# How to Prepare for Gender Affirming Surgery The real checklist nobody gives you — from someone who did it in 9 weeks. ![[shopping-list-cover.png]] --- When I started preparing for my nulloplasty in 2024, I Googled "how to prepare for gender affirming surgery" and got exactly what you'd expect: vague platitudes about self-care, clinical checklists written by people who'd never been patients, and nothing—_nothing_—about the financial maze, the emotional whiplash, or the reality that paperwork might break you before surgery ever could. The information landscape was fragmented and incomplete. Medical websites offered sterile bullet points about "consulting your healthcare team" without acknowledging that finding that team can take months of phone calls to offices that have never heard of your procedure. Support forums provided emotional validation but rarely concrete logistics. Insurance representatives gave contradictory information depending on who answered the phone. And nowhere did I find a comprehensive resource that treated preparation as the complex, multi-dimensional challenge it actually is. I spent weeks piecing together information from dozens of sources, cross-referencing conflicting advice, learning insurance terminology through trial and error, and making costly mistakes. Every question generated three more. Every answer came with unexpected caveats. The process felt deliberately obscure, as if designed to exhaust you before you reached the operating room. So here's the guide I wish I'd had—not just tips, but a roadmap through the entire terrain. > **A note:** I'm not a clinician or attorney. This is lived experience combined with extensive research. Always confirm specific requirements with your insurer, surgeon, and providers. This isn't theoretical. I navigated insurance authorization, gathered documentation, found a surgeon who'd actually heard of my procedure, arranged travel from Wisconsin to San Francisco, set up a recovery space, and had surgery—all within nine weeks of my first consultation. It was aggressive. It was exhausting. And it's absolutely doable if you know what you're preparing for. But here's what I learned: preparation matters more than timeline. Whether you have nine weeks or nine months, the fundamentals stay constant. What changes is your breathing room—how much time you can dedicate to each phase without the pressure of an imminent surgery date. A longer timeline lets you be more methodical, more thorough, more forgiving of inevitable delays. A shorter timeline demands focus, organization, and willingness to make phone calls during lunch and submit paperwork at midnight. Whether you're pursuing vaginoplasty or phalloplasty or top surgery or nulloplasty or something the medical literature barely has a name for—the preparation fundamentals are the same. Let me walk you through them. --- ## Define Your Constraints First Before you dive into research spirals, take thirty minutes and answer four questions. Everything else flows from these: **Insurance or self-pay?** This determines your entire financial strategy, which surgeons are accessible, and how much documentation you need. **How far are you willing to travel?** Your ideal surgeon may be across the country. Know your travel tolerance before you start falling in love with a practice you can't realistically get to. **How much time can you take off work?** Recovery timelines range from two weeks to six months depending on procedure. If you can't take unpaid leave, that shapes your options. **Do you have a caregiver available?** Most surgeons require a dedicated caregiver for the first one to two weeks. If you don't have one lined up, that's a constraint to solve early—not the week before surgery. Write these down. They're the guardrails that keep your research focused instead of overwhelming. --- ## Start With Insurance—Right Now Before you research surgeons, before you daydream about results, before you do anything else: **call your insurance company and find out what your plan covers.** This single phone call transforms your entire approach. It determines which surgeons are financially accessible, what documentation you need to gather, and how much time to build into your timeline. ### The phone script Calling insurance while anxious is hard. Here's exactly what to say: > _"Hi, I'm calling to verify coverage for gender affirming surgery under my plan. Can you tell me the specific coverage criteria and prior authorization requirements for [your procedure name]? I'd also like a reference number for this call."_ Then ask: - Does my plan cover gender affirming surgery according to the WPATH Standards of Care? - What documentation do I need? (Letters from mental health providers, hormone therapy records, etc.) - How many referral letters are required, and from what type of provider? - Is prior authorization required, and how long does it typically take? **Document everything.