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Non-Binary Options For Bottom Surgery

People who identify as non-binary represent a substantial and growing population within the LGBTQ community. Historically, gender-affirming bottom surgery has been binary in nature: Male to Female or Female to Male. However, there's an increasing number of Gender Surgeons who offer individualized treatment options for non-binary people seeking bottom surgery.

Non-binary individuals identify as neither exclusively male or female. The 2015 US Trans Survey, which included 28,000 participants, revealed that 35% of trans respondents identified as non-binary.

People who identify as non-binary may want hormones and surgery, hormones but not surgery, surgery but not hormones, or neither hormones or surgery. In one study, 77.2% of non-binary participants indicated that they had some interest in using hormones or surgery to alleviate gender dysphoria.

In 2015, researchers in the Netherlands examined the motivations behind what they termed as "partial treatment" requests by people applying for gender-affirming surgery. They concluded that only a small number of applicants requested partial treatment to bring their body into alignment with their non-binary gender identity. But a lot has happened since 2015! They/them pronouns are in the Merriam-Webster dictionary now. Historically, only binary trans people were eligible for gender reassignment procedures and the development of non-binary options for bottom surgery has mostly happened in the years since 2015. If a similar study were undertaken now, the results would probably be different.

The researchers acknowledged that a "substantial" number of people had requested partial treatment and this emphasizes the need for information about the medical possibilities and limitations of non-standard treatment options within gender-affirming surgery. For non-binary people who were assigned male at birth and are seeking gender-affirming genital surgery, there are a number of different surgical options to consider.

Orchiectomy
Orchiectomy refers to the removal of the testicles through a scrotal incision. This interrupts the production or testosterone, making androgen-blockers no longer necessary and allowing some people to also lower their estrogen dose. Scrotectomy is the removal of the scrotal sac and is usually performed at the same time as Orchiectomy. If you plan to have Vaginoplasty at a later date, be sure to discuss this with your surgeon as scrotal skin grafts are often incorporated into Vaginoplasty.

Penectomy
Penectomy refers to the removal of the penis. It's sometimes performed for non-binary individuals who wish to no longer have a penis and don't plan to pursue any further genital feminization. Penectomy makes a future Penile Inversion Vaginoplasty impossible so if you think Vaginoplasty might be in your future be sure to discuss this with your surgeon.

Nullification
When Penectomy is performed in conjunction with Orchiectomy and Scrotectomy it's referred to as Nullification or Emasculation. The urethra is re-routed down to the perineum. If preservation of an erogenous zone is desired, sensate glans tissue can be buried it in the deep tissue of the lower mons, above the urethra.

Vulvoplasty
Vulvoplasty is the creation of the labia and clitoris. Unlike Vaginoplasty, Vulvoplasty does not include the creation of the vaginal canal, though a vaginal introitus dimple can be constructed, if desired. The surgery is shorter than Vaginoplasty and risks to adjacent structures such as the rectum are decreased. Vulvoplasty is a suitable surgical solution for those who identify as non-binary and feel that Vulvoplasty offers a result that's more gender-affirming than Vaginoplasty.

Penile-Preserving Vaginoplasty
For some individuals, preservation of the penis is desired, while also creating a fully functional vagina. With Penile-Preserving Vaginoplasty, the vagina can be created using a scrotal or other skin graft, or peritoneal tissue.

In terms of vaginal sensation, one could expect pressure sensation but not touch sensation. "Pressure is felt with insertion of toy or partner and this sensation originates from the muscles surrounding the vagina, the bladder and rectum—same as a natal vagina," says Dr. Heidi Wittenberg, a Urogynecologist in San Francisco who works exclusively with transgender and non-binary patients. "The cool thing is that patients do have an area that is an erogenous zone in the vagina. It's the G-spot! While elusive in many natal vaginas, it is present 3-4 cm in on the top side... the prostate. The prostate is not removed with these surgeries and remains in place."

With a scrotal graft alone, desired vaginal depth may not be possible. With a peritoneal graft, the testicles and scrotum could be kept, but there would be less room and less skin available for the vulva. The urethra can be re-routed or left in the penis. Labiaplasty is optional and often done 6-12 months after the initial surgery.

Insurance
Surgical practices that specialize in gender-affirming surgery have staff who are experienced with successfully billing insurance for both transgender and non-binary patients.

Requirements
To be eligible for genital surgeries, you'll need to provide two letters from mental health professionals who support your desire and medical need for surgery.

The WPATH SOC criteria for genital surgery includes a requirement for 12 continuous months of hormone therapy, but if HRT isn't medically safe or appropriate this doesn't apply. Patients should be taking some form of hormone supplementation after Orchiectomy though, either estrogen or testosterone.

Not every Gender Surgeon is comfortable offering non-binary options, but there's a growing number who recognize the medical need of these procedures and are enthusiastic about providing truly inclusive care. An experienced Gender Surgeon will work with you to create a treatment plan that is specific to you and your needs.

Last updated: 04/08/20