FOR TRANSPARENCY, my name is Dex, these are just my notes from the top surgery letter

writing group I attended last week, and things I had learned in that space plus additional
personal commentary. Your mileage may vary, this is advice and knowledge from Californian
gender affirmation medical providers/workers from the clinic I attended, and I thought the
information was really valuable and I wanted to share and give folx access to what I learned too.
It is a lot but it is by no means a complete summation of absolutely everything you could know

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or experience going through these processes. It’s awful that we have to jump through so many
hoops, but I hope this can be helpful in some way to someone else who might need it

LETTER WRITING GROUP PROCESS

- normally you need 2 letters, one from a social worker and one from a therapist
(sometimes you can find a clinic/center like the lgbt center where this can happen in one
group session, which is what I did! It’s easier/more accessible, but if you aren’t
comfortable disclosing your info in a group session, it might not be for you—that being
said, my group was organized by folx going for the same procedures and had shared
identities and there were only 3 of us so it felt safer to me)
- if you go through a center, you can ask about the resources you have for support/getting
the care you need! Ask for phone numbers of the facilitators (your social worker and
therapist)
- The questions they will ask you are your ​name​ (they should clarify that they want your
legal name, but ask! I’m in the process of changing my name on all my paperwork but
was told as long as it’s in the system/ my social security then it’s fine. But ask!), ​age​,
insurance​, your ​doctor/pcp​ (primary care physician), what procedure you want done
(chest masculinization*, note on that below), ​are you on hormone replacement
therapy​ (are you taking t? it's okay if you aren't! people totally get top surgery without
hrt! ), ​how long​? ​when did you ‘know’/socially transition​, ​what do you do/what your
occupation is, do you smoke/ use substances ​(it’s best to be honest, but essentially
you have to be clean before surgery because they *will* take a lab)​, what does your
support network look like/ who is taking care of you/taking you home after your
surgery​?
- *be careful about the language you use when speaking to insurance
providers/receptionists/medical providers; *we* know what top surgery is, but they only
know it as “chest masculinization”. Even if you don’t see top surgery as a “masculinizing”
process for you personally, this is the binarist language we have to use to navigate
transphobic institutions. I was told this by my facilitators who have both navigated gender
affirming healthcare and insurance hell hundreds of times over.
- ASK THEM WHEN YOU WILL GET YOUR LETTER BY! Some people can get you your
letter that day, others will take longer. (ex: Mine will be sent out toward the end of the
month, so I’m expecting them to arrive in about 4 weeks to my address, but the center
will be submitting them to my insurance and doctor for me)
 - Come with questions you have about the process, and what resources you have
available through them, ask them if they have any surgeons they’ve heard good things
about from previous clients in your position. Take advantage of the opportunity to be in
space with people who have either gone through the process with other folx seeking top
surgery and care, or if they aren’t very knowledgeable, ask them what they will do to
learn to better support you. You deserve the care you need!
- Ex: ask what legal help you can get, ask if you will be connected with a medical social
worker so you can get time off, ask for contact information to trans care providers, and
also your therapist and social worker’s contact information if you have follow up
questions
- I learned a ton in my writing group and I personally was not very prepared but thankfully
my group facilitators were really helpful and chill and having other people in my group
meant I was able to listen in on questions they had.

AFTER GROUP/ GETTING YOUR LETTER

- right after group, if you haven’t already, CHECK OUT SURGEONS THAT MIGHT WORK
FOR YOU. It’s research time—get about three options you feel good about to ask your
pcp (primary care physician/ main doctor) to refer you to! Check their sites, check reddit,
check transbucket.
- EMAIL FORMAT: Hello Dr. X, today, DATE, I went to my letter writing group and I need
a medical referral for chest masculinization. Please address your letter to these three
surgeons:
- if it takes some time to figure out who you want to see you can also ask your doctor if
they have recommendations esp if they see other trans patients in this email instead
- call your insurance and see who is in network! even if you don’t like who is in network,
then you can ask for multiple memorandum—an exception to the network because it’s a
‘exceptional’ procedure. You SHOULD ask for who you Need and Want!
- You can even call the surgeon’s office to ask if you can get a consultation, saying that
you will get your letter in 2 weeks (if you don’t have it yet) or tell them the date it’s
expected by, and see if they will book you!
- Once you get your letters, definitely go right ahead and start calling your insurance (ask
for the trans care navigator, insurance companies are required to have them apparently)
don’t be afraid to be firm: where are the referrals for my chest masculinization? Have
they gone through yet? (remember, cis people don’t know what top surgery is)
- When you call, you will likely be passed around if you arent firm, and may be asked to
wait a couple days. DON’T WAIT FOR THEM TO CALL BACK PAST THAT TIME. Write
down Who you spoke to, the person who told you when to call back/ when *they* would
call back, and say it when you call. Ex: Hello, two days ago I talked to ______ and they
said to call back today and i want to know if my referral went through/ has been
approved
- this can sound pushy but if you leave this, insurance can take forever and can really
prolong the process from months to years so it's better to be a good advocate for
yourself and not let it slide!
 - don't leave space for transphobic shit, say 'okay can i talk to your supervisor?' if they
refuse to help you (I know, it's hard, but you deserve to advocate for yourself!)
- if calling is difficult/anxiety inducing, maybe ask a loved one to help you with this!

