The Spectrum of Options#
The first thing to understand is that surgical options exist on a spectrum, not in binary categories. You're not choosing between "male body" and "female body"—you're choosing which specific changes would reduce your dysphoria and increase your comfort in your own skin. Research increasingly supports this individualized approach: a 2024 study found that people who pursue surgical pathways aligned with their specific goals—rather than a standardized "full transition"—report higher satisfaction and lower regret rates (van de Grift et al., 2022).
For people assigned male at birth, options range from targeted removal procedures to feminizing reconstruction to complete nullification. For people assigned female at birth, options range from removal procedures to masculinizing reconstruction to various combinations. The question isn't "what category do I fit into?" but "what specific changes would help me?"
Nonbinary and gender non-conforming people may pursue any of these options, or combinations that don't fit standard categories—phalloplasty while retaining the vagina, vaginoplasty while retaining the penis, nullification from either starting point. The WPATH Standards of Care Version 8 explicitly recognizes this diversity, noting that gender-affirming care should be "individualized based on the needs of the patient" rather than following a one-size-fits-all pathway (Coleman et al., 2022).
AMAB Bottom Surgery Options#
Orchiectomy and Scrotectomy#
Orchiectomy removes the testicles while leaving other genital structures intact. It's one of the simplest gender-affirming procedures—often outpatient, with recovery measured in days rather than weeks. Removing the testes eliminates the body's main testosterone source, and some people find that it simplifies the medication plan they discuss with their hormone clinician. For many people, it also eliminates a specific source of distress.
What strikes me about the research on standalone orchiectomy is how recently it's been taken seriously as an endpoint rather than a stepping stone. A study from Amsterdam found that 29% of patients pursued orchiectomy as their final genital surgery with no plans for vaginoplasty, while another 39% viewed it as a bridge—giving themselves time to decide about further procedures without the daily reality of testosterone production and tucking (van der Sluis et al., 2025). Both approaches are valid.
Scrotectomy removes the scrotal sac, often combined with orchiectomy. Together they're sometimes called GAOS (gender-affirming orchiectomy and scrotectomy). This creates a smooth perineal area while leaving the penis intact—an option for those whose dysphoria is specifically about testicles and scrotum rather than the penis itself.
Penectomy#
Penectomy removes the penis partially or completely. Total penectomy removes all external and internal penile structures; the urethra is shortened and repositioned for sitting urination. Penectomy is often combined with orchiectomy and scrotectomy as part of nullification, or performed as a stage of vaginoplasty where the penile tissue is repurposed for vaginal construction.
The clinical literature on standalone penectomy for gender affirmation is surprisingly thin—most research focuses on penectomy as a component of other procedures or as cancer treatment (Dy et al., 2021). This gap reflects broader blind spots in how medicine has historically conceptualized gender diversity. For people who want penectomy without vaginoplasty, finding experienced surgeons may require additional research.
Vaginoplasty#
Vaginoplasty creates a vaginal canal and vulva. Several techniques exist: penile inversion (the most common, using penile skin to line the canal), peritoneal flap (using tissue from the abdominal lining, often robotic-assisted), and intestinal methods (using bowel tissue, typically for revision cases or when other tissue is insufficient). The choice of technique affects outcomes including self-lubrication, depth, and complications, though all approaches can produce functional results when performed by experienced surgeons (Manrique et al., 2021).
Vaginoplasty is complex surgery requiring significant recovery time and lifelong vaginal dilation to maintain depth. This maintenance requirement is worth serious consideration: dilation starts at multiple times daily in the early months and typically continues as a permanent part of life, though the frequency decreases over time. For some people, this is a worthwhile trade-off for anatomy that feels right. For others, it's a dealbreaker that points toward different options. Vaginoplasty covers vaginoplasty in comprehensive detail.
Vulvoplasty#
Vulvoplasty (also called zero-depth vaginoplasty) creates external female-appearing genitalia—labia, clitoral hood, clitoris—without a vaginal canal. This is less complex than full vaginoplasty, with faster recovery and no dilation requirement. Outcomes research suggests high satisfaction rates among people who choose this option, particularly those who don't desire penetrative vaginal intercourse or who want to avoid the maintenance demands of a vaginal canal (van de Grift et al., 2022).
Nulloplasty#
Nulloplasty removes all external genitalia to create a smooth, neutral appearance. For AMAB individuals, this means penectomy, orchiectomy, and scrotectomy, with the urethra repositioned for sitting urination. The result is a flat groin with minimal scarring. Partial nullification options can preserve buried sensate tissue for sexual pleasure while maintaining a smooth external appearance.
