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Non-Binary / Nullification (Special Population)

Non-binary and nullification gender-affirming procedures are individually customized operations that may combine, modify or differ altogether from standard masculinizing or feminizing surgery. For binary frameworks, see Feminizing and Masculinizing procedures.

Defining the Population and Surgical Landscape​

Nonbinary people were 672 of 2,176 participants (30.9%) in a U.S. primary-care cohort surveyed in 2019–2021.1 In a single-institution chest-surgery series, 13% of all patients were nonbinary, and in another cohort, nonbinary patients accounted for 30.8% of all gender-affirming mastectomies.23

The distinguishing principle is that non-binary patients may desire selective elements of masculinization or feminization, or neither, rather than a complete binary transition. Surgical goals are highly individualized and may include removing gendered features without replacing them, combining features from both binary paradigms, or creating an anatomy that is intentionally ambiguous or neutral.45

Non-Binary Chest Surgery​

Chest surgery is the most commonly performed procedure for nonbinary AFAB individuals, with 90.7% of nonbinary AFAB patients who had undergone any GAS having had chest surgery.1

Unique Considerations for Nonbinary Patients​

  • Aesthetic goals. These may differ from those of transmasculine patients. Some nonbinary patients desire a flat chest identical to a masculine result; others prefer breast reduction to a smaller, more androgynous chest rather than complete mastectomy. A 755-patient NSQIP analysis of transmasculine chest surgery reported 30-day complication rates of 4.7% after mastectomy and 3.7% after reduction.6
  • Nipple preferences vary. In one series, 72% of nonbinary patients underwent double incision with nipple grafts, and 19% chose double incision without nipple grafts.2 In a separate cohort, double incision without nipple grafts was more common in nonbinary than transmasculine patients (18% vs 2.7%; P < .001), reflecting diverse aesthetic goals.7
  • Hormone therapy. SOC8 recommends considering gender-affirming surgery without hormones when they are unnecessary for the desired result (Statement 8.3); chest surgery does not require prior hormones.8 For eligible transgender and gender diverse adults seeking gonadectomy, SOC8 suggests considering surgery after at least six months of tolerated hormone therapy, unless hormone therapy is not clinically indicated or is inconsistent with the person's goals (Statement 13.5).8 For genital procedures, it suggests stability on the current regimen, which may include hormones but need not when they are undesired or contraindicated (Statement 13.6).8 A separate prospective study of adolescents and young adults found improved chest dysphoria after surgery, but was observational and does not establish eligibility for every age group.9
  • Breast reduction as gender-affirming surgery. A NSQIP analysis included 1,222 reductions across cisgender, transgender and nonbinary adults; 73 patients (6% of the entire cohort) were nonbinary. The nonbinary subgroup had a 1.4% 30-day complication rate. Adjusted comparisons were not statistically significant.10
  • Outcomes. Among 33 of 58 nonbinary chest-surgery patients who completed a postoperative questionnaire, comfort with physical appearance scored 4.97/5 with clothes and 4.69/5 without clothes, with improved comfort in exercise (4.07/5) and sex life (4.02/5).2
  • Timeline differences. One 208-patient mastectomy cohort, including 64 nonbinary patients, found group differences in presentation age and treatment timing. The timing associations are specific to this institutional cohort and do not define a universal developmental trajectory.3

Minimal-Depth Vulvoplasty (Shallow-Depth Vaginoplasty)​

Vulvoplasty, the creation of external female genitalia without a vaginal canal, is an option for nonbinary AMAB patients and transfeminine patients who do not desire vaginal penetration or wish to avoid lifelong dilation. Later canal creation may be more difficult if skin that could have lined the canal was discarded during vulvoplasty.11

