Exploring experiences of metoidioplasty: A qualitative study

Abstract

Background: Genital gender-affirming surgery is often considered an important step in the gender transition process. However, there is currently limited information available about the full surgical trajectory of trans men who choose to undergo metoidioplasty. Aim: This qualitative interview study explored the multifaceted experiences of transmasculine individuals who undergo metoidioplasty. Method: We conducted in-depth, semi-structured individual interviews with 15 participants who had previously undergone metoidioplasty at the national center in Norway. The interviews covered topics such as the participants’ motivations prior to surgery, their experiences throughout the surgical process and the impact on their daily life. The interview data were analyzed via thematic analysis using the framework of van Manen’s hermeneutic phenomenology, with the aim being to understand how individuals make sense of their lived experiences. Results: Three subthemes were developed during the analysis—namely, metoidioplasty as an important step toward affirming masculinity, the process of adjusting to the surgical outcome and the impact of the procedure on daily life. Clinical implications: The findings of this study provide valuable insights for health professionals and patients concerning shared decision-making before undergoing genital gender affirming surgery in regard to expectations and outcome. Conclusion: This study shows that metoidioplasty represents more than a physical change; rather, it is a significant step toward affirming one’s masculinity and integrating one’s gender identity. The subsequent transition into everyday life involves adjusting to the bodily outcomes of the procedure and navigating psychosocial challenges. These findings highlight the importance of comprehensive follow-up care that supports both the physical and psychosocial dimensions of this process.

Introduction

Genital gender-affirming surgery (GGAS) is commonly regarded as an important surgical step in a comprehensive gender-affirming treatment pathway. In Norway, GGAS procedures are provided by the public healthcare system at a single national center, the Center of Expertise for Gender Incongruence (NCGI) at Oslo University hospital (OUH), ensuring both accessibility and continuity of care. For transmasculine individuals—those assigned female at birth who identify as male—gender-affirming surgery includes a range of procedures tailored to their individual needs and goals (Coleman et al., 2022).

Metoidioplasty is a gender-affirming surgical option chosen by individuals seeking to change their genital configuration without undergoing the more extensive procedures involved in phalloplasty, which creates a neopenis using a free, local, or pedicled skin flap (Frey et al., 2017). This technique entails using the hormonally enlarged clitoris to construct a neo-phallus and typically also involves urethral lengthening to enable urination while standing (Bizic et al., 2020; Bordas et al., 2021; Oles et al., 2022). While metoidioplasty preserves erogenous sensitivity and may require only a single surgical stage, complications such as urethral strictures and fistulas are not uncommon (Jolly et al., 2021; Sundhagen et al., 2024).

Despite the growing body of literature on GGAS, most research has focused on surgical techniques, complication rates and functional outcomes. Hence, while the existing literature suggests that patients’ overall quality of life tends to improve following GGAS (Akhavan et al., 2021; Eftekhar Ardebili et al., 2020; Jellestad et al., 2018; Murad et al., 2010), there remains limited insight into how transmasculine individuals experience their full surgical journey, from the initial decision-making through the perioperative phase and into their long-term life post-surgery. Notably, perspectives from European contexts remain especially underrepresented in the literature as current literature is mainly based on the northern American population.

This study aims to explore how transmasculine individuals navigate and make sense of the metoidioplasty experience, including the decision-making process, the operative and recovery phases and life post-surgery. By examining the voices and lived experiences of participants, this study seeks to generate new insights into both the physical and psychosocial dimensions of care. Such insights have the potential to improve the pre- and postoperative information provided to patients, strengthen patient support and contribute to the development of more holistic, person-centered care.

Methods

In line with this study’s overall aims, research questions and psychosocial perspectives, a qualitative design was adopted, with semi-structured interviews forming the basis of the data collection. More specifically, this study was guided by van Manen’s (2016) hermeneutic phenomenology, which provides a framework for exploring how individuals make sense of their lived experiences. Through a structured process centered on lived experiences, we aimed to capture the essence and complexity of participants’ everyday realities. This approach involved attentive and emphatic listening to participants’ accounts of their experiences—identifying the significant moments, emotions and embedded meanings to better understand how such experiences are interpreted and embodied. By shifting between close reading of the data, reflecting on the essential themes, writing and rewriting, we sought to illuminate the core of what the related experiences signify for the individuals themselves. This allowed us to add depth and nuance to the largely clinical focus that characterizes much of the prior literature on transgender health.

Positionality statement

The research team comprises four researchers with diverse yet complementary backgrounds, contributing valuable insights to the study’s design, analysis, and interpretation. The first and third authors are trained in plastic surgery and have extensive experience in surgical research. The second author brings expertise in counseling transgender youth and clinical research, enhancing the study’s relevance to evidence-based practice and patient outcomes. The final author specializes in qualitative methodologies with a particular focus on patients’ perspectives, ensuring that participant voices are meaningfully represented and interpreted with nuance.

