 Greetings, mortals. My name is Ryan and I'm a hacker. I'm also a transgender androgyne who's been doing a bit of gender-affirming biohacking with supervision by licensed medical professionals. If you didn't see the schedule, there's a content warning on this talk. Do what you want with this information. I'm going to be talking about genitals. I'm going to be using words like gender fuck without further warning. I have some pictures to share at the end of nonstandard genital configurations. There will be warnings again before that, so nobody should be surprised. All right, let's get started. First off, why are there so many queers these days? This is kind of what happens when they stop hiding because society is moving from coercive suppression to acceptance. Let's talk about gender a little bit. Rather than trying to describe gender, which just is a mess, let's think about how to represent it in a computer. Nively binary. That's wrong. What about enum? This is a little better, but we can get some nuance in here. Floating point, continuous scale, male on one side, female on the other, some stuff in the middle that's getting there, but this is even better. We have a two-dimensional plane here, male on one axis, female on the other. This captures complexities like agender people who feel very little of either gender or androgynes who feel significant amounts of both, and pretty much everything in between. This is just a shitpost. This is also a shitpost, but it's actually really good. A loosely bimodal point cloud in indimensional space, that's great. Some quick notes here. This is a sensitive subject for a lot of people. Myself personally, I was never male. I pretended to be male for a while, very badly. I also want to note that people who say there are only two sexes vastly underestimate the complexity of human biology and the prevalence of intersex conditions. This is a two-page spread from Scientific American in 2017, which really barely touches the surface about how messy biological sex is in humans. Obviously, you can't read this because that is a shit ton of information. Gender dysphoria is what it's typically called when a person's mental conception of their gender does not match their body. For those who are not aware, the Matrix, aside from being an obscure film released in 1999, is an allegory about being transgender. This is not speculation. It was made by two trans women, the Wachowskis, who were at the time deeply closeted, but they've both since come out and confirmed that their experiences as closeted trans women were significant to the development of this film. This particular line is about gender dysphoria. I do want to note that not all transgender people experience dysphoria, but if you've never felt it, this is spot-on. Okay, so what do we do about dysphoria? That bit about driving you mad, actually not far off the mark. It's far, far easier to address dysphoria physically and socially rather than trying to alter one's mind. This is usually referred to as conversion therapy when you try to talk the trans out of someone and it's torture, and that's why there's a lot of attempts to completely ban it in a lot of places. For many people, transition starts socially. I a few years ago received some amazing advice about this, which was that you don't need to decide what you're going to do all at once. You can just try things, see how they feel, experiment, find some joy for yourself. I also want to say if you have trans people in your life, please support them, even the ones who are not out yet. More matrix stuff that is extremely applicable to gender. In terms of social transition, this is all social convention that exists from society, and most of it has changed over time. High heels were originally for men, wigs, makeup used to be really common for men. Even the most gendered thing that most people can think of these days, the pink and blue motif, has actually swapped over time. For the meat of the talk, I'm going to go into medical transition. That generally starts with hormone replacement therapy, HRT. One of the components of HRT can be reducing the level of testosterone in one's body, which has quite a few effects. What's really interesting is how feminizing this alone can be. There's actually an intersex condition called total androgen insensitivity, where a person is born with XY chromosomes, but their body simply doesn't respond to testosterone, and these people will look female at birth, grow up looking female, develop in puberty as females, and they usually only find out when they turn out to be sterile. If you suppress testosterone, even as an adult, there's a lot of feminization that happens. One of the more interesting things is changes to emotional states. This stacks with increased estradiol, basically turning up the saturation. Otherwise, a lot of this is what you would expect. Another thing that's common is adding external estradiol. The big thing that this does is cause breast growth. It also changes facial shape a bit, redistributes body fats, changes sexual response, even