Prevalence and Motivations​

  • In a single-center SDV cohort (35 of 110 primary feminizing genital surgeries, 32%), 29 of 35 SDV patients completed a questionnaire; all but one respondent was age ≥ 40, had exclusively feminine-identifying sexual partners, and / or strongly disliked lifelong dilation and douching.12
  • In a Dutch series, 59% chose vulvoplasty because they did not wish for neovaginal penetration and 24% because of medical contraindications to full-depth vaginoplasty.13 In a 2026 Delphi panel of 27 specialist urologists, prior pelvic surgery or radiotherapy and Charlson Comorbidity Index ≥3 were considered relative contraindications to vaginoplasty, but not vulvoplasty.14
  • In a Danish cross-sectional study, 35 of 134 complete AMAB TGD survey respondents (26.1%) preferred vulvoplasty; among those 35, 71% cited perceived lower risk, 54% no desire to dilate, and 48% no need for a vagina.15

Surgical Technique​

The operation includes orchiectomy, penectomy, creation of a sensate clitoris from the glans, construction of labia majora and minora, and meatoplasty for a downward-directed urine stream. A "dimpled" introitus may be created for aesthetic purposes without a functional vaginal canal.121316

Outcomes​

  • Of 29 respondents among 35 SDV patients, 86% would choose SDV again; 14% preferred full depth, with almost all in that subgroup describing new masculine-identifying partners. This is a respondent-based preference estimate.12
  • Satisfaction averaged 8.2/10 among 12 respondents in the 17-patient Dutch cohort.13
  • In a 2026 cross-sectional GENDER-Q survey, 295/765 patients responded (103 vulvoplasty, 192 vaginoplasty; 80% at least one year postoperative), and sexual-well-being scores did not differ statistically by procedure type.17
  • In the same 35-patient SDV cohort, 27% required additional surgery for complications; 82% of these complications were related to urinary spraying.12
  • Postoperative complications were generally minor and treatable (65% uncomplicated course in the Dutch series); meatal stenosis was the most significant complication.13

Implications of Omitting a Vaginal Canal​

There is no constructed canal to dilate, douche or develop canal stenosis. Meatal problems, urinary spraying and other external wound complications can still occur. Patients often choose vulvoplasty to reduce operative or aftercare burden; these small selected series do not establish a universal reduction in overall complications compared with full-depth surgery.1218

Genital Nullification (Removal of Genitalia With Perineal Urethrostomy)​

Genital nullification customizes removal and reshaping of genital structures to a patient's desired perineal appearance and urinary function. The structures to remove or preserve, urethral outlet, sensation and gonadal plan require explicit discussion. In one published AMAB approach, the surgeon decides whether to preserve the penile neurovascular bundle for sensation and whether to bury or expose the glans; incompletely de-epithelialized buried tissue can cause infection, while exposed tissue can cause irritation.19

Ascha et al. described 16 patients across three types of customized genital procedures, including genital removal with perineal urethrostomy. Unlike vulvoplasty, the intended result does not necessarily include a vulva. Long-term urinary, sexual, sensory and patient-reported outcomes for individual variants remain sparsely documented.4

Phallus-Preserving Vaginoplasty​

This procedure creates a neovaginal canal while retaining the native penis, with the goal of retaining penile function alongside receptive vaginal intercourse. It is primarily sought by nonbinary AMAB patients or those who identify outside the gender binary.

Technique​

  • Gonadal preservation or orchiectomy is decided separately according to patient goals; retaining the penis does not require removal of the testes.8
  • A neovaginal canal is created posterior to the urethra using peritoneal flaps, skin grafts, or other tissue sources.
  • Retaining the penis removes penile skin as a canal-lining option. A 2025 technical perspective describes peritoneal or graft lining and identifies urethral or rectal injury, fistula and cavernosal-nerve injury as operative risks.420

Considerations​

  • Requires lifelong dilation similar to standard vaginoplasty.
  • Discuss potential changes in erections, ejaculation and sensation.
  • Limited published outcome data; one of the procedure categories in Ascha et al.’s 16-patient mixed series.4
  • Discuss fertility preservation before any gonadectomy; retaining gonads does not guarantee fertility.8

Vagina-Preserving Phalloplasty: Shaft-Only Option​

Shaft-only phalloplasty can create a neophallus while retaining the native vaginal canal and omitting urethral lengthening.

