This can take different forms, including the removal of breasts — a mastectomy — and the altering of the genital region, known as “bottom” surgery.
Examples of bottom surgery include:
- removal of the uterus, known as a hysterectomy
- removal of the vagina, known as a vaginectomy
- construction of a penis through metoidioplasty or phalloplasty
In this article, we describe female-to-male gender-affirming surgeries. We also discuss recovery and what to expect from a transgender penis.
Before having female-to-male gender-affirming surgery, a person will receive testosterone replacement therapy.
They may then undergo one or more of the following types of procedure.
A person undergoing surgery to transition from female to male typically has a subcutaneous mastectomy to remove breast tissue. The surgeon will also make alterations to the appearance and position of the nipples.
Meanwhile, testosterone therapy will stimulate the growth of chest hair.
Removal of the uterus, ovaries, and fallopian tubes
There a number of different surgical procedures for female-to-male sex reassignment.
A person may wish to undergo this type of surgery if they are uncomfortable having a uterus, ovaries, or fallopian tubes, or if hormone therapy does not stop menstruation.
In a partial hysterectomy, a surgeon will remove only the uterus.
In a total hysterectomy, they will also remove the cervix.
A bilateral salpingo-oophorectomy, or BSO, involves the removal of the right and left fallopian tubes and ovaries.
A metoidioplasty is a method of constructing a new penis, or neopenis.
It involves changing the clitoris into a penis. A person will receive hormone therapy before the surgery to enlarge the clitoris for this purpose.
During the procedure, the surgeon also removes the vagina, in a vaginectomy.
In addition, they lengthen the urethra and position it through the neopenis. To achieve the lengthening, the surgeon uses tissues from the cheek, labia minora, or other parts of the vagina. The aim of this is to allow the person to urinate while standing.
Another option is a Centurion procedure, which involves repositioning round ligaments under the clitoris to increase the girth of the penis.
A metoidioplasty typically takes 2–5 hours. After the initial surgery, additional procedures may be necessary.
A Centurion procedure takes approximately 2.5 hours, and removing the female reproductive organs will add to this time.
An advantage of a metoidioplasty is that the neopenis may become erect, due to the erectile abilities of clitoral tissue.
However, a neopenis resulting from a metoidioplasty is often too small for penetrative sex.
A phalloplasty uses grafted skin — usually from the arm, thigh, back, or abdomen — to form a neopenis. Doctors consider taking skin from the forearm to be the best option in penile construction.
Compared with a metoidioplasty, a phalloplasty results in a larger penis. However, this neopenis cannot become erect on its own.
After a period of recovery, a person can have a penile implant. This can allow them to get and maintain erections and have penetrative sex.
During a phalloplasty, the surgeon performs a vaginectomy and lengthens the urethra to allow for urination through the penis.
Disadvantages of a phalloplasty include the number of surgical visits and revisions that may be necessary, as well as the cost, which is typically higher than that of a metoidioplasty.
A person may decide to have a scrotoplasty — the creation of a scrotum — alongside a metoidioplasty or phalloplasty.
In a scrotoplasty, a surgeon hollows out and repositions the labia majora to form a scrotum and inserts silicone testicular implants.
A person may have to stay in the hospital for a couple of days following surgery.
The recovery time from female-to-male surgery varies, depending on the type of procedure and factors such as the person’s overall health and lifestyle choices.
For example, smoking slows down recovery and increases the risk of complications following surgery. If a person smokes, vapes, or uses any substance with nicotine, a medical team may consider them less eligible for this type of surgery.
Following gender-affirming surgery, most people need to stay in the hospital for at least a couple of days.
After leaving the hospital, the person needs to rest and only engage in very limited activities for about 6 weeks or longer.
Also, when a person has had a urethral extension, they need to use a catheter for 3–4 weeks.
Some complications of a metoidioplasty or phalloplasty include:
- urethral fistula — a tunneled connection that forms between the urethra and another part of the body
- urethral stricture — a narrowing that causes a blockage of urine flow within the urethra
A person who has had a phalloplasty may experience:
- scarring in the area where the graft was taken
- skin graft failure or tissue death
Risks of a scrotoplasty include rejection of the testicular implants.
All gender-affirming surgeries carry a risk of:
- reactions to anesthesia
- dissatisfaction with the results
What to expect
A person’s experience after surgery may vary, depending on the procedure they had.
A person who undergoes a metoidioplasty may have erections and enjoy more sensation in their neopenis. However, the penis will be relatively small in size.
A neopenis that results from a phalloplasty is usually larger, though it may be less sensitive. To have erections, a person will need a penile implant.
If a person has urethral extension, the goal is to be able to urinate while standing after a full recovery from the procedure. Some studies report a high number of urological complications following phalloplasties. It is important to attend regular follow-ups with a urologist.
A 2005 study of 55 people who underwent gender-affirming surgery — including 23 female-to-male participants — notes that 80% of all participants reported “improvement of their sexuality” following surgery.
Transgender men tended to report more frequent masturbation, sexual satisfaction, and sexual excitement than transgender women. They also reported reaching orgasms more easily than they had before surgery and a tendency toward “more powerful and shorter” orgasms.
Transgender men with penile implants for erections experienced pain more frequently during sex than those without implants. However, they also reported that their sexual expectations were more fully realized, compared with participants who had not received implants.
A 2018 study found that 94–100% of participants who had undergone gender-affirming surgery reported satisfaction with the surgical results, with the variance depending on the type of procedure.
The 6% of people who reported dissatisfaction or regret did so as a result of preoperative psychological symptoms or complications following the procedures.
The outlook for female-to-male surgery depends on the type of surgery, the person’s health, and other factors. Most people report satisfaction following the procedure.
However, the complication rate is relatively high, especially in relation to urinary health.
It is also essential to follow recovery guidelines and attend all follow-up appointments.