Orchiectomy and Penectomy#

Introduction: Who This Guide Is For#

This guide is for anyone who has looked at the map of gender-affirming genital surgeries and found themselves somewhere between the landmarks.

Perhaps you're a transgender woman who wants to eliminate testosterone production and simplify your hormone regimen, but vaginoplasty feels like more surgery than you need—or more maintenance than you want to commit to for the rest of your life. Perhaps you're nonbinary and seeking a body that's neither what you were born with nor what the typical "male-to-female" surgical pathway creates. Perhaps you've heard terms like "orchiectomy" and "penectomy" mentioned in passing but couldn't find clear information about what these procedures actually involve, who pursues them, and what life looks like afterward.

Perhaps you already know exactly what you want—testes gone, penis gone, a smooth and simple anatomy that finally matches how you've always seen yourself—and you're looking for the comprehensive guide that helps you get there safely. Or perhaps you're a partner, family member, or healthcare provider trying to understand options that don't fit neatly into the binary narratives that dominate most discussions of transition.

Whoever you are, this guide welcomes you.

Orchiectomy and penectomy represent distinct surgical pathways for individuals assigned male at birth who seek gender affirmation without pursuing vaginoplasty. These procedures have historically been overlooked in medical literature, treated as stepping stones toward "complete" transition rather than valid endpoints in themselves. That framing does a disservice to the many people for whom these surgeries represent exactly the outcome they want—neither more nor less than what their bodies need to feel like home.

The research landscape is uneven. A two-center retrospective cohort of 119 people reports clinical follow-up after gender-affirming orchiectomy, including recorded complications and no recorded cases of postoperative regret; it does not report self-reported dysphoria, tucking, medication, or satisfaction outcomes (van der Sluis et al., 2025). Penectomy as a standalone gender-affirming procedure has far less formal literature—most research concerns penectomy as part of vaginoplasty or treatment for penile cancer, which serve different goals. This guide keeps those evidence gaps visible.

What follows covers the goals, eligibility requirements, surgical processes, recovery timelines, complications, and long-term outcomes for both orchiectomy and penectomy. The aim is not to advocate for or against any particular path, but to provide the information necessary for informed decision-making. Your body, your choice, your life.

A note on terminology before we proceed: this guide discusses procedures primarily sought by transgender women, transfeminine individuals, nonbinary people assigned male at birth, and those who identify as eunuchs or nullos. Language around gender is evolving, and the terms used here may not perfectly capture every reader's identity. If the procedures described resonate with your needs, this guide is for you regardless of how you name your gender. The clinical framework exists to help you access care—your identity belongs to you, and no diagnosis or terminology needs to define it.

Orchiectomy: Removal of the Testes#

Understanding the Procedure and Its Goals#

Orchiectomy is the surgical removal of the testes. Its operative approach, anesthesia, duration, discharge plan, and recovery restrictions depend on the proposed procedure, medical history, and operating team. The cited cohort is not used to supply a universal time or same-day-discharge promise.

The goals people seek from standalone orchiectomy can include changing testicular hormone production, reducing dysphoria, changing body maintenance, or choosing an endpoint rather than another genital operation. Medication, hormone-dose, tucking, libido, and dysphoria outcomes need individualized discussion with the surgical and prescribing teams. The previously cited cohort does not provide patient-reported data for those outcomes, so this guide does not attach percentages or a medication change to it.

People's reasons and experiences remain important. A person's own account of relief, discomfort, or a changed relationship with their body is lived knowledge; it is not a population rate.

Who Chooses Standalone Orchiectomy—And Why#

Orchiectomy can be a destination, a bridge to another procedure, or one part of an individualized plan. People's goals and the reasons a later procedure may or may not fit are personal and clinical questions, not a universal pathway. The cited 119-person cohort is not used here to assign motivation percentages or explain another person's decision.

These numbers tell an important story: there is no single "right" reason to choose orchiectomy. Some people know with certainty that this is all they want. Others use it as a way to buy time while they figure out their path. Still others face medical realities that make more extensive surgery inadvisable. All of these are legitimate reasons.

What unites most patients is the desire for hormonal liberation—freedom from testosterone and the constant pharmaceutical battle to suppress it—combined with a recognition that they don't want or need a vaginal canal. For nonbinary individuals in particular, orchiectomy can provide substantial relief from genital dysphoria without requiring commitment to anatomy that doesn't match their sense of self.

