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What I wish I’d known before I had gender-affirming surgery

The media makes out procedures like the one I had to be cure-alls. They're not.

I have nightmares about growing a beard and having a penis. They've occurred more and more frequently the further I've progressed into my transition from male to female.

Last July, New York magazine published a video explaining what nightmares are: our brains' way of taking whatever is bothering or frightening us in life and morphing it into tales that we can process as memories. Thanks to hormone therapy, laser treatments, and vaginoplasty surgery, I no longer grow facial hair or have a penis, but the thought of being a boy still terrifies me and always will. These nightmares are my brain's way of helping me distance myself from that fear.

Much of what you can find about gender-affirming surgeries like vaginoplasty makes you think that after you've had one, all your problems fade away and your life becomes instantaneously better. Take a look at these recent videos by the New York Times and NPR, and this article by NBC: All three leave you with the impression that the surgery is a type of transition denouement. In the video by the Times, for example, Katherine, supported by pleasant and hopeful music, says this about her surgery: "It's, like, the new me. I finally feel like myself, so it kind of, in a sense, is a rebirth day … a renaissance."

NPR similarly ends its video with Jetta'Mae Carlisle, who, having undergone the surgery, says, "I have that white picket fence dream, and that's where my future is." The NBC article quotes Denee Mallon saying, "I feel complete."

These reports obscure the truth: While gender-affirming surgeries can make people more comfortable in their bodies, they're not a fix-it for everything wrong in your life. I know this from my own experience with surgery, and from studying the research on it.

I wish I had better resources to help prepare me for my surgery

People who want to have a vaginoplasty must get referrals from two different therapists. Dr. Molly Parks, a gender therapist in Durham, North Carolina, told me the goal of preoperative therapy is to make sure patients have really thought through their decision, and to determine whether they have any mental health issues that could hamper their decision-making.

"I ultimately think that the client is the only one who can determine whether a procedure is the right decision for them," said Parks.

My pre-op therapy largely went the way Parks described. With my first therapist, I explored how long I'd had gender dysphoria, a medical condition characterized by an extreme discomfort with the primary and secondary sex characteristics of one's body. We talked about how I thought of myself as a girl, therapy history, my relationships with friends and family, what support structures I had in place, and what goals I was pursuing in life. My second therapist and I made sure I was mentally capable of grasping the decision I was making.

Thinking back, though, my pre-op therapy didn't help me realize how extraordinarily hard it would be to recover from the surgery I had: the stress from being unable to eat solid food for a week and a half, and the feeling of helplessness from being so bedridden and unable to walk normally for weeks, to name only two difficulties. I'm also, apparently, not the only one who's had this gap in his or her therapy experience.

"I would think, and hope, that most gender therapists … would talk through the potential difficult side effects of surgery," said Parks. "The therapists I work with do tend to do this, although I have had clients who have come to me from therapists where this was not the case."

Parks said that currently there are "no specific guidelines in place as to what therapy has to look like presurgery." That could change, though — she is a member of the World Professional Association for Transgender Health, and she said she thinks the organization should adopt guidelines for preoperative therapy.

Researching on your own the gender-affirming surgery you need, especially one so enigmatic as vaginoplasty, and without guidance from an informed therapist on the subject, can be excruciating. There was no formal education I could find about vaginoplasty. Even with information provided by my surgeon, I still found myself reading online Q&As, visiting forums, and reading news articles. Trying to form a clear picture of the surgical experience seems impossible when the information you find is so disjointed and often so hateful and frightening.

I've seen several horrible euphemisms used to describe a postoperative vagina: "frankenpussy," "mutilated dickhole," "an open wound," "penis bits." Sometimes the sentiment behind these phrases manifests in very violent ways: Vice published a moving article last year about the 23 trans women killed in 2015.

It's also really easy to come across articles that describe the surgery as mutilation. In her article for Public Discourse, Margaret A. Hagen, a professor at Boston University, described a woman like me as a "mutilated male pumped full of estrogen."

