Trans People Are Seeking Nonbinary Bottom Surgeries
Across the gender spectrum, some patients are looking for mixed sets of genitals, or none at all. Actually receiving this affirming care isn't easy.
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“How do you describe to someone else the process of becoming real?” asked Hyde Goltz, a 42-year-old nonbinary mortuary student from Minnesota’s Twin Cities. They’ve been trying to find the words to describe their journey since 2014. That year, they received a vagina-preserving phalloplasty, meaning they now have both a vagina and a surgically constructed penis.
Goltz is part of a growing cohort of trans patients who’ve undergone surgeries that allow for dual sets of genitals or other medical interventions that don’t strictly adhere to binary gender norms. VICE spoke to Goltz and three other people about their experiences with individually customizable genital surgeries that affirmed their gender identities. All of them talked about how that put them at odds with some medical providers, compounded systemic barriers to gender-affirming care, and, for some, alienated them from others within the trans community. However, these surgeries ultimately helped them feel more at home in their bodies.
Goltz and many others seeking bigential anatomy—or, both a penis and a vagina—call themselves “Salmacians,” a term coined by sci-fi writer Raphael Carter in the 90s to describe people who want a mixed set of genitals. The term “Salmacian” is derived from the Greek myth of Salmacis and Hermaphroditus, wherein the nymph Salmacis begs the gods to unite her with her male object of desire, Hermaphroditus, and the gods merge the two into a single androgynous being. Despite the relative obscurity of the term—none of the medical professionals VICE interviewed for this article had heard it before—online trans communities claiming it as an identifier have grown into the thousands.
https://www.vice.com/en/article/n7wnbb/tony-mcdade-nina-pop-how-to-help
So, too, has come backlash. Many of the people interviewed for this article requested that their names be changed or partially omitted for privacy reasons, citing public vitriol and violence towards trans people. But for Goltz, who runs a blog chronicling their transition, the majority of the online harassment they receive comes from other trans people. They said they’ve received messages telling them they’re “making a mockery” of the community by “only going halfway.” They described a torrent of derogatory comments from self-proclaimed “trans-medicalists”—those who believe transness is contingent upon a diagnosis of gender dysphoria and a full medical transition. “That was the hardest hate mail to take—other trans people saying, ‘No, you're doing it wrong,’” Goltz said.
The vast majority of trans people never receive genital reconstruction surgery for a host of reasons, including fertility concerns, sexual preference, and systemic barriers in cost and access. Most of those who do undergo genital surgery end up with “binary” external genitalia—a penis or a vagina. Genital reconstruction is commonly known as “bottom surgery,” but the umbrella term covers many different procedures that trans people receive: orchiectomy, penectomy, scrotectomy, vaginectomy, vaginoplasty, phalloplasty, metoidioplasty, and more, often in combination with one another.
There are no national or international databases tracking the prevalence and outcomes of these procedures, but three trans healthcare providers interviewed for this article anecdotally said the same things: Fully binary surgeries are most common. Vagina-preserving phalloplasties, in which a person receives a surgically constructed penis without removing the vulva and vaginal canal, are somewhat common; and phallus-preserving vaginoplasties are extremely rare. Gender nullification, a series of surgeries that remove all external genitalia beyond a urethral opening, is less common but also practiced among cisgender gay men. None of the providers were aware of a case of gender nullification performed on someone assigned female at birth.
Richard Santucci, a surgeon at The Crane Center for Transgender Surgery in Austin, Texas, estimated that he performs the vagina-preserving phalloplasty Goltz received on about 20 percent of his trans-masculine patients each year, and not just nonbinary ones. Many binary trans men don’t pursue vaginectomy, or the surgical closure of the vaginal opening and removal of the vulva, to preserve fertility or sexual function, or because it simply doesn’t trigger their dysphoria.
Santucci emphasized that while trans medicine, including bigenital procedures, is safe, sound, and proven science, trans healthcare providers need to pay more attention to patients seeking these procedures, especially as more queer people embrace explicitly nonbinary identities.
Since he began practicing trans-focused medicine in 2016, Santucci said he has seen shifts in the field. He wrote several dozen papers on genital reconstruction for trans patients at the start of his time at The Crane Center. At the time, he said, this made up a considerable amount of the abstracts on the subject. “One research group should not be able to write a significant chunk of the literature in a year.”
This gap in resources dedicated to trans healthcare can make it substantially harder for trans patients to access it. “It’s been a challenge to get tailored hormone replacement therapy as a nonbinary person,” said Ryan, a London-based computer security researcher in their late 30s who has become an advocate in their industry for trans issues.
Ahead of their phallus-preserving vaginoplasty in 2021, Ryan felt tacit pressure to go on hormones. Although the surgeon they ultimately chose had a hormones-optional policy, other trans providers expressed skepticism surrounding Ryan’s transition. The Standards of Care 8, the professional guidelines crafted by the World Professional Association for Transgender Health (WPATH) discourages antiquated practices of requiring hormone regimens for trans patients to “prove” their transness.
Other notable additions to this version include, for the first time in the SOC’s 40-year history, sections distinctly set out to address the nonbinary community and “eunuchs” (a subset of gender non-conforming individuals who are assigned male at birth, may or may not identify as cisgender, pursue chemical or surgical castration and self-identify with the term).
