Five days after having surgery to create my neovagina, my surgeon did his rounds with a box of surgical gloves and a tray of packaged, single-use speculums. I was still in a great deal of pain, with my stitches rapidly unraveling and purplish-green bruising appearing and intensifying around my new internal cavity. The cock-and-ball skin that was used to shape the facsimile of a vagina was still throbbing, and when I looked at her in a tiny magnifying mirror, she resembled a really fucking angry monkey’s bottom, the kind that attracts male monkeys to fuck without warning or care. She was no porn centerfold, even when viewed through my rose-tinted eyes.
It was the morning of the “depth test”—a trans coming-of-age ceremony performed without robes or incense, apart from the nurse’s uniform and the heat pumping unrelentingly from the broken radiator next to my bed. My surgeon asked me to relax and allow my legs to fall open. He covered his finger in clear lube and pushed it hard inside of me, probing and exploring. After my first vaginal fingering, he withdrew, greased up the plastic speculum, and then—without any warning—pushed the tool firmly between my stitched vaginal lips and deep inside my newly formed orifice. My first penetration was agonizing and intrusive. Like every other punter I’d asked to slow down, he didn’t register my gasps as pain, so eventually I became silent. As I lay in the hospital bed with my head turned to one side, he said, “You have six inches of depth. Perfect.”
Up until that point, I had only dreamed about having a vagina, spending years tucking my cock and balls between my legs and running my hand over my flat pubic mound. Tears welled up as I realized that my cavity, filled now with congealing lube, would be able to accommodate a six-inch penis (though there was a silent presumption that it would be a cisgender man’s penis). In the surgeon’s eyes, I was now “all woman” and ready to please without being pleased. I looked up at him and he smiled, misreading my moist eyes as a sign of joy. I turned away again, thinking, I’m much deeper than my cunt.
This moment was my first real sense of vaginal powerlessness—a newly self-imposed pleasureless principle. I realized then, in my mid-40s, that I would still be defined by the gaze, touch, and rejection of another person, as I had been my whole life, and my vaginal depth would do little to cure the dysphoria, sexism, and misogyny that so often prompts bodily shame.
The real price of vaginoplasty
During the presurgery process, I saw at least three psychiatrists, none of whom asked me about sex, sexual attraction, or what turned me on. Some of them asked me to define my sexuality, but we never talked about pleasure. Trans elders had told me that mentioning sex could keep me from being approved because medical professionals might interpret my doing so as signaling a fetish rather than dysphoria. So I never mentioned it, and gatekeepers saw a middle-aged woman who they presumed wouldn’t be having sex—because who has sex with middle-aged women, much less middle-aged trans women? The clinical side of the gender-confirmation surgery process is centered around resolving visual dysphoria; if everything’s made to look real, then the dysphoria will simply disappear, as if my femininity were based solely on my genitals and not in the giving and receiving of pleasure.
In the surgeon’s eyes, I was now “all woman” and ready to please without being pleased.
As the depth test suggested, the vaginal cavity itself is often the main focus during vaginoplasties, and cock size and the skin remaining after circumcision are used to decide how the procedure will be carried out. If a trans woman has a decent-size and uncircumcised penis, then the skin from the shaft can simply be turned inside out in a process called penile inversion. If the cock is smaller or circumcised, then skin from the scrotal sac must be used in the procedure. (Both options are almost universally used and have been standard since the first vaginoplasty was performed in Berlin in 1931.) There’s also a third procedure that involves taking a section of the sigmoid colon, which naturally lubricates, and using that skin to line the vagina.
The options for surgery vary widely depending on where you live. For instance, it’s illegal to undergo any gender-confirmation surgery in Vietnam, so many trans folks travel to Thailand, where procedures can cost more than $5,000. In the United States, vaginoplasty can cost anywhere from $5,000 to $50,000. (Estimates for trans male phalloplasties, by contrast, can be as high as $100,000.) In the United Kingdom, female gender-confirmation surgery can cost between £13,000 and £20,000. For people like myself whose surgery comes via the U.K.’s National Health Service (NHS), the estimated cost is around £13,000. (That price doesn’t include other alignment procedures, such as facial feminization surgery, hair removal, or breast augmentation.) Traveling to Thailand or the United States for a vaginoplasty is a privilege rarely afforded to trans women, many of whom already struggle to retain secure employment. Some trans women go to extreme measures to afford the surgery: One friend refinanced her home for “improvements” in order to pay for her £20,000 vaginoplasty, while others engage in sex work to fund the procedure. In recent years, crowdfunding surgery has also become an option.
For U.K. citizens, accessing healthcare with the goal of eventual gender-confirmation surgery is a fairly lengthy process. It begins with a referral from your family doctor into the gender-care pathway, where at least two psychiatrists assess suitability for both hormones and surgery. From start to finish, the process is supposed to take two years or less, but austerity cuts and increased demand have substantially increased the waiting time. For 10 years, I was refused gender-confirmation surgery because different family doctors thought that being HIV positive was too much of a risk factor. Plus, gender confirmation (then described as “having a sex change”) was seen as an elective procedure, and HIV-positive people were discouraged from having “optional” surgeries. (Globally, trans people are 49 times more likely to be HIV positive than any other group.) Even now, private clinics in the European Union and the United States have similar policies regarding elective procedures for HIV-positive people. Dealing with rejection on the basis of my HIV status was crushing, but there was absolutely nothing I could do to change that. I felt trapped.
