Editing Metoidioplasty

{{Content warning|genitals (with diagrams), reproductive organs, surgery (with photos of it in process)}}

{{disclaimer|The Nonbinary Wiki is written by volunteers who are not necessarily experts on medical topics. This wiki and its editors make no representations or warranties of any kind. This wiki and its editors shall not be liable for any physical, psychological, emotional, financial, or commercial damages, prosecutions, or proceedings instituted against any person or entity as a result of the use of information from this file, or any loss, injury, or damage caused thereby. You claim full responsibility for your own health decisions. This wiki will not be held responsible for your actions. Any information here does not constitute legal, financial, medical, business, or other advice. This wiki should not be used to recommend a path for diagnosing or treating any medical condition. For that, you must consult your physician.}}
{{Template:Surgeries}}
'''Metoidioplasty''' or '''metaoidioplasty''' (informally called a '''meta''') is a kind of surgery that some transgender and transsexual people seek.<ref>[https://archive.today/20121017065438/http://www3.interscience.wiley.com/journal/118853935/abstract Metoidioplasty: a variant of phalloplasty in female transsexuals] by S.V. Perovic and M.L. Djordjevic (BJU International, Volume 92 Issue 9, December 2003)</ref> It is sought by some transgender men, some trans-masculine people, some nonbinary people, and some intersex people. A meta surgery increases the exposed length of a person's phallus.<ref name="trans bodies 280">Laura Erickson-Schroth, ed. ''Trans Bodies, Trans Selves: A Resource for the Transgender Community.'' Oxford University Press, 2014. P. 280-281.</ref> For people who have certain kinds of phallus (called either a large clitoris or small penis), a meta surgery frees the phallus from the tissues that hold it close to the body,<ref name="trans bodies 280" /><ref name="hudson">Hudson. "FTM Genital Reconstruction Surgery (GRS)." ''Hudson's FTM Resource Guide.'' 2004. https://www.ftmguide.org/grs.html#meta</ref> and pulls it outward, making its external size larger, so that it can be easier to use for penetrative sex. A patient has a range of different options for other details of this surgery, or procedures that can be done at the same time as this surgery, which are described below. 

==History==

Metoidioplasty surgeries were developed in the 1970s. Since then, a variety of different methods for it have been developed by different surgeons.<ref name="hudson" />

==Process==

[[File:Vagina 1.jpg|thumb|200px|Diagram of the vulva. As seen in an adult who was assigned female at birth, and who has not had hormone therapy or surgery.]]
[[File:Clitoris inner anatomy.png|thumb|200px|Diagram of the inner anatomy of the clitoris. As seen in an adult who was assigned female at birth, and who has not had hormone therapy or surgery.]]

In order to prepare for a meta, doctors prefer for the patient to first be on an appropriate [[hormone therapy]] ([[testosterone]]). When someone has been on [[testosterone]] [[hormone therapy]] for several years, this gradually enlarges the clitoris to a mean maximum size of 4.6 centimeters<ref>[https://doi.org/10.1007%2FBF01542220 Physical and hormonal evaluation of transsexual patients: A longitudinal study] by Meyer W, et al. (Archives of Sexual Behavior, Volume 15, Number 2, April 1986)</ref>. How much growth happens on hormones varies from one person to the next, and depends on their genes. Even without any kind of surgery or procedure, hormone therapy alone is enough to make a person's clitoris grow to be up to about the length of a thumb.<ref name="hudson" /> Without surgery, the clitoris is still tied down with skin, and partly buried in the body, so some people still find it difficult to use it to penetrate a sexual partner. Hormone therapy also doesn't make it easier for someone to pee standing up. Most surgeons recommend that patients should be on testosterone for at least six months to two years before getting a meta,<ref name="hudson" /> but it takes longer than that to have the most growth possible from testosterone. Having the largest size of clitoris that a person is able to have through hormone therapy makes it easier to do a meta. The surgeon usually advises the patient to prepare for a meta by using clitoral [[pumping]] on a regular basis in order to make the phallus bigger. However, there is no research yet as to whether pumping helps do that, and pumping does have a risk of causing injury.<ref name="trans bodies 280" /> 

In the metoidioplasty surgery itself, the surgeon cuts some tissues that had held the clitoris down. They cut a ligament that holds the clitoris under the pubic bone. They also separate the clitoris from skin connected to it, such as the labia minora. The surgeon may take away some fat from the pubic mound, and pull the skin upward, in order to bring the phallus forward.<ref name="hudson" />

