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Non-Binary / Nullification (Special Population)

Non-binary and nullification gender-affirming procedures represent a rapidly evolving area of surgical practice that moves beyond the traditional binary framework of masculinizing or feminizing surgery, offering individually customized approaches that may combine, modify, or altogether differ from standard binary procedures. For binary frameworks, see Feminizing and Masculinizing procedures.

Defining the Population and Surgical Landscape​

Nonbinary people were 672 of 2,176 participants (30.9%) in a U.S. primary-care cohort surveyed in 2019–2021; this describes the surveyed population, rather than current national surgical prevalence.1 In a single-institution chest-surgery series, 13% of all patients were nonbinary, and in another cohort, nonbinary patients accounted for 30.8% of all gender-affirming mastectomies.23

The key distinguishing principle is that non-binary patients may desire selective elements of masculinization or feminization — or neither — rather than a complete binary transition. Surgical goals are highly individualized and may include removing gendered features without replacing them, combining features from both binary paradigms, or creating an anatomy that is intentionally ambiguous or neutral.45

Non-Binary Chest Surgery​

Chest surgery is the most commonly performed procedure for nonbinary AFAB individuals, with 90.7% of nonbinary AFAB patients who had undergone any GAS having had chest surgery.1

Unique Considerations for Nonbinary Patients​

  • Aesthetic goals may differ from transmasculine patients. Some nonbinary patients desire a flat chest identical to a masculine result; others may prefer breast reduction to a smaller, more androgynous chest rather than complete mastectomy. A 755-patient NSQIP analysis reported 30-day complication rates of 4.7% after mastectomy and 3.7% after reduction; this observational comparison does not establish equivalent safety or describe long-term outcomes.6
  • Nipple preferences vary — in one series, 72% of nonbinary patients underwent double incision with nipple grafts, but notably 19% chose double incision without nipple grafts, a significantly higher rate of nipple removal than in transmasculine patients, reflecting diverse aesthetic goals.2
  • No hormone therapy is required as a universal prerequisite for adult chest surgery under WPATH SOC8, which is particularly relevant when hormones are not desired.7 A separate prospective study of adolescents and young adults found improved chest dysphoria after surgery, but was observational and does not establish eligibility for every age group.8
  • Breast reduction as gender-affirming surgery — a NSQIP analysis included 1,222 reductions across cisgender, transgender and nonbinary adults; 73 patients (6% of the entire cohort) were nonbinary. The nonbinary subgroup had a 1.4% 30-day complication rate. Adjusted comparisons were not statistically significant, and the absence of observed severe systemic complications does not establish zero risk.9
  • Outcomes — nonbinary patients reported excellent quality-of-life improvements after chest surgery: comfort with physical appearance scored 4.97/5 with clothes and 4.69/5 without clothes, with improved comfort in exercise (4.07/5) and sex life (4.02/5).2
  • Timeline differences — one 208-patient mastectomy cohort, including 64 nonbinary patients, found group differences in presentation age and treatment timing. These institution-specific associations should not be treated as a universal developmental trajectory.3

Minimal-Depth Vulvoplasty (Shallow-Depth Vaginoplasty)​

Vulvoplasty — creation of external female genitalia without a vaginal canal — is an important option for nonbinary AMAB patients and transfeminine patients who do not desire vaginal penetration or wish to avoid lifelong dilation.

Prevalence and Motivations​

  • In a single-center SDV cohort (35 of 110 primary feminizing genital surgeries, 32%), the most common patient characteristics were age ≥ 40, exclusively feminine-identifying sexual partners, and / or strong aversion to lifelong dilation and douching.10
  • In a Dutch series, the most common motivation was no wish for neovaginal penetration (59%), followed by medical contraindications to full-depth vaginoplasty (24%).11
  • In a Danish cross-sectional study, 26.1% of AMAB TGD respondents preferred vulvoplasty over vaginoplasty, citing lower risk (71%), no desire to dilate (54%), and no need for a vagina (48%).12

Surgical Technique​

Includes orchiectomy, penectomy, creation of a sensate clitoris from the glans, construction of labia majora and minora, and meatoplasty for a downward-directed urine stream. A "dimpled" introitus may be created for aesthetic purposes without a functional vaginal canal.101113

Outcomes​

  • 86% of 29 respondents among 35 SDV patients would choose SDV again; 14% preferred full depth, with almost all in that subgroup describing new masculine-identifying partners. This is a respondent-based preference estimate.10
  • Satisfaction averaged 8.2/10 among 12 respondents in the 17-patient Dutch cohort.11
  • 27% of SDV patients had complications requiring additional surgery; urinary spraying accounted for 82% of these complications.10
  • Postoperative complications were generally minor and treatable (65% uncomplicated course in the Dutch series); meatal stenosis was the most significant complication.11

Implications of Omitting a Vaginal Canal​

There is no constructed canal to dilate, douche or develop canal stenosis. Meatal problems, urinary spraying and other external wound complications can still occur. Patients often choose vulvoplasty to reduce operative or aftercare burden, but these small selected series do not establish a universal reduction in overall complications compared with full-depth surgery.1014

Genital Nullification (Removal of Genitalia With Perineal Urethrostomy)​

Genital nullification customizes removal and reshaping of genital structures to a patient's desired perineal appearance and urinary function. The structures to remove or preserve, urethral outlet, sensation and gonadal plan require explicit discussion; there is no single procedure that applies to every anatomy or goal.

