Sex Reassignment Surgery Female To Male

How can I access sex reassignment surgery?

Before pursuing SRS, particularly genital reassignment surgery, it is recommended that you reflect on whether the procedure is right for you, and the right time to pursue it.

The World Professional Association for Transgender Health (WPATH) suggests the following prerequisites:

• You have been diagnosed with gender dysphoria

• Surgery has been recommended by 2 mental health specialists trained in gender identity issues, preferably who have known the patient for more than a year

• Hormone treatment for at least one year

• Living as your gender identity for a minimum of one year

• Emotionally stable

• Medically healthy with any medical conditions being treated and under control

Your physical and mental well-being prior to surgery are vital to preparing for the changes that you will go through in the lead up to and recovery from sex reassignment surgery.

Physical readiness means you have considered the following and consulted a health professional throughout the process:

• Health condition: You should be healthy overall, but if you have any pre-existing conditions, they need to be discussed with your surgeon and healthcare provider to ensure they can be managed before and after surgery (for example diabetes or HIV can impact surgery, but not necessarily prevent you from having it).

• Pre-surgery physical requirements: You will need to have undergone hormone therapy for a minimum of 12 months prior to surgery, but will also need to taper off your hormone therapy use in the lead up to surgery. It could be necessary to undergo electrolysis before urethoplasty if using forearm skin to avoid hair growth in future.

• Post-surgery requirements: Do you have a safe, supportive space to recover post surgery? This includes access to understanding healthcare professionals and a support network (friends, family, community and mental health professionals) who can help you through the process.

Mental well-being means you have the following:

• A solid sense of your gender identity: This is not a procedure for people who have just started to explore issues around gender identity. Medical professionals recommend you have lived as your chosen gender identity for a minimum of a year.

• Understanding of the mental journey ahead: While it is common to feel liberated after genital reassignment surgery, this is not always an immediate feeling. It is important to consider your readiness for the emotional ups and downs after surgery. It can be difficult to adjust to changes to how your body looks and feels, to cope with pain or other physical complications, or other people’s reactions. While the negative emotions are not guaranteed, if you don’t feel you have the emotional resilience to deal with these possibilities, now might not the right time to pursue this procedure.

If you are sure that this is the option for you, but not right now, you don’t have to abandon genital reassignment surgery altogether. You can still work towards the procedure by considering what might help you get to the point where you are ready – counselling, medical treatment, peer support, etc. – and slowly but surely making life changes to move closer to readiness.

In fact, there are even clinics who specialise in genital reassignment surgery who can also help you locate and access these resources.

The most important thing is ensuring you are pursuing surgery on the terms that are best for you and your journey.

What questions should I ask my doctor before sex reassignment surgery?

Each person’s reasons for pursuing genital reassignment change are highly personal with varied ideal outcomes for each person.

Overall, it is important to understand the surgeon’s goals (based on best practice) and assess if and how they align with your own. Your aims in having genital surgery can determine which doctor will be best for you.

Generally, the surgeon will aim to:

• Create a neophallus with realistic appearance and size

• Enable the ability to have sexual intercourse

• Allow the ability to orgasm

If any of these goals are particularly important, for example being able to stand to urinate, or having a penile implant in order to achieve an erection, it is best to thoroughly discuss this with your surgeon to ensure that by surgery day, you feel comfortable about your own realistic post-operative goals.

How does female to male genital reassignment surgery work?

Female to male genital (FTM) reassignment surgery, also known as female to male bottom surgery, has three key parts:

• Removal of the vagina (vaginectomy or colpectomy) or closure of the vagina (colpocleisis)

• Creation of a scrotum and testicular implants (scrotoplasty)

• Creation of a penis either by:

  • Enlargement and repositioning of the clitoris into the approximate position of where a penis would be (metoidioplasty)

  • Constructing a penis from skin grafts (phalloplasty)

As discussed further below, it is possible to combine the above surgeries.