In addition to the metoidioplasty surgery itself, the patient has many options for other procedures that they may want to be done along with it. If the patient wants to be able to pee through their phallus after metoidioplasty, then they can ask to have their urethra extended through it, during the metoidioplasty surgery. If the patient prefers not to have their urethra extended, then the urethra stays where it was before, which is likely not on the phallus. The patient has the options to create a scrotum (a [[scrotoplasty]]) or not.<ref name="trans bodies 280" /> If the patient has a vagina (the orifice), then this also stays where it was. If the patient has already had their uterus taken out (a [[hysterectomy]]), then the patient has the option to close or get rid of the vagina (a [[vaginectomy]]) during the metoidioplasty, or to leave their vagina as it is.<ref name="trans bodies 280" /> The patient has the option to have a complete hysterectomy (taking away the uterus, cervix, and ovaries) at the same time as a meta, but only if they choose to do so.<ref name="trans bodies 280" /> The amount of time that a metoidioplasty surgery takes depends on how many other procedures the patient wanted done at the same time. It can take about three to five hours.<ref name="hudson" />

Recovering from a metoidioplasty surgery may take up to two to four weeks,<ref name="trans bodies 280" /><ref name="hudson" /> in which the patient should limit their activity. During recovery, the patient may temporarily have a plastic catheter tube in their urethra that they need to pee through. Usually, this catheter will be taken out one or two days after surgery.<ref name="trans bodies 280" /> If the patient chose to have urethral lengthening, then the catheter may have to stay in for two to three weeks.<ref name="hudson" />

After a metoidioplasty surgery, most people have a phallus that has a flaccid length between 3 and 8 centimeters.<ref name="trans bodies 280" /> A phallus created by a meta usually has full sensation, an ability to become erect naturally, an ability to orgasm,<ref name="trans bodies 280" /> and a look very much like a relatively small but natural and normal penis of a person who was assigned male at birth.<ref name="hudson" /> A meta doesn't leave any visible scars on other parts of the body.<ref name="hudson" /> For some people, a phallus from a meta is still not large enough for them to use to penetrate a sex partner.<ref name="hudson" />

{{Clear}}
==Compared with phalloplasty==
Metoidioplasty and phalloplasty are two very different methods for creating a larger phallus. Metoidioplasty is technically simpler than [[phalloplasty]], costs less, and has fewer potential complications. However, phalloplasty patients are more likely to be able to use their phallus to penetrate a sexual partner after they recover from surgery, because phalloplasty can usually create a larger penis.<ref>Frey, Jordan D. et al. “A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-Male Transgender Genital Reconstruction: Is the ‘Ideal’ Neophallus an Achievable Goal?” Plastic and Reconstructive Surgery Global Open 4.12 (2016): e1131. PMC. Web. 5 July 2018.</ref>

In a phalloplasty, the surgeon creates a penis by grafting tissue from a donor site, such as from the patient's own back, arm, or leg, whereas a meta does not require any tissue grafts.<ref name="trans bodies 280" /> A phalloplasty takes about 8–10 hours to complete (the first stage), and is generally followed by multiple (up to 3) additional surgical procedures including glansplasty, scrotoplasty, testicular prosthesis, and/or penile implant. A meta takes less time, and typically requires 2–3 hours to complete. Because the clitoris's erectile tissue still works normally in a meta, a meta does not need a prosthesis implanted for erection, although the phallus might not become as rigid as the erection of a cisgender man. In nearly all cases, meta patients can continue to have clitoral orgasms after surgery.{{Citation needed}}

Neither metoidioplasty nor phalloplasty make it so that a person can produce semen or get others pregnant. A procedure that gives someone those abilities does not yet exist.

If someone has had a metoidioplasty, then they will still be able to get a phalloplasty later, if they choose to do so.<ref name="trans bodies 280" /> If a patient who is planning to get a meta thinks that they might convert it to a phalloplasty later, they should talk about it with their meta surgeon, to find out which methods for a meta would give them the best options for a phalloplasty later.<ref name="hudson" />

{{Clear}}
==Urethral hookup==
Some patients choose to have an additional procedure in which their urethra will be extended through their phallus, called a "urethral hookup." This makes it so the person will be able to pee through their phallus, which makes it easier to pee while standing up. The surgeon can do a urethral hookup at the same time as a metaoidioplasty. There are two different methods for extending the urethra. One method takes a graft of skin from inside the patient's mouth. A newer method instead uses the inside of the labia and a flap from the vagina, which is called a "ring matoidioplasty."<ref name="trans bodies 280" />

