One question a lot of people want to ask trans people, but are afraid to ask, is what happens during bottom surgery. Where does everything go? 

In the beginning…

To understand how everything changes, it helps to understand the development of the organs in question. Until about nine weeks after conception, the parts that will become the sex organs are the same in all fetuses. Between nine and eleven weeks, the following changes start happening:

Female	Male
The gonads start to develop into ovaries.	The gonads start to develop into testicles.
The genital tubercle grows slowly and develops into the clitoris.	The genital tubercle grows rapidly and develops into the penis.
The labioscrotal folds remain separate and develop into the labia.	The labioscrotal folds fuse together and develop into the scrotum.
The vagina develops.	The testicles descend from inside the body into the scrotum.

This is highly simplified, of course. You can read a more detailed timeline in this article from the National Library of Medicine. 

So how do they change that?

There are several gender affirming procedures for trans women and men, depending on what the patient wants to achieve. 

Penile inversion vaginoplasty

This is the most common type of bottom surgery for trans women. In this procedure, the penis is removed, and the glans (head) is removed from the shaft. The surgeon opens the scrotum and excavates a vaginal cavity behind it. The skin from the shaft of the penis is inverted, then attached inside the neovagina (new vagina). The glans is dissected so it is much smaller, and is reattached to form a clitoris. The tissue of the scrotum is formed into labia. 

The advantage of this procedure is that it has been performed for many years, and is available from a lot of clinics around the world. The disadvantage is the possibility that the nerves of the new clitoris won’t provide full sensation. 

Sigmoid colon vaginoplasty 

In this procedure, the penis does not have to be removed because the tissue for the neovagina is taken from the patient’s colon. The main disadvantage is the higher possibility of infection if the section of colon tissue isn’t sufficiently cleaned. Another disadvantage is that the patient will need to wear a colostomy bag while their colon heals.

Peritoneal pull-through vaginoplasty

This is the newest type of feminizing bottom surgery. It is becoming popular because it does not require removing the penis, and it doesn’t have as much risk of complication as the sigmoid colon procedure. 

In this procedure, the skin for the vaginal lining is taken from the patient’s peritoneum, which is an internal membrane that lines your abdominal cavity. The peritoneum is a seral membrane, meaning that it secretes serum, which makes it appropriate for the vaginal lining, which secretes fluids. 

The biggest advantage of the peritoneal pull-through is that you can keep a fully functional penis—as long as you have maintained its function through regular “exercise.”¹ The disadvantages are that it’s new enough it’s not available in many clinics, and there isn’t a lot of data on possible complications. 

But how do they…stick it on?

Trans men go through the opposite process. There are several procedures that transform their parts into a form that affirms their identity. I haven’t done nearly as much personal research into trans masculine procedures, so I’ve adapted this information from Johns Hopkins.

Radial forearm free flap phalloplasty

In this procedure, skin is taken from the patient’s forearm, and a penis is constructed from it. The patient’s urethra is lengthened and moved into the new penis. The labia are formed into a scrotum, and the vagina is removed and closed. Implants give the appearance, but not the function of testicles. To achieve an erection, a device is implanted in the penis. 

Anterolateral thigh flap phalloplasty 

Most of this procedure is the same as the previous one, but the skin for the penis is taken from the patient’s inner thigh. If the patient has very slender arms, the forearm procedure might not have enough tissue to construct a large enough penis, so this procedure could be used instead. 

Musculocutaneous latissimus dorsi flap phalloplasty

In this procedure, the skin for the penis is removed from the side of the patient’s back. This procedure generally has a shorter recovery period than the others, but the skin on the back does not have as many nerve endings, so the new penis might not have as much sensation. 

Metoidioplasty

All of the phalloplasty procedures have the same disadvantage. Although the penis can be made as large as a “home-grown” penis, it can’t achieve an erection without an implanted device. 

Before a metoidioplasty, the clitoris is enlarged during a year or more of hormone therapy. Then the surgeon cuts the ligaments that hold the clitoris in place and lengthens the organ, resulting in a penis that, while it’s only 4-6 centimeters long (two inches or so), can achieve an erection without an implanted device. This also preserves full clitoral sensation. The urethra is lengthened and rerouted through the new penis. 

So which one are you going to have?

This isn’t a question you should ask a trans person—it’s considered very invasive—but I’m happy to answer. The only surgery that will affirm my identity without compromising the sensation or functionality I want to retain is the peritoneal pull-through. Unfortunately, it’s not currently available in Canada, and medical travel to the US is out of the question. 

My greatest hope is that the surgeon at the GRS clinic in Montreal (where Alberta Health services will cover the surgery) trains for the procedure I want, or a qualified surgeon from the US moves to Canada—in the current political environment, they may not be allowed to continue performing such surgeries in the US. 

But why do you get to have both?

I have a complex relationship with my sexual needs. Even now, it’s as if I can feel where I should have a vagina. But I’m not willing to compromise my current sensation for a “consolation clitoris.” Besides, I like the one I have, even if it is a little larger than the average clitoris. And it’s my choice. 

Unfortunately, it may never happen. Alberta Health won’t currently cover anything but a the penile inversion procedure at GRS Montreal, and for me that would be too much of a loss for what I’d gain. 

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1. During hormone replacement therapy (HRT), testosterone production is greatly reduced, and spontaneous erections stop. If you don’t achieve regular erections through sexual stimulation, scar tissue develops, and you lose the ability to have an erection. This is fine for some women, who want their penis to be removed, but if they want to keep it, they have to use it so they don’t lose it. ↩︎