Metoidioplasty

Metoidioplasty is a type of gender-affirming surgery that creates a small-sized neophallus, or new penis, from an enlarged clitoris. Gender-affirmation surgeries are procedures that alter a person’s body, typically sexual characteristics like the genitals, to align a person’s sex with their gender identity so that they can move through society more comfortably. Such procedures treat gender dysphoria, which is the distress or discomfort that may be felt by transgender people. Transgender people’s gender identities differ from the genders they were assigned at birth, usually conflated with the sex they were assigned at birth. As opposed to a phalloplasty, a procedure where a neophallus is created using tissue from other areas of the body and not just the existing genital tissues, metoidioplasty allows transgender individuals to have a penis with less noticeable scarring, preservation of erogenous sensation, and, if the patient desires, the ability to urinate while standing. The technique was first suggested in 1973, then performed in 1974, however, doctors and researchers did not refer to it as metoidioplasty until 1989. Since its implementation, several modifications have ensured lower risks and better results for patients. Metoidioplasty improves the quality of life for people seeking gender-affirmation surgery by treating gender dysphoria.

1. The Need for Metoidioplasty
2. Relevant Anatomy
3. Historical Development of Metoidioplasties
4. Undergoing a Metoidioplasty
5. Impacts of Metoidioplasty

The Need for Metoidioplasty

Metoidioplasty is a surgical intervention to treat gender dysphoria, a condition that the American Psychiatric Association recognizes with agreed-upon diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5. One of the ways to medically affirm an adult who experiences gender dysphoria is through gender-affirming surgery. Metoidioplasty fills the need for a gender-affirming genital surgery without the large, and sometimes very visible, scars left by a phalloplasty, another type of affirmation surgery that requires skin grafts from an arm, leg, or back to form the neophallus. Metoidioplasty creates a penis that is only a few centimeters in length, making penetrative sexual intercourse difficult post-operation. However, the procedure can be performed in a single stage compared to the multiple stages that could be required for a phalloplasty. The single-staged metoidioplasty, when compared with a phalloplasty, requires less time in a hospital and less total time healing, which could make it more cost-effective, depending on health insurance coverage.

Relevant Anatomy

Metoidioplasties involve operating on external and internal female genitalia to create more typically male features. Some external genitalia that make up the vulva are the clitoris, labia majora, labia minora, opening of the urethra, opening of the vagina, hymen, perineum, and anus. Metoidioplasties construct the neophallus out of an enlarged clitoris. The clitoris is a sensory organ, meaning it is very sensitive to tactile stimulation, and is formed by erectile tissue that protrudes away from the vulva and pubic bone. The clitoris has two sections, the clitoral head, or bulb, and the body of the clitoris. The clitoral head is the bundle of tissue that can be seen under the hood made by the labia minora. The body of the clitoris, most of which is internal, starts at the head and folds back and under itself, allowing the head to become erect and protrude further, before the structure splits into two and continues down both sides of the vulva, following a similar path as the labia majora.

Metoidioplasties use tissue from the labia majora and minora to help cover the neophallus. The labia majora, or the larger lips, are the more prominent pair of skin folds that form laterally, alongside the labia minora. The labia minora, or the smaller lips, are smaller skin folds that begin at the clitoris and extend downwards. The top portion of the labia minora form the covering for the clitoris, called the clitoral hood. Between the labia minora and under the clitoral head is the opening of the urethra, where urine exits the body after traveling through the urethra from the bladder, and the opening of the vagina, leading to the vaginal canal. The hymen is located at the opening of the vagina, which marks the start of the vaginal mucosa, part of the internal anatomy. From the opening of the vagina and continuing down and back, is the perineum, the area of skin between the anus and the vulva, and moving further back is the anus, where solid waste leaves the body. Metoidioplasties remove or use those parts of the patients’ bodies to create a neophallus, giving the patient more typically masculine genitalia than they previously had.

