When it comes to lower surgery, transgender and nonbinary people who were assigned female at birth (AFAB) have a few different options. One of the most common lower surgeries that is routinely performed on AFAB trans and nonbinary people is called metoidioplasty.
Metoidioplasty, also known as meta, is a term used to describe surgical procedures that work with your existing genital tissue to form what is called a neophallus, or new penis. It can be performed on anyone with significant clitoral growth from the use of testosterone. Most doctors recommend being on testosterone therapy for one to two years before having metoidioplasty.
There are four basic types of metoidioplasty procedures:
Also known as simple meta, this procedure consists only of the clitoral release — that is, a procedure to free the clitoris from surrounding tissue — and doesn’t alter the urethra or vagina. Simple release increases the length and exposure of your penis.
Surgeons who perform full metoidioplasty release the clitoris and then use a tissue graft from the inside of your cheek to link the urethra with the neophallus. If desired, they may also perform vaginectomy (removal of the vagina) and insert scrotal implants.
This procedure is very similar to full metoidioplasty. However, instead of taking a skin graft from the inside of the mouth, the surgeon uses a graft from the inside of the vaginal wall combined with the labia majora in order to connect the urethra and the neophallus.
The advantage to this procedure is that you’ll only have to heal at one site as opposed to two. You also won’t experience complications that may arise from surgery in the mouth such as pain while eating and decreased production of saliva.
The Centurion procedure releases the round ligaments that run up the labia from the labia majora, and then uses them to surround the new penis, creating extra girth. Unlike other procedures, Centurion doesn’t require that a skin graft be taken from the mouth or from the vaginal wall, meaning there is less pain, less scarring, and fewer complications.
Phalloplasty is the other most common form of lower surgery for AFAB trans and nonbinary people. While the metoidioplasty works with existing tissue, phalloplasty takes a large skin graft from your arm, leg, or torso and uses it to create a penis.
Metoidioplasty and phalloplasty each have their own unique benefits and disadvantages.
Pros and cons of metoidioplasty
Here are some of the pros and cons of metoidioplasty:
- fully functioning penis that can become erect on its own
- minimal visible scarring
- fewer surgical procedures than phalloplasty
- can also have a phalloplasty later if you choose
- Shorter recovery time
- significantly less expensive than phalloplasty, if not covered by insurance: ranges from $2,000 to $20,000 versus $50,000 to $150,000 for phalloplasty
- new penis relatively small in both length and girth, measuring anywhere from 3 to 8 cm in length
- may not be capable of penetration during sex
- requires use of hormone replacement therapy and substantial clitoral growth
- may not be able to urinate while standing
The initial metoidioplasty surgery can take anywhere from 2.5 to 5 hours depending on the surgeon and on which procedures you choose to have as part of your metoidioplasty.
If you’re seeking out simple meta only, you’ll likely be placed under a conscious sedation, meaning that you’ll be awake but mostly unaware during the surgery. If you’re having a urethral lengthening, hysterectomy, or vaginectomy performed as well, you’ll be placed under general anesthesia.
If you choose to have scrotoplasty, the doctor may insert what are known as tissue expanders into the labia during the first procedure in order to prepare the tissue to accept the larger testicle implants during a follow-up procedure. Most surgeons wait three to six months to perform the second surgery.
Most doctors perform metoidioplasty as an outpatient surgery, meaning you’ll be able to leave the hospital on the same day that you have the procedure. Some doctors may request that you stay overnight following your surgery.
As with any surgery, the recovery process will vary from person to person and from procedure to procedure.
While recovery times vary somewhat, you’re likely to be out of work for at least the first two weeks. As well, it’s generally recommended that you don’t do any heavy lifting for the first two to four weeks following surgery.
In general, doctors typically advise against travel between 10 days to three weeks after the procedure.
Apart from the standard issues that may arise from having surgery, there are a few potential complications you may experience with metoidioplasty. One is called a urinary fistula, a hole in the urethra that can cause leakage of urine. This can be repaired surgically and in some instances may heal itself without intervention.
The other potential complication if you’ve chosen scrotoplasty is that your body may reject the silicone implants, which may result in needing to have another surgery.
There are several procedures that can be performed as a part of metoidioplasty, all of which are completely optional. Metoidioplasty.net, a useful resource for those interested in pursuing metoidioplasty, describes these procedures as follows:
The ligament, the tough connective tissue that holds the clitoris to the pubic bone, is cut and the neophallus is released from the clitoral hood. This frees it from the surrounding tissue, increasing the length and the exposure of the new penis.
The vaginal cavity is removed, and the opening to the vagina is closed.
This procedure reroutes the urethra up through the neophallus, allowing you to urinate from the neophallus, ideally while standing up.
Small silicone implants are inserted into the labia to achieve the look and feel of testicles. Surgeons may or may not suture the skin from the two labia together to form a joined testicular sac.
A portion of the skin from the mons pubis, the mound just above the penis, and some of the fatty tissue from the mons are removed. The skin is then pulled upward to shift the penis and, if you choose to have scrotoplasty, the testicles further forward, increasing the visibility of and access to the penis.
It’s entirely up to you to decide which, if any, of these procedures you would like to have as a part of your metoidioplasty. For instance, you may wish to have all of the procedures performed, or you may wish to undergo the clitoral release and urethroplasty, but retain your vagina. It’s all about making your body align best with your sense of self.
It’s important to do your research and figure out which surgeon is the best fit for you. Here are some factors that you may want to consider when choosing a surgeon:
- Do they offer the specific procedures I want to have?
- Do they accept health insurance?
- Do they have good reviews for their results, instances of complications, and bedside manner?
- Will they operate on me? Many doctors follow the World Professional Association for Transgender Health (WPATH) standards of care, which requires that you have the following:
- two letters from medical professionals recommending you for surgery
- presence of persistent gender dysphoria
- at least 12 months of hormone therapy and 12 months of living in the gender role congruent with your gender identity
- age of majority (18+ in the United States)
- ability to make informed consent
- no conflicting mental or medical health issues (Some doctors won’t operate on persons with a BMI of over 28 under this clause.)
The outlook after metoidioplasty is generally very good. A 2016 survey of several metoidioplasty studies in the journal Plastic and Reconstructive Surgery found that 100 percent of people who undergo metoidioplasty retain erogenous sensation while 51 percent are able to achieve penetration during sex. The study also found that 89 percent were able to urinate while standing up. While the researchers argue that further studies will be necessary to improve the accuracy of these results, the initial findings are very promising.
If you wish to have lower surgery that is affordable, has minimal complications, and offers great results, metoidioplasty might be the right option for you to align your body with your gender identity. As always, take time to do your research to figure out which lower surgery option will help you to feel like your happiest, most authentic self.