Jan 252016

800px-Mercury_fig_leafThe metoidioplasty is one of two potential genital surgeries for trans men. It takes advantage of the fact that trans men already have a penis: their clitoris!

With testosterone, the clitoris grows. A metoidioplasty removes tissue around the clitoris. This exposes more of it and helps it to hang in a more male position. That’s why a metoidoplasty is sometimes also called a “clitoral release” or a “free-up”. That’s it — that’s the core of a metoidioplasty.

In addition, the urethra can also be routed through the neopenis. At the same time the vagina can also be removed, and a scrotum made from the labia. A metoidioplasty does not remove the cervix, uterus, or ovaries. That would be a different surgery. However some surgeons will perform a hysterectomy at the same time as a metoidioplasty.

All in all, a metoidioplasty preserves the tissues that are already there. It shuffles them around into a masculine shape. Not everybody will have everything done, and there are many options.

Why would I want a metoidioplasty?

Everyone has their own reasons. Here are some that I have heard:

  • Ability to “pass” in male spaces, such as bathrooms and locker rooms. With genital surgery, the fear of having a towel around the waist slip at an awkward moment is gone.
  • Relieving gender dysphoria. What’s not to like about that?
  • Ability to pee standing up. Only with a urethral lengthening procedure, which carries its own risks.
  • Keeping erections and erogenous sensation. Some men are also able to have penetrative sex after a metoidioplasty.
  • Cheaper, easier to find a surgeon, and fewer surgeries than a phalloplasty with good results.

What is involved in metoidioplasty? What are my options?

Different surgeons will include different specific stages to a metoidioplasty. But the core of a metoidioplasty is clitoral release. The clitoris is freed from its surrounding tissues so it can hang the way a penis hangs.

Others steps are often included, including…

  • Vaginectomy: Removal of the vagina. May be required for some forms of urethral lengthening. Usually combined with a scrotoplasty, which fuses the labia together to make a scrotum. At the same time testicular implants can also be placed.
  • Urethral lengthening: The urethra is routed through the neopenis and lengthened using other tissue. This allows peeing through the penis and while standing.
  • Hysterectomy, oophorectomy: Removal of the uterus, fallopian tubes, and ovaries.

I’ve heard there are different techniques. What are they?

The biggest difference centers around urethral lengthening. Since the urethra is only so long, other tissue is used to lengthen it. That tissue can come from the vagina or inner labia, or it can come from the inside of your cheek (“buccal”).

Surgeons often have their own individual techniques and strategies in addition.

Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

It depends on which specific procedures you have done.

For a simple metoidioplasty only without urethral lengthening, vaginectomy/scrotoplasty, or hysterectomy, some surgeons will perform it under “twilight” anesthesia. This is also called conscious sedation. You’ll be relaxed and won’t feel pain but will likely stay awake. This level of sedation is also used by some dentists according to what you can learn at Healthcare Guys, so it’s not unique to this procedure. If you’re also having more intense procedures, like urethral lengthening, then you’ll be under general anesthesia.

The surgery itself lasts anywhere from 2-5 hours depending on what procedures you’re having. You’ll likely spend one night in recovery in the hospital. Full recovery time also varies. One surgeon advises bed rest for 24 hours, plus either 7-14 days off work with no heavy lifting for 2-4 weeks. Again — this depends on the intensity of your surgery.

What are the possible risks of metoidioplasty?

The usual risks with surgery apply here: adverse drug reactions, bleeding, infection and the like. Permanent loss/reduction in sensation may occur, as with all surgeries. And pain can persist for a long time.

The penis itself can end up twisted (torqued), which is repairable by surgery. The length may also be less than was hoped.

Urethral lengthening caries its own risks, including urethral narrowing or blockage, and urethral fistula. Urethral fistula is when a hole forms between the urethra and somewhere it shouldn’t be — so urine may spray from the underside of the penis, for example. Narrowing, blockage, and fistula can be repaired surgically. The stream of urine may also spray or be not what you expect.

What about scars?

The beauty of metoidioplasty is that it doesn’t leave very visible scars.

How will metoidioplasty affect my long-term health?

The metoidioplasty itself (the clitoral extension) doesn’t generally have long-term health implications unless there were complications. The same applies to the urethral lengthening.

Vaginectomy removes your risk for vaginal cancer. If you also had a hysterectomy/oophorectomy, you no longer are at risk for those cancers. However in order to maintain bone health it’s important to stay on sex hormones (testosterone) life-long.

Can I have penetrative sex with my partners after a metoidioplasty?

It depends, but the answer is definitely not “no”. Different people have different results, and different surgeons have different results too. Some surgeons report 4-6cm (1.6-2.4″) long penises, others boast 6-12cm (2.4-4.7″).

If being able to penetrate a partner is the most important thing for you, then you might want to consider a phalloplasty.

More information?

I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:

May 192013

I got back from the 2013 National Transgender Health Summit (NTHS) in Oakland last night. What a fabulous conference! I’m still processing a lot of my notes, but wanted to give a quick report on it before I flood the blog with new resources.

First some basic information. NTHS is cosponsored by UCSF’s Center of Excellence for Transgender Health and the World Professional Association for Transgender Health. It’s designed for medical professionals, mental health professionals, advocates, health administrators, students, and others. I can’t speak for previous years, but this year it was a two-day event. Sessions were broken into various tracks: research, medical, mental health, policy, and special topics. And boy, did we cover quite a lot! And, as always, I wanted to be in five different places all at once.

