Approximately half of those men were interested in a phalloplasty, the surgical creation of a penis using tissue from elsewhere on the body. The other half were interested in a metoidioplasty.
What Is Metoidioplasty?
Metoidioplasty is the creation of a phallus (penis) from the hormonally-enlarged clitoris. The clitoris naturally enlarges when a person begins to take testosterone. During a metoidioplasty, the clitoral ligaments are detached, which allows the clitoris to lengthen and drop into a position similar to that of a natal phallus. On average, the created phallus is between 5 and 7 centimeters long, which may or not be sufficient to penetrate a partner sexually. (Depending on the individual, this is not always a concern.) A plastic surgeon then sculpts the head of the clitoris to more closely resemble the glans peniAt the same time, the labia can be reshaped into a scrotum (scrotoplasty), with or without testicular prostheses. Metoidioplasty can be done either with or without urethral lengthening procedures. Urethral lengthening extends the urethra along the new phallus. Then, one is able to urinate from their phallus. However, urethral lengthening does increase the risk of surgical complications. These complications can include dribbling or spraying during urination, urinary blockages, or a fistula (a leak or rupture of the lengthened urethra). Metoidioplasty is usually considered to be a single-stage surgery. However, some people may require additional surgeries in order to achieve their desired results. Additional surgeries may address either appearance or function.
What Is Phalloplasty?
Phalloplasty is the construction of a neophallus or reconstruction of a penis. This procedure is used to create a phallus in gender confirmation surgery. It is also used to repair the penis in cases of trauma, cancer, congenital defects, and other issues. Phalloplasty requires multiple surgeries to complete the process and can result in numerous complications, although most of them are relatively minor and fixable. The surgery has decreased in frequency in favor of metoidioplasty, which is a more recently developed procedure.
Metoidioplasty vs. Phalloplasty
There are advantages and disadvantages to both metoidioplasty and phalloplasty. It’s important for trans individuals to discuss their interests and priorities with their surgeon during the early consultation phase. Many people who choose metoidioplasty are happy with the outcome of their surgery. However, depending on surgical goals, as well as body composition and structure, it is not always the best choice.
Potential Benefits of Metoidioplasty
Some advantages of metoidioplasty over phalloplasty include:
Erotic sensitivity of the clitoris is maintained in the phallus.It has lower complication rates and requires fewer procedures, even with urethroplasty.It does not result in large scars that may be considered stigmatizing. The scars left by the most common phalloplasty technique (using a skin flap from the arm or groin) are large and recognizable to anyone who knows what to look for. For some, that is not an issue. For others, it may be a significant drawback.Metoidioplasty usually has a slightly lower risk of complications than phalloplasty, although both procedures have high frequencies of side effects, most of which are relatively minor.Metoidioplasty is usually more affordable.This procedure offers a shorter healing time.The phallus created by metoidioplasty has natural erectile function, and there is no need for a penile prosthesis.
Potential Benefits of Phalloplasty
Some advantages of phalloplasty over metoidioplasty include:
Patients are more likely to be able to sexually penetrate their partners, although erectile rods are needed to achieve an erection.The phallus is significantly larger than those created through metoidioplasty, although the drawback is the lack of erogenous sensation.Some people feel that this surgery creates more natural-looking genitalia.
Phalloplasty After Metoidioplasty
For transmasculine individuals who initially choose metoidioplasty, it is possible to later undergo a phalloplasty. This is true regardless of whether the person decides to have a urethral lengthening at the time of the procedure. However, the reverse is not true. The procedure for embedding the clitoris in the penis during phalloplasty makes a later metoidioplasty not feasible.
