My Story:
The Medicine, The Surgeries, and The Bureaucracy
I've tried really hard over the years to let go of feeling shame wherever I'm able to, so I'm going to answer those questions that are impolite to ask trans people.
Medically transitioning is not a prerequisite for the validity of your trans identity. Not everyone has a desire to modify their body and that should be supported without judgement. Some people find homeostasis from Hormone Replacement Therapy (“HRT”) while others have no interest in it. Some people like using the equipment they were born with while others do not. Some people want to have surgeries, or only some surgeries but not others, and that is equally valid. Our only goal should be gaining a comfort with our own identity and bodies.
WPATH, World Professional Association for Transgender Health, has set a standard of care for trans folks to help guide providers in aiding in our medical transitioning; however, you still needed to find a provider who was willing to support you.
The requirements aren’t simple either, even if you find an informed consent clinic that supports vs. gatekeeps medical care. Keeping a focus on those over 18 years old, the most common path is:
· Find medical providers willing to support trans patients
· Meet with a medical provider and/or a mental healthcare provider to discuss transgender related care
· Receive referral letters from mental health provider or agree to Informed Consent disclosures
· Showcase “Persistent, well documented gender dysphoria”
· Have the capacity to make fully informed decisions and to consent for treatment
· Have reached the age of majority in a given country
· If significant medical or mental health concerns are present, they must be well controlled
For those seeking surgical interventions, there are extra steps:
· 12 continuous months of HRT as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones)
· 12 continuous months of living in a gender role that is congruent with their gender identity
And let’s not forget the insurance hurdles:
· Hopefully your insurance covers HRT, otherwise you need to beg your employer to add it to your insurance program
· Hopefully your insurance covers surgeries you desire, otherwise you need to beg your employer to add it to your insurance program
· Hopefully there is a quality provider in-network that your insurance will allow you to work with, or you may be forced to see a bad provider, or choose to forego surgeries for the sake of avoiding further harm by inappropriate providers
· Some insurances require additional referral letters from mental health professionals & some require at least one of those letters to be completed by a PhD level provider, whereas others may require only Masters’ degrees
My reality in getting my gender affirming surgeries became a mix of independence, supportive providers, and traumatizing bureaucracies.
Starting HRT
I started my path toward medical transitioning when I was leading an IT team while living/working in Yellowstone National Park in Wyoming. Needless to say, it wasn’t especially easy to find a medical provider when the closest Walmart was a 90-minute drive away.
I was forced to research providers in Montana who were trans friendly, which seemed like a dauntingly unrealistic ask for Google. Thanks to a trans advocate in the state, I stumbled upon a list of all providers who would help my community & scheduled appointments with a provider an hour-drive away from home. It was an informed consent clinic, so there was a lot of paperwork for me to sign, acknowledging the health risks of the medications I was seeking and that medical intervention may not resolve my issues, amongst many other line items detailing the process.
It all started with a conversation with a mental healthcare provider at this random clinic in the middle of nowhere. I was petrified that I wouldn’t get their approval and would be perceived as “faking my trans-ness” that I almost cancelled my appointment multiple times. I just couldn’t let myself stay in the state I was any longer though and forced myself to be brave. I was determined to present authentically, so I did my best to present as feminine as I could with a recently purchased, moderate quality, wig and the minimal women’s clothes hidden in my closet.
The walk from my car to the clinic was frightening as I projected the risk of being attacked onto every male on the sidewalk. It was a very conservative area after-all, so I had so much fear for my safety as I presented as authentically feminine as I could. Trans people were starting to become a hot-button item in the news as easy targets for hate. I can’t keep living a lie, is what I told myself as I approached the clinic. I absolutely didn’t “pass” at this point and anyone who saw me could tell that I was not born female. I was too in my head, assuming the worst thoughts from everyone around me.
Honestly, I was so lost in my own apprehension about my answers to the psychiatrist’s questions being “appropriate” that I can’t even recall the majority of the conversation we had. It ranged from asking when I first thought I may be a girl, to my history of trying to find depth to that identity, to when I’d try to cross-dress as an outlet for my gender identity, to many other biographical items. My heart skipped a beat when they confirmed their belief that seeking medical transition sounds like the right path for me & I was instructed to schedule another appointment with the Nurse Practitioners. I left the office with an appointment for a week later to get bloodwork done, alongside a general physical.
