Surgeons explain the slow, careful process.
With the trans community growing more visible, so has the cis fascination with gender confirmation surgeries available to people of all genders. But this fascination tends to be paired with enduring myths among cis and trans people alike. For transmasculine people, one of the biggest myths is that constructing a neophallus—otherwise known as a penis—is too big a technical challenge to pull off and won't be "the real thing" anyway.
That myth isn't keeping pace with surgical reality, as it's come a long way since the first known phalloplasty for the purpose of gender confirmation surgery in 1946.
While the penis is a potent and loaded symbol of masculinity, not all transmasculine people opt for one of the constellation of procedures known as "bottom surgery." Some don't feel that bottom surgery is necessary for them; there is no single right way to do gender, and surgical procedures aren't required to affirm someone's masculinity. Others opt to wait for a variety of reasons, from worries about costs to concerns about surgical outcomes.
Those who do face some decisions about the kind of surgery that's right for them. "Not everyone chooses to pursue phalloplasty," says Loren Schechter, a plastic surgeon in Chicago, referring to procedures in which surgeons build a penis for the patient. "Some men opt to undergo a metoidioplasty [or meta], which is less complex."
"With metas," says Marci Bowers, a gynecological surgeon and gender confirmation specialist based in California, "the cool thing is that they're all local tissue. Nothing is imported." Everyone, she explains, "has erectile tissue, spongy tissue, we all work sexually in similar ways." Patients on testosterone tend to experience an increase in clitoral size over time, and it can be accentuated through this procedure, in which the clitoris is freed from the labia to make it more prominent. A surgeon can also construct a scrotum, and lengthen the urethra to allow the patient to urinate while standing. The results tend to be smaller than with phalloplasty, which leaves some patients feeling dissatisfied. "But it is a penis. There's no doubt about it," Bowers says.
For those who feel phalloplasty is a better choice, navigating the series of surgeries involved is a long and sometimes frustrating experience. "It's a very long recovery period," says Kaleb Payne, a trans man who underwent the first stage over the summer. "It's really hard. One of the toughest things I've ever done, not just physically but emotionally and mentally." It includes weeks of living with a bruised, painful, swollen groin, and a period of time with a catheter while the body heals enough to allow a patient to try peeing independently.
The surgery requires a series of stages, Schechter says, in which a skin graft is taken from the forearm or thigh and used to construct a phallus; at the same time, patients may opt for a vaginectomy and scrotoplasty, in which a surgeon constructs testicles that can be filled out with implants. "We've continued to improve and evolve our techniques," he explains, noting that surgeons all over the world have their own preferred approaches, but that most take several stages because of the surgery's complexity.
Once they've fully recovered, patients can also opt for flexible rods or inflatable implants, which allows them to achieve erections—with or without implants, the penis has sensation and patients experience orgasms. The procedures may stretch over the course of a year or more, and come with risks like strictures (blockages in the urethra causes by changes in diameter) and fistulas (unwanted openings that cause leakage), Bowers explains. Payne notes that the procedure also leaves the patient with a very distinctive scar and the need for physical therapy—he'll bear a marker of his experience on a very public part of his body for the rest of his life.
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There's an enduring attitude among some surgeons and occasionally trans people themselves that the outcome of phalloplasty and meta is substandard—something Bowers says may be exacerbated by worries about masculinity. Complaints about poor outcomes include suggestions that the resulting phallus isn't "realistic" or offers limited sexual performance. Given a collective social obsession with the size, shape, and general characteristics of penises, it's perhaps not surprising that questions of self-image and worries about appearance arise; for people getting a brand-new penis from scratch as adults, the pressure to compare can be immense.
"Even myself post-surgery," Payne says, "I was still like: 'I don't know…it's on my body, and I like it because it's mine, but I don't know.' But now that I've had glansplasty, it's healing, the swelling is going down, and it changes everything. People who say results aren't where they want them to be are just seeing very early healing photos, and it's just not the same."
The question, Payne argues, shouldn't be one of why it's so difficult to construct a penis that feels affirming for a patient, but why surgeons and patients alike can't communicate about the tremendous advances in surgical outcomes. He notes that it's much harder to show photos of surgical results on social media when it comes to genitals, and that consequently, it's hard for those considering the surgery to find pictures of what to expect in both the short and long term. Instead, they're forced to rely on a trans information underground that can be hard to find.
Payne only intended to transition socially, but found that the further he got into transition, the greater his dysphoria became, a path that led him to exploring phalloplasty options. Along the way, he reached out to other people who'd had the procedure for information and mentoring, and advises others to do the same. "It's important to talk to as many people as you can," he says, "because everyone has a different experience."
Schechter also notes that this is a family of surgeries with a bright future: The more surgeons practice and share techniques and advice, the better they get. In a world where the future of medicine includes lab-grown skin and organs, for example, it's not impossible to think that labs might someday allow people to grow their own phalluses. A handful of cadaver transplants for cis men have opened up another avenue of possibility, though they've come with loaded implications—one man later asked for a reversal of the procedure because he felt uncomfortable with his new penis.
Payne hopes to see myths about bottom surgery dispelled in the coming years. It will always be challenging to build a penis, but outcomes are getting better and better for patients. Among transmasculine people who experience intense dysphoria because of their genitals, these can be not just affirming but lifesaving procedures; and at the end of the day, a penis is a penis is a penis.
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