Malcolm macdonald and Benjamin Simpson Phalloplasty, surgery to make a penis

Benjamin Simpson in the N.Y.U. Langone recovery room.

Benjamin Simpson in the N.Y.U. Langone recovery room.

How Ben’s penis came to be.

Trans men are getting more and more phalloplasty, which is surgery to make a penis. But because there are a lot of problems with it, it is still a controversial procedure.

Nothing about Benjamin Simpson’s change was a given, and his penis was not one of them. Even though he grew up to be a man in the end, he freely admits that in another place or time, he could have grown up to be a sad woman, the town’s weirdo, or a person who committed suicide when they were too young. Growing up in a village near the Finger Lakes, where cell service is still spotty to this day, he didn’t know what “transgender” meant. When he was a little girl, he thought he would grow up to be a man. When he realized that he wouldn’t, he gave up on the idea and started looking for other clues to explain why something always felt wrong in his life.

First, he wore clothes that were too big for him in the summer. (Although, a lot of teenage girls don’t like how they look.) Then there were rumors about lesbians at school. (Ben knew he liked girls, but he didn’t feel at all like a lesbian.) To stop the talk, he started dressing more like a girl and had a few dates with boys. He was more interested in judging their bodies than in getting sexual with them. He wanted to know who he was when he looked at a MySpace group for lesbians. Where did he fit into the big picture? He tried to kill himself a few times because he couldn’t understand what was going on. Soon after that, he went to New York University to find himself.

In 2009, Ben started college. There, he started calling himself a “queer lesbian” as a way to explain how he could like women but also be interested in men’s bodies. He joined an LGBT group on campus and met people who seemed to know who they were. They called themselves things like “gender-fluid” or used “ze” or “zir” pronouns. Ben didn’t think these words fit him, but for the first time, he had a group of people and a language to help him figure things out. This was a tense and interesting break. He went out wearing clothes from both sexes, including things he would never wear today. He argued for a long time about what the difference was between a “butch” lesbian and a “transgender man.” Why did you use these words in the first place?

Ben at his upstate New York home.

In the spring of 2015, Ben went to a Midtown barbecue place with two friends for happy hour drinks. As usual, they sat at the bar and talked about sex and gender, taking them apart and putting them back together. They had done this many times before, but something clicked this time, and Ben suddenly realized he was a man. He got off the bar stool and said to his friends, “[Expletive]! I’m a trans person! I have to go!” When he got outside, he took off his shoes and ran five blocks to the train while crying. That night, he started the paperwork for his transition. He texted his mother, updated his Facebook status, and made an appointment with his doctor to start taking testosterone.

Soon after that, Ben quit college and moved with his cousin to North Carolina. There, he became an adult. He got a job at a hotel, wore a uniform, and smiled when people from the South called him “son.” The so-called bathroom bill in his state sent him back to his hometown. Neither bathroom in North Carolina felt safe to him. Back in New York State, he could finally relax, knowing that he wasn’t just a man, but a certain kind of man who belonged in the country. College had helped him learn more about gender, and now he could finally narrow it down. In 2017, he had “top surgery,” or a double mastectomy to change his gender. As far as he knew, he had made the change. His gender confusion was not too bad. He was happy with his sexual life. Even though he’d read about “bottom surgery” online, he didn’t think the results were good enough to be worth the risks. He says that people were saying that the results looked like soda cans. “They said that they weren’t working. You couldn’t urinate through them. You weren’t able to feel anything.”

In the fall of that year, he was out with some friends at the local college dive when his calculus changed. It was a dirty place. The management took away the bathroom stalls so that people wouldn’t use cocaine there. A urinal next to an unprotected toilet is not the best place for a trans man to go to the bathroom, but Ben was sure of himself and had to go. He walked by a man who was using the urinal, then quickly unzipped himself and sat down on the toilet. The man kept his eyes to himself (the men’s room code), but when he left, he told the people waiting, “It’s going to be a while. “That person has just sat down.”

This wasn’t much of a call to harass trans people, though. He just thought Ben was going to the bathroom. Still, as Ben sat there acting like he was going, he thought about how a more hostile group of drunk men might act if they saw his penis was gone. Bathroom bills were going up, and taking a leak would always mean taking a risk for the rest of his life. He was only 26, which was still pretty young. When I thought about doing this for the rest of my life, the bad things about surgery suddenly didn’t seem so bad. Even if he still had to sit in a stall, having a penis would make him feel safer. “I thought that any problem that might come up, even death, would be better than the alternative,” he says. That night, when he got home drunk, he looked up “FTM bottom surgery” and spent the whole night reading about phalloplasty. He asked for a meeting with Dr. Rachel Bluebond-Langner at N.Y.U. Langone the following week.

