FTM genital reconstruction is a
controversial topic, even among transmen.
Everyone seems to have an opinion about what is
acceptable, what is abominable, which technique
is the "right" one to achieve the "best"
results. And, yes, there are FTM people who are
completely opposed to surgery and who think it
should not be necessary to have our parts
rearranged in order to be legally male. I
believe the important thing is to make real
information available so that transmen can make
informed decisions, and none of us should be
judgmental against people who make decisions
about their bodies that do not conform to our
own: our own decisions or bodies. We can
certainly have opinions, but there is no need to
express them in a way that invalidates the
opinions of others.
We may never know how long and hard someone
worked to save the money to get surgery, how
many complications they endured, how hard they
have struggled to come to terms with the results
of their decisions, or conversely, how pleased
they are with them. The genital surgical
reconstruction options available to transmen
today leave much to be desired. If genital
reconstruction is what you need in order to feel
at home in your body, you will have to learn to
want less. Sometimes surgery is necessary for us
in order to feel like we can leave transition
behind and get on with our lives, or in order to
attain legal status as a male. One reason for
having surgery may be sexual satisfaction or
other complex, erotically driven desires. The
factors that drive those of us who do to have
genital surgery are as different as one person's
genitals are from another's.
There are two basic ways to surgically make a
penis: phalloplasty and metaoidioplasty. Modern
phalloplasty techniques came into use
around 100 years ago, driven by the need to
replace penises on men who lost them in wars and
industrial accidents. The techniques were
applied to male-identified female-bodied people
as early as the 1930s, with the first documented
procedure in peer-reviewed surgery journals
appearing in England in 1948. The last
significant advance occurred about 25 years ago
with the advent of microsurgery, which enabled
surgeons to connect nerves to make the penis
sensate. Prior to that, phalloplasty could
result in a possibly good-sized and occasionally
realistically shaped penis that had no erotic
sensation.
The skin to make the penis was (and still is,
in the classical phalloplasty technique) usually
taken from the abdomen or hip and grafted into
the groin area, sometimes above the mons pubis,
sometimes directly on it. The ability to urinate
through the penis has been technically
problematic until relatively recently, and
urethral extension is still not always
successful. Erections are achieved with either a
stent or rod implanted permanently or inserted
temporarily in the penis, or with an implanted
hydraulic pump like those used to assist some
men who have lost erectile capability.
The type of phalloplasty that can be
erotically sensate usually employs the skin and
muscle from the forearm, though sometimes thigh
or deltoid muscle is used. The muscle makes a
denser phallus, and nerves in the tissue can be
connected with existing nerves in the genital
area, most importantly the pudendal nerve that
enervates the penis (and clitoris). The scrotum
can be constructed from the labia majora (better
for sensation, but possibly not forward enough
on the body) or from tissue from the lower
abdomen, depending on the surgeon's technique.
These procedures can range in cost from around
$15,000 to well over $100,000, depending on
technique, complications, etc. Usually more than
one trip to the operating room is required, as
the procedure is rarely successful when done in
one stage, though exceptions do occur.
Metaoidioplasty (commonly spelled
metoidioplasty), meaning "a surgical change
toward the male," is a term coined by one of the
surgeons who developed the technique in the
1970s. It results in a small penis, but one that
is erotically sensate and capable of unassisted
erection. Derided by some as not masculine
enough, for many transmen it is an acceptable
alternative because it does not leave scars on
other parts of the body, and because of the
promise of erotic sensation. Not all transmen
are good candidates for this procedure because
acceptable results require a significant amount
of testosterone-induced growth in the clitoris
(usually discernable after about one year of
testosterone treatment). And not all transmen
are capable of accepting themselves with a small
penis.
Metoidioplasty techniques can be compatible
with urethral extension, and with the proper
placement of the penis and scrotum forward on
the body (which sometimes doesn't happen, due to
the transman's original physical construction or
the surgeon's technique), a very
natural-looking, natural-feeling package is
achievable. This procedure may be done as an
outpatient in a clinic, though, as with
phalloplasty, a general anesthetic is required.
It can be done in one stage, though some
surgeons prefer to construct the penis and
scrotum first, then place testicular implants in
the scrotum in a second procedure using local
anesthetic and a sedative rather than a second
general anesthesia. Costs for this procedure
range from roughly $10,000 to $20,000.
For more information on FTM genital
reconstruction, as well as photos of surgical
results, readers should consult surgery journals
such as Annals of Plastic Surgery, Plastic
Reconstructive Surgery, or Journal of
Reconstructive Microsurgery, which are
usually available in the libraries of
universities with medical schools. Ask the
librarian to show you how to do a search on the
topic of penis reconstruction or male genital
surgery, and you'll be amazed at how much there
is to read!
Online, you can start with my article
"Getting Real About FTM Surgery," available at
www.gender.org,
then comb the archives of the International
Journal of Transgenderism for more medical
articles and other references. You can also see
some results of surgery on photographer Loren
Cameron's Web site, at www.lorencameron.com.
We're not done yet! Next month, further
surgical considerations for transmen.
