Orchiectomy and Penectomy#

Penectomy: Removal of the Penis#

Understanding the Procedure and Its Goals#

Penectomy—the surgical removal of the penis—is typically performed as part of nullification surgery, which creates a smooth, featureless transition from abdomen to perineum. If orchiectomy removes what produces testosterone, penectomy removes what most visibly marks someone as male-bodied. For many nonbinary individuals seeking a body that defies binary categorization, this surgery represents a path to profound alignment between external anatomy and internal identity.

I know what it's like to search for information about this procedure and find almost nothing. When I was preparing for my own nulloplasty in 2024, I could find clinical descriptions of penectomy for cancer treatment and brief mentions of penectomy as a component of vaginoplasty, but almost nothing about penectomy for people like me—people who wanted the penis gone, full stop, not replaced with something else. The absence of information felt like the medical establishment saying this choice wasn't legitimate enough to document.

The primary motivation is relief from genital dysphoria—eliminating the distress associated with having a penis. This might sound straightforward, but the specific goals vary considerably from person to person. Some seek simplified genital anatomy, avoiding the complexity and lifelong maintenance requirements of vaginoplasty. Others have strong aesthetic preferences for a smooth perineal appearance. Still others find that neither a penis nor a vagina reflects their sense of self, and nullification offers what neither leaving things alone nor pursuing vaginoplasty would provide.

In a secondary analysis of the 2015 U.S. Transgender Survey, respondents reporting one or more gender-affirming surgeries at least two years earlier had lower adjusted odds of severe psychological distress and suicidal ideation than respondents who desired surgery but had not had it (Almazan & Keuroghlian, 2021). This observational association does not establish causation and is not penectomy-specific. The specific literature on penectomy for gender affirmation remains limited—a point I'll return to.

An important caveat: formal peer-reviewed literature specifically on gender-affirming penectomy as a standalone procedure is extremely limited. Most published research focuses on penectomy as a component of vaginoplasty, which serves different surgical goals, or on penectomy for penile cancer treatment, which involves different patient populations and priorities. The information in this guide represents the best available evidence, but readers should understand that some outcome data is extrapolated from related procedures rather than directly studied in this context. Being transparent about these limitations is part of providing trustworthy guidance.

In gender-affirming contexts, total penectomy is the standard approach, removing the entire penis. Partial penectomy, which removes only the distal portion while retaining the shaft, is rarely used for gender affirmation—if the goal is eliminating dysphoria associated with having a penis, leaving part of it defeats the purpose.

A crucial difference from cancer surgery is that gender-affirming penectomy typically preserves neurovascular tissue from the glans to maintain sensation. This tissue may be buried in the mons pubis or used to create a clitoris-equivalent structure (MacPhee, n.d.). The goal is removing what causes dysphoria while preserving the capacity for pleasure—unless the patient specifically prefers otherwise.

Who Is a Good Candidate#

Candidacy requirements align with WPATH Standards of Care Version 8 criteria for genital surgery: persistent, well-documented gender incongruence or gender dysphoria that is marked and sustained over time; age of majority (eighteen or older in most jurisdictions); capacity to provide informed consent and understand the permanent nature of the procedure; mental health that is stable with any significant concerns "reasonably well-controlled"; medical fitness for surgery; and realistic expectations about outcomes (Coleman et al., 2022).

Documentation requirements are set by the surgeon, program, payer, and jurisdiction. Confirm the current written criteria that apply to the proposed operation. SOC8 recommends assessment by a health-care professional competent in transgender health and says one assessment letter can be sufficient if written documentation is required; it does not prescribe a universal letter count, issuer credentials, or template for penectomy (Coleman et al., 2022).

Certain conditions present contraindications. Uncontrolled psychiatric conditions, unrealistic expectations about what surgery can achieve, and inability to provide informed consent are absolute barriers. Relative contraindications—factors that increase risk but don't necessarily prevent surgery—include morbid obesity (which can complicate the perineal urethrostomy), prior perineal surgery, and history of pelvic radiation.

Smoking cessation is required, typically for at least three weeks before and after surgery (Mount Sinai Health System, n.d.). As with any surgery, smoking impairs healing and increases complication risk. This is worth emphasizing: if you smoke, quitting is one of the most important things you can do to improve your surgical outcome.

Fertility preservation discussions are essential. Penectomy is permanent and irreversible. If there's any possibility you might want biological children in the future, sperm cryopreservation must happen before surgery. See Fertility for comprehensive information on fertility preservation options.

The Surgical Process#

Total penectomy for nullification follows a carefully orchestrated sequence. The patient is positioned supine with legs elevated in what's called the lithotomy position—the same position used for many gynecological procedures. A catheter is inserted to identify and protect the urethra throughout the procedure.