** Date, time, representative's name, reference number, what they told you. Write it down. I kept a running Google Doc that eventually stretched to forty pages—not because I'm unusually organized, but because insurance companies sometimes "lose" previous conversations. Your own records will save you. > ✅ **You're done with this phase when:** You have written confirmation of benefits, prior authorization requirements, and clarity on who submits what documentation. Here's the frustrating reality: WPATH Standards of Care Version 8 uses criteria that generally involve one referral letter for most genital surgeries, down from the previous requirement of two. But many insurers haven't caught up. They still require two letters, often with at least one from a doctoral-level provider (Ph.D., Psy.D., M.D., or D.O.). Prepare for the stricter requirements even if your insurer theoretically follows SOC-8. It's easier to have extra documentation than to scramble for what you need. If your insurance denies coverage, that's not the end. Appeals exist, and they work. Some recent federal appellate decisions have found categorical exclusions for transgender surgery discriminatory in certain contexts—but these cases evolve, and the legal landscape continues to shift. Use them as leverage in appeals, not guarantees. Organizations like the Trans Health Project offer free appeal letter templates. Lambda Legal's Help Desk (866-542-8336) and the Transgender Law Center can help. I've seen community members win appeals that seemed hopeless—denials overturned after months of fighting, coverage secured for procedures insurers initially called "cosmetic." The system rewards persistence. Treat "no" as the opening bid—ask what documentation would change it, then appeal. --- ## Get Your Letters Early (But Not Too Early) I thought the letters would be the hardest part. I really did. I built them up in my head as this enormous barrier—finding therapists who understood gender affirming care, scheduling multiple appointments, explaining myself over and over, waiting for providers to write the letters, then waiting for them to be acceptable to insurance and my surgeon. I imagined months of work. The real barrier wasn't the letters. It was giving myself permission to get out of my own way first. Once I stopped treating the process like something I had to earn through extended justification, once I accepted that I knew what I needed and didn't require anyone's philosophical approval—just their documentation—the letters happened in a forty-eight hour period. Both of them. From two different providers. Done. Here's what actually matters about the letters: Most surgeons and insurance companies require one or two letters from qualified mental health professionals documenting your gender dysphoria and confirming readiness for surgery. The letters need to include a diagnosis of gender dysphoria, confirmation that criteria for surgery are met per applicable standards, confirmation of your capacity for informed consent, confirmation of readiness for surgery and aftercare, the provider's credentials and contact information, and—this is critical—the specific procedure being requested. Generic letters requesting "gender affirming surgery" get rejected. The letter needs to specify your exact procedure—whether that's nulloplasty, phalloplasty, vaginoplasty, or any other gender affirming surgery. Be specific. The timing matters, but not in the way you might think. Letters are typically valid for six to twelve months depending on your surgeon's requirements and your insurance company's policies. Get them too early and they expire before your surgery date, becoming expensive paperwork you have to redo. Get them too late and you're scrambling when you should be focusing on pre-operative logistics. But the window is wide enough that you don't need to stress about hitting a perfect moment. > ✅ **You're done with this phase when:** Your letters include the specific procedure name, DSM diagnosis, confirmation of readiness, and the provider's credentials and contact information. What I actually needed wasn't more time with therapists. I'd already done years of therapy. I'd already processed my gender identity, worked through internalized transphobia, built self-acceptance, done the psychological labor that actually matters. What I needed was someone willing to write down what I already knew about myself in the specific format insurance required. That's a documentation task, not an emotional one. If cost is a barrier—and therapy appointments add up quickly—GALAP (Gender Affirming Letter Access Project) provides free surgery letters from volunteer mental health providers. This can save you hundreds of dollars while connecting you with providers who affirm rather than pathologize your experience. I've heard from multiple people in the community who used GALAP successfully when paying out of pocket wasn't feasible. It's a legitimate resource, not a workaround. The psychological shift that mattered for me was this: I stopped waiting for permission I didn't actually need. I stopped treating the letters as validation of whether my decision was correct. They're administrative documentation, not proof of worthiness. Once I understood that distinction, the process moved fast. --- ## Finding the Right Surgeon Is Its Own Full-Time Job The surgeon who operates on you will shape your body for the rest of your life. That's not hyperbole—it's why this decision deserves more rigor than most people give it. When I started searching, I lived in Southeast Wisconsin. Even Chicago had wait times measured in seasons—not weeks or months, but entire quarters stretching into the next year. When I finally reached a gender clinic at a major university hospital after days of dropped calls and hour-long holds, the earliest consultation was seven months away. Seven months just for an initial conversation