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.

On a model of a man’s penis, Dr. Lee Zhao shows how an erectile implant works. A man can get an erection by squeezing a pump inside the scrotal sack. On the right side is a silicone testicular prosthesis.

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.

The phallo groups are a mix of a support group, a fake med school education, and maybe the world’s first fraternal order that says openly what others try to hide as subtext. Here, people from all walks of life and all parts of the country come together to talk about their shared interest in the penis. The largest group was started in January 2015, when phalloplasty became more popular after the Affordable Care Act. It now has more than 17,000 members at all stages of the surgery process, from right after the surgery to people who are just looking around. Wisdom is passed down from generation to generation as people give their time to be honest in a way that medicine can’t.

When people join phallo groups for the first time, they often ask something like, “Which surgeon should I go to for the best penis?” A more experienced member might ask gently, “What do you mean by the “best penis”?” In the United States, there are two common types of phalloplasty: radial forearm flap (or R.F.F., which uses the forearm as a skin-flap donor site) and anterolateral thigh flap (or ALT, which uses the thigh). These flaps make up the shaft, and they can be combined with other procedures to help with the four most important things after surgery: being able to urinate while standing, looking good, having an erection, and feeling good. Most surgeons start by asking patients to put these things in order of importance. Even though it is possible to do all four at the same time, the high rate of problems means that nothing is for sure.

In the phallo groups, people are pointed to resources that can help them figure out which penis is best for them. On Phallo.net, an information hub, there are guides that compare different combinations of procedures and the three kinds of erectile implants. On the photo-sharing site Transbucket, users have posted thousands of pictures of themselves after surgery, from the front, from the side, with or without testicles, on fat guys, on skinny guys, on tall guys, on short guys, and on nonbinary people of medium size. When you decide what kind of phalloplasty you want, you’re not just picking a penis. You’re also picking the shape of your life for the next few years, including your budget, your job, your ability to travel, and your ability to give yourself enough time to heal.

The program for transgender surgery at NYU Langone is run by Drs. Rachel Bluebond-Langner and Lee Zhao.

Once people in a group know what they want, the next questions are often about where they want to go: Does anyone in Ohio know a good doctor? Close to Albuquerque? In Indiana’s northeast? Has anyone in Austin been to Curtis Crane? Is Mang Chen in San Francisco? Where is Loren Schechter? Getting surgery close to home is easier and lets you get better care while you heal. Still, many patients have to travel across state lines to get good care. This means getting better in a hotel, which is a big hassle and a big expense. To help keep costs down, the groups give advice on how to get the most out of complicated systems like hotel points, credit card points, and hospital indemnity insurance. It seems strange that a group that is often seen as socially deviant would be so good at being a capitalist subject.

Jens Berli, a surgeon at Oregon Health & Science University who specializes in phalloplasty, says, “You will have patients who know more about it than you do.” “They know what other surgeons are doing, so they’ll come in and ask, “Do you do an XYZ scrotoplasty?” If you don’t know about all the different kinds, you might be the one in the hot seat as the surgeon.”

Ben did research on the differences between ALT and R.F.F. as he got ready for his meeting with Bluebond-Langner and Lee Zhao, a reconstructive urologist and co-director of the N.Y.U. Langone transgender surgery program. The skin on the thigh is longer and usually has more fat, which can make the penis bigger or smaller. The skin on the forearm, on the other hand, is shorter and thinner. More people can see the scar it leaves behind. Both procedures have about the same number of problems. Ben’s main goal was to urinate while standing. He decided that his next goals would be penetrative sex and looks, in part because he would be dating in a rural area and would probably be the first trans guy most women had ever been with. At 4 feet 10 inches and 97 pounds, he thought he had some things going against him. He said, “Women don’t like short men.” “I had to give myself as much of an advantage over the competition as I could.” He was so skinny that ALT seemed like a good fit. He said, “If I got R.F.F., my penis would be very thin for sure.”

Bluebond-Langner and Zhao both agreed that ALT was the right choice, especially since Ben’s penis had to be thick enough to support urethral lengthening. At his first appointment in March 2018, they told him that his surgery would be done in three steps: one to make the phallus, and two to make the new urethra. With a fourth stage added to his erectile implant, his surgeries could take anywhere from two to three years, if there were no problems.

