Note: This blog is 18+ and graphic. However, this post will have no adult content so that it can be shared freely. There may be NSFW images in the related post suggestions at the very end of the post.
I see a lot of people trying to figure out how to balance the demands of ordinary life with the demands of phalloplasty. This surgery requires many weeks off work or school. I have been seeing more often the question of how to balance bottom surgery with attending college.
I had bottom surgery while attending college myself, so I learned a few tricks to navigating this. I’d like to share them and help more people find out how to have phalloplasty during college. You’ll need to consider your surgeon’s staging, where you’re getting your coverage, and the tools for medical withdrawal and medical leave. Figuring out college and bottom surgery along the way was stressful, and I think it will help the process go more smoothly to give these elements serious consideration ahead of time. If you’re savvy about it, you can have your cake and eat it, too.
How many stages?
You need to know that phalloplasty is usually don e in two or three stages. Whether it is two or three stages depends on the surgeon. A few examples, Dr. Devin O’Brien-Coon in Maryland performs phalloplasty in three stages. Rachel Bluebond-Langer in New York has more stages. Chen-Safa-Watt are a two stage group. Should you try to go to a surgeon with fewer stages, to be compatible with school? No. You should not select your surgeon just based on having fewer stages, because condensed staging increases complication risk, which can lead to a revision or repair stage or more time needed for recovery. However, two stages is the most common, and almost everyone has a complication of some kind or another. Most resolve with time and a little help from your doctor.
What are Dr. Coon’s stages, times required to be in Baltimore, and times off school/work?
Dr. Coon has this pattern for staging:
0 – Hysterectomy, which must be completed a minimum of three months before stage 1. Dr. Coon does not require hysterectomy if you do not want to have vaginectomy.
Stage 1. Phalloplasty, that is, the formation of the penis with nerve hookup; split thickness graft taken to cover the donor site. Requires minimum 6-8 weeks off work or school. Requires 6 weeks living very near Johns Hopkins
Stage 2. A minimum of three months after stage 1; Scrotoplasty, glansplasty, vaginectomy, burial of the tdick, hookup of the new urethra to the old urethra [whichever of these you need]. Requires minimum 3-4 weeks off work or school. Requires 2 weeks living very near Johns Hopkins
Stage 3. A minimum of nine months after stage 2; Erectile implant and testicular implant(s). Requires minimum 2-3 weeks of work or school. Requires 1 week living very near Johns Hopkins.
These minimums are given imagining there are no complications and imagining you feel up to getting back to things. You know how after hysto, they recommend 3-6 weeks off? But some people feel up to work in a couple days, if they have a chill job, and if you take it easy, you’re good. This schedule is not like that. These minimums are really the minimums. You could not go back sooner. An example after stage 1, Dr. Coon has strict restrictions like no bending at the waist and no sitting, for six weeks. You can’t go back to work or school like that. Your mind will be in a foggy place– not because of pain medicine, but because your body will have directed all of its resources toward healing these major wounds. One exception to the above is if you live within an hour of Baltimore, that they may not require you to live near the hospital during recovery weeks. Also, the staging can be more spread out, but it can’t be faster.
Staging and the Plan Year
So, what does that mean? Here’s a hypothetical staging–
Jan. 1, stage 1
April 1, stage 2
December 31, stage 3
Actually, that would be a dream come true staging financially, for someone using commercial insurance. The plan year is usually Jan. – Dec., so you would only have to pay one out-of-pocket maximum instead of two. It would cut medical cost to you in two to be in the same calendar plan year. Important: If you are using your school’s insurance, your plan year will likely be something like September 1 – August 31 rather than Jan – December. Check on this! To get that translated to a school insurance plan year–
Sept. 1, stage 1
Dec. 1, stage 2
Aug 31., stage 3
So if your plan out of pocket maximum is $5000, if you keep all surgeries within the same plan year, you would be billed $5000 for all of these surgeries and everything else the year medically is free, paid at 100% by the insurance company. If you have surgery in two different plan years, your total costs would be $10,000.
This advice will save you a lot of money. Try to get a surgery date as close to the beginning of your plan year as you can, to the day, to save 50% of your costs, even if it means waiting longer to start.
School-offered Health Insurance
Most people don’t know your school-offered insurance will continue between terms. You can use it while you’re on medical leave from classes, too.