about whether I was even a candidate. Worse, the person on the phone had never heard of nulloplasty. She kept redirecting me to vaginoplasty resources, as if I didn't know what I wanted. As if my request was a misunderstanding rather than a clearly articulated goal. The experience illustrated a fundamental problem: even in major metropolitan areas with university hospitals and specialized clinics, the infrastructure for gender affirming care remains fragmented, understaffed, and often poorly informed about the full spectrum of procedures people actually seek. If a major research hospital's intake coordinator doesn't recognize your procedure, what does that tell you about the depth of expertise available? Then I remembered a website a friend had shared two years earlier: the Crane Center. When I called them, someone answered within a minute—friendly, knowledgeable, actually helpful. She'd heard of nulloplasty. She knew what I was asking for. She understood the procedure, could speak to the specifics, and didn't treat my request as unusual or confusing. Days later I had a telehealth consultation. The day after that, I had a surgery date. The contrast between these two experiences—months of gatekeeping versus days of straightforward access—wasn't about shortcuts or lowered standards. It was about finding a surgical practice that actually specialized in the work I needed done. ### Where to search **[TransHealthCare.org](http://TransHealthCare.org)** is the most comprehensive surgery-specific directory currently available, covering 50+ countries and 18 procedure categories. You can filter by insurance type, geographic location, and specific procedures. Treat "featured" listings as advertising, because that's exactly what they are. Featured placement doesn't indicate superior surgical outcomes; it indicates a practice paid for visibility. Use the directory as a starting point for generating names, then verify everything independently. **WPATH's Provider Directory** lists thousands of providers globally, but not exclusively surgery-focused. WPATH membership indicates engagement with professional standards and continuing education in transgender health, not necessarily surgical expertise or volume. A provider can be deeply committed to affirming care while performing very few surgeries annually. Verify what each provider actually does, how frequently they do it, and what their specific areas of focus are within the broader field of gender affirming care. **Community wisdom** comes from support groups, online forums, social media networks, private conversations with people who've been through the process. When someone who's been through it tells you a surgeon's results look beautiful but their office never returns calls, that's information no directory captures. When multiple people mention the same surgeon's name with genuine enthusiasm or the same practice with consistent warnings, pay attention. Community knowledge exists outside formal channels because it addresses the practical realities of navigating surgical care—the responsiveness of staff, the accuracy of pre-operative information, how complications are handled, whether the surgeon treats you like a person or a procedure. ### What to verify Board certification from a recognized board—ABPS (American Board of Plastic Surgery) for plastic surgeons, ABU (American Board of Urology) for urologists. The American Board of Cosmetic Surgery is _not_ recognized by the American Board of Medical Specialties. This distinction matters. Always ask: certified by _which_ board? Don't accept vague answers. Use **[CertificationMatters.org](http://CertificationMatters.org)** to verify any board certification claim, and **[DocInfo.org](http://DocInfo.org)** (provided by the Federation of State Medical Boards) for license status, disciplinary history, and any malpractice actions. These are public databases. Use them. A surgeon unwilling to provide their state medical license number or board certification details is a red flag before you've even had a consultation. Ask about specific volume: a surgeon who's performed 500 vaginoplasties may have performed only 5 nulloplasties. Volume matters. Technique refinement happens through repetition. Complication management improves with experience. Be specific about _your_ procedure. Ask how many times they've performed it in the past year, the past five years, over their career. If they can't or won't provide numbers, that's information too. ### Red flags in consultations Can't provide specific case volume numbers—"I've done many" or "I have extensive experience" aren't answers. They're evasions. Gets defensive when asked about complications—every surgeon experiences complications. It's not a moral failure; it's statistical reality. A surgeon who becomes defensive, dismissive, or evasive when you ask about complication rates is telling you they don't handle difficult conversations well. You need someone who can face complications honestly. Pressures you to schedule quickly or discourages second opinions—legitimate surgeons want you to make informed decisions. Pressure tactics suggest the practice prioritizes filling their schedule over your wellbeing. Doesn't use your correct name and pronouns—if a surgeon can't get this right in the consultation, they won't get it right in the operating room, in your medical records, or when complications arise. This isn't about