Transgender Female to Male: Bottom Surgery

Feelings about gender and sex run deep.  Meeting with someone to discuss what lies beneath seemed invasive to me. My exact words to my best friend were “How do I go up to the nearest trans person and say ‘hey, can we talk about your junk & how you got it?”.  Fortunately, my conversation with one trans person I interviewed (who prefers not to be identified by name) began a bit smoother than that. Soon, we were talking about the general fears one must face with any surgery—choosing the right doctor, risk of infection or complications and death—then we moved on to issues specific to his surgery. The talk of penis sensitivity, scrotum implants that weren’t placed identically (one was placed deeper than the other creating sometimes painful swelling), and follow up surgeries to correct and perfect his body opened my mind to intricacies of surgery that I wasn’t aware of before.  Jay, another trans man I interviewed for this article, eloquently noted “Transitioning is a scary, rewarding, long, painful yet ultimately worthwhile process. It’s also a process that is different for everybody.” It’s a process that, for some, involves surgery.  Money, support from friends and family, and personal preference all factor into whether or not someone gets it done. Deciding to surgically alter one’s body for any reason is rarely a black or white decision and definitely isn’t easy. But, when it comes to making the sex organs you were born with match the ones you should’ve been born with, it seems the shades of gray in decision making are as endless as the identities of the people who comprise the “T” in LGBT.

Genital reassignment surgery, sex reassignment surgery, gender reassignment surgery, and bottom surgery are all names for procedures that, in the case of female to male trans people, rid them of a vagina and give them a penis.  Surgical procedures to align the mind and body of FTMs are being reinvented and revised every day. However, all procedures fall under 2 categories—metaoidioplasty and phalloplasty. Metaoidioplasty works with the lengthening of the clitoris that occurs when a trans man undergoes hormone therapy. The ligament that holds the clitoris to the pelvis is cut and some tissue surrounding the clitoris is removed. This, along with removal of fat from the pubic mound, brings the phallus forward. This form of surgery creates a very small yet sensate penis that can achieve erection when aroused (though the penis is too small for penetrative sex).  Variations of this procedure vary based on the surgeon as well as the patient’s needs. The urethra can be lengthened (using tissue from the mouth or vagina) in order to urinate standing up, testicular implants may be placed inside the labia majora to create a scrotum (and the two labias may be combined to create a scrotal sac) and/or the vaginal cavity can be removed or closed.

Phalloplasty is the construction of a penis using skin from other parts of the body. Depending on the procedure donor skin can come from the torso, leg/groin, forearm or abdomen which is then grafted onto the pelvic region. Phalloplasty usually involves a urethra lengthening in order to be able to stand while urinating and testicular implants. However, the similarities in procedures vary widely in other ways.  The oldest techniques take skin from the abdomen and roll it into a tube that becomes the penis.  This method does not produce realistic results nor does it allow the trans man to have any feeling in his penis and a pump or flexible rod must be used for it to become erect.

Somewhat newer procedures, such as the pedicled groin flap and pedicled pubic flap techniques use donor tissue from the groin/pelvis to create the penis. At first, the rolled skin flap is left attached to the donor area to ensure proper blood flow. Additional surgeries are required to separate the skin from the donor area and graft it on the genitals. After the final procedure the penis will hang freely though it will not have feeling and will need a rod/pump to become erect.

Advances in microsurgery have allowed for better phallopasty techniques to be developed. The most advanced techniques use a flap of skin from the groin, thigh, forearm or upper torso to create a new penis. This is called Free Tissue Flap Transfer (FTFT).  With FTFT, a flap of skin is completely and carefully removed so that the blood vessels and nerves stay intact. Then, the flap’s blood vessels and nerves are microsurgically connected to those of the groin. This ensures the penis gets proper blood flow and allows it to have feeling.  As with the other surgeries the urethra can be lengthened in order to enable urination while standing, testicles may be implanted, and a rod/pump must be used to get an erection.  Also, the specific technique used by a doctor can vary.  All of the skin can come from the forearm (which leaves a large scar that must be covered with skin from the thigh) or most of the skin can come from the groin with forearm skin used to create a sensate head for the penis. Another variation involves taking skin from the upper torso underneath the arm which allows a less obvious scar, a sensate penis, and length of up to 7 inches.

With the numerous variations in procedures and results, if you are considering genital reassignment surgery it is best to do as much research as possible and discuss all of your options with a doctor.  Your body, your future, your life can be changed with GRS. Make sure it is a change you will be happy with.

-M.J

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