Technique​

  • A neophallus is constructed using standard flap techniques (RFFF, ALT, etc.) without urethral lengthening.
  • The vaginal canal is preserved; vaginectomy is not performed.
  • Scrotoplasty may or may not be performed (vulvoscrotoplasty).
  • The clitoris may be buried at the base of the phallus or preserved externally.
  • A Y-to-V advancement technique can address clitoral-hood redundancy and improve aesthetics.2122

Outcomes​

  • In a 4-patient series from Oregon Health & Science University, the technique and surgical outcomes of four patients were reported. Long-term outcome data have not been published.21
  • Omitting urethral lengthening avoids creating the additional neourethra and its anastomoses. It does not eliminate all urinary or flap-related complications; published evidence for these customized variants remains limited.2122 If urethral lengthening is planned while preserving the vagina, a systematic review of case series reported more urethral complications with vaginal preservation in metoidioplasty and phalloplasty; all included studies had high risk of bias.23
  • Standing micturition is not possible without urethral lengthening; patients void in a seated position through the native urethra.
  • Retaining a uterus preserves the potential to carry a pregnancy; after hysterectomy, retained ovaries may allow oocyte retrieval for assisted reproduction with pregnancy carried by another person. Discuss fertility preservation before gonadectomy; shaft-only phalloplasty may be accompanied by hysterectomy.162124

Isolated Gonadectomy as Non-Binary Procedure​

Orchiectomy (AMAB) or oophorectomy (AFAB) may be performed as standalone procedures for nonbinary patients whose goals include reducing gonadal sex-hormone production without additional genital reconstruction.

  • Simple orchiectomy removes the main source of testicular testosterone; adrenal androgen production remains. Medication needs should be reassessed. It can serve as a bridge to future vaginoplasty or as a definitive standalone procedure.25
  • A two-center retrospective orchiectomy series of 119 patients (eight nonbinary, two agender) had a median 2.3-year clinical follow-up; 102/119 (86%) had an uncomplicated postoperative course, with hemorrhage in 5/119 and abscess in 7/119.26
  • When orchiectomy is performed as a standalone procedure (not as a bridge), scrotal skin may be removed. When orchiectomy is a bridge to future penile-inversion vaginoplasty, plan scrotal-skin preservation with the future reconstructive surgeon. In a 235-patient prospective cohort, prior orchiectomy was associated with threefold greater odds of requiring extragenital skin grafts for penile-inversion canal construction.27
  • Bilateral gonadectomy requires a long-term endocrine and bone-health plan. Adequate sex-steroid therapy is generally important to avoid prolonged hypogonadism; the regimen depends on age, goals, contraindications and ongoing assessment.168

Eligibility, Insurance, and Access Barriers​

WPATH SOC8 includes nonbinary and gender-diverse patients and recommends consultation with a comprehensive multidisciplinary transgender-health team when eligible patients request individually customized surgery (Statement 13.8).8 For adults who meet the criteria, SOC8 recommends one opinion from a competent professional when an opinion or documentation is required; this is not necessarily a mental-health-only assessment.28298

Published insurance studies describe barriers at the time their policies were sampled:

  • Insurance concordance with WPATH SOC 8 remains incomplete. Most preauthorization policies in one national review required at least 12 months of hormone therapy before surgery, a criterion that may be inappropriate for nonbinary patients who do not desire hormonal treatment.3031
  • Reversal and revisionary procedures are covered by less than 25% of insurance policies.30
  • Facial GAS procedures with "cosmetic overlap" are frequently excluded.30
  • Individually customized procedures (phallus-preserving vaginoplasty, vagina-preserving phalloplasty, genital nullification) often lack specific CPT codes and may face coverage denials due to their novelty and lack of established medical-necessity criteria.4
  • A 2022 Center for American Progress survey, cited in a JAMA Health Forum viewpoint, found that 28% of transgender or nonbinary respondents to the hormone-therapy insurance item reported a coverage denial in the preceding year; 22% of transgender or nonbinary respondents to the surgery item reported a gender-affirming-surgery coverage denial.3233