CONSULTATION
- have a LIST of questions: is anaesthesiologist also covered, how many chest
masculinization surgeries have you done, what happens if you mess it up, if i need a
revision, what is your procedure? what is the risk of losing my nipples? do you do 3d
tattooing or grafts, will you ask me to go off testosterone (you don’t have to, there’s no
reason to, it’s not like estrogen/ isn’t blood thinning, so if they require this, it may be a
red flag), will you ask me to do a mammogram? will you do drains? what are your
feelings about them/do you use them/why? how do you think my body will heal? what do
i need to do if things change or shift? what is your procedure? ask about cbd/ other
forms of pain management and options if that is important to you (cbd under tongue for
example) ask about keloid scarring shots, ask about keloids especially if you are a
person of color, they are raised hypertrophic scarring we are prone to getting. Ask about
silicone bandages! I've used them for my keloid scars for rejected dermal piercings and
they were magic.
- you might dissociate because they take pics of your chest, might send you to do a
mammogram, will look at, touch, and draw on your chest, be prepared mentally!
- write out your list of questions to be answered in writing so you can review it later! ask
them to read their response to someone who is there to support you as well! (esp helpful
if you are dissociated at this time)
- you can still say no! just because you went through your consult doesn't mean you
HAVE. to go with this surgeon.
- if the surgeon misgenders you, touches you inappropriately, treats you like shit, you say
NO and you file a GRIEVANCE
- if consult went well and you have a date, start prepping!

HOW TO PREPARE FOR TOP SURGERY

- prepare your house/environment, prepare everything to be accessible for a person that
has little arm mobility and reach! top surgery leaves u with ‘t-rex arms’
- declutter your space and make it sanitary and accessible because you won't be able to
clean anything post op
- you won't be able to wipe yourself so remember that and have button ups because you
won't be able to put on regular shirts, and forgo underwear/boxers because it won't be
worth it
- get maternity donuts and have lots of pillows to prop yourself up
- top surgery is an outpatient procedure! you’re in and out, so there shouldn’t be additional
costs for hospital stay
- it's a very simple surgery in the grander scope of things, most of it comes down to
aftercare
 - if you would like to work out for the 6 months before surgery, having the muscle
developed underneath can help the surgeon lay things out!
- they will pull your blood 3 days before so make sure to be clean for a couple weeks prior,
and also eat clean because anaesthesia and the painkillers will make you constipated so
you don't want anything super solid in your system because it will suck
- what are your coping skills? what can you do while you're recovering? line up things you
want to watch/do, set up a schedule with people to check on/ support you!
- write letters to yourself for post op to prepare yourself because you can feel
grief/sadness, can be from loss of hormones stored in your chest, and also from
painkillers and anaesthesia
- top surgery is 3-4 hours long. you Need a person to go with you, someone who can sign
for your release.
- you may experience anxiety and depression after, so prepare coping mechanisms and
support networks beforehand; ex: affirmations given to you, spoken or written by loved
ones
- who can say affirmations to you, do you need it from others or do you need them from
yourself? what works? prepare these beforehand!

POST OP TIPS
- medical binder is very very tight and horrible, remember to breathe. it is temporary but
necessary because it keeps everything together. some folx experience panic attacks
from not breathing, maybe make yourself a poster to remind yourself to breathe!
- any kind of smoking takes oxygen out of the system and makes it harder to heal, you
can lose nipples/cause complications because of this. Please exercise caution, I know
this can really suck
- every hour under anaesthesia is another month that it stays in your system; you may feel
weird/off/depressed after surgery. this is normal! read your letter to yourself, it's not
because you are feeling regret or you made a mistake
- you can get a therapist for after, that might be helpful
- it will not look the way it looks forever, and the healing will be a process. take care of and
baby your chest, it will be so so worth it i promise
- give yourself time to heallll. you dont want to rip your stitches and have to go through the
process all over again
- dont wait for your surgeon if you have weird discharge or are running a fever. if you have
signs of an infection, go immediately to urgent care
- you wont be able to drive for a while
- just because you feel okay doesnt mean you are all healed. just because you have a
high pain tolerance doesnt mean you are all better and can do whatever you want
because you can really fuck your chest up in the healing stage. just be safe.
- sensation returns at different times for everyone, can be 3 months, 6 months, a year. be
patient
- nipples can change color and skin can come off, but it doesn’t necessarily mean your
nips are coming off
- just take it slow! it will be worth it