How to Use This Guide#

How This Knowledge Base Is Organized#

The guide is structured to take you from foundational understanding through specific surgical pathways to practical recovery and long-term thriving, with a comprehensive section on navigating healthcare across different countries.

Understanding Body Dysphoria (foundational guides)#

This section establishes the emotional and conceptual foundation for everything that follows. You'll find my personal story (Axl's Story), a deeper exploration of what dysphoria actually is beyond clinical definitions (Understanding Dysphoria), responses to common myths and misconceptions (Trans Myths), and guidance on separating how you feel about specific body parts from your broader sense of identity (Body Parts and Identity).

If you're early in your exploration or struggling to articulate what you're experiencing, start here. These guides provide language and frameworks that will help you understand your own feelings and communicate them to others.

Medical Foundations and Preparation (planning guides)#

Before diving into specific surgical procedures, this section covers the knowledge and preparation that applies across most surgical pathways. Topics include hormone replacement therapy (Hormone Therapy), an overview of available surgical options (Procedure Options), navigating financial, legal, and administrative barriers (U.S. Insurance, Costs, and Documents), fertility preservation and reproductive considerations (Fertility), accessibility for neurodivergent and disabled readers (Accessibility and Planning), and finding and choosing the right surgeon (Choose a Surgeon).

These guides are essential reading for anyone moving toward surgery, regardless of which procedure you're considering. The information here will help you make informed decisions and avoid common pitfalls.

AMAB Surgical Pathways#

This section covers surgical options for people assigned male at birth who are seeking genital reconstruction or removal. Guides address nulloplasty (Nulloplasty), vaginoplasty (Vaginoplasty), vulvoplasty (Vulvoplasty), and orchiectomy and penectomy (Orchiectomy).

Each guide provides detailed information about the procedure itself, what to expect before and after surgery, potential complications, and realistic outcomes. Read the guide that corresponds to your goals, but consider skimming related guides as well. Understanding adjacent options can help clarify your own desires.

AFAB Surgical Pathways#

This section covers surgical options for people assigned female at birth. Guides address hysterectomy and oophorectomy (Hysterectomy and Oophorectomy), metoidioplasty (Metoidioplasty), and phalloplasty (Phalloplasty).

As with procedure guides, focus on the guides most relevant to your path while remaining open to learning about related procedures.

Comprehensive Surgical and Recovery Support#

This section expands beyond genital surgery to address facial surgery (Facial Surgery), top surgery (Top Surgery), and voice surgery (Voice Surgery). It then transitions into the emotional and practical realities of recovery: managing dysphoria and expectations during healing (Recovery Emotions), recovery essentials for patients (Recovery Essentials), guidance for primary caregivers (For Caregivers), documenting your surgical journey (Documenting Healing), navigating sexuality and intimacy with your new body (Intimacy After Surgery), and thriving in the long term (Thriving Long-Term).

These guides are relevant regardless of which specific procedure you're pursuing. I particularly encourage caregivers and support people to read For Caregivers, and everyone to read Recovery Emotions before surgery. The gap between "surgery complete" and "results visible" catches many people off guard.

International Healthcare Navigation (international care guides)#

The final section of the knowledge base addresses the reality that healthcare access varies dramatically depending on where you live. International Care provides an introductory framework for navigating international care, followed by a detailed analysis of the current landscape in the United States (U.S. Care Context). Subsequent guides cover specific countries and regions: Canada, Mexico, the United Kingdom, France, Germany, the Netherlands, Spain, Italy, Turkey, Thailand, Japan and South Korea, and Australia and New Zealand.

These guides are particularly relevant if you're considering medical tourism, if you've recently moved or are planning to relocate, or if the healthcare infrastructure in your home country is inadequate or actively hostile.

Reading Paths by Reader Type#

Not everyone comes to this knowledge base from the same place. Here are suggested starting points based on where you are in your journey.