more emotional changes. Some of the more fascinating ones are that the pelvic tilts can change, which makes the body a bit more curvy and can reduce height by one to three inches. I've also heard of people losing a shoe size or two. Then there are also changes to genitals, sensitivity increases, odor changes to be more feminine. The skin becomes more moist, thinner, and fragile. All of these, by the way, the lists are not exhaustive. There's really not been enough research into fully enumerating the effects. Progesterone is interesting because there is a lot of anecdotal data from trans feminine people stating that it does help with breast development. There's some clinical studies that say it does not, which makes a lot of doctors reluctant to provide it to patients. I would trust the anecdotal data far more here. Anyway, what happens when we increase testosterone? Again, this is things that you would expect. Vaginal masculine puberty effects. Even in an adult, you will get changes in body structure, fat distribution. The bone structure is, of course, mostly fixed, but redistribution of fat does quite a lot. The other interesting things are if someone has a clitoris, that will grow bigger, sometimes quite significantly, and vaginal canal will generally experience some degree of atrophy, though it's highly variable how much. Anyway, so if you don't like these packages and you want a pony, well, you might actually be able to have that pony. As I mentioned earlier, research on transgender hormone replacement therapy is rather lacking something I found recently that really made that sink in for me was this paper discussing differences in breast development from cis and trans people. It was published in 1999, sorry, 2019. I am thinking of the Matrix still. Anyway, so it was talking about how in cis people, breast development usually takes four to five years, and it pointed out that as of the date of this paper, there hadn't been any studies following trans patients for four to five years. It all stops after about three. So they don't know the full potential for breast growth in transgender women. What? Then for non-binary people, this image is from a paper that was put out in 2020. Most of the stuff in here is actually just theoretical, probably hasn't been tried on in the actual patients. But it's a nice overview of theoretically what can be done for non-binary patients who want to transition, and even since then, even since then, this, there's not a whole lot. Anyway, so you want a pony, or additions, substitutions, if we're going with the restaurant analogy. There's a couple of strategies for selective HRT effects. There's blockers, which includes receptor antagonists, which can be selective or not. There's inhibitors that prevent production of certain enzymes or homerans. There's targeted topical application, which is another one that a lot of medical professionals will say doesn't work, but anecdotally works great. There's mitigations, and there's surgery. Common one is opting out of balding and or the increases in facial hair and body hair caused by testosterone. The usual strategy for this is to take something called a 5-alpha reductase inhibitor. What this does is prevent the metabolization of testosterone into a stronger androgen called dihydrotestosterone, which is what's responsible for a lot of facial and body hair growth and especially hair loss. There's a couple of these. The commercial name for the most common one is propitia, also known as finasteride. Most of these kinds of drugs do have some level of collateral effects. There's some neurotransmitters that use 5-alpha reductase to be metabolized, and there are potential problems with that. The clinical studies all say that it's fine in the vast majority of cases. The other thing you can do is take an androgen that doesn't metabolize into dihydrotestosterone. There is one called nandrolone, which is mostly used illegally by bodybuilders, but is suggested in the study I took that previous graphic from as an option for non-binary patients. So it's structurally almost identical to testosterone, basically acts on all of the receptors in the body the same way. The only real difference is that when it meets up with 5-alpha reductase, it turns into an inert compound that's just excreted out of the body. Other things, if you want to have only mental effects from having testosterone in your body, you can take an anti-androgen, which does not cross the blood-brain barrier. This is experimental, and if you want to do experimental things, I recommend getting a doctor to supervise it, but theoretically that should work. Another big thing that people want to opt out of is penile atrophy and or decreased erectile function when suppressing testosterone. For some reason, there's an anti-androgen, and I'm not even going to try to pronounce the name of it, that blocks the effect of testosterone without preventing its production in the body. I cannot understand why this works, but it does, and then the typical erectile dysfunction drugs for cis men actually work