Summary of Non-Binary & Nullification Procedures​

ProcedureTarget PopulationKey FeatureSatisfactionEvidence Base
Chest surgery (mastectomy ± nipple removal)Nonbinary AFABFlat or androgynous chest; no HRT requiredQoL improvement 4.88/5 among 33 of 58 questionnaire respondentsModerate (multiple series)12
Breast reduction (non-mastectomy)Nonbinary AFABSmaller, androgynous chestNot reported in the cited NSQIP studyRetrospective 30-day complications data610
Minimal-depth vulvoplastyNonbinary / transfeminine AMABExternal vulva, no vaginal canal, no dilation86% of 29 SDV survey respondents would choose it again; 93% of completed-surgery patients in a separate vulvoplasty series were satisfied with surgery and their decisionLimited: small heterogeneous studies12131518; a 2024 systematic review of five low-quality studies could not draw reliable conclusions34
Genital nullification / perineal urethrostomyIndividually selected anatomy and goalsCustomized perineum and urinary outletLimited dataSubset of 16 mixed customized procedures4
Phallus-preserving vaginoplastyNonbinary AMABRetains penis + creates vaginal canalLimited dataSubset of 16 mixed customized procedures4
Vagina-preserving phalloplastyNonbinary AFABCreates phallus + retains vaginal canalLimited dataVery limited (n = 4)2122
Isolated orchiectomyNonbinary AMABReduces testicular testosterone; standalone or bridge—Technique review and vaginoplasty-planning cohort2527
Isolated oophorectomy / hysterectomyNonbinary AFABHysterectomy stops uterine bleeding; ovarian removal is a separate hormonal decisionThe 4.4–4.6/5 reproductive-region mean is not procedure-specificPletta et al. report individual procedure scores in Supplement 1116

Key Takeaways for Clinical Practice​

The evidence base for most non-binary-specific procedures remains limited to small case series, and applicability of standardized measures to each customized procedure remains uncertain.4 The 2025 GenderCOS project established 11 core outcomes for feminizing genital surgery, including seven applicable across those operations and four for canal construction.35 Preoperative counseling should address the irreversibility of certain procedures (particularly genital nullification), fertility implications, long-term endocrine needs after bilateral gonadectomy, and the limited long-term outcome data available for novel procedures.

Footnotes​

  1. Pletta DR, Quint M, Radix AE, et al. "Gender-Affirming Surgical History, Satisfaction, and Unmet Needs Among Transgender Adults." JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494 ↩ ↩2 ↩3 ↩4

  2. Esmonde N, Heston A, Jedrzejewski B, et al. "What Is 'Nonbinary' and What Do I Need to Know? A Primer for Surgeons Providing Chest Surgery for Transgender Patients." Aesthet Surg J. 2019;39(5):NP106–NP112. doi:10.1093/asj/sjy166 ↩ ↩2 ↩3 ↩4

  3. Skorochod R, Rysin R, Wolf Y. "Gender Affirming Surgery in Non-Binary Patients: The Importance of Patient-Centered Care." J Plast Reconstr Aesthet Surg. 2023;84:176–181. doi:10.1016/j.bjps.2023.05.050 ↩ ↩2

  4. Ascha M, Rigsby S, Shoham M, et al. "Individually Customized Gender Affirming Genital Procedures: Techniques and Considerations." J Sex Med. 2024;21(9):827–834. doi:10.1093/jsxmed/qdae075 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  5. Bouman WP, Thorne N, Arcelus J. "Nonbinary Gender Identities." Best Pract Res Clin Obstet Gynaecol. 2023;88:102338. doi:10.1016/j.bpobgyn.2023.102338 ↩

  6. Cuccolo NG, Kang CO, Boskey ER, et al. "Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes." Aesthetic Plast Surg. 2019;43(6):1575–1585. doi:10.1007/s00266-019-01479-2 ↩ ↩2