"I'm just starting to explore"#

If you're questioning your relationship with your body or trying to understand what you're feeling, begin with the foundational topics. Axl's Story offers my personal story as one example of how this journey can unfold. Understanding Dysphoria will help you develop language for your experiences. Body Parts and Identity can help you separate questions about specific body parts from bigger questions about identity.

After the foundational topics, browse Procedure Options (Surgical Options Overview) to understand what possibilities exist. You don't need to decide anything yet. Just knowing the landscape can be grounding.

Take your time. There's no urgency. This knowledge base will be here when you're ready for the next step.

"I'm actively planning surgery"#

If you have a surgery date or are working toward one, prioritize the following:

If you have a caregiver, have them read For Caregivers. If you're preserving fertility, read Fertility before surgery.

You'll also want to review the guide for your country or the country where you're having surgery (international care guides) for location-specific guidance.

"I'm supporting someone through surgery"#

Start with For Caregivers: A Comprehensive Guide for Primary Caregivers. This guide is written specifically for you and covers both practical caregiving tasks and the emotional labor of supporting someone through major surgery.

Additionally, read the guide specific to the procedure your loved one is having. Understanding what they're going through physically will help you provide better support.

Recovery Emotions (Managing Dysphoria and Expectations) will help you understand the emotional rollercoaster they may experience. Post-surgical depression is common, and knowing what's normal can help you recognize when additional support is needed.

If you want broader context, the foundational topics provide foundational understanding of what dysphoria feels like and why surgery matters so much.

"I've already had surgery"#

If you're post-operative and seeking guidance, focus on:

These guides address the challenges that persist after the surgery itself is complete. The post-operative period can be surprisingly difficult emotionally, and you're not alone if you're experiencing that.

If you're considering revision surgery or additional procedures, the relevant procedural guides will still be useful.

"I'm a medical professional"#

Welcome, and thank you for seeking to understand your patients' experiences. The clinical guides that may be most relevant include:

  • Procedure Options: Surgical Options Overview (comprehensive landscape of procedures)
  • genital procedure guides: Detailed surgical procedure information
  • Accessibility and Planning: Neurodivergence, Disability, and Accessibility (supporting diverse patients)
  • Recovery Emotions: Managing Dysphoria and Expectations (understanding the emotional reality of recovery)

For broader context, Axl's Story (my personal story) and Understanding Dysphoria (reimagining dysphoria) may help you understand the lived experience behind the clinical presentations you see.

Using the Reflection Questions#

Each guide ends with reflection questions. These aren't tests. There are no right or wrong answers, no grades, no judgment. They're invitations to think more deeply about what you've read and how it relates to your own experience.

Their Purpose#

The questions are designed to help you:

  • Process complex information at your own pace
  • Connect general concepts to your specific situation
  • Clarify your values, fears, and hopes
  • Identify areas where you may want to seek additional support
  • Deepen self-understanding without requiring external validation

I developed these questions with the mindset of an LGBTQ+-affirming counselor. They're meant to open doors, not close them. If a question doesn't resonate with you, skip it. If one provokes strong feelings, that's information worth sitting with.

Journaling Suggestions#

Many readers find it helpful to write their responses rather than simply thinking about them. Consider keeping a dedicated journal for this knowledge base. You might:

  • Write freely in response to each question without censoring yourself
  • Return to earlier responses as your understanding evolves
  • Note questions that feel particularly charged and explore why
  • Track patterns in your responses across guides
  • Write letters to your past or future self based on what you're learning

There's no requirement to journal. But if you find yourself ruminating on the same questions repeatedly, getting thoughts onto paper can help them move through you rather than circling endlessly.

Processing with Others#

Some questions may be worth discussing with a therapist, trusted friend, or partner. If you're working with a gender-affirming therapist, the reflection questions can serve as starting points for productive sessions. You might share specific questions that felt difficult or bring your journal entries to discuss.

