Obamacare Vagina: Medicaid Coverage of SRS, Part Two
By Rani Baker
At the buttcrack of dawn one morning in late August 2016, I arranged a ride with Uber. I dressed up in some loose-fitting but comfortable clothes and took out all my piercings, many of which I would wind up not putting back in. I had shut down all the electronics and did a quick look over to make sure I didn’t have anything laying around in my room that couldn’t remain untouched for a week or two without running up a bill, catching fire or growing mold. The driver pulled up as soon as I reached the sidewalk, and as I closed the car door behind myself a familiar echoey guitar riff filled the space around us.
The radio was blasting “Don’t Fear The Reaper” by Blue Oyster Cult. I shit you not.
As we approached the hospital, the outro from “Jump” by Van Halen was jangling from the car speakers, bookending the ride. You can’t make up cinematic timing like that. I spent the ride in silent contemplation, but as I approached the hospital doors my stomach began to get queasy.
We’re doing this. After all this time and work put in, we’re really fucking doing this.
Check-in was pretty straightforward. After filling out some forms I was undressed and tucked into a hospital bed. At one point my clothes had to be retrieved and I was asked to put my underwear back on again, to see where the waistline fit so markings could be placed to locate potential skin grafts. Across the hall from me another trans woman, about twenty years older than me and covered in biker tattoos, was being prepped for… I’m honestly not sure what surgery. I wonder what her story was, outside of the mostly medical-related details I had overheard.
I was asked to sign some consent forms about a new technique they were trying out. Representatives of the company that developed the technique would be watching the surgery. Seemed certain somebody was gonna be using my experience in a research paper, based on all the measurements and questions and introductions being taken. And then, much like with top surgery before, I was wheeled into the surgery theater, the anesthesiologist asked me what I was gonna dream about and then… lights out.
I didn’t dream about a goddamned thing.
Next thing I remember I was getting picked up by four nurses to load onto a gurney, and then into a rolling bed. The light hurt my eyes, my whole body was incredibly sore and I had no idea who or what or where I was. Apparently, I still knew the f-word tho, and was liberally applying it towards everything and everyone around me. I, um, wasn’t having a good time.
Then I was in a patient room. It was dark outside, 10 pm or something. That was strange; what the hell happened to the whole day? I had all these tubes sticking out of me, and I was stiff and miserable and hungry. A nurse came in, explained I wasn’t ready for food yet and instructed me on what all the buttons near my bed did. I got a cup of water, turned on the television, watched some movie I never heard of and can’t remember anything about, and hit the Dilaudid button every time it lit up until I just sort of dissipated into a cloud of water vapor for the rest of the night.
Morning meant I got my phone back. My voicemail was crammed with messages from folks that weren’t sure if I had died. I was starving. Due to pre-surgery bowel prep, I hadn’t had anything to eat but small cups of alternating lime jello and beef broth for over 48 hours. I had a short meeting with the surgeon, who explained that my surgery had been more difficult than expected. Normally this surgery takes 4-6 hours, mine was almost 12. He didn’t really explain why except to note that my genitals were “particularly difficult to dissect”. I also lost a lot of blood, so much they considered a transfusion. He wasn’t quite sure how that would affect my recovery.
Laying in bed for a week is weird. It felt like much longer because I was fading in and out of catnaps every three to five hours until waking up from the pain meds wearing off. I lost track of what day it was frequently. I had these little chores to keep me busy, a device to exercise my lungs and another machine massaging my legs and visiting hours and short walks and video games on my phone. But most of the day was just laying there, feeling very powerless and small and alienated. I knew my body had changed because I could feel the pain of it but everything was swaddled in bandages and completely mysterious. Between my legs was this mysterious blank, hollow and painful space and I had not quite wrapped my head around how I felt about it.
About two days in they removed my bandages. From then on every few hours, a different group of RNs and urologists would come by and admire my new genitals; taking notes and photos. I didn’t have a whole lot of non-medical visitors; my boyfriend and a local trans lady friend who had also gotten GRS earlier this year came by. At one point they offered to let me meet a therapy dog, probably because I seemed lonely. Using the restroom was terrifying; I found myself worried that I would turn myself inside out squeezing the wrong thing. Still, nothing seemed to happen I couldn’t handle.
Well, until they took out the catheter.
