Nothing about Benjamin Simpson’s transition was inevitable, certainly not his penis. Though he did, in the end, grow up to be a man, he freely admits that in another place or time he might have grown into an unhappy woman, or the local eccentric, or a person who died too young from suicide. Raised in a village outside the Finger Lakes — a place, to this day, where cell service is spotty — he did not know what “transgender” was. As a young girl, he assumed he would become a man when he grew up. When he realized he would not, he forgot the whole idea and started collecting other evidence to explain why something in his life always felt off.
First, there was the way he wore baggy clothes in the summer. (Then again, lots of teenage girls dislike their bodies.) Next came the lesbian rumors at school. (Though Ben did know that he liked girls, he did not feel like a lesbian at all.) To combat the gossip, he started dressing girlier and tried having sex with boys a few times. His interest in their bodies was more appraising than erotic. Browsing a Myspace group for lesbians, he found himself yearning for a clear identity. Where did he fit in the scheme of the world? Incomprehensible to himself, he tried a few times to end his own life. Soon after, he went looking for himself at New York University.
Ben arrived at college in 2009. There, he started calling himself a “queer lesbian,” a term he used in an attempt to reconcile his attraction to women with his interest in men’s bodies. He joined a campus L.G.B.T. group and met people who seemed to know who they were, who called themselves things like “gender-fluid” or used “ze”/”zir” pronouns. Ben did not feel that these words applied to him, but for the first time he had community and language to help him disentangle himself. This was a stressful and exciting interlude. He went out in outfits from across the gender spectrum, in clothes he wouldn’t dream of putting on today. He had long debates over terms: What was the difference between a butch lesbian and a transgender man? What was the reason to use these words at all?
In the spring of 2015, Ben got happy hour drinks with two friends at a Midtown barbecue spot. The setup was the usual — sitting at the bar, dissecting sex and gender, putting the pieces together again. They had done this many times before, but this time something clicked, and suddenly Ben understood he was a man. He stood up from the bar and told his friends: “[Expletive]! I’m trans! I gotta go!” Out in the street, he took off his heels and ran five sobbing blocks to the train. That night, he began the bureaucratic work of transition: texting his mother, posting a Facebook status, scheduling a doctor’s appointment to start testosterone.
Shortly after that, Ben dropped out of college and moved to North Carolina with his cousin. There he began his life as a man, working at a hotel, wearing a uniform and smiling when Southern types called him “son.” The state’s so-called bathroom bill drove him back to his hometown; in North Carolina, neither restroom felt safe. Back in New York State, he could finally unclench, secure in the knowledge that he wasn’t just a man but a certain kind of man who belonged out in the country. College had expanded his knowledge of gender; now, finally, he could narrow it down. In 2017, he had “top surgery,” or a gender-affirming double mastectomy. As far as he knew, his transition was complete. His gender dysphoria was manageable. He felt fine about his sex life. Though he had read about “bottom surgery” online, the final outcomes did not seem good enough for him to justify the risks. People were comparing the results to soda cans, he recalls. “They were saying they weren’t functional. You couldn’t pee out of them. You couldn’t feel anything.”
Ben at his home in upstate New York.Credit…Elle Perez for The New York Times
His calculus changed one night later that year, out with some friends at the local college dive. The place was filthy. Management had removed the bathroom stalls to keep people from doing cocaine. An undefended toilet next to a urinal is not an ideal place for a trans man to take a leak, but Ben was confident — and had to go. He walked past a guy using the urinal and quickly unzipped to sit on the toilet. The man kept his eyes to himself (the men’s room code), but as he left, he told the people waiting: “It’s going to be a while. That guy just sat down.”