Ascha et al. described 16 patients across three types of customized genital procedures, including genital removal with perineal urethrostomy. This is not a series of 16 nullification operations. Unlike vulvoplasty, the intended result does not necessarily include a vulva. Long-term urinary, sexual, sensory and patient-reported outcomes for individual variants remain sparsely documented.4

Phallus-Preserving Vaginoplasty​

This procedure creates a neovaginal canal while retaining the native penis, with the goal of retaining penile function alongside receptive vaginal intercourse; erectile, ejaculatory and sensory outcomes cannot be guaranteed. It is primarily sought by nonbinary AMAB patients or those who identify outside the gender binary.

Technique​

  • Gonadal preservation or orchiectomy is decided separately according to patient goals; retaining the penis does not require removal of the testes.7
  • A neovaginal canal is created posterior to the urethra using peritoneal flaps, skin grafts, or other tissue sources.
  • The procedure is technically challenging because the standard penile-inversion technique cannot be used (penile skin is not available for vaginal lining).4

Considerations​

  • Requires lifelong dilation similar to standard vaginoplasty.
  • Discuss potential changes in erections, ejaculation and sensation rather than promising preservation.
  • Limited published outcome data; one of the procedure categories in Ascha et al.’s 16-patient mixed series.4
  • Discuss fertility preservation before any gonadectomy; retaining gonads does not guarantee fertility.7

Vagina-Preserving Phalloplasty: Shaft-Only Option​

Shaft-only phalloplasty can create a neophallus while retaining the native vaginal canal and omitting urethral lengthening. This section describes that specific option; vaginal preservation is a separate operative choice, not a synonym for every shaft-only technique.

Technique​

  • A neophallus is constructed using standard flap techniques (RFFF, ALT, etc.) without urethral lengthening.
  • The vaginal canal is preserved; vaginectomy is not performed.
  • Scrotoplasty may or may not be performed (vulvoscrotoplasty).
  • The clitoris may be buried at the base of the phallus or preserved externally.
  • A Y-to-V advancement technique can address clitoral-hood redundancy and improve aesthetics.1516

Outcomes​

  • In a 4-patient series from Oregon Health & Science University, all patients underwent successful shaft-only phalloplasty with vaginal preservation. Detailed long-term outcome data are pending.15
  • Omitting urethral lengthening avoids creating the additional neourethra and its anastomoses. It does not eliminate all urinary or flap-related complications; published evidence for these customized variants remains limited.1516
  • Standing micturition is not possible without urethral lengthening; patients void in a seated position through the native urethra.
  • The procedure preserves fertility potential if the uterus and ovaries are retained.1315

Isolated Gonadectomy as Non-Binary Procedure​

Orchiectomy (AMAB) or oophorectomy (AFAB) may be performed as standalone procedures for nonbinary patients whose goals include reducing gonadal sex-hormone production without additional genital reconstruction.

  • Simple orchiectomy removes the main source of testicular testosterone; adrenal androgen production remains. Medication needs should be reassessed rather than assuming all circulating testosterone is eliminated. It can serve as a bridge to future vaginoplasty or as a definitive standalone procedure.17
  • When orchiectomy is performed as a standalone procedure (not as a bridge), scrotal skin may be removed. When performed as a bridge to future vaginoplasty, scrotal skin should be preserved for use in neovaginal construction. Prior orchiectomy increases the odds of needing extragenital skin grafts during subsequent vaginoplasty by 3-fold.18
  • Bilateral gonadectomy requires a long-term endocrine and bone-health plan. Adequate sex-steroid therapy is generally important to avoid prolonged hypogonadism; the regimen depends on age, goals, contraindications and ongoing assessment.137

Eligibility, Insurance, and Access Barriers​

WPATH SOC 8 broadened language to explicitly include nonbinary and gender-diverse individuals, emphasizing that surgical interventions should be individually tailored rather than limited to binary paradigms. For adults who meet the criteria, SOC8 recommends one opinion from a competent professional when an opinion or documentation is required; this is not necessarily a mental-health-only assessment.19207