Bluebond-Langner thinks that about 35% of her patients will have complications overall. Some risks are common and, in the end, easy to deal with. These include dribbling while urinating, blockages or leaks in the new urethral plumbing, and the erectile device moving out of place or falling out. Some are more severe and less common, like getting an injury to the rectal area during a vaginectomy or losing the new penis because of necrosis. (This has happened to Bluebond-Langner once in her career.) Ben knew people from the phallo groups who had gone through with the surgery even though there were painful problems and small but persistently annoying setbacks. To him, these were risks he was willing to take. Two weeks later, he called and set up an appointment for his Stage 1 surgery for May 2019, which is more than a year away.

Rachel Bluebond-Langner, who is 44 years old, is the kind of person you’d want to sit next to at a wedding because she is friendly and has a unique job. As a child in Philadelphia, she spent a lot of time in hospitals following her anthropologist mother, Myra Bluebond-Langner, who studied children who were dying. The younger Bluebond-Langner thought she could help these kids by becoming a pediatric pulmonologist. As soon as she started medical school at Johns Hopkins, her career goals changed. First, she became interested in laparoscopic kidney surgery, and then she became interested in plastic surgery. The body’s inside was interesting but lonely. Plastics put both function and style first.

She did her residency at the same school, where she soon met Eduardo Rodriguez, the reconstructive craniofacial surgeon who would later do the first face transplant in the world. Rodriguez was studying face trauma at the time. To help Bluebond-Langner narrow down her own interests, he suggested she read “Facial Feminization Surgery” by Douglas Ousterhout. The book, which came out in 2010, is a practical guide for transgender women who want surgery. It looks at how small things, like a face’s hairline, can make it look like a woman or a man. Bluebond-Langner had never met a trans person, but she was drawn to gender-affirming surgery because it combined a lot of different fields, like plastics, urology, and gynecology, to help with something as fleeting as dysphoria.

Back in 2010, there was no official way to get surgery to change your gender. Even though most gender-affirming procedures use basic plastics techniques like sewing, grafting, tissue expansion, and flaps, it was very hard to find specific training in facial feminization, chest masculinization, and the finer points of working with a population that has a complicated relationship with medicine. At that time, most gender surgeons had made their own way into the field by getting formal training in plastic surgery and then learning from other gender surgeons or getting extra training in other fields to learn techniques that could help them in their work. People looked down on people who did this work. Some surgeons had two different websites: one for their regular patients and one for their transgender patients.

Bluebond-Langner says that when she first started seeing patients, older surgeons told her, “Be careful what you’re known for.” She didn’t pay attention and started getting the training she needed to do top surgery, vaginoplasty, phalloplasty, and metoidioplasty (a less involved surgery that constructs a smaller penis using only the natal tissue of the clitoris). This training took her all over the world. She went to Thailand and Canada to learn about vaginoplasty, and she went to Mexico City to learn about microsurgery, which is a way to connect nerves and blood vessels on a microscopic scale to help with skin-flap transfer. She started doing complicated urogenital surgeries, such as phalloplasty for micropenis and trauma, and she also did a lot of research. In 2016, she did her first gender-affirming surgery at the University of Maryland. As far as she knows, the surgery went well. (After two years, she stopped talking to the patient.) Rodriguez had moved to N.Y.U. Langone a few years before to lead the department of plastic surgery there. He finally asked Bluebond-Langner to help him start a program for transgender surgery.

The N.Y.U. program for transgender surgery has its own room on the sixth floor of a glassy Manhattan office building. I went there for the first time in March 2021. As soon as I got off the elevator, I saw how fancy everything was. There were Keurig machines, orchids in vases, and iPads with palm-print scanners that looked like something from the future. The names of donors were written on the wall. This was long before the time of secret websites. If a transgender journalist sat down on the midcentury sofa, leather swivel lounger, or chrome accent chair, it would be understandable if they felt more than just a little cynical. Trans people in the United States are in a tough spot with the medical community: On the one hand, there are calls to improve and expand care that has been denied in the past. On the other hand, most of us aren’t blind to the fact that our bodies are good for business in a system that is based on making money. “We’re paid a salary,” Bluebond-Langner said to explain why she doesn’t get more money if she has more patients. “Even though they do give us a little bit of a push. They will give us more money and supplies.”