Participant recruitment and selection

Patients who had undergone the metoidioplasty procedure at Oslo University Hospital between 2016 and 2020 were identified via an internal quality registry for gender incongruence treatment. The first and second authors (HPS and AW) conducted this identification. In August 2024, a recruitment letter providing information about this study was sent by post to all eligible participants as part of a purposive sampling approach. All who were contacted were above 18 years old and had necessary data available. Potential participants were excluded from the study if they were unable to provide informed consent or had an insufficient understanding of the Norwegian language. 15 participants ultimately took part in the study.

Setting

This study was conducted at the Center of Expertise for Gender Incongruence (NCGI) at OUH. The interviews took place either in an informal conference room at the NCGI (n = 6) or via a secure videoconferencing link (n = 9) between September 17 and November 11, 2024. Each session involved the participant and at least one interviewer, with the first author (HPS) being involved in all of interviews. The interview guide was intentionally comprehensive to allow for flexibility in terms of the responses. Only a subset of the material related to the surgical process was ultimately utilized in the analysis, reflecting the emergent focus of the conversations. The interview guide is available in the supplementary files (Appendix A).

Ethical considerations

This study was approved by the Regional Committee for Medical Research Ethics in South-Eastern Norway (no. 590115) and the data protection officers at the OUH (no. 23/08297), and it was conducted according to the principles of the Declaration of Helsinki (World Medical Association, 2001). An informed consent form was included with the recruitment letter, and only those patients who agreed to participate were contacted. Participants received oral information about the study, including their right to withdraw at any time. Their participation did not affect their treatment at the NCGI, and their travel expenses were reimbursed. The interviewer was not involved in their treatment. Signed informed consent was obtained from each participant prior to the interview. All 15 transcripts were de-identified. In the Results section, the patients are identified using pseudonyms.

Data collection and analysis

The interviews followed a structured interview guide and lasted 49–110 min (average: 66 min). They were recorded using a digital recorder and an encrypted voice recorder app (Diktafon), and the recorded data were subsequently stored in a secure database within the University of Oslo’s data system. The data were then transcribed using Whisper AI and manually edited. Field notes were made after each interview. After conducting 15 interviews, we considered that data saturation had been reached (Malterud et al., 2016). Demographic data were collected from the participants before each interview and are presented in Table 1. An overview of the details related to each participant’s surgery can be found in Table 2. The data were analyzed via reflexive thematic analysis, as outlined by Braun and Clarke (Braun & Clarke, 2006, 2019). This approach was chosen for its recognized strength in highlighting both shared patterns of meaning and meaningful differences within qualitative datasets (Braun & and Clarke, 2019).

Table 1.

Summary of the demographic data.

Age in years (median, range)	33 (29–65)
Years since metoidioplasty (median, range)	6 (4–8)
Marital status
Married or in a relationship	N = 10
Single	N = 5
Family status
Own-born children	N = 2
Children with female partner	N = 4
No children	N = 9
Patient-reported gender identity
Male	N = 12
Transgender man	N = 2
Non-binary	N = 1
Level of education
No formal education	N = 3
Lower secondary education	N = 9
Higher professional or academic education	N = 3
Employment
Full-time job	N = 8
Part-time job	N = 1
Student	N = 2
Disabled, unable to work	N = 4

Table 2.

Aspects related to the surgical outcome.

Previous surgical treatment
Mastectomy (OUH)	N = 9
Mastectomy (private)	N = 6
Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy(TLH/BSOE) (OUH)	N = 15
Complications affecting ability to void today
None	N = 8
Slow urine stream	N = 2
Daily self-catheterization	N = 4
Scattered urine stream	N = 2
Regret undergoing metoidioplasty procedure
Yes	N = 2
No	N = 13

The first author (HPS) engaged deeply with the data by repeatedly listening to and reading the transcript of each interview, developing a nuanced understanding of the participants’ experiences. Grounded in the participants’ own words, an inductive coding process was then manually carried out. This process resulted in codes specifically related to the motivations for undergoing GGAS and aspects concerning the surgical process itself.

After the initial coding, the data were examined for overarching categories, thematic similarities and discrepancies by the research team. This involved critically analyzing how the participants depict their main motivations, as well as their experiences at the hospital and on the surgery ward, identifying key issues of importance to them, particularly in relation to their gender identity and the surgical result.

In the final phase, the authors collaboratively reviewed and refined the codes and themes to ensure there was a shared understanding of the findings. The analysis was iterative, involving frequent returns to the original dataset to confirm that both the themes and the illustrative quotations accurately reflected the participants’ intended meanings (i.e. after having undergone interpretation and translation). Selected quotations were included to support each theme. These quotations were translated from Norwegian into English and, when necessary, lightly edited for clarity and readability (Braun & and Clarke, 2019). A reference group consisting of three transmasculine individuals from two different patient groups participated in giving feedback throughout the process; on the interview guide, the final themes and the manuscript, to ensure that the patient perspective was maintained.