  7. Schafer RE, Fodor R, Marlar R, et al. "Nonbinary and Transgender Male Patient Preferences for Gender-Affirming Top Surgery." Ann Plast Surg. 2024;93(5):e36–e44. doi:10.1097/SAP.0000000000004052 ↩

  8. Coleman E, Radix AE, Bouman WP, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8." Int J Transgend Health. 2022;23(Suppl 1):S1–S259. doi:10.1080/26895269.2022.2100644 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  9. Ascha M, Sasson DC, Sood R, et al. "Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults." JAMA Pediatr. 2022;176(11):1115–1122. doi:10.1001/jamapediatrics.2022.3424 ↩

  10. Miller AS, Escobar-Domingo MJ, Lee BT, et al. "Breast Reduction Epidemiology and Complications in Nonbinary, Transgender, and Cisgender Adults." J Surg Res. 2024;302:437–445. doi:10.1016/j.jss.2024.07.079 ↩ ↩2

  11. Ramirez ML, Wangamez M, Huynh R, Butler C. "Surgical considerations for genital reconstruction options for gender-diverse individuals assigned male at birth." Plast Aesthet Res. 2025;12:16. doi:10.20517/2347-9264.2025.10 ↩

  12. Stelmar J, Smith SM, Lee G, Zaliznyak M, Garcia MM. "Shallow-Depth Vaginoplasty: Preoperative Goals, Postoperative Satisfaction, and Why Shallow-Depth Vaginoplasty Should Be Offered as a Standard Feminizing Genital Gender-Affirming Surgery Option." J Sex Med. 2023;20(11):1333–1343. doi:10.1093/jsxmed/qdad111 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  13. van der Sluis WB, Steensma TD, Timmermans FW, et al. "Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes." J Sex Med. 2020;17(8):1566–1573. doi:10.1016/j.jsxm.2020.04.007 ↩ ↩2 ↩3 ↩4 ↩5

  14. Pezzoli M, Lo Re M, Pizziconi V, et al. "International Delphi consensus on feminising genital surgery in assigned-male-at-birth individuals." BJU Int. Published online 2026. doi:10.1111/bju.70196 ↩

  15. Aaen EK, Kesmodel US, Pop ML, Højgaard AD. "Requests for Vulvoplasty as Gender-Affirming Surgery: A Cross-Sectional Study in Denmark." J Sex Med. 2024;21(3):262–269. doi:10.1093/jsxmed/qdae003 ↩ ↩2

  16. Jackson Q, Yedlinsky NT, Gray M. "Lifelong Care of Patients After Gender-Affirming Surgery." Am Fam Physician. 2024;109(6):560–565. ↩ ↩2 ↩3 ↩4

  17. Harrison HV, Dy GW, Dugi D, et al. "Sexual satisfaction, sexual function, and orgasm after gender-affirming vaginoplasty and vulvoplasty." BJU Int. Published online 2026. doi:10.1111/bju.70391 ↩

  18. Jiang D, Witten J, Berli J, Dugi D. "Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women." J Sex Med. 2018;15(6):902–906. doi:10.1016/j.jsxm.2018.03.085 ↩ ↩2

  19. Ramirez ML, Wangamez M, Huynh R, Butler C. "Surgical considerations for genital reconstruction options for gender-diverse individuals assigned male at birth." Plast Aesthet Res. 2025;12:16. doi:10.20517/2347-9264.2025.10 ↩

  20. Ramirez ML, Wangamez M, Huynh R, Butler C. "Surgical considerations for genital reconstruction options for gender-diverse individuals assigned male at birth." Plast Aesthet Res. 2025;12:16. doi:10.20517/2347-9264.2025.10 ↩

  21. Chen W, Cylinder I, Najafian A, Dugi DD, Berli JU. "An Option for Shaft-Only Gender-Affirming Phalloplasty: Vaginal Preservation and Vulvoscrotoplasty. A Technical Description." Plast Reconstr Surg. 2021;147(2):480–483. doi:10.1097/PRS.0000000000007579 ↩ ↩2 ↩3 ↩4 ↩5