The surgeon begins with a circumferential incision at the base of the penis, then releases the penile shaft from surrounding tissues. If sensation preservation is a goal—and for most patients, it is—the neurovascular bundle that supplies feeling to the glans is carefully preserved at this stage. The corpora cavernosa, the erectile tissue that forms the bulk of the penis, is divided from its attachments to the pubic bone. The urethra is shortened and repositioned to its new location. Finally, the wound is closed to create the smooth appearance that characterizes nullification.

The most significant anatomical change involves urethral rerouting. The urethra is shortened and brought to a perineal position—between where the scrotum was and the anus. This is called a perineal urethrostomy, most commonly performed using the Blandy technique with an inverted U-shaped incision. The urethra is spatulated (widened at its new opening) and sutured to perineal skin to create the new urinary opening (Hadj-Moussa et al., 2025). This rerouting is necessary because without a penis, urine needs somewhere else to exit—and the anatomical answer is below, not in front.

The procedure requires general anesthesia—you'll be completely unconscious throughout. Unlike orchiectomy, which is typically outpatient, penectomy usually requires a hospital stay of one to three days. Penectomy alone takes approximately two to three hours; complete nullification (penectomy plus orchiectomy plus scrotectomy) takes approximately three to four hours.

Preparing for Surgery#

Pre-surgical assessment, documentation, medical clearance, testing, and hair-removal planning are specific to the proposed operation and program. Obtain the operating team's written plan. SOC8 is clinical guidance, not a universal payer or surgeon paperwork rule; it does not make a generic mental-health letter, test panel, or hair-removal threshold mandatory for penectomy.

Lifestyle modifications in the weeks before surgery include smoking cessation for a minimum of three to six weeks before and after surgery, reducing or stopping alcohol consumption, stopping blood thinners per your surgeon's instructions, and optimizing nutrition with adequate protein intake to support healing. Your body is about to do significant repair work; giving it good fuel helps.

Practical preparation means arranging a caregiver for the post-operative period and planning for four to eight weeks off work depending on your occupation. If your job involves sitting at a desk, you'll likely return sooner than if your work requires physical activity. Be realistic about what you'll be capable of, and err on the side of more time off rather than less.

Recovery and Healing#

Recovery from penectomy follows a predictable pattern, though individual experiences vary. During the first one to three days, you'll remain in the hospital with a catheter in place. Your activity will progress from bed rest to gradual mobilization—sitting up, standing, taking short walks in the hallway. The catheter handles urination while your new urethral opening heals.

Between days seven and fourteen, the catheter is typically removed—a milestone that marks the transition to using your new anatomy. Wound dressings are changed regularly, and sutures begin dissolving. You'll still be limited in what you can do, but you'll be able to manage basic self-care.

By two to four weeks, patients can perform limited daily tasks. The surgical site is still healing, but the acute recovery phase is past. By four to six weeks, most patients can return to sedentary work while lifting restrictions continue. By six to eight weeks, most normal activities resume. Full healing continues over two to three months, and final results may not be apparent for several months beyond that.

Pain management typically transitions from IV pain medication immediately after surgery to oral pain medication for the first week or so. Beyond that first week, most patients manage with over-the-counter options like acetaminophen or NSAIDs. Many patients report less pain than they anticipated—discomfort rather than agony.

Wound care involves keeping the surgical site clean and dry, gentle washing with mild unscented soap, dressing changes as instructed, and monitoring for signs of infection such as increasing redness, warmth, swelling, or discharge. Dissolving sutures are typically used, so you won't need to return for suture removal.

Activity restrictions are serious and worth following carefully. No heavy lifting—nothing over ten pounds—for the first two weeks. No strenuous activity for four to six weeks. No activities that put pressure on the groin, like bicycling, for six to eight weeks. And no sexual activity for a minimum of six to eight weeks—your surgeon will tell you when you're healed enough.

Urinary Function After Surgery#

After total penectomy with perineal urethrostomy, you will sit to urinate. This is not optional or negotiable—it's simply how anatomy works when the urethral opening is between your legs rather than at the end of a penis. Urine exits through the new opening between the former scrotum area and the anus.

The good news is that normal bladder control is maintained. The muscles that control when you urinate are above the surgical site and aren't affected by the procedure. You won't experience incontinence from the surgery itself, though there's an adjustment period as you learn optimal positioning for comfortable, complete urination.

I'll be honest: learning to urinate with new anatomy takes some adjustment. After my own nulloplasty, I spent the first few weeks figuring out positioning, angles, and how to ensure complete emptying. It's not difficult once you figure it out, but there's a learning curve no one really talks about. Sitting farther back on the toilet than you're used to helps. Leaning forward slightly can ensure complete emptying. And giving yourself patience during that adjustment period matters—you're not doing it wrong, you're just learning.

