Bottom Surgery 101

I know people probably have questions about bottom surgery, after yesterday’s post, so I wanted to shed light on something that’s probably pretty mysterious for most cisgender people. I will talk about some specifics of the procedure and its recovery, but hopefully not in a way that will squick people out. Nonetheless, if you’re squeamish, you might want to sit this one out.

OK, so what is bottom surgery? For trans woman, it’s creating a vagina and vulva out of male genital tissue. It’s not cut off, it’s reused. (I’ll talk about trans men later.) It’s commonly been referred to as sexual reassignment surgery, or more recently, gender confirmation surgery a term I’m personally not fond of because I know my gender identity regardless of what pink bits I have. The antiquated term, “sex change,” is one to avoid using.

Why go to Thailand? Short answer: If you were re-arranging the furniture, wouldn’t you want to go to the best surgeon you can find? While there are some excellent surgeons in the U.S. (and more surgeons are learning the procedure), surgeons in Thailand are usually using a technique that’s more advanced (the Thais have been pioneers in this field). Generally the results have better aesthetics, are better at retaining sensation, and involve a single surgery, rather than two months of surgery several months apart. The trade-off is that it’s a tougher recovery because more work is being done at once.

Does it look “natural” and perform “naturally”? Yes, definitely. (Trust me I’ve looked a more than my fair share of post-surgery pics when doing research.) Obviously there are some scars, most notably along the creases of the leg, but after healing, they’re surprisingly invisible. As far as the second question, usually you end up with the same depth as a factory-installed version, however it is a bit less stretchy, and some more adventurous forms of penetration are probably off the table. However, it doesn’t really self-lubricant to same degree, so lube is a must. Also, state the obvious, no, it doesn’t menstruate — one aspect of womanhood, I’m happy to miss out on — although it can it vulnerable to yeast infections, etc.

How do they do it? Contrary to popular lore, they don’t cut it off, rather the tissue is reused. The “penile inversion” technique that’s widely used in the U.S. is exactly what it sounds like: They essentially turn the penis inside out, strip away unneeded tissue — e.g. the erectile tissue — and reform that into a vagina and clitoris, as well as reroute the urethra into the proper location. Dr. Suporn invented the “Chouburi Flap” technique, now used by other Thai surgeons, which does things somewhat differently and places a premium on “mapping” tissue to it’s equivalent place, e.g. the foreskin and glans are similar tissue to that of the inner labia, so it’s used to create them. The technique also emphasizes making sure the appropriate levels of sensation are in the right place, e.g. the vulva is more sensitive than the vagina, and that the vagina uses more sensitive tissue near the opening and less further back (just like the factory-installed version). If there’s not enough genital donor tissue, then they may use skin grafts from other parts of the body. I’m not sure if it’s part of the Chonburi Flap technique per se, but Thai surgeons are adapt at stripping away the layer of skin (dermis) of scrotal tissue where the hair follicles are, eliminating the for genital electrolysis <shudders> pre-surgery. Either is necessary to prevent hair from growing inside the neo-vagina.

How long does it take to recover? With Dr. Suporn, you’re there for a month post-surgery, before you fly home. You need the time to physically recover, and he can fix any problems that might develop. (Usually they’re minor, but there can be some nasty complications if the some area don’t get enough blood supply and develop tissue necrosis.) After that, one really should take at least another 2-4 weeks before returning to work. As you might imagine, sitting can be uncomfortable for quite a while. Surgeons will give you a special pillow. But the worst part of it is dilation — insert a medical dildo to neo-vagina from closing during the first two weeks, and later on to prevent scar tissue from contracting, and yes, it hurts as much as it sounds like. Imagine trying to insert an oversized dildo (even though the dilators aren’t that large) and then pushing it hard against the back of your vagina at least 15 minutes, 3x/day for the first 2-3 months post-surgery, 2x/day for another 3 months, 1x/day for another 6 months. After a year all the healing is finished, although one still needs to do it 2-3 times a week (for the rest of your life), although… other things, ahem… can be substituted for the dilators. If there are problems after 12 months, Dr. Suporn offers one round of revision surgery for free — although you have to pay your way back to Thailand for it.

Do many trans people regret it? No, it’s only around 1-2% — much lower than almost any other kind of plastic surgery. In part that’s because — for better or worse — there is a lot of gatekeeping involved. Typically you need two psychologists/psychiatrists to sign off before surgeons will operate. Some of that is CYA on the surgeon’s part, they don’t want someone to sue because they ended up unhappy after an irreversible operation. Partly it’s just a smart thing to make sure your head is straight first. Honestly, I think the vast majority of people, trans or cisgender, would be wise to do some therapy before getting any form of major plastic surgery for their own benefit, since there’s number of people who get it done for reasons they later regret. (Reputable surgeons will screen for this, even for something as routine as a nose job.) But yes, it also raises huge issues about body autonomy, particularly in the bad old days, when fuckability was quite literally a criteria some surgeons used to determine who they’d operate on.

Does insurance cover it? Complicated question. Technically, yes. California is one of the states that requires insurance companies covers bottom surgery. (Usually insurers specifically prohibit coverage for any other trans-related surgery, and yeah it sucks, and many trans people can’t afford to do it out of pocket. Doesn’t make them any less trans for not doing so.) In practice though, it can be hard to get insurers to cover it if you go outside the U.S. You have to pay upfront and hope that they’ll reimburse you, which often times they never get around to doing. Which is particularly annoying because the Thai surgeons are less expensive, and usually have shorter waitlists.

What about trans guys? I admittedly only have a high-level knowledge about their procedures (trans guys feel free to chime in!), but here goes. There’s a greater a variety of techniques from ones that simply free the clitoris from it’s surrounding tissue, since if a trans man has been on testosterone, that often causes the clitoris to grow into a small penis (they’re both actually made of the same tissue), so freeing it makes it look more penis-like. The most ambitious technique is a phalloplasty, which reconstructs tissue to form a penis. That said, bottom surgery options for trans men are usually far more expensive than trans women, and the results less satisfactory. Partly, because as one surgeon put it, it’s easily to make a hole than a pole. Partly because there’s simply been less research into better techniques. So many trans men opt to skip bottom surgery,and just do “top surgery” to remove their breasts. Doesn’t make them any less trans for not doing so.