I was skeptical about genital reconstruction surgery because I didn’t know enough about it. After I allowed myself to truly consider an operation I needed to learn about genital surgery as much as possible to then make a decision. This article touches on the knowledge I gathered and the main sources I used.

The moment I walked into the operating theatre for my vulvoplasty was when I had been the most prepared of all my surgeries to that point. To consider surgery I needed to clearly visualize all of its aspects, including recovery. It was time to put on my learner’s hat on and explore in detail my options and what genital reconstruction meant. I was able to decide on going ahead with the surgery after I thoroughly understood the whole process.

This is the second of 3 very personal articles about my thought process and preparation for genital reconstruction. These articles are made in conjunction with a shorter, more concise version posted on the TransAvenue blog (en français). The inspiration came from a somewhat general question a friend posed to me: how to get a natural relationship with the neo-vagina (or neo-vulva in my case)?

The first of these 3 articles, The Dare of Genital Surgery, talks about the mental barriers I had to first overcome. I had a hard time with the concepts of either a vulvoplasty or a vaginoplasty even as I found them very intriguing. Now, let’s talk about what I did to learn about genital surgery.

Really (Really) Understanding the Procedure

I am a strong advocate of patient education and informed consent, rather ‘very well informed’ consent. Knowledge is power, and when it comes to surgery, it also means freedom from mayor worry.

Going Through the Assessments to Then Decide

For genital reconstruction surgery WPATH‘s SOCv7 requires 2 surgical readiness assessments done by 2 separate health professionals.

In my case I first went through all the assessments and paperwork and almost at the last minute I decided to have the surgery. My decision process for surgery I think diverts from most people. Before the psychological evaluations I was not sure if the surgery was for me. I was curious and tempted, but I felt the knowledge I gathered before I met the psychologists was not enough to make a decision.

Going through the assessments before deciding helped me better understand the details of the procedure. I was able to learn about genital surgery and what to expect by independently speaking with the 2 psychologists. Particularly the second assessor provided me with general surgical information (see below). I had also read about the surgical techniques from a few medical websites and I learned more about female and male reproductive anatomies. All that helped me connect the dots between surgery, recovery, my goals, and my expectations. In a figurative way what I learn about genital surgery allowed me to thread the story of my operation even before I arrived in Montréal.

Thank God For The Documentation

To decide if genital surgery was for me or not I looked for information and particularly documentation posted by different surgeons and surgical centres. Since I knew that GrS Montréal was the most likely candidate for me should I choose surgery, I read and read over again what was posted on their website. Included there were PDFs of the postoperative care booklets they provide their patients.

Reading through the post-op care protocols for both surgeries, with and without cavity, was extremely helpful. These PDFs provided me with the official aftercare schedules and valuable information on recovery and probable complications. This newly acquired knowledge, coming from the official source, helped me understand better the expectations for recovery, which in turn later became extremely useful in my decision to go ahead with surgery.

GrS Montréal Information Package

My case was referred to GrS Montréal shortly after I finally decided on having surgery. A few days later I received their information package along a request for my medical history and some lab work. From that point forward, that information package, along the postoperative care PDFs I got online, became my best friends. I read them over and over, making sure I understood as much as I could of everything in those packages. They truly gave a mental roadmap of how everything would evolve.

Though at that point I had no surgery date, I had a clear timeline of what needed to happen at every milestone. I had an overview from booking flights, to preoperative preparations months ahead, to the night before surgery. The information went all the way to convalescence and eventually full recovery months after the fact. These documents allowed me to gather specific questions that I later asked the surgeon and my caring nurse.

I strongly advise anyone that wants to learn about genital surgery to read the official documentation. GrS Montréal’s patient information packages are linked off their website. Look for the links at the end of the surgerys’ respective webpages:

Look for the links to Parts A,B, and Postoperative Care (Part C) for each surgery. I urge you to read those PDFs even if you aren’t sure about surgery or you choose to go elsewhere. These official info packages are extremely useful because of their unbiased details.

Support From the Documentation When I had an Issue

The bulk of the info package (Parts A and B) revolves around preparing the patient up to the night before surgery. Right after surgery the patient focuses on the postoperative care booklet (Part C). I still had to refer to Part C on a daily basis during recovery, though I had read the full package 1,000 times and I understood it all. That’s because the first few days post-op are packed with constantly changing events. Then, when I got home after surgery and being on my own, this post-op care booklet became even more important. It pretty much became my ‘how-to manual’ at home.

