The Cost of Bottom Surgery

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For the cost of the author’s phalloplasty, he could have bought 86,153 cucumbers.

Among some communities of trans men, the sentiment that getting phalloplasty is an impossibility is fairly common. Between the high risk for physical complications and financial burden, it’s no wonder many guys who want bottom surgery don’t get it. After getting phalloplasty myself and dealing with the medical and financial complications, I found the financial aspect of the surgery more difficult than the physical. The only way I could afford this surgery was by limiting my income so that my surgeries were covered by Medi-Cal.  It’s kept me from marrying my partner, progressing in my career, and building savings. These sacrifices are amplified by the physical journey of now having a working penis. You’d think after so much sacrifice and hardship I wouldn’t recommend this surgery to those who want it, but you’d be wrong.

For those uninitiated, phalloplasty is the kind of bottom surgery which aims to give the patient a life size, workable, and realistic penis. It takes a large square of flesh, often from the forearm or thigh, and grafts it into a tube shape over the natal genitalia, where a plastic surgeon fashions it into the likeness of a penis. A phalloplasty can be made to enable standing to urinate, penetrative sex, and other similar functions.

If one wants to stand to pee, then the entire urethra gets lengthened, and that’s where a majority of the complications lie. If someone wants to have sex without the aid of external prosthetics, implants are placed inside the new organ. Each ‘feature’ requires an extra surgical step, and with every step comes the possibility of complications, some of which are treated with simple antibiotics and patience, while others require surgical intervention.

I knew I was prone to complications from my experience with top surgery, but I wanted a penis that could do everything a cis penis could do. I jumped in with both feet. I had to get electrolysis hair removal on my arm for over a year before surgery, going in weekly for two to three hours to a nice lady who would take a hot needle to every follicle on my arm. This was so that I wouldn’t grow hair in my new urethra and so that my new dick wouldn’t come out looking like a hairy caterpillar.

After electrolysis, I went to the surgeons. Both a urologist and a plastic surgeon were a part of my team, so I had to drive out to meet with both teams several times for various consultations and check-ups. Early on I realized that if I had a nine-to-five job I would have lost it before I ever had a chance to have surgery. My surgical team was two and a half hours away from my home, and my trans affirming primary care was an hour away. My electrolysis lady was an hour away, and none were in the same direction. I was averaging one day a week that I would have to take off work to get surgery rolling. When I figured out a rhythm to seeing my electrolysis lady after work, I was able to get a job that claimed to be amenable to my sporadic attendance. Then, during the summer of 2024, I got the surgery. 

I had more complications than what is statistically likely for this surgery (Radial Forearm Flap graft urethroplasty can expect 53.3% likelihood of complications according to this study).  I wasn’t surprised when I had a hole that urine leaks from, called a fistula, but having seven was virtually unheard of. After three different surgeries, they all healed. Then came the strictures, which made it so I couldn’t urinate at all. I had surgery for that this week, and since this was an urgent issue I had to drop everything to get it fixed. 

When I started having strictures my flexible job could no longer accommodate my frequent absences, and I had to go back to temp work, which was a significant pay cut. When I look back on my phalloplasty experience, all I can think is: “how the hell does anyone afford this?” Electrolysis was covered by my insurance, but for many trans men it isn’t. The average session of electrolysis costs $75 dollars an hour, sometimes more. This can add up to thousands of dollars, and that’s before the cost of surgery even enters the picture. Every single surgery I had was necessary to repair complications, but if I had to pay even the copays for all of them I would be in serious financial trouble.   

For comparison, I talked to a guy who got the same kind of phalloplasty as me from the same surgical team who had insurance. His insurance did not pay for electrolysis, he paid $3,600 dollars for that. After the initial surgery, a revision, and an emergency hospital stay he owes $8,500 to the hospital. He is lucky enough to live in the same city as his surgeon, so he didn’t have to pay for a place to stay while he recovered or gas to travel extensively. Many trans men have to temporarily relocate to have this surgery due to how few surgeons perform it, adding to the already daunting costs. According to a study from the National Library of Medicine that was published in 2022 “ the median total cost was $148,540” out of pocket for phalloplasty without insurance in the United States. If you’re an American reading this you might be jaded hearing the obscene cost for medical procedures, but to many trans men, these costs are why they don’t pursue gender affirming surgery.

I think the financial aspect of phalloplasty is one of the biggest barriers. I see on the online message boards people living like monks, saving every penny and living in questionable situations so that they can save up for phalloplasty. Without insurance, many save thousands of dollars to prepare for surgery, for housing needed to be close to surgeons during recovery, and additional medical supplies like bandages. I know I can’t be the only person who lost income and job opportunities due to the medical emergencies that come with phalloplasty. 

While it’s true that this is a high risk versus reward procedure, the financial implications attached to the physical complications compound the existing strains the preparation and initial surgery put on one’s finances. If we are to make this an accessible surgery, the financial barriers must be lifted. A more socialized healthcare would alleviate the financial stress and would be a great help to the trans male community. Having the state’s help kept me from truly losing all financial stability; others deserve the same support.

 

Emmitt Barnes is a writer and artist from Southern California. His work has appeared in Skateism Magazine and Backstory Journal.

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