When the NHS finally approved me for the vaginoplasty procedure in 2006, I knew how lucky I was. But I wasn’t prepared for the clinical reality of gender confirmation, which prioritizes depth over sensation, and confirmation over pleasure. As a trans woman with HIV and a history of drug addiction and sex work, I was expected to show gratitude for any kindness from the doctors I encountered. One even told me that I would live to regret the choices and risks I had taken in my life, but I was so used to discrimination that any “yes,” no matter how qualified, felt like an act of love.
A friend who had her vagina created in a private clinic in Thailand was offered a choice: sensation, depth, or appearance. It’s harsh to ask someone to decide between the safety of looking “real,” the ability to provide pleasure to another, and the ability to feel their own pleasure, but the choice offered a measure of ownership and a sense of embodiment. Socioeconomic privilege buys autonomy and choice in most aspects of life, and gender-confirmation surgery is no different: Having money means having the time to reflect, to decide, to ask the right questions, and to learn the right questions to begin with. Nobody involved in creating my vagina asked about my preference for depth or mentioned options that might increase my pleasure. And, postoperation, I didn’t push for answers. Most of the practitioners I encountered during the process—from my family doctor to psychiatrists to surgeons—were men, and it never felt like a safe environment to have those conversations. I didn’t feel comfortable talking to cis men, even doctors, about pleasure because my history of sex work made me guarded. I wanted to talk with other women, especially trans women, who had gone through vaginoplasty, but those weren’t the doctors I encountered. The dry, almost impersonal, conversations were always centered around the technical aspects of the skin available to create the vaginal cavity and labia. Thanks to this lack of options, my vagina, crafted from scrotal and penile skin, has very little sensitivity.
The narrative of transition assumes that before surgery we find our bodies physically repulsive and will locate pleasure only after our genitals are changed.
There are no recipes for pleasure
The narrative of transition assumes that before surgery we find our bodies physically repulsive and will locate pleasure only after our genitals are changed. To some extent this is true, particularly in the immediate aftermath of vaginoplasty. Masturbation was the defining process through which I explored my vagina and overcame my fears about life after gender-confirmation surgery. The tip of my penis, reduced down to the size of a pea, was supposed to be my magical button, refashioned and placed as a clitoral stand-in, a pseudo clit of sorts. But five weeks after surgery, skin grew over my clit, denying me access to easy pleasure. (I’m not sure if this is a normal part of the process, as I received little guidance or follow-up outside of checking for depth and capacity.) My clit looks up at me, like a pearl ingested in the flesh of an oyster. Though my healing pea-sized clit eased my initial feelings of bodily dysphoria, there was no handbook on how to care for, live with, and have sex with my new vaginal space. Fuck, even a microwave comes with recipe hints and tips, but doctors think it’s enough to send trans folks out into the world without a word about pleasure or what’s gone and how what’s left might function. I was sent home from the hospital with a single sheet that outlined when I could start doing certain activities such as driving or thinking about having sex. The only postsurgical advice given to me by friends and others who had had the procedure was: “Don’t expect sex to be the same. It’s different, deeper, and more spiritual for women.” But there’s no real conversation about the struggle most trans women will have with being fucked.
We don’t naturally lubricate and our caverns are finite, so it’s hard to relax in a way that might precipitate pleasure. Psychiatrists and surgeons consistently discuss visual dysphoria with patients, but they should also address life after surgery with a focus on receiving and giving pleasure. Trans women are sent off knowing that their new genital configurations look as real as can be, but with little information about caring for them. How, for example, do we discuss our prostates? How do we discuss proper medical care with family doctors who exclaim, “I’ve never seen one before!” Big squirting orgasms are good for the soul and body and could do much more holistic good for dysphoria than merely looking the part. I want the surgical process to prioritize pleasure and orgasms, not just for those lucky few but for all. I knew that I wanted my growth as a transgender person to be about more than a realistic cavity: I wanted to explore my sexuality and my body on my own terms. I’ve worked at this through masturbation, through connections, through trial and error.
My sex-toy collection is growing. I recently bought a prostate stimulator to explore a space I previously rejected because I saw it as “male.” I use my writing and interviews with other trans women to accept a body shaped by both sets of sex hormones. I know now that an honest conversation about the limitations of my refashioned cock, about its potential for pleasure and not its resemblance to the real thing, would’ve helped me better understand my body, what it’s capable of, and what I can accept. It seems strange that to keep society happy with its binary constructs, we have created surgery based on facsimile rather than pleasure: In trying to look just like cisgender women, we’re resolving their dysphoria, not ours.