If you are a transgender man or a gender nonbinary person, you may be thinking about having a phalloplasty. This is a gender-affirming surgery that creates a penis and scrotum. It's also called a male bottom surgery.

For this procedure, a penis and scrotum are made using tissue (including nerves, veins, and arteries) taken from another part of your body. Some people find this surgery is a key step in helping to align their body with their gender identity.

It's important to know that phalloplasty is a complex surgery. It's done in several stages over time. And it requires recovery time after each stage. If you are considering phalloplasty, it's natural to have questions and concerns. Read on to learn more about this procedure.

Phalloplasty creates a penis and scrotum. In addition, a new section of urethra is made and placed in the penis. This is the tube that carries urine out of the body. And implants are placed inside the penis and testicles.

This surgery may be right for you if you are a trans man or gender nonbinary person and you want to:

• Have a penis
• Be able to urinate from the tip of your penis while standing up
• Have a penis that feels sexual sensation and becomes erect
• Have penetrative sex

To create the penis, a skin flap may be taken from one of these sites:

• Forearm of your nondominant arm (radial forearm free flap)
• Thigh (anterolateral thigh flap)
• Belly (abdominal flap)

The skin flap will include nerves and blood vessels. If skin is taken from your forearm, you will have skin taken from your thigh and grafted onto the donor area of your arm.

Each method has pros and cons. Your surgeon will work with you to make the best choice for you.

Phalloplasty is a complex surgery. There are separate surgeries done in three stages over time. The entire process for all three stages may take from 18 months up to 3 years. This includes recovery time for each stage.

You may decide to do one, two, or all three stages. This is a personal decision. Your surgeon will work with you to find the best choices for you.

The stages are:

• Stage 1. This creates the shaft of the penis. This is done using skin taken from your arm, thigh, or belly (abdomen). A new section of the urethra may also be created. The new section will be inside the penis. This is done if you would like to be able to urinate while standing up.
• Stage 2. This surgery connects the new, longer urethra to the bladder. The head of the penis (glans) and the scrotum are also created at this time. This stage occurs about 6 months after stage 1.
• Stage 3. Implants are inserted in the penis and scrotum. This procedure allows you to have an erection. And to have penetrative sex. This surgery is done about 1 year after stage 2.

It's important to think about your fertility when planning for your phalloplasty. The choices you make will affect your ability to have biological children later.

Before you have a phalloplasty, your surgeon will likely require you to have surgeries that would affect your fertility. After these procedures, you won't be able to have biological children. These include surgery to:

• Remove the uterus (hysterectomy)
• Remove the ovaries (oophorectomy)

But if you do want to have biological children, fertility-preserving procedures are available. Talk with your health care team and surgeon about your choices. These procedures would be done before the surgeries listed above. They include:

• Freezing (cryopreservation) of ovarian tissue
• Freezing eggs (oocyte cryopreservation)
• Freezing embryos (embryo cryopreservation)
• Preserving the uterus

Some questions to ask yourself:

• Do I want to have a biological child?
• Do I want to have a biological child but not be pregnant? (Will a future partner or a surrogate carry the pregnancy instead?)

Talk with your surgeon about this issue. Also ask if you will need to have your vagina removed. They can help you find the best choices for you, based on your needs and future goals.

Before having any type of gender-affirming surgery, you may be advised that it is helpful to see a mental health provider.

You may also need to:

• Be age 18 or older
• Have hormone therapy for at least 6 months before surgery

These guidelines are from the World Professional Association for Transgender Health (WPATH) Standards of Care. Most insurance companies require people to meet these standards before starting any treatment.

Talk with your doctor, plastic surgeon, and insurance company to find out what's required in your case.

Choosing how and when to transition is a very personal decision. There are many ways to transition. Surgery is just one choice. Not all trans people want or are able to have surgery.

Cost can also be a major issue. This surgery is expensive. And it may not be fully covered by your health insurance. Talk with your doctor about your own personal situation and needs.