Metoidioplasty

Overview  

A metoidioplasty is a type of gender-affirming surgery that creates a neophallus, or new penis, using tissue from the clitoris, typically resulting in a length of 1.5 to 2.3 inches (4 to 6 centimeters). This procedure is often performed after at least one year of masculinizing hormone therapy, which involves the use of testosterone to induce physical changes such as a deeper voice, increased body hair, and clitoral enlargement. Other terms for metoidioplasty include bottom surgery, meta bottom surgery, female-to-male (FTM) bottom surgery, and clitoral release surgery.

Reasons for undergoing the procedure  

People assigned female at birth (AFAB) may request a metoidioplasty to align their physical appearance with their gender identity, helping to alleviate gender dysphoria. The surgery aims to create a natural-looking penis of sufficient length, allowing the individual to urinate while standing and providing sexual sensitivity, with the ability to achieve an erection without the need for a penile implant.

Risk 

All surgical procedures come with risks, such as:  

• Issues with anesthesia  
• Problems with healing  
• Infection  
• Scarring

Specific complications associated with metoidioplasty may include:  

• Urethral strictures  
• Unintended openings (fistulas) in the urethra  
• Urinary tract infections (UTIs)  
• Difficulties with sexual function, including dissatisfaction with erection quality, inability to achieve orgasm during masturbation, and challenges with penetrative sexual intercourse.  

Before the procedure  

To prepare for metoidioplasty, you’ll collaborate with healthcare providers for at least a year. Your preparation may include:  

• Physical examination: To evaluate your overall health and review your medical history.  
• Patient education: Engaging in discussions with your provider and reviewing educational materials to fully understand the risks, benefits, and post-surgical care requirements.  
• Mental health evaluation: A qualified mental health provider (therapist, psychiatrist, or social worker) will assess your understanding of the procedure, explore your reasons for seeking metoidioplasty, explain its impact on your life, and discuss your expectations. You will need referral letters from two mental health providers.  
• Hormone therapy: Undergoing testosterone therapy for at least one year.  
• Gender identity: Maintaining a lifestyle consistent with your gender identity for at least one year.

Additionally, you may receive health recommendations to minimize complications, such as quitting smoking.

Before undergoing metoidioplasty, you generally need to:  

• Document any known allergies you have.  
• List all medications and include both prescription and over-the-counter medications, as well as herbal supplements.  
• Discontinue blood-thinning medications, temporarily stop taking any blood thinners if prescribed.  
• Refrain from eating or drinking for eight to twelve hours prior to your surgery.

If you need to take certain medications before the surgery, you may do so with a small sip of water.  

During the procedure  

An anesthesiologist will first administer general anesthesia to ensure you are asleep and do not feel pain or any other sensations during the surgery.

Following this, the surgeon will use tissue from your enlarged clitoris to construct a penis. Depending on the approach taken, the procedure may involve:  

• Releasing the clitoris: Using a scalpel to cut the ligaments connecting the clitoris to your pubic bone, which is part of a simpler metoidioplasty.  
• Inserting a catheter: Placing a plastic tube into your urinary bladder and threading it through your neophallus to keep the urethra open.  
• Extending the urethra: Using tissue from your vagina or cheeks (buccal mucosa) to lengthen the urethra.  
• Enhancing the neophallus: Utilizing vaginal tissue to increase both the length and girth (circumference) of the neophallus.

The duration of the metoidioplasty can vary, generally taking between two to five hours, depending on whether additional gender-affirming procedures are performed simultaneously. 

After the procedure  

After the procedure, your incision will be stitched and covered with bandages by your healthcare providers. As the anesthesia wears off, you will gradually regain consciousness, though you may feel groggy. Your healthcare team will monitor your condition and manage any pain as you wake up. Once you’re stable and no longer require continuous monitoring, you’ll be discharged, typically after one or two days in the hospital. Healing from metoidioplasty takes time, and the surgery may be performed in multiple stages, with additional procedures often needed four to six months after the initial operation. 

Outcome 

One of the primary advantages of metoidioplasty is the significant relief it offers from gender dysphoria. Achieving a physical appearance that aligns with your gender identity can help reduce:  

• Emotional and psychological distress  
• Self-harm tendencies  
• Suicidal thoughts

The success rate for metoidioplasty is typically high. A 2021 study involving 813 participants who underwent the procedure reported consistently positive outcomes:  

• Nearly 80% of participants were fully satisfied with their results, while 20% reported being mostly satisfied.  
• All participants were able to urinate while standing.  
• All were satisfied with the sexual arousal capabilities of their neophallus.

Approximately one-week post-surgery, most individuals can walk and engage in light activities. However, it may take at least six weeks for many to resume their regular routines. Remember, recovery timelines vary from person to person, so it’s essential to follow your healthcare provider’s recommendations for managing any pain or discomfort.