politeness; it's about basic respect and competence in providing affirming care. Promises specific results—surgery involves uncertainty, always. Claims like "you'll definitely be able to orgasm" or "your sensation will be exactly like before" or "you won't need revisions" are red flags. Ethical surgeons discuss probabilities, typical outcomes, and the range of possible results—not guarantees. ### Green flags Explains _why_ specific techniques suit your anatomy, not just what they recommend—a surgeon who can articulate their clinical reasoning, who walks you through why they're suggesting one approach over another based on your specific body, demonstrates depth of expertise. Discusses alternatives honestly—including the option of not having surgery at all, or waiting, or pursuing a different procedure. A surgeon secure in their expertise doesn't need to sell you on surgery. They present options and help you make decisions. Acknowledges complications as a normal part of surgery, not a failure—complications happen. How a surgeon talks about them in consultation predicts how they'll handle them if they occur in your case. Treats your choices as valid without requiring justification—you shouldn't have to defend your gender identity, explain why you want surgery, or justify your specific procedural preferences. A surgeon whose practice centers informed consent respects your autonomy. That last one mattered to me more than I expected. After years of healthcare experiences where I had to explain and defend my existence, walking into a practice that simply treated my goals as legitimate felt revolutionary. The absence of interrogation, the lack of skepticism, the straightforward acknowledgment that I knew what I wanted—it created space for focusing on medical logistics rather than psychological justification. That's what affirming care actually means: care that affirms your stated needs rather than questioning whether those needs are real. --- ## Budget for the Costs Nobody Tells You About Even with insurance, gender affirming surgery involves costs that blindside people. The surgery itself may be covered. Everything surrounding it often isn't. **Travel:** Research published in JAMA found that 56% of vaginoplasty patients and 50% of phalloplasty patients travel out of state for surgery. I traveled from Wisconsin to San Francisco — a distance that added thousands to my total costs but gave me access to a surgeon with specific expertise in the procedure I needed. **Post-operative lodging:** Most surgeons require you to stay nearby for 6–14+ days after discharge. At $100–$300 per night, that's $1,000–$4,000. Some cities have trans-specific recovery housing — Quest House in Oakland, for example, offers rooms at $100–$150 per night. **Caregiver costs:** Most surgeons require a dedicated caregiver for the first 1–2 weeks. If they're traveling with you, budget for their flight, lodging, meals, and lost income. My husband KJ served as my primary caregiver — handling logistics, emotional support, and physical caregiving simultaneously. That level of dedicated support shaped my recovery profoundly, but it came with real financial costs. **Lost income:** Minimum recovery times range from 2–4 weeks for orchiectomy to 3–6 months for staged phalloplasty. If you don't have paid medical leave, this can be the single largest financial impact. **Hair removal:** Mandatory for certain surgical sites. At ~$120/hour for electrolysis and requiring 60–100+ hours for genital areas, total costs can reach $7,000–$12,000. Insurance rarely covers it fully. Start this as early as possible — it takes months to years to complete. **Mental health letters:** $150–$400 per evaluation session, with most patients needing multiple sessions across one or more providers. **The buffer rule: budget 20–30% above your surgery quote.** This handles the surprises without financial crisis. **Grants to apply for:** - **Point of Pride Annual Transgender Surgery Fund** — the largest resource, with grants ranging from $5,800 to $80,785. Applications open November 1–30 annually. - **DemBois Inc.** — grants specifically for trans men of color - **For the Gworls** — Black trans-led collective funding rent and surgical costs - **TransMission** — $500 micro-grants for various transition expenses I'll be honest: for every person who receives a grant, dozens are told no. Apply to everything you're eligible for. But don't let your surgery timeline depend on winning. --- ## Prepare Yourself Emotionally (The Part No One Talks About) Here's what the clinical literature calls "pre-operative adjustment" and what I call _the cruel irony of getting closer to what you need:_ **Your dysphoria will likely get worse right before surgery resolves it.** The closer you get to the finish line, the more unbearable the waiting feels. This is documented, this is common, and this is not a sign that something is wrong with you. When surgery was a distant dream, you may have protected yourself by not thinking too hard about what you were living with. Once a date is on the calendar, those protective walls come down. The body part you've tried not to see in the mirror is all you can see. The dysphoria that was a dull ache becomes sharp and insistent. And after surgery? The dysphoria doesn't magically vanish on day one. Swelling obscures results. Healing doesn't feel like the body you imagined — it feels like a patient's body. Anesthesia affects brain chemistry for days or weeks. Post-operative depression is common, and reported rates vary widely by study and population — but it's normal enough that you should expect it, not be blindsided by it. That's not a sign of failure. It's a sign of being human. **What helps:** - **Shorten your time horizon.