Metoidioplasty

After using hormone therapy to enlarge the clitoris, metoidioplasty involves cutting the ligament that tethers the clitoris under the pubic bone.

This allows the clitoris to show more, so it can then be lengthened and elevated into the position where a penis would sit.

The skin for the new micropenis is then created by cutting the labia minora, wrapping the skin around the tissue and securing it with stitches. Fat can also be removed from your pubic mound and the skin pulled upwards to bring the new penis forward.

Metoidioplasty can create a neophallus that is usually 3-6 cm long depending on the clitoral size and can be done with or without urethral lengthening.

Without lengthening, the urethra opening stays in its original position, usually under the scrotum. With urethral lengthening, the urethra opening is brought to the tip of the phallus which gives the ability to stand and aim better when urinating.

Phalloplasty

There are various techniques, but the most common involves removing a “free flap” from a donor site to create the neophallus.

A free flap will contain not only skin and underlying tissue but also requires dissection of the arteries, veins, and nerves so that the flap retains good blood supply and sensation when positioned to the pubic region.

The three donor sites used most often are:

• Radial forearm (RF) - the inside section of the lower arm

• Anterolateral thigh (ALT) - the outside thigh area

• Musculocutaneous latissimus dorsi flap (MLD) - the lateral or side area of the back

The choice of donor site will depend on several factors and each has its pros and cons. You should discuss with your surgeon what their preferred technique is and what’s right for you considering your surgical goals and body type.

While the flap is being prepared at the chosen donor site, another surgeon will prepare the recipient area so that the newly constructed neophallus can be placed at the top of the clitoral fold.

The flap is rolled to make "a tube within a tube" shape and microsurgery is used to connect the vessels, arteries and nerves of the neophallus to those in the pubic and leg regions (including the clitoral nerve).

The phallus is then kept in place by sutures and the donor site is either closed or covered with a skin graft.

A second popular phalloplasty technique is suprapubic phalloplasty. This is where a heart shaped flap of skin and subcutaneous tissue from the lower abdomen is elevated, rolled into a tube and then allowed to hang down to be positioned in the pubic area.

The skin of the lower abdomen is then closed and sutured together similar to a tummy tuck procedure.

With both techniques, the clitoris is mobilized and can be moved to the desired position, often this is at the base of the neophallus just underneath the skin. This allows the clitoris to be hidden but still retain the ability to be stimulated during intercourse or manually.

Choosing between metoidioplasty and phalloplasty

The key difference for patients to consider is metoidioplasty is a simpler and less invasive surgery, but the penis created is often too small to have penetrative sex with.

Phalloplasty is a more complex and invasive surgery, but the penis created is adult-male-sized and can be used for penetrative sex.

Unlike metoidioplasty, phalloplasty requires an implanted erectile prosthesis to achieve an erection. This is usually done in a separate surgery to allow time for healing.

Both metoidioplasty and phalloplasty preserve sexual sensation and can allow an individual to stand while urinating.

Deciding which one to have depends on many factors, including your overall goals for surgery and the health risks of each.

Some individuals will have metoidioplasty as a short-term solution due to costs and the length of time needed to complete metoidioplasty vs. phalloplasty. Often patients find that metoidioplasty satisfies their personal goals and is enough for them to feel they have completed their transition.

It is also possible to start with a metoidioplasty but decide to have a phalloplasty later on.

What other FTM sex reassignment surgery procedures can I combine?

There are various ways you can group your sex reassignment surgeries together, depending on your personal goals, health and the protocols used by your surgical team.

For example, common combinations include:

• Vaginal closure/removal, urethral lengthening, scrotal construction, and metoidioplasty/phalloplasty done at the same time, along with removal of the ovaries and uterus if they have not already been removed

• Vaginal closure/removal, urethral lengthening, and phalloplasty done at the same time, with scrotum construction and placement of a penile stiffening device done later (one year after phalloplasty)

• Vaginal/closure removal at the same time as removal of the ovaries and uterus, if there are no plans for urethral lengthening in the future

• Phalloplasty with scrotoplasty and removal of the vagina, uterus, fallopian tubes and ovaries

It is important to remember your SRS journey will often involve multiple surgeries, some with more than one repetition.