This week dragged on forever as I researched all of the different delivery methods for estrogen and anti-testosterone medications, trying to discover which is “best” for quickest results. One of the most common trans experiences I’ve heard of is the desire for instant gratification once we begin our journeys. We’ve been waiting for so long, many of us our entire lives, for this moment of corrective action that we don’t want to wait for our bodies to slowly change. Being told that it would be at least 4 months before I saw any breast tissue growth was infuriatingly slow. It truly is a 2nd puberty at the end of the day, but at least we chose this one.
The week passed uneventfully & I returned to my provider’s clinic. I met with my psychiatrist once again for a quick confirmation that this is what I wanted & they provided me my first referral letter to begin medically transitioning. Gleefully, I worked with the rest of the team to do all of my physical checks, including the beginning of regular bloodwork – these medications can harm your organs, so it’s important to make sure you’re doing no harm to yourself while we adjust dosages, trying to align our hormone levels to that of our desired gender expression. Being a trans woman, that meant I needed to both decrease my testosterone levels and increase both my estrogen and progesterone levels.
It’s worth noting that not all providers believe in the requirements of progesterone. The trans community anecdotally raves about progesterone as they perceive it directly impacts your breast development & we “all” want big tiddies; ultimately, I found progesterone to be most productive for me in improving the quality of my sleep, ability to recall my dreams, greatly increased my happiness levels, and revived my sex-drive, but I saw no impact to breast development. I didn’t get to start progesterone until a couple of years into my transition, so first we focused on testosterone and estrogen.
8/4/2014 - I was given two different anti-androgens to combat testosterone: spironolactone + finasteride (Propecia). There was zero hesitation as I began HRT. This act of self-care brought upon a sense of gender-euphoria to combat the dysphoria.
These two medications together limited my T production, and the binding of what still remained. Added bonus was the hair growth. The downsides were plentiful though: weight gain, constantly peeing, fatigue genital shrinkage, erectile dysfunction, and most shocking of all was something we refer to as “dry orgasms” when climaxing. It’s exactly what it sounds like: you climax, but there’s no ejaculate and it’s WEIRD and it takes some time to re-learn how to fully experience an orgasm.
This may sound like a deterrent to most, but it honestly proved to be beneficial to me as my understanding of my own orgasms greatly grew. I began differentiating between small and larger orgasms. I could climax from different sensations and my body reflexively responded in differing ways depending on the stimuli. I clearly recall one time that I finished only from having my breasts played with while they were going through an especially sensitive growth cycle. Most notably was how the orgasm itself was no longer a quick build and explosive release as I ejaculate, but rather a full body experience that grew from deep within and demanded a mental presence that wasn’t needed before. It took me many years to begin to understand my changed body.
In addition to the medications to fight testosterone, I began estrogen treatments 2 months later. The delivery method of this medication changed over the years from a topical spray -> a pill -> an intra-muscular shot (thigh) every other week -> my current method of surgically implanted pellets that are replaced approximately once a year. This all comes down to personal preferences between the patient and providers, along with what one can afford since insurance doesn’t always play nice with trans care.
After moving once again, I was fortunate enough to find a medical team that was incredibly supportive of my personal goals & began taking progesterone after approximately 6 months into my HRT regime.
Let’s pause for a second to talk about the mood swings! There’s little exaggeration in saying that we put our bodies through a second puberty as we adjust our hormones. Our breasts ache as they grow, headaches and irritability are commonplace as our hormones attempt to regulate themselves, our appetites come and go to the extremes… it’s all just so very messy. The delivery method and consistency is all we can really do to help keep ourselves even-keeled. If we miss an estrogen shot, our E levels may dip low, sending us into a deep sadness, or we may get a manic spike when we reach our peak levels 2 days after our shot. It’s hard sometimes to know if we’re losing our minds or if it’s just our bodies throwing a temper tantrum.
Regardless of the challenges associated with medically transitioning, the desire to do so in spite of it is telling to our true natures that we’re seeking to free. I don’t personally know of any trans individuals that didn’t feel a sense of confirmation in their identity when they took their first dose of HRT. I also know firsthand that my male friends have recoiled in absolute horror at the idea of taking a single estrogen dose, further confirming the relation between our hormones and identity.