Buying insurance from your college is often a great value, cheaper than commercial insurance. You will want to compare your commercial options to the insurance offered by the school. For me, my work’s insurance did not cover phalloplasty, nor did my spouse’s, but the college’s insurance did. If you live in an equality state, where transgender coverage is mandatory, you will be comparing the out of pocket costs on the insurance policy to figure out which one makes the most sense for you. Factor in commercial monthly premiums and the max out of pocket; for school, factor in the cost of one year of coverage and the max out of pocket. I had to call the school and find out who offered the plan and to learn if trans stuff was covered.
Tip: If you can’t get trans coverage in your home state or country due to discriminatory exclusions, enroll in an online college in an equality state. The online college’s health insurance will be inclusive of transgender benefits. This will always be cheaper than trying to buy bottom surgery out of pocket. Do not despair!
Remember to call the college to find out how many hours you have to be enrolled to purchase the insurance. Is it purchasable for students enrolled less than part time? Only for full time students? Enroll in that many hours.
Withdrawals, Incompletes, and Accommodations
Plan a Medical Withdrawal
You do not have to choose between school and bottom surgery. Schools have systems for medical leave and you staying a student. If you were suddenly sick or needed a major surgery during college, you would be able to take a medical withdrawal from classes. This means you would contact your professors that you have a serious medical condition that needs care, contact your student life office, and find out the procedure for medical withdrawal. Then, you would provide medical documentation to the college administration.
Phalloplasty is no different. I strongly advice you do not disclose the leave is for phalloplasty. It isn’t that it wouldn’t be allowed, but it opens a floodgate of microagressions from people who don’t think this is an urgent medical need. Most people think phalloplasty is something you just sign up for, not something that you take your date for when you can after years of waiting lists. They think you should take care of it over the summer or something, and some people will think you are a less serious or committed student for doing it during your schooling. Like keeping this a private from your employer, it opens up the chance for them to say this is cosmetic surgery and then you have to battle that. We have standards for medical necessity, per WPATH, and we meet the standards for medical necessity. Therefore, you have a medically necessary reason to take medical leave.
Your transcript will say W, withdrawn, or perhaps M for medical withdrawal. It will not impact your GPA. You will not have tuition reimbursed, unless it is very close to the beginning of the semester. If you withdraw soon enough, they may not put the W or M on the transcript at all.
Your downside is that the tuition will be a loss, and you will have to take these classes over again. It may add to your college loan debt. That’s why I recommended you not enroll in more classes than you absolutely have to that semester to get insurance. If you are in a tracked cohort, you can say that you have some personal business going on and ask if you can reduce your load this semester.
When to withdraw? To have it be a medical withdrawal, you need to be about to have surgery– that is, unless you have another medical condition for medical withdrawal. It depends on what you want to get out of the class. If your surgery is scheduled more toward the end of the semester, you can take the class for practice for when you will have to take it again, and it will be easier later when you take it post-op. You can build rapport with the faculty and classmates. If your surgery is nearer the start of the semester, you won’t have to do the work and can focus on preparations for surgery.
Medical withdrawal does not automatically enroll you in medical leave. It is important to initiate medical leave. While you are on medical leave, your insurance benefits will continue, despite not being enrolled in classes. You do have to pay for this extended coverage.
Medical leave is the key to keeping your school-offered coverage while you’re not an active student. It also keeps you from having to drop out. Since the year 2011 in the USA, it is the law that colleges must offer insurance to students on medical leave for ten months following the end of that most recent semester.
Example: Phalloplasty date is November 30, W taken. Student insurance would normally terminate the next semester, but on medical leave, you can pay for their insurance to continue January 15 – October 15.
Be prepared to pay ten months of premiums at once out of your pocket out of savings or on a credit card.
Plan to end leave to enroll in the semester when the insurance coverage would have ended.
Example: The ten months of extended coverage will end October 15. End medical leave right before the fall semester starts. Sign up for classes the fall semester and refresh your student insurance policy.
If you are not using the student insurance policy, the medical leave is valuable for getting extended time off.
You have another option besides withdrawal from classes. You can take an Incomplete. You might want to do this if the class is almost over, you were so close to finishing it, and you were going to get a good grade. This is a little dangerous, however, because you have to finish the work before the end of the next semester, or it turns into an F. A big fat F on your transcript for all of those classes, and in many colleges, this is grounds for dismissal from the college. However, if you can swing finishing it, you will save a lot of money in the form of your tuition.