Here is one version of how a metoidioplasty can go, for a patient who chose to have their urethra extended so they will be able to pee through their phallus, and who chose to have a scrotum created (scrotoplasty). In a metoidioplasty, the urethral plate and urethra are cut away from the clitoral corporeal bodies, then divided at the distal end, and the testosterone-enlarged clitoris straightened out and elongated. A longitudinal vascularized island flap is configured and harvested from the dorsal skin of the clitoris, reversed to the ventral side, tubularized and an anastomosis is formed with the native urethra. The new urethral meatus (the hole you pee through) is placed along the phallus to the distal end and the skin of the phallus and scrotum reconstructed using labia minora and majora flaps.<ref>Perovic, S. and Djordjevic, M. (2003), Metoidioplasty: a variant of phalloplasty in female transsexuals. BJU International, 92: 981-985. doi:10.1111/j.1464-410X.2003.04524.x</ref> The new phallus ranges in size from 4-10 centimeters (with an average of 5.7 centimeters), and has the approximate girth of a human adult thumb. <ref>Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience
Djordjevic, Miroslav L. et al., Journal of Sexual Medicine, Volume 6, Issue 5, 1306 - 1313</ref>

These are some photos of a meta surgery. Not every meta will look like this, because people vary in which other genital surgeries they want to have with it.
<gallery>
File:Metoidioplasty 2.png|Meta, urethral extension, removal of vagina, and creation of scrotum surgeries in process.
File:Metoidioplasty post op.png|Meta, urethral extension, and scrotoplasty, immediately post op. The stitches and catheter tube will be gone after healing.
</gallery>

{{Clear}}
==Clitoral release==
If a metoidioplasty is performed without extending the urethra and/or creating a scrotum, this is sometimes called a clitoral release or a clitoral free-up.<ref name="hudson" /> A clitoral release by itself is less expensive than a "complete metoidioplasty" that includes these other procedures. By itself, a clitoral release has fewer health risks, because the urinary system remains unaltered without a urethral extension, and still affords some of the visual effects of a complete metoidioplasty, along with the ability to use the penis for sexual penetration. If the urethra is not changed from its original position, this does not allow for urination through the phallus, so this version of the procedure does not make it easier to pee standing up.{{Citation needed}}

{{Clear}}
==Cost==
Patients have many different options for what surgeries they want to include in their metaoidioplasty surgery, such as whether they also want a urethral lengthening, or not. The price range varies according to these options, and also varies from one surgeon to the next. A clitoral release without urethral lengthening can cost about USD$2,000 to USD$5,000.<ref name="hudson" /><ref name="trans bodies 280" /> A metaoidioplasty that includes urethral lengthening can cost about USD$15,000.<ref name="trans bodies 280" /> A meta with urethral lengthening and testicular implants can cost about USD$20,000.<ref name="hudson" />

{{Clear}}
==Complications==
Complications occur in up to 50% of surgeries, varying in severity between those requiring only minor supportive care to those requiring surgical correction. Complications include:
* bacterial infections
* ileus
* wound dehiscence
* tissue death. This is rarer in metoidioplasty than in phalloplasty.<ref name="hudson" />
* urinary fistula (pee leaking out of an extra hole).<ref name="hudson" />
* narrowing or blockage of the urethra (urethral stricture).<ref name="hudson" />
* loss of sensation. Uncommon. 
* loss of ability to have an orgasm. Uncommon. 
* scarring of varying degrees.
* bleeding from the surgical site that may require surgery. 
* if the patient chose to have a scrotum created, and get testicular implants, one risk of complication from that is that the body may reject these implants.<ref name="hudson" />
* "One must also consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare)."<ref name="hudson" />

==Notes==
* [https://archive.today/20130105075906/http://www3.interscience.wiley.com/journal/121489446/abstract Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience] by Miroslav L. Djordjevic, Dusan Stanojevic (Journal of Sexual Medicine, Volume 6 Issue 5, Oct 2008)
* [http://journals.lww.com/plasreconsurg/Abstract/1996/01000/Metaidoioplasty__An_Alternative_Phalloplasty.26.aspx Metaidoioplasty: An Alternative Phalloplasty Technique in Transsexuals] by Hage, J. Joris (Journal of Plastic & Reconstructive Surgery, Volume 97 Issue 1, January 1996)
* ''Gender Reassigment'' by Dan Greenwald and Wayne Stadelmann (eMedicine Journal, Volume 2 Number 7, July 6, 2001)

==References==
<references/>

==External links==
* [http://www.metoidioplasty.net/ Metoidioplasty.net - The Metoidioplasty Surgery Guide]
* [https://web.archive.org/web/20130114072317/http://www.femaletomale.org/female-to-male-surgery/metoidioplasty/ FemaletoMale.org | Information about Metoidioplasty]
* [https://www.ftmguide.org/grs.html#meta Hudson's FTM Resource Guide - FTM Genital Reconstruction Surgery (GRS) - Metoidioplasty]

==Further reading==
* Trystan Theosophus Cotton, ''Hung Juries: Testimonies of Genital Surgery by Transsexual Men.'' Oakland, CA: Transgress Press, 2012.

== See also ==
* [[Practical resources]]

[[Category:Transition]]