Chapter 10

CHAPTER 10

SURGERIES

There are many different types of surgeries that trans people decide to have. This should be based entirely on your own needs, as different trans people need different things. Surgeries can help people feel happy in their own skin and make them feel like their true self. They are, in fact, lifesaving for those who need them. So let’s take a look at some of the surgeries that trans people often go for, what you can expect from them and how it all works.

While genital surgery works for some, there are differences in what different people need. For trans masculine people, top surgery is often more important than any genital surgery. This is often because of possible complications and compromises that have to be made, which makes some decide not to have any genital surgery.

Genital surgery for AFAB trans people has been progressing over the past decade and hopefully there will be even more advances in years to come.

Before any surgery, it’s important to weigh the pros and cons and see if it fits with what you want to achieve. In the case of trans masculine people, there are two major roads you can go down, and it’s important to consider which fits you better and what will make you happy. Make a list of questions regarding the surgery, weigh the pros and cons, and make an informed decision. Going under the knife is always a big deal, and genital surgery is irreversible. So be sure about what you’re doing, and don’t rush it.

Disclaimer: It’s important to mention that a lot of progress with surgeries can happen in a short space of time, so the information below might not always be 100 per cent in tune with what’s available. That’s why this information should only be seen as an indicator of what is available and all specifics should of course be discussed with your surgeon, who can give you much more comprehensive explanations and options!

VAGINOPLASTY

Vaginoplasty is a surgery where a vagina is created. There are two different types of vaginoplasty: penile inversion vaginoplasty and rectosigmoid vaginoplasty. For penile inversion vaginoplasty, which is the more common surgery, without going into too much detail, what is conventionally referred to as the penis is used to create the inside of the vagina, and the tip of the penis is used to create what’s conventionally referred to as the clitoris. Rectosigmoid vaginoplasty is rather different, as a part of the sigmoid colon is used to create the vagina lining. This latter surgery is often more suitable for those who do not have a lot of skin, have had a circumcision or have smaller parts.

Both surgeries have similar results and both are found to be successful and bring sexual satisfaction and sensitivity. People are different, and which surgery suits you is something that depends on your own anatomy, the health care system you’re accessing, the surgeons, what you want out of it, your health and so on. Asking your doctor about these options is very important and finding out what suits you is up to each and every person.

Many who have had this surgery can have orgasms and have full sensitivity, but there are rare cases of people losing sensitivity and not being able to orgasm. For many it takes a long time before they are able to learn how their genitals work and achieve an orgasm. It’s important to experiment and find out what works for you. It isn’t always the most conventional ways that work, so be creative and don’t be afraid to try different things!

After this surgery, you will need to use what is called a dilator to keep the vagina from closing. You have to use it several times a day for at least six months and up to a year while the body is healing. Many people keep dilating for the rest of their lives, but gradually start to do it less often as time passes (for example, many do so a few times a week or just once a week). It’s important to listen to your body and find out what works for you. Dilating regularly generally prevents you from losing depth and is also useful if you want to keep the width of the vagina.

Cleaning the vagina is different than if you were born with one, as it doesn’t self-clean. You need to take good care of it and make sure you wash inside, using a small pump for the water. The pump is called a douche and using a douche is known as douching. Using different soaps specifically designed for vaginal cleaning can also be useful, although you must be wary of what you use. We encourage you to be mindful about what sort of soaps you use, as some may not be suitable for vaginal cleaning and could cause irritation for our vaginal lining. Consult your doctor if you’re not sure what to use, or ask other trans people.

METOIDIOPLASTY

A metoidioplasty (or a meta) is a surgery where surgeons use the clitoral growth from hormone therapy to shape a penis. The size will always be quite small and not the same as from a phalloplasty but as these two organs are essentially the same (they develop in different ways due to hormones released in the womb and throughout people’s lives) it will function in pretty much the same ways. A urethra can be made through it, allowing people to pee standing up. It is also possible to have a ball sac created out of some of the skin down there and silicone testicles inserted, which is done as a separate procedure. Since it will not be large in size, it isn’t guaranteed that people can have penetrative sex, but they can still get an erection.

The pros include: appearance; it will function pretty much in the same way as any other penis; you will keep full sensitivity; you can pee standing up; it is much less invasive and there is a faster recovery time than with phalloplasty. The cons are: you might not be able to have penetrative sex; it will always be smaller than average; in rare cases there can be complications regarding sensitivity and the urethra.

A vaginectomy (removal of the vagina), hysterectomy (removal of the uterus) and/or oophorectomy (removal of the ovaries) can usually also be performed at this time if people want. Some people prefer not to have certain things removed, and what people want differs.

It’s important to mention that if you have had a meta, it does not preclude you from having a phalloplasty later on.

PHALLOPLASTY

Phalloplasty refers to a type of surgery where a penis is constructed. This is done in several stages. The first surgery is where skin is taken from your body (most commonly the forearm or thigh) and a penis is created that is then placed in the genital area, along with creating the pipe where the urethra will later be connected through.