Bluebond-Langner is friendly and direct, and she doesn’t have the surgeonly god complex that some people do. When she started the program at NYU in 2017, she only worked with Zhao and a microsurgeon named Jamie Levine. Over time, the team has grown to include a research department, an administrative staff, a physical therapist, two social workers, and two nurse navigators. More than half of the team is trans, and two of the surgeons-in-training are trans, too. Bluebond-Langner hopes that they will take over from her and Zhao one day.

Medical transition is a never-ending list of things to do. For phalloplasty to be approved, candidates must get separate referrals from two mental health professionals. They need laser hair removal on the skin-flap donor site and help during the many, often immobile, healing stages. Bluebond-Langner said, “Unfortunately, many of our patients have been left out.” They can’t always count on their jobs or their families to help them out. She thinks that the care team for the program is the most important part of a successful surgery. Even though trans rights have improved on paper, many of her patients still face problems like poverty, unstable housing, and being shunned by their peers that make it harder for them to get better. “If it’s hard for you to get a job because you’re trans, surgery won’t help.”

As we walked down the hall to Bluebond-office, Langner’s we had to get out of the way of people in custom N.Y.U. Gender Surgery track jackets who were in a hurry. (The logo for the program is a fig leaf.) Inside, a signed poster of the “Pose” actress Dominique Jackson hung above a consultation table. Back issues of Plastic and Reconstructive Surgery leaned against a stack of coffee-table books, including “The Vagina Bible,” “The Great Wall of Vagina,” and “A Celebration of Vulva Diversity.” Bluebond-Langner gives each penis three vaginas. She can sometimes finish three vaginas in one day. Each penis takes at least two surgeries, but often four or more. “Vaginoplasty is much more popular than it used to be,” she said. “I think this goes back to the fact that the process is simple and only has one step. There are less risks.” ’

A little more than 150 phalloplasties have been done through the NYU program so far. At the first surgery consultation, Bluebond-Langner tries to find out what kind of sex the patient likes so that she can suggest the best combination of procedures to improve the patient’s quality of life while reducing the risk of complications. In the early days of formalized transgender medicine in the United States, between about 1960 and 1980, phalloplasty was rare and pretty much one-size-fits-all. Its goal was to copy the idealized shape and function of an imagined standard American penis. Many patients still hope for this, but Bluebond-Langner and medicine as a whole have started to move away from this benchmark as an objective way to measure how well a surgery went.

Transgender surgery is meant to help people who have gender dysphoria, not people who are not cisgender. There are partial interventions that can help reach this goal while minimizing risk. One patient, for example, might want to be able to urinate while standing but have no use for an erectile implant. Another person might have dysphoria that is mostly visual but still enjoys vaginal receptive intercourse. Phalloplasty without vaginectomy could meet this need with fewer procedures. “You can get glansplasty or you can’t. No scrotoplasty, please. Bluebond-Langner said, “You can really do a whole mix-and-match thing to reach your goals.”

Even though patient-centered care is getting better, phalloplasty still has a long way to go. Even though the number of surgeries is going up, the number of patients is not yet big enough to know what reduces complications or makes people happy over their whole lives. Most of Bluebond-phalloplasty Langner’s patients are between 18 and 32 years old. The erectile implants that have been approved by the FDA are made for the bodies of cisgender men. Even if the one trans-specific implant were approved in the US, there is not yet a standard way to measure or report what makes for good surgical outcomes. Because doctors use different methods, their cases are rarely the same.

Bluebond-Langner said, “We need to improve the way things work.” “It doesn’t work perfectly.” In this case, she says, the risks are only worth it because of how much it will improve people’s lives. She said, “People understand the trade-off.” “But we wouldn’t always be okay with this rate of complications in other procedures.”

Ben in March, after his last surgery and a change to his “top surgery.” Ben’s penis took four years to grow from the beginning to the end.

Endocrinology and plastic surgery, the two main fields of gender-affirming care, were founded in the early 1900s, not as ways to change gender but as ways to fix it. Eugen Steinach’s hormone experiments on rodents in the 1910s led to the Steinach rejuvenation method, a 20-minute partial vasectomy that he said could turn old, weak men into “men of vigorous bloom who threw away their glasses, shaved twice a day, dragged loads up to 220 pounds, and even did such foolish things as buying land in Florida.” (Sigmund Freud and W.B. Yeats were both “Steinached.”)

