Introduction to Genital Gender Affirmation Surgery for Transgender Men

Transmen who would like to have gender affirming surgery have 2 main options: the metoidioplasty or a phalloplasty.

The metoidioplasty uses a hormonally enlarged clitoris to create a new penis. It takes about 2 years for testosterone to maximally increase the size of the clitoris. Addition of DHT cream will also increase the size but this cream is not available in the United States. A metoidioplasty is often done in conjunction with removal of the uterus and the vagina.

There are three major decision points prior to surgery: whether urethral lengthening is performed, whether a vaginectomy (removal of the vagina) is done, and whether a phalloplasty is planned for the future.

The metoidioplasty is a simpler operation than the phalloplasty with few complications and allows men to have orgasms. It can also be used as an intermediate step prior to a phalloplasty. The downside of the metoidioplasty is that the penis is small compared to a phalloplasty and a penetrative sex can be difficult. A penile prosthesis has been devised for the metoidioplasty but data on this is limited and it has not been widely used.

A phalloplasty allows creation of a much larger penis than a metoidioplasty. The phalloplasty involves bringing tissues from another part of the body and using it to create a new penis. There are 4 main types of gender affirming phalloplasty: the radial forearm free flap, the anterior lateral thigh flap, the latissimus doors flap, and the suprapubic phalloplasty. Each has risks specific advantages and disadvantages (see section on phalloplasty for more details).

This table summarizes advantages and disadvantages of each type of masculinizing gender affirmation surgery:

	Metoidioplasty	Phalloplasty
PROS	Less Complications Sensation/Orgasms intact Urinate standing Can convert to phallo later	Urinate standing Long, thick penis Penile Prosthesis
CONS	Short penis No erections No Penetrative Sex	High Complication rate Staged Less sensation Donor site morbidity

The phalloplasty creates a much bigger penis than a metoidioplasty and patients are able to have erections after placement of a penile prosthesis. However, the phalloplasty is a more complicated operation than a metoidioplasty and has a higher risk of complications and can leave significant scar and morbidity at the site the skin is harvested for the penis.