When I learned nulloplasty existed, something clicked. I had spent years trying to figure out which "destination" I wanted—male? female?—and feeling like neither fit. The possibility of a smooth, neutral anatomy wasn't on any map I'd seen. But the moment I understood it was an option, I knew it was my option. My dysphoria was anatomical—having a penis and testicles felt fundamentally wrong—but it wasn't about wanting a vagina. I didn't want to be female; I wanted to be free of the specific anatomy that caused me distress. Nulloplasty covers nulloplasty in detail, including my own surgical experience and complications.
Phallus-Preserving Vaginoplasty#
Phallus-preserving vaginoplasty creates a vaginal canal while retaining the penis—an option for those who want both sets of genitalia. This is technically complex surgery requiring alternative tissue sources for the vaginal canal since the penile skin is not available for lining. Complication rates are higher than standard vaginoplasty, but for people whose embodiment goals include both structures, those risks may be acceptable (Coleman et al., 2022). Finding surgeons experienced with this specific configuration requires targeted research, as not all vaginoplasty surgeons offer it.
AFAB Bottom Surgery Options#
Hysterectomy and Oophorectomy#
Hysterectomy removes the uterus; oophorectomy removes the ovaries. These procedures can be performed laparoscopically with relatively quick recovery—often a few weeks before returning to normal activities. For transmasculine people, these procedures eliminate menstruation, remove a source of dysphoria, and (with oophorectomy) eliminate the body's main estrogen source (Coleman et al., 2022).
Some people pursue hysterectomy/oophorectomy as standalone procedures; others have them as part of phalloplasty or metoidioplasty. The decision often depends on which aspects of internal reproductive anatomy cause distress, and whether the person wants to preserve fertility options for the future.
Metoidioplasty#
Metoidioplasty releases the testosterone-enlarged clitoris from surrounding tissue, creating a small phallus typically ranging from 4 to 10 centimeters. The procedure can include urethral lengthening for standing urination and scrotoplasty with testicular implants. The main advantage is natural erectile function and excellent sensation since the existing erectile tissue is preserved and enhanced (Dy et al., 2021).
The limitation is size—the phallus is smaller than with phalloplasty and may not be sufficient for penetrative intercourse depending on individual goals. For people whose priorities center on authentic erectile function, standing urination, and sensation rather than size, metoidioplasty often represents the better fit.
Phalloplasty#
Phalloplasty constructs a penis using tissue from elsewhere on the body—most commonly the forearm (radial forearm free flap), thigh, or abdomen. Phalloplasty creates a larger phallus than metoidioplasty and can include urethral lengthening and erectile implants for penetrative function. It's typically performed in multiple stages over one to two years.
Complications, particularly urethral complications, are more common than with other procedures—something to factor into decision-making. Studies report urethral complication rates ranging from 25% to 60%, depending on technique and surgeon experience, though many complications can be addressed with revision surgery (Dy et al., 2021). The forearm donor site leaves a visible scar, which is a consideration for some people. Guide [X] provides detailed coverage of phalloplasty outcomes and considerations.
Vaginal-Preserving Phalloplasty#
Vaginal-preserving phalloplasty creates a phallus while retaining the vagina—an option for those who want both or who don't experience dysphoria about having a vagina. Urethral lengthening with vaginal preservation carries higher complication rates, so some people opt for shaft-only phalloplasty (no urethral lengthening) to reduce risk while achieving their primary goals.
AFAB Nulloplasty#
Nulloplasty for AFAB individuals removes external genitalia to create a smooth appearance. This may include vaginectomy (closure of the vaginal canal), vulvectomy (removal of external structures), and optionally clitorectomy. As with AMAB nulloplasty, partial options exist for those who want a smooth appearance while preserving some sensation.
Chest Surgery#
Top surgery for AFAB individuals (mastectomy with chest masculinization) removes breast tissue and reshapes the chest for a masculine or flat appearance. Several techniques exist—double incision, periareolar, keyhole—with different scar patterns and candidacy requirements based on chest size. For many transmasculine and nonbinary people, top surgery is the first or only surgical step, addressing the most visible and daily source of dysphoria.
Breast augmentation for AMAB individuals increases breast size when hormone therapy alone hasn't produced desired development. Like cisgender breast augmentation, this involves implants placed under the breast tissue or chest muscle. Some transfeminine people pursue this; others are satisfied with hormonal breast development alone—it depends on individual goals and anatomy.
Facial and Voice Surgery#
Facial feminization surgery (FFS) encompasses procedures that soften masculine facial features: forehead reduction and contouring, brow lift, rhinoplasty, cheek augmentation, jaw and chin reshaping, lip lift, and tracheal shave (Adam's apple reduction). These can be done individually or combined in a single surgical session. FFS can significantly reduce facial dysphoria and affect how others perceive gender.
