Hi Anne Your questions are solid and you are correct that nobody but you and your partner will ever see your genitals so public visibility is not a barrier.
Why is genital surgery the last one?Genital surgery is not automatically at the end. The current WPATH Standards of Care Version 8 lists six readiness points: documented gender incongruence, informed consent, discussion of fertility, mental and physical health review, about six months of stable hormones when hormones are desired, plus at least one surgery letter with many surgeons still requiring two. They set no fixed order of operations, so once these points are met a person can move directly from hormones to vaginoplasty or phalloplasty without earlier face, chest or orchiectomy procedures. This is basically what happened to me.
My genitals are my main dysphoria elementThat priority is perfectly valid. Guidelines allow you to resolve your most distressing feature first once the readiness checklist is satisfied.
I have to go through other surgeries or more evident changes. But why?No rule requires earlier cosmetic or gonadal operations. The deciding parties are the surgeon, hospital and any insurer. Surgeons usually want at least one surgery letter that confirms persistent gender incongruence and decision making capacity plus basic health requirements. When those items have been satisfied, then a date can be offered even if you have not altered face, chest or legal documents.
HRT is lifelong after the gonads are removed so why not start with surgery?Removal of testes or ovaries leaves the body unable to make enough hormones. The body needs sex hormones regardless of whether they are testosterone or estrogen. Starting HRT before surgery shows that you tolerate the medication and that risks such as clotting or bone loss are controlled before replacement becomes absolutely necessary.
Legal ID seems to dictate everythingLegal gender markers can be changed before or after surgery in many jurisdictions and hospitals rarely treat them as medical prerequisites. Surgeons focus on clinical readiness not passport letters.
One year living in your gender role and professional certificationThe old twelve-month real-life rule disappeared in SOC 8. Some insurers or doctors still like evidence of social adaptation yet it is no longer universal. What matters most is informed consent, surgery letters and hormone stability.
Is there something else I am missing?Three practical items remain: at least one surgery letter (two if your surgeon or insurer insists); about six months of stable hormones, suggested unless medically exempt and control of modifiable risks such as smoking or uncontrolled illness.
I hope these points clarify in your mind what to expect or need to followThe pathway is simpler than it used to be and you can tailor the sequence to your needs.
Looking forward to surgery while enjoying the processI am Australian and my surgery was nearly thirty five years ago. When I arrived in Sydney I would have booked the operation straight away but I did not have the money and the requirements at the time mandated a two year wait. I had three surgery letters. I changed my life around without realising I was completing the real life rule, passed immediately with foam breasts and by the time surgery came around, my own breasts had grown.
No other surgery was ever considered. Once the calendar hurdle and finances were settled the operation went ahead and I have never regretted it. Your timeline can be shorter now that SOC 8 has trimmed requirements. Work with a doctor who follows the updated standards, obtain the letter or letters and genital surgery can be your first and only operation if that is what you want.
Ultimately it is up to the surgeon you choose who will tell you what you need to do before surgery can go ahead.
Update from your sideI am thrilled you have located a new doctor who follows the current guidelines and can review your needs even though the first opening is in September. Feeling excited thrilled and a little scared is perfectly normal. The detailed guidance above may seem redundant for your own path now, yet it remains useful for readers whose surgeons still work from the older protocol so I have left it in place for anyone who might need it.
Best Wishes AlwaysSarah BGlobal Moderator@Anne_lifetrip@Tills
