Trans couple smiles at each other and holds hands.
Trans couple smiles at each other and holds hands.
Trans couple smiles at each other and holds hands.

Metoidioplasty for Gender Affirming Care

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Metoidioplasty is a surgical procedure for gender affirmation that is sometimes called a meta procedure or bottom surgery. It is an alternative to phalloplasty. Metoidioplasty uses tissue from a hormone-enlarged clitoris to create a penis about 4 to 6 centimeters (up to 2 1/3 inches) long.

What You Need to Know

  • Metoidioplasty is a surgery for masculinizing gender affirmation.
  • A metoidioplasty may have fewer steps than a phalloplasty and may help the patient retain sexual sensation and the ability to have an erection without a penile implant.
  • The procedure may enable the patient to urinate (pee) in a standing position.
  • Metoidioplasty starts with a year of hormone treatment and may include several steps to create a scrotum and to add testicular implants.

What is metoidioplasty?

Metoidioplasty is a gender affirming, lower body (bottom) surgery. The procedure creates a penis about 4 to 6 centimeters long using the clitoris, which may be enlarged by hormone therapy. The surgery can be completed in stages, each performed a few months apart, depending on the patient’s objectives.

Metoidioplasty: What Happens

  1. The first step is enlarging the clitoris with a year (or more) of hormonal therapy with testosterone.
  2. Once the clitoris is enlarged, the surgeon performs a procedure to cut the ligaments that surround the clitoris to free it from the pubic bone.
  3. The released clitoris is used to create a penis that can become erect without the need of a penile implant.
  4. Surgeons connect the urethra (the passageway through which urine leaves the body) so the patient can urinate while standing. The urethra may be lengthened using local tissues or grafted tissue from elsewhere.
  5. A scrotum (the sac that holds the testicles) can be formed using skin from the outer labia (the vulva’s outer lips).

Metoidioplasty: Additional Options

Depending on the patient’s outcome preferences, the surgeon may perform additional procedures after the metoidioplasty.

Three to six months after creating the penis:

  • Fatty tissue near the penis can be removed to enhance the appearance of length, in some cases.
  • Later, implants can be inserted under the skin of the scrotum to create the look of testicles.

After a metoidioplasty, some people choose a phalloplasty to add length and girth to the penis. Experts advise that, in most cases, if length and girth are of primary importance to the patient, starting with a phalloplasty will lead to less surgery.

Bottom surgery for masculinization (metoidioplasty or phalloplasty) may also include procedures to:

  • Close the internal vaginal canal
  • Remove the uterus (hysterectomy)
  • Remove the ovaries (oophorectomy)

The Center for Transgender and Gender Expansive Health Team at Johns Hopkins

Embracing diversity and inclusion, the Center for Transgender and Gender Expansive Health provides affirming, objective, person-centered care to improve health and enhance wellness; educates interdisciplinary health care professionals to provide culturally competent, evidence-based care; informs the public on transgender health issues; and advances medical knowledge by conducting biomedical research.

Who might be a candidate for metoidioplasty?

Metoidioplasty is part of gender affirmation treatment and may be an option for people assigned female at birth who have gender dysphoria and who seek a transition to male or nonbinary gender.

Metoidioplasty Pros and Cons

Like phalloplasty, metoidioplasty can help a person reach their goals for gender affirmation, but the procedures are different. Each has its pros and cons. By exploring what is most important to the patient, an experienced surgeon can help the patient decide on the most appropriate plan.

Metoidioplasty Pros

  • Metoidioplasty includes a hospital stay of about three days.
  • Some people can urinate from a standing position after a metoidioplasty, depending on body build and their anatomy.
  • The procedure does not leave scars on the arms, thighs or back.
  • Metoidioplasty offers a chance for preserved sexual sensation since the shaft of the created penis contains the nerves and erectile tissue of the clitoris.
  • A person may be able to attain an erection without use of a penile implant.

Metoidioplasty Cons

  • The penis created by metoidioplasty is about 4 to 6 centimeters long and does not create a masculine contour or bulge in underwear or close-fitting pants.
  • Having penetrative sex is not possible with the penis that results from metoidioplasty.
  • Some people may still need to sit to urinate. Also, some may need to press on surrounding tissues to allow urine to pass through the penis.

Metoidioplasty Complications

Before surgery, the surgeon will review possible complications of the metoidioplasty procedure that can affect recovery or results. Though rare, these can include:

  • Buildup of blood (hemotoma) or fluid (seroma) in the surgery area that may require draining or an additional surgery to remove
  • Problems with sexual function
  • Decreased sensation, which can be temporary or permanent (this is less common, but still possible, after metoidioplasty than phalloplasty)
  • Dissatisfaction with results (the patient and doctor need to have a plan if this happens)
  • Complications associated with lengthening the urethra, such as:
    • Scarring, including scar tissue that can block or narrow the urethra
    • Frequent urinary tract infections
    • Infection
    • An abnormal opening (fistula) in the urethra

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