Facial masculinization surgery (FMS) enhances masculine facial features through procedures like forehead augmentation, jaw augmentation, chin implants, and cheek reshaping. FMS is less commonly pursued than FFS, partly because testosterone therapy produces some facial masculinization over time.
Voice feminization surgery raises vocal pitch by shortening or tightening the vocal cords, with several techniques offering varying degrees of pitch change. Voice surgery is an option when voice training alone hasn't achieved desired results. Voice masculinization surgery is rarely needed because testosterone therapy typically deepens the voice.
Nonbinary and Mixed Approaches#
If you're nonbinary, gender non-conforming, or your goals don't fit standard categories, understanding the full menu of options matters. You can mix and match: orchiectomy without any other genital surgery, phalloplasty while keeping the vagina, top surgery without any bottom surgery, FFS without vaginoplasty. The question is always what specific changes would reduce your dysphoria—not which package you're supposed to want.
Finding surgeons willing to work with non-standard goals requires some research. Many surgeons are flexible and welcome the opportunity to support diverse embodiment goals; some are not. Asking directly during consultations about their experience with nonbinary patients and unconventional combinations helps identify good fits. WPATH SOC 8 supports individualized approaches, which can be useful context when advocating for yourself with providers (Coleman et al., 2022).
Sequencing Multiple Surgeries#
If you're considering more than one procedure, sequencing matters. Some surgeries can be combined in a single session; others need to be staged with recovery time between.
Common combinations include orchiectomy with vaginoplasty or vulvoplasty, and hysterectomy/oophorectomy with metoidioplasty or phalloplasty. Multiple facial procedures are frequently done together. Top surgery is typically done separately from bottom surgery, though there's no medical reason they couldn't be combined if desired.
Phalloplasty is almost always staged—initial construction, then glansplasty, then erectile implant—with months between stages to allow healing and monitor outcomes. Vaginoplasty followed later by labiaplasty revision is common when patients want refinement of initial results.
The general principle is to allow full healing before the next procedure. For minor procedures like orchiectomy, this might be six to eight weeks. For major procedures like vaginoplasty or phalloplasty, this might be six months to a year. Your surgeon will advise based on your specific situation and healing patterns.
Order considerations also matter. If you're planning vaginoplasty and also considering FFS, either can come first—it's largely a question of which addresses more pressing dysphoria or fits better with life circumstances like work schedules and support availability. If you're planning phalloplasty with urethral lengthening, hysterectomy is typically done first or at the same time to reduce infection risk. Some tissue preservation matters—if you might want vaginoplasty later, don't have scrotectomy now, since that tissue is used in vaginal construction.
I've talked with people who planned their surgical sequence like a military campaign—every procedure mapped out for years in advance—and others who took each step as it came, seeing how they felt after each surgery before deciding on the next. Both approaches can work. What matters is thinking through how procedures interact and leaving yourself flexibility where possible.
Candidacy and Prerequisites#
Most gender-affirming surgeries have prerequisites established by professional guidelines and insurance requirements. Understanding these helps you plan realistically.
The WPATH Standards of Care Version 8 provide the most widely referenced clinical guidelines. For genital surgeries, SOC 8 recommends documentation of persistent, well-documented gender incongruence; capacity to make a fully informed decision; age of majority (18 in most jurisdictions); reasonably well-controlled mental health if concerns are present; and for some procedures, a period of hormone therapy unless hormones are not desired or are medically contraindicated (Coleman et al., 2022).
Letter requirements vary by procedure. SOC 8 now requires only one referral letter from a qualified mental health professional for most genital surgeries, reduced from two in previous versions. However, many insurance companies still follow older guidelines and require two letters. The gap between current clinical recommendations and insurance requirements creates frustration for many patients—a topic we'll explore further in Chapter 7.
Some procedures benefit from prior hormone therapy. Metoidioplasty works best after testosterone has maximized clitoral growth, typically requiring 1-2 years of hormone therapy. Vaginoplasty outcomes may be enhanced by estrogen therapy, though it's not always strictly required. Orchiectomy and hysterectomy don't require prior hormones. Your surgeon will specify requirements based on the specific procedure and their clinical protocols.
Medical fitness matters for all surgery—reasonable cardiovascular health, ability to heal, management of conditions like diabetes that affect surgical outcomes. Specific procedures have specific considerations: vaginoplasty requires ability to comply with dilation; phalloplasty requires adequate donor site tissue; certain conditions increase complication risk for certain procedures. A thorough surgical consultation should address these factors for your individual situation.
Setting Realistic Expectations#
Surgery can do a lot, but understanding its limits helps set appropriate expectations.