If you don't have a therapist, consider processing with:

  • A trusted friend who understands what you're going through
  • An online community of people with similar experiences
  • A support group (in-person or virtual)
  • A partner, if they're a safe person for these conversations

You don't have to process everything alone. You also don't have to share everything. Trust your instincts about what to keep private and what to open up about.

Cross-Referencing Between Guides#

This knowledge base is designed to be read non-linearly. Guides connect to and build upon each other, and you'll find references throughout pointing you to related content.

How Guides Connect#

The structure is intentional: foundational understanding (foundational topics) supports informed decision-making (planning guides), which enables you to engage meaningfully with specific procedures (procedure guides), followed by practical and emotional recovery guidance, all within the context of your specific healthcare landscape (international care guides).

But real life isn't linear, and neither is this knowledge base. You might be reading about vaginoplasty (Vaginoplasty) and realize you need to understand insurance navigation (U.S. Insurance, Costs, and Documents) first. You might be deep in recovery guidance (Recovery Essentials) and want to revisit expectations management (Recovery Emotions). Follow the thread that's most alive for you.

When to Jump Between Sections#

Consider jumping when:

  • A guide mentions a concept covered elsewhere. If I reference something explained in detail in another guide, a note will usually direct you there.
  • You hit a practical barrier. If you're reading about a procedure but realize you need to understand financing first, jump to U.S. Insurance, Costs, and Documents.
  • You need emotional grounding. If technical content becomes overwhelming, return to foundational topics to reconnect with the human reality.
  • Your situation changes. Life happens. If you started in the "just exploring" path and now have a surgery date, shift to the "actively planning" guides.

Using the Index#

If this edition includes an index, use it. Looking up specific terms, procedures, complications, or concepts will take you directly to relevant passages without requiring you to read entire guides.

The index is particularly useful for:

  • Quick reference during conversations with medical providers
  • Finding specific information you remember reading but can't locate
  • Checking whether a topic is covered before diving into guides

A Note on Currency#

Medical knowledge evolves. Legal landscapes shift. Surgeons retire, change practices, or gain new expertise. Insurance policies update. The information in this knowledge base reflects the best available evidence and guidance as of its publication, but some details will inevitably become outdated.

What Changes Fastest#

  • Surgeon availability and wait times. The specific surgeons mentioned may have different availability, new surgeons may have emerged, and some may have stopped performing certain procedures.
  • Insurance coverage and requirements. Policies change annually. What's covered in your plan this year may differ from next year.
  • Legal protections and barriers. Particularly in the United States, the legal landscape for transgender healthcare changes rapidly and varies by state.
  • Surgical techniques. New approaches emerge, and established techniques are refined.
  • Costs. Prices for procedures, travel, and recovery accommodations change with inflation and market conditions.

How to Verify Current Information#

When using this knowledge base for practical planning, verify time-sensitive information through:

  • Surgeon websites and direct contact. For current wait times, pricing, and procedure availability.
  • Your insurance company. For current coverage, requirements, and prior authorization processes.
  • Legal organizations. For current laws and protections in your jurisdiction (see Resources section below).
  • Community forums and groups. For recent patient experiences with specific surgeons or facilities.
  • Professional organizations. WPATH publishes updated Standards of Care, and surgical organizations release new guidelines periodically.

The principles and frameworks in this knowledge base will remain relevant even as specific details shift. Understanding how to evaluate a surgeon matters more than which specific surgeons I mention. Knowing what to expect from recovery matters more than exact timelines, which vary by individual. Use this knowledge base for the enduring guidance and verify the details.

Resources Beyond This Knowledge Base#

No single guide can contain everything you need. Here are additional resources to support your journey.

Online Communities#

Finding your people matters. Online communities can provide:

  • Peer support from people who've been through similar experiences
  • Answers to specific questions about surgeons, recovery, and logistics
  • Emotional support during difficult phases
  • Information about resources in your area

Look for communities that are moderated, supportive, and focused on the specific topics you need. For nulloplasty and non-binary bottom surgery specifically, the Flat Crotch Collective and the forums at bottomsurgery.info are communities I've helped build. For other procedures, Reddit communities, Discord servers, and Facebook groups can be valuable. Approach all online information critically and verify medical claims with qualified providers.