A few days after returning home I noted a dehiscense – a separation of one of the sutures. I found it explained in Part C of the information package after I unsuccessfully tried to contact the local gender clinic. Finding the references in the documentation calmed me until I saw my attending nurse a few days later.

Understanding Possible Complications

Even before I started considering genital reconstruction I was aware of some of the associated difficulties. Possible complications were of the utmost importance to me all along my decision process. Just like everything else, at first I had some naive awareness of typical post-op hurdles. I felt the need to better understand the very possible physical issues and how to avoid them.

Learning About Genital Surgery From my Assessors

My first opportunity to ask a professional about plausible complications was during my first surgical assessment. In my case that was done by my psychologist who I’d been seeing since before starting HRT. Having extensive experience with transgender individuals, my psychologist was able to tell me about some of the post-op issues she had seen. The perspective she offered focused around the mental well-being of her patients rather than the details of the physical problems. Nevertheless, this gave me a general idea of the possible complications and how they could impact my mental health. My psychologist really wanted to make sure I understood the commitment required, especially for a vaginoplasty [with cavity].

My second surgical assessment was done by another psychologist but with even more experience. For me this was fantastic because she was able to provide me with a bit wider perspective. Her office pointed me out to a vaginosplasty surgical summary sheet published by Rainbow Health Ontario. This is exactly the kind of documentation I thrive on. This summary sheet is a clinical document written for primary care providers, opposite to anecdotal narrative available online. Meaning it’s fact based without any personal colouring and with concise information.

Learn About Genital Surgery From The Gender Clinic Nurse

You may have noticed by now that I tend to value professional experience. With that premise I managed to make a first appointment to meet my attending nurse at the local gender clinic a few weeks before I left for Montréal. Not only did I want to meet and get to know her, but I was extremely interested in hearing about her experience with past patients, the horror stories, and more importantly her feedback on anything I could do to prevent any issues. After all I wanted my recovery to be as smooth as possible.

Meeting with the aftercare nurse before leaving for surgery helped me be at ease. I saw her, made a connection and gotten some tips particularly on how to prepare for the very first days after arriving back home. At that moment she helped me book my first followup appointment for a few days after my return home. As I mentioned above, that first appointment after returning home confirmed that the dehiscance I experienced was normal, and would not affect my recovery nor my results much. This connection with the gender clinic nurse was yet another important piece in my peace of mind puzzle.

The Scary List of Surgical Risks and Complications

A good list can be found under the Surgical Risks and Complications of the Vaginoplasty Surgical Sheet from Rainbow Health Ontario.

If you are considering trans-feminine genital reconstruction surgery, I strongly advice that you become familiar with the list of possible complications, their implications, and how to avoid them. Our behaviours as patients influence the majority of these complications. In most cases, what we do has a direct effect on our recovery and peace of mind in general.

Once I learn about genital surgery in detail these were my top concerns (in no particular order):

  • Infection/Abscesses.
  • Granulomas.
  • UTIs (urinary track infections).
  • Recto-vaginal Fistula (does not apply to vulvoplasties).
  • Prolapse of the neovagina (does not apply to vulvoplasties).
  • Hair growth inside the neovagina (or inside the dimple vestibule in a vulvoplasty).
  • Loss of sensation and inability to orgasm.

It was clear to me that regardless if it’s a vaginoplasty or a vulvoplasty the best is to follow the aftercare instructions from your surgeon/surgical centre. They revolve around hygiene to reduce the chance of infection and other complications. Granulomas, dehiscences, and UTIs are common, so having clinical follow-ups after returning home is a must. The good news is that if diagnosed quickly they’re easy to treat.

Learning From The Surgeon

My patient coordinator at GrS Montréal help me arrange a phone consultation with my surgeon, Dr. Brassard, a few weeks before my surgery date. I still had a few specific questions regarding the procedure and I wanted to hear from Dr. Brassard. Though I already had most of my questions regrading complications answered before speaking with him, I was looking forward to hearing his point of view. Not only did he answer my questions about possible complications but also about the surgery in general. Speaking with him opened a window for me to see into his personality and experience. Talking with him prior to flying to Montréal felt very reassuring.

