browsing the marketplace and calling providers could help you hit the ground running. If you started from square one today, you’re not likely to be in the operating room by the end of 2023, so don’t think of it as too much of an obstacle.

You may not have to wait. You have 60 days to sign up for insurance coverage after a “qualifying life event,” which includes job loss, marriage, a change in income, moving to Washington, and more.

You May Already Have a Plan Through Your Job (Private Options) 

This could be great or not so great. 

The first thing you should do when seeking any kind of gender-affirming care through your job’s insurance is to determine whether it's a fully insured plan or a self-funded plan. Armed with that knowledge, you’ll have a firmer grasp on your fundamental rights and how to wield them.

Your employer may have what’s called a fully insured health plan that it purchased through the marketplace. Basically, your employer went to an insurer like Aetna, Blue Cross, or Kaiser and agreed to pay the monthly premiums for each employee and deduct some of that from your paycheck.

If one employee’s health care costs more than the premiums, well, that’s on the insurance company’s dime. About 1.3 million Washingtonians are on these plans. 

The Washington state Office of the Insurance Commissioner (OIC) regulates fully insured plans (these insurers must comply with their rules to sell insurance in the state). State law requires they offer a broad array of gender-affirming care. That part’s new.

Before 2022, no state law explicitly protected access to trans care. Until then, we were working with a 2014 letter from the Insurance Commissioner's office that required insurers to cover gender-affirming care to comply with the Washington Law Against Discrimination and the Affordable Care Act’s nondiscrimination protections. The letter also told companies not to issue blanket exclusions for transgender care–with “blanket” being the key word here.

Transgender activists, including the Gender Justice League in Seattle, lobbied to strengthen protections beyond that memo, because insurers could and would exploit every opportunity to label doctor-prescribed facial procedures and breast augmentations as “cosmetic” procedures. To close the loophole, lawmakers passed the Gender Affirming Treatment Act, and required insurers regulated by the state to cover hormones, laser hair removal, electrolysis, surgical care, and other procedures.

For the hate-readers, no, comprehensively covering trans care didn’t raise the price of insurance for everyone. In fact, economic analyses and studies show that covering trans care is cost-effective when compared with the risks of untreated gender dysphoria, including this Johns Hopkins study published in the Journal of General Internal Medicine.

While fully insured plans can’t legally deny trans care in Washington, they may try to. Always appeal denials of care, and do it quickly; then file a complaint with the Office of the Insurance Commissioner. By law, insurers must respond to the OIC within 15 days. The OIC will follow your case and examine whether or not your insurance company broke the law. To file a complaint, call 1-800-562-6900 or visit this website.

Your employer may have a self-funded health plan, which could cause some issues. 

In this case, your employer has assumed the financial risk for you and your coworkers, and under federal law the state cannot regulate their health plan. About two-thirds of insured people in the state of Washington are on employer-sponsored plans. 

Federal nondiscrimination protections for trans health care still apply here, but these plans can more easily violate them, and your protections are muddier than for people with fully insured plans. Your employer could voluntarily offer trans care, or not.

For instance, Blue Cross Blue Shield of Illinois lost a federal case in Tacoma last year over a transgender care exclusion clause in a self-funded health plan. A federal judge found that the Blue Cross plan administered through a Catholic health care nonprofit was still subject to a nondiscrimination clause (Section 1557, to be exact) in the Affordable Care Act (ACA).

You’ve also got the Mental Health Parity and Addiction Equity Act (MHPAEA) at your hip. Because trans people seeking care are doing so to alleviate symptoms of dysphoria, and because coverage for surgical care is backed by a mental health evaluation, this law protects you.

Self-funded health plans are not all bad news. 

Several big companies such as Microsoft, Intuit, and J.P. Morgan Chase–evil as they may be–self-fund health plans that explicitly cover trans care. According to the Human Rights Campaign’s 2022 Corporate Equality Index, 67 percent of Fortune 500 companies offer trans-inclusive health care policies.

