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Page 2 of 13 Ramirez et al. Plast Aesthet Res. 2025;12:16 https://dx.doi.org/10.20517/2347-9264.2025.10

[1]
nearly 50,000 patients . Notably, GAS were originally classified by the binary standard of feminizing or
[2]
masculinizing surgeries due to our limited understanding of gender identity . With a more improved
understanding of gender as a spectrum, GAS may include a wider scope of procedures beyond the
traditional gender binary, aiming to modify sex characteristics to better align with an individual’s
experienced gender identity. While our understanding of gender identity has improved, the discussions
surrounding the preferred surgical options for gender-diverse patients remain limited.

As of 2021, there are an estimated 1.2 million adults in the U.S. who identify as nonbinary, with an
[3,4]
increasing number choosing to pursue surgery due to increased access to care . A recent retrospective
study of a cohort of non-binary adults reported that over half either received or were interested in receiving
GAS . Despite these trends, there is limited information and discussion on surgical considerations for
[5]
gender-diverse individuals, which may involve a combination of reconstruction and the removal of less
desired genitalia. Two less commonly discussed surgeries are nullification and penile sparing vaginoplasty
(PSV). Nullification refers to the excision of genitalia typically associated with the binary sexes (e.g., labia,
penis, testicles, scrotum), resulting in a more neutral physical appearance. PSV, on the other hand, allows
patients to retain a functional penis while also constructing a functional vaginal canal. Individuals may opt
for these surgical options based on unique personal or anatomical priorities that best align with their gender
identity and sexual preferences.

Given the paucity of information and the limited number of reported cases, we aim to provide an initial
framework for discussing the provision of less frequently requested GAS for gender-diverse individuals
assigned male at birth (AMAB). We outline the counseling strategies, surgical techniques, and postoperative
care protocols practiced at our institution. In doing so, we seek to highlight the importance of open
communication in ensuring patient comfort, safety, and satisfaction throughout the process.

PREOPERATIVE COUNSELING
The TGD community has historically faced pervasive discrimination, rejection, and even violence within
the medical system . A 2012 study conducted by Harvard Kennedy School found that trans-identifying
[6]
[7]
patients experienced medical care refusal at a rate of 14%-20% . Understandably, there is a deep distrust of
the medical community - an issue with potentially dire consequences when patients are navigating complex
and life-altering endeavors such as genital-affirming surgery. To promote patient safety and achieve optimal
health outcomes, healthcare providers should make special efforts to build rapport and trust with their
[8]
patients . One suggested approach is the use of a trauma-informed care (TIC) approach [9,10] . TIC
acknowledges that many patients have experienced trauma from various sources and seeks to adapt care
systems to be responsive to those experiences. It offers practical strategies for breaking down barriers and
fostering trust, including patient-centered communication, an understanding of the health impacts of
trauma, and awareness of one’s own implicit biases.

While the field of gender-affirming care has made significant strides in the past decades, it has long been
practiced under a binary standard - presuming that individuals seeking gender affirmation are transforming
[11]
from one gender to another . This perspective reflects a White Western view of gender, overlooking the
needs of non-binary individuals and people of color (POC) communities, who may hold more inclusive
gender perspectives . With this awareness, the author’s institution approaches preoperative counseling for
[11]
GAS with the goal of creating a safe and inclusive environment that enables patients to articulate their goals
for surgery.