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:

Feb 262014

Got ethics ?Summary: Evaluation and review of proposed ethical principles for genital surgery for minor transgender women.

The WPATH Standards of Care are the international guidelines for health care for transgender people. Among other items, the standards detail requirements, risks and expected results for various therapies. The most recent version of the SOC, version 7, requires that transgender people be at least the age of majority to have genital surgery. In the United States, this is age 18. This presents a problem for trans adolescents who may want genital surgery earlier.

The paper I’m reviewing today took a look as some of the factors involved in deciding the ethics of genital surgery for young trans people. With more trans people transitioning at an earlier age than ever before, demand for surgery at a younger age seems to be going up. There have been cases, some prominent and some not, where a trans person (usually a trans girl) received genital surgery before they reached the age of majority.

As the author, Dr. Christine Milrod (PhD) points out, there are no ethical standards for determining if surgery is the right choice for a minor trans person. In this article Dr. Milrod discusses factors related to genital surgery, relevant background for an ethical standard, and tentatively proposes a set of standards. Because the article itself is behind a paywall, I’m going to roughly summarize the points she brings up as well as summarize her proposed standards.

Dr. Milrod seems to be focusing on young trans girls because they seem to be the ones accessing surgery as minors. Much of what she says is applicable to trans boys as well.

Issues and factors relating to genital surgery in adolescent trans people

  • Lack of genital surgery exposes them to a potential accidental exposure of their trans status, which may not be to the young person’s benefit. Stigma, shame, and feelings of inadequacy may result.
  • Trans youth are at very high risk for discrimination and harassment, which impacts both their physical and mental health. The ability to pass (including surgery) may reduce or eliminate the risk of discrimination/harassment.
  • Genital status may impact a young trans person’s ability to start a romantic or sexual life.

So what’s the current status when it comes to Standards?

WPATH states that an individual must be the age of majority for genital surgery. The Endocrine Society generally agrees. However, Dr Milrod points out that this is not necessarily always followed. She points to some Dutch clinics where the policy is essentially “no genital surgery until age 18” even though the age of majority in the Netherlands is 16.

Dr. Milrod points out that the current standards try to find a balancing point between minimizing the waiting time for a trans youth with limiting chances of post-surgical regret. However in the same section she points out that studies of Dutch youth 1-4 years after surgery finds no regret whatsoever.

Some quick background information on age of majority and informed consent from my own research, courses, and so on…

The age of majority is the age at which a person can legally give informed consent to a medical treatment. Informed consent means that the individual has been told all the possible risks and benefits of an activity/treatment/research, has understood them, and is agreeing to the activity/treatment/research. It’s an extremely important concept in medicine, psychology and human-related research, one that has emerged out of human rights abuses. An important part of informed consent is that the person being asked for consent has to be capable of giving it, and giving it freely. A person who is mentally altered, such as a person who’s consumed a large amount of alcohol, is not considered able to consent because their judgment is altered. A person who is mentally disabled or who has something like dementia is also considered not to be able to give consent.

And then there are minors. Because their ability to comprehend and judge accurately all the risks/benefits may not be fully developed yet, a minor is not considered able to give consent. Before the age of majority, it is the legal guardians of the young person who give consent on behalf of the young person. The young person instead gives assent – they can agree or not agree to something, but it doesn’t have the full meaning of consent.

So what does informed consent have to do with genital surgery? A lot. Can a person under the age of majority agree to something as irreversible as genital surgery? Does it do more harm than good, or is there more harm in making them wait? Surgeons, physicians, therapists, parents, and young people themselves are currently wrestling with these issues.

Dr. Milrod points out some things on informed consent in addition to my summary. The regulations and laws on informed consent vary very heavily from country to country and from region to region, and vary depending on the procedure involved. For example, in Australia a minor cannot receive genital surgery even with parental consent without a court order. However in some areas of the United States, a minor could petition to become an emancipated minor and thus be legally responsible for themself and consent to treatment. In other words… whether or not a young person can consent is heavily debated. Can a person at age 16 consent? 14?

