This is the second blog post on a theme. The first is called “What exactly is a neovagina, then?“
This post is about the creation of an artificial penis for women who believe they are men. The operation (or series of surgeries) appears to be known generally as a phalloplasty – described by the NHS as “the surgical creation of an artificial penis (phallus), scrotal sac and testes. It involves using a flap of tissue, including arteries, veins, and nerves.”
Technically a phalloplasty is just the creation of an artificial penis. A glansplasty is the creation of a helmet to the artificial penis (or more politely, its “corona”), metoidioplasty is the surgical creation of a mini phallus by using the enlarged clitoris, and a scrotoplasty is the construction of an artificial ball-bag from bits of the vulva/labia majora.
Dr J is a fellow of the Royal College of Surgeons in Edinburgh. He contacted me in 2024 and provided the information for the vaginoplasty post. Dr J has retired from working full time as an Associate Specialist for the NHS. He is currently serving as a locum senior registrar in the emergency department of an NHS University hospital. Dr J believes it is “unacceptable” for NHS surgeons to subject physically normal young adults to what he calls “mutilating” operations. He believes they are “inherently deceptive” and wants them banned until they have been reviewed by anatomists, physiologists, pathologists and the surgical Royal Colleges who he believes should make a detailed, objective assessment of the operations’ benefits and harms.
Dr J’s starting point is that we should not be slicing and dicing perfectly healthy tissue to assuage mental distress. He writes that gender-affirming surgery:
“is being done on physically normal human beings who have a mental health condition called gender dysphoria. This is listed in the DSM-5 of psychiatry manual. None of the well-established standard surgical textbooks recognise this condition as a surgical illness needing surgical treatment. Gender dysphoria is in the mind of the person and not in his/her genitals which are normal in structure and physiology. Psychiatrists of Great Britain and Northern Ireland need to own up to their responsibility and treat this mental health condition rather than referring their patients to surgeons.”
Dr J is particularly concerned about the long term health implications for those undergoing surgery and/or taking hormones. He has written to several authorities spelling out his concerns. Most recently he contacted the Department for Health and Social Care (DHSC) who told him he needed to contact NHS England, who told him he needed to contact the DHSC. At the least this suggests bureaucratic confusion, at worst, an unwillingness to take responsibility for the potential harms being done.
Choose your weapon
To illustrate matters, Dr J supplied me with a table comparing and contrasting a typical male penis with a neophallus – or what Dr J calls a “skin and fat flap mound”. The processes described in Dr J’s table are just one way of doing things. There are a number of different operations available which can have different desired (and undesired) outcomes. For instance, whilst Dr J is right to say the neophallus cannot become erect, “erections” can be artificially achieved by the insertion of a plastic pump into the neoscrotum, which can squeeze fluid into the shaft of the phallus. This usually requires a separate operation. Anyway, do have a read. I certainly learned a lot:
| Normal Male Penis | Skin and Fat Flap mound/Neophallus |
| The penis consists of three parallel cylindrical bodies: two dorsally placed corpora cavernosa and a ventrally placed corpus spongiosum. The corpus spongiosum enlarges proximally to form the bulb of the penis and distally as the glans penis [ie the helmet or more politely, “corona” of the penis – Ed]. These cylindrical bodies are the building blocks of erectile tissue of penis. | The skin flap transfer, derived from the forearm, thigh or abdomen, lacks the anatomical complexity of the penis. It is simply a chunk of skin and subcutaneous tissue, with no bulb or cylindrical structures and no erectile tissues. |
| The skin of penis is delicate, elastic and hairless except at the base. Distally this skin forms a tubular fold called the prepuce. The penile skin is freely movable over the surface of the penis due to the presence of underlying loose areolar tissue (superficial fascia). | The skin flap transfer does not include a prepuce. Instead, it is made from the coarse skin of the forearm/leg, including its natural appendages (hair). This artificial skin flap lacks the mobility of penile skin, as it does not have the underlying loose areolar tissue. |
| The corpus spongiosum encases the urethra and expands distally to form the glans penis, into which the tapered ends of the corpora cavernosa are inserted. The urethra runs through the glans and exits through a vertical slit at its tip. Microscopic examination reveals that both the corpus spongiosum and the glans penis are composed of a fine mesh of erectile tissue encased in a delicate fibrous capsule. Additionally, two arteries run through the entire length of the corpus spongiosum, reaching up to the tip of the glans penis. It is through this structure the urethra passes and the delicate capsule ensures non-collapsability of the urethra when corpus spongiosum fills with blood during erection. | In this man-made [or woman-made, hem hem – Ed] skin flap, there is no corpus spongiosum. The phallus, created by rolling the skin into a sausage-like shape, lacks both the fine mesh of erectile tissue and the delicate fibrous capsule that typically surround the corpus spongiosum. The mound of tissue tends to contract as it heals. As it contracts, the artificial passage that is constructed inside as an artificial urethra also tends to contract and narrow down. This leads to stricture formations and poor urinary stream. Such strictures become long term issues for the patients. |