Plastic surgery has been around for more than 2,000 years, but the field really took off during World War I, when it was used to fix up the bodies of soldiers who had been hurt in bombings so they could go back to being men and husbands. Harold Gillies, an early British plastic surgeon, made the tubed pedicle popular. This is a general way to move tissue across the body by turning a flap of skin into a tube and cutting and reattaching it in small steps until it reaches the site of an injury. Gillies wrote in his book “Plastic Surgery of the Face,” published in 1920, that “deformities are not only the constant source of the most distress and anguish, but they also lower the market value of the individual.” In 1939, the British Ministry of Health asked Gillies to start Rooksdown House, a hospital for plastic surgery. They did this because they knew that World War II would cause a lot of people to lose their looks. There, he met Lawrence Michael Dillon, the man on whom he did the first known gender-affirming phalloplasty.

Dillon was born in 1915. As a girl, he lived on a run-down estate near Dover with his two sad aunts. At St. Anne’s, a women’s college in Oxford, he spent most of his time rowing crew and wore his hair in the Eton crop, a short, slicked-back style that was popular with lesbians on campus. Dillon liked girls, but he didn’t think of himself as a lesbian. He had a dream that he was taken to the blacksmith and turned into a man. At the start of World War II, he went to a doctor who specialized in sex. The doctor gave him testosterone pills. A few years after that, he had a mastectomy. This doctor told him to talk to Gillies about his penis.

Gillies was busy with the war at Rooksdown, but he told Dillon to come back when it was over. When he came back in 1945, he started either 13 or 17 operations. (His and Gillies’ papers say different things.) Gillies’s tubed-pedicle method was used to make Dillon’s penis. This involved lifting a flap of skin, shaping it into a phallus, and letting it heal while still attached at both ends and hanging from the abdomen like a suitcase handle. Dillon finished medical school while he was in this state. After the pedicle got to where it was supposed to go, he stopped practicing medicine, went to a bunch of Buddhist monasteries in India, changed his name to Jivaka, and started writing his autobiography. He only wrote one thing about the finished penis: “How different life was now! I could walk by anyone without worrying about what they might say because no one looked at me twice.” Gillies was also pleased with the surgery. He wrote about the case in his 1957 textbook, “The Principles and Art of Plastic Surgery,” taking a lot of creative license. He wrote, “With the new organ, the patient’s life has been a social success. He has become an active and successful businessman and is very eager to have everything done that would make it okay for him to get married.”

Dillon/Jivaka didn’t end up getting married, but the idea of marriage and social success became a big part of how gender-affirming medical care was thought of and given in the decades that followed. Transgender medicine became official in the United States between 1960 and 1980, when the first “gender-identity clinic” opened at a college. People who wanted to change their sex were taken on by these programs so that medical research could move forward. In exchange for hormones and surgery, they had to go through years of psychological testing. Patients could only get in if they were employed heterosexual men or women who had the best chance of doing well in life. Most of the time, these people were white. “The big test was, ‘Could you disappear in a crowd?'” says Jules Gill-Peterson, an associate professor of history at Johns Hopkins and the author of “Histories of the Transgender Child.” “The goal of medicine wasn’t to make trans people happy. Medicine tried to make trans people follow the rules.

Trans women were usually given hormones, breast implants, and vaginoplasty at gender identity clinics. Trans men often used testosterone and had their breasts removed, but genital surgeries were still uncommon. This was partly because phalloplasty hadn’t changed much since Gillies’ tubed pedicle in the 1940s. In a 1978 paper called “Construction of Male Genitalia,” researchers from Stanford’s gender clinic wrote, “In the female-to-male transsexual, the goal of the surgical program is to build a penis and all the external male genitalia, including the scrotum, and implant testicular prostheses.” By this measure, and often by the patients’ own measures, the penises of the late 1950s couldn’t be called a success. They rarely let people urinate while standing, and sexual pleasure was seen as a side effect. Even for those who still wanted one, it was almost impossible to get one. During the time of gender clinics, care was free, but only for models. When the clinics closed, surgery became available on the free market, but only to people who had the money and time to deal with the red tape. At that time, a domestic phalloplasty cost more than most people made in a year.

