Content Note: In this article I’m talking about genitals. I’m going to use words that some transgender people might not use for their own genitals and therefore might find uncomfortable to read. I use the terms ‘clitoris’ and ‘new phallus’ to describe the genitals of certain trans people. And I use the term ‘natal-penis’ to describe the genitals of cis-gendered men.
Disclaimer: I am not a medical expert and am simply speaking from my own experience and research on the topic.
Metoidioplasty is a surgical procedure for trans and non-binary people who are assigned female at birth.
The topics covered in this post are:
- Who Can Have Metoidioplasty Surgery?
- What Does This Surgery Entail?
- Metoidioplasty: Simple Release
- Metoidioplasty: Urethral Lengthening
- Metoidioplasty: Scrotoplasty
- Metoidioplasty: Vaginectomy
- Urinary Catheter
- Surgical Outcomes and Sexual Function
- What About Phalloplasty?
Who Can Have Metoidioplasty Surgery?
In order to be eligible for this surgery, you will usually need to have been taking testosterone for at least two years. This is because testosterone naturally enhances the size of the clitoris, which is then further enhanced surgically during metoidioplasty surgery.
What Does This Surgery Entail?
There are several different approaches and possible stages to this surgery.
Some people choose to simply undergo one stage, which is generally known as the simple release. However, it is also possible to extend the urethra to allow for urination while standing. It is also possible to opt for the addition of a scrotum and testicles.
Metoidioplasty: Simple Release
During surgery for the simple release, ligaments which hold the clitoris in place are cut away. This allows the clitoris, or new phallus, to be positioned further forward of the body, in a similar way to a natal-penis. Additionally, the head of the new phallus is sculpted to become similar in appearance to a natal-penis.
The simple release is a fairly simple surgery. The patient should expect to resume normal day to day activities after a few weeks.
Metoidioplasty: Urethral Lengthening
If the patient wants to be able to stand to urinate, then a process known as urethral lengthening can be used to extend the urethra up and underneath the new phallus.
If this is the case, then a skin graft will usually be taken from the mouth. This graft of skin will be surgically attached beneath the new phallus. This will all be done during the same surgery as the simple release.
The patient will then be required to heal for several months before undergoing a second procedure.
During the second surgery, the skin graft will be used to create a tube. This tube allows the urethra to extend up underneath the tip of the new phallus.
Urethral lengthening is not without risk of complication and this is a problem that I experienced. You can read all about that by clicking here.
Complications include the risk of a fistula, which is a leak in the urethra, as well as problems with leakage or trouble urinating properly.
Upon successful completion of urethral lengthening, a person should be able to stand to urinate. The potential to do this at a public urinal will vary depending on the result. For some, it may not be possible to urinate as far as required to do this without issue. However, urinating at home or in a private toilet cubicle should be possible.
Some patients wish to undergo further procedures to add prosthetic testicles.
The scrotum will be created using skin from the labia majora, which is the outer fleshy tissue surrounding the genitals. Prosthetic testicles, usually made of silicone, will be implanted into the newly created scrotum.
This is a process that can involve several surgeries as the skin may need to be adequately stretched. It is also possible that corrective surgeries may be required to adjust the positioning of the new testicles, or to rectify additional complications.
A vaginectomy is the surgical removal and closure of the vagina. Metoidioplasty patients may wish to do this but they are not required to do so.
It is worth noting that not having a vaginectomy has been known to increase the risk of complication for those who are undergoing urethral lengthening.
During the simple release and the urethral lengthening stages of metoidioplasty, you will be required to use a catheter to urinate. Depending on the surgery, this will either be a single catheter through the urethra, or a combination of a stent catheter through the urethra to stem the flow of urine and a suprapubic catheter directly through the lower abdomen into the bladder.
The catheter will usually remain in place for ten days for the simple release surgery. It will remain for three weeks for the urethral lengthening procedure.
A common side effect of being catheterised, that your surgeon for some reason may not tell you about, is bladder spasms. This is when the bladder contracts due to irritation from the catheter. Bladder spasms can be quite painful and distressing, but this problem should be easily resolved by taking oxybutynin.
Side note: Personally, my surgeon had not warned me about bladder spasms On Christmas Day (unfortunate timing) an out-of-hours GP refused to accept my request for this medication due to a lack of knowledge. This meant I had to go to A&E to obtain the medication and finally get some relief. This could have been entirely avoided and was the worst few days of my recovery. So, I recommend either getting oxybutynin in advance, or knowing how to get it at short notice should you need it.
Surgical Outcomes and Sexual Function
The new phallus will likely be between five and seven centimetres in length once metoidioplasty is healed and complete. Similarly, to a natal-penis, the new phallus can become erect. In my experience, even when erect, the new phallus is not really big enough to penetrate a sexual partner. However, opinion on this differs and some people report that it is possible and satisfactory.
Concerns about maintaining sexual sensitivity are common among those considering this surgery. Some people report that orgasm is the same as it was pre-surgery, while some report that it is better or simply different.
A word about ejaculation – Around one year after my second surgery, I started to notice that sometimes I appear to ejaculate out of the tip of my new phallus. This only happens if I have been aroused for a while and is a small amount of fluid. It doesn’t usually happen if sex or masturbation is brief. For me, this is visually quite exciting and adds to the experience.
This fluid comes from the Skene’s glands. These are two glands located on either side of the urethra. In people who are assigned female at birth, the Skene’s glands are often compared to the prostate of people who are assigned male at birth. This is due to similarities in behaviour and pleasure potential, and is not actually concerned with a similarity in function or purpose.
The tissue surrounding the Skene’s glands will swell as blood flows to the area when the person becomes sexually aroused. This will also cause the new phallus to swell. The glands will release fluids which contain mucus as they are stimulated. This fluid acts as a lubricant during penetrative sex at the front (not anal sex).
For people who have had urethral lengthening as part of metoidioplasty surgery, this fluid can present at the tip of the new phallus as though ejaculation is taking place.
Metoidioplasty patients may choose to have a hysterectomy during the surgical process. However, this is not a requirement, and it is totally fine and normal to choose not to do this.
A hysterectomy is a surgical procedure to remove the womb. People who choose to have a hysterectomy will no longer be able to get pregnant and will no longer have periods.
As a part of having a hysterectomy, patients may also choose to have the cervix and the ovaries removed. The recovery period from a hysterectomy is between six and eight weeks.
What About Phalloplasty?
Undergoing metoidioplasty surgery does not mean that you can’t later go on to have phalloplasty. The process of phalloplasty cannot be reversed for metoidioplasty instead.
I hope you found this to be informative and helpful – thanks for reading!
If you have any feedback on anything that I’ve said or you would like to ask a question about my personal experience of having this surgery, then please shoot me a message over on Instagram.