Internal organs and structures altered by metoidioplasty procedures include the vagina, cervix, and the urethra. The vagina, sometimes referred to as the vaginal canal, is a tube or tunnel-like structure that starts at the vaginal opening by the hymen and connects all the way back at the cervix, the lower and narrow part of the uterus that connects the main body of the uterus to the vagina. The vaginal canal is covered by vaginal mucosa, which is a thin layer of mucous membranes that produce mucus and protect the skin inside the vagina. The last internal anatomy that is important for metoidioplasty is the urethra. The urethra is a tube-like structure that connects the bladder to the urethral opening, and can be separated into a few separate structures. The first is the urethral groove, usually called the urethra, which is where the urine travels through to exit the body. The second structure is the urethral plate, which is made of tissue that surrounds the urethral groove and keeps it in place. The urethral groove and plate are present in both typically-male and typically-female anatomy and can cause curvature of the penis in males. Surgeons may remove the vaginal canal and use the mucosa to cover and protect the neophallus, inside of which they can lengthen the urethra to allow for urination while standing.

Historical Development of Metoidioplasties

Researchers in the twentieth century developed metoidioplasty techniques by building on the work of surgeons who developed phalloplasty techniques. Harold Delf Gillies, a plastic surgeon in England, was one of the first surgeons to successfully complete a modern phalloplasty with urethral extension for gender-affirming purposes in 1946. In 1973, building on the technique Gillies helped develop, researchers presented the idea of the using clitoral enlargement as a substitute for a penis at the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome. The Symposium was a conference where scholars and physicians presented on transgender issues in a variety of fields at Stanford University in Palo Alto, California.

The following year, a US plastic surgeon from Milwaukee, Wisconsin, Donald R. Laub Sr., expanded on the presentation from the Symposium, describing a metoidioplasty approach in a 1974 article titled “The Surgical Construction of Male Genitalia for the Female-to-Male Transsexual.” Laub used that approach to perform the first metoidioplasty later the same year. He published another article in 1978 where he detailed performing the surgery and its outcome. Laub’s procedures were successful in creating a phallus that retained erogenous sensitivity, but the patients were unable to urinate in a standing position. That led one of Laub’s patients to seek additional surgical reconstruction so the urethra would reach the tip of the neoglans, or head of the new penis. In 1989, Laub and his colleagues published an article that named the procedure metoidioplasty for the first time. They derived the term from the Greek words meta, meaning toward, oidion, meaning male genitalia, and -plastia, meaning molded or formed. As of 2023, surgeons still use the techniques Laub developed in some metoidioplasty procedures.

In the early 1990s, J. J. Hage, a medical researcher and plastic surgeon in the Netherlands, combined Laub’s techniques with his understanding of how to lengthen the urethra to develop a metoidioplasty technique that resulted in allowing patients to urinate through their penis while standing. In 1993, Hage and his colleagues published an article that included a literature review and fifty-three patients’ experiences with urethra lengthening that used tissue from the vagina, or a vaginal flap, to encircle and hold the extended urethra, or neourethra, to the clitoris. They concluded that, if performed by surgeons with enough education and experience in the area, such a urethral lengthening technique would have few risks associated with it. Using surrounding and nearby tissue to protect the lengthened urethra became standard practice to treat transgender individuals following the publication.

In studies of patient satisfaction in the early 2000s, a common concern was that the patients’ neophalluses were developing curves and impacting the ability to urinate while standing. Such reports led Laub and a colleague to explain that the neophallus was usually small and curved due to the urethral plate, which lines the urethral groove, being intact. In 2003, Sava Perovic and Miroslav Djordjevic, two surgeons working in Belgrade, Serbia, published new modifications where the surgeon cuts through the urethral plate to allow the clitoris more freedom of movement. In their method, a surgeon uses a tubed flap for urethral reconstruction, making a tube from the skin from on top of the clitoris to fully encapsulate both the neophallus and the neourethra.

