Metoidioplasty is a gender-affirming surgery for transgender men (female-to-male, or FTM) and some non-binary individuals. It involves constructing a penis from the clitoris, which has been enlarged through the use of testosterone. Unlike phalloplasty, which involves the creation of a penis from other donor tissues, metoidioplasty uses the individual's existing genital tissue to form a neophallus. This procedure is generally less invasive than phalloplasty and can offer individuals the ability to urinate while standing and experience sexual sensation.

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Purpose and Importance

Metoidioplasty is chosen by many transgender men because it can provide a penis that allows for sexual function and, in some cases, urination while standing, without the extensive surgical interventions required for phalloplasty. The main advantage of metoidioplasty is that it retains the existing sensation in the clitoris, providing a natural basis for sexual pleasure, while still masculinizing the genital area.

For transgender men, alleviating gender dysphoria by achieving a more masculine genital appearance can be a significant aspect of their transition. Metoidioplasty offers an option that is less invasive than phalloplasty but still allows for physical alignment with one’s gender identity.

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Procedure

The metoidioplasty procedure focuses on using the clitoral tissue that has been enlarged through testosterone therapy. The basic steps of the procedure are as follows:

1. Hormone Therapy (Preparation):

   • Prior to surgery, the individual must undergo testosterone therapy for a period of time. Testosterone promotes clitoral growth, which is necessary for metoidioplasty. Typically, the clitoris grows to about 4–6 cm in length, which forms the basis of the neophallus.

   • Hormone therapy also causes the development of other male secondary sexual characteristics, such as facial and body hair and deepening of the voice.

2. Clitoral Release:

   • In the main surgical step, the surgeon releases the clitoris from its surrounding tissues, lengthening it and giving it the appearance of a small penis. The surrounding labial tissue may be reshaped to create a scrotum-like structure.

3. Urethral Lengthening (Optional):

   • Some individuals opt to have their urethra extended through the neophallus, allowing them to urinate while standing. This step involves constructing a new urethra from existing tissue and connecting it to the clitoris. Urethral lengthening is one of the more complex parts of the surgery and can carry risks of complications, such as urethral strictures or fistulas.

4. Scrotoplasty (Optional):

   • Scrotoplasty is the creation of a scrotum using the labia majora. Silicone testicular implants may also be inserted to enhance the appearance, depending on the individual’s preference.

5. Vaginectomy (Optional):

   • Some transgender men choose to have a vaginectomy (removal or closure of the vaginal canal) as part of their metoidioplasty. This procedure is optional and depends on whether the individual wants to retain their vaginal anatomy.

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Types of Metoidioplasty

There are several variations of metoidioplasty, allowing individuals to customize the surgery based on their goals:

• Simple Metoidioplasty: Only the clitoris is released, and the urethra is not extended. This is the least invasive option and has the shortest recovery time. However, the individual will not be able to urinate while standing.

• Full Metoidioplasty: This includes urethral lengthening and, in some cases, scrotoplasty. This option provides more complete masculinization but comes with a higher risk of complications.

• Centurion Procedure: A type of metoidioplasty that includes additional surgical steps to create a more defined neophallus and urethral extension.

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Recovery

Recovery from metoidioplasty is generally faster than from phalloplasty, though it depends on the specific procedures involved. Some key aspects include:

• Immediate Post-Operative Care: Patients will typically remain in the hospital for a few days for observation. Swelling and bruising are common, and patients may need a catheter for urination if urethral lengthening was performed.

• Dilation and Hygiene: If the individual has undergone urethral lengthening, maintaining the new urethral opening may require regular dilation. Proper hygiene is also essential to prevent infection, particularly around the surgical site.

• Activity Limitations: Individuals must avoid strenuous activities, heavy lifting, and sexual activity for several weeks or even months post-surgery to ensure proper healing. Full recovery can take several months.

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Risks and Complications

Although metoidioplasty is less invasive than phalloplasty, it still carries certain risks and potential complications, such as:

• Urethral Issues: Complications related to urethral lengthening, such as strictures (narrowing) or fistulas (abnormal connections), are possible and may require additional surgeries to correct.

• Aesthetic Concerns: The appearance of the neophallus may not meet all expectations, as the size of the clitoris after testosterone therapy is typically smaller than a fully developed penis. Some individuals may choose additional procedures for cosmetic enhancement.

• Loss of Sensation: While metoidioplasty generally preserves sexual sensation, there is a risk of nerve damage during surgery, which could affect sensitivity.

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Mental Health and Emotional Impact

For many transgender men, metoidioplasty offers a significant improvement in quality of life by reducing gender dysphoria and increasing feelings of comfort and congruence with their gender identity. The ability to urinate while standing, the masculinization of the genitals, and the preservation of sexual sensation are all key factors that can enhance an individual’s sense of self and improve mental well-being. However, metoidioplasty may not meet everyone’s needs, as some individuals prefer the more substantial results of phalloplasty.

Psychological preparation and counseling are typically recommended before and after surgery to help individuals set realistic expectations and cope with any emotional challenges during recovery.

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Advantages Over Phalloplasty

Metoidioplasty has certain advantages over phalloplasty, such as:

• Less Invasive: The surgery is less complex, and recovery is faster compared to phalloplasty.

• Preservation of Sensation: The procedure preserves the natural sensitivity of the clitoris, which is a significant consideration for sexual function.

• Fewer Surgeries: While phalloplasty often requires multiple surgeries, metoidioplasty can be completed in fewer stages.

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Conclusion

Metoidioplasty offers a gender-affirming surgical option for transgender men and non-binary individuals seeking to masculinize their genitals without undergoing the more invasive procedures involved in phalloplasty. The surgery provides the potential for sexual sensation, urination while standing, and a more masculine appearance, making it an attractive option for those seeking alignment with their gender identity. With proper planning, mental health support, and experienced surgeons, metoidioplasty can significantly reduce gender dysphoria and improve quality of life.