Sex reassignment surgery from female to male includes surgical procedures which will reshape a female body into a body with a male appearance. Many trans men do not opt for genital reassignment surgery, but most undergo a double mastectomy, the removal of breast and shaping of a masculine chest and hysterectomy, the removal of internal female sex organs, along with hormone treatment with testosterone.
Most trans men require bilateral mastectomy, the removal of female breasts and the shaping of a male contoured chest. Transmen 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 needs not 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 women whose nipples are removed as part of treatment for breast cancer.
For transmen 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.
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 cisgender women is sometimes referred to as a ‘partial hysterectomy’ and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. Within the Transgender community, a hysterectomy/BSO combination is often simply referred to as a ‘full hysto’.
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses cease with hormonal therapy. Some undergo this as their only gender-identity-confirming ‘bottom surgery’.
For many transmen, however, hysterectomy/BSO is done to eliminate the risk of developing cervical, endometrial (uterine), and ovarian cancer. It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in Transgender men on testosterone compared to the general female population. Unfortunately, it will probably never be known, since ovarian cancer is a relatively rare disease with an overall lifetime risk in women of only 1/70, with a median age of onset of 60 years. Because ovarian cancer is uncommon, the overall population of Transgender men is very small, and 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), it is essentially impossible to do the appropriate epidemiological study to answer that question. 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. Regular Pap smears drastically reduce the risk of cervical cancer, and are the only way to prevent it without having the cervix removed.
Eliminating cancer risk is particularly important, however, as transmen often feel uncomfortable seeking gynaecological care, and many do not have access to adequate and culturally sensitive treatment. Ideally, though, even after hysterectomy/BSO, transmen should see a gynecologist for a check-up at least every three years. This is particularly the case for transmen 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 gynaecological 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 gynaecologist. This is equivalent to post-menopausal bleeding in a cisgender woman and may herald the development of a gynaecological cancer. Even if you do not have cancer, vaginal bleeding while on testosterone may indicate that your hormone levels are not in the male range, which means no further changes will happen and reversible changes may start to reverse until your hormone levels are settled back in the male range.
Genital reconstructive surgeries (GRS) use either the clitoris, which is enlarged by androgenic hormones (Metoidioplasty), or rely on free tissue grafts from the arm, the thigh or belly and an erectile prostheses (Phalloplasty). The latter usually include multiple procedures and are more expense. However, the resulting phallus is much larger and is capable of penetration. Metoidioplasties usually do not result in a phallus big enough to achieve penetration, but do allow for spontaneous erections. Both of these surgeries have results that come close to the appearance and function of cisgender male’s penis in some aspects and not in others. Satisfaction depends on personal preference; most people who undergo either one of these surgeries are happy with the results.
In either case, the urethra can be rerouted through the phallus to allow urination through the reconstructed penis. The labia major are united to form a scrotum, where prosthetic testicles can be inserted. These are sometimes preformed in later, separate surgeries, but may be preformed at the same time as the phalloplasty or metoidioplasty.
- Rachlin, K., Factors Which Influence Individual’s Decisions When Considering Female-To-Male Genital Reconstructive Surgery, International Journal of Transgenderism (This article also discusses some general issues of FTM GRS)