If you face discrimination, insurance denials, or legal barriers, these organizations may help:

  • Lambda Legal (lambdalegal.org): Legal advocacy for LGBTQ+ rights
  • Transgender Law Center (transgenderlawcenter.org): Policy advocacy and legal assistance
  • National Center for Transgender Equality (transequality.org): Policy and resources
  • ACLU LGBTQ Rights Project (aclu.org): Legal challenges to discriminatory policies

In countries outside the United States, look for local transgender legal organizations. The international guides (27-40) include country-specific resources.

Crisis Support#

If you're in crisis, please reach out:

  • Trans Lifeline (US: 877-565-8860, Canada: 877-330-6366): Staffed by transgender people, for transgender people
  • The Trevor Project (1-866-488-7386): Crisis intervention for LGBTQ+ youth
  • 988 Suicide and Crisis Lifeline (call or text 988): General crisis support in the US
  • Crisis Text Line (text HOME to 741741): Text-based crisis support

These services are available 24/7. If you're having thoughts of suicide or self-harm, please reach out. Your life matters, and this moment will pass.

Staying Updated#

For current information as the landscape evolves:

  • bottomsurgery.info: The resource site I maintain with current surgeon information and community updates
  • WPATH (wpath.org): Standards of Care and position statements
  • TransHealthCare.org: Directory of transgender-friendly healthcare providers
  • Point of Pride (pointofpride.org): Financial assistance and resources
  • Gender Confirmation Center (genderconfirmation.com): Educational resources

Follow trusted trans journalists and advocates on social media for breaking news about healthcare access and legal changes.

Taking Care of Yourself While Reading#

This knowledge base contains difficult material. You'll encounter clinical descriptions of surgical procedures, discussions of dysphoria and psychological distress, references to discrimination and healthcare barriers, and honest accounts of complications and challenging recoveries. This content is included because accurate information empowers good decisions, but accuracy doesn't prevent emotional impact.

Permission to Put This Guide Down#

You have complete permission to stop reading at any time. This isn't a race. This guide will still be here when you're ready to continue. If you find yourself:

  • Feeling increasingly anxious or distressed
  • Dissociating or feeling disconnected from your body
  • Experiencing intrusive thoughts
  • Unable to sleep after reading
  • Crying more than feels manageable

Put this guide down. Do something grounding. Return when you're ready, or don't return at all if that's what you need.

Recognizing When Content Is Triggering#

Some signs that you may need to step back:

  • Physical symptoms: Racing heart, shallow breathing, tension, nausea
  • Emotional flooding: Overwhelming sadness, anger, or fear that feels disproportionate
  • Dissociation: Feeling detached from yourself or your surroundings
  • Rumination: Unable to stop thinking about something you read
  • Behavioral changes: Difficulty sleeping, eating, or functioning normally

If you notice these patterns, that's useful information. It doesn't mean something is wrong with you. It means your nervous system is responding to difficult material, and it deserves care.

Self-Care During the Research Process#

Planning surgery or exploring major medical decisions requires extensive research. That research can become consuming. Some suggestions for maintaining balance:

Set boundaries around research time. Designate specific times for reading and researching rather than doing it constantly. Give your mind time to process and rest.

Balance information intake with grounding activities. After reading heavy material, do something that reconnects you to the present: walk outside, cook a meal, watch something lighthearted, spend time with people you care about.

Keep perspective. This guide contains comprehensive information about complications because you deserve full transparency. But complications are the exception, not the rule. Don't let the detailed discussion of what can go wrong obscure the reality that most surgeries go well.

Talk to someone. Processing alone is harder than processing with support. Whether that's a therapist, a friend, an online community, or a partner, share what you're going through.

Remember why you're doing this. When the research feels overwhelming, reconnect with your reasons. The difficulty of this process is in service of something meaningful. That meaning can sustain you through the hard parts.

