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Genital Nullification — AMAB (Penectomy + Bilateral Orchiectomy + Scrotectomy + Perineal Urethrostomy)

Genital nullification (also termed nullo surgery or gender nullification) for AMAB individuals is the removal of penis, testes, and scrotum without creation of a neovagina, resulting in a smooth perineal contour with a perineal urethrostomy (PU) for urinary function.[1] It is an individually customised gender-affirming procedure falling outside the binary surgical options (vaginoplasty or stand-alone orchiectomy) and is most commonly sought by nonbinary or gender-diverse individuals.

This is the dedicated atlas page. For the broader variant-GGAS framework and decision matrix, see Non-Binary / Nullification Gender-Affirming Surgery. For the perineal-urethrostomy component, see 7-Flap Perineal Urethrostomy and Blandy Perineal Urethrostomy. For the orchiectomy component, see Bilateral Simple Orchiectomy. For the canal-creating alternative (external feminine appearance without vagina), see Zero-Depth Vulvoplasty.

Indication and Surgical Goal​

The goal is absence of external genital structures with a smooth, aesthetically neutral perineum and seated-position voiding via a perineal urethrostomy.[1]

This is distinct from:

  • Zero-depth / shallow-depth vulvoplasty — which creates external vulvar structures (labia, clitoral hood, neoclitoris) but no vaginal canal.[1]
  • Full-depth vaginoplasty — neovaginal canal + vulvar structures.
  • Stand-alone bilateral orchiectomy — testes removed but penis and scrotum retained.

Nullification specifically aims for the absence of any genital structures.

Eligibility​

WPATH SOC v8 (2022) recognises that gender-affirming surgical goals are highly individual and that nonbinary individuals may seek procedures that do not conform to traditional binary options.[2][3] General eligibility criteria for irreversible genital surgery include:[4]

  • Persistent, well-documented gender dysphoria.
  • Capacity for informed consent.
  • Well-managed coexisting medical and mental-health conditions.
  • Typically two independent mental-health-professional letters of recommendation.
  • ≥ 12 mo hormone therapy generally recommended for gonadectomy, though individualised.[4][3]

Pezzoli 2026 Delphi consensus on feminising genital surgery in AMAB individuals (largely applicable to nullification) identified BMI > 24.9 kg/m², diabetes, smoking, and cardiovascular disease as significant risk factors for postoperative complications; advanced age alone was not considered a contraindication. Major psychiatric disorders and spinal cord injury are relative contraindications; Charlson Comorbidity Index ≥ 3 is a relative contraindication for vaginoplasty (applicability to nullification extrapolated).[5]

Preoperative optimisation​

  • Smoking cessation ≥ 4 weeks before surgery reduces major pulmonary and wound-healing complications (ACC 2018 expert consensus).[21]
  • Genital hair removal recommended by Delphi consensus to reduce wound complications.[5]
  • Glycemic optimisation — HbA1c screening and optimisation in patients with diabetes or metabolic syndrome (Schaschinger 2025 JAMA Surg preop-HbA1c outcomes).[22]
  • Fertility counselling — sperm cryopreservation should be discussed prior to surgery (bilateral orchiectomy is irreversible).[4]

Surgical Technique — Step by Step​

Per Ascha 2024 individually customised genital procedures (the central GAS-specific reference for this operation):[1]

1. Bilateral orchiectomy​

Rahman / Ferrando 2026 describes the gender-affirming orchiectomy as analogous to vaginal gynecologic procedures — urogynecologists can perform it with minimal additional training.[23] Key steps: midline raphe or bilateral scrotal incision; tunica vaginalis opened; testis delivered; spermatic-cord structures (vas deferens, testicular artery, pampiniform plexus, cremasteric vessels) individually identified, clamped, ligated, divided; gubernaculum divided; hemostasis confirmed; layered closure. Cross-link to Bilateral Simple Orchiectomy for full technique.