Published insurance studies describe barriers at the time their policies were sampled; they are not a current coverage inventory:

  • Insurance concordance with WPATH SOC 8 remains incomplete. Many policies still require 12 months of hormone therapy before surgery — a criterion that may be inappropriate for nonbinary patients who do not desire hormonal treatment.2122
  • Reversal and revisionary procedures are covered by less than 25% of insurance policies.21
  • Facial GAS procedures with "cosmetic overlap" are frequently excluded.21
  • Individually customized procedures (phallus-preserving vaginoplasty, vagina-preserving phalloplasty, genital nullification) often lack specific CPT codes and may face coverage denials due to their novelty and lack of established medical-necessity criteria.4
  • A national survey found denial rates of 28% for hormone therapy and 22% for GAS among transgender people seeking coverage.23

Summary of Non-Binary & Nullification Procedures​

ProcedureTarget PopulationKey FeatureSatisfactionEvidence Base
Chest surgery (mastectomy ± nipple removal)Nonbinary AFABFlat or androgynous chest; no HRT required4.88/5 QoLModerate (multiple series)12
Breast reduction (non-mastectomy)Nonbinary AFABSmaller, androgynous chestHighModerate (NSQIP data)69
Minimal-depth vulvoplastyNonbinary / transfeminine AMABExternal vulva, no vaginal canal, no dilation86–93%Moderate101112
Genital nullification / perineal urethrostomyIndividually selected anatomy and goalsCustomized perineum and urinary outletLimited dataSubset of 16 mixed customized procedures4
Phallus-preserving vaginoplastyNonbinary AMABRetains penis + creates vaginal canalLimited dataSubset of 16 mixed customized procedures4
Vagina-preserving phalloplastyNonbinary AFABCreates phallus + retains vaginal canalLimited dataVery limited (n = 4)1516
Isolated orchiectomyNonbinary AMABReduces testicular testosterone; standalone or bridgeHighModerate1718
Isolated oophorectomy / hysterectomyNonbinary AFABHysterectomy stops uterine bleeding; ovarian removal is a separate hormonal decision4.4–4.6/5Moderate13

Key Takeaways for Clinical Practice​

The overarching principle for non-binary and nullification procedures is individualized goals and informed choices. Surgeons must move beyond a menu of binary options and engage in detailed, patient-centered goal-setting conversations. The evidence base for most non-binary-specific procedures remains limited to small case series, and applicability of standardized measures to each customized procedure remains uncertain.4 The 2025 GenderCOS project established 11 core outcomes for feminizing genital surgery, including seven applicable across those operations and four for canal construction; this is progress in outcome standardization, not validation for every nonbinary procedure.24 Preoperative counseling should address the irreversibility of certain procedures (particularly genital nullification), fertility implications, long-term endocrine needs after bilateral gonadectomy, and the limited long-term outcome data available for novel procedures.

Footnotes​

  1. Pletta DR, Quint M, Radix AE, et al. "Gender-Affirming Surgical History, Satisfaction, and Unmet Needs Among Transgender Adults." JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494 ↩ ↩2 ↩3

  2. Esmonde N, Heston A, Jedrzejewski B, et al. "What Is 'Nonbinary' and What Do I Need to Know? A Primer for Surgeons Providing Chest Surgery for Transgender Patients." Aesthet Surg J. 2019;39(5):NP106–NP112. doi:10.1093/asj/sjy166 ↩ ↩2 ↩3 ↩4

  3. Skorochod R, Rysin R, Wolf Y. "Gender Affirming Surgery in Non-Binary Patients: The Importance of Patient-Centered Care." J Plast Reconstr Aesthet Surg. 2023;84:176–181. doi:10.1016/j.bjps.2023.05.050 ↩ ↩2

  4. Ascha M, Rigsby S, Shoham M, et al. "Individually Customized Gender Affirming Genital Procedures: Techniques and Considerations." J Sex Med. 2024;21(9):827–834. doi:10.1093/jsxmed/qdae075 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  5. Bouman WP, Thorne N, Arcelus J. "Nonbinary Gender Identities." Best Pract Res Clin Obstet Gynaecol. 2023;88:102338. doi:10.1016/j.bpobgyn.2023.102338 ↩

  6. Cuccolo NG, Kang CO, Boskey ER, et al. "Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes." Aesthetic Plast Surg. 2019;43(6):1575–1585. doi:10.1007/s00266-019-01479-2 ↩ ↩2

  7. Coleman E, Radix AE, Bouman WP, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8." Int J Transgend Health. 2022;23(Suppl 1):S1–S259. doi:10.1080/26895269.2022.2100644 ↩ ↩2 ↩3 ↩4 ↩5