Surgery can create anatomy that significantly reduces dysphoria. It can enable physical functions you couldn't achieve before—standing urination, penetrative sex, sitting comfortably without tucking. It can change how your body looks and feels in ways that increase comfort and congruence. Research consistently shows that the overwhelming majority of people who pursue gender-affirming surgery report improved quality of life and reduced dysphoria, with regret rates typically below 1% across studies (Bustos et al., 2021).
Surgery cannot guarantee perfect outcomes. Results vary based on anatomy, surgeon skill, healing, and factors no one can predict. Looking at a surgeon's results gives you a range of possibilities, not a guarantee of a specific outcome. Surgery cannot create natal anatomy—surgical results differ from cisgender anatomy, though they can be functional and affirming. And surgery cannot solve all problems: dysphoria about other body parts may remain, and other life challenges remain life challenges.
Healing timelines matter for managing expectations. Final results take months to years to fully emerge. Swelling distorts appearance for weeks to months post-surgery. Scars mature over 12-18 months. Sensation often returns gradually over one to two years. The body you see at two weeks post-op is not the body you'll have at two years—and judging outcomes during early recovery causes unnecessary distress.
Making Your Decision#
How do you decide which procedures, if any, are right for you?
Start with what bothers you. What specific aspects of your current anatomy cause distress? Is it focused—testicles specifically, or chest, or voice—or is it diffuse, where everything feels wrong? The answer points toward targeted procedures versus more comprehensive approaches.
Consider what you want to be able to do. Do you want to urinate standing? Have penetrative sex—giving, receiving, both? Wear certain clothing without dysphoria? Different procedures enable different functions, and being clear about functional priorities helps narrow options.
Factor in what you're willing to undergo. Surgery involves pain, recovery time, potential complications, and cost. More complex procedures involve more of all of these. Some people want the most complete transformation possible and will accept significant surgical burden; others want minimum intervention that addresses their worst dysphoria. Neither approach is wrong—it's about knowing yourself.
That's the framework: identify what's wrong, understand what options address it, and choose based on what fits your specific situation rather than what you're "supposed" to want. The guides that follow will help you explore each option in depth.
Let's begin. The guides are about to get much longer!
Reflection Questions#
As you survey the landscape of surgical options, which procedures seem potentially relevant to your situation? Which can you immediately rule out? What does that tell you about the specific nature of your dysphoria?
Are your surgical goals primarily about relief—removing sources of distress—or creation—building something new? Both are valid. The answer helps clarify which options to explore further.
How do factors like recovery time, complication risk, and cost affect your thinking about which procedures to pursue and in what order? What are you willing to accept, and what would be dealbreakers?
If you're considering multiple procedures, what sequence makes sense for your goals and life circumstances? What would you want to address first?
What aspects of the decision feel clearest to you right now, and what still feels uncertain? What information would help with the uncertain parts?
References#
Bustos, V. P., Bustos, S. S., Mascaro, A., Del Corral, G., Forte, A. J., Ciudad, P., Kim, E. A., Langstein, H. N., & Manrique, O. J. (2021). Regret after gender-affirmation surgery: A systematic review and meta-analysis of prevalence. Plastic and Reconstructive Surgery - Global Open, 9(3), e3477. https://doi.org/10.1097/GOX.0000000000003477
Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(Suppl 1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644
Dy, G. W., Granieri, M. A., Fu, B. C., Vanni, A. J., Voelzke, B., Rourke, K. F., Elliott, S. P., Nikolavsky, D., Zhao, L. C., & Gaither, T. W. (2021). Transgender reproductive health: A narrative review on the role of the urologist. Translational Andrology and Urology, 10(6), 2687–2706. https://doi.org/10.21037/tau-20-1136
Manrique, O. J., Adabi, K., Martinez-Jorge, J., Ciudad, P., Nicoli, F., & Kiranantawat, K. (2021). Complications and patient-reported outcomes in transfeminine vaginoplasty: An updated systematic review and meta-analysis. Plastic and Reconstructive Surgery Global Open, 9(3), e3510. https://doi.org/10.1097/GOX.0000000000003510
van der Sluis, W. B., Smit, J. M., Schäfer, T., & Bouman, M. B. (2025). Gender-affirming orchiectomy in transgender and non-binary individuals: A large cohort study with middle- to long-term follow-up. International Journal of Transgender Health, 26(2), 459–463. https://doi.org/10.1080/26895269.2024.2396939
van de Grift, T. C., Elfering, L., Bouman, M. B., Buncamper, M. E., & Mullender, M. G. (2022). Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review. International Journal of Transgender Health, 23(1-2), 34–65. https://doi.org/10.1080/26895269.2021.1891643