Standing urination is not possible after total penectomy. Some patients use assistive devices like specialized funnels if standing urination is important for specific situations, but most patients adapt quickly to sitting. If you've spent years uncomfortable with standing at urinals anyway, this aspect of recovery may feel more like relief than loss.

Cancer-treatment literature can describe reconstruction and complications in its own population, but it cannot estimate a gender-affirming penectomy rate. Urinary stream changes, infection concerns, stenosis or stricture, and any need for intervention should be discussed with the surgeon offering the proposed operation and with their procedure-specific follow-up data.

Sexual Function and Sensation#

When glans tissue is preserved and either buried in the mons pubis or used to create a neoclitoris, erogenous sensation can be maintained. The nerve tissue that made the glans sensitive before surgery retains that sensitivity in its new location. Full sensation typically returns within three to nine months as nerves heal (MacPhee, n.d.).

Sensation and orgasm after gender-affirming penectomy depend on the actual operation, retained tissue, nerve work, healing, medications, and the person. The cited Esmonde chapter concerns penile-inversion vaginoplasty, not a standalone gender-affirming penectomy cohort. This guide therefore does not use a six-month 90% orgasm figure or any related-procedure result as a penectomy outcome rate.

The prostate, which remains in place during penectomy, can also provide erogenous sensation. Some patients discover that prostate stimulation becomes a more significant part of their sexuality after surgery.

If you specifically prefer to have all erogenous tissue removed—and some people do make this choice deliberately—orgasm may not be possible afterward. This is a deeply personal decision that should be discussed thoroughly with your surgeon. There's no wrong answer, but it's important to understand the implications of each approach before making an irreversible choice.

Complications and How They're Addressed#

Common complications and their approximate rates include wound infection (5-10%), wound dehiscence or separation (5-10%), bleeding or hematoma (variable but usually minor), urethral stenosis or stricture (12-21%), and urinary tract infections (variable, especially in the early post-operative period). These rates derive primarily from oncology literature and may differ in gender-affirming contexts where patient populations, surgical goals, and absence of underlying disease create different conditions (Hadj-Moussa et al., 2025).

Risk factors for wound healing problems include diabetes, smoking, obesity, and poor nutrition. Prevention involves smoking cessation, optimizing blood sugar control if diabetic, maintaining good nutrition, and carefully following activity restrictions during recovery. Treatment when complications occur may involve wound care, antibiotics, or occasionally revision surgery.

Urethral stricture is the most common long-term complication. When it occurs, it may require dilation in the surgeon's office—a procedure that stretches the narrowed area—or surgical revision using techniques like VY-plasty or tissue grafts. Novel techniques are being developed to minimize stricture rates using principles from vaginoplasty surgery (Hadj-Moussa et al., 2025). If you're considering penectomy, asking potential surgeons about their stricture rates and management approaches is a reasonable question.

Complications can happen even with excellent surgical teams and patients who follow every instruction perfectly. I know this firsthand. After my nulloplasty, I developed complications that led to revision surgery, and that revision led to sepsis that put me in the hospital with a fever over 103°F. If you're reading this post-op and something feels wrong—not just painful, but wrong—trust that instinct. Call your surgeon. Go to the ER. Early intervention can prevent minor issues from becoming major ones.

Psychological adjustment is normal and expected. Some patients experience temporary post-operative depression as they process the reality of permanent bodily change, even when that change was deeply wanted. An adjustment period to changes in body image is typical. Mental health support before, during, and after surgery helps navigate these transitions. If you experienced dysphoria before surgery, you may also need time to learn what it feels like to live without that constant weight—relief can be disorienting in its own way.

Long-Term Outcomes and Satisfaction#

Penectomy results are permanent. Unlike some surgeries that may require revision or maintenance, the perineal urethrostomy is typically stable long-term with no ongoing dilation or special care required. Occasional follow-up for urethral health may be needed, particularly if you experience changes in urinary flow, but there's no equivalent to the daily dilation that vaginoplasty requires.

Regret rates across gender-affirming surgery are remarkably low—lower than most people expect, and lower than many other elective surgeries. A meta-analysis of 7,928 patients across 27 studies found a pooled regret rate of approximately 1% (Bustos et al., 2021). For context, this is lower than regret rates for breast reconstruction (which range from 0-47% depending on the study), bariatric surgery (up to 19.5%), and even major life decisions like having children (7-13%). A 40-year follow-up study of gender-affirming surgery patients found no patient regret and high satisfaction maintained over decades (Pfäfflin, 1993).

When regret does occur, researchers distinguish between different types. True gender regret—regretting having transitioned at all—is very rare. Social regret stems from external pressures or discrimination rather than feelings about the surgery itself. Medical regret relates to complications or unmet aesthetic expectations rather than the decision to have surgery. Understanding these distinctions matters because "regret" is often weaponized in political discourse about trans healthcare without acknowledging that most reported regret is not about being trans or wanting surgery, but about specific outcomes or circumstances.

