What is phalloplasty?

Phalloplasty is surgery to create a penis, often with the ability to urinate out of the end of it and to make it erect.

What does phalloplasty do?

• Lower body

  Creates a penis and ability to stand to urinate

Who can have phalloplasty?

• You must have had 12 continuous months living as your gender identity

• You must have had 12 continuous months of HRT, unless you’re unable to

• You must have capacity to consent for this treatment

• If you have significant medical conditions, these need to be “reasonably well-controlled”

• Under 18s cannot have this but can be referred at 17

• You typically need a BMI of less than 30

How long does phalloplasty last?

The effects are permanent and cannot be reversed. Phalloplasty usually takes several separate surgeries to complete, with healing time in between them, and may take more than a year to complete.

What should I be aware of?

Phalloplasty involves a degree of risk. UK surgeons have reported a 3% rate of phallus loss, though this risk can be reduced by avoiding smoking and not being overweight. In the event of phallus loss, further attempts can be made 6-12 months later 2, p.284. It is important to note that if a prosthetic erectile implant is used, it will likely need replacement later in life, so you will need to be prepared for further surgeries in the future 2, p.299.

Why might I want phalloplasty?

There are several reasons you might want a phalloplasty:

• you want a penis that is of an average size
• you want to be able to penetrate someone with your penis during sex
• you want to be able to urinate while standing without needing an STP device
• you don’t want to be visibly different to other men when naked
• you were dissatisfied with alternative options like packing and prosthetics, genital growth from testosterone, or metoidioplasty

For some people, phalloplasty can provide a significant improvement in mental health. There is overall agreement in medical studies that after gender confirming medical interventions, rates of psychiatric disorders and psychiatric symptoms reduce considerably 3, p.181. However, as with other major life changes, you may find that counselling before and after surgery may be helpful.

Why might I not want phalloplasty?

There are a number of reasons you might wish to not have a phalloplasty:

• you do not experience dysphoria related to your genitals
• you feel that the risks involved in a major surgery are not worth it
• you do not wish to have multiple surgeries and recoveries over an extended period
• you do not like the long term effects such as donor site scarring
• you do not feel you would be happy with the surgical results

Many people choose metoidioplasty instead of phalloplasty because:

• it will usually provide an organ with good erogenous sensation
• it provides results that can become erect without the use of prostheses
• it often requires less surgeries, less time in hospital, and less scarring

A disadvantage of metoidioplasty is that unlike phalloplasty, which usually creates an average sized penis, metoidioplasty results are much smaller (5-7cm length).

How do I get phalloplasty?

Before phalloplasty surgery, you will need to choose to decide whether you wish to be able to use the penis to pass urine standing, and whether you wish to be able to make the penis hard for penetrative sex using prosthetic implants. Both of these will increase the length and complexity of surgery. Often scrotoplasty is performed at the same time, and you will also need to work out if you wish to be performed.

You will normally need to meet the following conditions to be eligible for phalloplasty:

• persistent and well-documented gender dysphoria
• capacity to make fully informed decisions and to consent to treatment
• if significant medical or mental health concerns are present, they must be reasonably well controlled
• two medical opinions, usually at least one from a gender clinic, that surgery is appropriate
• 12 months’ continuous endocrine treatment as appropriate to the patient’s goals (unless the patient has medical contraindications or is otherwise unable to take hormones)
• at least 12 months’ living continuously in a gender role that is congruent with the gender identity 4.

NGICNS maintains a list of NHS surgery providers providing various gender-related surgeries. At the moment, all of these surgeons are based in England, so you will have to travel if you live in another part of the UK. If you have decided to pay for your own surgery, rather than using NHS funding, there are additional options available to you. For more information about these private surgery options read our private surgery page.

What kinds are there?

Three types of phalloplasty are performed in the UK, which differ in which skin is taken from to create the penis 2, p.281:

• radial artery phalloplasty using a free flap from the forearm; this is the most commonly used technique in the UK
• pubic phalloplasty using a local flap from the lower belly and crotch area; this may not be possible if you have had surgeries on your abdomen such as Caesarian section or hysterectomy
• antero-lateral thigh phalloplasty using either a free or pedicled flap from the outer thigh

The amount of sensation in the penis will depend on the technique used, with radial artery phalloplasty giving the best results. There is no guarantee of sensation: UK surgeons report 10% of patients have no sensation after two years with radial artery phalloplasty 2, p.282.

The donor area receives skin grafts to replace the removed skin (normally from the buttocks 2, p.285), but there will be significant scarring on donor area 1, and it should not be exposed to strong sunlight as it will get sunburned easily 2, p.286.