Unlike orchiectomy performed as part of vaginoplasty, standalone orchiectomy uses careful surgical techniques to preserve scrotal tissue. This matters because if you later decide you do want vaginoplasty, that preserved tissue can be used as lining for the vaginal canal (Jeftovic et al., 2018). The surgery doesn't close doors—it opens some while leaving others accessible.

Eligibility and the Path to Surgery#

WPATH SOC8 outlines eligibility considerations for orchiectomy, including marked and sustained gender incongruence, capacity for informed consent, age of majority, and assessment of health concerns that could affect outcomes. For orchiectomy, its criteria describe 12 continuous months of hormone therapy and adequate testosterone blockade when hormones are wanted and clinically appropriate; hormones are not a prerequisite when they are not desired or are contraindicated. Individual programs and insurers may apply additional requirements (Coleman et al., 2022).

SOC8 does not impose a universal one-referral-letter rule from a mental health professional. It recommends assessment by a health-care professional competent in transgender health and says that, if written documentation is required, one assessment letter from a competent health-care professional can be sufficient. Insurers and surgical programs may request different documentation, including more than one letter, so confirm the requirements that apply to your care (Coleman et al., 2022; Lai et al., 2023).

SOC8 does not prescribe a universal mandatory checklist for a referral letter. A surgeon, program, or insurer may request information about diagnosis, informed consent, capacity, or relevant health concerns, and those requests should be confirmed with that specific organization rather than presented as a SOC8-wide letter mandate (Coleman et al., 2022).

For those not on estrogen—some nonbinary individuals, for example, who don't want feminization—orchiectomy requires careful planning around hormone replacement. Without adequate sex hormones, the body rapidly loses bone density and experiences menopausal symptoms including hot flashes, mood changes, and fatigue. Options include low-dose estrogen sufficient for bone health (around 2mg oral estradiol or equivalent) or, for those seeking a more neutral or masculine hormonal state, low-dose testosterone. UCSF guidelines recommend remaining on at least minimal hormone replacement until age fifty (Deutsch, 2016). This isn't about gender—it's about keeping your bones from becoming dangerously fragile.

The Surgery Itself#

The scrotal approach is standard for gender-affirming orchiectomy. The surgeon makes a single midline incision of two to three centimeters in the scrotum, then removes the testes and portions of the spermatic cords through this opening (Jeftovic et al., 2018). This approach preserves scrotal skin for potential future use and heals with minimal visible scarring.

You might encounter references to the inguinal approach, which involves an incision through the groin. This technique is primarily used for cancer treatment and is generally avoided in gender-affirming care because it can complicate future procedures if you later decide you want vaginoplasty (Jeftovic et al., 2018).

Simple orchiectomy—removing the testicles and portions of the spermatic cords—is the standard for gender affirmation. Radical orchiectomy, which removes more tissue including the entire spermatic cord, is reserved for cancer treatment where margins matter in ways they don't for our purposes (Jeftovic et al., 2018).

Anesthesia options vary by center. Most commonly, the procedure is performed under general anesthesia—you're completely unconscious throughout. Some centers offer spinal anesthesia or local anesthesia with sedation, which means you're awake but numb and relaxed. The choice often depends on your preferences, your medical history, and what your surgical team is most comfortable providing.

Preparing for Your Surgery#

Pre-surgical preparation is relatively straightforward compared to more complex procedures. You'll have a physical examination to assess testicle position and check for conditions like inguinal hernias or hydroceles that might affect the surgical approach. Your surgeon will review your surgical history, particularly any prior inguinal hernia repairs that could complicate the procedure. Current hormone regimens typically continue through the perioperative period—you don't need to stop estrogen before surgery (Jeftovic et al., 2018).

Documentation requirements are determined by the surgeon, program, and insurer. They may include an assessment, written documentation, hormone-history information when relevant to the person's care, and informed consent addressing the permanent nature of the procedure. Confirm the current requirements directly; SOC8 does not create a universal six-month paperwork rule (Coleman et al., 2022).

Many surgical centers require smoking cessation for six weeks before and after surgery, and some verify compliance by checking urinary nicotine levels (Mount Sinai Health System, n.d.). If you smoke, this requirement is worth taking seriously—smoking significantly impairs wound healing and increases complication risk. BMI above 35 has been identified as a significant risk factor for complications, nearly tenfold higher odds of infectious complications in one study (Massie et al., 2023).