| In the midline, in the urethral surface of glans penis, a free fold of skin passes from tip of glans to the deep aspect of prepuce. This structure is called the frenulum of the prepuce. The frenulum anchors the prepuce to the glans during intercourse. | There is no frenulum nor prepuce. |
| The superficial fascia of penis is of loose areolar tissue. | No similar superficial fascia. The skin cannot freely slide. |
| The deep fascia of the penis creates a snug sheath around the corpora cavernosa. This deep fascia prevents the spread of infection to deeper planes of the penis and into the pelvis. | The neophallus lacks a comparable deep fascia. The deep fascia remains in the forearm/thigh after the procedure. Hence the mound of tissue is more vulnerable to the spread of infection deep into the body and subsequent sloughing. |
| The suspensory ligament of the penis is a fibroelastic condensation of the deep fascia extending from the abdomen. It fuses with the deep fascia on the dorsum and sides of the penis, serving to anchor the penis in place during sexual activity. | During a metoidioplasty and/or phalloplasty operation to lengthen the virilised clitoris, the equivalent of the suspensory ligament is disrupted. Consequently, the neophallus lacks this crucial supportive structure. |
| The superficial and deep dorsal veins are situated along the midline dorsally, with the superficial veins lying above and the deep veins below the deep fascia of the penis. The deep dorsal vein of the penis drains directly into the prostatic plexus of veins. This type of surplus venous channels ensures swift return of blood from an erect penis during the resolution phase following intercourse. | In the neophallus, there is no equivalent venous drainage system, such as the prostatic plexus, to handle the venous return. Instead, the venous return must be anastomosed to the femoral vessels via vascular surgery. This connection can fail either immediately or later due to infection, potentially leading to flap necrosis. |
| The deep dorsal vein is flanked by two deep dorsal arteries and nerves, each located on either side. The deep dorsal artery, a direct branch of the internal pudendal artery, and the deep dorsal nerve, a terminal branch of the pudendal nerve, are responsible for transmitting normal touch and proprioceptive sensations. This ensures plentiful blood supply to the penis. | The neophallus does not contain deep dorsal vessels or deep dorsal nerves. Instead, the surgeon attempts to anastomose the radial vessels with the femoral vessels and to connect the cutaneous touch sensation nerves of the forearm with the ilio-inguinal nerves. The procedure has a failure rate of 10%. In successful cases, only touch and pain sensations of the skin are transmitted, not sexual sensations. The blood supply of neophallus is fully dependent on the integrity and adequacy of the vascular anastomosis. |
| In a normal penis, independent deep arteries supply the cylindrical erectile structures: the corpora cavernosa and the corpus spongiosum. This robust blood supply significantly reduces the risk of penile necrosis, making it exceptionally rare at any stage of life. | The blood supply to the neophallus transferred from the forearm/leg is entirely dependent on the delicate anastomosis between the radial and femoral arteries. Any technical failure or postoperative thrombosis can quickly lead to occlusion of this blood supply, potentially resulting in cell necrosis. |
| The corpora cavernosa are a pair of cylindrical bodies located on the dorsal aspect of the penis, each comprising a mass of cavernous erectile tissue. They are encased in a dense sheath of white fibrous tissue known as the tunica albuginea. When the erectile tissues fills up rapidly during erection the tough tunica albuginea does not stretch contributing to the hardness and rigidity of a fully erect penis. | The neophallus does not contain erectile tissue or a tunica albuginea. Hence the tissue cannot become erect due to lack of the necessary infrastructure. |
| Bulbourethral glands (Cowper’s glands) open into the bulb of corpus spongiosum just below the urogenital diaphragm. Cowper’s glands secrete mucus material during intercourse that helps lubricate the penis. | There are no bulbourethral glands (Cowper’s glands). There is no corpus spongiosum with its proximal bulb in the neophallus. Therefore there is no secretion that can lubricate the structure. |
| The mucosa of normal penile urethra is pseudostratified columnar epithelium except at the tip of the penis. | The rolled-up skin structure lacks the mucosal characteristics found in natural tissue. |
| The urethral glands of Littre have their orifices located within the normal male penile urethra. These glands secrete mucus which lubricates the glans penis during sexual intercourse. | There are no urethral glands, and therefore, no corresponding orifices. There is no gland to lubricate the vaginal orifice. |
