After recieving my letter to let me know that the publicly funded surgery list was moving ahead, and if I was still interested, I knew I had to do research. This was a big life altering decision that I needed to make. I will be explaining surgeries and using terminology in a way that some people might not want to here, so if you're not interested in surgery and body parts talk, look away now!
The two types of lower surgery for trans masculine people are metoidioplasty and phalloplasty. I will very basically explain these surgeries for people who are not familiar with them. Metiodioplasty (meta) is a more simple, and less intrusive and complicated surgery where the ligament holding the clitoris (which is often enlarged and has grown from testosterone hormone replacement therapy) is cut, allowing the clitoris to protrude further from the body and appear larger. Phalloplasty (phallo) is the creation of a new penis using a skin graft from a donor site - usually the thigh (ALT) or forearm (RFF). There are a few other techniques that can use the back or groin region for donor sites but these are far less common and not practiced by Rita Yang.
Other complimentary surgeries that often accompany either phallo or meta are:
- Scrotoplasty: the creation of a scrotum using labia majora tissue
- Urethral lengthening: creating an extension to the existing urethra to allow urination through the newly created penis
- Vaginectomy: the closure/removal of the vagina
- Testicular implants: surgical implants to place within the newly created scrotum to provide the appearance and weight of testes
Phalloplasty only surgeries:
- Glansplasty: the creation of the glans/head of the new penis to provide a more natural shape
- Erectile implants: the insertion of an erectile device to allow for erections with the new penis (I will explain this a little further soon)
So as you can see, lower surgery has a lot of different aspects to consider. Despite what a lot of cisgender (people who's gender identity is aligned with their sex assigned at birth) people think, there isn't just one 'sex change' surgery. There are many different options for people to consider. These procedures are not reliant on each other - one may have one or two of the options, but not undergo scrotoplasty, or even a vaginectomy. Each person has the ability to decide what they want, or what they don't. In this post I'm going to share my thoughts and feelings about the pros and cons to each procedure and inevitably share what I am hoping to have on the other side of the operating table.
There is no 'perfect' surgery when it comes to exactly replicating what cis-men are born with. Each different surgery has different pros and cons to them, in terms of what they can and can't achieve in terms of sensation, appearance and functionality. While I have already made my decision on what I want, I want to provide a detailed explanation and deconstruction of all the ups and downs to each procedure, to further help others who may want to consider gender confirming surgery in the future.
Metoidioplasty is very desirable for many trans people because of a few reasons. With meta you retain the ability to naturally have an erection. The clitoral tissue can indeed get 'hard' so this is a very appealing option for many people. The post-op appearance of someone who has undergone metiodioplasty is very similar to a cis-male who has a micro-penis. After all, the tissue is all the same, with the clitoris being a much smaller, compact version of a cis penis. The clitoral hood acts as foreskin for the new penis which also provides a very appealing prospect for many people, especially in parts of the world where circumcision is less common. This is a much less intrusive surgery as well, adding to the appeal. The downtime from meta is considerably less than phallo. Because the procedure only enhances what is already present, the chance of losing sensation is very minimal, and the chances of complications in general is significantly less.
However the risk of complications increase when considering urethral lengthening, which isn't as common with meta and is very dependant on the size of the tissue of the clitoris that can be worked with. So not all people who get meta are able to get urethral lengthening which many find to be a deal breaker. Another con to meta over phallo is the size. Some people want an average, cis looking penis and as a result, a few people may recieve metoidioplasty and feel unsatisfied with the results because of this. As well as appearance, size can be an issue when considering sexual function. Results can vary regarding the ability to penetrate a partner after meta because of the average size sitting around only 5cm which means that in many cases, penetration cannot be achieved in a way that provides satisfaction to those involved.
Now for phalloplasty. Phallo is what most cis people consider 'the surgery' when assuming what post-op trans mens' junk looks like. In terms of both appearance and function this is more comparable to a cis penis, as an average size and shape is formed and is very commonly done with urethral lengthening and allows the ability to stand to pee. Believe me, the standing to pee is a huge plus in my books! One thing that I have noticed since transitioning is how lacking most mens bathrooms are with actual toilets compared to womens. As someone who can't currently use a urinal, I have constantly had to awkwardly wait by the ONE stall in a mens room surrounded by walls of urinals. While I don't particularly have dysphoria about having to sit to pee like a lot of other people do, I appreciate the advantages that standing to pee brings in public bathrooms. During the creation of the new penis, nerves are also taken from the donor site and connected with microsurgery to nerves located in the groin area, connecting both tactile and erotic sensation to the penis. Many people who have had phallo have mentioned a state of gender euphoria with feeling their new penis hanging as they walk, the weight in their pants and the bulge that is produced from this procedure which also provides people with reasons to chose phalloplasty over meta.