  8. Ascha M, Sasson DC, Sood R, et al. "Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults." JAMA Pediatr. 2022;176(11):1115–1122. doi:10.1001/jamapediatrics.2022.3424 ↩

  9. Miller AS, Escobar-Domingo MJ, Lee BT, et al. "Breast Reduction Epidemiology and Complications in Nonbinary, Transgender, and Cisgender Adults." J Surg Res. 2024;302:437–445. doi:10.1016/j.jss.2024.07.079 ↩ ↩2

  10. Stelmar J, Smith SM, Lee G, Zaliznyak M, Garcia MM. "Shallow-Depth Vaginoplasty: Preoperative Goals, Postoperative Satisfaction, and Why Shallow-Depth Vaginoplasty Should Be Offered as a Standard Feminizing Genital Gender-Affirming Surgery Option." J Sex Med. 2023;20(11):1333–1343. doi:10.1093/jsxmed/qdad111 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  11. van der Sluis WB, Steensma TD, Timmermans FW, et al. "Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes." J Sex Med. 2020;17(8):1566–1573. doi:10.1016/j.jsxm.2020.04.007 ↩ ↩2 ↩3 ↩4 ↩5

  12. Aaen EK, Kesmodel US, Pop ML, Højgaard AD. "Requests for Vulvoplasty as Gender-Affirming Surgery: A Cross-Sectional Study in Denmark." J Sex Med. 2024;21(3):262–269. doi:10.1093/jsxmed/qdae003 ↩ ↩2

  13. Jackson Q, Yedlinsky NT, Gray M. "Lifelong Care of Patients After Gender-Affirming Surgery." Am Fam Physician. 2024;109(6):560–565. ↩ ↩2 ↩3 ↩4

  14. Jiang D, Witten J, Berli J, Dugi D. "Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women." J Sex Med. 2018;15(6):902–906. doi:10.1016/j.jsxm.2018.03.085 ↩

  15. Chen W, Cylinder I, Najafian A, Dugi DD, Berli JU. "An Option for Shaft-Only Gender-Affirming Phalloplasty: Vaginal Preservation and Vulvoscrotoplasty. A Technical Description." Plast Reconstr Surg. 2021;147(2):480–483. doi:10.1097/PRS.0000000000007579 ↩ ↩2 ↩3 ↩4 ↩5

  16. Moorefield AK, Veith JP, Mills A, et al. "Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty." Plast Reconstr Surg. 2024;154(1):186e–189e. doi:10.1097/PRS.0000000000010932 ↩ ↩2 ↩3

  17. Hehemann MC, Walsh TJ. "Orchiectomy as Bridge or Alternative to Vaginoplasty." Urol Clin North Am. 2019;46(4):505–510. doi:10.1016/j.ucl.2019.07.005 ↩ ↩2

  18. Sineath RC, Butler C, Dy GW, Dugi D. "Genital Hypoplasia in Gender-Affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning." J Urol. 2022;208(6):1276–1287. doi:10.1097/JU.0000000000002900 ↩ ↩2

  19. Lai A, Johnson R. "World Professional Association for Transgender Health Guidelines: 2022 Surgical Treatment Updates in the Standards of Care for Transgender and Gender Diverse People." Neurourol Urodyn. 2023;42(5):900–902. doi:10.1002/nau.25099 ↩

  20. Amengual T, Kunstman K, Lloyd RB, Janssen A, Wescott AB. "Readiness Assessments for Gender-Affirming Surgical Treatments: A Systematic Scoping Review of Historical Practices and Changing Ethical Considerations." Front Psychiatry. 2022;13:1006024. doi:10.3389/fpsyt.2022.1006024 ↩

  21. Diaddigo SE, LaValley MN, Asadourian PA, et al. "Concordance of National Insurance Criteria With WPATH Standards of Care for Gender-Affirming Surgery." Plast Reconstr Surg. 2024;154(3):685–693. doi:10.1097/PRS.0000000000011144 ↩ ↩2 ↩3

  22. Ngaage LM, Knighton BJ, McGlone KL, et al. "Health Insurance Coverage of Gender-Affirming Top Surgery in the United States." Plast Reconstr Surg. 2019;144(4):824–833. doi:10.1097/PRS.0000000000006012 ↩

  23. Sandhu S, Liu M, Keuroghlian AS. "Strategies for Insurers to Promote Health Among Sexual and Gender Minority People." JAMA Health Forum. 2024;5(4):e240439. doi:10.1001/jamahealthforum.2024.0439 ↩

  24. Vallinga MS, Roijer PJ, Pidgeon TE, et al. "The Core Outcome Set for Studies on Feminizing Genital Gender-Affirming Surgery: Findings From the GenderCOS Project." EClinicalMedicine. 2025;85:103323. doi:10.1016/j.eclinm.2025.103323 ↩