The cited Amodeo paper concerns adult attachment and transgender identity; it is not a systematic review of surgery outcomes. Standalone gender-affirming penectomy literature remains limited, so this guide does not infer mental-health or quality-of-life outcomes from an unrelated paper or from broader surgery evidence.

Current Clinical Standards#

The WPATH Standards of Care Version 8, published in September 2022, represents a significant evolution toward reduced gatekeeping and greater patient autonomy in gender-affirming care (Coleman et al., 2022). For both orchiectomy and penectomy, the core eligibility requirements include meeting diagnostic criteria for gender incongruence that is marked and sustained over time, capacity to consent for the specific intervention, understanding of effects on reproduction with exploration of fertility preservation options, exclusion of other possible causes of apparent gender incongruence, assessment of mental and physical conditions that could negatively impact outcomes, and stability on a gender-affirming hormonal treatment regimen unless hormones are not desired or contraindicated.

SOC8 does not create a flat rule that every genital surgery changed from 12 to 6 months of hormones or from two letters to one. Hormone criteria are individualized to the intervention and a person's goals, including when hormones are not desired or are contraindicated. SOC8 recommends assessment by a competent health-care professional and says one assessment letter can be sufficient if written documentation is required; surgeons, programs, and insurers may set their own requirements (Coleman et al., 2022; Lai et al., 2023).

SOC8 includes a chapter on eunuchs with recommendations for competent professionals serving eunuch-identified people. It discusses individualized care and may discuss orchiectomy or penectomy in context; it does not define a standard nulloplasty/penectomy operation, create an insurer entitlement, or provide a procedure-specific outcome rate (Coleman et al., 2022).

The guidelines endorse an informed consent model emphasizing patient autonomy and shared decision-making. Mental health evaluation is recommended when concerns about capacity exist, not as a blanket requirement for all patients regardless of circumstances. The goal is ensuring patients are making informed decisions—not creating barriers to care.

Insurance Realities#

Federal law under the Affordable Care Act prohibits discrimination based on gender identity, and most public and private insurance plans cannot maintain blanket exclusions of transition-related care. A 2024 federal court ruling confirmed that state health plans must cover medically necessary gender dysphoria treatment. Over 22 states have explicit protections, with particularly strong coverage in California, Oregon, Washington, New York, and Colorado. Medicare now authorizes coverage for gender-affirming care, though VA coverage remains limited and TRICARE still excludes surgical coverage for dependents.

Prior authorization requirements are payer-specific and may include diagnosis documentation, letters, and hormone-history information. They should not be framed as a contrast with a universal SOC8 six-month rule, because SOC8 does not impose that rule across genital surgeries. See Chapter 7 for detailed guidance on confirming the current documentation requirements with the payer and surgical program.

Common barriers include self-funded employer plans that may exclude transgender coverage, out-of-state plans following different state laws, network limitations since specialist surgeons are often out-of-network, procedure-specific exclusions, and arbitrary BMI cutoffs that exceed what clinical guidelines require.

Insurance and surgical-program requirements can differ from each other and from SOC8 clinical guidance. Confirm the requirements that apply to your procedure rather than assuming a universal SOC7-versus-SOC8 transition from 12 to 6 months of hormones or from two letters to one. SOC8 supports individualized assessment and says one letter can be sufficient if written documentation is required, but it does not dictate every surgeon or insurer's paperwork policy (Coleman et al., 2022).

Major Surgical Centers#

Several major centers in the United States offer these procedures with established track records.

Mount Sinai Center for Transgender Medicine and Surgery in New York performs over 800 transgender-specific surgeries annually with no waiting list. They follow WPATH SOC 8 but require two letters for genital surgery to satisfy insurance requirements. Physical requirements include a BMI target of 33 or lower, nicotine-free status, and hemoglobin A1C of 8.0 or lower for diabetic patients (Mount Sinai Health System, n.d.).

OHSU Transgender Health Program in Portland, Oregon follows WPATH SOC 8 and requires a mental health letter using their standardized template. They offer orchiectomy, vaginoplasty, and vulvoplasty through their urology department and work with Oregon Health Plan (Medicaid), which explicitly covers these surgeries (OHSU, n.d.).

the surgical practice for Transgender Surgery has locations in Austin, San Francisco, and Boulder, and is one of the highest-volume gender-affirming surgery centers in the country. They perform over 130 vaginoplasties and 200 top surgeries annually. They still adhere to SOC 7 requirements for insured patients until insurers adopt SOC 8, requiring two letters and twelve months of hormone therapy for those using insurance. Wait times are approximately four to six weeks for consultation (the surgical practice for Transgender Surgery, n.d.). This is where I had my nulloplasty, and while my experience included complications, I can speak to the skill of the surgical team and the quality of care I received—the complications that arose were managed professionally, and I never felt unsupported through the process.

