Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the 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).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
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 doesn't need 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. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in 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'.
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. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] 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.[improper synthesis?]
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 woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
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 stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.
Notes and references
A transgender woman who underwent a vaginoplasty to have her penis turned into a vagina has described in graphic detail what the process was really like.
Jessica, who identifies as a queer woman, had already started hormone replacement therapy and gone all the way to South Korea to have vocal chord surgery to transform her baritone voice when she decided to have a breast augmentation surgery and a vaginoplasty in one operation.
After her vaginoplasty, which she had near her home in East Bay Area, California, she warned 'there are going to be parts of you that are going to melt off' in an interview with Truth Speak Project.
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Melting: A transgender woman has described what it is like to undergo gender reassignment surgery; a video reenactment by the European Association of Urology shows what genitals might look like after the procedure
Jessica, whose partner was also born male and had already had the surgery, said there were elements of her recovery that she was not warned about by doctors, adding that it was 'really scary'.
She said: 'There are going to be parts of you that are going to melt off...It is really scary. But it’s also perfectly normal and most people recover from that completely as if nothing has happened.
'Basically the furniture down there gets rearranged during the surgery. One of the many things I learned along this journey is that male genitalia and female genitalia aren’t that different. They’re arranged differently, but the individual parts are really similar.
'So vaginoplasty consists of a re-positioning and folding of all these tissues using the existing tissues.
'When that’s done, some of the tissues might not get as much blood flow as they did before, so they get starved of nutrients and oxygen.
'That’s when the surface tissue tends to die off — which is as gross as it sounds. It is really really awful.'
Warning: Jessica, who was born male, said: 'There are going to be parts of you that melt off' after surgery (medical diagram shown)
Although Jessica said she was expecting her vagina to 'look like Frankenp***y' after surgery, it was much worse that she could have imagined.
At one point she claims she thought she was 'dying'.
'It’s red, there’s stitches and it’s swollen, you can see the stitch lines. You expect that,' she said.
'What you don’t expect is this yellow-y, clumpy, almost mucus-y, looks-like-someone-sneezed-on-your-p***y kind of residue.
'So you might have a chunk of your inner labia just die off, just fall off, and it’ll just grow right back. It’s hard to believe because when you lose a limb or a toe it doesn’t grow back. But it turns out that your p***y does. It’s strange.
'And it’s gross and it’s funky and it’s awful and you think, "Oh my god, What is happening? My p***y is melting. I’m dying." But it turns out that it is perfectly normal.'
She said doctors should better prepare patients for what will happen following the surgery.
'It’s something doctors should tell patients beforehand. Because you’re already dealing with so many changes, working with so many geographic changes on your body.
Healing: She said she had anticipated her vagina looking 'like Frankenp***y' after surgery, pictured in diagram, but said it was much worse than she expected (medical diagram shown)
'Your clitoris, which used to be the head of your penis, is positioned in a completely different way,' she said.
In the early days after the operation, Jessica said there were occasions when she thought she still had male genitalia.
She said: 'There were times early on when I felt like I could feel my penis. I figured out what was going on though.
'Basically, my clit was telling me that it was still the head of my penis, that the most sensitive part of it was still there. It took a lot of adjusting and it was pretty weird at first.'
She said she has shown her new sexual organs to cisgender females who have told her the surgeon 'did a great job'.
Jessica said she has a G-spot and that she has had orgasms - but they are 'very different' to what she experienced before surgery.
She said: 'I do have a G-spot. In fact, I still have a prostate, even though it’s much smaller than it was because of hormone replacement therapy. But it’s still there and it can still be stimulated. It’s still very enjoyable...
'Orgasms are very different. Oh my goodness. They were different even before my surgery after I started hormone replacement therapy. That’s when I started having more full-body orgasms.
Icon: Transgender actress Laverne Cox, 31, left, has previously said she was pleased she could undergo gender reassignment in private; transgender model Andreja Pejic, right, also underwent the procedure in 2014
'The sensation wasn’t just concentrated immediately around my genitals anymore. It was more like waves of pleasure throughout my body.
'So that started happening with just hormones. But then, of course, the surgery changes everything.'
She added: 'I didn’t think that I would get such good results from my surgery but there they are.
'I definitely experience internal stimulation orgasms and they are different from the orgasms I get from clitoral stimulation.
'They’re deeper and they’re more intense — always gush from internal orgasms.'
She said the development of surgery has made experiences for people undergoing the procedure 'a lot better' in the last decade.
She added: 'Some things are different for trans feminine people who had their surgery ten years ago.
'Doctors have gotten to a point now where they can make a vagina that allows you to come and really gush from internal vaginal stimulation just like a cis-gendered woman does, if that’s something that you’re capable of doing.'
Jessica paid for her breast augmentation herself but the vaginoplasty was covered by her insurance as required by California law after a doctor said it was medically needed.
Despite having done so herself, Jessica warned against having both surgeries in one operation.
'I woke up in the recovery room in a world of pain, unable to move,' she said. 'I really underestimated how much the recovery from breast augmentation takes out of you.'
She said she opted for a full vaginal canal because she wanted to experience penetrative sex and to 'relate to cis-gendered women'.
Content: Jessica said she is pleased with the surgery, pictured above, and said since then she has found she has a G-spot and has had orgasms
Progress: Jessica said vaginoplasty surgery, pictured in diagram, has developed considerably over last decade
She added: 'I had to wear a pad every day and I get it. The struggle is real...I have this newfound respect and empathy for my fellow sisters. I get it now...
'I just had my first p-in-v sex as a vagina-haver and it was different from what I expected. It was more intense than I expected.
'I had gotten used to the process of dilating my vagina, which I do with a medical phallus one to two times a day, to keep the new vagina from closing up.
'I’ve been doing that for 9.5 months since my surgery. So having something in my vagina is a normal sensation for me because I experience it every day.
'There are going to be parts of you that are going to melt off... It is really scary. But it’s also perfectly normal
Jessica, transgender woman
'But having a person inside my vagina was a relatively new experience for me. I’ve had fingers but I’ve never had a penis.
'It was a little overwhelming, but it was pleasant and fun and I would totally do it again. The person I had sex with was a preoperative trans woman.'
Transgender model Andreja Pejic underwent gender-reassignment surgery, also known as gender-reconfirmation surgery, in 2014.
Talking about the decision last year the Bosnian model told Vogue: 'Society doesn't tell you that you can be trans. I thought about being gay, but it didn't fit…
'I thought, well, maybe this is just something you like to imagine sometimes'.
Orange Is The New Black star Laverne Cox said she does not like the focus on gender reassignment surgery - saying she is 'grateful' she could have gender reassignment surgery in 'private' unlike Caitlyn Jenner.
The transgender actress told Entertainment Weekly last year: 'I’m so grateful that I had the luxury of transitioning in private because when you transition in the public eye, the transition becomes the story.
'I’m always disturbed when I see conversations about trans people that focus on surgery. But I believe Caitlyn will transcend this moment.'
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