Non-Binary / Nullification Gender-Affirming Surgery
Variant genital gender-affirming surgery (variant GGAS) comprises genital procedures that fall outside the binary surgical paradigm and are sought by some non-binary and gender-diverse patients: combinations of native and reconstructed anatomy, or removal of all external genitalia. Non-GU non-binary content (chest preferences, voice, FFS) is in the Non-Binary / Nullification clinical-conditions article. WPATH SOC 8 (2022) is the reference framework for eligibility.
A 2025 BJU Int systematic review by Claeys et al. identified 23 case series of variant GGAS (17 masculinizing, 6 feminizing) in three principal categories: genital nullification, phallus-preserving vaginoplasty, and vagina-preserving phalloplasty or metoidioplasty. Ascha et al. 2024 (J Sex Med, n = 16) describe operative techniques for all three categories.[3] In one single-surgeon mastectomy cohort (n = 208), 30.8% of patients identified as non-binary.[5] In a primary-care cohort of 2,176 transgender and gender-diverse adults, 17.8% of non-binary AMAB participants (24/135) and 33.9% of non-binary AFAB participants (182/537) reported any gender-affirming surgery; among those operated, genital surgery was reported by 11/24 and 1/182, respectively (Pletta 2025 JAMA Netw Open).[6] Non-binary and binary transgender participants did not differ in desire for GAS (p = 0.411; Kennis 2022).[3][4][5][6][7] Insurance criteria are often written around binary endpoints, and most variant GGAS evidence is limited to case series.
Decision Framework
Identify the Patient's Genital Goals
Unlike binary GAS, non-binary procedures require an explicitly individualized consultation that does not assume a binary endpoint:[3][4]
- Which natal genital structures cause dysphoria? (some / all / none?)
- Which natal genital structures are desired to be retained? (phallus? vagina? both? neither?)
- Is receptive vaginal intercourse desired?
- Is penetrative phallic intercourse desired?
- Is standing micturition desired?
- What is the tolerance for surgical complexity and complications?
Match Goals to Procedure
| Patient Goal | Genital Nullification | Phallus-Preserving Vaginoplasty | Vagina-Preserving Phalloplasty / Metoidioplasty | Standalone Gonadectomy |
|---|---|---|---|---|
| Remove all external genitalia | ✓✓✓ | ✗ | ✗ | ✗ |
| Retain phallus + add vagina | ✗ | ✓✓✓ | ✗ | ✗ |
| Add phallus + retain vagina | ✗ | ✗ | ✓✓✓ | ✗ |
| Remove gonadal hormone production[14] | If gonadectomy included | Optional | Optional | Only after orchiectomy or BSO; hysterectomy alone retains ovarian hormone production |
| Receptive vaginal intercourse | ✗ | ✓✓✓ | ✓✓✓ | n/a |
| Penetrative phallic intercourse | ✗ | ✓ (native phallus) | Phalloplasty: discuss erectile-device options[16]; metoidioplasty: 10 of 11 studies reported penetrative ability in 0–24% of respondents, with one 70% outlier[15] | n/a |
| Procedural scope | Genital excision and perineal urethrostomy; gonadectomy may be included | Vaginal canal construction while preserving the phallus | Phallic reconstruction; shaft-only surgery can omit urethral lengthening | Isolated gonadectomy |
| No lifelong dilation commitment | ✓✓✓ | ✗ (required) | ✓✓✓ | ✓✓✓ |
| Bridge / option to future binary procedure | ✗ (irreversible) | ✗ (donor tissue committed) | Variable | ✓ (preserve scrotal skin) |
Anchors: Ascha 2024 individually-customized procedures (n = 16); Claeys 2025 BJU Int SR (23 case series); Saltman 2023 NSQIP standalone orchiectomy (n = 246; 3.7% complications, not different from cisgender orchiectomy for nononcologic indications); Chen et al. 2021 OHSU shaft-only with vulvoscrotoplasty (n = 4); Moorefield 2024 Y-to-V advancement variant.[3][4][2][8][9]
Urethral Lengthening Decision in Vagina-Preserving Procedures
| Clinical Scenario | Option to discuss | Other option | Counseling caution |
|---|---|---|---|
| Vagina preserved + standing micturition is a priority | Discuss urethral lengthening as an option after counseling that case series report more urethral complications with vaginal preservation than with concurrent vaginectomy.[4] | Vagina-preserving shaft-only surgery without urethral lengthening retains the native urinary outlet for seated voiding; the described perineal-urethrostomy variant includes vaginectomy.[16] | Avoid presenting urethral lengthening as routine or risk-free in vagina-preserving anatomy. |
