Sex Reassignment Surgery is performed to transition individuals with gender dysphoria to their desired gender.
It is important to note that Sex Reassignment Surgery is the umbrella term for a number of procedures that transform the anatomical sex of an individual, with the most prominent procedure being Genital Reassignment Surgery.
The below guide is designed to be a primer for individuals seeking information about Sex Reassignment Surgery (SRS), but will have a focus on Genital Reassignment Surgery.
Genital Reassignment Surgery for trans men generally includes at least one of the following:
However, the term Sex Reassignment Surgery for trans men can also include:
We have tried to be as objective as possible in presenting the most accurate information available, but due to the highly personal nature of this procedure, each individual should also conduct their own research beyond this guide to ensure they are making an informed choice that is best for their needs.
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Before pursuing Genital Reassignment Surgery, it is recommended that you reflect on whether the procedure is right for you, and the right time to pursue it.
The World Professional Association for Transgender Health (WPATH) suggests the following prerequisites:
Your physical and mental wellbeing prior to surgery are vital to preparing for the changes that you will go through in the lead up to and recovery from surgery.
Physical readiness means you have considered the following and consulted a health professional throughout the process:
Mental wellbeing means you have the following:
If you are sure that this is the option for you, but not right now, you don’t have to abandon Genital Reassignment Surgery altogether. You can still work towards the procedure by considering what might help you get to the point where you are ready – counselling, medical treatment, peer support, etc. – and slowly but surely making life changes to move closer to readiness.
In fact, there are even clinics who specialise in Genital Reassignment Surgery who can also help you locate and access these resources.
The most important thing is ensuring you are pursuing surgery on the terms that are best for you and your journey.
Each person’s reasons for Genital Reassignment Change are highly personal with varied ideal outcomes for each person.
Overall, it is important to understand the surgeon’s goals (based on best practice) and assess if and how they align with your own. Your aims in having genital surgery can determine which doctor will be best for you.
Generally, the surgeon will aim to:
If any of these goals are particularly important, for example being able to stand to urinate, or having a penile implant in order to achieve an erection, it is best to thoroughly discuss this with your surgeon to ensure that by surgery day, you feel comfortable about your own realistic post-operative goals.
Genital Reassignment Surgery has three key parts:
After using hormone therapy to enlarge the clitoris, metoidioplasty involves cutting the ligament that tethers the clitoris under the pubic bone.
This allows the clitoris to show more, so it can then be lengthened and elevated into the position where a penis would sit.
The new micropenis is then provided with skin by cutting the labia minora and wrapping around the tissue and secured with stitches. Fat can also be removed from your pubic mound and the skin pulled upwards to bring the new penis forward.
Metoidioplasty can create a neophallus that is usually 3-6 cm long depending on the clitoral size and can be done with or without urethral lengthening.
Without lengthening, the urethra opening stays in its original position, usually under the scrotum. With urethral lengthening, the urethra opening is brought to the tip of the phallus which gives the ability to stand and aim better when urinating.
There are various techniques, but the most common involves removing a “free flap” from a donor site to create the neophallus.
A free flap will contain not only skin and underlying tissue but also requires dissection of the arteries, veins, and nerves so that the flap retains good blood supply and sensation when positioned to the pubic region.
The three donor sites used most often are:
The choice of donor site will depend on several factors and each has its pros and cons. You should discuss with your surgeon what their preferred technique is and what’s right for you considering your surgical goals and body type.
While the flap is being prepared at the chosen donor site, another surgeon will prepare the recipient area so that the newly constructed neophallus can be placed at the top of the clitoral fold.
The flap is rolled to make "a tube within a tube" shaped and microsurgery is used to connect the vessels, arteries and nerves of the neophallus to those in the pubic and leg regions (including the clitoral nerve).
The phallus is then kept in place by sutures and the donor site is either closed or covered with a skin graft.
A second popular phalloplasty technique is suprapubic phalloplasty. This is where a heart shaped flap of skin and subcutaneous tissue from the lower abdomen is elevated, rolled into a tube and then allowed to hang down to be positioned in the pubic area.
The skin of the lower abdomen is then closed and sutured together similar to a tummy tuck procedure.
With both techniques, the clitoris is mobilized and can be moved to the desired position, often this is at the base of the neophallus just underneath the skin. This allows the clitoris to be hidden but still retain the ability to be stimulated during intercourse or manually.
