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Non-Binary & Nullification Procedures

Non-binary and nullification gender-affirming procedures represent a rapidly evolving area of surgical practice that moves beyond the traditional binary framework of masculinizing or feminizing surgery, offering individually customized approaches that may combine, modify, or altogether differ from standard binary procedures. For binary frameworks, see Feminizing and Masculinizing procedures.

Defining the Population and Surgical Landscape​

Non-binary individuals constitute a substantial and growing proportion of patients seeking gender-affirming surgery. In a large U.S. primary-care cohort, nonbinary AFAB patients comprised 33.9% and nonbinary AMAB patients 17.8% of those who had undergone at least one GAS procedure.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 key 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 may differ from transmasculine patients. Some nonbinary patients desire a flat chest identical to a masculine result; others may prefer breast reduction to a smaller, more androgynous chest rather than complete mastectomy. Both mastectomy and reduction mammaplasty are safe options with comparable complication rates (4.7% vs 3.7%).6
  • Nipple preferences vary — in one series, 72% of nonbinary patients underwent double incision with nipple grafts, but notably 19% chose double incision without nipple grafts, a significantly higher rate of nipple removal than in transmasculine patients, reflecting diverse aesthetic goals.2
  • No hormone therapy is required before chest surgery per WPATH SOC 8, which is particularly relevant for nonbinary patients who may not desire testosterone or any hormonal intervention.7
  • Breast reduction as gender-affirming surgery — a NSQIP analysis of 1,222 patients found that 6% of gender-affirming breast reductions were performed in nonbinary patients, with an overall complication rate of only 1.4% (lower than both cisgender and transgender cohorts, though not statistically significant after adjustment). No severe systemic complications occurred in any group.8
  • Outcomes — nonbinary patients reported excellent quality-of-life improvements after chest surgery: 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 — nonbinary patients present significantly younger, initiate HRT earlier, and have a shorter interval from first dysphoria to surgery compared with binary transmasculine patients, suggesting a distinct developmental trajectory that warrants tailored counseling.3

Minimal-Depth Vulvoplasty (Shallow-Depth Vaginoplasty)​

Vulvoplasty — creation of external female genitalia without a vaginal canal — is an important option for nonbinary AMAB patients and transfeminine patients who do not desire vaginal penetration or wish to avoid lifelong dilation.

Prevalence and Motivations​

  • In the largest SDV cohort (35 of 110 primary feminizing genital surgeries, 32%), the most common patient characteristics were age ≥ 40, exclusively feminine-identifying sexual partners, and / or strong aversion to lifelong dilation and douching.9
  • In a Dutch series, the most common motivation was no wish for neovaginal penetration (59%), followed by medical contraindications to full-depth vaginoplasty (24%).10
  • In a Danish cross-sectional study, 26.1% of AMAB TGD respondents preferred vulvoplasty over vaginoplasty, citing lower risk (71%), no desire to dilate (54%), and no need for a vagina (48%).11

Surgical Technique​

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.91012

Outcomes​

  • 86% would choose SDV again if given the choice; 14% who would choose FDV cited new interest in receptive intercourse after finding masculine-identifying partners postoperatively.9
  • Satisfaction rated 8.2/10 in the Dutch cohort, with all patients reporting satisfaction.10
  • Complications occurred in 27% of SDV patients, with urinary spraying accounting for 82% of complications requiring additional surgery.9
  • Postoperative complications were generally minor and treatable (65% uncomplicated course in the Dutch series); meatal stenosis was the most significant complication.10

Advantages Over Full-Depth Vaginoplasty​

  • No lifelong dilation requirement.
  • Shorter operative time and recovery.
  • Lower complication rate.
  • No risk of vaginal stenosis.
  • No douching required.913

Genital Nullification (Removal of Genitalia With Perineal Urethrostomy)​

Genital nullification is the most radical individualized procedure, involving removal of all external genitalia and creation of a perineal urethrostomy for voiding, resulting in a smooth, featureless perineum. This is the least studied of all gender-affirming genital procedures.

In the only published series describing this procedure in the gender-affirming context, Ascha et al. (2024) reported on 16 patients who underwent individually customized genital procedures, including removal of genitalia with creation of perineal urethrostomy.4 The procedure involves:

  • Complete removal of the penis, testes, and scrotal tissue (in AMAB patients) or clitoris, labia, and vaginal tissue (in AFAB patients).
  • Creation of a perineal urethrostomy for seated voiding.
  • Closure of the perineum to create a smooth contour.

This procedure is distinct from vulvoplasty in that no vulvar structures are created — the goal is a neutral, non-gendered perineal appearance. Published complication data and long-term outcomes remain extremely limited, and the procedure should be considered investigational with respect to outcome evidence.4

Phallus-Preserving Vaginoplasty​

This procedure creates a neovaginal canal while retaining the native penis, allowing patients to maintain penile erectile and ejaculatory function alongside receptive vaginal intercourse. It is primarily sought by nonbinary AMAB patients or those who identify outside the gender binary.