However, if you happen to work for a company that doesn’t cover trans care, then the state’s insurance regulators won’t be able to help you out. It might be tougher to build that argument based on Section 1557 of the ACA all by yourself, but you should surely try–though you don’t have to go it alone, keep reading. 

How to Fight a Discriminatory Health Plan 

I can’t promise you a trans Erin Brockovich moment in slamming this shit down on your insurance company’s desk, but those federal protections, evidence-based medical research, transgender care guidelines, and any previous court decisions are your ammunition.

One expert told The Stranger that writing a respectful letter to your employer or to the person who handles employee benefits at your company (sometimes called a benefits administrator) is a good first step in addressing a trans-exclusionary clause in your health plan. In this case, going directly to the insurer is a crapshoot since they only manage payments for the services your employer bought. It’s your employer’s responsibility to purchase the coverage, and your mission is to change their mind.

For instance, your letter can point out that a trans-exclusionary clause does not align with the company’s mission, vision, or values. Businesses in Washington state generally want to appear trans-affirming because it’s good business, so pushing back against a discriminatory health plan may work. Sometimes, employers are just ignorant to trans issues, don’t know they have trans employees, or feel like nobody is going to make a stink about their policy. The National Center for Transgender Equality shared this letter template.

Whatever you do, don’t fade into the background because that’s exactly what they’re hoping for. At the end of the day, there are still ways to take legal action against employers who don’t cover your health care if you feel like you’re being discriminated against. 

If you’ve played Ms. Nice Girl, and your employer is still fighting you, and you want to be really practical, call the Employee Benefits Security Administration at the Seattle office of the Federal Department of Labor. You should also call the Federal Department of Health and Human Services Office of Civil Rights (OCR). OCR is responsible for enforcing the nondiscrimination provision in Section 1557. You can also reach out to legal aid organizations (more on that below). Worst case scenario, take the company to court. 

Experts said just filing a complaint is helpful, because it can help watchdogs and activists identify patterns and fight on behalf of better protections for everyone. (Your report could appear in a public records request, so they can access it.) Even when the state government implements trans-inclusive policies, it is impossible to know whether or not they’re working unless people like you speak up. Collective advocacy is a proven way forward to defeating benefit exclusions in Washington.

If you’re job-hunting, don’t shy away from asking about the company’s benefit plan. If you’re thinking about gender-affirming surgery, the insurance could be a factor in whether you accept the position or not. You don’t have to say why you’re asking–it is a normal question. If you need the job regardless of inclusive insurance coverage, at least you’ll know what you’re getting into.

The most recent Kaiser Family Foundation / the Washington Post Trans Survey found one in seven trans adults have switched jobs for insurance coverage.

Don’t Let a Denial Letter Discourage You. Get Help!

Appeal, appeal, and appeal a denial of services. Write that on your arms in permanent marker if you have to, because an appeal keeps the ball in the air. Data shows people only appeal one out of every 500 insurance denials. Be the one! But you don’t need to take on this exhausting, demoralizing process alone. The law is on your side.

There are plenty of legal aid organizations in Washington who would gladly write an appeal for you–for free. It should be a breeze for any lawyer or older law student.

The University of Washington’s law school has legal clinics and a pro bono program. The Washington Bar Association holds free legal clinics. Transcend Legal is a national organization. (This is not an exhaustive list, but this national list of legal resources is extensive.)

Also, check out Northwest Justice Project and QLaw Foundation of Washington. The Gender Justice League is another resource. If you haven’t noticed, there are a lot of anti-trans legal actions happening around the country, so small but mighty queer organizations may be tied up at the moment. They’ll at least point you in the right direction.

You can find help in the medical system, too. Your surgeon may have staff who can file appeals for you. Big hospital systems and insurers sometimes employ “healthcare navigators,” or trained experts who help patients understand the processes and submit important forms for them, including appeals. In Washington, that at least includes Kaiser, Premera Blue Cross and Regence BlueShield. If that service is available to you, do call.

But not all health care navigation systems are created equal, so your mileage may vary. If you’re stuck and don’t know what to do next, then ask your insurer, doctor, or hospital about health care navigation services. Even if you’re not technically working with that hospital system, they may still answer your questions because you could be in the future.