Fertility preservation deserves careful consideration before surgery. In the two-center cohort, 18 of 119 people (15%) chose sperm cryopreservation before surgery; that cohort proportion does not predict an individual choice (van der Sluis et al., 2025). If there is any possibility you may want genetically related children, discuss preservation options before an irreversible operation. Fertility covers fertility preservation in detail.

If future vaginoplasty is a possibility—even a remote one—consider consulting with a vaginoplasty surgeon before your orchiectomy. They can assess whether your tissue adequacy might be affected by how the orchiectomy is performed and ensure your surgical team preserves what might be needed later.

Recovery: What to Expect#

Orchiectomy has one of the fastest recovery timelines of any gender-affirming surgery. Same-day discharge is typical—you'll be monitored for a few hours after surgery, then sent home with care instructions and pain medications. Most people are fully mobile within one to two days, though "mobile" means gentle walking rather than your normal activity level.

Swelling and bruising are normal and expected. The surgical area will look worse before it looks better, with discoloration and puffiness that typically resolve within two to four weeks. Ice application and supportive underwear help manage both the swelling and the discomfort.

Pain control, supportive garments, ice, medication choices, and the point at which an unexpected symptom needs review are specific to the operation and patient. Follow the prescribing and operating teams' instructions; this guide does not use the cited cohort to provide a day-by-day pain-medication forecast.

Most patients return to usual activities within two to three weeks. Desk work is often possible within one to two weeks if you can work from home or have a comfortable commute. Physically demanding jobs may require four to six weeks off (Kaiser Permanente, n.d.).

Activity restrictions include avoiding heavy lifting for one month, no strenuous activities like biking or weightlifting until your surgeon clears you, no driving while taking prescription pain medications, and no baths, swimming, or hot tubs for one month to protect the healing incision (Kaiser Permanente, n.d.). Sexual activity should wait until the surgical site is fully healed—your surgeon will tell you when it's safe.

Hormonal Changes and Long-Term Management#

The hormonal shift after orchiectomy is immediate and dramatic. Testosterone levels drop to near-zero within days, fundamentally changing your body's hormonal landscape. For those who have been on anti-androgens, this means stopping those medications immediately—your body is no longer producing the testosterone they were blocking.

After orchiectomy, hormone needs and medication changes should be individualized by the prescribing clinician. This guide does not use the cited cohort to supply an estrogen-dose percentage, an anti-androgen discontinuation rate, or a risk-reduction promise.

Bone health becomes a critical long-term consideration. Estrogen is essential for bone health in all humans regardless of gender, and orchiectomy without hormone replacement leads to accelerated bone loss. Studies show that 18-26% of transgender women after gonadectomy have low bone mass (Singh-Ospina et al., 2017). Protecting your bones requires ongoing attention: continue estrogen therapy long-term (or until at least age fifty), ensure adequate calcium intake of 1000-1200mg daily, supplement vitamin D if you're deficient, engage in weight-bearing exercise, and reduce smoking and alcohol consumption (UCSF Transgender Care, n.d.).

Bone density screening through DEXA scans is recommended for those who have been post-orchiectomy without hormones for five or more years, those with traditional osteoporosis risk factors, or anyone over age sixty-five (UCSF Transgender Care, n.d.). This isn't something to panic about, but it is something to monitor.

Complications: What Can Go Wrong#

In the two-center retrospective cohort, 102 of 119 people (86%) had no recorded complications during a median 2.3-year clinical follow-up (range 0.3–9.4). Five people had hemorrhage requiring return to the operating room and seven had an abscess. Those are recorded outcomes in that cohort, not an individual forecast or a complete nulloplasty/penectomy rate (van der Sluis et al., 2025).

A national database study of 246 orchiectomies found an overall complication rate of 3.7%, with infectious complications being most common at 2.4% and reoperation within 30 days occurring in 2.0% (Massie et al., 2023). These rates are comparable to orchiectomy performed for non-oncologic indications in cisgender men—the surgery carries similar risks regardless of why it's being performed.

Long-term pain, cosmetic concerns, hormone management, and complication risk require procedure- and person-specific discussion with the operating and prescribing teams. The reviewed cohort records two chronic-pain cases (1.7%) more than three months after surgery; it does not report the previously stated self-reported satisfaction, tucking, or dose-change outcomes.

Long-Term Outcomes and Satisfaction#

The reviewed 119-person cohort reports no recorded cases of postoperative regret, but it does not provide a validated self-reported satisfaction measure or a quality-of-life package. That chart-based result cannot predict an individual outcome. Broader mixed-procedure literature also cannot supply those outcomes for this operation. People considering surgery can ask programs for their own definitions, denominators, follow-up, patient-reported instruments, and management pathways.