The rigor of this qualitative study was ensured by adhering to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist (Tong et al., 2007), which is provided in the supplementary files (Appendix B).

Results

Participants

A total of 52 transmasculine individuals were contacted by post and invited to participate in this interview study. Sixteen individuals (30.8%) responded via letter or email, agreeing to participate. One respondent was unable to participate due to illness. The median age of the participants was 33 years (range: 29–65 years). Ten participants were either married or in a relationship. Of these ten, two participants had a cis-male partner, and one was in a relationship with a trans man. The remaining seven each lived with a female partner. Five participants were single. One of the single participants expressed attraction to trans women. Additional demographic data concerning the participants is presented in Table 1.

Qualitative analysis

A thorough analysis of the transcripts shed light on the participants’ initial motivations for undergoing GGAS with metoidioplasty, the practicalities related to having a new genital area and how this affected their daily life. Three subthemes were identified after a further rearranging of the topics—namely, feeling complete, adjusting to the new genital area and adaptations in daily life.

Feeling complete

Choosing to undergo GGAS was described as a decision made after thorough consideration and assessment by all of the participants. For the participants, it was the final plastic surgical procedure in their transitional process and a necessary step toward feeling complete:

I went through it to feel complete, and to be finished. Cause even though I felt a lot better after the first surgeries, it was still something that was missing down there. (Adrian)

They reported a lot of dysphoria to be related to this organ due to its mere existence and it being visible when undressed. The decision to undergo GGAS was clear from the start for some, while others explained that they had not initially thought of going ‘all the way’:

Yeah, it’s like the body doesn’t fit. I still don’t like using the phrase ‘born in the wrong body’ because I feel like there’s so much about my body that isn’t wrong. So, I’m not sure what words to use, but there was something there, like when I had to pee and stuff. This girl body, it just didn’t fit. It didn’t fit anymore. It became really clear to me that I was going to go through that process [genital surgery] (Jonas)

The participants talked about how they associated having a female genital area with being a woman and how it felt wrong. No longer having this appearance in their genital area due to altering the last feminine part of the body was expressed as a motivation for metoidioplasty surgery by six participants. Exploring their sexual identity and sexual activities were difficult before the genital surgery. Seven participants reported mental inhibition in terms of enjoying and engaging in sexual intercourse before the genital surgery. Four participants even outlined how the female genital area stopped them from making their sexual debut:

No. I categorically avoided it. And I knew that if it was going to happen, I needed that surgery. Because I can’t use this [vagina]. I can’t… I don’t want anything to do with it. So, I must have that surgery before it can happen in my life. (Tobias)

An important aspect of the GGAS was how the male genital appearance would finally align with how they have perceived themself since childhood. During the interviews, many participants pointed out that the ability to urinate while standing was a significant and measurable goal that influenced their decision when choosing between the two surgical methods (i.e. metoidioplasty or phalloplasty). This function was frequently associated with traditional markers of masculinity, reinforcing their sense of alignment with their gender identity and relieving their gender dysphoria. For many, achieving this capability was not only a practical advantage but also a symbolic milestone in their transition.

Marius: I felt more like a man when I had the surgery—I felt that it made me whole. In the period leading up to my final operation, I did what many others do: I used a packer to create the feeling of having something there. For me, it was important to feel that presence. Until I had the surgery, even though I had a beard, and everyone saw me as a man, I still felt like something was missing. I completely understand those who feel like a man even without surgery, but for me, it was essential.

Interviewer: What factors were important for you in deciding to undergo the surgery?

Marius: The ability to stand while urinating and to physically experience it—it’s difficult to put into words. I just felt like a part of me was missing and I wouldn’t feel complete until everything was in place. I don’t really know how else to explain it.

Before the surgery, many participants sought advice and shared experiences with trans men who had already undergone the same procedure, both in Norway and abroad, most commonly via social media and various online forums. Several participants stated that this information was more valuable than what was provided by the hospital, given that it was based on first-hand experiences.

After going through the actual surgery, the participants stated that they were surprised by how mentally challenging the postoperative period was. Being stuck in bed for several days due to the epidural and movement restrictions, being dependent on others for help and being unable to move freely were especially challenging. To lose control and not know if the result was successful evoked a lot of negative feelings.

It’s an intense operation. The surgery itself takes many, many hours. And then you wake up with a new organ, not knowing if it works or how it will feel. How is it going to look? (Benjamin)

Several participants also referred to feelings of liberation and relief, including instantly reduced dysphoria and a feeling of being complete after the surgery.