One of the most tiring factors of transitioning is having to be on constant emotional guard everywhere you go. Despite your best efforts, though, you have to wonder how much negativity has been internalized. My vagina is not a mutilation, but I must admit I might not like it as much as I should after reading so much horrible language directed toward it.

Lily Carollo.

What happens when expectations meet reality

Being inadequately prepared for surgery has real consequences.

In an essay published last summer, Don Terry explored the horrible struggles black trans women face. One woman told Terry she knew several people who'd killed themselves after having surgery. "They really thought life was going to be completely different," she said. "Nothing changed. That's a whole lot of money to invest to still have the same life."

If you're in a shit situation before surgery, you'll be in a shit situation after. If your co-workers aren't supportive of your transition, they're not going to change their minds once you have a vagina. The friends you've lost aren't going to come back now that you have female genitalia. If you've made it far enough to get surgery without support from your family, they won't come around in the aftermath of the operation; what they say to you might change, but their true feelings certainly won't.

And you'll still come across news articles that say your vagina is mutilation. You're still going to have people calling you a man. You're still going to see people freak out about you using a certain bathroom. Surgery will not change any of this.

And indeed, people who have gender-affirming surgeries still experience higher suicide and attempted suicide rates than the rest of the population, according to a 2011 study from Sweden. Some cite this research in the hopes of convincing others that the surgeries are ineffective and ultimately harmful, but they do so in error. The researchers go out of their way to explain that the surgeries are not the cause of the high suicide rates: "The results should not be interpreted such as [the surgery] per se increases morbidity and mortality." They say "things might have been even worse" without the surgery.

The latest research shows that it's discrimination and stigma, not surgery itself, that causes the high suicide and attempted suicide rates. A study published in Ontario in 2015 revealed that those who have a supportive social environment (the most important social support being parents) were far less likely to seriously consider suicide. Other factors, like having one official document properly identifying your sex, also correlated with lower suicide attempts and rates.

My major problem, like many others, is employment. According to the National Center for Transgender Equality's 2011 survey, 44 percent of the respondents were experiencing underemployment, the unemployment rate was twice that of the national average, and 90 percent said they had experienced workplace harassment or had to hide who they are to avoid such harassment.

It's been almost two years since I graduated, and I still don't have a full-time job. Though I've been recently accepted to the University of North Carolina's Graduate School of Media and Journalism — a very encouraging development! — I need to find a part-time job soon, because my mom isn't doing so well financially at the moment. I'm terrified, however, of encountering harassment on the job, so I'm forced to be very selective in my search. Recent developments here in North Carolina have only heightened my concerns.

Transitioning is a long, challenging road

Transitioning is one of the hardest, most overwhelming experiences someone can go through. It's the kind of gamble you make when your back is against the wall and everything seems at stake. Some people take years to finish if they're lucky enough to finish or start at all; others think they never finish simply because learning what a woman or man is takes a lifetime.

Transitioning is also not a cure. I needed gender-affirming surgery to alleviate gender dysphoria and feel as comfortable in my body as possible, but there is no cure for gender dysphoria — you can only treat the symptoms, and our ability to treat the symptoms is limited. I still experience dysphoria even though my physical results have turned out well. When I'm stressed out, my dysphoria worsens, making it harder to deal with whatever was stressing me out in the first place.

In February 2013, a month into my transition, I admitted myself to a psychiatric ward because I was afraid I was going to hurt myself. Though I've thankfully never had so serious a situation since then, I've had suicidal thoughts every year since I started transitioning. Maybe, hopefully, finally 2016 will be the first where I don't have any at all.

The morning of my surgery, the day of my last big step, I realized that right now in our society, transitioning isn't just some process you go through; it's also something you survive.

I've had vaginoplasty. I've finished transitioning. But I've yet to survive it.

Lily Carollo is a rising graduate student at the University of North Carolina’s School of Media and Journalism. She writes about gender dysphoria on her blog, A Little Lilypad. You can follow her on Twitter @alittlelilypad.


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