This was hardly an incitement to anti-trans harassment — he just thought Ben was taking a dump. Even so, as Ben sat there pretending to go, he pictured a more hostile group of drunken men and how they might react to the absence of his penis. Bathroom bills were on the rise, and every day for the rest of his life, taking a leak would mean managing risk. He was just 26 — still quite young. Looking ahead at a lifetime of this, the downsides of surgery suddenly seemed reasonable. Having a penis would help him feel safe, even if he still had to sit down in a stall. “I felt that any complication that would arise, including dying, was better than the alternative,” he says. That night, drunk at home, he ran a search for “FTM bottom surgery” and spent all night reading up on phalloplasty. The following week, he submitted a request for a consultation with Dr. Rachel Bluebond-Langner at N.Y.U. Langone.
Phalloplasty, or surgery to construct a penis, is one of medicine’s most complex procedures. Though it technically refers to one step in a long process — the construction of a phallus from a flap of one’s own skin — the term is used more generally to describe a suite of modular surgeries, each attending to a different penile function. The penis, as an organ, is idiosyncratic, assigned to a seemingly random set of duties that you might not group together if designing it from scratch. The heart pumps blood; the stomach digests food. The penis procreates, urinates and transmits pleasure. It reacts to temperature, emotion and touch — a complex assemblage of tubes, tissue and nerve, configured in the awkward crook of space between the legs.
The main recipients of phalloplasty are transgender men and nonbinary people, intersex people and cisgender men with penile injuries. These groups can have different starting anatomy, but in general, the surgical techniques are the same. Beyond the initial construction of the shaft, a phalloplasty might also include extending the urethra, creating a scrotum, defining the glans, adding testicular prostheses or inserting an erectile implant. Depending on the combination of procedures, a penis might take a couple of years to complete, involving many surgical stages and revisions and a long-term commitment to organizing life around access to doctors, insurance coverage, time off from work and postoperative care. For trans patients, the risk of complications is high — according to surgeons I spoke with, about 70 percent. (The small patient pool and customizable nature of the procedure pose challenges for empirical analysis.) Nevertheless, patient satisfaction rates are high. According to one report, presented at the 2012 Canadian Professional Association for Transgender Health Conference, which analyzed 29 studies of gender-affirming phalloplasty from 1980 to 2012, it is as high as 97 percent. In a 2021 survey published in The Journal of Sexual Medicine, which asked 79 patients to respond on a seven-point scale to the statement “I feel positively about my genitals,” transgender men who had completed at least one stage of phalloplasty scored equal to cisgender men.
Dr. Lee Zhao demonstrating how an erectile implant works on a model of a penis. Squeezing a pump inside the scrotal sack provides an erection; on the right side is a silicone testicular prosthesis.Credit…Elle Perez for The New York Times
Phalloplasty for trans men and nonbinary people — known in medicine as gender-affirming phalloplasty — has existed in some form since at least the 1940s, but until recently, it was rare in the United States, where insurance coverage was unreliable and few surgeons catered to the needs of trans patients. Some trans men traveled to Belgium, Serbia or Thailand, where care was both cheaper and easier to access; 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). As hormones and top surgery became standard forms of health care, a penis remained an unlikely prospect, even to some who wanted it badly.
Today, both access and attitudes are changing, thanks to efforts in peer education, recent advancements in surgical technique and, most consequential, the Affordable Care Act, which prohibits health programs that receive federal funding from discriminating on the basis of certain federally protected criteria, including sex. When the act passed in 2010, it was not immediately clear whether nondiscrimination would ultimately apply to transgender health care. The law protected sex, but not transgender status in particular, starting a 10-year legal dispute about whether one implied the other. This question intersected with some of the most hotly contested axes of American civil rights, including the freedom of religious organizations that receive federal funding.
The Supreme Court’s Bostock v. Clayton County decision, handed down in 2020, resolved this ambiguity, at least for the time being: Transgender status is now understood to fall under the umbrella of sex, which in turn makes it a protected civil right, which in turn mandates coverage under the Affordable Care Act. Today, according to the L.G.B.T. organization Movement Advancement Project, Medicaid programs in 24 states explicitly cover transition-related care. Many companies — McDonald’s, Starbucks, Amazon and more — have begun offering insurance plans that follow suit, a sea change that puts phalloplasty within reach for more trans Americans than ever. Without insurance, phalloplasty would cost the patient as much $200,000 from start to finish.