They deflated and removed the stint in my vagina and removed the stitching and gauze attaching everything together before removing the catheter. Everything looked like an unholy horror and I was noticeably oozing blood onto the pee mat they stuck underneath me; but, I mean so far so good. All I had to do was prove I could pee without the catheter and I could finally go home and be able to wash and brush my hair and try to work on living my life again.
I couldn’t pee.
A few hours after removing my catheter, they did a sonogram of my bladder revealing it was well past a healthy level of full. This led to the emergency insertion of a catheter, which was far and beyond the worst part of this entire experience which literally involved the complete reconstruction of my genitals. I had a bit of an emotional meltdown at that point and just could not stop crying. Up until that point I hadn’t really been processing how any of this felt emotionally, and this was my first clue things were going to be way harder than I had ever expected. The urologists awkwardly excused themselves and said they would be sending another therapy dog that I could pet, and I was alone in the room again, a dull ache in my crotch, a stress migraine brewing and a catheter tube lying across my thighs.
This was a problem. Catheters are terrifying and a pain in the ass to maintain. You have these little rituals of sterility you have to perform multiple times a day or risk completely horrible consequences. You never want the bag or tube to be elevated higher than your bladder or else fluid can travel back up your urethra, carrying whatever microbes made it into the bag regardless of your rigorous and obsessive cleaning. But you also don’t want to have it on the floor because you are not an animal and also that is gross. This works fine when you are in the hospital and have all these specially crafted bars and such to hang stuff off of, but at home, you have to… improvise. Stacking some books or a shoebox or something that gets it off the floor but also low enough for gravity to pull the piss out of you.
You’re issued a large gross “night” bag and a smaller gross “leg” bag that comes with velcro straps for attachment. The idea of strapping a bag of piss to my leg for any reason just did not appeal to me so when I did any significant walking around I carried the “night” pouch alongside me in a clean fabric grocery bag. Also not switching out bags means one less nozzle/tube arrangement I would have to sanitize and still worry I did it wrong condemning me to some horrible infection. Also, the bag has to be emptied multiple times a day, which requires it’s own special handwashing and juggling ritual to make sure nothing gets on the spigot, which could then travel into the bag, back up the tube and into your bladder because you are also doing all of this while popping a couple Oxycodone every four hours so fuck knows how good a job you are doing at any given point in the process.
So there I was, stuck with a catheter in me for another two weeks until my next appointment with the surgeon, where I was to be issued dilators and begin that process. This may seem unusual to folks, going three weeks without dilation after surgery. According to my surgeon, dilation use is frequently initiated in the first week by surgeons that are used to their patients being from out of state, or even from another country. They want to pack all the direct patient/surgeon contact they can into the time of that initial stay, but it is not necessary to initiate that early.
Lemme go ahead and elaborate. You’ll see suggestions around the internet that a neovagina is an “open wound” between your legs which needs to be dilated open to keep from healing over. That’s actually quite stupid. A permanently open wound that never heals is a punishment from Greek Mythology, not something that happens in real life. This is your pelvic floor, one of the most densely concentrated area of blood vessels in your body where blood frequently settles via gravity when you stand upright. An “open wound” (or like TERFs tend to insist upon in their memes, a mess of necrotic tissue) down there will kill you deader than shit. A handful of tough-guy gun owners find out how debilitating and potentially lethal an actual open wound between your legs can be when they irresponsibly tuck their guns in the waistbands of their pants and blow part of their genitals off. Seriously, this is a thing that happens roughly twice a year just in the United States. Google it.
Anyway, that’s not what dilation is for. Dilation has less to do with “keeping the vagina open” and everything to do with your pelvic floor muscles. Normally, the vagina itself is a muscular organ in the pelvic floor. A neovagina is a fleshy pocket inserted into the pelvic floor muscle. There have been rare recorded cases of neovagina skin graft tissue converting to vaginal epithelium, but otherwise, that is the extent of the resemblance. Those surgically displaced muscles want to return to their initial state, so you have to train them to open up when you want them to so you can have PIV sex. It’s an exercise, basically. If one were to stop dilating, her neovagina wouldn’t “close up” but muscles and internal scar tissue might contract so much it’d be unusable. Once you get to the point where you are dilated wide enough and have a consensual partnership available for regular sex, you no longer even need to dilate because sex pretty much does it for you. On the opposite side of the coin, if you don’t want PIV-style sex, there’s also not a whole lot of reason to dilate. In fact, there is a GRS option that has little to no depth at all, and all the tissue is used in the crafting of the labia and clitoris. I like dick, so that wasn’t on the table for me, but I know folks that have taken that option and are incredibly happy with it.