  22. Moorefield AK, Veith JP, Mills A, et al. "Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty." Plast Reconstr Surg. 2024;154(1):186e–189e. doi:10.1097/PRS.0000000000010932 ↩ ↩2 ↩3

  23. Claeys W, Wolff DT, Zachou A, Hoebeke P, Lumen N, Spinoit AF. "Variant genital gender-affirming surgery: a systematic review." BJU Int. 2025;135(1):40–53. doi:10.1111/bju.16513 ↩

  24. Greenwald P, Dubois B, Lekovich J, Pang JH, Safer J. "Successful In Vitro Fertilization in a Cisgender Female Carrier Using Oocytes Retrieved From a Transgender Man Maintained on Testosterone." AACE Clin Case Rep. 2022;8(1):19–21. doi:10.1016/j.aace.2021.06.007 ↩

  25. Hehemann MC, Walsh TJ. "Orchiectomy as Bridge or Alternative to Vaginoplasty." Urol Clin North Am. 2019;46(4):505–510. doi:10.1016/j.ucl.2019.07.005 ↩ ↩2

  26. van der Sluis WB, Smit JM, Schäfer T, Bouman MB. "Gender-affirming orchiectomy in transgender and non-binary individuals: A large cohort study with middle- to long-term follow-up." Int J Transgend Health. 2025;26(2):459–463. doi:10.1080/26895269.2024.2396939 ↩

  27. Sineath RC, Butler C, Dy GW, Dugi D. "Genital Hypoplasia in Gender-Affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning." J Urol. 2022;208(6):1276–1287. doi:10.1097/JU.0000000000002900 ↩ ↩2

  28. Lai A, Johnson R. "World Professional Association for Transgender Health Guidelines: 2022 Surgical Treatment Updates in the Standards of Care for Transgender and Gender Diverse People." Neurourol Urodyn. 2023;42(5):900–902. doi:10.1002/nau.25099 ↩

  29. Amengual T, Kunstman K, Lloyd RB, Janssen A, Wescott AB. "Readiness Assessments for Gender-Affirming Surgical Treatments: A Systematic Scoping Review of Historical Practices and Changing Ethical Considerations." Front Psychiatry. 2022;13:1006024. doi:10.3389/fpsyt.2022.1006024 ↩

  30. Diaddigo SE, LaValley MN, Asadourian PA, et al. "Concordance of National Insurance Criteria With WPATH Standards of Care for Gender-Affirming Surgery." Plast Reconstr Surg. 2024;154(3):685–693. doi:10.1097/PRS.0000000000011144 ↩ ↩2 ↩3

  31. Ngaage LM, Knighton BJ, McGlone KL, et al. "Health Insurance Coverage of Gender-Affirming Top Surgery in the United States." Plast Reconstr Surg. 2019;144(4):824–833. doi:10.1097/PRS.0000000000006012 ↩

  32. Sandhu S, Liu M, Keuroghlian AS. "Strategies for Insurers to Promote Health Among Sexual and Gender Minority People." JAMA Health Forum. 2024;5(4):e240439. doi:10.1001/jamahealthforum.2024.0439 ↩

  33. Medina C, Mahowald L. "Discrimination and Barriers to Well-Being: The State of the LGBTQI+ Community in 2022." Center for American Progress. 2023. https://www.americanprogress.org/article/discrimination-and-barriers-to-well-being-the-state-of-the-lgbtqi-community-in-2022/ ↩

  34. Aaen EK, Højgaard AD, Pop ML, Kesmodel US. "Outcomes and Experience of Gender-Confirming Vulvoplasty: A Systematic Review." Transgend Health. Published online September 30, 2024. doi:10.1089/trgh.2023.0231 ↩

  35. Vallinga MS, Roijer PJ, Pidgeon TE, et al. "The Core Outcome Set for Studies on Feminizing Genital Gender-Affirming Surgery: Findings From the GenderCOS Project." EClinicalMedicine. 2025;85:103323. doi:10.1016/j.eclinm.2025.103323 ↩