…it finally happened. Everything’s in place now. I can finally breathe easy (Tobias)

Adjusting to the final outcome

After completing the surgery, it is necessary to adjust to the new reality of an altered genital area. After returning home from the hospital, many participants expressed having a lot of questions and feeling insecure about how to handle their new genitalia and the practicalities of having a urine catheter. Urinating still involved the same mechanism, but it felt different because the urine came out through a new hole. When the catheter was finally removed, finding a new rhythm took some time:

And then I sat down, but it hadn’t fully healed yet, so it sprayed in all directions—and that went on for quite a while, kind of sporadically. So, it was really strange. In the beginning, I had to go in the shower at home when I needed to pee. That felt safest, in a way. (Emil)

Even though they could phone the plastic surgery ward at any time, the majority of participants expressed a wish for closer follow-up during this period, especially from their surgeon. Many participants considered the ability to urinate while standing to be important, and 11 of the 15 participants were able to do so after the surgery. However, while it was possible, eight participants preferred to sit because doing so led to better emptying of the bladder and less mess. Many experienced dribbling or spilling when using the toilet. Spending more time in the toilet than before was now a habit. Others did not achieve the ability to urinate while standing, which led to frustration:

I can’t stand and pee. And it’s not that I have to stand and pee to confirm myself as a man, it’s just very practical when there are these horrible men’s restrooms like at a petrol station. But basically, I sit and pee at home. I find it very comfortable. (Magnus)

Two participants said that they only intended to stand to urinate when under the influence of alcohol or at a party or festival. In such situations, they released themselves from the gaze of others and blended into the crowd. Two participants had an immediate complication in the form of a urethral fistula, leading to them having to go through a corrective procedure. Neither of these participants have sequela from this complication today. Six participants struggled with symptoms related to a urethral stricture, with five having to perform regular self-catheterization. Three of these participants experienced a complete blockage of the urethra, leading to them having to put in a temporary suprapubic catheter. The severity of these complications varied in terms of affecting the participants’ daily quality of life. One participant reflected on an omnipresent fear:

Yeah, it’s that fear. That it will be blocked again. I think that’s the hardest part for me. Not like, this summer, we were in Spain for a month. And then I worried: what if it is blocked down there? What happens then? So, I went to the pharmacy and stocked up on all the catheters and wound care stuff, and God knows what else, just in case. I even looked up where the closest and best hospital was in case something happened. So, I think that’s what affects me the most in my everyday life, you know. It’s the fear that it will be blocked. Like, shit, it’s happening again. (Sebastian)

Other participants had grown accustomed to the habit of self-catheterization, which one illustrated as follows:

But it’s always like this, no matter how prepared you are for it, you can’t really imagine what it’s like when the urethra gets blocked. And it’s… You get scared. But now I have a catheter always available. And if it’s a bit blocked, I just unblock it myself. It’s just become… like brushing your teeth, you know? A completely normal habit. It’s not something I think about for long. (Benjamin)

The participants talked about how having a genital appearance that aligns with their gender identity affected their sex life in different ways. All of the participants described feeling more comfortable and satisfied with their sexual activities, whether through intercourse with a partner or increased pleasure during masturbation. However, three participants had not debuted sexually after having the GGAS. In the interviews, these participants expressed concerns about how potential partners might react in intimate situations. One participant reported uncertainty about his future sexual debut:

I felt like I had to become familiar with myself, do all the things that I felt like… Now, this is when life is really starting, you know? So, I haven’t been dating. Sometimes, I think there’s a bit of fear right away. […] It gets to the point where you’re supposed to go to bed together, and you’re not quite ready for… How should you explain it? I think that if I meet someone, I’ll tell them fairly early on, this is how it is, so they won’t be surprised when we get to that point. (Marius)

Retaining sufficient sensation in the affected area to achieve orgasm was important. The participants explained how they had taken the time to figure out how to maneuver their new genital area to feel confidence and pleasure. Some participants explained that they used different sex toys during intercourse, both for external stimulation and penetrative intercourse. Many expressed relief that their ability to orgasm was maintained or even enhanced. The overall increased self-confidence and self-image were long awaited. For some, the surgery facilitated a sexual awakening:

No, I avoided doing it [having sex]. There were plenty of opportunities where I could’ve done it. But… I just consciously avoided it. So, right after I had my surgery, that same year, just a couple of months later, when things had healed and looked a bit nicer, I debuted. As soon as I could. (Oliver)

With this surgical technique, the patient is informed prior to surgery by the surgeon that a small opening is left where the native vaginal canal had been. When asked about this, the majority of participants said that it was a big problem because it reminded them of being a woman and that it was especially uncomfortable during arousal. By contrast, four participants reported that they enjoyed still having this part and used it actively in sexual activities. Some also expressed the need for improved guidance on how to use the new genital area and additional information on sexual aids and accessible resources.

Changes and adaptations in daily life

From the initiation of gender-affirming treatment, passing as a man becomes increasingly natural. After completing the surgical procedure by undergoing genital surgery, most participants described themselves as living the life they had always envisioned. Many emphasized that it was liberating to be finished with the treatment. Those who underwent the surgery in adulthood expressed some regret over not having pursued the procedure earlier. However, despite their overall satisfaction with the outcomes of the GGAS, ten participants specifically noted their disappointment with the size of their neo-penis.