The updated chapters call for removing barriers to gender-affirming healthcare by focusing on “individual assessments.” For example, it urges surgeons to consider taking on nonbinary patients regardless of whether there has been a “social transition” and regardless of whether a patient has been on hormones, unless necessary for their desired procedure.
Ryan liked the hormones and stuck with them, but has been frustrated by the lack of standards for hormone levels catering to nonbinary patients and their goals. “There was a lot of me digging through publications and medical journals trying to figure out what might be good to do and finding providers willing to work with me.”
Patients seeking bigenital surgery aren’t the only trans people receiving less common forms of gender-affirming care. Mels, a 34-year-old office manager in Delaware, is agender and asexual. She wanted a full gender nullification procedure—a wholly smooth exterior. “It used to always be at the forefront of my mind—anytime I'd go to the bathroom, take a shower, or change my clothes, so multiple times a day,” Mels said. “But now that I don't have any genitals, it's not something I think about, which is the goal.”
Following her orchiectomy, or the removal of the testes, Mels filed with insurance to receive a vaginoplasty, which is the surgical construction of a vagina. In the months of waiting, she discovered there was another, better option: she could just remove her penis, also known as having a penectomy. But she couldn’t find a surgeon in New England or New York who was willing to do it. Mels had to fly out to a private practice in Michigan to receive the care she sought.
“I got fed up with waiting for something that I didn't even want,” she said.
Because Mels had to travel for the surgery, she said she racked up exorbitant bills for flights, hotels, and post-op care—in addition to paying $7,000 out-of-pocket for the procedure itself, because many insurance companies don’t cover penectomies in the same way they do for orchiectomies.
Healthcare providers for the queer community have been expanding their care to accommodate these diverse requests, according to Loren Schechter, a Chicago-based plastic surgeon and the treasurer of WPATH. “The underpinnings of the SOC8 is the individualized nature of care. We have to address the person who's sitting before us,” he said.
Schechter emphasized that while medical providers are still finding new ways to better serve the trans community, modern procedures have a long and storied history in the fields of urology, gynecology, and plastic surgery.
“We often are tasked with creating different and innovative approaches using our knowledge of anatomy, wound-healing, physiology, and drawing from our experience in reconstruction of other areas to meet patients’ needs,” he said. “It’s important to have that historical perspective, the recognition that surgery and medicine are evolutionary processes where we build on all of the work of our predecessors. The field didn't start yesterday, and it didn't start five years ago.”
Cis- and heteronormative perspectives have long overshadowed queer healthcare. This framework has become especially fraught as ideas surrounding what genitals can do and mean evolve.
According to Eric Plemons, a medical anthropologist at the University of Arizona who studies the politics and practice of transgender medicine, early surgeons could only remove—or add—a phallus. “In the same way that the absence of a penis constituted a female, the presence of the organ was a way of constituting maleness for trans men,” he said. “You can see the centering of straight sexual pleasure.”
Pursuing so-called anatomical “correctness” has been the motivating goal for trans medicine for decades. “We can see in the history of trans medicine specifically—the idea that you're asking for [trans-affirming medical interventions] means that you're not really healthy enough to consent to me doing it,” he said. At the same time, he emphasized that “medical boards, licenses, and personal ethics inform what a surgeon perceives as beneficial to a patient[...] Surgeons are not just technicians-for-hire who alter bodies in whatever way a person requests.”
“There are quite a few surgeons that don't do [bigenital surgery],” said Curtis Crane, the founder of The Crane Center. “They believe there’s an inherent harm, that you're leaving someone halfway, in-between, and therefore, incomplete.”
Crane’s practice rejects that line of thought, as does the WPATH. “The main thing I learned from the trans community is that we don't live in a binary world. So why should my treatments be binary?”
Goltz told VICE they were initially turned away by multiple surgeons when they articulated their request for a bigential procedure. But bias impacts not only patients’ access to surgery—it can also increase risks in their post-op care, which, for many patients, is a lifelong endeavor. Vaginoplasty patients use dilators indefinitely so that their vagina doesn’t close up after healing. Orchiectomy recipients, or those who have their testes removed, must often go on testosterone to balance out their hormone levels. Those who receive a surgically constructed penis through metoidioplasty or phalloplasty often need additional surgical shaping and upkeep.
“I'm afraid to leave New York. What if something happened to my genital region and the surgeons don't even know what to do with me?” said Julien, a Brooklyn-based 26-year-old performance artist and sex worker under the name TS Hermaphrodite. He received a vagina-preserving metoidioplasty and phalloplasty in August and November of 2021, respectively. “I am chained to my surgery team for the rest of my life. Until more doctors know how to deal with this kind of surgery I can only go to them with it.”
Still, Julien said the rewards of surgery outweighed the cost of aftercare. “I would not have been a happy, full individual unless I had bottom surgery,” he said.
Back in Minnesota, Goltz recalled their early days post-op. “I woke up in the hospital bed, and I had a definite feeling of completeness,” Goltz said. One of their nurses asked them if they’d pursue chest masculinization, or top surgery, next.
“I thought about it for a minute and said, ‘I think I'm done,’” Goltz said. “I feel like me now.”