Saltman 2023 NSQIP (n = 246 transgender orchiectomies) — overall complication rate 3.7%, comparable to cisgender orchiectomy for non-oncologic indications; safely performed as outpatient.[6]

2. Penectomy​

Total penectomy removes the entire penile shaft (glans, corpora cavernosa, corpus spongiosum). Technique adapted from the oncologic-penectomy literature:[1][24][25]

  • Circumferential skin incision at the base of the penis.
  • Dorsal neurovascular bundle ligated — dorsal arteries, deep dorsal vein, dorsal nerves. Detailed anatomy mapped by Breza 1989 — the cavernous nerves are grossly identifiable structures traceable from penile hilum to prostate. In the nullification context, preservation is unnecessary since the goal is complete removal — distinguishing this operation from feminising-vaginoplasty disassembly (no clitoroplasty target).[26]
  • Corpora cavernosa dissected from pubic-rami attachments (crura). Samm / Steiner technique — a noncrushing vascular clamp placed across the corporal bodies before transection significantly reduces blood loss.[27]
  • Urethra carefully dissected free from the corpus spongiosum and preserved to the length needed for PU.
  • Suspensory ligament divided.
  • Corporal stumps oversewn with absorbable suture for hemostasis.

Penectomy-specific outcomes — Velazquez 2019 NSQIP penectomy n = 304 oncologic cohort: overall complication 19.7%; UTI 3.0%, superficial SSI 3.0%, transfusion-requiring bleeding 3.9%.[28] The oncologic cohort is older (median 67–71 yr) with cancer-related comorbidities — complication rates in younger, healthier gender-affirming patients are expected to be lower. Falcone 2023 penectomy + PU series (n = 10 oncologic): OR time 195 min (IQR 155–275); LOS 8 d (IQR 6–10); postoperative complications 20% (1 surgical revision); postoperative IPSS improved significantly from 15 to 6.[9]

3. Scrotectomy​

Excision of scrotal skin and dartos fascia after orchiectomy. In the nullification context, the goal is complete removal of scrotal tissue to achieve a smooth perineal contour.[1][25]

  • Redundant scrotal skin excised; only enough preserved for tension-free closure.
  • Perineal body carefully preserved to maintain pelvic-floor integrity.
  • For primary closure (typical in nullification given smaller defects), redundant skin is approximated under appropriate tension.
  • For larger defects — fasciocutaneous flaps from thigh or abdominal wall. Staniorski 2023 (n = 20) reported 100% closure rate with 15% complication rate (1 wound infection, 2 bleeding episodes) using fasciocutaneous-flap closure for scrotal defects.[29]
  • Historical oncologic-emasculation literature: a retained scrotum can hang in front of the neourethrostomy and become wet during micturition, causing urinary dermatitis — eliminated when scrotectomy is performed concurrently.[25]

4. Perineal urethrostomy creation​

The bulbar urethra is mobilised and brought to the perineum; meatus spatulated and matured to the perineal skin to create a widely patent stoma. Preservation of the dorsal urethral plate and longitudinal blood supply is critical to minimising stenosis risk:[7][8]

  • Myers 2011 dorsal-plate-preservation technique — 83% primary success; 93% secondary success.[8]
  • Joshi / Morey 2024 algorithmic midline approach — 95.1% success with only 4.9% requiring re-intervention.[7]

Technique selection follows the same algorithmic framework as cisgender PU — see the canonical 7-Flap Perineal Urethrostomy (modern algorithmic midline approach; French / Hudak / Morey 2011) and Blandy Perineal Urethrostomy (classical inverted-U flap; Blandy 1968) pages for technique detail.

5. Closure​

Remaining skin edges approximated to create a smooth, flat perineal contour. The goal is an aesthetically neutral genital area.

Perioperative Management​

Per the Pezzoli 2026 Delphi consensus on feminising genital surgery in AMAB individuals (largely applicable to nullification):[5]

  • Preoperative — genital hair removal recommended; structured counselling on wound care, voiding changes, and irreversibility essential.
  • Catheterisation — urethral catheter typically 3–5 d per Delphi (feminising GAS); PU-specific literature reports 10–21 d (median 15) in the penile-cancer cohort.[5][9]
  • Hospital stay — varies; stand-alone orchiectomy is outpatient; combined nullification may require short inpatient stay (median 8 d in Falcone penectomy + PU series).[6][9]
  • Pelvic-floor PT — pre- and post-operative recommended.[5]
  • No dilation required — unlike vaginoplasty, no neovaginal canal → no lifelong dilation maintenance burden.

Perioperative hormone-therapy management​

Notably no Delphi consensus was reached on the optimal timing of estrogen interruption or re-initiation perioperatively.[5] Newer evidence supports continuation of estrogen perioperatively in most patients:[30][31][32]

  • Herndon 2024 — 75.4% of transfeminine individuals continued estradiol perioperatively with only 0.05% VTE incidence; no significant difference in complications vs those who held estrogen.[31]
  • WPATH guidelines now recommend continuation of estrogen perioperatively to avoid estrogen-withdrawal symptoms (gender dysphoria, vasomotor symptoms).[3]
  • Elevated VTE risk (older age, cardiometabolic comorbidities, higher Caprini score) — individualised assessment with temporary discontinuation may be appropriate.[31][33]
  • Spironolactone can be discontinued after orchiectomy — endogenous testosterone source has been removed.[34]
  • Hung 2024 patterns-of-perioperative-hormone-therapy survey: majority of surgeons provide DVT prophylaxis to all patients for < 30 d postoperatively.[35]

Thromboprophylaxis​

Enoxaparin prophylaxis recommended by Delphi.[5] Transfeminine patients on estrogen are at higher VTE risk than the general population, but absolute risk remains low.[33][36] See Maharaj 2025 for an illustrative case study of postoperative-VTE prophylaxis on estrogen.[30]

Complications​

Component-procedure complication data:

Orchiectomy (Saltman NSQIP n = 246 transgender)[6]​

  • Overall 3.7% complication rate; no significant difference from cisgender orchiectomy for non-oncologic indications.
  • Hematoma, wound infection, rare DVT.

Perineal urethrostomy (aggregated)[10][11][7][8]​

ComplicationIncidenceManagement
Stomal stenosis5–18%Dilation or surgical revision
Wound infection~11%Antibiotics, wound care
Wound dehiscence~4%Conservative or surgical
Urinary spraying / misdirectionVariablePositional adjustment, revision
Urinary incontinenceRare (median ICIQ 0)Pelvic-floor PT

Largest multicentre series (de Vries 2021 penile-cancer n = 299): stenosis in 12%; 74% of stenoses required surgical revision; median time to revision 6.1 mo; stenoses rare after 2 yr follow-up.[10] Prior radiation therapy is the strongest stenosis risk factor (OR 11.2)[8] — likely confers lower stenosis risk in the gender-affirming population, which is typically younger and without radiation history.

Urinary Function After PU​

Long-term urological outcomes are well-characterised:[11][12][7][13]

  • Voiding position — all patients void seated. Morey series: 76% unbothered by the change; 82% reported improvement in overall health.[7]
  • Voiding function — significant LUTS improvement. Shinchi 2021: Qmax 3.8 → 17.6 mL/s; PVR 77.6 → 21.3 mL.[13]
  • Continence — generally well preserved. Klemm 2024 median ICIQ-UI 0 (range 0–21) at median 55-mo follow-up.[11]
  • Retreatment-free survival — 84–95% depending on technique and population.[11][7]
  • Patient satisfaction — consistently 84–86% satisfied or very satisfied.[11][7][13]

Psychological and Quality-of-Life Outcomes​

Nullification-specific PRO data are limited, but the broader GAS literature provides strong support:

  • Almazan / Keuroghlian US Transgender Survey n = 27,715 — GAS associated with lower psychological distress (aOR 0.58, 95% CI 0.50–0.67), lower past-year suicidal ideation (aOR 0.56, 95% CI 0.50–0.64), lower smoking (aOR 0.65, 95% CI 0.57–0.75). Patients who underwent all desired surgeries had significantly lower odds of all adverse mental-health outcomes.[14]
  • Yeo 2026 longitudinal-cohort SR (14 studies, n = 3,023) — initial improvement in psychological well-being and QoL within the first year post-GAS, followed by plateau. Younger age, higher education, and supportive social environment predicted positive outcomes; higher pre-GAS psychopathology predicted poorer outcomes.[37]
  • Cooney 2025 SR (13 studies) — all 4 QoL studies showed statistically significant improvement; all 5 gender-dysphoria studies showed improved gender congruence after surgery.[15]
  • Pletta 2025 (large cohort) — reproductive surgeries (including gonadectomy) rated most satisfactory across all gender-identity groups (mean 4.6/5).[17]
  • Ren 2024 regret-rate SR (24 studies, n = 3,662) — pooled regret prevalence 1.94% (transfeminine 4.0%, transmasculine 0.8%).[37]
  • Hung 2023 validated GAS-specific instrument — 2.8% regret rate across GAS.[16]
ProcedureStructures removedStructures createdDilation requiredVoiding position
Genital nullificationPenis, testes, scrotumPerineal urethrostomy onlyNoSeated
Penile inversion vaginoplastyPenis, testesNeovagina, neoclitoris, labiaYes (lifelong)Seated
Zero-depth vulvoplastyPenis, testesVulvar structures (labia, hood, neoclitoris) — no canalNoSeated
Simple orchiectomyTestes onlyNoneNoStanding

