Transition: Medical if Trans Male

In the previous episode, I described medical transition if trans female or nonbinary and to conclude this three part exploration of transition, I will look at trans male medical transition.

And in the same episode, I said that due to how we develop, the most major operation of gender affirming surgery if trans female, vaginoplasty, is very successful, and can be completed in one operation, whereas the equivalent trans male surgery is more complex, and requires several operations.

And before we begin, you may have noticed the symbol used in the cover art for this, and the previous episode, a snake coiling up a staff, this was based on “The Rod of Asclepius”, however you may have also seen similar depictions with two snakes coiling up a staff, and this is a “Caduceus”, and both have been used to represent medicine and healing, however, whilst the caduceus initially was more widely used, “The Rod of Asclepius”, has supplanted it.

And, if you would like to learn more about these two symbols, the “Science Museum Group” has a blog, The symbols of medicine: a story of snakes, staffs and Greek gods

Welcome to “Trans Wise Trans Strong”, I am Carolyne O’Reilly.

Episode twenty-four, “Transition: Medical if Trans Male”

As before I will examine medical transition, by first exploring non-surgical and then surgical, and the first area is Gender Affirming Hormone Therapy (GAHT), which is not an inversion of trans female GAHT.

The aim of trans male GAHT is in a sense to replicate cisgender male puberty, by bringing about secondary sex characteristics, which is achieved just by taking the hormone testosterone, which will result in the menstruation stopping and the lowering of the ovaries' ability to make estrogen.

Therefore before embarking on GAHT, if there is a desire to have biological children in the future, then egg preservation should be considered.

However, before trans male GAHT can be prescribed, like trans female GAHT, a clinical criteria must be met, and in my case that was a diagnosis by an authorised psychologist of gender dysphoria.

And to quote the BMA, the British Medical Association, gender dysphoria is a psychological and physiological discomfort or distress caused by a discrepancy between a person’s gender identity, their sex assigned at birth and their primary and secondary sex characteristics.

However with the release of the W.H.O.’s ICD-11, the term gender incongruence was introduced, which is characterised by a marked and persistent incongruence between an individual’s experienced gender and their assigned sex.

And this I feel more accurately reflected how I felt, although now two years post my vaginoplasty surgery, my body now is congruent with my gender.

And as mentioned, estrogen production is lowered just with testosterone, and this is why, trans male GAHT is not an inversion of trans female GAHT, which as well as a drug to suppression testosterone, another is required to raise the estrogen level.

Other changes trans male GAHT will bring about are: facial and body hair growth, body fat redistribution, clitoral enlargement, and the vagina will become drier and the lining thinner.

Also, muscle mass and strength will increase, which is the opposite to what happens with trans female GAHT, are you listening sporting bodies?

And also, unlike trans female GAHT, where for most it will be via speech therapy that the voice is modified, the pitch as a result of testosterone will drop, although voice masculine speech therapy may still be of benefit.

The Mayo Clinic has a quite detailed explanation of Masculinizing hormone therapy, and like trans female GAHT there are risks; weight gain, acne, developing male-pattern baldness, and blood clots.

However one risk that is higher for trans women on GAHT, compared with cisgender women, is breast cancer, whereas for trans men it is the same, as only testosterone is prescribed.

And for up to date information about prescribing masculinising hormone therapy, The Nottingham Centre for Transgender Health Network, has a guide.

Blood tests will also be needed, to monitor the hormone levels, to check that the testosterone dose is the lowest necessary to achieve and maintain the desired physical effects, and the blood tests will also measure the blood sugar level and check liver function.

And now lets examine the various surgical options, starting with as in the previous episode at the top, and Facial Masculinization Surgery, which the Johns Hopkins Hospital has a detailed explanation of.

If you compare cisgender female and cisgender male’s forehead’s, the latter is softer and more rounded, whereas the former is flatter and higher, which can be achieved by hair removal, and a brow ridge can be made more prominent with implants.

