Jun 182018
 

Open Minded Health has been running for 7 years.

Just let that sink in. For seven years I’ve been posting about gender and sexual minority health. Sometimes I posted weekly, other times biweekly. All through medical school, personal illness and injury and tragedy. And Open Minded Health is still here. Some marriages don’t survive medical school (mine did!). But Open Minded Health did.

On March 16 I found out that I matched into my preferred specialty of Family Medicine. And I learned where I will spend the next three years of my training. On May 13 this year I graduated medical school. I am now a physician. And on the 29th of this month I will begin the next phase of medical training: Residency.

For those unused to thinking about medical education, residency is a kind of on-the-job training all physicians must go through to become licensed. Residency is so called because residents almost live at the hospital. Long gone are the days of 72 hour shifts and wheeling patients to the X-ray machines ourselves. However, residency is still a grueling time. We may now be capped at 80 hour work weeks. And I may personally only rarely need to pull a 24 hour shift. But it’s still an intense time in medical education.

For me, residency is made all the more complicated by location. I was lucky enough to get one of my top two residencies. It was one of the three closest to my home. However that means it’s only..a one hour drive away. My wife and I have made the difficult decision to continue to live at home. So I will be entering the hardest education of my life, and adding a commute on top.

All this leaves very little space for Open Minded Health. That doesn’t mean Open Minded Health will end. I firmly believe in the mission of Open Minded Health: To bring health information to all gender and sexual minorities, so that we can all make the best health care decisions for ourselves.

What this may mean is less frequent, sporadic updates. It may mean guest posts and additional authors. It may mean a formal hiatus from new posts for a while. At least, until I get settled. I’m exploring options.

What this does not mean is a complete end to Open Minded Health. This website, and Trans 101, will stay up. I will continue to do my best to check on and respond to comments and questions.

For now, please accept my gracious thanks for being an Open Minded Health reader. I will update when I can.

Take care, all. Remember to play safe, see your doctor regularly, and enjoy life!

– Dr Rose Lovell

Apr 052016
 

Readers,

Open Minded Health is temporarily going to a biweekly post schedule. That is, posts will go from once a week to once every two weeks.

This is for a few reasons. My second year of medical school is coming to an end. I begin prepping for the first, and biggest, of the board exams next week. And I’ll be going into my clinical years in June. The clinical year is one of the busiest years in medical education, only surpassed by residency (the “internship” of medicine).

Going to a biweekly update schedule means updates can still come at regular intervals. I will do my best to make the posts more in depth so the wait is worth it.

I’m also working on a full update to Trans 101. I’ll let you all know when that’s done.

Thank you for continuing to read Open Minded Health!

~Rose

Feb 222016
 

Phalloplasty is one of two options for genital surgery for trans men. While it’s more expensive and extensive than the metoidioplasty, the additional size is often appreciated by the men who opt for it.

Suggestive flower is suggestive

Suggestive flower is suggestive

Why would I want a phalloplasty?

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.
  • Having a large penis. It both clearly identifies you as male and allows for penetrative sex.

What is involved in phalloplasty? What are my options? And what different techniques are there?

Phalloplasty is one of the most complex genital surgeries, with a lot of different varieties. Phalloplasty is anywhere from 1 to 4 surgeries, and often includes these procedures:

  • Creation of a phallus. There are two basic techniques: either a pedicled flap or a free flap. Pedicled flaps are from nearby areas and remain attached to the body at all times. Free flaps can be from other areas of the body (common areas are the forearm and back) and are fully detached and then reattached. Here’s an NSFW diagram comparing the two. We’ll talk more on these in a moment…
  • Urethral lengthening. The inner labia, among other tissues, are used to lengthen the urethra so you can pee from the tip of the penis. Not all surgeons do this.
  • Vaginectomy and scrotoplasty with implants. The vaginal tissue is removed and may be used in urethral lengthening. The labia are stitched together to make a scrotum, which can then have testicular implants.
  • Hysterectomy and oophorectomy. Removal of the uterus, fallopian tubes, and ovaries.
  • Penile implant. An implant to allow for erection is inserted. This is an additional surgery after the original surgeries have well healed, often 9 months or more.
  • Glansoplasty. Refinement of the appearance of the head of the penis.

Different surgeons do these parts at different stages. Some surgeons don’t do certain techniques at all — I know of at least one surgeon who doesn’t do urethral lengthening in their phalloplasties.

Now, what about where the penis comes from? The tissue is typically “rolled up” to make a penis, no matter where it’s from. That’s an unflattering description, but it produces some fabulous results. As for the technique — they’re either a pedicle technique or a free flap technique. Pedicle techniques take tissue from the abdomen or inner thigh and rotate it into its final place. Pedicles have their original nerves and blood supply, so some say they have less erogenous sensation. Pedicles do have less visible scarring than free flap.

Free flap detaches tissue completely from its old location and attaches it using microsurgery to its new home as a penis. Sensation is often intact because of this microsurgery. The tissue is usually from the forearm, back, or inner thigh. Scarring can potentially be an issue.

Both techniques provide erogenous and non-erogenous sensation. Both can be used for penetrative sex and for urinating while standing. Both are considered aesthetically pleasing — it’s up to what you want and what your chosen surgeon recommends for you.

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?

Phalloplasty is an intense surgery. All phalloplasties require full anesthesia. Pedicle generally requires less surgery time than free flap. I’ve seen hospital stays vary from 2-6 days, and initial recovery lasting 2-4 weeks. Return to work is often from 4-8 weeks depending on the surgery, your recovery, and how strenuous your work is.

For multiple stage phalloplasties, the first stage is often the longest and additional stages take less time and are less expensive.

What are the possible risks of phalloplasty?

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. And rarely some or all of the tissue can become infected or even die.

Penile implants occasionally have complications. They can slowly erode through the penis or be associated with infection. These complications are rare with today’s techniques and implants.

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?

Pedicle techniques have less scarring than free flap. Free flap scars can be significant but aren’t always — it depends on how you heal.

How will phalloplasty affect my long-term health?

The phalloplasty itself 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 phalloplasty?

If you have a penile implant, yes. A penile implant is required to achieve an erection.

Can I stand to urinate after a phalloplasty?

If you have a urethral lengthening procedure, yes.

What about the clitoris?

The clitoris can be buried at the base of the penis or tucked just underneath the penis. Either way, it can and does provide erogenous sensation.

Can I have a phalloplasty if I’ve already had a metoidioplasty?

Yes!

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:

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, 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: