Gender-Affirming Aftercare for Trans Women: Healing From Vaginoplasty

Shannon Whittington, M.S.
Shannon Whittington, R.N., M.S.N.
Linda Farwell for VNSNY

For some trans women, accessing vaginoplasty (bottom surgery) is a major hurdle on the path toward a more gender-affirmed life. But all too few resources are available to prepare trans folks for what to expect before, during, and after surgery. Even after going through the substantive steps it takes to obtain surgery and to have the surgery itself, there's the crucial period of recovering from the surgery -- much of which happens at home. Shannon Whittington, R.N., M.S.N., gender affirmation program director with the Visiting Nurse Service of New York (VNSNY), spoke at Community Healthcare Network's 7th Annual Conference on Transgender Health in October and laid out what women could expect, and prepare for, when it comes to aftercare.

Shannon Whittington: What I'm going to talk about today are some of the things that you can expect to happen when you do come home [from vaginoplasty surgery]. You've had your surgery, you spend about four days in the hospital, and then you come home. And you come home with things attached to your body that you may not be used to or aware of.

Basically, the nurse comes there to show you how to deal with those things.

Let me tell you just a few things that you're going to need when you come home. I think the most important thing is that you need someone to be with you for the first week or two. You've had surgery. You're going to be tired. That bathroom is going to feel like it's way down there around a corner, after you have surgery.

You're going to need to take it easy, basically. And these are some of the things that you probably will come home with.

Foley catheter
Foley catheter
Olek Remesz [CC BY-SA 3.0], via Wikimedia Commons

A Foley catheter is an in-dwelling catheter that goes into your bladder that drains out your urine. You will likely come home with that.

You will likely have a JP drain, which stands for Jackson-Pratt drain, right after surgery. It may or may not be pulled out before you come home. That drains the blood.

The third thing is called a vac. That's kind of like a miniature vacuum cleaner. You know how the vacuum cleaner sucks up all the dirt? Well, the vac sucks up all the blood and puts it in a canister.

Related: Interested in Having Gender-Affirming Surgery? Keep These Four Pieces of Advice in Mind

That vac is going to be sucking blood from the vagina, if you're having male-to-female, or from the phallus, for female-to-male. There's going to be clear dressing over the vagina area, and that's going to suck into that canister in the back.

One thing I really want to point out to you that patients often get really frightened of: This vac is supposed to purr like a kitten, just a very soft kitten. But sometimes it squawks like a cat. And a lot of times, patients get really, really nervous when it starts making that noise, and they feel like they've got to go to the emergency room. "Oh, my God. What am I going to do?" They're in a panic.

And basically, the nurse comes in to tell you, "Don't panic." If you've had a couple of days of getting used to the vac, that's all that's really necessary. So, we show you what to do if that happens. Hopefully it doesn't happen. But usually, half the time, it does happen. So don't be alarmed about that.

Here's how you might feel when you come home: tired. Just think about it. You've had surgery. So, just the least little bit of a thing that you would normally do -- like getting up and brushing your teeth and having breakfast -- suddenly takes a lot of energy. Your body knows that it's had surgery, so it's working on healing itself. All the energy is going to healing. Some of those normal activities of daily living are going to be kind of stressful and take up a lot of energy.

You're not going to have a big appetite. You're going to be waiting for a bowel movement. And waiting. Remember, you took a bowel prep before. So, you may not go for around a week. Sometimes patients get really nervous about this. But, eventually, you will go.

You're going to have some discomfort. They send you home with pain medication. The nurse will teach you how to regulate that.

You're going to have mood swings. Think about it: You're not on your hormones. You've been off your hormones for a while. You're going to go home, and you'll start back on your hormones.

But -- and this is the good news -- as each day passes, you will start to feel better. It just takes time, like anything.

And this is a good time to talk to your friends and watch Housewives of Atlanta; catch up on whatever it is you want to binge watch on Netflix. You just really need a supportive environment, someone that's there with you.

We have a lot of patients come in from all across the country, and a lot of times, they come here by themselves. And they really need someone with them. If you've already got your date booked, book a friend, OK? So they can be with you.

As you feel better, you'll become more active. After you go back to the doctor, it's likely he's going to remove everything. You're going to have the vac taken off, the JP pulled, the Foley pulled, your vaginal packing removed. And that's when you're going to do your first dilation, at the doctor's office.

Then, the very next day, the nurse will come to your house to make sure that you're dilated correctly. Now, let's say for instance -- because this is what normally happens; normally the patients go home on a Friday. But guess what? VNSNY is open every single day. So, the nurse comes to see you on Saturday. If you come home on a Wednesday, the nurse will come to see you on a Thursday. If you go to see the doctor on Monday, the nurse is coming the next day, Tuesday, to make sure you're dilating correctly.

Let's talk about the dilation process. There are various plans of care around dilation, usually between two and four times a day, for approximately 20 minutes. It's very important. Very important. Can't say that enough.

I know they tell you that before you have your surgery. But if you think of it like getting your ears pierced, and you don't keep that -- well, back in my day, you put a straw in there -- but if you don't keep that in there, it's going to close up. Your vagina will close up if you don't dilate. And it may or may not be reversible. Make sure you dilate.

You're going to get a gel at the doctor's office that's an approved gel to dilate with. And the nurse is going to help you, to make sure that you're dilating correctly.

Basic care of the dilator is just washing it off with soap and water, drying it, putting it back in the pouch. Very simple. Make sure you mind your dilators. I did have a patient who was so excited about having a new vagina that she had a party to celebrate her vagina. And someone stole her dilators. So, she didn't dilate for two weeks. She went back to the doctor, and she had closed up. And they couldn't reverse back. So, it's very important. Not to scare you, but just do it.

So, how often does the nurse come? It really varies, based on the individual need, based on how you're doing, how you're progressing, if you had complications, or if you had a very easy surgery and no complications at all. When you first come home, we come more often. As you get better, we come less often. If something happens, you have it set up to come more often. It's based on the doctor's request, as well. And let's face it: It's also based on insurance. We have to have approval to come. Medicare always approves, so we come.

And so, that's the variance of when we come: two or three times a week for four to 10 weeks. Sometimes the patient will say, "I'm good; I don't need you anymore; I've learned everything I need to learn; thank you very much," and we're done much sooner. And sometimes the patient's like, "Please come again; I just want to make sure I'm doing this right."

This transcript has been lightly edited for clarity.