Associated Surgeries
Transmasculine people seeking bottom surgery may also choose to undergo one or more associated surgeries as a part of their gender affirmation process. Common related procedures that some transgender men choose include the following:
Hysterectomy and Ovariectomy
Trans people who do not have any interest in carrying a pregnancy may choose to have a hysterectomy and ovariectomy. These procedures are abdominal surgeries used to remove the uterus and ovaries. Hysterectomy and ovariectomy are also options for individuals who do not want a phalloplasty or metoidioplasty but also do not want to worry about the possibility of cervical, uterine, or ovarian cancers later in life. Removing the uterus, cervix, and ovaries also eliminates the need for gynecological screening. Such screening can be dysphoric for transgender individuals, especially for trans survivors since trans people are more likely to experience sexual assault.
Gamete Banking
For individuals who want to preserve the option to have their own biological children but would find pregnancy dysphoric, gamete banking is an option. This needs to be done prior to ovariectomy and hysterectomy. Ideally, it should also be done before starting testosterone therapy, but that is not a requirement.
Vaginectomy
Vaginectomy is the surgical removal (or closing up) of the vagina. Some surgeons who offer phalloplasty and/or metoidioplasty will offer this surgery as part of a single-stage reconstruction. Others prefer patients to have a vaginectomy in advance if that is something the patient wants. Of note, some surgeons who perform transmasculine bottom surgeries do not offer vaginectomies and advise against them because of concerns about complications. More research needs to be done to establish the risks of vaginectomies. The outcome of such procedures is likely closely related to the skills and experience of the surgeon. Outside the context of gender-affirming surgery, this procedure is primarily used to treat certain types of gynecologic cancer. As such, some plastic surgeons may refer patients interested in vaginectomy to a surgical gynecologist.
Scrotoplasty
Scrotoplasty is the construction or repair of the scrotum. This procedure can be done on its own or as part of a vaginectomy. The scrotum is created out of the labia majora of the vulva. Sometimes, multiple procedures are required to stretch and grow enough skin. Silicone prosthetic testicles can then be inserted into the newly formed scrotum.
Weighing Surgical Options
It can be helpful to discuss your goals and concerns for surgery with someone who is knowledgeable about the risks, benefits, and likely results of the various options. This could include not just your surgeon but your therapist or friends who have gone through a similar decision-making process. There are online groups on some social media websites dedicated to gender affirming surgeries where trans people post about their experiences. Such groups are also good spaces to find community and to also get recommendations or warnings about specific surgeons from their patients. Transbucket, a site dedicated to trans people informing each other about gender affirming procedures, is also another option. However, remember that different people have different preferences and motivations.
Finding the Right Doctor
It’s important to note that the procedures offered by a particular surgeon may not be the ones you want. If that is the case, consider seeking out other options to find a doctor whose perspective and surgical practices align with yours. It’s never a bad idea to consider a second opinion, although getting one is not always a practical option. There are many areas of the country with no surgeons, or only one surgeon, performing these procedures. Some of surgeons do offer phone or virtual consultations, but be aware that you may have to pay out of pocket. The cost may not be reimbursable, and you may need to demonstrate your surgical eligibility before they will discuss your case.
Insurance and Eligibility
Eligibility for insurance coverage is usually provided in the form of a letter from your hormone prescriber and one or two letters from behavioral health professionals. Eligibility guidelines for genital surgeries generally include documentation of gender dysphoria, a minimum of 12 months on hormone therapy, and at least a year of living as the gender you wish to surgically affirm.
Other Factors to Consider
What additional surgeries people choose are a matter of individual preference. However, the recommendations of their surgeon and the type of phalloplasty or metoidioplasty they choose will also impact these decisions. For example, a surgeon who uses the vaginal lining to create the urethra in a phalloplasty will probably advise the patient to undergo a vaginectomy either prior to or at the time of that surgery. On the other hand, a transmasculine person who wants to maintain the option to carry a pregnancy would not want to undergo any of these additional procedures.
A Word From Verywell
Decisions about whether or not to undergo gender-affirming surgeries are a personal choice—this includes both whether you want surgery and which procedures may be right for you. Doing your research to explore all of your surgical options, insurance coverage, recovery times, and potential doctors will help you make the best plan for you.