In the late 2000s, surgeons working around the world created new metoidioplasty techniques that use skin from different donor sites to create the neophallus. In 2008, Djordjevic and Perovic, along with other colleagues, published an article regarding a new technique that they termed the Belgrade Metoidioplasty. The update changed the location that the surgeon took skin and tissue from in the patient’s body to cover, protect, and support the neophallus. Instead of only using tissue from the vagina and skin from on top of the clitoris, they combined tissue from the vaginal mucosa with tissue from the inside of the patient’s cheek to cover the neophallus. In 2009 two surgeons in Saitama, Japan, Takamatsu Ako and Takao Harashina, built on Hage’s work and published an article on their new technique, called ring metoidioplasty, that uses the labia minora skin along with tissue from the vaginal mucosa for covering and protecting the lengthened urethra and neophallus. As of 2023, there have been small changes in the processes, depending on individual patient needs, but the larger surgical techniques remain the same.

Undergoing a Metoidioplasty

As of 2023, before a patient can undergo a metoidioplasty in the US, they need to have a mental health evaluation, receive surgery referral letters from at least two mental health professionals, live for at least one year consistent with their gender identity, and undergo physical assessments and educational visits with different specialists to ensure an understanding of the procedure and its risks. Another main requirement of the pre-operative care for metoidioplasty is for the patient to have been on testosterone hormone replacement therapy for at least one year so that the patient has an enlarged clitoris. During discussions with their doctors and specialists, patients also have the opportunity to express their own expectations for the surgery. Using those discussions and expectations as a guide, the surgeon decides which metoidioplasty technique will give the best results for their patient.

Patients and their surgeons decide together between three main metoidioplasty techniques, including a simple metoidioplasty, a ring metoidioplasty, or a Belgrade metoidioplasty. Patients can also preemptively add on or opt out of procedures such as vaginectomy, the closing of the vagina, scrotoplasty, the creation of a scrotum with or without testicular implants, or urethroplasty, also called urethral lengthening, which allows patients to urinate when standing. Each metoidioplasty technique requires a clitoris that is enlarged due to the patient’s use of testosterone prior to the operation.

The first and least complex of the three types of metoidioplasties is the simple metoidioplasty, also called clitoral release. In the procedure, the patient’s enlarged clitoris becomes a neophallus after a surgeon releases it from the pubic bone and uses skin from the clitoris, labia minora, and labia majora to cover and support the phallus. A simple metoidioplasty does not typically include urethral lengthening or vaginectomy. The process starts with the surgeon degloving the clitoris via an incision using an electrosurgical pencil, a pen-like tool that makes and cauterizes incisions at the same time. Degloving the clitoris means that the surgeon will cut the skin and tissue on the underside of the enlarged clitoris, being careful not to cut into any of the organ itself. The surgeon cuts most of the way through the clitoral suspensory ligaments, which help hold the clitoris in place and attached to the pubic bone. Doing so permits the clitoris a slightly wider range of motion. Next, the surgeon dissects and divides the urethral plate. As Laub noted in 1999, an intact plate shortens the neophallus and creates a curve most patients do not want. The division of the plate gives additional length to the neophallus and lets the surgeon cut through the tissues that connect the urethral plate and create the curved appearance in the neophallus. The surgeon uses the remaining clitoral skin and labia minora and majora to cover the body of the neophallus, suturing along the under-side of the released structure. Then, the surgeon repositions a group of three muscles which helps support and raise the pelvic floor, to add more and better support for the neophallus, as it has more weight to it than a clitoris.

In a simple metoidioplasty, the surgeon leaves the urethral opening in place, and a patient can decide to pursue urethral lengthening at another time if they would like the ability to urinate while standing. At the end of the procedure, the surgeon inserts a urinary catheter into the urethral opening to drain urine and prevent leakage onto the surrounding reconstructed skin. After a couple of days, a physician will check the area to ensure enough healing has taken place and can approve the removal of the urinary catheter. Complications occur in less than five percent of simple metoidioplasty cases and are mainly due to unwanted twisting of the healing skin, which is a complication that can be painful, but is not difficult to repair. A simple metoidioplasty can include the removal or preservation of the vagina or a scrotoplasty, depending on the patient’s desired results. Surgeons can also perform a urethroplasty, or lengthen the urethra. However, in a small study by Perovic and Djordjevic, there was a twenty-three percent complication rate mainly related to urethral reconstruction.