And whilst testosterone will lower the pitch of the voice, it will not enable the Adam’s Apple to grow, however a Y-shaped implant can create an appearance of an Adam’s Apple, whilst newer techniques create an implant from the patient’s own cartilage, harvested from a rib.

And, implants can also be used elsewhere on the face, and whilst generally safe there can be rare side effects, a few of which are: moving out of position, infection, and an allergic reaction to the implant material.

As a generalism, a masculine nose is larger and broader, which can be achieved with rhinoplasty, to make it wider at the bridge and not turned upward at the tip.

And lastly, the chin and jaw can be made wider and squarer with implants, which can be inserted through an incision inside the mouth, which has the advantage of no visible scars.

A non-surgical alternative are fillers, however the results are temporary and may require repeated injections.

And moving down we come to the chest, and this surgery is commonly called top surgery, which is a double mastectomy, that may also include reshaping of the nipples and areolae, as these are more prominent in a person assigned female at birth, compared to a person assigned male at birth.

And lastly we come to the most major operation, which is masculinising genital surgery, which is also known as bottom surgery, and the most major component is phalloplasty, the creation of a phallus.

And whilst I have had personal experience of the trans female equivalent, vaginoplasty, phalloplasty and associated surgeries, is definitely outside my area of knowledge.

Therefore after some research, I found three hospital’s website pages, that was invaluable in providing a detailed explanation of masculinising genital surgical procedures.

The York & Leeds NHS Foundation Trust has a leaflet, Phalloplasty Masculinising Surgery, and then there is the Johns Hopkins Hospital’s webpage, Phalloplasty for Gender Affirmation, and finally there is the, Chelsea and Westminster Foundation Trust’s, Chelsea Centre for Gender Surgery, that has the webpage, Phalloplasty Surgery.

And if you are listening to this episode via the transcript page, on the website supporting this podcast at www.twts.co.uk, there are hyperlinks to these three hospital’s, webpages.

However before we look at modern phalloplasty, lets look at its origin and how this surgical technique has evolved.

The first phalloplasty was performed by Nikolaj A. Bogoraz, who was born in 1874 in Taganrog, Russia, and studied medicine at the Medical Academy for Military Surgeons in St. Petersburg.

And from the start of his career, Dr Bogoraz showed an interest in urology, and it was in 1936 that they performed the world’s first phalloplasty, although it was not on a trans male patient, but an unknown 23 year old cisgender man, who had suffered a traumatic injury that resulted in their penis being severed at its base.

Dr Bogoraz created a penis using a tubed abdominal flap, and from the patient’s own rib, cartilage for rigidity, and later a tubularised flap of scrotal skin was used for the construction of a urethra.

Twelve years after this pioneering surgery, Dr Bogoraz related that a number of his fellow surgeons had replicated his phalloplasty technique, including a Dr Voloshin, who had treated 17 patients during World War II, that required plastic surgery to their penis.

Dr Bogoraz died in July 1952 aged 78, and during his career performed 30 phalloplasty’s surgeries.

However for the first phalloplasty on a trans male patient, we need to move forward to 1946, and Dr Harold Delf Gillies, but before this pioneer surgery, Dr Gillies had developed groundbreaking techniques in facial reconstruction, and is widely considered to be the father of modern plastic surgery.

Harold was born in Dunedin, New Zealand in 1882, and qualified as a doctor in 1906, and was made a Fellow of the Royal College of Surgeons in 1910, and then four years later, began a global conflict that was yet to acquire an ordinal number.

And with what was then considered modern warfare, came physical injuries to match, and it was for treating the extensive facial injuries he encountered, that Dr Gillies in 1915 convinced the British Army Surgeon General to allow him to establish specialised facial surgery wards in Aldershot.

And in 1916 there would be the Battle of the Somme, that lasted from the 1st of July to the 18th of November, and over its devastating course, a total of two thousand casualties would arrive on Dr Gillies wards, with face and jaw wounds.

Then Dr Gillies moved his team to Frognal House, a converted old mansion in Sidcup, Kent, in June 1917, which would become known as the Queen’s Hospital, later renamed Queen Mary’s Hospital.