So there were these weeks leading up to the beginning of dilation that were spent changing out blood-soaked maxi-pads and doing the catheter rituals and just basically being terrified of this horrible thing between my legs. Like, during that initial healing process it’s really ugly down there. I’ve heard it described as “a science experiment that someone blew their nose on;” I was making comparisons to Cronenberg’s The Thing, all melted bubble gum and sinewy mess. Swelling had burst some of my sutures and caused my labia to separate in aesthetically displeasing ways. I honestly would not have made it through this without the emotional support and nurturing of a close friend whose place I stayed at through most of the early part of my recovery.
If you’ve done some research into this process, you’ve probably read that the most dreaded words your surgeon can say to you during recovery are “granulation tissue.”
And I had a lot.
To facilitate the healing process, my surgeon was having me do a variation of “wet to dry bandaging” that had me stuffing my vagoo with gauze and then pulling it out to agitate improperly healing tissue. I’ve never had a surgery or other medical situation where I had to deal with this much granulation tissue, and it was honestly pretty shocking. Having all this snot-like goo spiderwebbed down through the vaginal canal looked terrifying. When the time came for me to begin dilation, my surgeon had to physically snip out some of the tendrils of it in order to fit the dilator in, and again I found myself uncontrollably crying. Not because of pain but because everything just seemed like a horrible nightmare. At one point, I thought my vagina had eaten a wad of gauze, which led to several terrified phone calls until they were able to reassure me that is not actually a thing. Eventually, over the next couple visits, my surgeon began to apply silver nitrate to cauterize what was left. This leads to its own set of horrible consequences, as your body sloughs off dead burned gray zombie tissue from the cauterization for days afterward.
Dilation is pretty weird. At first, it was gruesome, having to shove this device into the hamburger meat mess between my legs. Having lube leaking out of you all damn day. Rips and tears appearing over and over. Eventually, as everyone made effort to reassure me, it became fairly boring, hindered only by me forcing myself to relax enough to open up. I spend my time (and my free hand) exploring the realm of idle and one-click games on my phone.
Re-learning how to pee again was also a surprising challenge. There’s like a trick or two to figuring out how to pee downwards without spraying everywhere, which by the way sucks so bad. You have to like to lean a little bit forward and position yourself just right. Also, with your urethra a fraction of the length it was, urgency takes on a whole new level. There was also a lot of trickiness involved with dilation because shoving devices into your pelvic floor stimulates particular nerves. More than once I found myself striking a nerve cluster that sent me running to the bathroom.
I mean, I don’t wanna give the idea that I have any regrets, because that certainly isn’t the case. I’m not trying to talk anyone out of this. However, I’m also not sure that I really gained any particular epiphanies about myself from this change either. I had a lot of complications that aren’t common and had to struggle more through the recovery process than most will. I definitely had moments in distress and pain where I wondered aloud what I had done to myself, why I couldn’t just be a crossdressing gay man or whatever, whether this had ever really been something I wanted. Just, you know, psychologically torturing the fuck out of myself because apparently, my experience wasn’t already difficult enough. I can confidently say, however, that with time even the most gruesome, aesthetically unpleasing and unfortunate recovery experiences seem to be well behind me and I’m distinctly more pleased with the results than I expected to be.
Also, not all the recovery struggle was surgical in nature. The physical shock of going without hormones for weeks compounded with the likely outcome of my body attempting to hormonally overcompensate for losing my testicles seems to have reversed some of the laser hair removal I had on my face, which is also frustrating. Hopefully, I can correct that with electrolysis in the future. In a lot of ways, this experience, rather than being a mystical miracle transformation, actually alienated me even further from my body than I had been previously. Like, this is a pretty difficult thing. It seems to have worked out in the end, but damn getting there was tough.
Hopefully what you will take from this is a more robust understanding of what the recovery process is like. It wasn’t some magical butterfly transformation for me that solved all my problems, but it’s also not a mistake or a regret of mine either.