The result could have been better, but I have sensations and… That’s the most important thing to me. I don’t have the biggest in the world. And that’s not what matters anyway, because it’s not what determines your gender. It’s how you use it, and how you feel about yourself. And, of course, there are some days in-between, where things are more sensitive than others. And some days, I don’t think about it at all. (Leo)

Many participants used cis-men with a micropenis (a dorsal penile length of at least 2.5 standard deviations smaller than the mean penis size) as a comparison when discussing their size issue. One participant explained it in this way:

… I know there are some boys who are born with a micropenis, but I still think theirs is bigger than mine. So, … it’s going to be noticeable no matter what if I undress and stand there—people will be able to see it. Just like how you’re born with ten fingers and ten toes. It’ll be like something is missing. (Felix)

Even though urinating while standing was possible, not all of the participants used male restrooms. Some wished that they were able to use the male facilities, while one said that just having the choice to do so was a relief:

If I’m alone at a urinal, then I use it—just for practice—because I’ve come to understand that it’s not just trans men, but also cis men, who can feel a bit of performance anxiety when using a urinal. But I feel very trans when I have to stand in line for the toilet because I can’t use a urinal. But if I can use a urinal, then it feels like I have a choice. (Emil)

When in situations where they must undress in front of others, the participants reported different emotions related to discomfort to occur:

It feels quite natural now. So, I don’t think about it much anymore. But I turn my back when I have to take off my swimming trunks. I do that. And it’s partly because… The size is so small that I’m not comfortable with strangers seeing it. But I’m comfortable enough in a relationship for it to be fine. (Adrian)

Those who struggled with complications of the surgery talked about challenges in daily life related to urination and the different adaptations that were necessary:

It’s like I have to take it into account. I always have to remember to not go on long walks without an empty bladder first. Because if I have to go, or if it starts feeling like an urge, I mean, once I feel like I need to pee, I just have to go. I need to have a bathroom nearby, so there’s a bit of planning at that level. (Oscar)

Among those individuals for whom the surgery was successful and postoperative complications were absent or limited to minor inconveniences, they did not dwell on issues related to urination. It was simply not a problem. Many appreciated the time they were forced to spend waiting before the GGAS, which helped assure them that it was the right decision. However, for some participants, the esthetic and functional surgical outcome was not what they hoped for, and they outlined different challenges. One participant, for instance, reflected on the disappointment with the result:

I’d rather be a man with a pussy than a man with a micropenis. One that doesn’t work the way it’s supposed to. Given how natural things have become now. Everyone can change their gender now. (Jan)

When asked directly about regret, Jan and one other participant stated that the result did not match their expectations and that they regret undergoing the metoidioplasty procedure. This regret was mainly due to the lack of satisfaction with the result and having to undergo many corrective procedures. One participant still struggled daily with urination, and even though he was happy with the esthetic result, he was waiting for an appointment to try to correct the urinary function. The process evoked reflections on the necessity of genital surgery to feel like a man:

… I think the main reason I wanted to have that surgery was to feel like a man from head to toe. And I don’t think that if I had chosen not to have the surgery, that I would’ve felt any less of a man. (Sebastian)

Some participants had completed the entire transition process with the same partner. Three of these participants had subsequently gone through an IVF process and started a family. All of the participants had gained some temporal distance from the surgical procedure, which enabled them to reflect on how they experienced it and what it has come to mean in their lives. When asked what they would have liked to be different, many stated that they wished for closer follow-up and more detailed information about the restrictions and expectations in the postoperative period. Many felt left to their own devices to figure out their new genital area, which led to a great deal of insecurity, especially if complications occurred. One participant said that it took a long time after going through the GGAS before he felt like he had settled into himself:

But after the last two surgeries, I suddenly didn’t have to do anything anymore, and then I felt like my body just went, ‘Oh, so now you’re supposed to live, how do you do that?’ So, it was really many different processes after that last surgery [metoidioplasty]. (Emil)

Some reflected on how they could not imagine where they would be today without having undergone the GGAS. Another participant emphasized the importance of having a supportive network alongside gender-affirming care and how this helped ease his overall transition process.

What I’ve gone through in this process hasn’t been my entire everyday life. I’ve had my own things to do on the side that have been important to me. So, I’ve lived a relatively normal life alongside what I’ve been through. (Adrian)

Discussion

To the best of our knowledge, this is the first study to document the full patient trajectory following advanced surgical treatment with metoidioplasty. It includes the long-term follow-up, highlighting significant biomedical, psychosocial and sociocultural aspects. This qualitative study, in line with Van Manen (2016) phenomenological approach, sheds light on the multifaceted experiences of trans men, revealing diverse motivations, complicated trajectories and the impacts of surgery on their everyday lived experience.

