Metoidioplasty

Surgeries are an option for anyone who wants to align their body with their gender, including non-binary people. There’s no one way to be trans, and you can choose whatever journey feels authentic to you. 

This might include hormone therapy and transition-related surgeries, or it might include surgeries without hormones. It might not include medical treatments at all. Not every trans, non-binary or gender diverse person has surgery – it’s a decision that’s yours to make. 

What is metoidioplasty?

Metoidioplasty or clitoral release is often known as “bottom surgery”. Other names include “gender-affirming surgery (GAS)”, “gender-confirmation surgery (GRS)” and “sex-reassignment surgery (SRS)”. SRS is an outdated term and it is used less often.

Metoidioplasty is a procedure to create a small penis using tissue from your genitals (clitoris). This can only be performed after you’ve been on testosterone (T) for a while. The exact amount of time can vary because it depends on how much bottom growth you’ve had from T. This could take two to three years.

As part of metoidioplasty, you can choose other elements to include. The surgery technique and your final outcome will depend on your goals, your anatomy, your surgeon and insurance coverage. Not all techniques are offered in Canada.

One of these elements is urethral lengthening, which uses tissue from your genitals (or, with some surgeons, your inner cheek) to extend your urethra through your penis. You can also choose a vaginectomy, which removes or closes the vagina.

If you are having surgery at GRS Montreal, you can only have urethral lengthening if vaginectomy is also performed. Some people will include a scrotoplasty, which is where the surgeon creates a scrotum from your labia and adds testicular implants.  

Why do people get metoidioplasty? 

There are many reasons someone might get metoidioplasty. The most common is that it can help ease feelings of dysphoria, which improves your wellbeing. If you have urethral lengthening, you can usually pee standing up, and some people might also get surgery to feel more comfortable in environments like the pool, gym or beach.

Alternative treatment options

If you’re not ready for surgery or are still exploring your options, packing is a way to change the shape of your genitals. This guide from Trans Care BC has a helpful summary.

Testosterone can also change the shape of your genitals by causing bottom (clitoral) growth. See our guide to T for more information.

Surgical techniques

Metoidioplasty techniques can vary depending on your surgeon. In Canada, metoidioplasty is mostly performed at GRS Montreal. This is the only surgery clinic that is covered by OHIP in Ontario and Alberta Health in Alberta, if you have received a funding approval letter. In some cases, OHIP will fund surgeries performed in other countries (e.g. the United States).

OHIP and Alberta Health require that you have been on hormone therapy for at least 12 continuous months before applying for coverage. If you would like the vaginectomy and scrotoplasty parts of this surgery, you may also need to have undergone a hysterectomy and bilateral salpingo-oophorectomy (BSO) – surgery to remove your uterus, ovaries and fallopian tubes – at least six months beforehand. 

Metoidioplasty steps

• Before surgery, hormone therapy (T) is used to increase the size of your erectile tissue (clitoris). This can take two to three years.

• The surgeon cuts ligaments around the erectile tissue, creating more length.

• Your urethra can be extended using tissue from the inside of your cheek or your genitals.

• Skin and fatty tissue from the surrounding area can be used to give the penis more girth.

• Your vagina can be removed or closed (vaginectomy).

• Your surgeon can create a scrotum using skin from your labia (scrotoplasty) and insert testicular implants.

Other surgical techniques exist but they are not covered by public insurance or offered in Canada at this time. If you have decided to pursue one of these options through private payment and you need a pre-surgical assessment, contact Foria to see if we can provide this. Please email support@foriaclinic.com before booking an appointment. 

Before and after surgery

Metoidioplasty is a major surgery, so you’ll need a plan for how you’ll prepare and recover. You’ll need to take time off work afterwards and will also need someone you trust to help out in the days and weeks after surgery. Your pre-surgery assessments will give you a chance to discuss this. 

Each surgeon or clinic will also have their own guidance for preparation and recovery. They’ll also stay in touch with you throughout the recovery process to ensure you’re healing well. After surgery you may have regular check-ups and aftercare appointments. 

Side effects and risks

As with all surgery, metoidioplasty comes with side effects and risks. These include:

Urethral lengthening complications

• Being unable to urinate standing up due to problems with urine stream (spray or dribble) or size of penis

• Urethral fistulas: a leak between your urethra and skin

• Urethral stenosis: when your urethra narrows, making it harder to urinate

• Urethral strictures: when your urethra completely blocks, which prevents urinating. This requires a catheter (a small tube to help you urinate) and/or surgery to fix.

• Hair growth in urethra: may cause stenosis, stricture, or stones (crystals or lumps) in the urethra

• Urinary tract infections (UTIs)

Other metoidioplasty risks

• Complications with your testicular implant, like discomfort, infection, extrusion (where the implant comes out of the skin), or poor positioning

• Change in sensation in your penis (less sensation, tenderness, hypersensitivity)

• Feeling dissatisfied with how your genitals look and/or function

General surgery risks

There are some general risks that come with most surgeries. They are:

• Bleeding

• Blood clots in your legs or lungs

• Injury to surrounding organs, nerves or blood vessels

• Hematoma (a collection of blood) or seroma (a collection of fluid)

• Infection or abscess

• Wound opening or delayed healing

• Chronic pain

• Scarring

• Feeling dissatisfied with the outcome

• Feelings of regret about surgery

These risks can be higher with certain medications and health conditions, like immune or clotting disorders, or if you smoke. Tell your doctor about any medications and supplements you take, along with any health conditions you have (even if they don’t seem relevant!). 

Anesthetic risks

Bottom surgery requires going under general anesthetic. General anesthetic has the following risks (most of which are very rare):

• Nausea/vomiting

• Damaged teeth

• Aspiration pneumonia (pneumonia from inhaling liquid like saliva or vomit)

• Respiratory failure (i.e. stopping breathing)

• Heart attack

• Coma

• Death

Ready for surgery?

If you'd like to get metoidioplasty, your surgeon will require two assessments to confirm you're ready for surgery.

If you're in Ontario and would like to apply for OHIP funding to cover your surgery then you also need to submit an application to the Ministry of Health. Foria can provide your assessments, and we can also submit and track your funding application for you. See our Surgical Referrals in Ontario article for more information.

If you're in Alberta and would like to apply for Alberta Health funding to cover your surgery then you also need to submit an application to the Ministry of Health. One of your two assessments must be done by a psychiatrist. See our Surgical Referrals in Alberta article for more information. Foria does not currently offer assessments in Alberta, but these services will be available soon.

This content has been reviewed by Foria’s Medical Director, Dr. Kate Greenaway and our community advisory team. Medical sources include Rainbow Health Ontario’s TRS Surgical Summary Sheets, Trans Care BC and GRS Montreal.

by Foria Clinical Team

Oct 16, 2023・ minute read

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