The key difference for patients to consider is metaidoioplasty is a simpler and less invasive surgery, but the penis created is often too small to have penetrative sex with.
Phalloplasty is a more complex and invasive surgery, but the penis created is adult-male-sized and can be used for penetrative sex.
Unlike metoidioplasty, phalloplasty requires an implanted erectile prosthesis to achieve an erection. This is usually done in a separate surgery to allow time for healing.
Both metaidoioplasty and phalloplasty preserve sexual sensation and can allow an individual to stand while urinating.
Deciding which one to have depends on many factors, including your overall goals for surgery and the health risks of each.
Some individuals will have metoidioplasty as a short-term solution due to costs and the length of time needed to complete metoidioplasty vs. phalloplasty. Often patients find that metoidioplasty satisfies their personal goals and is enough for them to feel they have completed their transition.
It is also possible to start with a metoidioplasty but decide to have a phalloplasty later on.
There are various ways you can group your Sex Reassignment Surgeries together, depending on your personal goals, health and the protocols used by your surgical team.
For example, common combinations include:
It is important to remember your Sex Reassignment Surgery journey will often involve multiple surgeries, some with more than one repetition.
For example, you should take the following into consideration when planning the timeline of your procedures, to give your body time to fully recover between procedures:
If you have recently had your ovaries/uterus removed, you must wait at least 4–6 months before having genital surgery If seeking a penile implant, this should be done no sooner than a year after your phalloplasty
Generally you will be admitted to hospital the day before your surgery, so that your doctors can assess your overall health.
The surgeon will assess if you are at a healthy weight, because if you are underweight or overweight you can experience an increased risk in blood clots (thrombosis), wound infections, and also delays in healing.
Additionally, as the phallus will be made from skin and fat from your forearm, upper thigh, or back; being overweight can result in a phallus that is too fat and may need revision later.
Due to the length of surgery time and the area operated on, you will also likely have a “bowel prep” to clean out your intestines. This helps to prevent problems during surgery and also reduces discomfort going to the bathroom after surgery.
You will be unable to eat or drink after midnight the night before you have surgery.
After your surgery, you will be monitored by hospital staff as you come out of the anesthetic. You will then stay in hospital until you are recovered enough to be sent home.
This is usually:
After phalloplasty you will need to stay in bed most of the time that you are in hospital. Your penis will be very closely monitored (every hour for the first 2 days) by the nursing and surgical staff.
You will be on bed rest for at least the first 48 to 72 hours after surgery to protect the surgical anastomses (the surgical connections when the flap’s vessels and nerves are joined to the groin nerves and vessels). Most likely, the new phallus will also be kept elevated off the abdomen to prevent any kinking and you will have a variety of drains to remove any excess fluid from the areas that were operated on.
You can generally walk unaided after 3 days when you’re allowed to move around again.
A catheter will need to stay in place for 2 to 3 weeks after the surgery and will be removed once you are able to urinate through your new phallus.
If you are traveling abroad for surgery, it is recommended that you stay in-country and nearby to the clinic for several weeks afterwards for follow-up visits and in case any complications should arise.
The skin-grafted forearm will be wrapped under special bandages for 5 days.
If you are having urethral extension done (required as part of phalloplasty, optional with metaidoioplasty), a tube (suprapubic catheter) will be placed to bring urine from your bladder out through your lower abdomen.
This gives your new urethra time to heal and is usually removed during the first week.
Generally people start to feel more physically comfortable during the second week after surgery, but it can take a long time to fully heal, and there can be pain and soreness for a long time in the surgical sites.
After phalloplasty you will have to follow up with the plastic surgeon and urologist frequently in the first couple weeks after surgery, and periodically after that. You should plan to stay in the same city as the hospital for at least 1–2 weeks after surgery.
The surgeon will do a physical exam to check your general health and will also check your new penis for healing, blood flow, and ability to urinate. Your donor forearm will also be checked for healing and hand/wrist sensation and function.
All of the surgical incisions will be checked for infection and scarring. The skin graft donor site will be covered with a sheet of gauze which becomes absorbed into the scab. It may be gradually trimmed away as it lifts up from its edges over the following 1 to 2 weeks.
After you go home, it is important to have appointments scheduled with your trusted GP and mental health professionals to ensure you are supported in this stage of your recovery.
You can go back to your usual routine when you feel well enough to do so, which is typically 4–6 weeks but can also be longer in some cases.
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