Unfortunately in Washington, there’s no general support line or system for trans people who have questions about all this (nor cis people for that matter; we all share that hell). 

More Financial Help 

Grants! If you’re struggling to find a way to pay for your surgery, you can apply for a grant, which could cover 100% of the cost. 

I mentioned Point of Pride, but there’s also the Jim Collins Foundation (JCM). Both organizations review hundreds of applications a year, so it is by no means something to count on, but it is worth trying. You can apply here. The fund asks applicants to demonstrate a genuine need for financial assistance and evidence that you’ve already tried fundraising. If selected, JCM’s payment goes directly to the doctor or hospital.

Some hospitals and providers have financial assistance available to those who aren’t eligible for Medicaid or can’t afford a marketplace plan. One expert said these programs are invaluable for people who are undocumented and thus ineligible for Apple Health and ACA plans.

I’ve read guidance that suggests charging your surgery to a credit card, and as a counterpoint, I’ll say, uh, maybe don’t?? That debt could bury you alive, even if that shiny plastic card comes with a year of deferred interest. Your credit score determines how much you can borrow, so this may not be an option anyway. There are medical credit cards out there, too, but if you don’t pay off the surgery during the no-interest financing period, the creditor will charge interest retroactively. Medical loans are another option, but, again, you are assuming major debt.

Saving! If you have the ability to save, I think it would have occurred to you. Read on! 

Don’t Call a Surgeon First. Call a Therapist (or Two or Three)

Early on in the process, you’ll need a psychological evaluation from a therapist, who will then write you what’s called a “letter of readiness” or a “letter of medical necessity.” Your surgeon or insurance company will require between one and three of those before they let you schedule the procedure. If you’ve already got a therapist who understands trans issues, great! One letter down. You’ll probably need at least one more. 

These letters are like the part of a video game where you collect three amulets or whatever to progress further.

But why do I need them? Because insurance companies want justification, damn it. 

Each independent assessment and analysis of your life and experiences is proof to insurers that you meet DSM-5 criteria for gender dysphoria and that surgery is the next essential step of your mental health journey rather than some other option. It’s kind of like when a doctor orders an MRI, and the insurance company says, “Hey champ, how about an X-ray?”

Letters of readiness appease insurers by explaining why a procedure (vaginoplasty) will get to the bottom (ha) of your complaint (dysphoria) from a therapist who says you’re of sound mind after plumbing your mental depths for some secret psychological problem. Very dramatic stuff. 

Insurers also want to hear your detailed plan for surgical recovery, which is maybe the most sensible aspect of this tiresome enterprise. Use the opportunity (not that you have much of a choice…) to sketch the basics of where you’ll stay, what you’ll need, and who will be there to help you. Then repeat that plan to one or two more therapists. Recovery renders you helpless at first, so you’ll actually want to prepare. Expect six weeks without exerting yourself in any way, doctors say.

These letters are also a necessary evil in our fabulous medical system that works so well for everyone, where so much is driven by liability. In order for insurers to pay for any procedure, there has to be a diagnosis code attached to it. The definition of gender dysphoria, updated from “gender-identity disorder” in 2013, swapped the pathologizing of transness for a medical definition for the feelings of despair associated with living inauthentically and the serious mental health consequences of doing so. 

We’re playing a for-profit health care game here, so it's important to provide a bedrock reason insurance should pay up.

Save time with the right therapist. If you’ve picked someone who understands trans issues, you won’t spend three sessions explaining what trans is. No therapist is going to approve something they don’t understand, even well-meaning people. If it takes more than one appointment for this letter, jump ship.

Fortunately, therapists who understand trans patients love to say so on Psychology Today. In Washington, you’ll find many with a quick search (and you’ll also find many trans therapists, all the better), but they’re very busy people. 

There’s a lingering shortage of mental health practitioners in the US, and those providing a specialized service are in even shorter supply. One trans-affirming therapist I wrote to for this story didn’t have 15 minutes to spare for the next month. You’re familiar with this problem if you live in Seattle and access any kind of trans care. Despite any supportive and liberal spirit or kumbaya around here, the demand for services is greater than what trans-affirming doctors can provide.