Boobs 10/15/18
4 years of estrogen and 3 years of progesterone had rewarded me with an acceptable level of breast development. I was a full B cup; however, I wanted more.
Breasts are one of those things that scream “woman” to strangers passing by. They can be a form of armor for trans-women that protects us from being clocked as trans. It wasn’t just me wanting bigger boobs, but rather wanting to complete an unfinished project. What I saw in my mirror didn’t appropriately convey the feminine image in my head or in the eyes of others & I wanted us all to see me as that. It’s so incredibly annoying to feel like you need to project hyper-femininity and being a sex-object to be ogled for it to help you feel like your own femininity is validated in the eyes of society.
The reality of breast growth for trans-women starting later in life is that we’re not likely to develop through all 5 tanner-stages of breast development & to be honest, most natal females don’t either unless they’ve gone through child-birth. Most are told to expect to be a cup-size smaller than their closest female relative.
As with all things HRT, “your miles may vary” is a common phrase espoused by the community at large.
Since I had been an athlete my whole life, I had developed a wide set of shoulders and large chest to accommodate a strong set of runner’s lungs. Because of this starting point, a modest B-cup appeared smaller than they were, which was exasperated by them being widely set. This is a common concern not only for trans folks seeking breast augmentation, but cis-women as well, so I felt comfortable seeking a surgeon who did boobs really well.
I didn’t spend time seeking a surgeon who specializes in BA’s for trans folks because to me, boobs are boobs – So I searched for someone who just did really good boobs! To my delighted surprise, I found a surgeon practicing in my remote part of Montana whose work met my level of desire.
While I was fairly comfortable showing off my tits already, I felt so much more apprehensive about my consultation appointment than any other time I’ve taken off my top around others. What if they treat me poorly because they’re “trans boobs,” or treat me crappy because I’m trans, or half-ass their efforts and I end up with boobs that I can’t stand to see on me, or worst of all they say that they can’t work on me because I’m trans.
All of my fears were entirely unfounded as I was welcomed into this space and treated like any other patient seeking to modify their appearance. Measurements and photos were taken before discussing options with the surgeon. Silicone or saline, round or tear-drop shape, above or partially-below the muscle? So many options to choose from, but I’d done my research. I find it easier to process stressful moments where it’s easy to get lost in anxiety when I’ve done my research ahead of time. I knew what the best materials were and what the best techniques would be.
Ultimately, I told my provider to “make them proportional and pretty.”
We agreed upon 600CC round silicone implants, to be placed partially under the pectoral muscle. This approach should result in a full breast, a well rounded but not sagging under-boob, my b-cup breast tissue on top of the implant for the sake of how it will feel, and a bit of cleavage for when I wanted to show off. I learned during my follow-up appointment that they used 650CC implants & that up-sizing is an industry practice; however, I wasn’t miffed about this.
$5000 – I made a payment in full ahead of time thanks to a personal loan, so I got a slight discounted on the total expense, inclusive of their surgical suite built into their practice. Since the clinic was only a 15-minute drive from home and my wonderfully supportive neighbor was happy to help transport me, I jumped at the opportunity & got scheduled for 10/15/18.
Everything went as expected & I got home to start my recovery. Honestly, none of these surgeries were easy to go through or recover from, but they were what I needed to do.
You can’t lift anything more than 10 pounds. You can’t lift your arms. You can’t undress/dress yourself so you can take a shower. You have to sleep on your back. You have to wear a compression bra as you heal.
You need help.
I was lucky in that I had made a friend this year while working in the parks that quickly became my bestie. She came over when she could to help me get something to eat, or be able to shower, or just to keep me company as I kept rotating ice-packs on my chest. I couldn’t have done it without her & I love her so very much for how supportive she has been throughout all of my transition.
Slowly over the next few weeks, life returned mostly to normal except for being incredibly weak.
To make life even more complicated, I interviewed for a job in Oregon 2.5 weeks after my surgery and then had to figure out how to move when I was still barely able to lift a gallon of milk. Once again the bestie came to the rescue as her and her beau helped me load up my belongings into a u-haul and I moved when I was 6 weeks post-surgery. Having no other choice, I hired a moving company to unload the truck for me & began to settle into my new life in a new state with a brand new pair of tits.
