Female-to-Male Reassignment Surgery in the ’90s (1991)
©1991, 2013 by Dallas Denny
Source: Dallas Denny. (1991, June). Female-to-Male sex reassignment in the ’90s. Our Sorority, No. 25, pp. 42-44.
I somehow doubt any female-to-male transsexual would read a magazine called Our Sorority, but editor Betty Ann Lind was happy to have my article. Read the text or click below to view the PDF.
Female-to-Male Reassignment Surgery in the ’90s
By Dallas Denny
In speaking about the difficulty of phalloplasty, an unknown wag once quipped, “It’s easier to make a hole than a pole.” This statement, although crude, is unfortunately true. While male-to-female reassignment surgery typically results in an aesthetically pleasing and functional vagina, construction of male genitalia calls for a series of difficult compromises. To date, no surgeon has created a cosmetically acceptable, sensate, erectile penis which allows standing micturition (urination). Phalloplasty is expensive (it can cost as much as $40,000), requires large skin grafts, which can leave extensive scarring, has a high rate of complications, and, as noted, has less than optimal results.
For these reasons, many female-to-male transsexual persons do not seek phalloplasty, and settle for breast reduction, hysterectomy, and oophorectomy (surgical removal of the uterus and ovaries). Still, the phallus is a badge of masculinity, and for some, it is important to have; it is this minority which goes ahead with this difficult and often disappointing procedure. And yet, there is good news: the 1980s saw introduction of new techniques which produce better results, often with a single-step procedure. A few surgeons are doing work which is sufficiently cosmetically acceptable to pass casual inspection, standing micturition is possible, and micrografting can ensure sensation, allowing orgasm from stimulation of the penis. The problem of erections has not been solved, but it is not unlikely that the 1990s will see even greater improvements.
Advances in phalloplastic techniques may at least partially explain the increasing numbers of known female-to-male transsexual people. In the 1960’s and 1970’s, incidence rates were considered to be about one-fifth that of male-to-females. The 1980’s, however, saw many more female-to-males come forward, until the incidence in some programs reached 1:1 or even higher. Certainly, transsexualism is no longer a one-sided coin.
Phalloplasty was developed as a reconstructive technique. The male genitalia being external, their traumatic amputation has not been uncommon, and early attempts were made to rebuild partially amputated penises. As techniques improved, phallic construction was attempted. Construction techniques were of direct benefit to female-to-male transsexual persons. Arguably, the first phalloplasty in a transsexual person occurred in 1948, when Laura Dillon, a British citizen, became Michael Dillon.
Early phalloplasty was a series of complicated and painful procedures, requiring numerous hospitalizations. The neophallus, which usually consisted of a raised flap of skin which was formed into a tube shape, was attached at both ends, like a suitcase handle. It was “walked” up or down the body from the donor site to the groin, with alternate ends being detached and reattached until the groin area was reached. These early penises did not have sensation, did not typically allow standing micturition, and were not erectile, although attempts were sometimes made to incorporate cartilage and bone into the graft. The “phallus” generally looked like a loose lump of flesh. It served none of the traditional functions of the penis, but it was something. It was there, in the right place, and the few transsexual people who opted for phalloplasty generally expressed happiness with the results.
The early surgeries had many complications. Some common problems were rejection of transplanted tissue (the penis would fall off), formation of calculi (hard deposits) on hair-bearing skin which was used to form the urethra within the penis, and extrusion of mechanical devices which were used to make the penis erect. In 1984, the publication of an article by T.S. Chang and W.Y. Hwang marked a major improvement in phalloplastic techniques. The radial forearm flap provided a hairless donor site, allowed sufficient material for construction of an urethra, and required but a single surgery. David Gilbert, of the Center for Gender Reassignment in Norfolk, Virginia, and his co-workers, have used the radial forearm flap exclusively. Gilbert uses microsurgical techniques to incorporate nerves from the arm into the neophallus; a nerve from the groin is subsequently moved into the arm.
Other new techniques include molding the clitoral tissue into the base of the phallus, and using the labial tissue to form a scrotum. Edgerton and his co-workers have pioneered the formation of a urethra from bladder tissue. Cosmetics have also improved, with attempts being made to form a glans penis, and with increased use of silicone testicular implants.
Dr. Gilbert has described an alternate technique to phalloplasty, in which the clitoris, which is typically enlarged as the result of androgens, is loosened from its moorings and brought forward and lengthened by means of a skin flap made from the labia minora. The labia majora are fused to form a scrotum. This technique is called metaidoioplasty (a surgical change towards male genitalia). It has a low complication rate, and is probably relatively inexpensive, but the resulting “penis,” although sensate, is typically too short for intromission.
Despite the improvements, phalloplasty has a long way to go. The problem of erections remains unsolved, and is likely to remain so for an indeterminate time, for the erectile tissue of the penis is unique, and there is no other tissue which can simulate it. Still, for the person desperate for a penis, a cosmetically acceptable organ which will allow standing micturition is finally possible.