Other possible metabolic associations require their own population and design limits; they are not used here to promise a health benefit from orchiectomy.

Orchiectomy can be an important option for many people, but its value and trade-offs are personal rather than a package of guaranteed outcomes.

References#

Almazan, A. N., & Keuroghlian, A. S. (2021). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery, 156(7), 611-618. https://doi.org/10.1001/jamasurg.2021.0952

Amodeo, A. L., Vitelli, R., Scandurra, C., Picariello, S., & Valerio, P. (2022). Adult attachment and transgender identity in the Italian context: Clinical implications and suggestions for further research. International Journal of Transgenderism, 23(1-2), 14-30.

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., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F., Monstrey, S. J., Motmans, J., Nahata, L., ... Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(S1), S1-S259. https://doi.org/10.1080/26895269.2022.2100644

the surgical practice for Transgender Surgery. (n.d.). Nonbinary surgery. Retrieved January 17, 2026, from

Deutsch, M. B. (2016). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people (2nd ed.). UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. https://transcare.ucsf.edu/guidelines

Esmonde, N., Bluebond-Langner, R., & Berli, J. U. (2019). Penile inversion vaginoplasty. In C. J. Salgado (Ed.), Gender affirmation: Medical and surgical perspectives (pp. 187-199). Thieme.

Hadj-Moussa, M., Ohl, D. A., & Panoff, J. E. (2025). Sexual and urological reconstruction following penectomy for penile cancer: Phalloplasty. International Journal of Impotence Research. Advance online publication. https://doi.org/10.1038/s41443-025-01161-z

Jeftovic, M., Stojanovic, B., Bizic, M., Stanojevic, D., Kisic, J., Bencic, M., & Djordjevic, M. L. (2018). A simple guide for simple orchiectomy in transition-related surgeries. Journal of Sexual Medicine, 5(4), e433-e436. https://doi.org/10.1016/j.esxm.2017.08.005

Kaiser Permanente. (n.d.). Orchiectomy for gender affirmation: What to expect at home. Retrieved January 17, 2026, from https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.orchiectomy-for-gender-affirmation-what-to-expect-at-home.acp8994

Lai, M. C., Chiu, C. C., & Yang, C. (2023). World professional association for transgender health guidelines: 2022 surgical treatment updates in the standards of care for transgender and gender diverse people. Neurourology and Urodynamics, 42(1), 128-135. https://doi.org/10.1002/nau.25099

MacPhee, K. (n.d.). Nonbinary genital reconstruction. Retrieved January 17, 2026, from https://keeleemacpheemd.com/nonbinary-genital-reconstruction/

Massie, J. P., Morrison, S. D., Van Maasdam, J., & Satterwhite, T. (2023). Outcomes of orchiectomy for gender-affirming surgery: A national surgical quality improvement program study. Urology, 180, 154-159. https://doi.org/10.1016/j.urology.2023.06.039

Mount Sinai Health System. (n.d.). Preparing for transgender surgery. Retrieved January 17, 2026, from https://www.mountsinai.org/locations/center-transgender-medicine-surgery/care/surgery/preparation

Nadjarzadeh, A., Dehghani-Firouzabadi, R., Daneshbod, Y., Lotfi, M. H., Vaziri, N., & Mirjalili, M. R. (2017). Transwomen and the metabolic syndrome: Is orchiectomy protective? Transgender Health, 2(1), 58-64. https://doi.org/10.1089/trgh.2016.0050

OHSU. (n.d.). Patient guide to gender-affirming care. Retrieved January 17, 2026, from https://www.ohsu.edu/transgender-health/patient-guide-gender-affirming-care

Pfäfflin, F. (1993). Regrets after sex reassignment surgery. Journal of Psychology & Human Sexuality, 5(4), 69-85. https://doi.org/10.1300/J056v05n04_05

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

Singh-Ospina, N., Maraka, S., Rodriguez-Gutierrez, R., Davidge-Pitts, C., Nippoldt, T. B., Prokop, L. J., & Murad, M. H. (2017). Effect of sex steroids on the bone health of transgender individuals: A systematic review and meta-analysis. Journal of Clinical Endocrinology & Metabolism, 102(11), 3904-3913. https://doi.org/10.1210/jc.2017-01642