Ask what therapists charge ahead of your appointment. If you don’t have insurance, therapists may charge between $30 and $150 for each session, while others write letters for free. 

What are the appointments like? Expect intimate conversations and a memoir-length recitation of your trans life. Therapists will ask for details about your childhood, when you started experiencing dysphoria, how you think about your gender, when you started transitioning, and why you need the surgery. They’ll also ask about your mental health history, from depression to suicidal ideation (if you experience this), and how you’re managing those feelings. A therapist may want to know if you have a support system, or how dysphoria affects your life and work.

Sharing this personal compendium with three strangers is draining, and you may worry this information will be used against you. A therapist wants their letter to be an unassailable argument for your surgery, even if they have negative thoughts about the system as a whole. 

Some therapists would even say this whole process is gatekeeping nonsense built on the transphobic assumption that you don’t know what your body needs. People don’t have to justify other medical or elective surgeries with the help of a therapist if their doctor says they need it. 

Gender-affirming procedures for cis people (and cis minors!) for, say, nose jobs and breast implants, don’t meet the same mass social resistance. This double-standard forces trans people to prove their sanity, as if insurance companies and the medical infrastructure routinely shake trans people by the shoulders and demand to know if they’re really sure about transitioning. 

It’s worth mentioning that trans surgeries have low regret rates.

When researchers at Cornell University systematically reviewed 55 primary-research studies published between 1991 and June 2017 that assessed how transition affected well-being, they found regret is rare and studies suggested it has become rarer as surgical techniques improved over time. Pooled results found regret rates between 0.3% at the lowest, to 3.8% at the highest. Researchers concluded regret came from a lack of social support and implies broadly poor outcomes.

A review of 27 studies published in 2021, comprising the collected cases of 8,000 trans minors and adults in the US, Europe, and Canada found just 1% expressed regret. For some, the feeling eased over time, but a small number sought reversal procedures. The data is imperfect, researchers wrote, because the classification of regret was highly subjective across studies and because researchers didn’t ask the same questions of every person, highlighting the need for standardized questionnaires.

The World Professional Association of Trangender Health (WPATH), which sets the standards of care for trans people around the world, says evidence of regret is infrequent, but they recommend that doctors discuss the possibility with their patients.

Detransition rates tend to be higher, but they are not driven by regret. A 2021 secondary analysis of data from the US Transgender Survey found most who reported a history of detransition cited external factors like social stigma, family pressure, and discrimination as their primary reason. Researchers said doctors should be aware of these pressures, and people who detransition may seek care again in the future.

These Letters Don’t Last Forever!

Your letters of readiness are not letters for life, but they will last 12 to 18 months. Ask your surgeon and insurer what they require. It does not matter if you’ve been on hormones for one year or 20, or if you’ve had a gender-affirming procedure before. You’ll have to do this again, again, and again throughout your life to receive trans medical procedures. Insurers won’t cover laser hair removal without an updated letter. (To prevent beard loss regret? C’mon.) It’s just like updating car tabs, and it’s just as annoying. Know when they expire to avoid bumps in the road.

Most gender-affirming therapists are amenable to updating their letters if you send them an email. If you’ve experienced major life changes, they may ask for another appointment, but otherwise it won’t take long. Once you’ve had one appointment, scheduling this check-in should be much easier. Many clinicians will accommodate patients in need. But if you’re having trouble for whatever reason and the clock is ticking, find someone new. In that case, see above.

If you’re far enough along in the process, your surgeon may ask your therapist directly for an updated letter, but don’t count on it. Your insurance company will not do this for you.

But Wait, There Are More Letters to Consider! 

In health care, you hear the term “medically necessary” a lot. By law, insurance companies have the right to ask for proof that certain types of care subject to prior authorization are medically necessary. Talk to your doctor or therapist about a letter of medical necessity and file that as your Uno reverse-card to insurers. This letter includes pertinent medical information that basically names the medically necessary procedures, consistent with the standards of care under the WPATH.