The second of the three types of metoidioplasty is the ring metoidioplasty. A ring metoidioplasty starts very similarly to the simple metoidioplasty as it involves a partial, or in some cases complete, cutting of the ligaments that attach the clitoris to the pubic bone, however, it also includes a urethral plate extension using a dorsal urethral ring flap. The dorsal urethral ring flap is made from a tissue graft from the vaginal mucosa. The tube of vaginal mucosa is removed from the vagina starting at the back by the cervix and pulled forward to the hymen, keeping the removed tissue in a ring-like structure. The surgeon performs a colpocleisis, where they sew the front and back of the vaginal walls together to shorten and, if the patient wants, close the vaginal canal, which gives the appearance of a typically-male perineum, the space between the anus and scrotum. The surgeon brings the ring flap forward from the vaginal canal and attaches it first on the underside urethral plate, then onto the clitoral body. The placement of the ring flap is important for urethral lengthening, allowing urine to pass through to the tip of the head of the new penis structure, as well as lessening the pressure required when covering the neophallus with the remaining labial skin. If a patient wants to add a scrotoplasty with testicular implants, the surgeon does so as a separate procedure when using the ring flap technique. Complication rates tend to be higher in a ring metoidioplasty, with ten to twenty-six percent of patients experiencing urethral fistulas, or holes in the urethra. In 2019, Djordjevic and his colleagues note in “Metoidioplasty: Techniques and Outcomes” that the ring metoidioplasty technique demands further revisions and mention the complication rates as a concern.

The third and most complex of the three types of metoidioplasties is the Belgrade metoidioplasty. The Belgrade metoidioplasty is typically the most successful technique with the lowest complication rates, as it is a one-stage metoidioplasty that includes simultaneous removal of internal and external female genitalia. It starts with the removal of vaginal tissue through colpocleisis. The surgeon removes all vaginal mucosa except for a small part around the urethral opening, which is only left to aid in urethral lengthening later in the procedure. Next, the surgeon degloves the clitoris, starting at the urethral plate and cutting around the clitoris, completely severing all of the suspensory ligaments. The surgeon then cuts the urethral plate in half along the underside, which enables additional clitoral length.

Unlike with other techniques, surgeons using the Belgrade metoidioplasty separate the urethral lengthening and reconstruction, a built-in part of the procedure instead of an optional addition, into what they refer to as bulbar and neophallic parts, which allows for the use of more intricate techniques. The bulbar section consists of the end furthest from the body, the bulb of the clitoris or the tip of the neophallus, and the neophallic section consists of the rest of the clitoris or shaft of the neophallus. The bulbar portion of urethroplasty uses tissue from around the urethra and part of the divided urethral plate. The surgeon covers the constructed urethra with vascularized tissue and the clitoral bulb to prevent postoperative fistulas. The surgeon performs the rest of the urethral lengthening by combining oral mucosa graft and genital skin flaps, depending on how much graft material is needed. The surgeon collects the mucosa graft from the inside of the patient’s cheek, as the skin there is used to constantly being wet. Djordjevic showed that the oral mucosa graft from the inside of a cheek is the most successful donor site, resulting in less than seven percent complication rate. The surgeon sutures the graft to the gap created after dividing the urethral plate, which creates a new urethral plate for the patient. To complete the urethroplasty, the surgeon uses either a dorsal clitoral or labial skin flap, which they also use to finish the construction of the penile body. If the patient wants a scrotoplasty, the surgeon joins both labia majora, inserting silicone implants either through the midline or using separate incisions above the labia.

