I think some people don’t consider phalloplasty because they imagine it will be more expensive than it is. Yes, it does require some money– but I wanted to share my bare minimum, shoestring budget and how we got by.
Before we start: I admit middle class privilege, having general good health, to living in the USA, a supportive spouse and many friends, and white/white passing privilege. Many of these elements will be unavailable to a great number of trans people. My education has allowed me access to information that would be inaccessible to others. My comfort with technology has made things easy for me which would be hard for others. This is not an ‘anybody can have phalloplasty’ post; rather, I want to outline how I personally did it or observed others do it, with limited funds. This is my context of finding out how I myself could actually afford it.
Here’s where you start:
$200k cash with Curtis Crane, Austin
$90k cash in Thailand
$54k with Maud Belanger, Montreal
$30k with Doc Miro in Serbia
I was once so desperate to complete my body that I considered that maybe I could take out a huge, unwise loan to save my life? People used to do this. Some people still do. We don’t have to do this anymore as our only option.
Settle on a donor site
I know, it sounds to early for that. But you need to get hair removal going as soon as possible, since that hair cannot be present or else the hair will block your urethra when it starts to grow. Generally, your options are forearm, leg, or back/side. Abbreviated RFF, ALT, MLD. MLD. Abdominal flap are pretty rare in the USA, but not unheard of. Most people go for RFF or ALT. Read up on these in phallo.net. Reddit is also a good resource for anonymous chatter about trans surgeries. You need very low body fat to get ALT. You may not want RFF if you have a forearm tattoo of Mister Rogers and your mom.
Book a day to go to your general doc to get an Allen Test for good circulation in your arms. Usually people go with the nondominant side for accessibility during recovery, unless Allen shows poor circulation there.
Start your hair removal
I mean it. When you want surgery, before you do anything else, start getting electrolysis or laser on your donor site. Most people need a year or two of treatments minimum. If you don’t get enough hair removal, you can’t have urethral lengthening aka you won’t be able to pee out of your dick. You’ll pee out of your perineum. Which is okay if you want that– I did.
Buy generous short term disability, long term disability, hospital indemnity, and legal insurance plans.
They are usually going to have a pre-existing conditions exclusion the first year, which will expire. So you need this set up at least one plan year before you will use them. Hospital indemnity and legal insurance don’t have a lookback period. You’re going to feel the pinch, but this is going to buy your food and pay your bills when you are off work. In the event of complications, it is wise to have the long term to kick in after 60 days for example. Then you won’t rush back to work when you really need more time for rest.
Getting on inclusive coverage
In the USA– I am quite sad we do not have a national health system like most places in the world– but here, we have to find out where we can get health insurance policy coverage that includes transgender health care. You have a few options. You can get a plan which will cover bottom surgery through:
- The Marketplace / ACA / Obamacare plans in states which forbid health discrimination against trans people (“equality states”)
- Medicaid in equality states
- Medicare sometimes
- Companies, groups, and private plans based in equality states– like, their headquarters
- Companies which make a point of it– See the Human Rights Campaign’s Equality Index. Their plans in inequality states will still offer trans benefits. Think Target, Starbucks. Some of these companies give benefits to part time employees too, so you could get this as a side job.
- Colleges in equality states. You can purchase a plan from the college while you are a student. If you are willing to be an online student, you can access these colleges from anywhere in the country. If you take medical leave and withdraw, your benefits continue for 10 months by law. You can sometimes get inclusive plans in inequality states just because the college really wanted that coverage.
- Progressive city government jobs. Even if your state does not have an equality climate, if you have a very Blue city, they sometimes have fought to add trans inclusion to their policy. If you’re up for it, work with your city council on this.
- Getting your group/company’s LGBT or diversity group to spearhead change to existing exclusionary policies. This is a tough one, sometimes. Other times, the company leadership 100% believes in trans coverage; they just don’t realize we were cut out, and they fix it. Buckle up for a ride. I’ve done this. I recommend calling up Transcend Legal in New York City to get legal advice on the best way to approach this. Even just a consult with them to get a plan for self-advocacy.
- Move to an equality state and take a vow of poverty. Medicaid will usually cover at close to 100%. Or you know, just purchase a plan there.
- Emigrate to a place with a national health system. Beware: It may be covered and paid for, but the waiting lists are often much longer and frequently fraught with outdated gatekeeping. Or maybe not.
Find your doctor & location
Say you were getting your wisdom teeth out. Do it at the closest place to your house and pharmacy. Getting phalloplasty? You get your ass on a plane to the best your plan covers. You can see a list of surgeons on phallo.net and Callen-Lorde’s booklet. Just go down the line and find out who is in network. Take this with a grain of salt, because my list may not be yours– but.
My Fav US Docs with Quality Work List
- Devin O’Brien-Coon, my surgeon 🥰
- Rachel Bluebond-Langer
- Jens Berli
- Mang Chen / Safa/ Watt
My Shitlist, Would Not Allow to Spay Aggressive Feral Cats for Charity List
- Christopher “The Ultra Creep” Salgado
- Kathy “I’ve really never heard of nerve hookup” Rumor
- Loren “got a new patient now, who dis?” Schechter
- Jess “Magic Patented Inventions Which I Have Not Actually Fleshed Out” Ting (who is no longer performing phallo but just in case he starts back.)
Now that you have your list of who is in network, start listing their locations. This is where you’ll have to stay six weeks for stage 1. Are you able to afford the $6k-$10k to stay six weeks in San Francisco? It was a big plus for me that I could get the same place in Baltimore for $1300 for six weeks. Texas is also cheaper to stay in, if you like Curtis “Controversial in the Community lol” Crane. Just consider this an important factor.