Final Thoughts#

This knowledge base exists because I needed it and it didn't exist. Now it does, and it's yours. Use it however serves you best.

Some of you will read every guide, take notes, journal extensively, and approach this as a comprehensive education. Some of you will flip directly to the guide about your specific procedure, get what you need, and move on. Some of you will return to this knowledge base repeatedly over years as your journey unfolds. All of these approaches are valid.

Whatever path brought you here, I'm glad you're reading. The fact that you're seeking information, trying to understand yourself or someone you love, taking your experience seriously enough to invest time in learning about it, that matters. It matters regardless of what you ultimately decide about your body.

I hope this guide serves you well. I hope you find the information, the language, the validation, and the practical guidance you need. And I hope that wherever your journey leads, you find your way to a body that feels like home.

With warmth and solidarity,

Axl

Welcome to bottomsurgery.info#

Cover Image

Hello! I'm Axl. On August 9, 2024, I became a nullo through nulloplasty surgery — a deeply personal and transformative journey that inspired me to create this space.

When I first began researching bottom surgeries, especially nullification, I found the available information frustratingly scarce, scattered, or overly clinical. Reliable, practical, firsthand knowledge was almost impossible to find. This site is the result of that gap: a community-driven, evolving resource dedicated to sharing real experiences, practical advice, and thoughtful insights about nullification and other bottom surgeries.

Whether you're just starting to explore your options, preparing for surgery, or navigating life post-op, you'll find a welcoming space here. Let's walk this journey together.

Understanding Dysphoria Beyond the Binary#

There are important nuances to dysphoria that need highlighting. Most public understanding of "trans-ness" centers on a heteronormative binary where men become women, or women become men. Our stories show there is far more diversity possible. Many individuals experience genital dysphoria without disidentifying with their assigned gender at birth.

Speaking from my own experience as an AMAB (assigned male at birth) nonbinary person, I experienced profound lifelong dissatisfaction with my genitals, without feeling the need to "become a woman." For my own body, I enjoy presenting as masculine but wanted neither a penis nor a vagina. So I became a nullo and continue to take testosterone after surgery — which I plan to do indefinitely. Similarly, there are AMAB men who get vaginoplasties while maintaining their male gender identity and continuing testosterone after surgery.

My Story#

Axl Pre-Op Nullo Q&A#

A candid pre-operative Q&A as I prepared to leave for San Francisco for Nulloplasty in August 2024. I share why I pursued this path, the steps I took (hormone therapy, insurance navigation, securing support), and the preparations I made before surgery.

Axl's Nulloplasty Journey#

The complete bottom surgery story: from a 9-week preparation sprint, through a 22-day stay in San Francisco, and back home to Wisconsin. Includes pre-op prep, the surgery itself, daily recovery updates with photos, and my interactions with the surgical team. I faced a few challenges — a catheter I named Wilson, a UTI, and an unexpected fluid pocket — but the journey was ultimately successful and transformative.

Axl 1-Year Post-Op Nullo Q&A#

One year after my August 9, 2024 nullification surgery. A candid, question-by-question look at living as a nullo — nerve preservation, sensations, sexuality, daily routines, insurance, and the emotional and financial realities of post-op life.

Procedure Guides#

Scroll horizontally to view all columns.
Procedure Description
Nulloplasty Complete genital removal creating a smooth contour
Orchiectomy Removal of the testes
Penectomy Full or partial removal of the penis
Vaginoplasty Penile inversion, peritoneal, or colovaginoplasty
Vulvoplasty External vulva creation without vaginal canal
Penile-Preserving Vaginoplasty Vaginoplasty while retaining the penis
Phalloplasty Masculinizing genital construction using tissue flaps
Metoidioplasty Masculinizing genital construction using testosterone-enlarged clitoris
Top Surgery Chest masculinization, feminization, and nonbinary options

Practical Resources#

Continue exploring#