Bottom surgery
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Bottom surgery, also called lower surgery, is used in the transgender community to mean a variety of kinds of gender-validating surgeries and other procedures that can be done on the reproductive organs or genitals. This is as opposed to top surgery, which is any kind of gender-validating done on the chest or breasts. This article includes some procedures that are non-surgical procedures, or methods of body modification. Some nonbinary people call themselves transsexual and seek bottom surgery, whereas other nonbinary prefer to avoid this word, or prefer not to have surgery. A person doesn't need to have or want bottom surgery in order to be nonbinary. This is true for transgender people of all kinds. Bottom surgery is an option that a person can take on their transition path only if they personally want or need it.
Bottom surgery and gender identity
For binary trans people who want to have surgery, bottom surgery usually means a fairly specific variety of procedures, depending on the individual's needs to treat their gender dysphoria or make their body like that of a cisgender dyadic person of their own gender. For transgender women, bottom surgery usually means taking away the gonads (orchiectomy) and perhaps also making a vagina (vaginoplasty). For transgender men, bottom surgery usually means making a penis (metoidioplasty or phalloplasty), and perhaps also taking away the uterus (hysterectomy) and maybe the vagina as well (vaginectomy). Trans women and trans men need not have their goal with bottom surgery to make their genitals as much like those of a cisgender woman or cisgender man as possible, unless if that is what they personally want or need.
Nonbinary people may want to have bottom surgery as well. In particular, they may want to find out about a much wider variety of ways to change their genitals and reproductive organs, without necessarily having their goal to make theirs look as much like those of a cisgender dyadic person. For this reason, this page lists many other kinds of body modifications to the reproductive organs and genitals. Some of these are not usually called "bottom surgery."
Resources about bottom surgery usually put different kinds of surgeries into groups based on whether they are in the female-to-male or male-to-female transition spectrums. In order to make this page's resources useful and helpful to nonbinary people, people born with intersex conditions, and people seeking kinds of bottom surgery that aren't about making their genitals like that of a cisgender dyadic person, this page instead puts different kinds of surgeries into groups based on which parts of the body they change. This page is written to use anatomically correct and yet gender-neutral language everywhere possible. This includes calling the surgery patient the "patient" or "person," rather than "woman" or "man," and calling the patient by gender-neutral "they" pronouns.
Changes to the gonads
The gonads are the ovaries, testes, or ovotestes. This section is about removing, adding, or otherwise changing the gonads. Depending on what kind of body they started out with, a person can have one or more kinds of these surgeries, if there is something they want or need to change about their gonads.
- Gonadectomy, or castration. A kind of sterilization. Surgery to take away gonads of any kind. This makes it so the person's body can't make hormones any more, so the person needs to either take hormone therapy for the rest of their life, or take the health risks of having very low hormones.
- Orchiectomy. Surgery to take away the testicles. For people on the male-to-female spectrum, they can want this because then their body no longer makes high levels of testosterone, and they don't have to take testosterone blocking medicine anymore. The patient can still get a vaginoplasty later.
- Penectomy with orchiectomy. Removing the penis as well as the testicles.
- Oophorectomy. Surgery to take away the ovaries. For people on the female-to-male spectrum, this can be wanted because it makes pregnancy impossible, but they don't need to do it for hormone balance reasons, which in their case don't call for it. An oophorectomy is usually only done as part of a hysterectomy, or to prevent or treat disease.
- Testicle implants. Surgically putting artificial testicles into the scrotum. These are just for look and feel, and don't make hormones.
- Scrotoplasty. Surgery to create a scrotum, and put artificial testicles into it.
- Vasectomy. For people with testicles, this operation sterilizes them (makes it impossible for them to get others pregnant). It doesn't change their hormone balance or other sexual functions. This can be an alternative to orchiectomy for nonbinary people whose only concern about their testicles is that they feel gender dysphoric about the possibility of getting others pregnant.
Changes to the phallus
On this page, "phallus" means the erectile organ called the clitoris or the penis. This section is about creating, removing, or otherwise changing a person's phallus. Depending on what kind of body they started out with, a person can have one or more kinds of these surgeries, if there is something they want or need to change about their phallus.
- Penectomy. Surgery to take away the penis.
- Penectomy with orchiectomy. Removing the penis as well as the testicles.
- Metoidioplasty. For people with certain kinds of phallus (called either a large clitoris or small penis), this surgery frees the phallus and pulls it outward, making its external size larger, so that it can be easier to use for penetrative sex. If this surgery doesn't involve urethral lengthening, the urethra stays where it was before, which might not be on the phallus. If the patient has a vagina (orifice), this also stays where it was.
- Metoidioplasty with scrotoplasty. This makes the clitoris more like a phallus, and also creates a scrotum.
- Pumping. Not surgery, but a body modification. This practice uses vacuum suction to stretch the phallus and make it larger. Normally this is temporary, but if done on a regular basis, it has long-term or possibly permanent effects toward making the phallus larger. For people who were assigned a female gender at birth, pumping can make it possible or easier to use their phallus for penetrative sex.
- Phalloplasty. Surgery to create a penis by using tissues from other parts of the body, usually skin from the arms or legs. With the addition of a prosthesis inside the penis so that it can become erect, a penis created by phalloplasty can be larger than one created by metoidioplasty. This may or may not involve urethral lengthening.
- Urethral lengthening. For people whose urethra (pee hole) was not located on the end of their phallus, surgery to move the urethra to the end of the phallus. This can optionally be done as part of a metoidioplasty or phalloplasty. Today, the extra piece of urethra tube is made from tissue from another part of the patient's body. In the future, it will be made from lab-grown tissue instead.
- Penis transplant. There have been some successful experiments with this in animals and humans. It could become available to trans people in the future.
