Decisional Uncertainty Around Metoidioplasty and Phalloplasty

Decisional Uncertainty Around Metoidioplasty and Phalloplasty


Gender-affirming surgeries like metoidioplasty and phalloplasty are important for transgender or gender nonbinary people assigned female at birth who wish to achieve gender identity congruence.

Metoidioplasty is a surgery that makes a small penis using the clitoris and nearby skin. It is generally a lower-risk procedure than phalloplasty because it maintains the erectile functioning and sensation of the clitoris. However, the penis may not be large enough to allow for standing urination or penetrative sex.

Phalloplasty, on the other hand, is a surgery to build a larger penis using a skin flap, usually taken from the arm or thigh. The creation of a larger penis can allow for standing urination and penetrative sex, but the surgery carries a higher rate of urethral complications (up to 50%) and a higher risk of sensation loss.

Given the different risks and benefits of these surgeries, people face tough choices about which surgery to get, and they may feel unsure or conflicted. Decision support tools can help by providing patients with more information. However, there is a lack of such tools for gender-affirming surgeries. Therefore, this study aims to understand patients’ knowledge, needs, goals, and conflicts when deciding on which surgery to get (or whether to get surgery at all) in order to create better decision support tools for these individuals.


For this study, the researchers interviewed 26 transgender men and nonbinary individuals assigned female at birth and collected survey data from 39 individuals (24 of whom also completed the interviews). The surveys asked about the participants’ gender health, life satisfaction, and goals for the surgeries. They also asked about any uncertainty or conflict in their decisions.

During the interviews, the participants were asked about factors influencing their decisions, like their knowledge, values, and barriers. The interviews lasted up to 60 minutes and were audio recorded to be transcribed verbatim for later analysis.

Interestingly, the participants were at different stages of deciding on or having these surgeries, so some were pre-surgery, some were post-surgery, some were considering surgery, and some had decided against surgery.


Through these interviews and surveys, the researchers gained information on the participants’ thoughts, feelings, goals, and decision-making processes in terms of metoidioplasty or phalloplasty. They found that the main goals of gender-affirming surgery for the participants were sensation, standing urination, gender congruence, and the ability to “pass” as male.

A third of the participants reported uncertainty in their decision-making process. This uncertainty stemmed from a strong desire for gender affirmation pitted against fears of complications including possibly undesirable changes in urinary and sexual functioning.

Discussion & Conclusion

The results of this study illuminate the challenges that individuals face when deciding whether or not to undergo metoidioplasty or phalloplasty. It shows that the complex interplay of the different risks and benefits of each surgery can make people unsure about what to choose and what’s most important to them. It also showed that people in this community want help with making these decisions. The results of this study will help to provide guidance on the creation of a tool to support decision-making for these surgeries in the U.S.


  • Butcher, R.L., Kinney, L.M., Blasdel, G.P., Elwyn, G., Myers, J.B., Boh, B., Luck, K.M., & Moses, R.A. (2023). Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study. The Journal of Sexual Medicine, 20(7), 1032-1043.

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