just fine in trans patients. That's Cialis, Viagra, and the generic versions thereof. Cialis is kind of interesting because there's a once-daily dosage that can be taken. There's also the option of topical application of testosterone directly to the genitals, and if you just want to prevent atrophy, regular use of a vacuum pump will do that. Another thing that people commonly want is to opt out of breast growth from estradiol. The surgical tissue removal is super reliable, but you have to have enough of it to remove, which usually means that you're going to have to accept some initial growth before getting it surgically taken out. But once the tissue is gone, it won't regrow. The other option is selective estrogen receptor modulators. These drugs are mostly all developed for treatment of breast cancer. A lot of them have fairly unpleasant side effects to varying degrees, but as with all drug side effects, your mileage may vary, but these are known to work. This first one here, I found on a website called Mad Gender Science. The idea is to get feminization and mental effects of increased estrogen reliably. This is a testosterone blocker. Instead of actually taking estrogen, the recommendation here was to take one of those serums that I mentioned in the last slide, and then another drug to block the body's natural metabolization of testosterone into estrogen. This last bit, the body naturally processing testosterone into estrogen is why some body builders have breast growth. Anyway, vaginal atrophy, that one's pretty easy to solve. Application of a topical estrogen to the vaginal canal will fix that. Objectively opting into clitoral growth is a thing that there are some communities that just, they're doing that. There's some communities on Reddit for this. They're very much not safe for work, but this is a pretty well-tested thing. It's topical application of either testosterone or dihydrotestosterone, usually the former because the latter is really hard to get a hold of, and then regular vacuum pump use. Selectively getting muscle growth, well, that's just bodybuilding, so there's a bunch of non-viralizing steroid regimens that are designed for cis women which work fine for this. There's also a class of drugs called, oh, I fucked up this slide, selective androgen receptor modulators, SARMS. These are all experimental. I don't think any of them have been approved by drug regulatory bodies for use in humans, but they're available great market. Then there's just fucking gender fuck around and find out, take some testosterone, take some estradiol, take some progesterone, fuck with the dosages, see what happens. Kind of like this. Somebody I showed this to called it a hormone speedball, and I can't argue with that. I'm sorry. I can't. There's a few things that we don't know how to do yet, but really this field of study is only a few years old, so who knows what we'll see in five years. A big one is opting out of voice changes from testosterone. You can mitigate this with voice training, but it's a lot of work. Haven't seen any well-supported regimen for selectively opting into breast growth. Topical application of estradiol does not work and is supposedly a cancer risk. There's some communities that are trying to do this with non-bioidentical estrogen-like substances available in supplements, stuff like fenugreek. It's really not a well-supported thing. I haven't seen any ways to block the mental effects of testosterone without also blocking its effects on the body. I haven't seen any way to block the physical effects of estradiol whilst allowing the mental effects. Anyway, let's talk about hair removal. Hair removal sucks. Most of these are relatively cheap and not too painful or time-consuming, but somewhat fleeting in effect. IPL and laser are the middle grounds here. They have somewhat long-lasting effects, but are more expensive. The only thing that's reliably able to permanently remove the hair is electrolysis. How that works is they stick a thin metal probe into the hair follicle, run an electric current through it to fry the roots, and then pull the hair out one at a time. This is as painful, expensive, and tedious as you would expect, but it is permanent. So usually it requires three to four passes over a particular area because not all of the hair follicles will be killed the first time. Surgeries, masculinizing or de-therminizing surgeries depending on what one's goals are. The big one is chest reconstruction or breast removal. Body contouring, liposuction type things. Facial masculinization surgery exists. I didn't know about that until I started researching for this talk. A lot of the other ones you would expect, removal of uterus, hysterectomy, in terms of creation of a penis. There's actually two options here. There's phalloplasty, which is the only way you'll get one that is sized similar to what a cis man would have. And then there's metoidoplasty, which I might be mispronouncing, which is a surgical enlargement of the clitoris, typically combined with causing growth hormonally. Basically they