There he established a multi-disciplinary team of surgeons, nurses and artists, and the reason artists where included was to meticulously detail the ground breaking surgery that was being performed there, and a total of 2,500 soldiers underwent facial reconstruction surgery at the Queen’s Hospital.

Then 12 years after the end of the First World War, in 1930, Dr Gillies was knighted for his pioneering work in plastic surgery.

During the Second World War, Sir Gillies setup a network of surgical units across the UK, and it was after the Second World War in 1946, that Sir Gillies performed a series of surgeries on a fellow physician, Dr Laurence Michael Dillon, which was the first phalloplasty, on a trans male patient.

This procedure required a total of 13 separate operations, and the technique that Sir Gillies developed would be the standard for the next 40 years.

And it was Sir Gillies who also performed Britain’s first vaginoplasty, when he operated on Roberta Cowell in 1951, he would continue to work and teach until his death in 1960, at the same age that Dr Bogoraz died, 78.

The next development originated in China in 1978 and was, the Radial Forearm Free Flap technique, and was first officially published in the “National Medical Journal of China”, in 1981, and then in 1982, Dr. Ruyao Song and his team introduced the technique to the West by publishing their landmark paper, "The Forearm Flap" in English.

And two years later in 1984, Doctors Chang and Hwang dramatically improved the Radial Forearm Free Flap technique, with their “tube-within-a-tube” method, that constructed the shaft and the urethra in a single stage, and this became the basis for the global standard for phalloplasty.

However, their technique did have some issues and up to 42% of their patients may have required additional surgical revisions.

Then in 1993, Doctors Gottlieb and Levine, refined the Radial Forearm Free Flap technique by redesigning how the tissue was harvested and placed the urethra more centrally.

And before we look at modern phalloplasty surgery, there are a number of other surgical procedures that a patient may want, and these should be performed before phalloplasty surgery.

These may include a hysterectomy, which may be a total, where the womb and cervix are removed, or subtotal, where the main body of the womb is removed, but the cervix is left in place.

And at the same time as the hysterectomy surgery, the fallopian tubes may be removed, this is called a salpingectomy, and the ovaries may also be removed, this is called an oophorectomy, and is the equivalent to an orchiectomy that trans female patients will have as part of their vaginoplasty surgery.

So now lets look in detail at phalloplasty surgery, which as the name implies is to create a phallus, however there are also several other procedures associated with phalloplasty.

And although greatly reduced from the number operations that Dr Laurence Michael Dillon had to undergo, modern phalloplasty is still some way off, as mentioned, the single operation of vaginoplasty.

However, there are some commonalities with vaginoplasty, as detailed by the NHS, that a patient must meet before they can have their surgery.

They must have documented evidence of gender dysphoria, they must, be able to make a fully informed decision and consent for treatment, be 18 years or older, and have been living at least 12 months continuously in their gender role that is inline with their gender identity.

Also, they must have had continuous GAHT for at least 12 months, and if they have significant medical or mental health concerns, they must be well controlled.

Finally, two clinicians from a specialist Gender Identity Clinic, must provide a recommendation for the surgery, and once all these requirements have been met, the patient can then proceed with their surgery.

And there are three surgical stages to phalloplasty surgery.

The first stage is the creation of the phallus and neo-urethra within the phallus, then the next stage is gland sculpting, creating a scrotum and connecting the neo-urethra to the bladder, and the final stage is erectile and testicular prosthesis.

And to match the three stages, there are three forms of phalloplasty.

The first is “Radial Artery” phalloplasty also known as, which we have met this term before, “Radial Forearm Free Flap” phalloplasty, which is the procedure of choice if the prime requirements are: to be able to urinate whilst standing, aesthetics and sensation.

A small flap of skin from the forearm will be rolled into a tube, with the skin on the inside to form the neo-urethra, then a larger flap of skin with the skin on the outside will encased the neo-urethra.

This double tube will be moved to the pubic area and connections will be made to the, veins, artery, and nerves, with the radial artery from the forearm providing the blood supply to the phallus.