| Vagina preserved + standing micturition is NOT a priority | No established first-line procedure: vagina-preserving shaft-only phalloplasty without urethral lengthening (Chen-Berli 2021 vulvoscrotoplasty; Moorefield 2024 Y-to-V) retains the native urinary conduit for seated voiding in the described OHSU variant; perineal urethrostomy is a separate shaft-only option paired with vaginectomy. Omitting urethral lengthening also omits a principal source of complications in variant masculinizing series.[4][8][9][17] | Vagina-preserving metoidioplasty without UL | UL "just in case", because urethral complications are higher when the vagina is preserved (Claeys 2025 SR) |
| Genital nullification in AMAB anatomy | No established first-line package: penectomy, bilateral orchiectomy, scrotectomy and spatulated perineal urethrostomy with seated voiding have been described as an individualized option.[3] | Two-stage approach (gonadectomy first, then nullification) | Nullification in patients without explicit, durable counseling about loss of native genital tissue |
| Genital nullification in AFAB anatomy | No established first-line package: consider hysterectomy, optional BSO, colpectomy/vulvectomy, and perineal urethrostomy according to anatomy and patient goals; decide ovarian preservation separately.[18] | Staged approach (HBSO → vaginectomy → vulvectomy → urethrostomy) | Single-session nullification when patient pathways are unclear |
Counseling Considerations Unique to Non-Binary Patients
| Topic | Counseling Point |
|---|---|
| Irreversibility | Genital nullification permanently removes the excised structures and their associated sensation. Discuss the planned extent of tissue removal and expected changes in sexual function, document explicit and durable consent, and explain that nullification-specific sensory outcomes have not been quantified.[3][4] |
| Fertility and hormones after gonadectomy | Bilateral gonadectomy permanently eliminates fertility from the removed gonads; offer fertility-preservation consultation before surgery. Establish a postoperative sex-hormone and bone-health plan before gonadectomy to avoid prolonged hypogonadism.[1][18] |
| Evidence base | All variant GGAS procedures have high risk of bias in available studies — case series only, no comparative studies, no long-term follow-up (Claeys 2025 SR).[4] |
| Insurance coverage | A review of ten US payer policies obtained in 2020 found that most used binary gendered language; verify current coverage for each proposed component with the patient's plan.[20] |
| Postoperative gynecologic care | After vaginal preservation, preventive screening follows the organs retained; offer STI testing at exposed sites according to sexual history, including vaginal swabs when indicated.[1] |
| Postoperative urologic surveillance | Patients with perineal urethrostomy require urology follow-up for stenosis surveillance — Retrospective series of perineal urethrostomy for stricture (not gender-affirming patients) report re-intervention or recurrent stenosis in 4.9% (5/103, Joshi 2024 Urology), 16% (Klemm 2024 J Urol; 76 patients, median follow-up 55 months) and 18% (Myers 2011 Urology; 40 patients, median 31 months). Klemm reported 84% retreatment-free survival, and 86% (42/49) of Joshi's survey respondents (median 61 months) were satisfied or very satisfied.[10][11][13] |
| Psychosexual adjustment | Discuss sensory goals and planned nerve/glans management; some nullification techniques aim to retain erogenous sensation, but nullification-specific sensory outcomes are unquantified. Offer psychosexual support according to patient needs.[12][19] In a mastectomy cohort, non-binary patients had shorter intervals from first reported dysphoria to hormone therapy and surgery than transmasculine patients.[5] |
Treatment Database
| Procedure | Domain | Best for / indication |
|---|---|---|
| Genital Nullification — AMAB (penectomy + bilateral orchiectomy + scrotectomy + perineal urethrostomy) | Genital Nullification | AMAB nullification creating smooth perineal contour with perineal urethrostomy. |
| Genital Nullification — AFAB (HBSO + colpectomy + vulvectomy + perineal urethrostomy) | Genital Nullification | AFAB nullification combining HBSO, colpectomy, vulvectomy, and perineal urethrostomy. |