International Options#

For those willing to travel, international options exist with different requirements and cost structures.

Thailand is the world's most popular destination for self-pay gender surgery, with costs of $10,000-25,000 compared to $30,000-100,000 or more in the United States. Requirements include minimum age of 20 at major centers, psychiatric evaluation, and twelve months of hormone therapy per Thai law. A significant advantage is availability—bookings are often possible within weeks rather than months.

The United Kingdom NHS pathway requires documented persistent gender dysphoria, age 18 or older, twelve months living in a congruent gender role, twelve months of hormone therapy unless contraindicated, and two opinions with the second from an external doctor. Wait times through the NHS are notoriously long, often 12-18 months or more from gender identity clinic referral to surgery.

Canada's British Columbia adopted SOC 8 in February 2023, now requiring only one letter and six months of hormone therapy for genital surgeries (Trans Care BC, 2023). This makes BC one of the more accessible options in North America for those who can access care there.

Making Your Decision#

Questions to Ask Yourself#

Before pursuing orchiectomy or penectomy, consider these questions honestly:

What specific aspects of your current anatomy cause you distress? Is it the presence of testes, the presence of a penis, both, or something else? Understanding precisely what bothers you helps determine which procedure—or combination of procedures—addresses your actual needs.

What do you want your body to look like and feel like afterward? Can you visualize living in that body? If you struggle to imagine it, talking with people who have had these surgeries may help.

How important is fertility to you? If there's any possibility you might want biological children, have you preserved that option? Once these surgeries are done, that door closes permanently.

How do you feel about sitting to urinate? For penectomy, this is the permanent reality. If standing urination is important to you, that's worth examining before proceeding.

What are your expectations about sexual function and sensation? Have you discussed sensation preservation goals with your surgeon? Do you understand what outcomes are realistic?

What is your support system for recovery? Who will care for you in the weeks after surgery? Who will you talk to when recovery is harder than expected?

If complications occur—and they can occur even with excellent surgeons and careful patients—how will you cope? What resources will you draw on?

Questions to Ask Your Surgeon#

When consulting with surgeons, ask about their experience specifically with standalone orchiectomy or penectomy for gender affirmation, not just as components of other procedures. Ask about their complication rates and how they handle complications when they occur. Ask about their approach to sensation preservation if that matters to you. Ask about what recovery support they provide and how you can reach them if something seems wrong.

Ask about realistic timelines—for consultation, for surgery scheduling, for recovery milestones. Ask what insurance they work with and whether they have staff who can help navigate prior authorization.

Ask what they need from you: documentation requirements, pre-surgical preparation, lifestyle modifications. Ask what happens if your circumstances change between consultation and surgery.

And ask any questions specific to your situation that this guide hasn't addressed. There are no foolish questions when you're making decisions about permanent changes to your body.

Reflection Questions#

  1. As you read about orchiectomy and penectomy, which aspects resonated most strongly with your own feelings about your body? Which aspects felt unfamiliar or not relevant to your experience?

  2. What are your primary goals in considering these surgeries? Is it hormonal liberation, relief from tucking, elimination of specific anatomy, simplified body maintenance, or something else? How clearly can you articulate what you're seeking?

  3. How do you feel about the different recovery timelines and demands of orchiectomy versus penectomy? Does the simpler recovery of orchiectomy appeal to you, or are you prepared for the longer recovery that penectomy requires?

  4. If you're considering penectomy, how do you feel about sitting to urinate permanently? Have you thought through what this means for your daily life, travel, and various situations you might encounter?

  5. What are your feelings about fertility and biological children? If there's any uncertainty, have you explored preservation options?

  6. Who in your life knows you're considering these surgeries? Who would support you through recovery? If your support system is limited, what steps could you take to build more support?

  7. How do you imagine your relationship with your body five years after surgery? What would be different? What would be the same?

  8. What fears or concerns about these procedures remain after reading this guide? What additional information would help you address them?

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

Pigot, G. L. S., Al-Tamimi, M., Nieuwenhuijzen, J. A., Buncamper, M. E., Mullender, M. G., & Bouman, M.-B. (2024). Gender-affirming orchiectomy in transgender and nonbinary individuals: A large cohort study with middle- to long-term follow-up. International Journal of Transgender Health, 25(4), 531-541. 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 surgical procedures that alter an individual's physical appearance and sexual characteristics to better align with their identified gender. These procedures, also known as sex reassignment surgery or gender confirmation surgery, form a significant aspect of medical transition for many transgender individuals. While not all transgender people choose surgical interventions, for those who do, these surgeries can play a crucial role in alleviating gender dysphoria and improving overall well-being. Gender affirmation surgeries include both genital and non-genital procedures, tailored to each individual's specific needs and goals. As transgender identities gain increasing recognition and understanding, expertise in gender affirmation surgery continues to grow.