Proposed “Principles for Decisions Concerning Genital Surgery of the Adolescent”

First, Dr. Milrod notes that recommendations regarding the surgical treatment of intersex infants and children were part of the framework for her principles

  • The Principle of Psychological Support and Education: The young person and their parents/guardians should be given both full education regarding the surgery and full emotional and psychosocial support. They should be given all the information: all the risks, benefits, potential side effects, permanency, and alternatives. They should be given room to sort through emotions and pressures. This heavily implies and almost requires the presence of a therapist for both the young person and their family members.
  • The Principle of Medical Management: Only a surgeon experienced in transgender genital surgeries should perform such a surgery on an adolescent, and that surgeon is responsible for providing complete information on the procedure and post-operative management. If the surgeon approached declines to perform the surgery, they should offer a reasonable explanation and a referral.
  • The Principle of Risk: Naturally, all risks should be minimized as much as possible. The physicians and surgeons involved are responsible for evaluating the physical risks of surgery for the young person. The psychosocial risk (of either performing surgery or delaying) falls to the therapist and/or other mental health professionals involved. The familial and social standards surrounding the young person also need to be taken into account.
  • The Principle of Human and Legal Rights: The young person must have given “full, free, and informed consent” to the surgery. All professionals involved must be in agreement that the young person is capable of giving such consent and has given it. The young person should be treated as any other patient with regard to privacy laws.

These aren’t exactly earth shattering. Rather, I think they’re very conservative measures. Conservative is not necessarily a bad thing. In my clinical experiences so far, I’ve come to view any hard and fast rule about transition with suspicion. One person may truly need a year of “real life experience” before hormones, for another that may be dangerous, and for yet another that may simply be an unnecessary postponement of hormone therapy.

This seems to me to be especially true for minor trans people, who have their families and schools and their vulnerable legal status to contend with. So I think Dr. Milrod did right in setting such conservative principles/guidelines. Each person must be treated individually – the possibilities are simply too broad and too serious to be treated otherwise.

If you’re interested in finding out more about issues facing transgender and gender nonconforming youth and their families, please check out Gender Spectrum. A more loving, kind, knowledgeable organization on the topic I have yet to find. Their professionals and family conference is wonderfully informative and supportive. I’ll be there this year if my medical school plans allow.


Feb 052014

This post is a legacy page, and was part of an on-going series, Trans 101 for Trans People. It covers questions about medical transition, hormones, surgeries, or seeking health care for transgender people.

For the material that once lived on this page, please see this page.

Please update your links to the full Trans 101.

Feb 202013

CC BY-NC-ND 2.0 - Santiago Alvarez

A new study has come out examining the differences between eating disorders and transsexuality. It’s not immediately obvious why those two should be compared. The causes of both are unknown. When you don’t know the cause of a phenomenon it’s often useful to compare it to other phenomena that seems similar. Both eating disorders and transsexuality can be categorized as body-centered phenomena; eating disorders involve weight, transsexuality involves sex characteristics. However there are differences; people with eating disorders are more likely to have other psychiatric diagnoses (e.g., borderline personality disorder) than trans people are. Trans people seem to have psychiatric diagnoses as frequently as the general population, though the data are still tentative.

This Italian study compared three groups, all roughly the same size (100 participants):

  • Trans people, both trans women and trans men. Both pre-op (no sexual reassignment surgery) and post-op folk were included. There were roughly equal numbers of trans men and trans women, and of pre-ops and post-ops. Trans participants had to have a diagnosis of Gender Identity Disorder.
  • People with eating disorders, divided into three groups: anorexia nervosa, bulimia nervosa and binge eating disorder. These participants were mostly female, except in the binge eating group which was half female.
  • Control participants with normal BMI who did not have an eating disorder and were not trans.