cut a ligament to allow it to extend further out of the body. Scrotoplasty is an option, vaginectomy, removal of the vagina is an option. Urethral lengthening is done with a phalloplasty to allow peeing out of the newly created penis, which is really convenient. Feminizing, well, breast augmentation is an obvious one, though hormonal breast growth is better than a lot of people would expect. There's body contouring, Adam's apple can be removed, face can be feminized in general. There is something called voice feminizing surgery. I think they use a laser to fuck with the vocal cords. This is not super recommended. There's a lot of risks of complications and it's not super reliable, but it's a thing. Orchaeotomy, removal of the testes, this is a thing that is fairly common for patients to get and not plan to get anything else done on the bottom. There's penectomy, which is almost always not simply removing it, but preserving some of the tissue and moving it elsewhere. Vaginoplasty has actually come in several varieties. The oldest one is the sigmoid vaginoplasty, chooses a portion of the sigmoid colon. Most common type these days is a penile inversion vaginoplasty, which is exactly what it sounds like. There's vaginoplasty using skin grafts from various possible sources. There's hybrid techniques, and then the newest one is known as the peritoneal pull-through. This uses tissue from the abdominal lining, which has a lot of the nice features of the intestinal tissue without a lot of the drawbacks of having to remove intestinal tissues. Also peritoneal tissue goes back really fast, and the whole thing can be done laparoscopically. Tissue self-lubricates a bit, nice and flexible. It's a good option for some people. Vaginoplasty, which is in a lot of cases more accurately referred to as a vulvaplasty, does what you expect. Cliteroplasty is a creation of a clitoris from part of the penile tissue. Quick note here. What medical procedures people have or plan to have for their transition has no bearing on the validity of their identity, and not really any of your business, so don't ask. It's rude. This list is actually much shorter than I expected when I went to go make it. I will note that there are some combinations of things that have not been tried and some that surgeons won't do for various reasons, but if you want urethral lengthening, well, you've got to have a, you've got to build a new penis to put the urethra in. If you want a clitoroplasty, you know, you're going to have to give up your penis. That might not always be true if they find other places to source nerves from, though. Penile inversion, vaginoplasty, obviously you can't turn your penis inside out and keep it. And vaginectomy, if you want the vaginogon, the uterus has to go too, otherwise there will be problems. Okay, so bottom surgery secret menu. In general, no matter how you're born, you can get something called nullification, which is removal of all genitals, optionally a sensate portion of tissue can be left on the pubic mound. Urethra can be left approximately in place or rerouted to the perineum. That's just forward of the anus, though if one does that, they are under significantly increased risk of urinary tract infections because of the bacteria down there. In terms of masculinizing and defeminizing surgeries, there's phalloplasty without burial, which just basically means you leave the clitoris in place and build a penis out of skin graft. Interestingly, you can also get a phalloplasty with a mytoidoplasty, so then you end up with a smaller penis and a bigger penis, two dicks. Like double dick dude on Reddit, like this is a real thing. Anyway, hysterectomy, scrotoplasty, vaginectomy, urethral lengthening, all pretty much optional. Varies from surgeon to surgeon, what you can opt into or out of. There's only a couple surgeons now that will do urethral lengthening on patients who don't get a vaginectomy just because it really has very high complication rates. I think the best surgeons for doing this have 50% complication rates and some surgeons had complication rates as high as 90 before they stopped doing it. Interestingly, there are also some options. The other way around, vaginoplasty without panectomy. This goes by a couple names. It's new enough that the terminology hasn't really been standardized. You might hear it referred to as penile preservation, vaginoplasty, phallus preserving vaginoplasty, penis sparing vaginoplasty, probably other names. As far as anyone can determine, the first time this was done was in 2018. This is possible with any type of vaginoplasty except for penile inversion. Currently, this is mostly done with peritoneal pull through just because that offers a fairly good set of trade-offs. I'm aware of four surgeons openly offering this. I have heard rumors that there are another four. I do not know who they are. As far as I have been able to determine, number of patients who have gone through with this is currently somewhere in the 100 to 150 range, possibly a little higher. This is pretty experimental, but