Purpose of Phalloplasty

Phalloplasty, sometimes known as “bottom surgery,” is a procedure in which a penis is created or restored from tissues elsewhere in the body, such as the arm or thigh. The procedure may be paired with scrotoplasty, which is the construction or reconstruction of the scrotum.

Primarily, this surgery is used along with hormone therapy in transgender men as part of gender reassignment or gender confirmation (though some transgender men may choose an alternative, metoidioplasty, or not opt for surgery at all).

Phalloplasty may also be used in certain cases in which cisgender men are born without a penis or have lost it due to cancer or medical accident.

Diagnosis Related to Phalloplasty

Transgender men seeking GCS, are typically diagnosed with gender dysphoria, in which a person identifies with a gender identity that is not their assigned or biological gender at birth.

What are the traits of gender dysphoria? According to the American Psychological Association, a person is diagnosed with this condition if they display two or more of the following for a period of at least six months:

• A significant incongruence between one’s expressed and experienced gender and their primary or secondary sex characteristics (that is the physical signs of gender, including genitalia and body shape)
• A strong desire to change from primary or secondary sex characteristics
• A strong desire for the primary and/or secondary sex characteristics of a different than assigned gender
• A strong desire to be another gender
• A strong desire to be treated as another gender
• A conviction that one has the feelings and reactions of the other gender

Alongside cases related to gender dysphoria and GCS, a number of other medical conditions may require phalloplasty. These include:

• Congenital issues: This includes cismen being born with no penis (congenital absence), an underdeveloped penis (also known as penile hypoplasia or micropenis), or other deformities.
• Ambiguous genitalia: Some people are born with undifferentiated or ambiguous genitalia.
• Mutilating trauma: Injuries to the genitalia due to road accidents, accidents caused by heavy machinery, or dislocation or fracture of the pubic bone (known as avulsion injury) may be treated with this surgery.
• Blast injuries: Injuries related to explosions, whether due to accident or in combat, may also severely damage the groin.
• Self-inflicted damage: Certain cases of psychological distress or drug abuse may cause a person to mutilate their genitals.
• Infection: Several kinds of bacterial and fungal infections can affect the penis, including balanitis (an infection in the head of the organ) and necrotizing fasciitis, a flesh-eating disease.
• Accidents during circumcision: Very rarely, misadventure during a circumcision will cause serious damage.

Criteria

As with any major surgery, doctors will want to ensure that patients considering or requiring phalloplasty fit the proper criteria for the procedure. These may vary somewhat based on the hospital, but tend to be as follows:

• Age: Barring medical circumstances that require this work—and especially for those undergoing GCS—patients should be 18 or over.
• Lived experience: For GCS, doctors will want to see evidence that you have at least 12 months of lived experience in the affirmed gender.
• Hormone therapy: Another requirement for phalloplasty as part of GCS is at least 12 months of gender-affirming androgen (testosterone) hormone therapy.
• Body mass index (BMI): To ensure safety of the procedure, doctors want to see patients with a body mass index (BMI) of 35 or less. This is a flawed but commonly used measure of body fat level based on weight and height; a BMI above 30 is considered clinically obese.
• Smoking: Since tobacco or nicotine use increases the chances of complications and hinders post-surgical recovery, doctors want patients to quit smoking and vaping for the 60 days before, and six weeks after phalloplasty.
• Hysterectomy: For GCS, hysterectomy—the surgical removal of the uterus—needs to occur prior to phalloplasty.
• Hair removal: As noted above, the tissue used for phalloplasty may be harvested from the forearm or thigh. Hair removal procedures need to be performed prior to this.
• Fertility preservation: For those seeking GCS interested in preserving fertility, gamete preservation procedures should be done before surgery.
• Clinician recommendation: Required for GCS is a letter of recommendation from your physicians or nurse practitioner affirming diagnosis of gender dysphoria and stating any physical or health factors that might influence the success of the surgery. Most often, this letter comes from the doctor who diagnosed the condition, or the physician who has prescribed the hormone therapy.
• Behavioral health letter: In cases of GCS, you also need a letter from a mental health provider affirming that you’re of sound mind to make the decision to undergo surgery, basic information about gender identity, psychosocial assessment results, and duration of professional relationship, among other pieces of information.  
• Second behavioral health letter: For GCS, a second letter by a mental health professional affirming the above and stating that you’ve been living as your affirmed gender for at least 12 months. This one should also include assessments of your understanding of the procedure, fertility and health implications, as well as an evaluation of your support systems.

Tests and Labs

To help ensure a safe outcome for phalloplasty, several tests and labs need to be performed prior to the procedure. These include:

• Complete blood count (CBC): This refers to a battery of tests that indicates the amount of white blood cells, red blood cells, platelets, and hemoglobin in the blood. Among other aspects, this gives doctors a sense of a patient’s immune health.
• Type and screen: This is a blood test that determines blood type and screens for any antibodies that could attack transfused cells of a different type. Primarily, this is performed to ensure safety for blood transfusion, which may be necessary during phalloplasty.

Once the safety of this procedure is confirmed—and any risks mitigated—patients will be ready to go into surgery.

A Word From Verywell

For those considering GCS, it’s important to note that phalloplasty is far from the first step; the process of transitioning is lengthy and multifaceted. As sketched out above, there’s a great deal of both physical and psychiatric work that’s required prior to your going into surgery.

The road shouldn’t be taken alone, and, as much as possible, you’re well-served seeking support from family, friends, and medical professionals as you undertake it. In addition, you may find additional information and support from groups like the National Center for Trans Equality and the Trans Lifeline, among others.

The good news is that phalloplasty—and GCS surgeries in general—are safer than they’ve ever been before.