Trans Care BC. (2023, February). WPATH SOC-8: Changes to gender-affirming surgery in B.C. https://www.transcarebc.ca/about/news-events/wpath-soc-8-changes-gender-affirming-surgery-bc

UCSF Transgender Care. (n.d.). Bone health and osteoporosis. Retrieved January 17, 2026, from https://transcare.ucsf.edu/guidelines/bone-health-and-osteoporosis

Last updated July 30, 2025

Introduction#

Gender affirmation surgery encompasses a range of medical procedures designed to help individuals align their physical characteristics with their gender identity. Within this spectrum of options, orchiectomy stands out as a common and frequently considered initial surgical step, particularly for transfeminine individuals and others seeking to feminize their bodies. This surgical procedure involves the removal of the testicles and plays a significant role in the broader context of gender transition.

This wiki provides a comprehensive overview of orchiectomy within the framework of gender affirmation surgery, covering its definition, techniques, motivations, variations, integration with other bottom surgery options, typical recovery process, and long-term effects, with particular focus on hormonal changes and their management.

Understanding Gender-Affirming Orchiectomy: Definition and Purpose#

Orchiectomy is the surgical removal of one or both testicles. For gender affirmation, bilateral orchiectomy—removing both testicles—is typically performed. This procedure serves several key purposes for individuals undergoing gender transition, primarily helping to align their physical body with their internal gender identity. One of the most significant outcomes is the substantial reduction or complete elimination of the body's testosterone production, supporting feminization and reducing androgenic effects.

The removal of testicles can significantly reduce or eliminate the need for testosterone-blocking medications (anti-androgens), simplifying hormone therapy regimens and potentially reducing associated side effects. In some cases, orchiectomy may also allow for lower estrogen dosages while maintaining feminizing effects, potentially decreasing risks linked to higher estrogen levels. A fundamental motivation for gender-affirming orchiectomy is alleviating gender dysphoria—the distress experienced when gender identity doesn't match sex assigned at birth. By addressing this incongruence, the surgery often positively impacts psychological well-being.

It's important to note that orchiectomy results in permanent infertility due to the cessation of sperm production. This irreversible outcome requires careful consideration, especially for those who might want biological children in the future. Additionally, orchiectomy frequently serves as either a precursor to or component of other gender-affirming bottom surgeries, such as vaginoplasty or metoidioplasty.

Surgical Techniques for Orchiectomy: A Step-by-Step Overview#

The surgical procedure for a gender-affirming orchiectomy is typically performed by a urologist in an operating room. In many cases, it is conducted as an outpatient procedure, allowing the individual to return home on the same day. Anesthesia options include local anesthesia, where the genital area is numbed, or general anesthesia, where the patient is asleep throughout the procedure.

The standard surgical steps begin with positioning the patient on the operating table, often lying flat with the penis gently secured against the abdomen or sometimes in a lithotomy position. The surgical area, which may range from the nipples down to the mid-thighs or focus specifically on the genitals, is meticulously cleaned with an antiseptic solution and then covered with sterile drapes. The surgeon then makes a small incision, typically about one inch in length, in the midline of the scrotum. This incision is often strategically placed along a natural skin crease to minimize the visibility of the resulting scar. This particular incision style is frequently chosen to avoid any hindrance to a potential future vaginoplasty procedure.

Following the incision, the surgeon carefully identifies, isolates, and gently separates the testicles from the surrounding tissues within the scrotum. The spermatic cord, which contains the blood vessels that supply the testicles and the vas deferens (the tube that carries sperm), is then located. The surgeon will clamp the spermatic cord, tie it off securely with strong stitches (a process called ligation) to prevent any bleeding, and subsequently cut it. In some techniques, the spermatic cord is ligated as close as possible to the external inguinal ring. This approach is believed to reduce the likelihood of palpable cord stumps and generally does not negatively affect the possibility of a future vaginoplasty. Once the spermatic cords are secured and cut, the testicles and a portion of the spermatic cords are carefully removed through the scrotal incision. Meticulous hemostasis, the process of stopping any bleeding, is then performed, often using a technique called diathermy, which utilizes heat to seal blood vessels. The scrotal incision is then closed in layers using absorbable stitches that will dissolve naturally over time. Finally, the incision site may be covered with a surgical adhesive or a sterile dressing to protect it during the initial healing phase. The entire surgical procedure typically takes around 20 to 60 minutes to complete. It is also standard practice for the removed testicles to be sent to a pathology laboratory for histopathological examination, which involves a detailed microscopic analysis of the tissue.