But as microsurgery got better over time in the 1980s, the procedure itself started to get better. By connecting blood vessels on a microscopic level, it made phalloplasty possible with a lower risk of loss and a greater ability to feel both sexually and physically. By this time, trans men were talking to each other through a small but strong network of newsletters, such as FTM Newsletter and Twenty Minutes, which reported on these medical advances with great hope. Slow and often disappointing progress was made. Microsurgery didn’t really get good until after 1998, when the Women’s Health and Cancer Rights Act made it so that insurance had to cover breast reconstruction after a mastectomy. The huge rise in free-flap breast surgeries, which could be seen as a form of gender-affirming care, made microsurgery more advanced, which led to the birth of the modern phalloplasty.

Ben only told his family and close friends that he was getting ready for Stage 1 surgery. He knew that some people in his life would only accept him if everything went well, and he felt like he had to explain why he wanted what he wanted. Even though surgery can build a penis today, it can’t fix millennia of phallic anxiety: the complicated relationship between penises and manhood, the idea that the penis is inherently violent, the idea that the vagina is its wanting opposite, and the feminist call to get rid of gender essentialism. Even among trans men, wanting phalloplasty is still closely looked at. Fighting for the penis is like cheering for the Yankees. It’s easy to stand up for some vague and shiny right to gender self-determination.

“Every time I thought about problems, I could hear someone in the back of my mind saying, ‘See? Ben says, “That’s why you shouldn’t go against nature. “I never wanted to hear, “See, I told you so!”

Ben woke up in a hotel on the day of his surgery. He then went to the hospital and checked in. He changed into a gown and sat in a chair to watch Cartoon Network. He felt like he had been waiting for a long time. At 12:30, he was taken to the operating room and given medicine to make him sleepy. Stage 1 was done after six hours. Even though the doctors poked and prodded him, he was swollen, had a wound on his thigh, and was on drugs, the new penis felt like his right away. He says, “I’d never had a penis before, but once I did, it was obvious that it was there.” The next few days were mostly filled with pain and small victories: on May 11, she stood up for the first time, on May 13, she got rid of the catheter, and on May 15, she left the hospital (May 14). Even simple tasks were easier for him to do now that he had this new part. He wrote on Facebook, “Shower was AWESOME!!!” “I had a lot of chances to hold my dick.”

Ben spent two weeks getting better in a long-term-stay hotel in New Jersey after he got out of the hospital. At his first appointment with Bluebond-Langner and Zhao after surgery, he gave them bubble gum cigars that said “It’s a boy!” At that point, his penis was basically just a tube, with no bumps or other details. Five months later, in Stage 2, the team started making plans for an organ with more functions. Bluebond-Langner took out Ben’s vagina to start this surgery. (Before Stage 1, he had already had a hysterectomy.) Next, in what may have been the worst part of the surgery, she cut his penis lengthwise up the underside and used more tissue from his thigh to cover the open face. This area would become his new urethra someday, but this tissue graft had to heal first. Ben was getting better when the pandemic hit, so he had to live for more than seven months with his penis open. He said, “The “hot-dog bun” stage was the hardest for me.” “Healing is weird in general, but especially when you have a big open wound on something as important and sensitive as your genitalia. It’s sometimes scary. You can see a lot of different colors. You can see a lot of liquid. You smell a lot of different things.”

In May 2020, Bluebond-Langner stitched up the channel to connect his old urethra to his new one. Ben was potty-trained again when he was 28. He taught himself to pee while standing up by sticking a children’s urinal to the wall of his shower. (“If you hit the target, it would spin,” he told me.) A few months later, on crab-leg night at a restaurant in his home town, he used a public toilet for the first time. “Oh, yeah!” said my stepfather. Ben, go!'”) A few months later, a stranger asked out loud if he was in the wrong bathroom at the Port Authority Bus Terminal. “I said, ‘Bro, do you want to see my dick?'” The man said he was sorry, and Ben was relieved. The surgery was a success just by this one measure. Also, Ben’s goals had been greatly surpassed.

“The best way I can describe the feeling is that it was complete and total peace with my body as it was, without thinking about the next step, the next surgery, or any kind of dissatisfaction,” he says. “If the world ended right then, I would forget I was a trans man living in a trans body. I didn’t do anything.”

During those months, I talked to Ben on and off. Even though he hadn’t gotten his erectile implant yet, he was starting to feel good about his sex life in the future. He had already tried some “American Pie”-style experiments with multiple condoms for stability and a sex toy from an online store called Cherry Pie. He knew he could feel hot, cold, tactile, and erogenous sensations. The Coloplast Titan pump was the implant he wanted. It would let him get an erection whenever he wanted by squeezing a device inside his scrotal sac. Ben hoped to get the implant and a matching silicon testicle in early 2022, but he had to deal with two problems first. First, the flow of his urine had slowed down, and he was worried that he might have a urethral stricture. Second, his penis was still very thick, much too thick for him to put his hand around.

