I wish I had a less boring answer for this one, but the long and the short of it was: starting a savings account and adding to it every week, even little bits at a time if that’s all I had, for a little over seven years. It really does add up over time, and if I *could* add more in a given week, I did, all that I could.
This last year (since November 2014 or so), I had an added leg up thanks to getting insurance through HealthPartners, which allows for phalloplasty if they deem it medically necessary. Though I wish I could say that part was more help than it ended up being; I battled with them all the way from the start through the last weeks before surgery trying to get them to accept it as “medically necessary,” and again to have the surgery be counted as “in network,” as paying the out-of-network costs literally would have bankrupted me.
(Fun fact! It takes an average of two “Can I speak to your manager"s before you can talk to someone who actually knows how something is determined to count as medically necessary.)