Motivations for Choosing Orchiectomy: Why Individuals Opt for This Procedure#

Individuals choose to undergo gender-affirming orchiectomy for a variety of deeply personal reasons. A primary motivation for many is to alleviate gender dysphoria and achieve a greater sense of psychological well-being through physical congruence with their gender identity. The surgery also plays a crucial role in hormone therapy by significantly reducing or eliminating the body's production of testosterone. This hormonal shift can simplify or even eliminate the need for anti-androgen medications and may potentially lower the required dosage of estrogen, leading to fewer side effects and potentially reduced medical costs.

For many, orchiectomy is a significant step towards future gender-affirming surgeries, particularly vaginoplasty or vulvoplasty. In these cases, the scrotal skin is often intentionally preserved during the orchiectomy to be utilized in the creation of the neovagina and labia. However, orchiectomy is not always a precursor to further genital surgery. Some individuals choose it as a standalone procedure, particularly if they do not desire vaginoplasty or other genital reconstruction but wish to significantly reduce their testosterone levels.

The motivations for orchiectomy also extend to non-binary individuals who seek a body that aligns more closely with their unique gender identity. For some, this may even be part of a broader gender nullification process. In certain situations, individuals may opt for orchiectomy because they are not yet eligible for more complex surgeries like vaginoplasty due to factors such as a high body mass index, smoking habits, or other underlying health concerns. In these cases, orchiectomy can serve as a crucial intermediate step. Other reasons for choosing orchiectomy include a fear of the risks or the perceived invasiveness of more extensive surgeries like vaginoplasty, a personal preference for the outcomes of orchiectomy alone, or a lack of genital dysphoria related to the penis itself. Additionally, some individuals find that orchiectomy improves their comfort with genital tucking.

Orchiectomy with Scrotectomy: Procedure, Implications, and Considerations#

Scrotectomy involves the surgical removal of all or part of the scrotum, the sac of skin that contains the testicles. This procedure is most commonly performed simultaneously with an orchiectomy, though it can occasionally be done as a separate surgery. Combining orchiectomy with scrotectomy has several implications. It completely removes both the primary testosterone-producing organs and the scrotal sac. For some individuals, this combination creates a smoother genital area, which may be desired for aesthetic reasons or enhanced comfort.

However, a significant consideration when opting for scrotectomy is the reduced availability of scrotal tissue for any potential future vaginoplasty. Scrotal skin is frequently used in vaginoplasty to construct the labia majora and to line the neovaginal canal. Therefore, if an individual anticipates potentially undergoing vaginoplasty in the future, a scrotectomy might not be recommended. Conversely, for individuals who are certain they do not want to pursue vaginoplasty and who experience dysphoria specifically related to the presence of the scrotum, combining orchiectomy with scrotectomy during the same surgical procedure can be beneficial. This combination can also be a component of a gender nullification procedure, aiming to create a more ambiguous or neutral genital appearance. There are different surgical techniques for performing a scrotectomy, including the excision of the majority of the scrotal tissue with primary closure of the perineal wound, or the excision of all rugated skin with mons and groin (Y-flap) advancement. Ultimately, it is crucial for individuals considering orchiectomy to have a thorough discussion with their surgeon about their future surgical plans before deciding whether or not to include a scrotectomy.

Orchiectomy without Scrotectomy: Procedure, Implications, and Considerations#

In orchiectomy without scrotectomy, only the testicles are surgically removed while preserving the scrotal sac. This procedure effectively reduces testosterone production while maintaining the scrotal skin for potential future use in vaginoplasty or vulvoplasty. For individuals planning to undergo vaginoplasty later, this approach is typically recommended because the preserved scrotal tissue plays a crucial role in creating the labia and lining the neovaginal canal.

A key consideration with this approach is that the empty scrotal sac remains after surgery. While this is advantageous for those planning future vaginoplasty, individuals who don't intend to pursue additional surgeries might find the empty sac aesthetically undesirable or may continue to experience dysphoria related to it. Over time, the scrotal skin typically undergoes atrophy, becoming smaller and less prominent due to the absence of testicles and reduced testosterone levels. Although this atrophy occurs, it generally doesn't significantly impact future vaginoplasty procedures. However, for individuals with limited scrotal tissue before surgery, a consultation with a vaginoplasty surgeon can help assess potential impacts on future tissue availability. Ultimately, the decision between orchiectomy with or without scrotectomy depends on the individual's personal goals, bodily comfort, and plans for future gender-affirming procedures.