This study underscores previous findings concerning GGAS being an important milestone that can alleviate gender dysphoria (Bjørnson & Sagbakken, 2023; Javier et al., 2022; Wierckx et al., 2011). Searching for a body that matches the way they have always perceived themselves was a dominant motivation among the participants. The findings of our study give the impression that this surgery was the final step that helped the participants live the life they had always envisioned. Still, the descriptions offered by the participants provide a nuanced picture of the different aspects of satisfaction after surgery. It is possible to have good days and bad days, and it is also possible to be satisfied with having undergone GGAS while still having reservations about specific outcomes, such as the size of the neo-phallus.

Previous studies have highlighted similar motivations for undergoing GGAS. For instance, Van De Grift et al., 2017 reported that affirming one’s gender identity, having the ability to urinate while standing and enjoying improved sexual function were the most common reasons transmasculine individuals sought genital surgery. The participants in this study often expressed that the ability to urinate while standing signified far more than mere functionality, serving as a powerful symbol of traditional masculinity. Such western culture-based symbols significantly influence decision-making processes and illustrate Connell’s (1995) theory of hegemonic masculinity, where societal expectations shape the understanding of what it means to be a ‘man’. Interestingly, while the functionality was achieved, many participants chose to sit to urinate at home for practical reasons. This may suggest that public situations reinforce symbolic gender expressions more strongly than private ones, underscoring how surgical outcomes should be interpreted in light of sociocultural contexts. Brown et al. (2025) reported that preserving both erogenous and tactile sensation ranked highly among trans men and non-binary individuals when considering GGAS, particularly those choosing metoidioplasty over phalloplasty. These findings resonate with the experiences of our participants, many of whom described bodily alignment and specific functional outcomes as central drivers of their decision.

When looking into the motivations and expectations of trans women, Mokken et al. (2025) described how genital surgery is perceived as the big final surgery. Still, they reported how not all trans women desire a vaginal canal, which is commonly included in full vaginoplasty. This may also apply to trans men. In our study, those who expressed regret regarding the surgery were primarily individuals who experienced complications related to voiding. For some, metoidioplasty without urethral lengthening might have been an option, suggesting the need for more tailored surgical adjustments (Pigot et al., 2020).

The embodied and psychological dimensions of GGAS have also been highlighted in recent qualitative work by Vestering et al. (2025) and Bakir et al. (2025; Vestering et al., 2025). These authors describe how gynecological procedures and the remaining anatomical features can carry layered meaning for trans men, evoking either discomfort or dysphoria, while for others, they can represent retained function or identity complexity. Our findings reflect this heterogeneity. The presence of a residual vaginal opening was experienced as challenging by several participants. For some, it enhanced their dysphoria due to serving as a reminder of previous feminine traits, while others found it sexually meaningful, illustrating the importance of individualized counseling and expectation management.

Post-surgery, many participants experienced enhanced sexual pleasure and found it easier to share their bodies with others due to the reduction of their gender dysphoria. This aligns with the findings of Bartolucci et al. (2015) and Martin and Coolhart (2022), who emphasized the role of bodily comfort and affirmation in sexual well-being in a transmasculine and transfeminine population. Anzani et al. (2021) also found that becoming comfortable with one’s body during sex, especially in the context of intercourse with a partner, was key to sexual pleasure among transmasculine and non-binary individuals. In our study, three participants had not debuted sexually with a partner post-surgery, mainly because they did not feel ready yet but also because they feared how a new person might react to their body in an intimate situation. A growing number of studies have examined the broader psychosocial impact of GGAS (Pipkin et al., 2024). For example, Mmonu et al. (2025) emphasized how phalloplasty can influence multiple aspects of a person’s life, including their mental health and intimate relationships. Gieles et al. (2025) argued for the importance of providing comprehensive preoperative counseling, particularly regarding sexual function and pleasure, not just surgical complications. These perspectives are reflected in our study, where many participants sought advice and expertise from other trans men who had undergone metoidioplasty, and it was also evident that many participants felt that the follow-up during the postoperative period was inadequate. Moreover, many of them requested more information and counseling in relation to sexual function and sexual aids. This reflects the need for more holistic, person-centered support throughout the surgical trajectory.

Through the phenomenological approach of Van Manen (2016), the lived experiences of our participants clearly emerged, revealing their subjective understanding of the surgical outcomes. The ‘lived body’ is especially important, as the participants described not only physical changes in bodily function (e.g. urinating and healing) but also broader shifts in how they engage with the world, exemplified by how using a urinal is easier now. While many appreciated the functional gains, several participants voiced disappointment with the size of their neo-phallus. These concerns may reflect unrealistic expectations or internalized societal standards linking masculinity to penis size. Comparisons with cis men who have a micropenis were frequent. The participants found themselves balancing validation of their gender identity with their limitations in meeting perceived masculine norms. These findings highlight the intricate relationship between body image and self-esteem within the context of gender transition.