** Don't count the days until surgery. Focus on getting through today. - **Name the paradox:** "I feel worse because I'm almost done." Recognizing the psychological mechanics is validating. - **Know that the body you see at two weeks is not the body you'll have at two years.** Swelling distorts appearance for weeks to months. Scars mature over 12–18 months. Sensation returns gradually over one to two years. Judging outcomes during early recovery causes unnecessary distress. - **Line up mental health support before surgery, not during crisis.** A therapist familiar with gender affirming care is worth their weight in gold during the post-operative emotional rollercoaster. - **Let yourself grieve and celebrate simultaneously.** You can be excited about what's coming and heartbroken that it took this long. You can be scared and certain. Human emotional life is not a coherent narrative; it's a swirl. Let it swirl. The long-term data is reassuring: satisfaction rates for gender affirming surgery exceed 90% across procedures, regret rates average approximately 1%, and a 40-year follow-up study found that benefits persist for decades. Between the operating room and those long-term outcomes lies a hard stretch. But you get through it. --- ## The Timeline: What to Do When Adjust based on your own situation, but this is the skeleton: |Timeframe|What to do| |---|---| |**12+ months out**|Start electrolysis/laser if your procedure requires it. Begin researching surgeons and insurance coverage.| |**6–12 months out**|Call insurance, verify coverage, get it in writing. Begin gathering mental health letters. Schedule surgical consultations.| |**3–6 months out**|Submit prior authorization through your surgeon's office. Complete pre-op requirements (labs, medical clearance, procedure-specific prep). Begin financial planning for hidden costs.| |**6–9 weeks out**|Finalize travel and lodging. Set up your recovery space. Stock supplies. Arrange your caregiver. File FMLA paperwork if applicable. Fill prescriptions.| |**1–2 weeks out**|Confirm surgery date, arrival time, and last-minute instructions. Pack your hospital bag. Download entertainment. Tell your support network your timeline.| |**The day before**|Follow pre-op instructions exactly. Eat well (before the fasting window). Lay out everything you need. Try to sleep — and forgive yourself if you can't.| --- ## The Truth About Preparation Here's what I've learned from my own surgical journey and from supporting dozens of others through the Flat Crotch Collective and [bottomsurgery.info](http://bottomsurgery.info): **The people who navigate this process successfully tend to start early.** Not a month or two before surgery, but as far out as they can. Insurance authorization alone can take months. Legal name changes vary from weeks to half a year. The more lead time you give yourself, the less stress you'll experience when the inevitable delays hit. **Documentation is your armor.** Every phone call logged, every email saved, every letter filed. This becomes invaluable when you need to appeal a denial, prove what you were told, or simply remember where you are in a process that stretches across months. **Building a team matters.** Your surgeon's insurance coordinator, a knowledgeable therapist, a supportive employer, online community members who've been through it, and potentially legal advocates. You don't need everyone in place before you start. But knowing who can help — and being willing to ask — makes the journey more manageable. **Flexibility is harder than it sounds, but essential.** Plans will change. Dates will shift. Denials will require appeals. My own surgery date moved three times before it finally happened. Each time felt devastating in the moment. Looking back, none of those delays changed the outcome — they just tested my patience. And please: **take care of yourself through the process, even when the process fights back.** Pace yourself. Take breaks. Celebrate small victories — getting that call returned, receiving that document, finally understanding what your policy actually says. The paperwork is a means to an end, not the end itself. You've been waiting long enough. Let's get you ready. ~ Axl --- _This article draws from my book_ **[[Becoming Yourself - The Complete Guide to Gender Affirming Surgery|Becoming Yourself: The Complete Guide to Gender Affirming Surgery]]** _— 40 chapters covering every procedure, many countries, every system you need to navigate. It's the book I needed and it didn't exist, so I wrote it._ **[Get the book on Gumroad →](https://borgpup.gumroad.com/l/tyslr)** > [!tip] Related Pages > - [[Bottom Surgery Aftercare Shopping List]] — community-built recovery supplies list > - [[A Comprehensive Resource on Adult Hormone Replacement Therapy|HRT Guide]] — comprehensive hormone replacement therapy resource > - [[Borgpup Pre-Op Nullo Q&A]] — firsthand pre-op experience and lessons learned > - [[Borgpup 2024 Nulloplasty Journey]] — the full surgery and recovery story > - [[Global Resource Directory]] — providers, funding, and information across 10+ countries