How doctors create a penis from a vagina and why one trans man changed his mind about which surgery to get

• Creating a penis from a vagina is more complicated than turning a penis into a vagina.
• Adam M., a trans man, shared why he opted for a metoidioplasty over a phalloplasty.

Adam M. always knew that he was not a girl. He was born with a vagina, but he often felt what he describes as a phantom limb sensation for the penis he was missing.

"I could feel something between my legs, but there was in fact nothing for me to physically touch," said Adam, a trans man from Quebec known online as Trans Big Brother. Adam asked Insider to omit his full last name to protect his privacy.

Providing gender-affirming surgery to patients like Adam is more complex than making a penis into a vagina, said Dr. Nima Baradaran, a reconstructive urologist and director of gender affirming surgery at The Ohio State University Wexner Medical Center.

"We don't make a penis completely from a vagina," he said.

Instead, there are a couple of main options. Each process involves multiple surgeries and mutual decision-making between doctor and patient, said Rainy Horwitz, an incoming urology resident at Emory University and sexual medicine researcher.

Penile priorities

Before any surgical procedures start, patients typically need to do a couple of things: first, they have to have been living in their desired gender for at least a year or two, and have letters from psychologists saying gender-affirming surgery is necessary. Then, they must define their priorities for their penis, Horwitz said.

Adam had two priorities: physically filling the void that he had always felt between his legs, and maintaining sensitivity in his genitals.

"It was mostly for my brain to understand 'yes, there's finally something there,' and to be able to enjoy myself during intimacy," he said.

Patients also consider if they want to be able to pee while standing, penetrate a partner during sex vs. maintain maximum sensation, and whether to retain the ability to become pregnant in the future, Horowitz said. (While it's possible a person born with a vagina could still get pregnant after female-to-male surgery, a person who was born without a female reproductive system wouldn't be able to get pregnant after male-to-female surgery.)

These are tremendously difficult decisions to make. Adam said he actually changed his mind after signing up for one type of surgery he ultimately didn't go forward with.

Female-to-male gender affirmation can involve multiple surgeries

Most people who were assigned female at birth have a few surgeries before starting the process of getting a penis, Baradaran said:

• A hysterectomy removes the uterus and sometimes the ovaries, making a future pregnancy impossible.
• A vaginectomy removes all or part of the vagina to close an opening that many people feel contributes to their gender dysphoria.
• A urethroplasty lengthens the urethra – the tube that carries urine.

These procedures are necessary for patients who want to be able to stand to urinate, Horwitz said.

Adam chose not to have these procedures. He worried that a hysterectomy would complicate existing bladder pain he experienced. Also, his vagina didn't contribute to dysphoria and it was an important part of his sex life, so he wanted to keep that, too.

"I was born with a vagina and I never was a girl," he said. "It was never connected to my gender for me. It was more connected to my sexual life."

Meta is a type of surgery that creates a penis from the clitoris

The simplest way to create a penis is by metoidioplasty, a procedure known as meta in the trans community.

People who are transitioning and taking testosterone often experience clitoral growth, even without surgery. Then, during a meta, doctors cut ligaments around the newly enlarged clitoris, allowing it to extend away from the body.

"This takes a clit that has engorged, and makes it appear more like a micro-penis," Horwitz said.

A meta often results in a penis that is up to 2 inches (6 centimeters) long when flaccid, about 1.5 inches shorter than the average-sized penis. Doctors can also use skin from the labia to add girth.

If a patient has had a urethroplasty, too, doctors can surgically attach the urethra into the penis and the person will be able to urinate while standing.

Meta is a good choice for people who want to maintain sexual sensation from the clitoris, but most people who have a meta can't have penetrative sex because it's difficult to maintain a full erection. Yet Adam, who chose this procedure, said he can penetrate his partner and get erections.

Phalloplasty creates a penis from a skin graft

People who want to have penetrative sex or a longer penis usually opt for a phalloplasty, the surgical creation of a penis. This is a multi-step process that often unfolds over at least a year.

"This is a complex process that involves a team that includes a reconstructive urologist as well as a reconstructive plastic microsurgeon," Baradaran said.

First, doctors take tissue from the patient's body, usually the forearm but sometimes the thigh, that they then use to shape into a penis.

Once they've formed the neo-phallus (new penis), doctors surgically connect it to the genitals' nerve and vascular system.

The final step is lengthening the urethra and integrating it with the penis, so the person can use their penis to urinate while standing.

It's worth noting here that people who have a phalloplasty have sensation in the new penis, which is connected to the clitoris nerve. But they can only get an erection if they opt for a penile implant, Baradaran said, which requires additional surgeries.

They can also choose to change the shape of the penis head as well as add testicular implants, which use labial tissue to retain sensitivity, Horwitz said.

Creating a penis is very personalized

"It's all optional," Horwitz said. "That's what's really beautiful about these surgeries: there's a lot of shared decision making."

Adam initially wanted a phalloplasty, and even signed up for the surgery. He thought that the longer penis created by a phalloplasty would be more affirming. But as he researched more, he was concerned about the scar it would leave from the tissue graft.

"I knew a scar on my body would make me feel uncomfortable," he said.

So, he decided to go with meta knowing that in the future, he could opt for a phalloplasty if he chose. In the 18 months since his surgery, he's been satisfied with the results.

But he's had to get used to some unanticipated side effects of having a penis, like adjusting his position on a bike and getting more of a shock when he plunges into cold water.

"I didn't expect my penis to react that much like a cis guy's penis," he said.

He wants others to know that there are many, many ways to personalize bottom surgery in a way that's true to the patient, whether they want to be able to penetrate their partner, deliver a biological child, or pee standing up.

"There are so many options with bottom surgery, it's not just A or B," he said. "Don't feel pressure to fit in a mold. You are you."