While you’re warned about breast implants needing to “drop” it’s still a shock to live in that state where your tits feel like they’re under your chin. The muscles and skin needs to loosen up as the implants fall into place & that can take 6 months to a year for some people. I was lucky once again in that mine finished migrating by 6 months. I was absolutely in love with them.
I was so in love with my new chest that I decided to take advantage of their post-surgical numbness and revisited my interest in body-modifications. My nipples had been pierced since I was 18, but I had taken them out ahead of my surgery & the holes had mostly closed up. Getting them pierced again before I moved was incredibly simple as I felt nothing. Loving that experience, I found a new tattoo artist after moving who was willing to tattoo my nipples for me as well! In hindsight, I would’ve chosen a darker color, but I had them color match my areola and add hearts around each nipple. They were absolutely gorgeous… but they faded over time thanks to rubbing against a bra all-day for years.
I ended up being a 36-DD when all was said and done.
GAV = 9/23/2020
It was 2016 when I began getting my paperwork in order to seek my Gender Affirming Vaginoplasty. It was yet another thing that I wanted “now” but this was too important to rush. I needed to find the right provider for me, otherwise I’d never be happy with the results.
I researched every notable surgeon who performs Vaginoplasties and decided that I needed to see who I considered the best: Dr. Marci Bowers.
Not only are they an outspoken trans-woman themselves, but their experience speaks for itself. They had the lowest rates of complications & highest rates of patient satisfaction. No neo-vaginas self-lubricate like a natal vagina, but It was mission critical that I be able to orgasm after surgery and that was NOT a guarantee from any surgeon. I knew I’d be taking big risks, so I did everything I could to minimize those risks.
I wasn’t at all surprised to learn that their waitlist was 4.5 years long, as I received a surgical date of late 2020. Paying my $1000 deposit, I set my goals on using this time to gather other requirements, such as surgical referral letters and finding out how I was going to pay for this. This surgery was going to cost me $30,000-$50,000 if insurance didn’t participate, and my employer at the time’s insurance didn’t even cover HRT. Re-doubling my online sex-work efforts, I set my sights on being able to pay for this completely out of pocket.
Thankfully plans changed when my new employer in Oregon had Gender Affirming surgeries covered by our insurance. I had specifically sought a hospital to work for to garner better medical care, knowing I’d need some help in the coming years. As it turns out, this was both a blessing and a curse.
I started my new position in January 2019 & had engaged my insurance company as soon as my coverage began to ensure my preferred surgeon would be covered. I was reassured each time that I engaged them that it would be covered and at what costs, on a nearly bi-monthly basis.
I found two mental health providers to supply letters of referral to support my insurance claims. I even went as far as ensuring one of those providers had a PhD, which was above the requirements listed. Everything I could do to prepare myself was done.
Finally it was 2020 and my surgery date neared. Then covid hit. Elective procedures everywhere were placed on hold as risks were too high to do anything except the necessary surgeries. I received a message from my provider’s office in March, informing me that they were delaying all surgeries that year until further notice. I accepted my fate and proceeded with my life, until I received another message from them in April, offering me a surgery date in September of 2020, to which I jumped at the opportunity.
I began engaging with every trans surgery forum to pick their brains about things to buy to make recovery easy. I asked all of the questions about their experiences so I’d know what I’d likely experience as well. I researched everything I could and made all of my purchases. I booked my flights and hotel stay. It was all coming together and now all I had to do was wait.
It was the day before my surgery when I finally got to meet my provider at their offices outside of San Francisco & this is when my world imploded for a few hours.
Despite having confirmed with my insurance numerous times that my procedures would be covered, they changed their minds. I had checked in with the receptionist and began doing my paperwork when I received a call from the office manager. My insurance provider had revoked coverage & specifically instructed me, through the office manager, to reach out to a specific in-network provider that had begun scheduling consultations again after their covid lockdown loosened.
I was absolutely devastated. I couldn’t help but cry on the phone with the office manager in the lobby of this doctor’s office. I had done everything I could to set myself up for success & then the rug was pulled out from under me at the absolute last minute.