Start calling to set up a consult or intake toward a consult.
Scope out that inclusive plan
Y’all, I had to learn to speak insurance for this part. Pop a caffeine pill now. It’s a real sleeper. But you NEED TO KNOW THIS.
Look at the out of pocket maximum. That is what you will pay the year you have surgery. That’s the most you can pay out of pocket, including any deductible, coinsurance, hospital bills, all of it. With this surgery, you’re going to hit that max out of pocket.
Good news– once you hit it, everything else is free that year. Like anything medical at. Well, you’re still paying your monthly premium. But they pay 100% of the bills after that. Live it up, get lots of therapy! Hand therapy? Physical therapy? Whatever little aggravating thing you never took care of? This is the Millenial version of going hog wild… Unlimited health, mwahahaha!!
For me, my out of pocket max was around $4k, so about six months after surgery I got a ton of bills which added up to about that amount. After that I got bills for $0. It resets at your next benefit year– usually the calendar year in corporate America, usually the school year in schools.
TIP, listen up: Try to get a date very close to the beginning of your plan year. You can save a beaucoup when the 360 days of surgeries are all covered by one out of pocket max.
Bad, bad idea: Surgery right at the end of your plan year, where it resets the max soon, and you owe it twice almost immediately.
Scramble for those letters and medical records
Get these as fast as possible. Some places won’t even let you schedule consult until you have them (yuck). Go in to see your old therapist to fill in on your bottom surgery preparation, and they can update your top surgery letter with a little more info and to say bottom surgery. They can usually do this in one visit.
$$ hopefully they are in network. Some assholes charge additionally for the letter. Check with your potential surgeon to see if they have a guide for letters they need, just so it doesn’t get rejected.
Second letter is usually the one from the PhD psychologist who does an evaluation on you. This is also bullshit. But until we dismantle it, get it. Schedule one appointment for this, and they should have a letter about it ready within a couple weeks. It’s gonna suck to wait on their slowpoke molasses Sunday Driving.
You usually also have to prove you’ve been on hormones x amount of time, unless you declined HRT. This also trips us up if we have been getting it from friends illegally, stretching it out longer than we should because of price, or have needle issues and procrastinate the dose.
They’ll take your bloodwork results over time for T. Or, they can use your pharmacy records to show you bought T consistently. God, this is making me angry all over again. We are the only patient population of all other conditions subjected to this level of scrutiny and distrust.
Have everybody send you the records and send them in yourself by email scans. You do not want them to say they “faxed it but the surgeon never got it.” It takes the hospitals a while to approve your letters and get back with a consult date.
Waiting and waiting for consult
Squirrel away as much money as you can waiting. This is when people work a second job, hustle, odd jobs, doing what you gotta do. Use a flight prices app to start watching trends on the place(s) you want to go to consult.
Eventually you’ll get your consult date, maybe after phone intake. Get your questions ready. Read what Gaines wrote on his site, HealthyTrans, with suggested consult questions and materials to bring.
On a shoestring: fly ultra budget airlines. I paid $27 one way for a flight departing at 6 am and getting back at 10 pm. I wasn’t about to get a hotel, so I got on Spirit! Now, I got zero extras. It was uncomfortable. But I made it.
On a shoestring: find out how to use the bus system there and how you’ll get from the airport to the surgeon. Get your transportation card at the station. Or, if you’re in a hurry, have cash ready or the cab app already on your phone. Suggestion: a good charger bank.
After consult you’re waiting for a surgery date. Keep on with your hair removal and your reading the experiences of people who have gone through this or are also about to. Build intentional relationships of support. Don’t forget to nourish your partner-relationship, because you do NOT want a horrid breakup or divorce right before surgery. This is going to be quite a lot on your plate soon. Kick ass at your job, because you want this fresh on their minds while you’re out.
Buy your plane ticket. I also recommend Southwest, if you can, since you can change dates for free in the event of a reschedule.
Start getting together information and forms about FMLA, short term disability, long term disability, hospital indemnity which you purchased ideally over a year ago. Do FMLA stuff and get the paperwork ready about one month before your surgery.
This can be done at your general practitioner cheaper than with the surgeon, usually about a month out. Ask the surgeon’s office manager or nurse for a list of which blood and urine tests you want your family doctor to give you. They may or may not have the EKG or Xray ability. Get a referral for this if they can’t do it so you can knock it out. If you’re traveling, scout for a local urologist who is willing and able to coordinate care when you’re back home. I asked my queer friends and the center that specializes in HIV management to recommend some people I could confer with about all this. We found a talented fellow with no trans experience but an eagerness to help. My general doctor committed to help with general wound care advice.
Book the place you’ll stay. Maybe it will be an app-based room or apartment rental. Sweet baby Jesus, I am so glad I rented a whole apartment for when I got discharged from the hospital. $50ish a night, booked for 6 weeks. You’ll qualify for the monthly rate. Look for elevators, washer dryer. In stage 2 for my scrotoplasty, I stayed in a humble basement apartment for $17 a night. Another time a got a houseboat for $60. I had so much fun with it. I stayed very close to the outpatient center, for ease of bus or cab.
Make sure your leave paperwork is in. Use legal insurance or online forms to prepare a living will, advance directives, and medical POA. After it is complete, email to the surgeon’s office.
Your surgeon is probably turning in your pre/authorization and your letters to the insurance.
More waiting gameDo not overpack! It is too hard to move luggage later on if you’re on your own.
To be continued 🙂