Transition is a very personal journey, and surgery is something that is very often misunderstood by society. Surgery does not make a person transgender, and surgery does not make a person male or female. This is why trans surgery is often called “gender affirming surgery” – because the goal of surgery is to affirm the gender you know yourself to be. People often ask questions like, “So, when you have the surgery, you’ll be male?” or “Have you had all the surgeries?” These questions are problematic because not all transgender people have surgery, for a multitude of reasons, and there are not specific surgeries that transgender men have to “poof,” become male!
Gender is a complex thing. There are many factors that make up a person’s gender – not just genitalia, and not even just chromosomes. That said, surgery is not something every transgender person pursues. There are trans people who cannot afford surgery, don’t want surgery, can’t medically have surgery, or don’t have surgery for other reasons. Not having surgery, for whatever reason, does not have an impact on one’s gender. In the trans community, there is a saying that an easy way to help people remember the difference between sex and gender – “Sex is what’s between your legs, and gender is what’s between your ears.”
There are some trans people who only have top surgery, and there are even some trans folks who don’t have any surgery. It all depends on the person’s needs, wants, level of dysphoria, and of course, the kind of access to health care and trans care that the person has.
Below are the types of surgical procedures that are available and most often performed as part of female to male transition.
Chest or “Top” Surgery
The double incision method is usually performed for people who have breasts that are C cup or larger, although sometimes folks with B cup (and rarely, smaller) will opt for a double incision method because of the (generally) reduced need for revisions. Scars will generally follow underneath the pectoral muscle, in a “W” shape across the chest. Most surgeons use drains for approximately a week after surgery to help drain blood and lymphatic fluid from the chest to keep hematomas and seromas from forming post-operatively. Nipples are either free grafted and positioned, or sometimes left on the nipple stalk to retain sensation. Some folks who undergo double incision choose not to have nipples reconstructed and grafted at all. For those that do have nipple grafts, there is a small chance that the graft could be rejected, although it is a very small chance and doesn’t happen terribly often. Some surgeons use liposuction to help create the most masculine chest possible. If you are a smoker, it is imperative to quit smoking before undergoing any surgery (top surgery or lower surgery). Continuing to smoke can seriously increase your chances of losing a graft or cause a number of complications.
Peri-areolar + Keyhole
With keyhole and peri-areaolar surgeries, the incision is either made all the way around the areola, or along the bottom side of the areola. The breast tissue is removed by scalpel, liposuction, or a combination of both. The risk is lower for loss of sensation with peri and keyhole surgeries than with the double incision method, although there is still a risk of loss of sensation with any FTM chest surgery. Many surgeons still use drains for peri and keyhole procedures, as with double incision, although there are surgeons who are using a new method that doesn’t use drains – both for double incision and peri/keyhole procedures.
Because the nipples are not removed and grafted, there is less control over the nipple placement with peri/keyhole procedures than with double incision. For this reason, there can be an increased need for revision surgeries with peri and keyhole procedures than with the double incision method. The advantage of peri and keyhole procedures, however, is that there is hardly any visible scarring. However, it’s good to remember that not every person sees scarring as a disadvantage. Some trans men see their scars as part of who they are – almost like a tattoo that represents their transition journey and/or their identity. It’s important not to speak negatively about scarring, and not to see scars as a bad thing because of this.
A more in-depth list and comprehensive list of lower surgery procedures can be found here, on the Hudson’s FTM website.
Metoidioplasty, or “meta,” is a type of lower surgery that involves severing the suspensory ligament of the clitoris and moving it to a more male position. Metoidioplasty can include urethral lengthening, which extends the native urethra through the neophallus, giving the ability to stand to pee – this is called a full metoidioplasty with urethral lengthening. Metoidioplasty without urethral lengthening is called a simple metoidoplasty, and it does not give the ability to stand to pee. Metoidioplasty can also include vaginectomy (removal of the vagina) and/or scrotoplasty (creation of a scrotum), which may or may not include testicular implants.
With metoidioplasty, there is less risk of losing erotic and tactile sensation than with phalloplasty. While metoidioplasty yields a smaller phallus (usually 1-3 inches), it functions like a penis of a natal male. Metoidioplasty usually yields better results when there has been significant growth of the clitoris with testosterone therapy. Whether a patient is a candidate for metoidioplasty depends on the body type, the amount of growth on testosterone, and the patient’s build. Many, if not most surgeons, have requirements for BMI (Body Mass Index) in order to be a candidate for surgery.
Phalloplasty, or “phallo,” is a type of lower surgery that uses a donor site to create a phallus, which is placed in a male position in the pubic region. Donor sites can include the radial side of the forearm, the musculocutaneous latissimus dorsi (MLD), or the anterior lateral thigh (ALT). Phalloplasty can also include urethral lengthening, vaginectomy, scrotoplasty, and penile implants, but all of those are optional.
Many phalloplasty procedures require at least two stages of surgery, if not more. Phalloplasty is a highly complex, major surgery that requires a lot of healing time. There is a high risk of complications with both the grafts and also the urethral lengthening, if it is included in the procedure. There is also a much higher risk of loss of sensation, both tactile and erotic.
Phalloplasty does, however, yield a phallus that is within the range of average size of a flaccid penis for a natal male. Depending on the surgeon and the results of the surgery, many phalloplasties are indistinguishable from that of a phallus of natal male.
Goals of Lower Surgery
The type of lower surgery someone may have is completely dependent on the needs of each patient. Every person is different and suffers from different types of dysphoria – some guys struggle with not being able to stand to pee, but don’t feel that they need a phallus that is as large as the average natal male phallus. In this case, a metoidioplasty may be a good option for them. Some guys feel most dypshoric because they can’t engage in intimate activities with their partners like natal males can. In which case, a phalloplasty may be a good option, with or without urethral lengthening, because it gives the ability to have penetrative sex. Some guys feel dysphoric just because they simply don’t have male genitalia – in which case, either a phalloplasty or a metoidioplasty may be an option, depending on access to surgery.