In Washington, you won’t have to wait for prior authorization as long as people in other states do. On January 1, 2024, House Bill 1357 will become law, and it will require insurers to respond to electronic pre-authorization requests in three days (five for paper submissions), excluding holidays. They have one day to answer expedited requests. Companies can ask for more information, and they probably will, so thorough letters help. If insurers do ask for more information, the law requires they give a clear deadline for a response and describe their requirements in easily understandable language.

Down the road, you’ll also need a letter from whomever else is prescribing your hormone replacement therapy (HRT). Much later on, your surgeon’s office will conduct a pre-surgical physical and review your medical history. Insurance companies want all that documentation, too. 

These bureaucrats just love paperwork!

Okay, NOW Call the Surgeon for a Consultation

Okay, so let’s review. 

You’ve chosen an insurance policy (or alternative), planned your recovery, seen some psychs, maybe fought your insurance company, and you are now ready to schedule your surgery, taking a step into a much wider (and/or deeper) world. Depending on your insurance plan (or, if you’re opting to pay out-of-pocket) there are many surgeons to choose from and myriad surgical techniques out there; it is enough variation to make your head spin. You’re right to wonder if one bottom surgeon is better or more experienced than another surgeon–of course that’s true. 

People like to talk about their experiences online. You can’t trust everything you read as truth, but it is a start.

If you have friends who’ve gotten bottom surgery, ask what they thought of their surgeon. It also doesn’t hurt to ask around your local trans community, just use common sense when asking personal questions. Nobody owes you that story.

There are plenty of online resources, too. If you're in a queer Facebook group, ask for recommendations. Some smart folks on Reddit compiled this list of surgeons. There’s also this useful list here.

If you’re curious to see examples of a surgeon's work, many, especially those in private practice, post galleries of surgical results stripped of all identifying information for privacy reasons. The photos typically show the healing process from the day of the surgery to one year after. If your surgeon doesn’t post their work online, it’s not a bad sign, they might be attached to a university and bound to their policies. Those surgeons should show you results at the consultation. 

Maybe you’re interested in a zero-depth vaginoplasty because penetrative vaginal sex isn’t important to you. Perhaps you’re interested in a peritoneal pull-through vaginoplasty, which creates a vagina with the inner lining of the abdominal wall. Research is advised to feel confident in your selection, but it is possible to over-research and overthink an important choice.

You don’t need 15 consultations with 15 surgeons to find the perfect vagina. You don’t need to consult with every doctor you research.

A friend once told me her excessive search led to rumination of what could have been if she had gone with someone else, despite how happy she is with her results. If you find someone you like, trust your gut, but verify they do good work. Understand how much experience this surgeon has, who trained them, their medical background, and please Google for evidence of a malpractice suit. You can also check the courts. Only you know what you’re comfortable with.

Know what you want and prepare specific questions about function, sensation, and aesthetics of your future vagina. This is your time to advocate for your needs and wants. 

Good doctors want to hear your goals and expectations to develop a safe surgical plan that works for you. Don’t worry about what they will understand or respect, because you’ll want an honest picture of what they can do for you.

Think of your consultation as their audition to be your surgeon. They may be the clinician and the expert, but you have the final word on working with them. Sometimes, hearing a “no” or feeling pressured to make a choice you don’t want to is the best information you could receive, albeit discouraging once you’ve come this far.

Scheduling your appointment is easy. Call or email the surgeon’s office and send whichever forms and letters of readiness they request.

Ask about BMI limits. Body Mass Index is an inaccurate and misleading metric based on flawed studies that doctors still use all the time (listen to this episode of Maintenance Phase for more on that). If doctors have discriminated against you because of your weight, it is worth asking about BMI limits before scheduling a consultation. 

They’re likely to say a BMI above a certain number increases the risk of necrosis, or tissue dying after surgery, or causes complications with anesthesia. Categorical denials for people with a BMI over 30 are common.

Different surgeons have different thresholds, though; data on the specific complications related to gender-affirming surgery are scant.

