What to Expect When Considering Phalloplasty

Even five years ago, there was little information on what was involved with phalloplasty, a genital reconstructive surgery where a penis is crafted through several procedures that lengthen the urethra, create a scrotum, remove the vagina and that requires erectile implants.

A 2019 study published in Translational Andrology and Urology reported that less than 5 percent of trans men had a procedure to create a phallus. Due to surgical complications, such as the body not accepting the graft, only 3 percent of trans men have had a successful phalloplasty. But 19 percent of the participants in the survey wanted it in the future but weren’t ready to get it just yet.

What is bottom surgery?

Bottom surgery, a phrase used to describe gender-affirming procedures, is done typically in two to four stages. The vagina must be removed before the phallus can be attached, and the area must heal before the graft will take. Breaking the process into multiple stages also reduces the risk of blood clots and infections, but going through multiple surgeries can increase anxiety and fatigue, taking a mental toll on top of a physical one.

The specific order of surgical stages depends on the surgeon's opinion and expertise. But they include some or all of the following:

• Getting a hysterectomy
• Removing the vagina
• Attaching the phallus
• Re-routing the urethra to go through the phallus
• Creating a penis
• Creating and attaching a scrotum
• Implanting an erectile device

Getting approved for surgery takes time. Patients must meet World Professional Association for Transgender Health (WPATH) criteria before they can schedule a surgery date. These criteria were created to facilitate transgender health and wellness and are based on research findings.

The criteria include documented gender dysphoria (severe distress about mismatching assigned gender and gender identity), able to make well-informed decisions, in good health, one continuous year of hormone replacement therapy (HRT) and one continuous year living as their gender identity. Patients also need to complete pre-op appointments and surgical assessments beforehand.

Different surgeons have their own criteria patients must meet before they qualify for the surgery, such as being a certain weight and eliminating medications that might complicate the procedure. A phalloplasty is expensive. Insurance plans may not cover the surgery, which can cost more than $25,000 out of pocket.

Not all phalloplasties are the same

There are three major types of phalloplasty that include taking a skin graft from either the arm, thigh or side of the torso. Overall health, fat distribution, blood flow, the patient's goals and other issues determine which graft site gets used.

Finlay Games, a gay trans man and author based in the UK, completed his phalloplasty in 2018 after four stages of surgery. Games said just as you recover from one and start to feel like yourself, your next surgery happens.

“Stage one was the hardest by far,” Games said, adding that he couldn't move from bed for three days after a skin graft taken from his arm was used to create the phallus. Other stages include urethral lengthening and glans sculpting, just to name a few.

What to expect for recovery

Recovery also looks different for each patient undergoing the procedure. And specific steps to recovery depend on each surgical phase. “The process is exhausting,” Games said, "mainly because of the many stages and surgeries.” Complications are almost to be expected since the procedure can be similar to a transplant that the body doesn’t always accept.

For Games, one of the most debilitating aspects was developing a massive infection, which resulted in his having his urethra surgery temporarily undone.

Right after surgery, patients can expect to spend at least four days in the hospital and up to five days at home with a caregiver, such as a friend or partner. During the first week, the patient will have to keep their penis elevated. Three to four weeks after the surgery, completing household tasks such as doing the laundry and preparing meals may require additional help to prevent aggravating the surgical site and developing complications. Complete recovery can take up to 18 months after the final stage of implant surgery.

Because phalloplasty is such a complicated procedure, it’s wise to educate yourself on possible side effects. Some of the most common include wound, bladder and transplant infections, pelvic bleeding and pelvic pain.

How the surgery will impact your sex life

Surgical complications mean your sex life might take a back seat for at least six weeks. It takes time to regain sensation after having the surgery, so sex may not be enjoyable for a while. For Games, it took nearly four months to develop any signs of sensation.

The first sensation he said felt was a vibration from his hair trimmer. Instead of feeling it in his newly created phallus, he felt it in his clitoris.

After six months, Games's sensation in his penis became much more sensitive. However, he wouldn’t experience erotic sensations for two years after his surgery. Three years after the first surgery, Games had an erectile device inserted. Once he healed from this surgery, he had much more direct sensation in his shaft and could feel the ribbed interior of his stroker toy.

Games described his experience as “positive and profound.” Before transitioning, he had no sex drive and no fulfillment in sex. Through the phalloplasty process, “it became easier to touch myself and be touched by others, without having to switch off in my head," he explained.

Getting a phalloplasty is a big decision—it's quite literally life-altering. Knowing ahead of time that it is a difficult journey involving a long recovery can help you decide if you want to go through with it or whether you want to wait until the surgical technology advances.