Aside from the official session topics, though, there were some themes that stood out to me…

  • There’s a very strong need for cross-cultural trans care. Trans care, like lots of medicine, has been focused on white people. I admit to being guilty of this too! I don’t know how being trans is handled in, for example, an urban latino/a community, and I don’t know how I can best respond to those needs as a future health care provider. I met some folks who were involved in the Trans People of Color Coalition, and I hope to not only educate myself but bring more awareness to my posts here.
  • There’s a disconnect in some areas between cultural knowledge about medical treatments in trans communities and medical knowledge. I want to give a shout out to Trystan Cotten, author of Hung Jury, for bringing attention to this within trans male communities. One of his examples? Something new for me, certainly: there are anecdotal reports that some trans men can have penetrative sex after metoidioplasty. Sounds like there needs to be a community-level conversation.
  • It sounds so far like the ICD-11 system will handle both the transgender/transsexual diagnoses and the paraphilia diagnoses much better than the previous ICDs and certainly better than the DSM system. More details when the preliminary criteria are out for comment.
  • Insurance coverages for trans-related care may improve with the Affordable Care Act. Again, more on this as information becomes more available.
  • There is a lot of research going on! Yay! I’ll try to link to some of the studies I heard about in a follow up.

Plus so much more! It was really exciting. I hope to post again with more information, links to lots of new resources and shout outs for on-going studies and organizations.

Mar 072013

4011035436_3477cddbbc_nTrans men generally have two choices for genital surgery: metoidioplasty and phalloplasty. Phalloplasty (creation of a penis with tissue grafts) will be a topic for another day; metoidioplasty (“Meta”) is more common and less expensive. Depending on the needs of the individual, a meta can involve the following:

  • Clitoral release: removing tissue and ligaments from the clitoris, allowing it to hang freely, in the correct position for a penis
  • Urethral reconstruction: lengthening the urethra and surgically inserting it into the new penis (formally the clitoris)
  • Vaginectomy/Scrotoplasty: removing the vagina (vaginectomy) and creating a scrotum using the labia tissue (scrotoplasty), potentially including testicular implants
  • Hysterectomy (removal of the uterus and/or cervix) and oophorectomy (removal of the ovaries and/or fallopian tubes) can also be done at this time

Dr. Djordjevic and Dr. Bizic recently compared two different methods of urethral lengthening at their clinic in Serbia. Urethral lengthening is the most technically challenging aspect of a meta. Complication rates can be high; this particular study cites a rate of 22% in previous studies. Part of the challenge is finding tissue to use for the new section of urethra (male urethras are much longer than female urethras; a different of perhaps 15 cm). So where do you find it? One of the options is buccal tissue, the tissue on the inside of the cheek. Have you ever scraped something like a q-tip inside your cheek, either for looking at the cells in a microscope or for a DNA test? That’s buccal tissue. Buccal tissue has previously, and successfully, been used in urethral lengthening surgeries for the treatment of hypospadias (when a male-bodied person’s urethra doesn’t come out the tip of the penis). Buccal tissue was used in both techniques in this study. But buccal tissue isn’t quite enough. One method used tissue from the underside of the clitoris/neopenis, the other used tissue from the labia minora. But before the results, let’s look at the study’s participants and the methodology.

207 trans men, with an average of 3.7 years on hormone therapy, had metoidioplasty with one of the two methods. Before the surgery, they were instructed to use dihydrotestosterone cream and a vacuum pump for three months to increase the size of their future penis. The surgery was a single stage surgery, including all the options I listed above: urethral reconstruction, vaginectomy, scrotoplasty with testicular implants, and hysterectomy/oophorectomy.

Participants chose their surgical method, so this was not random assignment. 49 (24%) of the participants had the clitoris/neopenis method. The other 158 (76%) participants had the labia method. Follow up varied, but ranged from 12 months to nearly 10 years, averaging around 3 years. There was no different in the time the surgeries took (roughly 4 hours).

So how about the surgical results? All the participants had good sensation and were satisfied with the appearance. No sexual problems were reported, though they generally were not able to have penetrative sex. Participants who had the labial method surgery had a longer penis than participants who had the clitoral/neopenis method surgery (5.9 cm vs 5.2 cm). Likewise, participants who had the labial method surgery reported a better ability to pee while standing.

There were no major complications. Minor complications included urethral fistulas (7.7% of the participants), testicular rejection (2%), testicular displacement (6.7%) and urethral stricture (3%). All were corrected with minor procedures. Some minor complications resolved on their own (e.g., dribbling/spraying while peeing). More urethra fistulas were reported in the clitoral/neopenis method group than in the labial method group. 19 participants (9%) chose to have esthetic (appearance-based) adjustments, and 13.5% chose to later have a phalloplasty to allow for penetrative sex. Dr. Djordjevic and Dr. Bizic also note that complications happened anywhere from a few months to years after surgery. Because of the long timeframe, they recommend “permanent follow-up.”

In all, this study supports using buccal and labial tissue as a superior metoidioplasty method rather than using buccal and clitoral tissue. Trans men should consider these results, as with all surgical information, when considering metoidioplasty.