Within the spectrum of gender affirmation surgeries for individuals assigned male at birth, penectomy involves the surgical removal of the penis, either partially or completely. This procedure is primarily sought by transgender women, transfeminine individuals, and nonbinary people who desire penile removal as part of their gender transition. Penectomy can be performed as a standalone procedure or as part of more comprehensive gender-affirming surgical plans. While penectomy is also used to treat penile cancer, in the context of gender affirmation, its primary purpose is to align an individual's physical presentation with their internal gender identity. This alignment can significantly reduce gender dysphoria—the distress experienced when one's assigned sex at birth mismatches their gender identity. For many, penectomy serves as a crucial step toward other feminizing genital surgeries, such as vaginoplasty (creation of a vagina) or vulvoplasty (creation of a vulva). Additionally, nonbinary individuals may choose penectomy as part of gender nullification to achieve a body that aligns with their non-binary identity. When combined with orchiectomy (removal of the testicles), penectomy can also potentially reduce the need for testosterone-blocking medications. The decision to undergo penectomy is therefore often driven by a desire for physical congruence, psychological well-being, and the pursuit of broader gender affirmation goals.

Types of Penectomy#

Penectomy in the context of gender affirmation surgery encompasses several variations, each with distinct characteristics and implications.

Full Penectomy: This procedure involves the complete surgical removal of the entire penis, including the root that extends into the pelvis. In cases of total penectomy, the urethra is typically rerouted to an opening in the perineum, the area between the scrotum and the anus. This procedure, known as perineal urethrostomy, requires the individual to sit down to urinate. A significant advantage of full penectomy for those seeking further feminization is that the penile skin is often utilized in subsequent vaginoplasty procedures to construct the vaginal canal.

Partial Penectomy: This variation involves the removal of only a portion of the penis. Often, enough length is preserved to allow for urination while standing. Partial penectomy might be considered by nonbinary individuals or those who are not planning to undergo vaginoplasty. Depending on the extent of the surgery, some individuals who undergo partial penectomy may still retain some erectile function and the ability to engage in penetrative sexual activity after the healing process is complete.

Penectomy with Orchiectomy: This combined procedure involves the removal of the penis, either fully or partially, along with one or both testicles. This is frequently performed together as part of feminizing bottom surgery. The removal of the testicles leads to a significant reduction in testosterone production, which can decrease or eliminate the need for androgen-blocking medications and potentially lower the required dosage of estrogen in hormone therapy. In many cases, the scrotal skin is preserved during orchiectomy as it can be used later in vaginoplasty or vulvoplasty procedures.

Penectomy with Scrotectomy: This involves the surgical removal of the penis, along with the scrotum, the sac that contains the testicles. This combination may be chosen by individuals who do not plan to undergo vaginoplasty or vulvoplasty. Penectomy with scrotectomy is often a component of gender nullification surgery, aiming to create a smooth and gender-neutral appearance in the genital area.

Penectomy with Orchiectomy and Scrotectomy: This comprehensive procedure involves the removal of the penis, both testicles, and the scrotum. It is often referred to as gender nullification or emasculation and results in a smooth genital area. Similar to total penectomy, the urethra is typically rerouted to the perineum. This combination is often chosen by nonbinary individuals who seek to have neither male nor female genitalia.

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Type of Penectomy Description Impact on Urination Impact on Sexual Function Use of Tissue in Future Surgeries
Full Penectomy Complete removal of the entire penis, including the root. Requires sitting to urinate (perineal urethrostomy). Eliminates penetrative sex. Penile skin often used for vaginoplasty.
Partial Penectomy Removal of a portion of the penis. May allow standing urination. May preserve some erectile function and penetrative sex. Less tissue available for future surgeries.
Penectomy with Orchiectomy Removal of the penis and one or both testicles. Depends on the type of penectomy. Depends on the type of penectomy. Scrotal skin may be preserved for vaginoplasty or vulvoplasty.
Penectomy with Scrotectomy Removal of the penis and the scrotum. Depends on the type of penectomy. Depends on the type of penectomy. No scrotal skin available.
Penectomy with Orchiectomy and Scrotectomy (Nullification) Removal of the penis, testicles, and scrotum, resulting in a smooth genital area. Requires sitting to urinate (perineal urethrostomy). Eliminates penetrative sex. No penile or scrotal skin available.

Pros and Cons of Penectomy for Transgender Individuals#

Undergoing a penectomy as part of gender affirmation carries both potential benefits and drawbacks that individuals must carefully consider.

