Not all trans guys are interested in surgical options or may feel that top surgery is as far as they want to go in that area. Some guys, however, long for the full anatomy of a cis-male. Any surgical procedures used to assist in the transition of a transgender person has gone through its own level of transition with what it’s called. Starting out with “Sex Change” then “Sex Reassignment Surgery” (SRS), “Gender Reassignment Surgery” (GRS) and now mainly referred to as “Gender Reaffirming Surgery” (GRS) – whatever you want to label it – for male bottom surgery it can be a complicated, expensive, and painful process.
We will discuss some of the options available here but every person is different. Discuss the options with your physician/surgeon to determine what the best and safest route would be for you personally. While there has recently been advances with penile transplants such as the 2014 case with a South African man or the more recent 2016 U.S. case in Massachusetts (and you can read our article from our very own jahn westbrook about Penile Transplant) it’s still such a new procedure and there’s questions about how it could transfer over to a trans male. It’s an important medical advancement that trans guys should keep their eyes open for as it continues to develop, especially now that the medical field is starting to realize trans guys exist. For now, though, we will discuss some of the more common surgical options.
There are a few different methods available to perform this type of surgery so it’s important to discuss all the options with your surgeon to find the one that’s best for your budget, your body type, recovery time, and impact on your body itself. TopSurgery.Net* defines “Top Surgery” as, “Top Surgery involves breast removal (Subcutaneous Mastectomy) and male chest contouring, and can also include free nipple grafts, or nipple/areola resizing and repositioning.” What is and isn’t included will vary drastically from doctor to doctor, so it’s important to get consultations with more than one surgeon if you can – at the very least contact their offices and ask what method they specialize in and an approximate quote.
BOTTOM SURGERY – NON-PENILE
For trans guys there are a few extra surgical options that may be a consideration beyond removal of breasts and adding of a penis.
Hysterectomy – A very common surgery performed for many years that’s pretty routine where the uterus/womb is removed. A surgeon may also opt to remove the ovaries and fallopian tubes (Oophorectomy) at the same time – this is a likely option for trans men as the ovaries are one of the organs involved in estrogen production.
Vaginectomy – A surgical procedure where the vagina is removed or closed. Some insurances may consider this a “cosmetic” procedure but it is performed on cis-women due to vaginal cancer and other medical risks. Gender Identity Dysphoria (GID) is becoming more recognized and more insurance companies are covering more complete surgeries. Having a vaginectomy will assist with better placement of testicular implants, although it is not required in order to have scrotal implants.
BOTTOM SURGERY – PENILE CONSTRUCTION
For some guys (myself included) having a fully functional penis is the ultimate dream, but it is only more recently becoming a more practiced procedure. One of the original options was a Metoidioplasty, but as medical technology has advanced other options like Phalloplasty are now available (and implants as mentioned above, but it’s still too new to see how it will work for trans men).
Metoidioplasty – Also known as a clitoral release or a micro-pensis. This if perhaps the oldest surgical option for trans guys as it was developed in the 1970s. It gives you a smaller penis but the most amount of natural sensation as it uses what you already have and just reconstructs it into a more penis-like feature. Since the clitoris is made from the same type of erectile tissue as a penis you can obtain an actual erection during arousal and it will make standing-to-pee (STP) easier without requiring STP devices. In most cases, however, you cannot get the length needed to penetrate during sex as-is but since you’re using all the natural materials (nerve endings) already there all the sensation (after recovery) is yours to enjoy.
Scrotoplasty can be included in this surgery as well as a urethra extension (urethroplasty), if needed. Adding either of both of these options could mean this surgery may require two or three more operations. A scrotoplasty may be more than one procedure itself as temporary testicles may be used to stretch the skin inside the labia majora before being finalized. Some guys who have had this reported sensation return and in some cases even more sensation than before.
Phalloplasty – This is a very extensive surgery that takes about three procedures to complete along with skin grafting. If you haven’t had a hysterectomy yet there is an option to use some of the mucosa (vaginal lining) in one of the phalloplasty procedures and this option should be discussed at length with your surgeon.
Not to scare you off but there will be a lot of preparation before you can get your penis with this option. First and foremost you will need epilation to prevent hair growth from interfering with skin regeneration and healing. This could take several months in itself. You will need to become your own skin donor (most commonly the forearm although abdominal is an option too). After this you will need to go through urethra extending (urethroplasty) to allow yourself to pee while standing.
You can also have two options on how to obtain erection (or you can remain flaccid). A bendable rod can be placed inside the constructed penis so that all you have to do is – literally – pull it up to make it erect or push it down to make it flaccid. The other alternative and far more complicated option is to have a pump placed inside a scrotal sac that will activate the expandable rod to cause an erection with a release valve in order to become flaccid again. However, despite the grafts and taking of nerves there is a loss of sensation. Some guys who have had this procedure done more recently have reported sensation return, but it is not a guarantee – there is a very real risk of losing sexual sensation.
The more options you select the more complicated and expensive this procedure becomes including more operations. The skin graft will leave a very extensive scar (which some guys have had tattoos designed over to help cover the scaring).
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Each surgical choice has many options within it which is great and allows for some variability depending on person, body-type, and budget. The most important thing, however, is to speak openly with your surgeon and if you feel even the slightest bit uneasy about their abilities go for a second or even a third opinion. Do your own research before going in so that you can help the doctor understand your end-goal. Thoroughly investigate your insurance plan and check with your local state laws on what they are requiring insurances to cover. Some states will mandate insurances cover a vast array of trans-related care while other states will allow insurance companies to duck out of paying anything. Personal knowledge about your local laws, insurance coverage, and surgeons is vital as these are all extremely impactful surgeries.
Recommended Web Resources:
TopSurgery.Net (has a great resource for surgeons experienced in top surgery and approximate costs along with detailed information on all the various options.)
Hudson’s Guide (One of the original and best ftm guides on the net)
GIRES lower surgery guide (UK) (great page for even for non-UK to learn about the procedures)