Orchiectomy as Part of Broader Bottom Surgery#

Orchiectomy frequently plays a significant role as part of more comprehensive gender-affirming bottom surgery procedures. Its relationship with vaginoplasty and metoidioplasty is particularly noteworthy.

Relation to Vaginoplasty: Orchiectomy is often a necessary component of vaginoplasty, a surgical procedure aimed at creating a vagina, labia, and clitoris. The removal of the testicles can be performed either simultaneously with vaginoplasty or as a separate preceding procedure. Performing orchiectomy before vaginoplasty offers several advantages, including shorter wait times, reduced procedure duration, and less complex outpatient recovery compared to concurrent procedures. A crucial aspect of this connection is that scrotal skin preserved during orchiectomy without scrotectomy is commonly used during vaginoplasty to create the labia majora and provide lining for the neovaginal canal. Additionally, undergoing orchiectomy prior to vaginoplasty eliminates the need for testosterone-blocking medications leading up to the more complex surgery, potentially simplifying hormone therapy management. Individuals might choose to separate these procedures to manage hormone therapy more effectively, due to personal preference for a staged approach, greater comfort with undergoing two less complex surgeries rather than one more involved procedure, or when not yet eligible for vaginoplasty.

Relation to Metoidioplasty: Metoidioplasty is a gender-affirming bottom surgery option for transgender men that involves creating a phallus using existing genital tissue, specifically the clitoris, which has typically been enlarged through testosterone hormone therapy. While orchiectomy is not always a direct component of the metoidioplasty procedure itself, it is frequently performed in conjunction with it. The primary reason is that individuals undergoing metoidioplasty often still desire a reduction in their natural testosterone production. Orchiectomy can be performed before, during, or after metoidioplasty, depending on specific goals and the overall surgical plan. Additionally, for individuals undergoing metoidioplasty, a scrotectomy and the placement of silicone testicular implants (scrotoplasty) can also be performed either simultaneously with metoidioplasty or in a subsequent stage to create a more typical masculine genital appearance. The relationship between orchiectomy and metoidioplasty thus primarily focuses on achieving hormonal goals and enhancing the overall masculine aesthetic of the genitalia.

The Recovery Journey After Orchiectomy: What to Expect#

The recovery period following an orchiectomy varies among individuals, but generally, most people can expect to return to their usual activities within a couple of weeks, with full healing taking up to approximately eight weeks. Common post-operative symptoms include pain and discomfort in the surgical area, which is typically manageable with prescribed or over-the-counter pain medications. Bruising and swelling in the scrotum and the surrounding groin area are also common and usually subside within two to four weeks. Some individuals may experience numbness or tingling sensations in the groin area due to nerve healing, and this can sometimes persist for several months.

General aftercare instructions typically include keeping the surgical wound clean and dry by showering gently with mild soap, avoiding any harsh scrubbing of the incision. Patients are usually advised to refrain from applying any ointments, lotions, or creams to the incision unless specifically instructed by their doctor. Wearing supportive underwear, as recommended by the medical team, is often advised to help with comfort and healing. It is crucial to avoid strenuous activities, heavy lifting, and driving for a few weeks following the surgery to prevent complications and allow for proper healing. Sexual activity should also be avoided until the surgical site has fully healed, and the individual has been cleared by their doctor to resume such activities. Maintaining adequate hydration and consuming a healthy, balanced diet can also aid in the recovery process. Patients should strictly adhere to their doctor's instructions regarding the use of pain medications and any prescribed antibiotics to prevent infection. Attending all scheduled follow-up appointments with the surgical team is essential for monitoring the healing process and addressing any potential concerns.

Potential Complications of Orchiectomy: Risks and Management#

As with any surgical procedure, gender-affirming orchiectomy carries potential risks and complications, although the likelihood of these occurring is generally low. Potential immediate complications can include bleeding and the formation of a hematoma (collection of blood in the scrotum). Infection at the surgical site is another possible risk. Poor wound healing or wound dehiscence, where the incision opens prematurely, can also occur. As with any surgery involving anesthesia, there is a risk of adverse reactions to the anesthetic agents used. In rare instances, there could be injury to surrounding organs during the procedure. Nerve damage in the groin area, potentially leading to temporary or permanent loss of sensation, is also a possibility. Other less common immediate complications include small blood collections within the scrotum and the formation of a seroma (collection of fluid beneath the skin).