Technique​

  • Orchiectomy is performed, but the penis is preserved intact.
  • A neovaginal canal is created posterior to the urethra using peritoneal flaps, skin grafts, or other tissue sources.
  • The procedure is technically challenging because the standard penile-inversion technique cannot be used (penile skin is not available for vaginal lining).4

Considerations​

  • Requires lifelong dilation similar to standard vaginoplasty.
  • Preserves erectile function and ejaculatory capacity.
  • Limited published outcome data; described in the 16-patient series by Ascha et al.4
  • Fertility may be partially preserved if orchiectomy is not performed (atypical).

Vagina-Preserving Phalloplasty (Shaft-Only Phalloplasty)​

This procedure creates a neophallus while retaining the native vaginal canal, allowing patients to maintain receptive vaginal function alongside a masculine external genital appearance.

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.1415

Outcomes​

  • In a 4-patient series from Oregon Health & Science University, all patients underwent successful shaft-only phalloplasty with vaginal preservation. Detailed long-term outcome data are pending.14
  • By avoiding urethral lengthening, this approach eliminates the most common source of phalloplasty complications (urethrocutaneous fistula and stricture, which occur in up to 48.9% of standard phalloplasty).15
  • Standing micturition is not possible without urethral lengthening; patients void in a seated position through the native urethra.
  • The procedure preserves fertility potential if the uterus and ovaries are retained.1214

Isolated Gonadectomy as Non-Binary Procedure​

Orchiectomy (AMAB) or oophorectomy (AFAB) may be performed as standalone procedures for nonbinary patients who desire elimination of endogenous sex-hormone production without full genital reconstruction.

  • Simple orchiectomy is a low-risk, minimally invasive procedure that eliminates circulating testosterone, allowing reduced hormonal supplementation. It can serve as a bridge to future vaginoplasty or as a definitive standalone procedure.16
  • When orchiectomy is performed as a standalone procedure (not as a bridge), scrotal skin may be removed. When performed as a bridge to future vaginoplasty, scrotal skin should be preserved for use in neovaginal construction. Prior orchiectomy increases the odds of needing extragenital skin grafts during subsequent vaginoplasty by 3-fold.17
  • Lifelong hormone replacement (estradiol or testosterone at physiologic doses) is required after gonadectomy to prevent osteoporosis and other sequelae of hypogonadism.12

Eligibility, Insurance, and Access Barriers​

WPATH SOC 8 broadened language to explicitly include nonbinary and gender-diverse individuals, emphasizing that surgical interventions should be individually tailored rather than limited to binary paradigms. The number of required mental health referral letters was reduced to one for most procedures.1819

However, significant barriers persist:

  • Insurance concordance with WPATH SOC 8 remains incomplete. Many policies still require 12 months of hormone therapy before surgery — a criterion that may be inappropriate for nonbinary patients who do not desire hormonal treatment.2021
  • Reversal and revisionary procedures are covered by less than 25% of insurance policies.20
  • Facial GAS procedures with "cosmetic overlap" are frequently excluded.20
  • 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 national survey found denial rates of 28% for hormone therapy and 22% for GAS among transgender people seeking coverage.22

Summary of Non-Binary & Nullification Procedures​

ProcedureTarget PopulationKey FeatureSatisfactionEvidence Base
Chest surgery (mastectomy ± nipple removal)Nonbinary AFABFlat or androgynous chest; no HRT required4.88/5 QoLModerate (multiple series)12
Breast reduction (non-mastectomy)Nonbinary AFABSmaller, androgynous chestHighModerate (NSQIP data)68
Minimal-depth vulvoplastyNonbinary / transfeminine AMABExternal vulva, no vaginal canal, no dilation86–93%Moderate91011
Genital nullification (perineal urethrostomy)Any assigned sexSmooth perineum, no genital structuresLimited dataVery limited (n = 16)4
Phallus-preserving vaginoplastyNonbinary AMABRetains penis + creates vaginal canalLimited dataVery limited (n = 16)4
Vagina-preserving phalloplastyNonbinary AFABCreates phallus + retains vaginal canalLimited dataVery limited (n = 4)1415
Isolated orchiectomyNonbinary AMABEliminates testosterone; standalone or bridgeHighModerate1617
Isolated oophorectomy / hysterectomyNonbinary AFABEliminates estrogen / menses; standalone4.4–4.6/5Moderate12

Key Takeaways for Clinical Practice​

The overarching principle for non-binary and nullification procedures is radical individualization. Surgeons must move beyond a menu of binary options and engage in detailed, patient-centered goal-setting conversations. The evidence base for most non-binary-specific procedures remains limited to small case series, and standardized outcome measures for this population are lacking.423 Preoperative counseling should address the irreversibility of certain procedures (particularly genital nullification), fertility implications, lifelong hormone replacement needs after 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

  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 ↩9

  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. 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 ↩

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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 ↩

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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 ↩

  19. 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 ↩

  20. 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

  21. 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 ↩

  22. 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 ↩

  23. 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 ↩