‘I felt that any complication that would arise, including dying, was better than the alternative.’
On Being Transgender in America
Elite Sports: The case of the transgender swimmer Lia Thomas has stirred a debate about the nature of athleticism in women’s sports.Transgender Youth: A photographer documented the lives of transgender youth. She shared some thoughts on what she saw.Remote Work: Remote work during the pandemic offered some people an opportunity to move forward with a transition. They are now preparing to return to the office.Corporate World: What is it like to transition while working for Wall Street? A Goldman Sachs’ employee shares her experience.
According to the most recent prepandemic data from the American Society of Plastic Surgeons, some 1,100 people in the United States had gender-affirming phalloplasty in 2019. This number is probably low, considering the modular nature of the procedure and inconsistencies in how data is reported. Surgeons at all four programs I spoke with confirmed that phalloplasty is on the rise. All claimed wait lists of over a year. This increase in surgery has set off a frenzied cycle: better access, new techniques and more doctors, but also an influx of less-experienced doctors and urgent calls for better analysis of outcomes to help bring down the complication rate. This narrative unfolds within a mass cultural one, in which America, at a larger scale than ever, tries to come to terms with what defines a man or a woman. In this context, phalloplasty occupies an impossible position, seemingly upholding both the malleability of sex and the essentialist claim that the penis makes the man.
In the six months before his phallo consultation, Ben spent a lot of time doing research. At first, his expectations were low; he could have been happy with a “frankenweenie,” he says, so long as it let him use the bathroom in peace. He scrutinized post-op photographs online, learning about the different techniques and their trade-offs. Though phalloplasty cannot yet produce a penis identical to the one most men are born with, it can provide for many of the classic penile pastimes: standing urination, penetrative sex, orgasm (without ejaculation), changing in a locker room. These prospects far exceeded Ben’s initial expectations. Many outcomes looked more than just fine to him; they looked great. Still, he was afraid to indulge in optimism. He needed rigor — candidness and data and photos of healing wounds. He found very little in mainstream trans resources. The search led him to a network of private Facebook groups, known to most people as “the phallo groups.”
The phallo groups are a virtual support group crossed with a bootleg med-school education crossed with perhaps the world’s first fraternal order that freely proclaims what the rest suppress as subtext. Here, people of seemingly every class and creed, hailing from every corner of the nation, unite to discuss their shared investment in the penis. The largest group was founded in January 2015, as post-Affordable Care Act phalloplasty picked up steam; it now has more than 17,000 members at every stage in the surgical journey, from post-op down to just kicking tires. Wisdom is handed down through generations as individual members volunteer their time to offer the frankness that medicine cannot.
Newcomers to the phallo groups often show up with some version of the question, “Which surgeon should I go to for the best penis?” Gently, an elder member might ask, “What do you mean when you say 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 (or ALT, which uses the thigh). These flaps form the shaft and can be combined with various other procedures in pursuit of four major post-op priorities: standing urination, aesthetics, erectile function and sensation. Most surgeons begin by asking patients to rank these priorities. Though it is possible to achieve all four at once, the high complication rate means nothing is certain.
In the phallo groups, members are directed toward resources to help decide the ideal penis for them. On Phallo.net, an information clearinghouse, there are guides comparing different combinations of procedures and the three different kinds of erectile implant. On Transbucket, a photo-sharing site, there are thousands of user-submitted post-op pics — from the front, from the side; with testicles, or without; on fat guys, on thin guys; on tall guys, on short guys; on medium-size nonbinary people. Choosing what type of phalloplasty you want is not just choosing the penis itself, but choosing the shape of your life for a few years — your budget, your job, your freedom to travel, your ability to reserve enough time to recover.