Ben took an overnight bus to New York in March 2021 to talk to Bluebond-Langner and Zhao about these concerns after surgery. At 8 a.m., I met him at the hospital. We both had big cups of iced coffee in our hands. Even after a bad night of sleeping on two bus seats, Ben had a game and smooth-talking attitude. He talked to everyone he met in a friendly, flirty way. We went upstairs to the waiting room, where he gave cupcakes to the people working in the office.

In the exam room, a nurse told Ben to take off his clothes from the waist down. I tried to leave, but Ben told me it was okay to stay. He took his pants off and put on a dress. Any way you look at it, his penis was a good length. It was thicker and paler than any I had seen before, but other than that, it didn’t look all that handsome.

Bluebond-Langner walked through the door, followed by a group of observers in white coats. She bent down before Ben could say hello. “You look good!” she said. “Did we get pictures?” She took out her phone and took a few pictures while Ben talked about his size. She agreed that some fat should be cut away before his erectile device was put in. Ben got up and dressed himself. I went with him to another room where Zhao would use a camera to look inside his penis. The nurse took out a syringe filled with numbing gel and shot it up Ben’s urethra. As he waited for his penis to go numb, he asked me to bring him his cup of iced coffee.

Zhao put the camera inside, and Ben’s urethra soon showed up on four screens. Ben pointed to some lines and curves. He asked, “Are those hairs?” Zhao said that they were from where his thigh used to be, but they weren’t thick enough to stop his urine from flowing. He kept pulling the camera deeper until he hit something. He said, “There’s just a little bit of a squeeze.” It was just old wounds. If you massaged the spot from the outside, it would help break it up and make it easier for him to pee. All of this was good news. Ben put on his clothes and threw away his empty cup of iced coffee.

Ben was with his mom and stepdad.

Ben had a procedure called “debulking” that summer. His penis didn’t get as thin as he had hoped, but he could finally hold it with one hand. He told me what Zhao had told him about the risks of further debulking: “Better is the enemy of good.” In March of this year, he went back for his last implant surgery. When he left the hospital, he was only half-erect because the pump had to be partially inflated to let his penis heal. When we met up at N.Y.U. Langone again in April, he was excited to get hard, but more excited to get soft. It had been strange to be at half-staff for a month.

Zhao was waiting in the exam room for a lesson on how to blow up and deflate after surgery. He put on some purple nitrile gloves and used his right hand to lift Ben’s penis up. He gently grabbed Ben’s scrotum with the other hand and began to talk about how the implant was made. In Ben’s groin, there was now a small reservoir filled with salt. Inside his scrotum was a bulb that looked like a testicle. This bulb pushed the saline into a tube that ran down the length of his penis.

Zhao pinched the bottom of the pump a few times, and Ben’s penis stiffened. He moved the skin back and forth a bit to show how strong the whole mechanism was. Zhao said, “Let’s try to pop it now.” Ben used his right hand to squeeze the pump inside his scrotum. With his left hand, he started to squeeze his shaft like an accordion, which pushed the salt water back into the reservoir. Zhao told him that he should feel something “whooshing.” After a few seconds, he gave the penis one last push, and it flopped over in a victorious way.

Zhao said, “I think Liberace had one of these.”

Zhao gave Ben the go-ahead for sexual activity in a tone that was both formal and happy, like a wedding officiant. A few minutes later, Ben took out his phone and turned on “Detachable Penis,” a song by King Missile that is popular on college radio and reminds Ben of his life before phalloplasty. He thought about how his surgery had made him different. It had taken just over four years for everything to happen, and in that time, his confidence had grown. The way he felt about his family had changed. His penis had changed the way he felt about being a man, making it much easier for him to act like a man. In another conversation, he had told me that this made sense for a guy from a small town like him, but that it made him “a bad trans.”

Ben’s only goal when he set out to get phalloplasty was to be safe. Along the way, he started to feel like he wanted to stand naked in front of a mirror and look at his body without feeling bad about it. I asked him out loud if surgery was supposed to let him stop thinking about his penis.

“No,” Ben said to tell me I was wrong. “I always think about it. Always put your hands on it. Always take a look at it. “I love doing that the most.”

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