Making a Final Decision

For all my prior gender affirming surgeries I gathered some initial knowledge, then I made the decision to go ahead, and finally I got to learn as much as I could from the official sources – from the surgeons themselves. For my vulvoplasty it was different. Probably it was because I had the misconception that my genitalia defined me, as I described earlier. So for this surgery I wanted to first learn as much as I could before making a decision.

Putting Most My Thoughts on Paper

To be honest with you, I gathered so many details prior to making a decision that it became overwhelming. I was trying to see the forest from within the trees and the forest was so dense that I could not even see sunlight. What I needed was to step back and organize my thoughts.

Some people follow their heart, while others may discuss their thoughts with others to hear perspectives that they may have missed. Me? I like to think that I’m so square that I make diagrams, and I’m proud of it. This was no exception.

Right after speaking with the psychologist that made may second surgical assessment I took a couple days’ break from thinking surgery and then I made my diagram. It was very simple. On a piece of paper I jotted down any thought that came to mind about the surgery. Ok, if was not on paper and it was not all my thoughts, but on the computer screen I wrote down the recurring thoughts that I had regarding a vulvoplasty. This exercise allowed me to see in one place all the pros and cons that floated inside my head.

These thoughts and ideas were not particularly organized. The only thing I did to prioritize them was to highlight my top objective or the most valuable thing I’d think I’d get from surgery. I finally got a helicopter perspective and was able to see the whole scope of the forest.

Not Looking Back

After I saw the major ideas and thoughts I had about the surgery on my diagram, supported with all the information I had gathered to that point, I was satisfied I was making the right decision for me. There were no questions in my mind about having surgery. I still had to learn about more details after I received the information package from GrS Montréal. Those were logistical details that would later help me tremendously during recovery, but I could move forward without questioning my resolution.

But What if I Changed My Mind After Surgery

Having chosen a vulvoplasty over a vaginoplasty meant that a vaginal canal would not be created and I would not be able to have penetrative or vaginal sex. Though I have given extensive thought to the options and my decision, I still had this little nagging question in the back of my head. What if I changed my mind after surgery and for some unforeseen reason I’d want a vaginal cavity created? I simply could not leave that question unanswered. I had to get all my t’s crossed and all my i’s dotted regardless of what the answer would be.

The day before my surgery, during the pre-op consultation with Dr. Brassard, I asked him the question. He explained to me that should I choose to have a vaginal vault created in the future, that he could do it. He went deeper and told me about having to wait a minimum amount of healing time before a revision. If I were to choose that later option, he’d have to graft skin from another body part like the inner thigh or forearm. But regardless if his answer had been a no instead of the yes he explained, I would still have been at peace because I asked. I got to hear his answer and explanations.

Considering Surgeons

To be happy with the results of my surgery, any surgery for that matter, I need to trust the surgeon. I need to feel comfortable with my ability to communicate with them before and after surgery.

Speaking With The Surgeon

A few weeks before my surgery date I was able to have a phone consultation with my surgeon. I had prepared a series of questions about the surgery and recovery, which he kindly answered. Speaking with him beforehand helped me be more at ease with my decision. Not only did I hear from him about what to expect, but I also got an idea of his personality. The opportunity to talk with him allowed me to connect, at least on a basic level, with the surgeon.

An Experienced Surgeon/Surgical Centre

If you’re considering but haven’t had any gender affirming surgeries, you should be aware that things can go wrong. One way of minimizing this very real possibility is by approaching skilled surgeons. For me, another big part of trusting the surgeon is based on their experience. It was a no-brainier to consider GrS Montréal simply because my health insurance covered my surgery there. More importantly they perform hundreds of male and female genital reconstruction surgeries each year and for many years. This didn’t mean I would be free of any post-op complications, but it meant that the chances of any issues caused by the surgeon were small.

With these three factors, 1) a sense of an open communication channel, 2) lots of experience, and 3) cost covered by insurance, I knew that GrS Montréal was the best choice for MY surgery. The underlying sense of having made a good decision on where and who to go to for my surgery gave me a peace of mind that later helped me during recovery. I say this because while I had a minor issue during recovery (a dehiscence – mentioned above), I did not wonder if having selected a different place would have made a difference.

First I got rid of my misconceptions to dare consider surgery. Then I gathered lots of info to learn about genital surgery. Lastly it was time to plan the actual surgery and recovery after my vulvoplasty.

P.S. The header image represents the cover of the “information and postoperative care” booklet that GrS Montréal had posted online at the time I did my research.

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