Recovery times for metoidioplasty may vary for individual patients based on which surgical methods they undergo as well as which optional surgeries they chose. Generally, a patient recovering from a metoidioplasty can engage in mild physical activity starting approximately one week after their surgery, with a return to full physical activity expected at approximately six weeks after surgery. A metoidioplasty patient will receive individualized instructions for post-operative care and physician appointments from their surgeon to check their healing progress as well as the insertion, maintenance, or removal of any urinary catheters.

Impacts of Metoidioplasty

Metoidioplasty procedures allow transgender patients to be comfortable living their life as their affirmed gender. In 2017, the Journal of Sex & Marital Therapy published an article titled “Surgical Satisfaction, Quality of Life and Their Association After Gender-Affirming Surgery: A Follow Up Study” in which the authors show that ninety-four to one hundred percent of participants were satisfied with their post-operative metoidioplasty results, and those who were satisfied reported higher scores for quality of life after surgery versus prior to receiving surgery as they are now more comfortable in their bodies and able to more easily live as their affirmed gender. Other research has replicated those higher satisfaction and quality of life scores. In 2019, Djordjevic and two of his colleagues, published “Metoidioplasty: Techniques and Outcomes” in which they include their experiences with 593 female-to-male patients who underwent a Belgrade metoidioplasty over a fifteen-year period. Of the 593 patients, 541 reported that they were completely satisfied with their male genitalia and the remaining fifty-two were somewhat satisfied, with no patients reporting dissatisfaction or unsatisfactory results.

Despite the positive effect metoidioplasties and other gender affirmation surgeries can have on transgender people’s quality of life, transgender people do not always have access to such procedures due to persistent intolerance and prejudice in the US as of 2023. In 2017, a small sample of people, 1,000 adults, in the US participated in a survey to examine the public opinion of transgender people and support for transgender rights. The survey found that a majority of the participants were more accepting of transgender individuals than not, with around seventy-four percent strongly or somewhat agreeing that gender-affirming surgery should be covered by health insurance. However, the survey responses also show that some people feel strongly that society has gone too far in allowing transgender people to pursue medical intervention, and worry about children seeing individuals who dress or live as one gender when they were assigned/assumed a different one at birth.

People debate whether the lives of transgender people are even equal to those of cisgender people, or people whose gender identity aligns with the one they were assigned at birth, according to the Centers for Medicare & Medicaid Services, or CMS, a federal organization in the US that controls the programming for Medicare and Medicaid. In 2015, CMS received a formal request to make a National Coverage Determination, or determination of whether a specific medical service, procedure, or device should be covered by Medicare nationally, on surgical remedies for gender dysphoria. However, the determination was ultimately not issued because the clinical evidence about gender-affirmation surgeries was considered inconclusive, leaving the coverage determinations to be made by local Medicare Administrative Contractors on a case-by-case basis. The public comments on the decision range from pleas for help to all-capitalized outrage that there are people who receive coverage for gender-affirming surgeries through Medicare and Medicaid.   

As of 2023, such anti-transgender sentiments have entered many US state laws, which restrict the lives and activities of transgender people, often focusing on transgender children seeking gender affirmation. The Human Rights Campaign reports that, as of June 2023, twenty US states have passed restrictions or bans on gender-affirming care for minors, and seven more states are considering similar restrictions. Additionally, multiple states have enacted bans on transgender students participating in sports in ways that align with their gender identities. Such restrictions conflict with the medical consensus that gender affirmation, both medical and social, improves the mental health of transgender youth and adults.

Metoidioplasty is a complex procedure that requires discussion and agreement between surgical team and patient to ensure the best outcomes and desired results. As of 2023, the technology is changing and progressing, lowering risks of complications and getting closer to patients’ desired aesthetic. The advancements have improved patient satisfaction and lowered complication rates. Metoidioplasty improves the health of transgender people by being a more efficient and cost-effective surgical option to treat gender dysphoria and affirm their gender identities.