Although regret after GGAS is rare—reportedly less than 1% according to a systematic review by Bustos et al. (Bustos et al., 2021)—poor surgical outcomes have been identified as a factor contributing to patients regretting undergoing the procedure in some cases. Urethral lengthening is particularly associated with postoperative challenges (Lumen et al., 2020; Waterschoot et al., 2021). Our findings illuminate how having to live with urethral complications may lead to a higher psychosocial burden. A constant fear of recurrent strictures may be emotionally burdensome, while the practical adjustments necessary in daily life seem to impact quality of life. Nonetheless, most participants described undergoing metoidioplasty as a necessary and ultimately affirming experience that has helped them live the life they have always envisioned.

The surgical journey is closely connected to participants’ lived reality and reflects van Manen’s (2016) concept of the lifeworld, where the lived body, time, space and relation converge. The integration of the complex transition from a post-surgical state into everyday life underscores the significant psychosocial adjustments made by the participants. For many, the newly constructed penis symbolized both a final step toward physical masculinity and a step away from femininity, leading to a sense of completion and coherence in their understanding of their gender.

Strengths and limitations

This study offers several strengths, one being the long-term nature of this study, with some participants being interviewed up to eight years after their GGAS. This offers unique insight into how the participants navigated the post-surgical landscape, adjusting to life after their treatment was over. Moreover, describing the experiences of both satisfied and unsatisfied individuals provides nuanced insight into how metoidioplasty can be experienced.

This current study also has some limitations. When interpreting the results of this study, some consideration should be given to the selection of participants, as only those patients who volunteered to participate were included, leaving out the valuable insights of those with different trajectories. However, the use of purposive sampling, where participants who have direct experience or knowledge of the phenomenon under study are selected intentionally, represents a known strength of qualitative research. It ensures that the data collected are rich, detailed and highly relevant to the research questions. It is important to also consider the local context, which limits our ability to adapt the results to other settings and the fact that exclusion of persons who have limited understanding of the Norwegian language may influence the different trajectories presented. Furthermore, we are aware of the homogenous backgrounds of the researchers, who are all cis-gender-identifying individuals. While engagement with a reference group provided valuable feedback on the study’s direction, it remains important to acknowledge the lens through which the researchers emerged in the data.

Clinical implications

The findings of this study will be utilized to provide more nuanced and comprehensive preoperative information to patients considering metoidioplasty. Additionally, the findings will serve as a framework for patient counseling in the context of gender-affirming care. Furthermore, the patient information concerning the postoperative phase will be revised to incorporate relevant insights from this study.

Conclusion

In conclusion, the findings of this study indicate the importance of understanding metoidioplasty not merely as a surgical procedure but also as a pivotal point in the broader context of gender identity and self-acceptance. As our participants navigate their paths toward realization of their true selves, it becomes evident that the implications of such surgeries extend deeply into the personal, psychological and social dimensions, warranting further investigation and discussion in the field of gender-affirming care.

Appendix A.

Interview guide

1. First – could you tell me a little about yourself and briefly describe your journey from being referred for assessment until today?

2. Life before surgery:

   What was your life like before the surgery?

   Do you have any examples or stories that might illustrate this?

   Can you tell me a bit about how you were doing right before the surgery?

   (For example: Were you living alone/working/studying? Did you have any mental/physical health issues? Were you living with someone, in a relationship, sexually active? Did you have support from others?)

3. Motivation:

   Why did you want to undergo genital surgery?

   How did you choose this particular surgical technique, and what factors were important to you when making your decision? (e.g., ability to urinate standing up)

4. Decision to undergo genital surgery:

   What was the process like for you when deciding to undergo genital surgery?

5. Information:

   Who or what helped you in the decision-making process – where did you find information? (Internet, patient organizations, books, courses, healthcare professionals)

6. Surgical procedure:

   What was it like to have the surgery?

   How has the follow-up been, both before and after?

   What do you think about the results?

   What are your thoughts now on the information and follow-up you received in connection with the surgery?

   During the operation, a remnant of the old vagina is left – how does this affect you, or what do you think about it?

7. Challenges:

   Do you have any physical challenges after the surgery?

   What is it like going to the bathroom? Can you, for example, urinate standing up?

   How does this affect your life and daily routine?

   If you’re in a relationship – how does it affect you in intimate situations?

   How will you describe your sex life?

   What else have you done to affirm your identity / transition your gender / change your body?

   Any other surgeries or treatments?

   What are your thoughts on masculinity?

   Are you receiving any follow-up care now? (Psychologist, etc.)

   Can you compare genital surgery with other surgeries you’ve had – in terms of pain, expectations before and after?

   How did you experience the information related to future fertility?

8. Openness:

   How do you experience interacting with others after going through this process?

9. What is it like to talk to others about what you’ve been through?

10. How open are you – with friends and family, in romantic relationships? In partnerships?

11. Current status:

    What are your thoughts today about the areas that were important to you at the beginning / that motivated you to have surgery – do you feel these have improved or been fulfilled?

    How do you experience your relationship with yourself today? How would you describe your self-image now?