Next there is “Pubic” phalloplasty, which uses a flap from the lower belly and crotch area and is the choice if no urethra is required but phallus size and penetrative sex is important, with minimal visible scarring.

This rectangle of skin will still have its original blood supply and nerve connections to the clitoris and pubic area, and is folded into a tube to form the phallus, and abdominal skin is moved down, to cover the area where the skin flap was removed.

There may be a requirement of further surgeries to close the abdominal skin graft area and to ensure the phallus is placed in the correct location.

And lastly there is “Antero-Lateral Thigh” (ALT) phalloplasty, which uses a flap of skin and fat, with its original blood vessels, from the front and side of the thigh, that is used to create the phallus, and can be performed with or without a urethral formation.

ALT phalloplasty with a urethra uses the same tube within a tube as the forearm technique, and because of the length of the feeding artery and veins, the flap can be moved to the groin, under the quadriceps muscle, without the need to disconnect and reconnect the blood vessels.

ALT phalloplasty without a urethra, requires a smaller width flap, and is sometimes chosen if a patient wants to potentially have sensation in the phallus but has little abdominal fat, or cannot use the forearm for the flap, and is happy to continue to urinate sitting down.

Next comes stage two, that will be scheduled about five to six months after the phalloplasty, and if there is sufficient labia majora skin, this can be used to form a scrotum, this is called a scrotoplasty, otherwise adjacent skin will be used.

A small minority of patients may have a vaginectomy, and if they do, then the scrotoplasty will be performed at the same time, and if the patient has a neo-urethra this will also be connected to the patient’s bladder at the same time.

There are two forms of vaginectomy, resection and ablation.

A resection vaginectomy is the removal of part or all of the vagina, however it is associated with high rates of complications such as: fistulae, voiding and defecatory dysfunction, and haemorrhage and as such is often not considered worth the surgical risk.

Where as an oblation vaginectomy, is where the inner lining of the vagina, the mucosa, is destroyed by electrocautery, which is a technique where electricity heats a small metal probe.

It is during stage two, that the clitoris is relocated to the base of the penis with the potential to provide erogenous sensation, and patients may wish for the clitoris to be covered by skin so that it is not visible, this is called clitoral burying.

And before penile prosthesis are implanted, any additional shaping of the gland is performed.

The final stage, will be completed about 12 months after stage 2, and is the placing of two solid silicone gel prostheses into the neo-scrotum, and then there are three options for the erectile prostheses.

The first option is an inflatable prostheses, that is implanted in the neo-penis, which is inflated by a pump, usually hidden inside one half of the neo-scrotum, which likely may need to be replaced later in life.

The second is a malleable rod that is implanted in the neo-penis, however this technique is not used in the UK, because of the damage it causes over time, due to the constant pressure on the skin that the implant exerts.

Finally there are external aids, that are worn around the neo-penis, to support and hold it straight and stiff, or to provide additional length and girth.

And that was medical transition if trans male.

And before you go I would like to relate a listener’s question that I had earlier this year, that I answered on the Have Your Say page of the website supporting this podcast, and given that soon the UK will see its sixth Prime Minister in ten years, when Andy Burnham becomes Premier, seems appropriate.

If you became an MP today, what would be the first policies you would implement?

Well I said, my first policy would be to restore the provision of puberty blockers for transgender children and young adults.

Next I would address the Supreme Court ruling in April 2025, that disenfranchised trans people, by reinterpreting the Equality Act 2010, although in reality it impacted trans girls and trans women, to a greater extent than trans boys and trans men.

The Supreme Court demonstrated a fundament misunderstanding of what gender identity is, and it is not determined by physiology, but by psychology, we all have a gender identity, even cisgender people.

And thirdly, I would increase support for renewable energy as we only have this one planet, and if we break it, we cannot ask, can we have a replacement?

And if you know anyone who you think would be interested in this podcast, I would be very grateful if you could let know about it.

This episode was written and presented by me, Carolyne O’Reilly, thank you for listening.

Next time, “Take Pride In Your Parade”