Phalloplasty

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 phalloplasty?

Phalloplasty 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 SRS is an outdated term and it is used less often.

Phalloplasty is a procedure to create a penis and scrotum using tissue from your existing genitals and your arm (or, in some cases, thigh). Some people will also choose to have testicular implants and a penile implant, which means you can have erections for penetrative sex. 

It takes multiple surgeries to complete a phalloplasty. This process and your final outcome will depend on your goals, your anatomy, your surgeon and insurance coverage. If you choose all surgical steps, it can take one to two years. Not all techniques are offered in Canada.

Why do people get phalloplasty? 

There are many reasons someone might get phalloplasty. The most common is that it can help ease feelings of dysphoria, which improves your wellbeing. It removes the need for packers and, depending on the type of surgery you have, means you can pee standing up and have penetrative sex (if you choose a penile implant). 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.

There are also other surgical options. Metoidioplasty is a surgery to create a small penis from your erectile tissue (clitoris), with the option to extend your urethra through this new penis. The surgeon can also build a scrotum from your genital tissues and insert testicular implants. This is different to phalloplasty because it uses the clitoris to create a penis instead of tissue from your arm or thigh.

Surgical techniques

Phalloplasty techniques vary depending on your surgeon. The most common type of phalloplasty offered in Canada is radial forearm flap phalloplasty, which is mostly performed at GRS Montreal. This is the type of surgery covered by OHIP in Ontario and Alberta Health, 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. To be eligible for phalloplasty you also need to have had a hysterectomy and bilateral salpingo oophorectomy (BSO) – surgery to remove your uterus, ovaries and fallopian tubes – at least six months prior. Additionally, your surgeon may require permanent hair removal on your skin donor site.

Radial forearm flap phalloplasty

This procedure consists of three steps. How many steps you choose will depend on your personal preference and your anatomy.

Step 1: Phalloplasty

• A flap of tissue containing skin, nerves, veins and an artery is taken from the forearm (usually your non-dominant arm)

• This tissue is used to create a urethra, penis and glans (head of the penis)

• Skin from the labia majora is used to create a scrotum

• The penis is attached to the body over the clitoris and connected with blood vessels and nerves

• The urethra is extended to the base of the penis

• Skin from the thigh or buttock is moved to replace the forearm skin

Step 2: Constructing the urethra

• The existing urethra (extended in phalloplasty) is connected to the penis

• This is usually an outpatient procedure (you can go home the same day as surgery)

• You will have a catheter (a small tube to help you urinate) inserted for a few weeks

Step 3: Penile and/or testicular implants

• Testicular implants are inserted into the scrotum

• A penile implant can also be inserted, which allows for penetrative sex

• Some implants come with a pump to inflate and deflate the penis for sex

Some surgeons may use tissue from other body parts, like your thigh, to create the penis. This may be an option if you have tattoos on your arm donor site. These alternative techniques are at your surgeon’s discretion.

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

Phalloplasty 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 – for example, getting permanent hair removal at your donor site before surgery. 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, phalloplasty comes with side effects and risks. It has a very high rate of complications (up to 76.5%). These include:

Urinary complications

• 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 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 complications

• Scarring, numbness, stiffness, swelling and/or pain at your donor site (wrist, elbow, arm)

• Graft failure (where the penis tissue partially or completely dies) 

• Nerve damage and loss of sensation in your penis

• Decreased sexual satisfaction, inability to orgasm

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

• Injury to bladder or rectum (including recto-perineal fistulas, a connection between your rectum and skin)

• Wound breakdown (common at base of the penis)

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

• Complications with your erectile device (infection, breakdown of the skin, failure of the device, or poor positioning)

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. Tell your doctor about any medications and supplements you take, along with any health conditions you have (even if they don’t seem relevant!). 

Smoking dramatically increases your risk of complications, and most surgeons will require that you quit nicotine (including vaping) for a fixed period before and after surgery. This is often a condition of surgery, and some surgeons may require tests to confirm you’ve not been smoking.

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 phalloplasty, 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 4, 2023・ minute read

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