To make matters worse, my insurance specifically said I should see somebody that I had zero confidence in. Yes, they....
----CUT until publication----
I couldn’t accept being forced to see this provider & would choose to not have the surgery if this was my only option.
To this day, that insurance provider claims no wrong-doing and that it was a clerical accident. They assert that they never told me to see the provider who they mentioned by name.
I don’t know what they did, but I owe the world to the office manager who got this decision reversed so that I would be able to see my preferred surgeon; however the harm had already been done. This was my one opportunity to spend time with my surgeon before my surgery and I was an emotional wreck still since the revised coverage news only came after my time with my surgeon. I was unable to ask the questions I wanted to, or fully digest what was being told to me. I was overwhelmingly sad and furious.
But the good news came & I was able to proceed with my surgery prep that night before arriving at the hospital in the early AM.
It was 4 days that I spent in the hospital, by myself aside from the medical staff. Pain management, nausea management, regaining my strength, re-learning how to walk were all that mattered for those first few days as I slept as much as I could.
I was traveling by myself as it was still the height of Covid and my older parents were already immunocompromised & I didn’t want to selfishly ask any of my friends to take off time from their work or families to hang out with me as I slept. When the time came for me to be discharged, I lied just the right amount to get released on my own into the uber which brought me to my hotel.
In an attempt to cheat the system, I started a free trial for a grocery delivery service and stocked the kitchenette of my hotel suite. Those first few days were a blur of pain medications and binge watching shows that I ran on my laptop to the room’s TV via a super-long HDMI cable.
It was a few days after my hospital discharge that I returned to my surgeon’s office. Today’s trip had two goals: remove the packing from new vagina and the catheter in my urethra + to teach me how to begin dilating. It was awkward and uncomfortable as the gauze was removed and I was handed a mirror to see my new vagina for the first time.
Honestly, it looked like a war-zone. Bruised and fresh suture lines, it wasn’t anything I would brag about, but it was my own custom designed vagina. My Gucci Coochie.
Then there was the dilating. Similar to keeping an earring in a new piercing to prevent the whole from closing, I had elected into a life-long duty to insert items into my new pussy to keep it open and functional. Nothing about this is for pleasure. You’re given 4 hard plastic rods or increasing circumference and told to insert them in yourself for 15 minutes a day, 3 times a day, and size up when you’re ready. The nurse showed me how to do it my first time, mirror in hand, legs in stirrups at the doctor’s office. Huh, first time I’ve actually used the stirrups. It hurt as I felt pressure inside of me in places that have never been pushed on. The closest sensation I could describe is anal sex, but the angles are different and the pressures are on new organs.
After my visit, I was released and sent back to my hotel, where I would stay for another 4 days before returning home. My time was filled with naps and dilating 3x daily for at least 15 minutes. The time factor was never an issue for me as I was just laying in bed anyways, so I’d reapply lube as needed and tried my best to get comfortable.
I eventually made it home to Oregon, sitting on a donut seat cushion from hotel to uber to plane to uber to home.
Again, I was at a point that I needed help. I was able to order delivery of groceries when away, but now I was home, and had a dog to pick up from doggy-daycare, and an empty fridge, and could barely even walk, much less any upcoming chores. Once again though, the bestie came to the rescue, meeting me at the airport when I landed. They had flown in specifically to take care of me & got me home, got my dog home, took the puppers for a walk, and got groceries for me before settling in with cocktails and stupid shows on a streaming site.
Alas our time together was short as their boss demanded they cut their vacation short and return to Montana because they had their own vacation desires that they hadn’t spoken about until this moment. It came down to them risking losing their job if they didn’t return, so we sent her home on the 2nd day after my return to Oregon. I don’t blame her, I blame her boss for being an asshole. It still hurt though, but I managed to take care of myself from that point forward.
Dilating became a chore that I devoted extra time to above what was ordered. I found that if I only let myself watch certain shows while dilating, it helped the time pass by AND kept me coming back for more sessions. My 3x15 minute sessions quickly because 3x 45-90 minute sessions as I’d get immersed in a show. This was actually very beneficial though as I sized up to the largest dilator much quicker than expected.
Eventually I received my bill and took out another personal loan to cover my portion after insurance, $7500. Very manageable at the end of the day.
FFS = 4/2/24
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