Key distinction: nullification is the only procedure with no constructed genital structures. Claeys 2025 variant-GGAS SR highlights that patients choose variant procedures primarily out of personal desire, to avoid complication risk (e.g., lifelong dilation, urethral complications), or because they do not have dysphoria about certain genital functions but do about genital appearance.[37]

Lifelong Postoperative Care​

After nullification:[18]

Hormone replacement therapy (mandatory after BSO)​

Without sex-hormone replacement, patients are at risk for osteoporosis, cardiovascular disease, metabolic syndrome, and cognitive changes.[4][18][37]

  • Estrogen (for those on feminising therapy) — post-orchiectomy, antiandrogens (spironolactone) can be discontinued. Estradiol dosing typically reduced to ~50 μg/d transdermal or equivalent; serum LH in the normal range is a reliable marker of adequate dosing.[37]
  • Bone health — estrogen preserves BMD in transfeminine patients who continue therapy. Singh-Ospina 2017 meta-analysis: significant lumbar-spine BMD increase at 12 mo (+ 0.04 g/cm²) and 24 mo (+ 0.06 g/cm²) with feminising HRT. However, up to 16% of transgender females have T-scores < − 1 before initiating HRT (baseline osteopenia).[37][4][37]
  • DEXA screening — considered after age 40 if risk factors are present, or with personal fracture history. Appropriate sex reference for FRAX assessment remains debated — some recommend assessing risk with both male and female calculators and using an intermediate value.[4]
  • Calcium and vitamin D — adequate intake recommended for all patients post-gonadectomy.[37][37]
  • Patients who discontinue HRT after gonadectomy are at significant risk for bone loss, vasomotor symptoms, CV disease, and metabolic syndrome.[4][37]

Prostate screening​

Prostate is retained; screening follows standard age and risk guidelines. Digital rectal examination remains the standard approach (unlike post-vaginoplasty where vaginal palpation is used).[34][18]

Breast-cancer screening​

Should follow guidelines for those designated female at birth if the patient has been on estrogen therapy.[34][4]

Other surveillance​

  • PU surveillance — regular follow-up first 1–2 years for stenosis; most present within 18 mo. Annual or as-needed thereafter.[10]
  • UTI surveillance — shortened urethra may increase susceptibility; standard treatment guidelines apply.[18]
  • Lifelong urologic follow-up with a urologist familiar with GAS — AAFP recommendation after masculinising genital surgery, applicable equally to nullification.[18]
  • Psychosocial support — particularly during adjustment; pre-existing mental-health diagnoses may predict worse PROs.[19]

Access and Ethical Considerations​

Only a small number of surgeons currently offer genital nullification — falls outside the standard binary surgical menu. Ascha 2024 reported on just 16 patients undergoing individually customised procedures across their institution.[1]

Nonbinary AMAB individuals have the lowest rate of prior GAS of any gender-identity group — only 17.8% had received any form of GAS in Pletta 2025, vs 58.3% of transgender men.[17] Disparity likely reflects both limited surgical availability and insurance barriers for nonbinary-specific procedures (many policies are structured around binary surgical pathways).[20][1]

Evidence Limitations​

  • Ascha 2024 (n = 16) is the central GAS-specific reference but the cohort spans all customised procedures, not nullification specifically — formal subgroup outcomes data not reported.[1]
  • PU outcomes data are largely extrapolated from cisgender reconstructive-urology and penile-cancer cohorts (Joshi-Morey, Myers, de Vries, Klemm, Shinchi) — younger transmasculine / nonbinary patients without radiation history may have lower stenosis risk.[7][8][10][11][13]
  • No nullification-specific PROMs validated in the nonbinary population.
  • Pezzoli 2026 Delphi consensus addresses feminising genital surgery, not nullification specifically — perioperative recommendations largely transferable but not formally validated for this indication.[5]

References​

1. 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. Jha S, Bouman WP. Introduction to healthcare for transgender and gender-diverse people. Best Pract Res Clin Obstet Gynaecol. 2023;87:102299. doi:10.1016/j.bpobgyn.2022.102299

3. Dakkak M, Kriegel II DL, Tauches K. Caring for transgender and gender-diverse people: guidelines from WPATH. Am Fam Physician. 2023;108(6):626–629.

4. Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6

5. Pezzoli M, Lo Re M, Pizziconi V, et al. International Delphi consensus on feminising genital surgery in assigned-male-at-birth individuals. BJU Int. 2026. doi:10.1111/bju.70196

6. Saltman AJ, Dorante MI, Jonczyk MM, et al. Outcomes of orchiectomy for gender-affirming surgery: a National Surgical Quality Improvement Program study. Urology. 2023;180:98–104. doi:10.1016/j.urology.2023.07.003

7. Joshi EG, VanDyke ME, Langford BT, Franzen BP, Morey AF. Algorithmic midline approach to perineal urethrostomy is associated with long-term success and high patient satisfaction. Urology. 2024;190:133–139. doi:10.1016/j.urology.2024.03.016

8. Myers JB, Porten SP, McAninch JW. The outcomes of perineal urethrostomy with preservation of the dorsal urethral plate and urethral blood supply. Urology. 2011;77(5):1223–1227. doi:10.1016/j.urology.2010.10.041

9. Falcone M, Preto M, Ferro I, et al. Surgical and functional outcomes of penile amputation and perineal urethrostomy configuration in invasive penile cancer. Urology. 2023;177:227. doi:10.1016/j.urology.2023.04.005

10. de Vries HM, Chipollini J, Slongo J, et al. Outcomes of perineal urethrostomy for penile cancer: a 20-year international multicenter experience. Urol Oncol. 2021;39(8):500.e9–500.e13. doi:10.1016/j.urolonc.2021.04.023

11. Klemm J, Dahlem R, Schulz RJ, et al. Perineal urethrostomy for complex urethral strictures: long-term patient-reported outcomes from a reconstructive referral centre and a scoping literature review. J Urol. 2024;212(5):738–748. doi:10.1097/JU.0000000000004169

12. Murphy GP, Fergus KB, Gaither TW, et al. Urinary and sexual function after perineal urethrostomy for urethral stricture disease: an analysis from the TURNS. J Urol. 2019;201(5):956–961. doi:10.1097/JU.0000000000000027

13. Shinchi M, Horiguchi A, Ojima K, et al. Evaluation of the efficacy of perineal urethrostomy for patients with anterior urethral stricture: insights from surgical and patient-reported outcomes. World J Urol. 2021;39(12):4443–4448. doi:10.1007/s00345-021-03795-2

14. Almazan AN, Keuroghlian AS. Association between gender-affirming surgeries and mental health outcomes. JAMA Surg. 2021;156(7):611–618. doi:10.1001/jamasurg.2021.0952

15. Cooney EE, Muschialli L, Yeh PT, et al. Provision of gender-affirming care for trans and gender-diverse adults: a systematic review of health and quality-of-life outcomes, values and preferences, and costs. EClinicalMedicine. 2025;88:103458. doi:10.1016/j.eclinm.2025.103458

16. Hung YC, Park BC, Assi PE, et al. Multidimensional assessment of patient-reported outcomes after gender-affirming surgeries using a validated instrument. Ann Plast Surg. 2023;91(5):604–608. doi:10.1097/SAP.0000000000003652

17. 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

18. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560–565.

19. Haley C, Roblee CV, Blasdel G, et al. Gender-affirming vaginoplasty improves quality of life in transfeminine individuals: a single-centre prospective study. Ann Surg. 2025. doi:10.1097/SLA.0000000000006988

20. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–e88. doi:10.1097/AOG.0000000000004294

21. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC expert consensus decision pathway on tobacco cessation treatment. J Am Coll Cardiol. 2018;72(25):3332–3365. doi:10.1016/j.jacc.2018.10.027

22. Schaschinger T, Niederegger T, Brandt J, et al. Preoperative hemoglobin A1C, glycemic status, and postoperative outcomes in general surgery. JAMA Surg. 2025. doi:10.1001/jamasurg.2025.4706

