On October 8 2024, I underwent gender-affirming surgery in Germany. While not every trans woman chooses surgery – research from Planet Wissen suggests that fewer than half do – I’d always known I would. Since the beginning of my transition in 2012, it was only really a question of how and when. Knowing the decision was not to be taken lightly, it took me nine years to reach a place where I felt stable and secure within myself to finally undergo the irreversible surgery and move forward. Honestly, it felt like a big jump, but I knew it was right.
The decision came with its own complexity. I had expected to go through layers of deep emotional processing; after all, this was the final point of my transition and my body would change drastically. But I hadn’t expected it to be so gruelling. Even before the major postoperative complications I would go on to experience and the subsequent euphoria of finally pulling through, there first came a frustrating amount of bureaucracy. After all, it wouldn’t be Germany without it.
So, in April 2021, I took my first steps toward surgery.
A Geschlechtsangleichende Operation (GA-OP) for trans women can include a variety of procedures, the most common being a vaginoplasty. Over the last twelve years, the number of GA-OPs in Germany has tripled. According to Statista.de, in 2013, there were just over 500 operations, compared to 1,834 in 2023. This is not a huge amount considering the eight million people who call Germany home. Obtaining a GA-OP on public health insurance has several requirements. First, I needed to obtain a diagnosis of “transsexualism” or “gender incongruence/gender dysphoria” from a qualified psychotherapist or psychiatrist.
In reality, this meant I had to attend twelve fifty-minute sessions over a period of six months to establish the legitimacy of my gender identity and the need for surgery. I knew that finding a therapist who accepted public insurance, who was available and had experience with trans patients in Berlin would be difficult, if not near impossible, and this process took me nine months from start to finish. As a 41-year-old woman, having to justify my identity and existence felt frustrating, and I could see how this might deter some people from taking it further.
Luckily, I was fortunate to have already lived in my desired gender role for nine years, changed my name and legal gender marker on my passport and been on hormone replacement therapy (estrogen/anti-androgen) for years prior. This satisfied the second requirement: a “real-life experience” period of living continuously in the desired gender role, typically one year. Still, additional reports were required from an endocrinologist to confirm hormone therapy and from a urologist, through a physical examination, to verify that I was not intersex.
This was the final point of my transition and my body would change drastically.
With the majority of the paperwork underway, it was time to arrange consultations with surgeons. In Germany, there are around ten surgeons who offer various vaginoplasty methods, but only a handful who accept publicly-insured patients. Choosing a surgeon required research. I had to consider their surgical methods, the cosmetic and functional outcomes, feedback from previous patients, their location and waiting times. I had two consultations in Munich and one in Essen. During a consultation in Munich, the surgeon pulled out her phone and flicked through picture after picture of postoperative results, clearly thrilled by her work. When she’d exhausted one photo library, she pulled out a second phone and did the same again. I’d never seen so many vulvas in my life.
In the end, I chose the ‘combined method’ vaginoplasty with Dr. Jochen Heß at Universitätsklinikum Essen, primarily based on his surgical technique and my friends’ feedback. A close confidant told me she enjoyed the experience of getting wet during arousal, which the technique allowed, and that intercourse was very pleasurable, which swung it for me.
Dr. Heß performs 150 GA-OPs annually, with a waiting period of two and a half to three years. Currently, no surgeons offering GA-OPs operate in Germany’s capital, despite Berlin’s historical significance in their experimental beginnings.
GA-OPs trace back to the Weimer era, where Dr. Magnus Hirschfeld and colleagues performed the world’s first surgeries on Dora Richter and Lili Elbe. Hirschfeld’s pioneering work ended abruptly when the Nazis destroyed his Institute for Sexual Science in 1933. After World War II, Dr. Harold Gillies operated on Roberta Cowell in Britain, and Christine Jorgensen’s surgery in Denmark brought global attention. In 1956, French gynecologist Dr. Georges Burou developed the penile inversion technique (PIV) in Casablanca, still widely used today. In recent decades, refinements like sigmoid and peritoneal vaginoplasties offer greater depth and natural lubrication.
The “combined method” offered by Dr. Heß is a variation on PIV. He had assisted with GA-OPs since 2007 and performed them independently since 2012, learning the method from Dr. Schaff in 2016. The procedure occurs over two operations: the first removes erectile tissue and testicles, creates a neovagina, shortens the urethra and uses the glans penis to form the neoclitoris. The second operation varies but usually addresses functional or aesthetic issues. This method more closely approximates cis female genital anatomy in appearance and function. Unlike standard PIV, it uses scrotal skin and urethral mucosa alongside penile skin to form the neovaginal canal, ensuring adequate depth regardless of genital size and creating a naturally moist environment inside. Incidentally, Dr. Schaff now operates at Klinic Sassouci in Potsdam and accepts only private patients. In 2021, the cost was €23,290.00 excluding hospital stay and anaesthesia.
From the first therapy session to the day of the surgery, it had taken three and a half years. I couldn’t wait for it to be over.