What did they measure? The researchers measured demographics, “anthropometric measurements” such as height and weight, psychiatric evaluations to verify diagnoses, psychological symptoms, and body uneasiness. Body uneasiness is multifaceted, including general body/weight dissatisfaction, compulsive self-monitoring (e.g., spending a lot of time in front of the mirror), feeling disconnected from one’s body, and worrying about specific body parts.

What did they find? Results included…

  • Pre-op trans folk had: a) higher levels of body uneasiness than people with eating disorders, b) lower levels of body satisfaction than post-op trans folk, and c) higher levels of depersonalization than all other groups.
  • There was no difference in overall body uneasiness between trans men and trans women. However, there were differences in various aspects of body uneasiness. Trans women were more likely to be concerned about weight gain than trans men. Trans women also self-monitored about as much as people with eating disorders, more than trans men and the control group.
  • Trans participants had lower levels of psychopathology than people with eating disorders. There was no difference between the trans participants and the control group for psychopathology.
  • Pre-op trans women were more likely to have adjustment disorder than all the other groups.

So how do we interpret this? First there’s the difference between trans folk and people with eating disorders. This study confirmed the findings of previous studies. It agrees that trans people are much less likely to have psychiatric diagnoses than people with eating disorders. It also agrees that, in general, trans people are not at elevated risk for psychopathology than the general population. Given the way many psychiatric disorders come in clusters (e.g., mood and anxiety disorders), this may be further evidence that transsexuality is not a psychiatric condition.

The finding that pre-op trans women are more likely to have adjustment disorder requires explanation. Adjustment disorder is not like mood or psychotic disorders. It means that the person is having difficulty adjusting to a life change. For pre-op trans women, the source is obvious: their transition is a major life change and a major stressor. The fear of being “outed” and assaulted or ostracized is very real. Pre-op trans women are also likely o be early in transition and hormone therapy and have a harder time “passing” than trans men.

Why might trans women worry about weight more than trans men? The authors comment, “It could be speculated that [trans women]’s drive for thinness is a way to suppress masculinity and to correspond to a female ideal of attractiveness.” Absolutely! Trans women are women, and so they get all the societal messages encouraging thinness that all Western women receive.

I do, however, feel that one “finding” of theirs must be questioned. As part of demographics, the authors asked about sexual orientation. They then categorized their participants by attraction according to “genotypic sex” (XX, XY, XXY, XO, etc) So when they later reported that their trans participants were more likely to be attracted to the same genotypic sex than their controls and people with eating disorders, they were actually comparing straight trans people to gay cis people. That makes no sense! Of course there were more straight trans people than gay cis people – there are more straight people than gay people overall. Further, “genotypic sex” as a category makes no sense unless you actually check the genotype! Even then, it doesn’t necessarily correspond to phenotypic sex (the sex that the person looks like).The primary limitation to this study is their inclusion of only gender binary trans people who were diagnosed with Gender Identity Disorder. This excludes all genderqueer folk, who may have more difficulty with transition because of societal pressure to be seen as either male or female. Otherwise, I think this study was fairly well put together.

The authors conclude saying that “Our findings suggest that in eating disorder patients [body] uneasiness is primarily linked to general psychopathology, whereas in [transsexuality] this relationship is lacking.” In other words, they suggest that eating disorders come from a general state of psychological illness and that transsexuality does not. The data I have seen, as well as anecdotes from the trans community, agree with this conclusion.


Jul 052011

A new study looking at transsexual health just came out. This one looked at the well-being and sexual health of transmen after sex reassignment surgery ( SRS – phalloplasty in this case). Unfortunately, I don’t have access to the full article so I can’t go into too much detail.

The study was conducted in the Netherlands, with 49 transmen. Most of the men had had phalloplasty on average eight years before the study and reported an increase in sexual activity after transition/surgery. They report that they can have orgasms, and that the quality of their orgasms has changed as a result of transition. Despite high rates of surgical complications, most were happy with the results of their sexual reassignment surgeries. They were also generally happy people.

These things may seem like, “Well… duh.” But this is the first study I’ve seen that confirms that “common sense” idea. I’m glad to see it. What do you think?