it works. Theoretically, testicles can be retained functionally. I am aware of a patient who had a surgeon agree to do it for her, but that surgery has not taken place yet. I also want to note that there is a clinic offering something called penile perinatail. Anyway, that is not penile preserving. That's a hybrid vaginoplasty technique. The clinic that is offering that, I looked at their website and they made some claims that I find really, really suspicious and unrealistic. That's what I'm going to say about that. I mentioned orchiectomy earlier. That can be done on its own. Confusingly, there is an option called zero-depth or minimal-depth vaginoplasty, which doesn't include a vaginoplasty at all and would be more accurately termed vulvaplasty. That's where they do basically everything in a standard bottom surgery package except for building the vaginal canal. This is great for patients who don't really desire that sort of penetration or aren't comfortable with keeping up on dilation because it's got a much faster recovery time. Okay, pictures. I want to be really clear. I have direct permission for all of these, and I have permission for even providing the links. These are pictures of genitals in non-standard configurations. If you are not comfortable seeing that, close your eyes or leave, please. Again, not my fault if you stay. Okay, this is believed to be the first person to have specifically non-binary bottom surgery. They did this in 2015. They've got a fairly extensive blog about the process. They go by gerbil. Fairly standard phalloplasty with a forearm donor site for the graft. They had urethral lengthening, which did have complications but eventually was sorted out. No scrotoplasty, no vaginectomy, and I believe no hysterectomy because they do mention on their blog still menstruating when they're not on birth control. There's some other people with similar procedures who have been able to even get pregnant after having this done and carried a term. So really not a good idea to give birth vaginally after this, so everybody who's done it has had a C-section. What else do we have? There's another person who I got in touch with who was born with feminine anatomy who has a slightly more interesting anatomical configuration. They did not want their photos shared directly but invited me to include a link. Here it is. They're on Reddit. They have posted pictures. You can go look at those if you like. This patient is, to the best of her knowledge, the second person to get a penis-preserving vaginoplasty. This was in 2018. She was the first person to talk about getting the procedure publicly and share pictures. She's on Reddit. You can go dig up those posts if you want to see it. She answered a whole bunch of questions. Hers was done with an abdominal tissue skin graft because at the time peritoneal pull-through was super, super new. You can see the somewhat healed scar. They're mostly faded. The first picture is 12 months post-op. The others are four years post-op and two years after a revision surgery. A lot of bottom surgeries require actually multiple surgeries because it's not really feasible to get everything right in one surgery. She also wanted me to mention that she's been diagnosed after surgery with classical Ehlers-Danlos syndrome which causes some loose tissue and odd scarring appearance. This is a patient who was actually the first one that was done by her surgeon. These photos are about six months post-op. They do porn, so if you go to her Twitter, it is porn, just so you know. Finally, this is another person also done around the same time as the previous patient. These photos are four months post-op. No labiaplasty attempted during the initial surgery. I will get into why in a moment. This is a dilator. She's able to comfortably accommodate an average size penis in her vagina. We have an immediate post-op photo here. Part of the reason all these are in grayscale, blood hits nowhere near as hard when it's desaturated like this. That's immediately post-op. The other two photos are about seven months later. In the middle, you can see in contrast to the immediate post-op photo, the labia has become detached from the vaginal opening and retracted back up. This is a fairly persistent problem with using scrotal tissue as donor tissue for building a labia, but it can be fixed in revision surgeries. One thing that I found really interesting in looking at this patient's photos is the thermoregulation reflex from the scrotal tissue still works. I don't know by what mechanism that is, but kind of cool. Right on time I have some resources if we can leave this slide up. I have a short link for where these slides will end up in a few hours once I have time to upload them. No Q&A section here, but the resources I've got on this slide are quite good and will lead you to pretty much any other information you could want. I'm happy to respond to people on Twitter. I have a contact page on my website, and I should get out of here so that Matthew Garrett can speak. You should stay for his talk, he's awesome.