    Do you think time plays a role?

12. Regret:

    If you had known what you know today – would you still have gone through with the surgery?

    Is there anything you wish had been different?

13. Relation to society:

    How did/do you experience the discussion and focus from activists and media?

14. Closing:

    What has been the biggest challenge related to this process?

    What has been the best experience?

    Is there anything we haven’t covered that you think is important to share?

    What was it like to participate in this interview?

Appendix B.

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist

No	Item	Guide questions/description	Response
Domain 1: Research team and reflexivity
Personal Characteristics
1.	Interviewer/facilitator	Which author/s conducted the interview or focus group?	Henriette Pisani Sundhagen conducted the interviews
2.	Credentials	What were the researcher’s credentials? E.g. PhD, MD	HPS: MD LF: MA PhD AW: MD PhD KAT: MD PhD
3.	Occupation	What was their occupation at the time of the study?	HPS: Plastic surgeon, PhD candidate AW: Pediatrician, Post-doc researcher LF: Researcher KAT: Plastic surgeon, professor
4.	Gender	Was the researcher male or female?	Three were female and one were male
5.	Experience and training	What experience or training did the researcher have?	HPS: Surgical research LF: Qualitative research/patients perspective AW: Clinical research KAT: Surgical research AW/LF/KAT: Are all experienced counselors for several master/PhD-students
Relationship with participants
6.	Relationship established	Was a relationship established prior to study commencement?	Yes, HPS Not by AW, LF and KAT
7.	Participant knowledge of the interviewer	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research	The participants were told about the interviewers’ professional background, and the reason for conducting the study
8.	Interviewer characteristics	What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic	Novice qualitative researcher Well known with the surgical field, not responsible of the treatment
Domain 2: study design
Theoretical framework
9.	Methodological orientation and Theory	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis	The data were analyzed using reflexive thematic analysis. Max van Manen’s hermeneutic phenomenology provided a framework for exploring how individuals make sense of their lived experiences.
Participant selection
10.	Sampling	How were participants selected? e.g. purposive, convenience, consecutive, snowball	Participants were recruited by HPS on a purposive basis
11.	Method of approach	How were participants approached? E.g. face-to-face, telephone, mail, email	By mail
12.	Sample size	How many participants were in the study?	15
13.	Non-participation	How many people refused to participate or dropped out? Reasons?	One did not participate in the interview due to illness
Setting
14.	Setting of data collection	Where was the data collected? e.g. home, clinic, workplace	6 of the interviews were conducted at the clinic 9 were conducted over video link.
15.	Presence of non-participants	Was anyone else present besides the participants and researchers?	No
16.	Description of sample	What are the important characteristics of the sample? e.g. demographic data, date	The study included 15 FtM-participants, the median age of the participants was 33 years (29–65).
Data collection
17.	Interview guide	Were questions, prompts, guides provided by the authors? Was it pilot tested?	The interview guide was drawn on the researchers previous experiences with surgical research, published literature in the field, and clinical experience One pilot interview
18.	Repeat interviews	Were repeat interviews carried out? If yes, how many?	No
19.	Audio/visual recording	Did the research use audio or visual recording to collect the data?	All interviews were audiotaped and transcribed
20.	Field notes	Were field notes made during and/or after the interview or focus group?	Yes, field notes were made after the interviews
21.	Duration	What was the duration of the interviews or focus group?	The interviews lasted from 49–110 min (average of 66 min
22.	Data saturation	Was data saturation discussed?	Yes, it was considered reached after 15 interviews
23.	Transcripts returned	Were transcripts returned to participants for comment and/or correction?	No
Domain 3: analysis and findingsz
Data analysis
24.	Number of data coders	How many data coders coded the data?	One, HPS
25.	Description of the coding tree	Did authors provide a description of the coding tree?	No
26.	Derivation of themes	Were themes identified in advance or derived from the data?	Themes were derived from the data
27.	Software	What software, if applicable, was used to manage the data?	No software used
28.	Participant checking	Did participants provide feedback on the findings?	No
Reporting
29.	Quotations presented	Were participant quotations presented to illustrate the themes / findings? Was each quotation identified? e.g. participant number	Yes, participant quotations were presented to illustrate the themes. A participant ID was assigned to each participant to ensure their confidentiality(P1-15). Neither gender nor age was linked to the quotes for the same reason. A reference group consisting of three transmasculine individuals from two different patient groups participated in giving feedback throughout the process; on the interview guide, the final themes and the manuscript, to ensure that the patient perspective was maintained.
30.	Data and findings consistent	Was there consistency between the data presented and the findings?	There was consistency between the data, but also deviations within the material which gave us rich and nuanced examples suitable to illuminate the experiences from the participants’ own perspectives
31.	Clarity of major themes	Were major themes clearly presented in the findings?	Yes, three major themes were presented
32.	Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?	Yes, deviations within the material were presented

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Disclosure statement

No potential conflict of interest was reported by the author(s).