Potential long-term complications are less frequent but can include chronic pain in the operative area and the possibility of feeling the remaining stumps of the spermatic cords. A hernia, although rare, is also a potential long-term risk. Some individuals may experience dissatisfaction with the cosmetic outcome of the surgery. Due to the significant reduction in testosterone production, there is a potential long-term risk of developing osteoporosis if hormone levels are not appropriately managed with estrogen replacement therapy. Changes in sexual function, such as a decrease in libido or erectile dysfunction, can also occur as a long-term effect. Research suggests that undergoing both orchiectomy and vaginoplasty at the same time may carry a higher risk of complications compared to having either procedure performed separately. Additionally, a higher body mass index (BMI) has been identified as a potential risk factor for developing infectious complications following orchiectomy. It is crucial for individuals considering orchiectomy to have an open and detailed discussion with their surgeon about all the potential risks and complications associated with the procedure.

Long-Term Effects and Hormonal Management Following Orchiectomy#

Hormonal Changes: The most significant long-term effect of a bilateral orchiectomy is a substantial and permanent reduction in the body's testosterone production. This hormonal shift leads to a decrease in male secondary sex characteristics and facilitates feminization in individuals undergoing gender transition. Following surgery, individuals will no longer produce sperm, resulting in permanent infertility. Some research suggests that after orchiectomy, the body may have an increased ability to produce estrogen naturally, potentially allowing for a reduction in supplemental estrogen dosage required for feminization. Consequently, anti-androgen medications, which block testosterone effects, are typically no longer necessary after testicle removal. However, it's important to be aware that if reduced testosterone levels are not appropriately managed with estrogen replacement therapy, individuals may experience side effects associated with low sex hormone levels, such as decreased sex drive, difficulties with erectile function, and reduced energy levels. Studies have indicated that testosterone levels in transgender women undergoing feminizing hormone therapy decrease significantly within the first three months and remain low, with no further substantial changes observed after gonadectomy. Similarly, adrenal androgen levels tend to decrease during hormone therapy and do not typically increase after gonadectomy when anti-androgens are discontinued.

It's worth noting that not all individuals who undergo orchiectomy identify as transfeminine or seek feminization. Some AMAB (assigned male at birth) individuals may maintain a male gender identity and masculine presentation while still experiencing genital dysphoria. These individuals may choose to undergo orchiectomy to address their specific dysphoria while continuing or beginning testosterone replacement therapy post-surgery to maintain masculine secondary sex characteristics. This approach allows for genital configuration that aligns with their personal needs while preserving their desired gender expression through hormone management.

Management Strategies: Following orchiectomy, lifelong hormone therapy, primarily with estrogen, is usually necessary to maintain feminization and to prevent potential health issues associated with very low sex hormone levels, such as osteoporosis. For those maintaining masculine presentation, testosterone replacement therapy would be prescribed instead. This ongoing hormone management is a critical aspect of post-operative care. Hormone dosages will likely need adjustment after surgery, and regular monitoring by an endocrinologist or other qualified healthcare provider is essential to ensure optimal hormone levels and overall health. Individuals may also experience changes in mood, energy levels, and sexual desire after surgery, which should be openly discussed with a healthcare provider to determine the best management approach. For those who may wish to have biological children in the future, it is crucial to discuss fertility preservation options, such as sperm banking, before undergoing orchiectomy, as the procedure results in permanent infertility. It is important to recognize that gender-affirming orchiectomy can have significant positive long-term effects on mental health by alleviating gender dysphoria, potentially leading to reduced depression and anxiety, and an overall increase in life satisfaction and psychological well-being.

Conclusion: Orchiectomy as a Significant Step in Gender Affirmation#

Gender-affirming orchiectomy is a surgical procedure involving the removal of one or both testicles, typically performed bilaterally for transfeminine individuals and others seeking to reduce testosterone production and align their physical bodies with their gender identity. The procedure can be performed with or without a scrotectomy, with the decision often depending on individual goals and whether or not the individual plans to undergo future vaginoplasty. Orchiectomy frequently serves as a component or precursor to more complex bottom surgery procedures. While the recovery process is generally straightforward, potential complications should be discussed with a surgeon. Long-term effects primarily involve significant hormonal changes, necessitating lifelong hormone therapy with estrogen and careful medical management. Ultimately, orchiectomy represents a significant and often beneficial step in the gender affirmation journey for many individuals, contributing to improved physical congruence, reduced gender dysphoria, and enhanced overall well-being.

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