Sex Question Friday: How Does Female-To-Male Sex Reassignment Surgery Work?

Every Friday on the blog, I answer people’s questions about sex, love, and relationships. This week’s question comes from a reader who wanted to know the following:

For female-to-male transsexual individuals, is it possible to construct a fully sexually-functional penis? Is it possible for them to get erections? That seems like a really difficult medical procedure.

Sex reassignment surgery (also known more commonly now as gender affirmation surgery) has come a long way in the last few decades; however, there are limitations to what modern medicine can achieve. In particular, creating a functional penis is one of the biggest challenges for persons who want to surgically transition their body from female to male (FTM). There are actually two different surgical procedures one might opt for in this case. One is metoidioplasty, which essentially involves transforming the clitoris into a penis. The first step is to enlarge the clitoris through hormone therapy (treatment with testosterone can increase its size). Afterward, the internal suspensory ligament is cut, allowing more of the clitoris to fall outside of the body. If desired, the urethra can be lengthened and routed through the newly formed penis. In addition, a scrotoplasty is usually performed, in which the labia are sutured together to form a scrotum and testicular implants are inserted. The primary advantage of metoidioplasty is that it takes advantage of the natural presence of erectile tissue in the clitoris, which means that the resulting penis has its own erectile capabilities. However, the primary disadvantage is that the size of the clitoris can only be increased so much and, for those who want to perform penetrative intercourse, the penis may not be large enough for this purpose.

If the person transitioning desires a bigger penis, the other option would be phalloplasty. This involves taking skin grafts from other bodily areas and using them to create a penis. Again, the urethra can be lengthened and routed through the penis and a scrotoplasty can be performed. Although phalloplasty may yield a larger penis, it would not be capable of erection on its own because it is simply not possible for doctors to create erectile tissue from scratch. However, a penile implant can be inserted, much like those that would be used in cisgender men who have incurable cases of erectile dysfunction.

In addition to the difference in penis size, one other way that metoidioplasty and phalloplasty differ is that metoidioplasty retains more of the original nerve pathways, which may yield greater potential for orgasm post-surgery.

As you can see, there are tradeoffs with both procedures. Metoidioplasty offers biological erectile capabilities and more sensation, but much smaller size; in contrast, phalloplasty offers larger size and more functionality for intercourse, but the penis cannot become erect on its own and is not as sensitive.

Among FTM individuals who have undergone sex reassignment, orgasm is possible and, in fact, ability to reach orgasm often increases [1]. In addition, satisfaction with the surgery tends to be very high (>80%), and frequency of sexual activity usually increases as well [1]. Thus, while there are limitations to what can be accomplished through sex reassignment/gender affirmation surgery, it is very much possible to produce satisfying outcomes.

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[1] Lief, H.I., & Hubschman, L. (1993). Orgasm in the postoperative transsexual. Archives of Sexual Behavior, 22, 145-155.

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