Less common/non-binary gender-confirming surgical procedures

Authors: Lilith, Nix, and Zennith. Reviewed by Moonbeam.

Sometimes referred to simply as genital nullification, this surgery aims to create a smooth appearance in the groin area by removing any external genitalia and leaving an opening for the urethra for urination. The processes for this surgery differ slightly between those who are Assigned Male At Birth (AMAB) and those who are Assigned Female At Birth (AFAB).

For AMAB patients, the penis, testicles, and scrotum are removed from the body and the urethra may be shortened in order to create a smooth, gender neutral look for the patient.

For AFAB patients, the vagina, uterus and ovaries, and labia are removed and the clitoris is buried to create a smooth, gender neutral look for the patient.

A full, comprehensive description of these surgeries can be obtained from a medical professional during a surgical consultation.

Penile-preserving vaginoplasty (PPV) is a procedure intended to create a functioning vagina without requiring the removal of the penis nor any urethral shortening or relocation.

Most commonly, PPV is performed by removing the testicles and utilizing the remaining scrotal tissue to construct the vaginal cavity in the location of the testicles. For additional depth, or for specific aesthetic requirements (labia, clitoral hood, etc.), skin grafting may be necessary if the scrotal tissue alone is not enough.

A second, newer type of PPV uses tissue grafted from the lining inside the patient’s abdomen (peritoneal pull-through or PPT). This procedure is most akin to a feminizing PPT vaginoplasty, and many of the steps will be similar in execution to that method of vaginoplasty.

Finally, some clinics perform PPV using a “hybrid” approach where the outer portion of the vagina uses scrotal or penile shaft skin, and the inner portion uses peritoneal tissue.

Some surgeons are able to perform PPV without requiring the removal of the scrotum or the testicles, though if depth is desired for the resulting vagina, tissue grafting will probably be necessary. Depending on the technique used, the graft may come from skin or peritoneal tissue.

Most steps can be done within one surgery, but clinicians may recommend planning a second surgery within 6-12 months depending on patient specifics. Like other methods of vaginoplasty where depth is an expected result, dilation will be required to strengthen kegel muscles and maintain vaginal depth. Other personal care steps may be required as well. Of course, each technique will have its advantages and disadvantages, and should be discussed with clinicians to help you make the right decision for your goals.

Metoidioplasties are possible to perform without a vaginectomy. If urethral lengthening is desired, there may be an increased risk of infections and post-operative complications. The specifics should be discussed with the surgeon who will be performing the procedure. For more information on metoidioplasty, click here.

Phalloplasties are possible to perform without a vaginectomy. If urethral lengthening is desired alongside this operation, there may be increased risk of infections and other complications after surgery. However, since the phalloplasty with vaginectomy uses a fair amount of labial skin alongside clitoral skin to create the penis alongside skin grafts, a phalloplasty without would require more grafted skin. This can, in turn, lead to less sexual sensitivity. For more information about phalloplasty, click here.

In addition to breast augmentation or breast reduction surgeries that are more classically binary, some cosmetic surgeons may be willing or able to make modifications to the nipples, either by changing their visual shape, or by removing them outright. Some individuals may express a desire to have other similar features, such as the belly button, removed. Requests like this may be able to be honored by the gender-confirming surgeon if they are able to approve doing so. Otherwise, this, and other less common cosmetic procedures can be discussed with the surgeon to determine if the option is available to you.

Some non-binary individuals may prefer to have a transition that is generally considered binary in nature. This is a perfectly valid way to transition, regardless of whether someone is binary trans or non-binary trans or something outside or in-between! These less common procedures are also a valid way to transition for those who identify as binary trans people as well. Talk to your surgeon or other medical professional about what you feel is right for you in terms of your transition.

If you are working with a surgeon that is experienced and knowledgeable with the transgender and non-binary communities, it is highly recommended that during surgical consultations, you make clear what exactly it is you’re looking for, even if it is not a documented procedure or something listed here. An understanding surgeon may be very willing to work with your specific needs and help you achieve your ideal surgical goals (as long as the goals are within the scope of their expertise and otherwise within reason).

• The Crane Center for Transgender Surgery: Non-Binary Surgery
• Align Surgical Associates: Procedures for People Who Identify as Non-Binary 
• Davis Plastic Surgery: Gender Nullification
• Metoidioplasty.net: Non-Binary Options for Metoidioplasty
• MTFSurgery.net: Non-Binary Options for Bottom Surgery