Female to male surgery (also known as sex reassignment or genital reassignment surgery) is a process in which a surgeon physically transforms a woman into a man. Sex reassignment surgery is actually a series of surgeries that includes: mastectomy (breast removal), hysterectomy (removal of female reproductive organs), genital reassignment, and testosterone treatment.

The mastectomy may include additional plastic surgery like nipple realignment and removal of excess skin for a more masculine-looking chest. The process can take up to a year, allowing the skin to heal before additional adjustments are made

During the hysterectomy, a surgeon removes the uterus and may also remove the ovaries and fallopian tubes for a “full” hysterectomy. The hysterectomy may also decrease the risk of ovarian, cervical, or endometrial cancer, although actual results are uncertain. Despite the potentially reduced risk of cancer after the surgery, patients should still consult a gynecologist, especially those with a family history of cancer.

The testosterone treatments after sexual reassignment surgery help to control or reduce the prominence of estrogen, a hormone that can speed up menopause. Some women also opt for genital reassignment where a surgeon enlarges the clitoris and combines it with skin grafts or attaches an erectile prosthetic. The surgeon can also connect the labia majora to make a scrotum. During reconstruction, the surgeon ensures that normal bodily functions (like urination) can still occur.

Candidates for Male To Female

Transsexual men are common candidates for this surgical procedure. As with most other forms of surgery, it is recommended that you’re healthy, with no significant heart or circulatory problems and are mentally stable. You can learn specific details on what is involved for a procedure by meeting with your general practitioner and gaining a referral to a specialized plastic surgeon.

Most transsexual men go through transition after adolescence. In addition with high levels of masculine hormones, significant changes to the facial appearance, including making the forehead heavier and more pronounced, altering the structure of the nose, and creating a more pronounced chin and jaw.

Preparing for GRS

Preparing for Gender Reassignment Surgery (GRS) begins by discontinuing Hormone Treatment. Patients must discontinue hormone treatment at least fourteen days prior to surgery. Hormones should be halted to reduce the risk of thrombosis (blood clots). Oral tablets should be halted two weeks prior to surgery and injectables should be halted four weeks prior to surgery. Oral anti-androgens can be halted three days before surgery (four weeks if injectables). Aspirin and smoking should be halted two weeks before surgery.

Patients must complete a health check up within three months prior to SRS. Patients must also be confirmed by a private physician to be free from serious medical diseases and must pass the following blood tests:

  • CBC, HIV Electrolytes, FBS, Creatinine Urinalysis
  • Alkaline Phosphatase, Chest X-ray
  • SGOT LDH EKG

Two letters are required from foreign patients. One letter must be from either a medical doctor or a psychologist that states the person is a candidate for SRS. The other letter may be from any doctors, showing proof of having been on hormones for at least one year.

Gender Reassignment Surgery Overview

Gender Reassignment Surgery, the sex reassignment surgery from female to male includes a variety of surgical procedures for transsexual men that alter anatomical traits viewed as physically female to provide physical traits more appropriate to the trans man’s male identity and functioning.

Many transsexual men considering the surgical option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).

Mastectomy

Many trans men seek bilateral mastectomy, also called “top surgery”, the removal of the breasts and the shaping of a male contoured chest.

Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.

By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola needs not to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.

For trans men with smaller breasts, a peri-areolar or “keyhole” procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return.

Hysterectomy and BSO

Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in cisgendered women is sometimes erroneously referred to as a ‘partial hysterectomy’ and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A ‘partial hysterectomy’ is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a ‘total hysterectomy.’

Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming ‘bottom surgery’. In other cases, sterilization may be required by the state in order for the sex marker on official documents to be corrected.

For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men compared to the general female population.

The risk will probably never be known since the overall population of transgender men is very small; even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.

Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years.

This is particularly the case for trans men who:

  • Retain their vagina (whether before or after further genital reconstruction,)
  • Have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
  • Have a personal history of gynecological cancer or significant dysplasia on a Pap smear.

One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a cisgendered woman and may herald the development of a gynecologic cancer.

Genital Reassignment Surgery (GRS)

Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (Metoidioplasty), or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (Phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the reconstructed penis. The labia majora (see vulva) are united to form a scrotum, where prosthetic testicles can be inserted.

Metoidioplasty/Phalloplasty

The procedure confers the advantage of minimal surgery with preservation of natural sensation and erectile function. Donor site forearm scars avoided. Overweight patients may achieve greater length with pubic lipectomy which will recess the body surface line.

In this procedure the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. When the female tissues have been primed with testosterone, the clitoral head may resemble an adolescent glans penis, although the proportionality or size may be smaller. The term “juvenile” sized phallus might be apt.

If you have been on testosterone and experience clitoromegaly, self examination of your glans and clitoral body will give you a very good idea of what to anticipate post-operatively once surgical swelling subsides (6 to 8 weeks). Although visible engorgement may occur during arousal, the phallus is not suitable for penetration, nor is ejaculation possible.

For those patients who desire to void standing, the urethra is extended into the neo-penis. This may be accomplished simultaneously or performed secondarily using either a vaginal flap or buccal mucosal graft. Please understand in that metoidioplasty involves a fair amount of tissue transfer, some degree of post-operative swelling is expected.

Complications may include but are not limited to less than anticipated length, torquing of the clitoris (usually amenable to release), loss of sensation, tissue necrosis, localized infection, persistent tenderness or hypersensitivity, transient or permanent narrowing of the vaginal opening which may render the vagina incapable of penile penetration, urethral narrowing, urethral obstruction, and urethral fistula (leakage of urine anywhere along the pathway of urethral extension). Between the first and second stages leading to urethral extension, voiding patterns and trajectory may be forwards or backwards and may splash wetting perineal, labial and vaginal skin.

Penile Implantation for the Neo-Phallus patient.

A penile prosthesis confers the wherewithal to penetrate which may be the defining moment for a successful conclusion to gender reassignment surgery. Clearly the intimacy of complete sexual contact is sought equally by patients and their partners.

Insertion of Testicular Implants into Labia.

This should be performed as a procedure unto itself or with urethral extension to minimize complications. To prepare the labia majora for implantation, a tissue expander may be employed for a few months. This also creates a more pleasing scrotal appearance.

Soft silicone implants are used and are available in varying sizes.

Related Procedures

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