Phalloplasty, which is surgery to build a penis, is one of the most complicated procedures in medicine. The term technically refers to one step in a long process, which is making a phallus out of a flap of a person’s own skin. However, it is more often used to describe a group of surgeries that each focus on a different part of the penile organ. The penis is a unique organ that does a bunch of different things that you might not put together if you were making it from scratch. The heart moves blood around, and the stomach breaks down food. The penis makes babies, pees, and sends pleasure. It responds to temperature, feelings, and touch. It is a complicated collection of tubes, tissue, and nerves that are set up in the awkward space between the legs.
People who get phalloplasty most often are transgender men and nonbinary people, intersex people, and cisgender men with injuries to their penises. The way these groups look at the start can be different, but in general, the surgical methods are the same. A phalloplasty might also include extending the urethra, making a scrotum, defining the glans, adding testicular prostheses, or putting in an erectile implant, in addition to making the shaft. Depending on how many procedures are done, a penis could take up to two years to finish. This is because there are many stages and revisions of surgery, as well as a long-term commitment to planning life around access to doctors, insurance coverage, time off work, and care after surgery. Surgeons I talked to said that trans patients have a high risk of complications—about 70%, to be exact. (Empirical analysis is hard because there aren’t many patients and the procedure can be done in different ways.) Still, most patients are happy with their care. One report, which was given at the 2012 Canadian Professional Association for Transgender Health Conference and looked at 29 studies of gender-affirming phalloplasty from 1980 to 2012, said that it could be as high as 97 percent. In a 2021 survey published in The Journal of Sexual Medicine, 79 patients were asked to rate how they felt about their genitalia on a seven-point scale. Transgender men who had gone through at least one stage of phalloplasty scored the same as cisgender men.
In medicine, phalloplasty for trans men and nonbinary people is called “gender-affirming phalloplasty.” It has been around in some form since at least the 1940s, but it wasn’t common in the U.S. until recently, because insurance coverage wasn’t always reliable and there weren’t many surgeons who knew how to help trans patients. Some trans men went to Belgium, Serbia, or Thailand, where care was cheaper and easier to get. Those who did have surgery in the United States often paid tens of thousands of dollars, forcing them to choose between a penis and a house (if they were well-off enough to face this choice at all). Even though hormones and top surgery have become common forms of health care, getting a penis is still a long shot, even for people who really want one.
Access and attitudes are changing now because of efforts to educate peers, recent improvements in surgical techniques, and, most importantly, the Affordable Care Act, which says that health programs that get federal funding can’t be biased against people based on certain federally protected factors, such as sex. When the act was passed in 2010, it wasn’t clear right away if nondiscrimination would eventually apply to health care for transgender people. The law protected sex, but not transgender status in particular. This led to a 10-year legal dispute about whether one implied the other. This question touched on some of the most controversial parts of civil rights in the United States, like the freedom of religious groups that get money from the government.
The Supreme Court’s decision in Bostock v. Clayton County in 2020 cleared up this confusion, at least for the time being: Transgender status is now seen as part of sex, which makes it a protected civil right and makes it a requirement that it be covered by the Affordable Care Act. Today, the LGBT group Movement Advancement Project says that Medicaid programs in 24 states cover care related to transitioning. Many companies, like McDonald’s, Starbucks, Amazon, and more, have started to offer insurance plans that work the same way. This is a big change that makes phalloplasty more accessible than ever for transgender people in the United States. Without insurance, the whole process of phalloplasty could cost the patient as much as $200,000.
The American Society of Plastic Surgeons’ most recent pre-epidemic data shows that about 1,100 people in the U.S. had gender-affirming phalloplasty in 2019. This number is probably low because the procedure is broken up into parts and the way data is reported isn’t always the same. All four surgeons I talked to at different programs agreed that phalloplasty is becoming more common. All said they had more than a year-long wait lists. This rise in surgery has set off a crazy cycle: better access, new techniques, and more doctors, but also more doctors with less experience and urgent calls for better analysis of outcomes to help lower the number of complications. This story is part of a larger cultural story in which America tries to figure out what makes a man or a woman on a larger scale than ever before. In this situation, phalloplasty seems to support both the idea that sex can be changed and the idea that a man’s penis is what makes him a man.
Ben spent a lot of time doing research in the six months before his phallo consultation. At first, he didn’t have very high hopes. He says he would have been happy with a “frankenweenie” as long as it left him alone in the bathroom. He looked at after-surgery photos online to learn about the different techniques and how they worked. Even though phalloplasty can’t yet make a penis exactly like the one most men are born with, it can make it possible to do many of the classic penile things, like urinate while standing, have penetrative sex, orgasm (without ejaculating), and change in a locker room. Ben’s first thoughts about these possibilities were way off. He thought that many outcomes looked better than fine; they looked great. Still, he was afraid to let himself be hopeful. He needed honesty, facts, and pictures of wounds that were healing. He didn’t find much in popular trans resources. He found a network of private Facebook groups called “the phallo groups” when he looked for them.