23. Rahman S, Ferrando CA. Gender-affirming bilateral orchiectomy for the urogynecologist. Int Urogynecol J. 2026;37(4):1091–1094. doi:10.1007/s00192-025-06463-w

24. Falcone M, Preto M, Ferro I, et al. Surgical and functional outcomes of penile amputation and perineal urethrostomy configuration in invasive penile cancer. Urology. 2023;177:227. doi:10.1016/j.urology.2023.04.005

25. Misra S, Chaturvedi A, Misra NC. Penile carcinoma: a challenge for the developing world. Lancet Oncol. 2004;5(4):240–247. doi:10.1016/S1470-2045(04)01427-5

26. Breza J, Aboseif SR, Orvis BR, Lue TF, Tanagho EA. Detailed anatomy of penile neurovascular structures: surgical significance. J Urol. 1989;141(2):437–443. doi:10.1016/s0022-5347(17)40789-0

27. Samm BJ, Steiner MS. Penectomy: a technique to reduce blood loss. Urology. 1999;53(2):393–396. doi:10.1016/s0090-4295(98)00508-1

28. Velazquez N, Press B, Renson A, et al. Development of a novel prognostic risk score for predicting complications of penectomy in the surgical management of penile cancer. Clin Genitourin Cancer. 2019;17(1):e123–e129. doi:10.1016/j.clgc.2018.09.018

29. Staniorski C, Myrga J, Hayden C, Sterling J, Rusilko P. Fasciocutaneous flap perineal closure with testicular thigh pouch for scrotal defects: surgical technique and initial experience. Urology. 2023;182:231–238. doi:10.1016/j.urology.2023.07.039

30. Maharaj SK, Yu A, Singh A, Khanijow K. Transforming culture: postoperative venous thromboembolism prophylaxis in a transgender patient on estrogen. J Gen Intern Med. 2025. doi:10.1007/s11606-025-09668-3

31. Herndon J, Gupta N, Davidge-Pitts C, et al. Genital surgery outcomes using an individualized algorithm for hormone management in transfeminine individuals. J Clin Endocrinol Metab. 2024;109(11):2774–2783. doi:10.1210/clinem/dgae269

32. Nolan BJ, Cheung AS. Estradiol therapy in the perioperative period: implications for transgender people undergoing feminizing hormone therapy. Yale J Biol Med. 2020;93(4):539–548.

33. Arrington-Sanders R, Connell NT, Coon D, et al. Assessing and addressing the risk of venous thromboembolism across the spectrum of gender-affirming care: a review. Endocr Pract. 2023;29(4):272–278. doi:10.1016/j.eprac.2022.12.008

34. Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg. 2017;152(4):394–400. doi:10.1001/jamasurg.2016.5549

35. Hung YC, Assi PE, Park BC, et al. Patterns of perioperative hormone therapy for gender-affirming surgery. Ann Plast Surg. 2024;92(4):442–446. doi:10.1097/SAP.0000000000003820

36. Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women. Lancet Diabetes Endocrinol. 2017;5(4):291–300. doi:10.1016/S2213-8587(16)30319-9

37. Gooren LJ. Care of transsexual persons. N Engl J Med. 2011;364(13):1251–1257. doi:10.1056/NEJMcp1008161

37. Singh-Ospina N, Maraka S, Rodriguez-Gutierrez R, et al. Effect of sex steroids on the bone health of transgender individuals: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2017;102(11):3904–3913. doi:10.1210/jc.2017-01642

37. Verroken C, Collet S, Lapauw B, T'Sjoen G. Osteoporosis and bone health in transgender individuals. Calcif Tissue Int. 2022;110(5):615–623. doi:10.1007/s00223-022-00972-2

37. Yeo KA, Yeo YJ, Ho CSH. Impact of gender-affirming surgery on psychiatric outcomes and quality of life in transgender individuals: a systematic review of longitudinal cohort studies. J Clin Med. 2026;15(6):2213. doi:10.3390/jcm15062213

37. Ren T, Galenchik-Chan A, Erlichman Z, Krajewski A. Prevalence of regret in gender-affirming surgery: a systematic review. Ann Plast Surg. 2024;92(5):597–602. doi:10.1097/SAP.0000000000003895

37. Claeys W, Wolff DT, Zachou A, et al. Variant genital gender-affirming surgery: a systematic review. BJU Int. 2025;135(1):40–53. doi:10.1111/bju.16513