Once group members have a sense of what they want, the next questions are often geographic: Does anyone know a good surgeon in Ohio? Near Albuquerque? In northeastern Indiana? Has anyone gone to Curtis Crane in Austin? Mang Chen in San Francisco? Loren Schechter in Chicago? Having surgery close to home is more convenient and allows for a better attended healing process. Even so, many patients must traverse state lines in order to access competent care. This means recovering in a hotel — a major inconvenience and significant expense. To help bring down the cost, the groups offer guidance on maximizing all sorts of arcane systems, from hotel rewards to credit-card points to hospital indemnity insurance. Such mastery of capitalist subjecthood feels unexpected from a group so often portrayed as socially deviant.
“You will have patients that honestly know more about it than you,” says Jens Berli, a surgeon who specializes in phalloplasty at Oregon Health & Science University. “They know what other surgeons are doing, and they’ll come in and say, ‘Well, do you do an XYZ scrotoplasty?’ If you’re not familiar with all the variations, you as the surgeon might be the one that sits in the hot seat.”
As Ben prepared for his consult with Bluebond-Langner and Lee Zhao, a reconstructive urologist and the co-director of N.Y.U. Langone’s transgender-surgery program, he researched the differences between ALT and R.F.F. The thigh’s skin is longer and tends to have more fat, which can add girth to the penis, for better or for worse. The forearm’s skin, by contrast, is shorter and leaner. The scar it leaves behind is more visible. Both procedures have similar complication rates. Ben’s primary goal was standing urination. He decided his next goals were penetrative sex and aesthetics, in part because he would be in a rural dating pool and would probably be the first trans guy most women had been with. At 4-foot-10 and 97 pounds, he felt he had certain disadvantages. “Women don’t like short men,” he said. “I kind of had to give myself all the edge up on the competition I could get.” Because he was so lean, ALT seemed like a fit. “If I got R.F.F.,” he said, “I would absolutely have a very thin penis.”
Bluebond-Langner and Zhao agreed that ALT was the right choice, especially because Ben’s penis needed to be thick enough to support urethral lengthening. At his initial consultation, in March 2018, they explained how they would split his surgery into three stages: one for the initial creation of the phallus, and two for constructing the neo-urethra. With an added fourth stage for his erectile implant, his surgeries could take anywhere from two to three years, barring any complications that came up.
Dr. Rachel Bluebond-Langner and Dr. Lee Zhao of N.Y.U. Langone’s transgender-surgery program.Credit…Elle Perez for The New York Times
Bluebond-Langner estimates about a 35 percent overall complication rate for patients in her practice. Some risks are common and ultimately manageable: dribbling while urinating, blockages or leaks in the new urethral plumbing, malposition or extrusion of the erectile device. Others are rarer and more severe, like rectal injury during vaginectomy or loss of the new penis by necrosis. (Bluebond-Langner has had this happen once in her career.) Ben knew people from the phallo groups who had stuck with the surgery through both excruciating complications and minor but persistently annoying disappointments. To him, these were acceptable risks. Two weeks later, over the phone, he scheduled his Stage 1 surgery for May 2019, over a year away.
Rachel Bluebond-Langner, 44, has the open affect and distinctive vocation of someone you’d love to sit next to at a wedding. Growing up in Philadelphia, she spent a lot of time in hospitals, shadowing her mother, Myra Bluebond-Langner, an anthropologist who studied terminally ill children. The younger Bluebond-Langner wanted to help these kids and thought she might become a pediatric pulmonologist. Arriving at medical school at Johns Hopkins, she soon found her professional interests diverted — first by laparoscopic kidney surgery and then by plastic surgery. The inside of the body was intriguing but asocial. Plastics prioritized both function and form.
She stayed at the same school for residency and soon found a mentor in Eduardo Rodriguez, the reconstructive craniofacial surgeon who would go on to perform the world’s first face transplant. Rodriguez, at that time, was researching face trauma; to help Bluebond-Langner refine her own interests, he recommended Douglas Ousterhout’s “Facial Feminization Surgery.” The book, published in 2010, is a practical guide for trans women seeking surgery, exploring the ways that minor traits like hairline might make a face read as female or male. Bluebond-Langner had never knowingly met a trans person, but she found herself drawn to gender-affirming surgery and the way it combined a broad range of disciplines — plastics, urology, gynecology — to help assuage something as ephemeral as dysphoria.