- Genital beading, pearling, and penis ribs. These are body modifications that implant materials under the skin of the penis, so that it has raised textures or a different shape.
- Circumcision (if on a penis), or clitoral hood reduction (if on a clitoris). Takes away some or all of the prepuce, permanently exposing the glans. If a person has been circumcised, one option to reverse it is foreskin restoration, which stretches nearby skin to create a new foreskin, to some degree.
Changes to the vagina
On this page, "vagina" refers only to the orifice itself, not the associated external genitals called the vulva. This section is about creating, removing, or otherwise changing a person's vagina. Depending on what kind of body they started out with, a person can have one or more kinds of these surgeries, if there is something they want or need to change about their vagina.
- Vaginoplasty. Surgery to create a vagina, meaning the orifice itself. If the patient was born with a penis, their penis can be part of what the surgeon can use to create a vagina. This is called penile inversion vaginoplasty. Another option is to use a piece of bowel to create a vagina (bowel vaginoplasty). Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used to create a vagina. In the future, patients can get a vagina made from lab-grown tissues, so it isn't necessary to use tissues from their penis.
- Minimum depth vaginoplasty, or labiaplasty without vaginoplasty. Surgery to create a vulva (the external genitals), without creating a vagina (the orifice).
- Vaginoplasty without penectomy. Surgical creation of a vagina, without changing the penis. This may or may not include orchiectomy. A patient might choose to remove the testes and penis in another operation, which may include clitoroplasty. Otherwise, the patient may be content to have a penis, testes, and vagina at the same time. This procedure has been called androgynoplasty, penile-preservation vaginoplasty, or phallus-preserving vaginoplasty, and has only recently started to be offered by some providers.
- Vaginectomy. Surgery to take away the vagina, so there is no orifice there. If the patient chooses to keep their uterus, then the vagina can just be made much smaller and unable to receive penetration, but still able to let menstrual fluids out. The vagina can be fully closed if the patient instead chooses to have their uterus taken away as well (hysterectomy), to make it impossible for the patient to receive vaginal penetration, have menstrual flow, or to get pregnant. Any type of vaginectomy can be done with or without making changes to the phallus or the location of the urethra.
Changes to the labia
Labiaplasty means any kind of change to the labia, whether to create, remove, enlarge, enhance, or otherwise change them. In context with transgender genital reconstruction surgery, labiaplasty usually means creating labia. Depending on what kind of body they started out with, a person can have one or more kinds of these surgeries, if there is something they want or need to change about their labia.
- One form of labiaplasty is surgery to take away the labia minora and/or majora. This can be part of genital nullification.
- One form of labiaplasty is surgery to create labia as part of doing a vaginoplasty (surgery to create a vagina).
- One form of labiaplasty is surgery to create labia and the other parts of the vulva, but without vaginoplasty, so there are external genitals, but no orifice. Also called a vulvoplasty or minimum depth vaginoplasty.
- Labia stretching. Not surgery, but a body modification practice that uses weights or methods of pulling over a long period of time to make the labia minora longer.
Changes to the uterus
In addition to the uterus, this section also deals with some parts connected to the uterus: the fallopian tubes and cervix. Depending on what kind of body they started out with, a person can have one or more kinds of these surgeries, if there is something they want or need to change about their uterus.
- Uterus transplant. A few people have been given a uterus by transplant. Some of those people were afterward able to gestate and give birth to healthy babies. The uterus had to then be removed, because it needed dangerous medicine to keep the body from rejecting the organ. This operation isn't available to transgender people currently.
- Hysterectomy. Surgery to take away the uterus, and sometimes other parts of the reproductive system, depending on the specific kind of hysterectomy.
- Hysterectomy without oophorectomy. Surgery to take away the uterus (and perhaps other parts of the reproductive organs, but without removing the gonads (ovaries), so the patient's body can still make hormones.
- Hysterectomy with vaginectomy. See elsewhere on this page.
- Tubal ligation. A form of sterilization. For people with a uterus, this operation is meant to make it virtually impossible for them to get pregnant. For nonbinary people whose only concern about their uterus is that a risk of pregnancy gives them gender dysphoria, this is an alternative to removing the uterus. This operation has no effect on the menstrual flow, cycle, or hormone balance.
- Uterine ablation. For people with a uterus, this operation is meant to lessen or stop a patient's menstrual flow, by cauterizing the inside of the uterus. This an alternative to removing the uterus, and has no effect on the menstrual cycle or hormone balance. Uterine ablation has to be done after a tubal ligation (or, alternatively, oophorectomy) to make pregnancy impossible, because otherwise the patient is at risk for getting dangerous non-viable pregnancies.
Combined changes
These surgeries make a combination of changes to several areas of the reproductive organs and genitals.
- Penectomy with orchiectomy, called emasculation. Surgery to take away the penis and testicles, without trying to make the genital area like that of a person who was assigned a female gender at birth. The result is a relatively featureless groin. Before the invention of vaginoplasty, this was the main surgery done on trans women and analogous gender-variant identities worldwide. Some such individuals still prefer this surgery, such as hijra, because it is a traditional part of their gender expression outside the Western gender binary. Emasculation reduces a person's options for methods for getting a vaginoplasty later, because one of the most popular options uses tissue from the penis, but it can still be done.
- Metoidioplasty with scrotoplasty. Surgical creation of a penis and balls, without changing the vagina, if the patient had one. Some such patients choose to get a vaginectomy in another operation, if the patient wants. Other patients are content to have a penis, balls, and vagina at the same time.
- Genital nullification. This can mean a variety of different surgeries, depending on what the person's body was like to begin with, to take away most or all of their reproductive organs and genitals. Some nonbinary people seek this in order to be sexless. However, one need not have genital nullification in order to be genderless, because gender identity is different than physical sex.