| Phallus-Preserving Vaginoplasty (peritoneal / skin / intestinal lining) | Phallus-Preserving | Canal creation while preserving the native penis; uses peritoneal, skin, or intestinal lining. |
| Shaft-Only Phalloplasty with Vaginal Preservation | Vagina-Preserving | Phalloplasty without urethral lengthening for patients prioritising vaginal preservation. |
| Vagina-Preserving Metoidioplasty (no vaginectomy) | Vagina-Preserving | Metoidioplasty for patients prioritising vaginal preservation; spectrum from clitoral release. |
| Standalone Bilateral Orchiectomy (as non-binary procedure) | Standalone Gonadectomy | Stand-alone gonadectomy as non-binary endpoint or bridge to later procedures. |
| Standalone Hysterectomy ± BSO (as non-binary procedure) | Standalone Hysterectomy | Stand-alone hysterectomy for dysphoria reduction without further genital reconstruction. |
| Perineal Urethrostomy (PU) — component of nullification or shaft-only phalloplasty with vaginectomy | Component / PU | Perineal urinary outlet when selected for nullification or phalloplasty with vaginectomy. |
| Shallow-Depth Vulvoplasty (as non-binary option) | Component / Vulvoplasty | Non-binary patients seeking external feminine appearance without canal commitment. |
See Also
- GAS Overview (Special Populations)
- Non-Binary / Nullification (Special Populations)
- Revision & Salvage GAS
- Pharmacology — Gender-Affirming Hormone Therapy
References
1. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560–565. PMID 38905554
2. Saltman AJ, Dorante MI, Jonczyk MM, et al. Outcomes of orchiectomy for gender-affirming surgery: a National Surgical Quality Improvement Program study. Urology. 2023;180:98–104. doi:10.1016/j.urology.2023.07.003
3. 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
4. Claeys W, Wolff DT, Zachou A, et al. Variant genital gender-affirming surgery: a systematic review. BJU Int. 2025;135(1):40–53. doi:10.1111/bju.16513
5. 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
6. 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
7. Kennis M, Duecker F, T'Sjoen G, Sack AT, Dewitte M. Gender-affirming medical-treatment desire and treatment motives in binary and non-binary transgender individuals. J Sex Med. 2022;19(7):1173–1184. doi:10.1016/j.jsxm.2022.03.603
8. 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
9. 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
10. Klemm J, Dahlem R, Schulz RJ, et al. Perineal urethrostomy for complex urethral strictures: long-term patient-reported outcomes from a reconstructive referral center and a scoping literature review. J Urol. 2024;212(5):738–748. doi:10.1097/JU.0000000000004169
11. Joshi EG, VanDyke ME, Langford BT, Franzen BP, Morey AF. Algorithmic midline approach to perineal urethrostomy is associated with long-term success and high patient satisfaction. Urology. 2024;190:133–139. doi:10.1016/j.urology.2024.03.016
12. 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
13. Myers JB, Porten SP, McAninch JW. The outcomes of perineal urethrostomy with preservation of the dorsal urethral plate and urethral blood supply. Urology. 2011;77(5):1223–1227. doi:10.1016/j.urology.2010.10.041
14. Collet S, Gieles NC, Wiepjes CM, et al. "Changes in Serum Testosterone and Adrenal Androgen Levels in Transgender Women With and Without Gonadectomy." J Clin Endocrinol Metab. 2023;108(2):331–338. doi:10.1210/clinem/dgac576
15. Goldstein B, Uloko M, Okamuro K, et al. "Sexual health outcomes following gender affirming metoidioplasty: a systematic review." Sex Med Rev. 2026;14(1):qeaf060. doi:10.1093/sxmrev/qeaf060
16. Practice Committee of the American Society for Reproductive Medicine. "Transgender and gender-diverse care: a committee opinion." Fertil Steril. 2026;126(2):294–311. doi:10.1016/j.fertnstert.2026.05.003
17. Peters BR, Ferrin PC, Berli JU. "Phalloplasty alternatives: shaft-only phalloplasty modifications." Plast Reconstr Surg Glob Open. 2026;14(5):e7627. doi:10.1097/GOX.0000000000007627
18. 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
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. Bond SM, Fouche T, Smith JR, Garza RM. "Review of health insurance policy inclusivity of gender nonconforming and nonbinary individuals seeking gender-affirming health care." Transgend Health. 2022;7(6):484–496. doi:10.1089/trgh.2020.0146