| The parasympathetic nerve endings in the penis have a unique ability – unlike anywhere else in the body – to release nitric oxide in abundance over the usual acetylcholine, when stimulated. This sets off a chain of biochemical reactions that cause blood vessels and spaces in the erectile tissues to dilate, allowing them to fill with blood and produce an erection. | This function is not present in the skin and fat flaps used in phalloplasty procedures. Surgeons are consequently unable to recreate the same anatomical and physiological response. |
| In a normal male penis, the spongy urethra ends in the navicular fossa of the glans penis. Navicular fossa is important for higher flow rate of urine with its wave like shape. | There is no navicular fossa within the external hole of the neophallus. Hence the mechanism for natural enhancement of urinary flow is not there. |
| The vessels and nerves deep to deep fascia plunge into the glans penis so there is rich blood and nerve supply. Normal male glans penis is rich in special receptors to generate sexual sensation. | There is limited blood supply to the glansplasty. There is poor nerve supply from the neurorrhaphy (anastomosis between ilioinguinal nerve, dorsal clitoral nerve, and the nerves of the forearm flap). There are no special receptors for sexual sensation. Hence this structure (result of glansplasty) of the fat and skin mound, is just a shape (if it is shaped well) and nothing more. |
| There is bulbospongiosus muscle surrounding the bulb of urethra which aids in the emptying of the urethra at the end of micturition. | The neophallus lacks bulbospongiosus muscle, so manual assistance/milking is required to help empty urine from this surgically created structure. |
| A normal penis is richly supplied with sympathetic and parasympathetic nerve fibres from the pelvic autonomic plexus, which are essential for sexual function. The glans penis contains specialized receptors which are responsible for perceiving sexual sensation. The parasympathetics are responsible for erection and the sympathetics are responsible for the emission and ejaculation phase of intercourse. | The neophallus contains only neurorrhaphied cutaneous nerves, which are responsible for detecting pain, touch, and proprioception [a sense that lets us perceive the location and movements of our body parts] but lack the ability to perceive sexual sensation. Additionally, there is no autonomic nerve supply (parasympathetics and sympathetics) to the neophallus. There is no framework to perceive sexual sensation or achieve a natural erection. |
Complications
There is a bland smiley NHS leaflet (dated 2021) describing phalloplasties. This tells the lad(d)ies what they’re in for, providing they have a gender dysphoria diagnosis, lose weight, stop smoking and show some commitment.
The leaflet (which you can download below) cites the following potential complications with phalloplasty:
Pain, Infection, Blood clots, Wound dehiscence (breakdown), Post-operative bleeding, Loss of sensation requiring return to the operating theatre, Forearm donor site complications (failure of the skin graft, large permanent scar, chronic pain, loss of feeling, hand weakness, numbness, stiffness and swelling), Loss of sexual function, Dissatisfaction with visual appearance of the penis, size of the penis, function of the penis, scrotum, Inability to orgasm, Urinary tract infections (UTIs), Urinary retention (unable to pass urine), Urinary incontinence (unable to control the need to urinate), Urinary Post-urination dribbling, spraying of the stream, Skin changes from urine moisture to the end of neophallus are common, Necrosis to skin of the penis (tissue dying resulting in blackening of the skin), Loss of neophallus (this can occur in 3% of cases, though this risk can be reduced by avoiding smoking and not being overweight), Wound breakdown (common at base of phallus), Fistula: An unwanted connection between urethra, vaginal space and/or the skin, Urethral strictures: Narrowing of the urethra or complete blockage, making it difficult to urinate, may require catheterisation until corrected, Testicular implant complications: infection, extrusion, poor/uncomfortable positioning, Erectile device complications: infection, skin-erosion, technical failure, poor positioning.
Dr J takes issue with some of the language used in the leaflet, eg: “Masculinising genital surgery aims to reduce gender dysphoria by aligning your anatomy with your gender identity and identity expression goals.”
He thinks the word “aligning” in this context is particularly misleading as he says a neophallus is little more than a crude simulacrum of a functioning penis:
“the operation irreversibly destroys the individual’s natural female anatomy, leaving no possibility of restoration in case of regret. In my view, this surgery misleads (and deceives) individuals into believing they are receiving a true penis, when the reality is far from it. Regarding the goal of creating a functional penis for sexual activity, it is clear that phalloplasty cannot fulfil this purpose. I strongly urge NHS England to clarify its stance on what I consider to be surgical malpractice occurring in the UK.”
If you want to keep up to date with where the NHS has got to on phalloplasty and phalloplasty “repairs”, this blog looks like a useful resource.
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