The second procedure is usually the scrotoplasty (creating a ball sac) as well as the urethra being connected to the phallus so you can pee standing up. Unlike with the meta, you will need a prosthesis implanted to achieve an erection, which is usually done in the third surgery once things have healed. There are several types of prosthesis: the most common types are those you can bend down into a flaccid position or bend up for an erect position; alternatively, a pump is installed into the ball sac and you can pump it to give an erection and then release it to be flaccid again.

The forearm is the most common place to get a skin graft to construct the penis. Surgically, this is the easiest option, but it does leave a big square scar on your forearm, which is quite a visible place. You might need to have laser hair removal from the parts of the skin that are used to avoid hair growing on the constructed penis. Sometimes a meta is performed first in order to avoid complications as sensation is retained through nerve endings and connected to the constructed penis. It’s rare to lose the ability to orgasm and many experience good sensation.

Other methods include taking skin from the side of your chest area or from your thigh to construct the penis. All options have their pros and cons when it comes to sensation, scarring and healing. We advise you to consult with your doctors on the methods available and consider what is best for you if you wish to have this type of surgery.

The biggest pros of phalloplasty are the ability to have penetrative sex, to pee standing up and the appearance of the constructed penis. The cons are that it won’t work the same as a penis someone was born with in regards to erections and ejaculation, and there is less sensation; also it involves a lot of operations and a long healing process, and of course there is the scarring on your forearm or thigh.

There are different types of phalloplasty, and the specific surgeries that are available vary from country to country. For details on specifics, we recommend you consult your doctor. As these surgeries are still very limited, results might differ. Phalloplasty is obviously a very big deal and often requires several surgeries and a long recovery time.

Trans Bucket (www.transbucket.com) is a great place to see the results of surgeries, ask questions or see specifically what results your surgeon achieves. You will have to register with them first in order to access the images.

TOP SURGERY

Nobody wants to go under the knife. However, trans people are generally excited to know that there are life-changing options to help them feel more comfortable on a day-to-day basis. In some cases, top surgery may not be necessary at all (for example, in the case of some trans masculine people who perhaps didn’t develop a massive chest due to hormone blockers or genetics, combined with lots of weight training).

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Fox Fisher

One surgery for trans masculine people is body masculinisation surgery (BMS). With this type of surgery, fat reserves are moved to create a more V-line, top-heavy shape, rather than a bottom-heavy, pear-shaped figure. Although the removal of fat is permanent, it’s up to you to eat healthily and maintain regular exercise to maintain your new trim figure after wearing a bodystocking and recovering with some heavy bruising for four weeks.

This costly treatment is not offered on the NHS. If you want to save yourself the cost of going private and avoid invasive surgery, you could hit the gym for the same four-week duration (the time it takes to heal from this type of surgery) and create your own V-shape, doing basic weight-lifting and cardio exercise, such as jogging or cycling.

Periareolar surgery technique (peri) is also known as the ‘donut’, and is one of the ways to surgically flatten the chest through skin removal using incisions around each areola (the area around the nipple). This surgery works best for smaller-chested people and won’t leave any major scars, although this is still the surgery that needs the most corrections afterwards if the skin is too rippled or uneven.

Double incision is the most common form of chest surgery, for those whose chest size is B cup or larger. The surgery removes unwanted skin tissue, causing the chest to flatten completely. The nipples are also removed during the surgery in order to place them in a more appropriate place. The advantage is that the nipples’ size and placement can be more easily controlled than with peri. The cons of the surgery are that it will leave two linear scars on your chest. How big they turn out to be is different for different people and also depends on the surgeon, but there are several things you can do to help with the healing process, such as using different creams or ointments. Some people have the skin in this area tattooed once it’s fully healed and others build up pec muscles in order to hide the scars.

The recovery time takes a while, and just after the surgery you have to be careful not to strain yourself or get the nipple area wet. It usually takes the new nipple grafts about 8–10 days to recover. Usually after the surgery you have to wear a binder, but after a few weeks you can be binder-free forever!

For many trans masculine people, top surgeries are the most important type of surgery and many are content without having any further interventions. This is sometimes partly because genital surgeries are complicated and involve some sort of compromise, while the top surgery has clear-cut, direct results.

BREAST AUGMENTATION

Trans feminine people might opt for breast augmentation surgery. There are various reasons for this, but the most common reason is because they feel that their breasts are too small. It’s not only AMAB trans people who seek them out, but also cisgender women. It’s important to weigh up the reasons behind your decision if you wish to have this surgery. Be sure you’re ready for it and that it’s what will make you feel better about yourself. If that’s the case, go for it!

It’s important to remember that you should never feel pressured to do it, or that you have to do it to be seen as a woman. There are many women who have small breasts, and different people have different bodies. There is no one way to be a woman and there is no one body that is the right body and the most beautiful body. We are all beautiful in our different ways and it’s important to be sure that this is what you want and need. Many trans feminine people don’t actually develop breasts until after several years on hormones, and some don’t really do so until they start taking progesterone. Therefore, be sure that you’ve tried different hormones and that you’ve been on them for some time before having any surgery. You might just end up getting breasts you’re content with, and avoiding surgery is always a good thing!