Pros: Penectomy offers profound alignment with an individual's gender identity, substantially reducing gender dysphoria. This physical congruence typically results in marked improvements in overall quality of life and mental health. For those planning further feminizing surgeries, penectomy serves as a crucial step. The removed penile skin can be skillfully utilized to construct a vagina (vaginoplasty), labia (labiaplasty), and a clitoris (clitoroplasty). Similarly, the glans of the penis may be repurposed to create a clitoris, while scrotal skin can be employed in vulvoplasty or vaginoplasty procedures. When combined with orchiectomy, penectomy significantly impacts hormone therapy by reducing or eliminating the need for testosterone-blocking medications and potentially allowing for lower estrogen doses, which may reduce side effects associated with long-term hormone therapy.

Cons: The irreversibility of penectomy is a primary consideration. This permanent alteration requires careful deliberation and thorough understanding of the implications before proceeding. Penectomy also results in significant changes to urination and sexual function. Total penectomy necessitates sitting to urinate due to the creation of a perineal urethrostomy. While partial penectomy may still allow for standing urination depending on the extent of tissue removed. Total penectomy eliminates the possibility of penetrative sexual intercourse, although partial penectomy might preserve this function in some cases. Furthermore, the surgery may alter how an individual experiences sexual arousal and orgasm. Like any surgical procedure, penectomy carries potential risks including infection, excessive bleeding, urinary tract infections, lymphedema, scar tissue formation, and potential narrowing of the urethra or vagina if vaginoplasty is performed later. Patients can expect pain and discomfort during recovery, with risks of nerve damage or loss of sensation. Wound dehiscence (separation of wound edges) is another potential complication. The recovery period presents additional challenges, often involving hospitalization, urinary catheters, surgical drains, prolonged swelling and bruising, and restricted physical activities. If vaginoplasty follows, lifelong vaginal dilation is typically necessary to maintain the depth and patency of the neovagina. While satisfaction rates after gender affirmation surgery are generally high, it's important to acknowledge that regret, though rare, can occur.

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Category Specific Point Detailed Explanation
Pros Alignment with gender identity and reduction of dysphoria Significant improvement in quality of life and mental health by aligning physical appearance with gender identity; alleviates distress caused by gender dysphoria.
Potential for subsequent feminizing surgeries Penile skin can be used for vaginoplasty, labiaplasty, and clitoroplasty; glans may be used to create a clitoris; scrotal skin can also be used for vulvoplasty or vaginoplasty.
Impact on hormone therapy (when combined with orchiectomy) Reduces or eliminates the need for testosterone-blocking medications; may allow for lower doses of estrogen; can reduce potential side effects associated with hormone therapy.
Cons Irreversibility of the surgery The effects of penectomy are permanent and cannot be reversed; requires careful consideration and informed consent.
Changes in urination and sexual function Total penectomy requires sitting to urinate; partial penectomy may affect the ability to urinate while standing; total penectomy eliminates penetrative sex; may change how one experiences sexual arousal and orgasm.
Potential surgical risks and complications Infection, excessive bleeding, urinary tract infection, lymphedema, scar tissue formation, narrowing of urethra/vagina, pain, nerve damage, wound dehiscence.
Recovery period and associated challenges Hospital stay, urinary catheter, surgical drains, swelling, bruising, time off work, restrictions on activities, potential need for long-term care like vaginal dilation.

Reasons for Choosing Penectomy#

The decision to undergo penectomy as part of gender affirmation is multifaceted, driven by a combination of psychological, emotional, and practical considerations.

For many transgender individuals, the primary motivation is a strong and persistent sense of gender incongruence, coupled with a deep desire for their physical body to align with their internal gender identity. This misalignment can cause significant distress, known as gender dysphoria, which penectomy aims to alleviate, along with associated feelings of anxiety and depression. By undergoing penectomy, individuals often report feeling more comfortable and authentic in their bodies, leading to improved self-esteem and a more positive body image. This deeply personal decision is often rooted in a fundamental need for psychological well-being and self-acceptance.

Personal goals for gender affirmation also play a crucial role. For transgender women and transfeminine individuals, removing the penis is frequently seen as a key step in the process of feminizing their physical appearance. Conversely, for nonbinary individuals, penectomy might be chosen as part of a broader set of procedures aimed at achieving a physical presentation that is gender-neutral or aligns with their specific non-conforming gender identity. The specific goals for gender affirmation are unique to each individual, and penectomy serves different purposes depending on these goals.