Another difference between phallo and meta are the options of usually 2 different types of erectile devices that are available with phalloplasty but not metoidioplasty. You have the option of either a semi-rigid rod implant or an inflation type device. The inflation device uses a saline solution that is stored in a reservior within the body, with a pump placed within one of the testicles. By pressing a button, the device transfers the saline solution from the reservior to the cylinder running along the length of the penis. When this is filled by the pump, the penis retains rigidity and can be used for sexual penetration. Once finished, a valve is pressed and the saline receeds back into the resevior and the penis becomes flaccid again.
Unfortunately, phalloplasty is usually a much more intense and vigorous procedure that is done in 2 or 3 stages because of the extent of work that has to be done to achieve the desired results. This means that it can be a much bigger strain on someone's life in terms of recovery time, taking time off work or study, and how long someone might need assistance after surgery. Due to the complicated process of phalloplasty more complications can arise, including necrosis of the grafted tissue and loss of erotic and tactile sensation which although very rare (usually less than 5% of cases) result in complete loss of sensation and is a big part in why many chose to not have phallo. There is also the donor site for the skin of the new penis, which is one of the biggest concerns of many trans masculine people. Usually taken from the thigh or forearm, these can be quite visible scars which makes many people reconsider phalloplasty as an option especially for those who are stealth and concerned about the appearance and link between the scar and surgery.
Separate from either meta or phallo are the optional add-ons as it were, which include glansplasty, vaginectomy, scrotoplasty, urethral lengthening, testicular and erectile implants. These also come with benefits and risks, so I will briefly outline them here. Urethral lengthening is by far the most problematic, with around 30% of procedures having complications with fistulas and strictures, where the newly made urethra is too narrow or there is a disconnect, either from scar tissue or the body trying to heal the passage closed. This in particular is why an average of 6-9 months of hair removal treatment is very important before surgery, because the donor site that creates the added urethral length has to be completely hair free, otherwise hair could grow back and cause blockages within the urethral passage. Thankfully this is something that can be managed and corrected very easily as long as the issue is identified and seen to in a timely manner. This does make up a large majority of complication related revisions so many people opt to not go through with UL to avoid the potential issues with recovery. Other complications are mostly general surgery and healing related issues with blood supply, infection, slow healing and rejection of implants which are experienced in many other surgeries so I won't go into detail here.
So, after explaining all that I will tell you what I hope to get done. I am looking to get RFF phalloplasty with glansplasty, urethral lengthening, scrotoplasty, vaginectomy, erectile device implant and testicular implants. Phalloplasty appealed to me over meta because the more I thought about it, the more I was okay with having an arm scar in exchange for a penis that would be closer in functionality to a cis penis. I had concern that because my growth from hormones wasn't huge, I would be unhappy with meta results and I possibly would be unable to have urethral lengthening. Additionally I would not be comfortable using a public urinal if I only received meta and I would still feel rather self-conscious. Additionally, the idea of increased sexual function is very appealing as well, even with the small risk of loss of sensation. One small concern I have regarding getting phallo is the size. Yes, I want an average sized dick but physiology plays a role in this. Because the phallo is not created with erectile tissue like what is found in the clitoris and penis, the size of the phallus does not grow. This means that while flaccid, my new penis will be the average erect size for an adult penis, and as a smaller guy I'm a little worried that it will appear too big or look out of proportion. It's a small problem, not one that is making me have any doubts on my decision but regardless I wish to be as open and honest about my thoughts and experience in order to help shine a light for others to learn about the process.
I know, it sounds like a lot of surgery. And that's because it is. Thankfully this will be done over 2-3 procedures spaced around 6 months apart, giving my body time to heal between surgeries. This is going to be one hell of a journey and will change my life in a lot of positive ways, but it will also be very difficult and trying. Putting my body through so much will wear me down, tire me out and probably make me feel crappy for a while, while my body recovers. So some of you may be wondering why I would chose to go through such hard and difficult surgeries. But while my body will be in pain and hurting, my mind and soul will be healing. Maybe I will finally understand the feeling of togetherness and a sense of home in my own body.
As a small side note, please understand that everything I have stated above is from my own research in viewing people's responses and results, and my own feelings about what I want for my own body. This is in no way supposed to make people feel like one surgery is better than another, and I am not a medical professional in any way. I don't know what may suit other people more for their mindset and body type. I'm just shedding light on the information I have found while researching in the hope to provide a little more information to those who are considering lower surgery but don't know the basics of what is available in New Zealand.
If you have any questions, head on over to the contact page and I will do my best to post answers on the blog.