These types of surgeries are generally not covered by health insurance in most countries and can be very expensive. It’s important to consult with your doctor about what suits you and what you want to achieve.

FACIAL FEMINISATION SURGERY (FFS)

Facial feminisations are surgeries that some AMAB trans people have to soften rough facial features that are generally seen as more masculine. Many choose to do this to alleviate dysphoria and feel better about themselves and their features. It can be very difficult to be constantly not seen as your true self and often these surgeries provide the person with what are considered more feminine features. This can help prevent misgendering by strangers or the people around you and help with how people perceive you and your gender. In other words, it often helps people ‘pass’ better as their authentic gender.

VOCAL TRAINING AND VOCAL SURGERY

Some AMAB trans people decide to have vocal training and even voice surgery. People’s voices obviously differ, but AMAB trans people who went through a testosterone-driven puberty often have different vocal cords and generally deeper voices. There are a lot of factors that weigh in when it comes to your voice, such as the size of your voice box, the length of your vocal cord, and its flexibility and thickness. There are also social factors and the way women and men are taught to use the pitch and melody of their voice.

Vocal training is obviously the less invasive method of changing your voice, and many people have had really good results. Often small changes such as rehearsing to speak in a different pitch and changing your melody can have massive effects. You can do this by either getting training from professionals or even following guides and tips from online sources and doing it on your own. Obviously you will get more out of a professional, but it is inevitably more expensive.

Those who feel that they cannot get the results they want through vocal training may look at the option of having vocal cord surgery. There are several types of surgeries, some of which are less invasive than others. Some require a small incision on the neck, but there are also methods by which the vocal cords are accessed through the mouth and leave no scars.

These surgeries are expensive, invasive, have a long recovery time and require extensive vocal training afterwards. It’s important to weigh up the pros and cons of undergoing such surgery. The results tend to be very good, however, and most people are very happy with their results. Having surgery is never a light matter; it should always be taken with full consideration of all possible outcomes and you should never feel pressured to have surgery of any sort.

PREPPING FOR SURGERY AND POST-CARE

There are a few things to keep in mind when preparing for surgery. First of all, it’s very important to follow instructions from your doctors very closely regarding what to do before your operation, what you’re not allowed to do and so on. If you are travelling from afar to get your surgery, make sure you’ve made travel arrangements and try to get someone to come with you or arrange for someone who lives close by to come and visit you and help you out just after the surgery.

Make sure you bring clothing that is comfortable to wear after surgery. If you’re having top surgery, for example, maybe bring a button-up shirt, as T-shirts can be tricky to get into and get out of. Make sure you bring some entertainment – either your laptop or a book to read. Depending on your surgery, you might have to stay as an in-patient for a few days up to a week, so try to make sure you won’t get super-bored!

You will be booked in for a post-op appointment with your doctor, where they will make sure everything is healing fine. It’s very important to make these appointments so that you’re sure you’re going to be alright.

A short interview with Lewis Hancox, trans man and comedy film-maker

Why did you choose meta over phallo?

I was on hormones for four years when I got approved funding for metoidioplasty on the NHS. It was a rough decision to choose between meta and phallo, as at the time I’d heard stories of the phallo resulting in lack of sensation. For me, retaining sensation was the number-one priority and I felt like I’d had reasonable growth down there from testosterone, so I chose meta in the end.

I was really happy with the end result, and although I had to sacrifice size and the ability to penetrate, I have full erotic sensation, can get erect without a device and can pee standing. Although it’s only small, it looks really natural.

What were the stages involved in the meta?

In the first stage I had a mouth graft taken from the inside of my left cheek and grafted onto the inside of my T-dick, which was sliced down the middle and left open to heal. This was so that in Stage 2, they could stitch it back up and have a tunnel left through the middle, creating my new urethra.

In the second stage I had a hysterectomy, vaginectomy, oophorectomy, urethroplasty (where the urethra is connected through).

The third stage was revision. My surgeon didn’t free my penis, meaning it was very attached to my body on the underside. It wasn’t cylindrical-shaped and couldn’t be lifted up. Also the scrotum skin was really high up and puffy, which totally covered my penis. I was really dysphoric for around a year until another surgeon agreed to do a revision. This freed up my penis and moved the scrotum skin/sac much lower down.

I’m currently in the fourth stage, still waiting for the scrotum implants. Because of the amount of skin, it already looks like a ball sac – it’s just lacking the balls!

How long has it taken?

So far, all in all, about two years.

What were you surprised by?

I wasn’t aware the graft from the cheek was even a part of the procedure until my pre-op appointment! This was one of the most painful parts of the whole thing, but thankfully it healed quickly. I also found the first stage really hard to cope with as I didn’t like my T-dick being left open like that, and was told to prise the sides apart often to keep it open. I didn’t do this enough so the sides started to fuse together and the second surgeon had to slice it back open under local anaesthetic.