So, I had finally submitted all my documents to my insurer. Now all I could do was wait. After months of gathering evidence, it was a tense time. I felt unnecessary anxiety regarding my case. I knew I’d submitted everything they needed, but what if they said no? I couldn’t bear that reality. Every day, I ran to my letterbox hoping for news. Finally, on March 8, 2022, I received confirmation that my insurance would cover the full cost – a message that arrived, fittingly, on International Women’s Day.
I forwarded it to Universitätsklinikum Essen and waited for a surgery date. Just under two years later, in late January 2024, they called. My GA-OP would take place on October 8. From the first therapy session to the day of the surgery, it had taken three and a half years. I couldn’t wait for it to be over.
Fast forward to the morning of the surgery and I’m waiting for the nurses to collect me and wheel my bed from the urology ward to the operating theatre on the floor below. The surgery is planned for 8 am. I’m the first one that morning and I’m ecstatic. The previous day, I’d met with the surgical team and we’d discussed every detail of the operation and all the possible complications.
I nodded my head, hoping for an easy recovery. As with any major surgery, complications arise and with vaginoplasty these range from 20% to 70%, the majority of which are minor issues resolved with simple management. Severe complications are much less common, but, of course, they happen. I understood the risks. I knew I would need to dilate my neovagina using various size dilators to retain its length and width whilst I was healing. I understood that would require a diligent schedule, but it still didn’t deter me.
On the way to the operating theatre, I felt pure relief. I remember going under. I remember the anaesthetist saying, “Sweet dreams.” And within a second of the mask covering my face, I was gone. I was woken up several hours later, groggy from the anaesthesia and given an ice pop to help revive me.
The first three days post surgery were arguably the worst – not painful, but definitely uncomfortable. My body became a surgical site. I lost all autonomy. I was required to lie on my back and refrain from moving around. Not that I could. The tops of my legs and genital area were numb from the pain medication administered through an IV in my lower back. On the fourth day, I was able to stand up and walk a few steps to the bathroom to brush my own teeth and pass a stool, an incredibly stressful moment due to the close proximity of the rectum and neovaginal cavity, and avoiding potential damage from pushing too hard. On day six, the packing inside my neovagina was removed and I dilated for the first time.
The next morning, I woke up lying in a puddle of blood.
The nurses took me to the acute emergency clinic, where the urologists quickly decided to operate. A blood vessel had ruptured inside the neovagina. I was losing blood rapidly. I was relieved by how swiftly the surgical team responded, but the experience was overwhelming. Rationally, I knew the hospital wouldn’t let me die, yet I had no idea how this complication might affect the outcome of my GA-OP. Lying on the operating table for the second time that week was terrifying. Fortunately, there was no lasting damage, but the days following the wound revision were mentally and physically debilitating. My haemoglobin level dropped to 7.5g/dL (compared to a normal adult range of 12–18), leaving me severely anaemic and weak. It took three days to be able to stand up by myself, and then incrementally, day by day, I regained my health.
Seventeen days after surgery, I was finally given the all clear and went home, supported by a devoted group of friends who cooked, cleaned and kept me company. I couldn’t manage daily life for nearly two weeks and I needed to rest; their care was invaluable. As a freelancer, I knew I would have to take some time off, risking financial burden, and I had to balance my recovery by slowly re-introducing professional responsibilities.
Six weeks after surgery, just as I was beginning to regain control of my life, I contracted my first UTI. I didn’t realise how serious it had become. It caused urethral meatal stenosis, a narrowing of the urethral opening that blocks urine flow. My bladder swelled painfully to the size of a small football: I was unable to urinate and in agony for days. A very attentive friend recognised the severity of the situation and escorted me to A&E, where I was fitted with a suprapubic catheter to drain my bladder immediately. The procedure, done under local anaesthetic, involved a large thick needle puncturing through my abdomen – still the most painful experience of this whole process. Looking back, that period, physically and emotionally, was undoubtedly the hardest of my life. Every day brought a new hurdle, and some days I honestly lost hope. When I was at my lowest, a friend said to me, “One day this will all be a distant memory” and it was the only thing that kept me going.
I needed the catheter for two months until my second operation with Dr. Heß was brought forward to 6th January 2025.
I was grateful to go back to Essen for the next operation. Not only would they fix my urethra and remove the catheter, they’d perform any needed cosmetic adjustments to the labia and clitorial hood. The surgical assessment alone (a doctor had to touch my clitoris and check its sensitivity) is definitely an experience I will never forget.
Just over a year later, I feel positive about the results, and since the final surgery in January, I’ve had no further complications. I would absolutely go through it all again for the peace it’s brought into my life. The surgery affirmed my gender, gave me a body I could fully inhabit and allowed me to move forward in a way I never could before. At the same time, my experience exposed the limits of gender-affirming healthcare with public insurance in Germany: long waits, few surgeons and complex bureaucracy make this journey inaccessible to many who need it. My story is proof that the system can work – but only for those persistent enough to navigate it. Ultimately for me, that is what being trans feels like: patience, resilience and the quiet but profound affirmation of living as yourself.
Follow Rhyannon on Instagram @rhyannon_styles.