Other types of phalloplasty are possible but not normally performed in the UK, including MLD (muscular latissimus dorsi meaning the side of the chest or back), Gracilis, Fibular (lower leg), Deltoid (upper arm/shoulder), and Gillies (from the abdomen but using a pedicled tube) 2, p.281.

Several options are available for people who wish to have erections:

• inflatable prostheses: this is an implant inside the penis. This is usually inflated by a pump, usually hidden inside one of the testicular prostheses, which you squeeze to inflate the penis implant. This is the usual approach to providing the ability to get erections used in the UK 5. It is important to note that if an inflatable erectile implant is used, it will likely need replacement later in life, so you will need to be prepared for further surgeries in the future 2, p.299.
• malleable rods: these are implanted into the penis. These are not usually used in the UK as the implant exerts constant pressure on the skin, causing damage over time 5.
• external aids: these are devices worn around the penis. They can either provide support to hold it straight and stiff, constrict around the base of the penis to hold blood in to stiffen the penis, or provide additional length and girth by providing a sleeve around the penis.

How do I get ready for surgery?

Doing some preparation in advance can help make sure everything goes smoothly during your hospital stays and recovery. To help you avoid forgetting to do or buy something we have created a Getting ready for gender surgeries page.

Where can I ask questions about surgery?

When you and your clinical team agree that you are ready for surgery on the NHS, the NHS Gender Dysphoria National Referral Support Services (GDNRSS) will process your referral to your chosen surgical provider. They have a Single Point of Access support line that you can call for information about your referral, the status of your chosen provider and practical information such as travel and parking, who can accompany you, what to take with you and where to report when you get there.

You can also book a virtual consultation with one of the GDNRSS Clinical Nurse Advisors who can provide information on:

• Surgical techniques used by various providers and surgeon teams
• Typical recovery times following surgery
• Potential post-surgical complications
• Surgical eligibility criteria, where providers have these in place
• Waiting times for surgical providers
• Supporting patients to change provider

You can contact the service by calling 01522 85 77 99 or by email. The service is open Monday to Friday from 9am until 5pm. You can find out more about the service in this booklet.

How much will it cost?

If you have a formal diagnosis, the NHS will usually provide funding for phalloplasty or metoidioplasty. The NHS will normally also fund hair removal from the donor skin sites for phalloplasty, either by laser hair reduction or electrolysis.

If you're receiving certain benefits, or are on a low income, you may be able to get help with the cost of travel for NHS treatment. Further information about help with travel costs can be found:

• on the NHS website
• on the Welsh Government website
• on the NHS Scotland website
• on the Northern Ireland government website

If not funded by the NHS, the cost of a phalloplasty performed in the UK is approximately £40,000-£70,000 (last updated July 2020). The exact cost will depends on exactly what surgery is required, and determining the best option for you will require a consultation with a surgeon. The only clinic currently performing phalloplasty in the UK is New Victoria Hospital.

Where can I learn more?

You can read more about phalloplasty in this booklet from the NHS Gender Dysphoria National Referral Support Service. They have also produced this booklet about hair removal prior to phalloplasty.

You can find information and regular updates about waiting times for phalloplasty and metoidioplasty in the UK on the TransActual website.

There is some detailed information about phalloplasty and metoidioplasty on the St. Peter’s Andrology Centre website. Please note that St Peter’s are no longer offering gender surgeries, so some information on this site may be out of date.

References

1. 1.
   Frey, Jordan D, Poudrier, Grace, Chiodo, Michael V and Hazen, Alexes (2017) “An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature.” Plastic and Reconstructive Surgery, 139(3), pp. 728–737. Link
2. 2.
   Christopher, Nim, Ralph, David and Garaffa, Giulio (2017) “Genital Reconstructive Surgery for Transgender Men,” in Bouman, W. P. and Arcelus, J. (eds.), The Transgender Handbook: A Guide for Transgender People, Their Families and Professionals, Nova Science Publishers Inc, pp. 277–300. Link
3. 3.
   Arcelus, Jon and De Cuypere, Griet (2017) “Mental Health Problems in the Transgender Population: What Is The Evidence?,” in Bouman, W. P. and Arcelus, J. (eds.), The Transgender Handbook: A Guide for Transgender People, Their Families and Professionals, Nova Science Publishers Inc, pp. 173–188. Link
4. 4.
   Royal College of Psychiatrists (2013) “Good practice guidelines for the assessment and treatment of adults with gender dysphoria.” Link
5. 5.
   Pryor, A J and Christopher, A N (2016) “Patients’ guide to Phalloplasty techniques.” Link

Acknowledgements

This page is illustrated using a photograph by Павел Сорокин available at Pexels.

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