Furthermore, considerations for future surgical procedures often influence the decision to undergo penectomy. For individuals planning to have a vaginoplasty, penectomy is often a prerequisite, as the skin from the penis is commonly used to construct the vaginal canal. The choice between a full or partial penectomy can also impact the options available for subsequent genital surgeries. Individuals who do not intend to pursue vaginoplasty might opt for penectomy alone or in combination with scrotectomy as a means of achieving gender nullification. It is also worth noting that some individuals may consider phallus-preserving vaginoplasty, a procedure that creates a vagina while retaining the penis. Therefore, the decision regarding penectomy, including the specific type and whether to combine it with other procedures, is often carefully considered within the context of an individual's broader surgical and gender affirmation goals.

Surgical Procedure and Recovery#

The process of undergoing a penectomy for gender affirmation involves several key stages, from pre-operative preparation to post-operative recovery and long-term considerations.

Prior to surgery, individuals undergo a comprehensive pre-operative process. This includes consultation with an experienced gender affirmation surgeon. Medical evaluations ensure the individual is in good health and fit for surgery. Psychological assessments are also crucial, often requiring support letters from mental health professionals specializing in gender identity. These assessments confirm persistent gender dysphoria and the capacity to provide informed consent. Many cases require hormone therapy for approximately 12 months before eligibility. Lifestyle adjustments, such as smoking cessation, are typically recommended. For those planning future vaginoplasty or vulvoplasty, genital area hair removal may be necessary. Fertility preservation discussions are essential, as penectomy and orchiectomy result in permanent infertility.

Surgical techniques vary depending on the type of penectomy and whether it combines with other procedures. Generally, surgeons make an incision in the penis and remove it either partially or completely. In total penectomy, the urethra is shortened and typically rerouted to the perineum. With concurrent orchiectomy, testicles are removed through a scrotal incision. If scrotectomy is included, the scrotal sac is removed. During surgery, tissues may be preserved for potential use in future vaginoplasty or vulvoplasty procedures. Finally, incisions are closed with sutures.

Immediately following surgery, patients remain under close hospital monitoring. Post-operative care focuses on pain management, infection prevention through wound care and dressing changes, and managing urinary catheters or surgical drains. The typical hospital stay lasts a few days. Initial recovery usually takes several weeks, often 4-6 weeks. During this time, patients must avoid strenuous activities, heavy lifting, and sexual activity to allow proper healing. Swelling and bruising are common and gradually subside over several weeks to months. Regular follow-up appointments with the surgeon monitor recovery progress and address potential complications.

Long-term outcomes include permanent changes to urination and sexual function. Ongoing hormone therapy typically maintains feminization. If vaginoplasty follows, lifelong vaginal dilation maintains the depth and patency of the neovagina. Despite these significant changes, studies generally report high satisfaction rates among individuals who undergo gender affirmation surgery, including penectomy. While the potential for regret exists, it remains low.

Resources and Support Networks#

For individuals considering or undergoing penectomy as part of their gender affirmation journey, access to qualified medical professionals, mental health support, and supportive communities is essential.

Finding experienced surgeons and medical professionals specializing in transgender care is a critical first step. Referrals can be obtained from primary care physicians or endocrinologists with expertise in this area. Gender clinics and transgender health centers serve as valuable resources by bringing together multidisciplinary teams of specialists. Professional organizations such as the World Professional Association for Transgender Health (WPATH) maintain directories of qualified providers who adhere to established standards of care. Various LGBTQ+ organizations also offer online directories and resources to help individuals find appropriate medical care.

Mental health support and counseling services are integral to the process, both for individuals contemplating penectomy and those recovering from the surgery. Therapists and counselors specializing in gender identity and transition provide guidance, support, and address psychological concerns. Mental health assessments are often required before undergoing surgical procedures like penectomy. These professionals help individuals cope with the emotional and psychological adjustments associated with surgery and recovery.

Connecting with support groups and online communities for transgender individuals provides invaluable emotional support and practical advice. Peer support groups offer a safe and understanding space to connect with others who have shared similar experiences. Online forums and communities serve as rich sources of information and emotional support, allowing individuals to connect with others from the comfort of their homes. National and local LGBTQ+ organizations often host support groups and maintain online resources. Building a strong support network is crucial for navigating the challenges and celebrating the milestones of the gender affirmation journey.

Conclusion#

Penectomy, the surgical removal of the penis, is a significant procedure within the broader context of gender affirmation surgery for transgender women, transfeminine individuals, and nonbinary people. Understanding its variations – full or partial, with or without orchiectomy and/or scrotectomy – along with the associated pros and cons, is crucial for informed decision-making. The reasons for choosing penectomy are deeply personal and often driven by a desire for congruence between physical appearance and gender identity, as well as considerations for future surgical options and hormone therapy. While the surgical procedure and recovery involve careful preparation and potential challenges, the long-term outcomes, including high satisfaction rates, underscore the positive impact this surgery can have on the lives of transgender individuals. Accessing qualified medical professionals, mental health support, and robust support networks are vital components of a successful and affirming experience.

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