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Kant et al. Plast Aesthet Res. 2026;13:4 Page 13 of 20

Staged procedures
These complexities are further elevated for those undergoing staged procedures - whether planned or due to
a complication. A behavioral health professional can help the patient understand the rationale for the staging
and offer support through extended periods of liminality, during which the body has already undergone
alteration but surgical goals have not yet been achieved. While not unique to such procedures, this
experience may be most prolonged during masculinizing genital reconstructions that also involve urethral
lengthening. These procedures may be performed in multiple stages, and even theoretically “single-stage”
procedures can involve extended healing periods - for example, when an individual is managing a
suprapubic catheter that will later need to be removed. It may also be helpful to show things such as catheters,
wound vacs, and drains to patients during consultation, as people often struggle to conceptualize what these
are or how they will affect their lives without seeing them in reality.

These liminal periods can cause people to have complicated feelings about their bodies and the experience of
moving towards their anatomical goals. They can be intensely frustrating and lead to feelings of needing to
leave one’s life on hold that may end up affecting decisions about later surgical stages - such as whether or
not to undergo a prosthesis insertion after healing of the neophallus is theoretically “done.” Staged
procedures may also involve unanticipated delays and require patient flexibility - for example, if a surgeon
leaves a practice or there are changes in insurance eligibility - which may necessitate more intensive periods
of support.

SUPPORTING THE WORK OF RECOVERY
Many individuals also experience difficulties when they come down from the initial rush of having achieved
their surgical goals to the reality of how long it takes to recover from these surgeries and start to get back to
“normal” life. Patients after phalloplasty and metoidioplasty often need to urinate through a suprapubic
catheter for a period of time, which may require social planning as well as discussions about workplace
adaptations. Behavioral health providers can help patients cope with this uncertainty, which may persist for
an extended period, and assist with brainstorming solutions to practical problems outside the medical sector
- such as how much to disclose to a supervisor regarding the reason for an accommodation.

Individuals who have undergone vulvovaginoplasty often express concern about the visual appearance of
their genitals in the early months after surgery, particularly regarding asymmetry and swelling. These
concerns may resolve over the first year of healing, but they may also reflect a limited awareness of the
natural diversity of vulvas. (Notably, this lack of awareness is also common among cisgender women and
healthcare providers [92-94] .) Showing images of diverse bodies can be helpful, as can emphasizing that the
tissues will continue to heal and settle over an extended period.

After vulvovaginoplasty, many individuals face challenges with dilation, due both to potential physical
discomfort and the need to reorganize home and work schedules to accommodate this intimate activity.
Behavioral health providers can support individuals in multiple ways - by helping develop coping strategies
for physical or emotional discomfort during dilation and by providing practical guidance for advocating for
necessary accommodations in the workplace . As described above, this may be particularly difficult for
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individuals who have experienced physical or sexual abuse and who, while happy with their new genitals,
may have difficulty caring for them in the ways needed after surgery. Ideally, behavioral health providers will
have helped patients address these concerns and complete some necessary work prior to surgery. After
surgery, they can remind patients of their coping and recovery plans. Pelvic floor physical therapy can also be
very helpful in these circumstances .
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