You should take into consideration the time needed for your body to fully recover between surgeries when planning the timeline of your procedures. For example, if you have recently had your ovaries/uterus removed, you must wait at least 4 to 6 months before having genital surgery. If seeking a penile implant, this should be done no sooner than a year after your phalloplasty.

What can I expect at the hospital during my FTM sex reassignment surgery?

Generally you will be admitted to hospital the day before your surgery, so that your doctors can assess your overall health.

The surgeon will assess if you are at a healthy weight, because if you are underweight or overweight you can experience an increased risk in blood clots (thrombosis), wound infections, and also delays in healing.

Additionally, as the phallus will be made from skin and fat from your forearm, upper thigh, or back, being overweight can result in a phallus that is too fat and may need revision later.

Due to the length of surgery time and the area operated on, you will also likely have a “bowel prep” to clean out your intestines. This helps to prevent problems during surgery and also reduces discomfort going to the bathroom after surgery.

You will be unable to eat or drink after midnight the night before you have surgery.

How long will I stay in the hospital after FTM sex reassignment surgery?

After your surgery, you will be monitored by hospital staff as you come out of the anaesthesia. You will then stay in hospital until you are recovered enough to be sent home.

This is usually:

• An overnight stay if you are having metoidioplasty without urethral lengthening

• 5 to 10 days if you are having metoidioplasty with urethral extension

• 7 to 14 days if you are having phalloplasty

After phalloplasty you will need to stay in bed most of the time that you are in hospital. Your penis will be very closely monitored (every hour for the first 2 days) by the nursing and surgical staff.

You will be on bed rest for at least the first 48 to 72 hours after surgery to protect the surgical anastomses (the surgical connections when the flap’s vessels and nerves are joined to the groin nerves and vessels). Most likely, the new phallus will also be kept elevated off the abdomen to prevent any kinking and you will have a variety of drains to remove any excess fluid from the areas that were operated on.

You can generally walk unaided after 3 days when you’re allowed to move around again.

A catheter will need to stay in place for 2 to 3 weeks after the surgery and will be removed once you are able to urinate through your new phallus.

If you are traveling abroad for surgery, it is recommended that you stay in-country and nearby to the clinic for several weeks afterwards for follow-up visits and in case any complications should arise.

The skin-grafted forearm will be wrapped under special bandages for 5 days.

If you are having urethral extension done (required as part of phalloplasty, optional with metoidioplasty), a tube (suprapubic catheter) will be placed to bring urine from your bladder out through your lower abdomen.

This gives your new urethra time to heal and is usually removed during the first week.

How long will it take to fully recover from FTM sex reassignment surgery?

Generally people start to feel more physically comfortable during the second week after surgery, but it can take a long time to fully heal, and there can be pain and soreness for a long time in the surgical sites.

After phalloplasty you will have to follow up with the plastic surgeon and urologist frequently in the first couple weeks after surgery, and periodically after that. You should plan to stay in the same city as the hospital for at least 1 to 2 weeks after surgery.

The surgeon will do a physical exam to check your general health and will also check your new penis for healing, blood flow, and ability to urinate. Your donor forearm will also be checked for healing and hand/wrist sensation and function.

All of the surgical incisions will be checked for infection and scarring. The skin graft donor site will be covered with a sheet of gauze which becomes absorbed into the scab. It may be gradually trimmed away as it lifts up from its edges over the following 1 to 2 weeks.

After you go home, it is important to have appointments scheduled with your trusted GP and mental health professionals to ensure you are supported in this stage of your recovery.

You can go back to your usual routine when you feel well enough to do so, which is typically 4 to 6 weeks but can also be longer in some cases.