Why do trans women and transfeminine people choose orchiectomy as a standalone surgery?

For trans women and transfeminine people, vaginoplasty – the surgical construction of a vulva and vagina from the penis and scrotum, along with grafts of other tissue as needed – is certainly the most well-known genital surgery undertaken as part of transitioning. Vaginoplasty has been found to reduce gender dysphoria, improve body image, boost mental health and well-being, and improve sexual functioning and satisfaction. But it’s also not the only game in town, and some trans women may instead opt for an alternative surgery: orchiectomy, the removal of the testes while leaving the penis and scrotum intact.

While this does not reconstruct the genitals, it does provide a number of advantages. Orchiectomy removes the body’s largest source of testosterone, without requiring the more complex and specialized procedure of vaginoplasty, and with a much shorter recovery time. This can eliminate the need for antiandrogen medications to suppress testosterone – and there are far more surgeons who perform the relatively straightforward procedure of orchiectomy, which is sometimes done for cis men as well, compared to the limited number of surgeons (typically with lengthy waitlists) who can competently craft a new vagina for trans women.

A recent study of all trans patients who received an orchiectomy at the Center of Expertise on Gender Dysphoria in Amsterdam from January 2012 to January 2020 examines what motivated them to choose this surgery and why they may have preferred it to vaginoplasty (van der Sluis, Steensma, & Bouman, 2020). Of the 43 patients who underwent orchiectomy over this time, 37% did wish to have vaginoplasty but were precluded due to smoking, severe health problems, or high BMI – notably, other literature suggests that high BMI is not necessarily a risk factor and should not exclude trans women from receiving vaginoplasty (Ives et al., 2019). A further 33% saw their orchiectomy as a step that precedes eventual vaginoplasty; the authors note that “scrotal skin and fatty tissue should not be excised” during orchiectomy so that it is available for future vaginoplasty, but also that it “may be trimmed according to the individual wish or desire” if later vaginoplasty is not wanted by the patient. 30% stated that they were not seeking to have vaginoplasty at some future time. Overall, 28% stated that they sought orchiectomy so that they could discontinue antiandrogen medication. Other reasons for choosing orchiectomy included a desire to seek vaginoplasty later from other surgeons abroad or using techniques not offered at the clinic, fear of invasive surgery and possible complications, and having a nonbinary gender identity.

91% of patients experienced no complications after surgery, and the most common complication was the formation of a scrotal abscess that needed to be incised and drained. At this clinic, the removed testes are sent for histopathological examination, as the surgery offers an opportunity to identify any malignancies; none were found in this study. The authors also noted that a substantial increase was seen from 2012 to 2020 in both absolute numbers of orchiectomies performed as well as their relative frequency compared to vaginoplasties performed at the same clinic, observing that this upward trend “could not be exclusively explained by the increase of treated transgender individuals in our center”. At least in Amsterdam, orchiectomy is so hot right now.

Following orchiectomy, trans women can typically discontinue all antiandrogen medication (Everett et al., 2020), while estrogen is usually maintained at a similar dosage (Korpaisarn & Safer, 2019). This is a significant benefit, as nearly all antiandrogens seem to come with their own disadvantages: spironolactone is a diuretic that lowers blood pressure and may not suppress testosterone effectively for some women, cyproterone acetate has a small risk of benign brain tumors and isn’t available in the United States, and GnRH agonists are generally very expensive and require injections every month or every three months. For those living in regions where trans-affirming surgeries are not covered by their healthcare providers, the cost of orchiectomy is also far lower than the cost of vaginoplasty. Whether as the last stop or just an intermediate step in your transition, orchiectomy can be a simple and appealing option for those who are ready to ditch testosterone for good. ■