Having a Plan for Before and After Surgery 

This section could (and should) be its own guide, but I wanted to pass along some sage advice I heard while researching all that insurance crap.

Hair removal is… hairy, coverage-wise. Each surgical technique and often surgeon requires a different hair removal pattern. Zapping the follicles with electrolysis prevents hair from growing inside you. Unfortunately, you’ll have to pay for the cost up front and submit invoices for reimbursement. Queen Anne Medical is the only electrolysis provider in Seattle that works directly with insurance, and they’re booked up, especially with all the surgical cancellations during the pandemic, experts say. Health systems are still catching up. Check with your insurer about how to do this. 

Many aestheticians offer package deals for electrolysis, bundling the price of several sessions at a discount. Be warned that insurance will not reimburse sessions until you’ve done them, so consider booking each session separately so that you can submit reimbursement requests to your insurance company as the sessions happen, rather than dropping $1,000 all at once.

Consider additional expenses, especially if you’re going out of state. Airfare, gas, hotels, and food add up fast, especially if someone is coming along to care for you. Estimate these costs ahead of time to avoid unpleasant surprises and stress, which you won’t need more of before a life-changing operation. If you’re on Apple Health, the state may reimburse your essential travel costs.

P.S. A Short Neovaginal History

Gender-affirming genital surgeries are not new or experimental.

In 1931, Dora Richter, a German woman born to poor farmers in the Ore Mountains, became the first-known recipient of a gender reassignment surgery at the Magnus Hirschfeld Institute for Sexual Science (Institut fĂĽr Sexualwissenschaft) in Berlin. This groundbreaking vaginoplasty surgery predated the first dose of mass-produced penicillin by a decade, the first cochlear implant by thirty years, and the first successful human heart transplant by 36 years. All are drugs and procedures we consider non experimental.

The procedure also predated the immunosuppressant drugs that prevent our bodies from rejecting transplanted organs. The painter Lili Elbe, another patient of the institute, died from a failed uterus transplant in 1931, her fifth procedure. (Elbe’s life inspired the maligned, historically inaccurate film The Danish Girl starring Eddie Redmayne.)

The gay, Jewish socialist, physician and sexologist who started the world’s first sex institute, Hirschfeld, fought to decriminalize homosexuality and believed people who did not fit neatly into categories of man or woman were a natural deviation of being. 

Two years after Richter’s surgery, the Sturmabteilung, a paramilitary arm of the Nazi party, ransacked its library and archives, and days later they burned much of the stolen trove of early research on gay and transgender people in the street before throwing an effigy of Hirschfeld on the fire. From Paris, Hirschfeld watched his work burn on newsreels. Hirschfeld was touring the world at the time and never returned home. Richter survived her surgery, but fascists likely killed her.

The American public learned about gender reassignment surgery a year later with front-page news about Christine Jorgensen, the “Ex-GI Becomes Blonde Beauty,” as reported by the New York Daily News in 1952. The reporter marveled at her transformation “by the wizardry of medical science into a happy, beautiful young woman.”

The story propelled Jorgensen to international celebrity, but not without consequence. Her first engagement fell through when the news broke, and so did a second after the state of New York refused to issue her and her would-be husband a marriage license. He lost his job and she lost him.

The same year as the headlines, doctor Harold Gillies, considered the father of modern plastic surgery, performed the first penile inversion vaginoplasty on a trans woman; in 1956 the French gynecologist Dr. Georges Burou independently developed his own penile inversion technique from his Clinique du Parc in Casablanca, Morocco and performed more than 800 surgeries. In 1968, Johns Hopkins University discovered penile inversion a third time. Together, their work laid the foundation for modern surgical techniques.

For this guide, The Stranger spoke with Mattie Mooney, senior coordinator of Transgender Health at Swedish Medical Center, Gender Justice League Executive Director Danni Askini, Amy Penkin, the Oregon Health & Science University’s Transgender Health Program’s clinical program manager, three licensed therapists in Washington, insurance experts, and a lot of insurance companies who told us nothing.