Gender dysphoria (GD) is defined as a "marked incongruence between an individuals'
experienced or expressed gender and the one they were assigned to at birth". This
definition is in accordance with the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). Many GD individuals seek medical aid in the form of psychological
counseling, hormonal treatment, and, if desired, surgery to align their physical
appearance with the perceived gender identity. A part of this population will eventually
undergo genital gender affirming surgery (GGAS) to align the appearance of the external
genitalia as well. In transgender men, GGAS can be performed as metoidioplasty or
phalloplasty with or without the removal of the native external genitalia. In
phalloplasty, anatomically sized external genitalia (penis with or without urethra,
scrotum, and perineum) are created using on the one hand a donor skin flap (usually from
the forearm, upper leg or inguinal region), and on the other hand tissues from the
original genitals. In metoidioplasty, the goal is to create anatomically looking but
undersized external genitalia in which the clitoris forms the base of a micro-penis. One
study in the United States reported that about 3% of transgender men have undergone a
phalloplasty and 19% would like to undergo the procedure in the future. For a
metoidioplasty, the numbers are 2% and 25%, respectively. One of the reasons for
undergoing masculinizing GGAS is to gain the ability to penetrate a partner during
intercourse. As there is no erectile tissue present in the neophallus after phalloplasty,
penetration is usually not possible without the use of external or internal erectile
aids. In metoidioplasty, the phallus does possess erectile tissue but the eventual size
of this microphallus is largely dependent on the individually obtained clitoral
hypertrophy after hormonal therapy and the body constitution. Therefore, the ability to
penetrate a sexual partner after metoidioplasty cannot be assured.
In patients having undergone phalloplasty a multitude of methods for obtaining phallic
rigidity are available. One option can be the implantation of an internal erectile
prosthesis. These form the main method of attaining penile rigidity after phalloplasty to
date. While a multitude of both malleable and inflatable devices are available, these
procedures, just as primary GGAS, carry a high risk of complication. Previous research
with prostheses originally designed for cisgender men has shown that up to 22% of
prostheses was explanted for various reasons including infection, erosion and malfunction
within 20 months. Another study showed that only 62% of patients still had their
prosthesis in place after 4 years. More recent publications with a prosthesis
specifically designed for phalloplasty patients (ZSI TM 475 FtM, Zephyr Surgical
Implants, Switzerland, Europe) have shown explantation rates of 19% and 23% at 9 and 18
months respectively. The lack of reliable, and durable erectile devices leads to the fact
that a large proportion of patients either chooses for phalloplasty but never goes on the
placement of an erectile prothesis or completely abandons the idea of GGAS under the form
of phalloplasty at this point in time. As underlined in a recent qualitative study,
transgender men may very well be concerned about the complication rates and likely need
for additional surgeries associated with the surgical treatments they seek to diminish
their gender dysphoria, specifically in penile implant surgery. In addition to internal
devices, external ways of obtaining phallic rigidity have been put forward. The use of
one or multiple tight condoms with or without the use of self-adhesive bandages tapering
the phallus has been reported, as well as the use of penile sleeves readily available on
the market or made to measure. Finally, the use of penile lifters or splints has been
evaluated in post-phalloplasty individuals with varying results. However, it is unclear
which of these erectile aids are most commonly used and, evenly important, how satisfied
patients and their partners are with them.
In metoidioplasty, the neophallus does contain cavernosal bodies. However, according to a
study in Belgrade in which 813 metoidioplasties were performed, penetration is not
possible due to the small size of the neophallus for those who reported sexual
intercourse. Other studies report patients who were able to penetrate after
metoidioplasty. According to a review by Frey et al. 51% were able to penetrate. Cohanzad
et al. reported a technique, extensive metoidioplasty which they performed on 10 people
after which 70% were able to obtain an erection rigid enough for penetration. In another
study, they used a penile traction device in 10 transgender and 4 cisgender men to
increase the length of the phallus after extensive metoidioplasty. The result was a mean
penile length increase of 28.42 mm (21-47 ± 6.86). 9 of 11 participants were eventually
able to penetrate during sexual intercourse (1 child and 2 virgin singles who had never
had sexual contact were excluded). However, it is not stated whether the participants
were already capable of penetration before they started using the device. As in cisgender
men with erectile dysfunction, some individuals have reported the use of
phospho-diesterase 5 inhibitors (PDE5i's) such as Sildenafil or Tadalafil to increase
their natural erection. These PDE5i's increase the inflow of blood into the phallus by
relaxing the smooth muscle cells in the cavernosal tissue. Another option is
intracavernosal injections (ICI's) with Alprostadil. However, knowledge about these two
options in post-metoidioplasty individuals is limited. A study by Khorrami et al.
examined sexual aspects that are deemed important to those who underwent metoidioplasty.
They found that being able to get and maintain an erection was very important in up to
93% of studied individuals, but only 40% valued the ability to have penetrative
intercourse equally. An explanation would be because patients do not expect to get a
phallus large enough for penetration after metoidioplasty. Thus, the reason they use
PDE5i or ICI to improve erection is not only to penetrate the partner, but also because a
better erection allegedly also makes for a better orgasm. Another study by Neuville et
al. describes the possibility of a semi-rigid prosthesis for metoidioplasty. This
technique seems to be successful in terms of post-operative satisfaction, regrets about
the surgery and urinary position. However, it is not examined whether penetration during
sexual activity with this semi-rigid prosthesis has improved. Other erectile aids used in
metoidioplasty apart from PDE5i and ICI are rarely studied.
Apart from the study of Boskey et al., the success and satisfaction rates of these non-
surgical erectile aids are unknown or limited to anecdotal reports of individual
patients. The erectile aid examined in this study is the Elator. This device seems to be
a good option for penetrative sex in trans men who do not (yet) want an internal
prosthesis. However, the results showed that only a few couples were able to use the
device effectively to have intercourse in the way they envisioned beforehand. For the
majority of the studied population, the Elator proved uncomfortable during use, or did
not appear to have the right fit since the device was originally designed for cis-men and
the phallus of transmen has a different anatomy. A limitation of this study, however, is
the small study population.
Given that no prescription or medical intervention is required to obtain these
non-surgical aids, only a small portion of the population that does not opt for an
internal prosthesis is still on the physician's radar. The limited knowledge on
erectile aids in scientific literature makes it difficult for health care providers to
offer supported advice to post-surgical transgender individuals in search of alternatives
to surgically implanted erection prostheses.
The purpose of this study is to investigate what methods are used for sexual intercourse
by transgender men who have undergone phalloplasty or metoidioplasty and how satisfied
they and their partners are with these erectile aids. All patients who are sexually
active and at least 6 months after primary genital gender-affirming surgery are eligible.