From now until sometime in Spring 2023, we’ll be writing about gender affirming procedures. We’re starting with bottom surgeries and will end with office visit procedures such as fillers and botox. This week, we’re discussing metoidioplasty. It is sometimes referred to as “meta,” and we’d love to hear your best puns about meta metas on Meta.
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
What is metoidioplasty?
Metoidioplasty is a surgical procedure where the ligaments that attach the clitoris to the pubic bone are cut, along with the tissues that connect the clitoris to the urethral structure and the labia. This “releases” the clitoris and separates it from the groin. The clitoral hood becomes the sheath and foreskin of the new penis. Metoidioplasty will not achieve the length and girth that is available via phalloplasty, and penetration might not be possible with a meta. Bottom growth from testosterone is usually sought before metoidioplasty and helps to achieve a larger and longer result. Metas average about 2″ in length.
OHSU provides an excellent guide to metoidioplasty
Dr. Blair Peters, a surgeon at OHSU, is doing pioneering work on nerve structures in the clitoris. Dr. Shane Morrison at UW recently published an article about extended-release metoidoplasty – aimed at creating more length while retaining sensation and erections (note – this article describes the surgical procedure in technical language and has pictures of surgery in progess.)
Options for Metoidioplasty
Meta may be done in combination with:
- urethral lengthening – to pee out of the tip of the penis and standing up
- scrotoplasty – creation of a scrotum
- testicular implants – either with silicone/salt water implants or fat from another place on the body
- hysterectomy – removal of the uterus
- salpingotomy – removal of the fallopian tubes
- oophorectomy – removal of one or both ovaries
- vaginectomy – removal of the vaginal canal and closure of the opening
- hysterectomy is required if vaginectomy is chosen
- monsplasty – to change the appearance of the fat pad which lies on top of the pubic bone. This can also move the new penis forward
Note: some surgeons will not create a scrotum (scrotoplasty) and put in implants on the same day.
None of these procedures are required for metoidioplasty. However, if urethral lengthening is desired, surgeons may require that hysterectomy and vaginectomy are done, too. Vaginal or cheek tissue may be used to create the new urethra length.
Metoidioplasty can be a final stage surgery, or can be a stage towards phalloplasty. If you’re not sure about phallo, you can have a metoidioplasty first and a phallo later on.
Depending on the options desired and the surgeon, metoidioplasty may be done in one or two stages.
Metoidioplasty.net has a discussion of the various techniques used in meta surgeries.
When: Expected Prep and Recovery for Metoidioplasty
Some surgeons recommend pumping before and after meta to achieve and maintain length. Most surgeons recommend at least 12 months of testosterone before metoidioplasty.
Prepping for meta is similar to other bottom surgeries, although hair removal is not required. The OHSU booklet we linked to earlier has a checklist and a list of supplies, and we wrote a blog about general prep for bottom surgery. If you’re a smoker, your surgeon will require that you stop smoking a few months before surgery. You’ll need to arrange transportation, housing, a caretaker, and time off from work.
Recovery is also similar to other bottom surgeries. Patients will stay in the hospital for a night or two after surgery. The average time off from work is four to eight weeks. Lifting and activity restrictions will apply for up to eight weeks, and significant restrictions will apply for the first month. Activity restrictions may depend on whether or not other procedures were done along with the metoidioplasty. Your surgeon may want you to stay in the area for a month, so you may need to arrange housing. Patients may have a catheter for up to a month if urethral lengthening is chosen.
OHSU offers a recovery plan worksheet.
MozaicCare offers a detailed FAQ on what the first few weeks and appointments after surgery look like. Montreal GRS has an extensive booklet on recovery.
Many surgeons post images of metoidioplasty during and after surgery on their websites.
How: Common Surgeon and Insurance Requirements
Like other lower surgeries, you will likely need two letters from mental health providers for your surgeon, along with letters from your surgeon and/or hormone provider for insurance. Surgeons generally require at least twelve months of testosterone use and sufficient bottom growth before metoidioplasty.
Some insurance policies may require that you document your support and housing plans during recovery. Your surgeon will want to know that your health is optimized for surgery, so you’ll likely have a physical/health exam and lab work ordered prior to surgery.
Why: Some Things To Think About
Form: what do you want your genitals to look like?
Function: what do you want to do with your genitals?
This surgery releases the tissues that hold the clitoris close to the body. Penises and clits both have a shaft and a head. The usual differences are in size, how they are attached to the body, and where pee leaves the body. A meta frees the shaft and alters the hood so that the main difference is size. Urethral lengthening can move where pee leaves the body to the tip of the new penis.
If you want to be able to see your genitals while looking down, a meta might not provide enough length, and you may wish to consider a phalloplasty.
Surgeons can preserve sensation, so if direct erotic sensation to your glans and shaft is important to you, a meta may more right for you than phallo.
You can have erections with meta, but they may not be long enough for penetration.
If you stop testosterone after meta, you may lose length.
Where: Surgeons Who Offer Metoidioplasty
There are many surgeons doing metas, and more surgeons are learning the techniques. Metoidioplasty.net offers a directory of surgeons.
Other tips for finding a surgeon:
We have a limited database of surgeons by procedure on our Gender Affirming Surgery page. It was designed for our internal use, so it contains medical terminology. Use with caution.
Some other directories of surgeons include:
- WPATH Provider Directory
- OutCare Health
- The r/TransSurgeries wiki on Reddit
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