I recommend extreme caution taking an I, because of the risk of getting a complication and being unable to complete it. Anything could happen during or after surgery which could make it difficult to impossible to finish your work after stage 1. Don’t underestimate how utterly exhausting recovery is, when your body is allocating all resources to healing, even months later when you’re back at work and so on. I recommend taking a longer medical leave than not, to give you room to breathe. This is not a time to worry about your expected graduation date and coursework– it is a time to focus on healing.
Yet, I want to allow for the possibility that there may be circumstances when it does make sense to take that Incomplete instead of Withdraw, like if your stage 3 implant surgery happens right at the end of your semester, and you’re likely going to bounce back to your old self in a month or two, provided there are no complications.
Requesting Medical Accommodations
There is another option available to you. You should take advantage of registering your diagnosis of gender dysphoria with the disability office, so that if you need an adjusted coursework schedule around medical events, the professors will be required to offer this to you. Warning: You will have to out yourself, which may go better at progressive schools and could go horribly at conservative colleges. If your school if conservative, it may be better not to get formal accommodations and to work directly with the professor about a “serious medical issue” in a vague way.
An example of medical accommodations while in class, let’s say that you had to spend three days traveling for consult during the midterms week. You can use your status as a person trying to have a medically necessary procedure as a reason for having your midterm date adjusted earlier or later than the rest of the class. You can request to turn in work early before your surgery date, to complete the class early. You can develop an adjusted deadlines schedule for yourself for the entire semester if you need it, due to intermittent fatigue following return to school.
During recovery, especially after stage 2, you may notice some days you will have energy and feel almost yourself, and some days you have none at all to do anything besides eat a little, move when absolutely necessary, and sleep. Medical accommodations are required to help students with medical needs be successful, and we should ask for them when we need them.
Keeping Your Business Your Own
I would counsel you keep your medical plans as private as possible around your program. You might think it would be a good idea to talk to your advisor or chair about having three stages of surgery coming up and how to plan them around the program, but once they know it is a trans thing, or if they guess it is, there are a lot of opportunities for them to behave inappropriately. In my experiences, it is better to say less than more. You can speak frankly with the person in charge of medical accommodations for the college, but make sure they know you do not discuss with professors etc. the type medical situation you are experiencing. If you are at a potentially hostile organization, know that Johns Hopkins can word the medical documentation for leave extremely vaguely, either about microsurgical repairs, grafts, or urological need. Even when providing medical information, you can still be vague.
If you would like to talk about your healing with friends on social media, develop iron-clad filters for the audiences so that coworkers or college contacts will not get to observe this. I am an unusually open person, but in my experience, it invites gossiping and pettiness in these professional circles. You will eventually return to school with a sleeve over your donor area, and a few people will know what that means. That’s okay. You can create private groups to share healing updates, or you can make a blog which is anonymous like this one, to share ups and downs somewhere.
Many people will ask you what was wrong, how you are, and what happened. Practice saying, “I’d rather not talk about it.” I asked my union legal representative what to say to my boss when she asked how I was feeling. She suggested the answer, “I’m doing well, considering,” and no other information. You will encounter ableism and intrusive questions. If you are not good at setting boundaries, practice your answers in role play by yourself or with a friend. Children, in particular, ask frequently about what happened to my arm. My arm has healed very well, but the skin texture is slightly different, and there is no hair. Some people find it fun to make up fantastical reasons to tell children about dragons or sharks, which indicates to adults around that you are not open about it. Sometimes I give a boring answer which doesn’t invite more conversation, like “I had a skin graft.” (Why?) “I needed one.” (Why?) “It was a medical necessity.” They usually stop asking if you have not already set the boundary about not discussing it.
As bottom surgery coverage has recently expanded, as transition age has become younger, and as phalloplasty outcomes have advanced in quality, it is leading more college students to make plans for bottom surgery while still in school. Utilizing accommodations, medical withdrawal, and medical leave, you will not have to chose between college, keeping insurance, and having bottom surgery. If you’re lucky, you will be able to plan your stages in the same plan year, or at least to overlap with planned time off in breaks from school. Combined with utilizing FMLA and work-offered disability pay, you can remain employed, financially solvent, and an active student until you are ready to come back.