Back in 2010, there was no formal path into gender-affirming surgery. Though the fundamentals of plastics — sewing, grafting, tissue expansion, flaps — are used in most gender-affirming procedures, it was still very hard to find targeted instruction in facial feminization, chest masculinization and the finer points of serving a population with a fraught relationship with medicine. Most gender surgeons in practice at that time had cobbled together their own paths into the field, completing a formal plastic-surgery training and then studying under other gender surgeons or seeking out additional training in outside specialties to master techniques that might be useful in their work. Pursuing this work was stigmatized. Some surgeons maintained separate websites: one for their mainstream practice, and one for their transgender clientele.
When Bluebond-Langner started her rounds, she says, older surgeons warned, “Be careful what you’re known for.” Unheeding, she started assembling the training she would need to perform 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: to Thailand and Canada to study vaginoplasty and to Mexico City, where she learned microsurgery, the technique that facilitates skin-flap transfer by connecting nerves and vessels on a microscopic scale. She began performing complex urogenital surgeries, including phalloplasty for micropenis and trauma. At the University of Maryland in 2016, she performed her first gender-affirming phalloplasty. The surgery, as far as she knows, was a success. (She and the patient lost touch after two years.) A few years before, Rodriguez had moved to N.Y.U. Langone to be chairman of the plastic-surgery department. Eventually, he recruited Bluebond-Langner to come start a program in transgender surgery.
The N.Y.U. transgender-surgery program occupies its own suite on the sixth floor of a glassy office building in Manhattan. I first went to visit in March 2021. Stepping out of the elevator, I immediately noticed how fancy everything was. The waiting room had Keurig machines and orchids in vases and iPads with futuristic palm-print scanners. Far from the age of the secret separate website, benefactors’ names were plastered on the wall. Taking a seat on the midcentury sofa (or leather swivel lounger or chrome accent chair), a transgender journalist could be forgiven for feeling more than just a little cynical. Trans people in America are in a complex bind with the medical establishment: On one hand, there’s the call to expand and improve care that has historically been denied; on the other, most of us are not blind to the fact that our bodies make good business in a for-profit system. “We’re salaried,” Bluebond-Langner said, by way of explaining that she doesn’t get more money for more patients. “Though they do incentivize us a little bit. They’ll give us more resources.”
Bluebond-Langner is smiley and direct and generally immune to the surgeonly god complex. When she came to N.Y.U. in 2017 to start the program, she had only two colleagues — Zhao and Jamie Levine, a microsurgeon. Over the years, the team has grown to include an administrative staff, a research department, a physical therapist, two social workers and two nurse navigators. More than half the team identifies as trans, including two surgeons in training, who Bluebond-Langner hopes will someday succeed herself and Zhao.
Medical transition is an endless to-do list. In order to be approved for phalloplasty, candidates must secure separate referrals from two mental-health providers. They need laser hair removal on the skin-flap donor site and support through recurrent (and often immobilizing) stages of healing. “Unfortunately, many of our patients have been marginalized,” Bluebond-Langner said. They cannot always depend on their jobs or families for support. She sees the program’s care team as key to achieving a sound surgical outcome. Though trans rights have progressed on paper, many of her patients still experience adversity — poverty, unstable housing, social ostracization — that makes recovery more difficult. “If it’s hard to get employment because you’re trans, it’s not going to help you with surgery.”
‘People understand the trade-off. But we wouldn’t accept this rate of complication necessarily in other procedures.’
Walking down the hall to Bluebond-Langner’s private office, we pushed past people rushing to and fro in custom N.Y.U. Gender Surgery track jackets. (The program’s logo is a coy fig leaf.) Inside, above a consultation table, hung an autographed poster of the “Pose” actress Dominique Jackson. On a bookshelf, back issues of Plastic and Reconstructive Surgery leaned next to a stack of coffee-table books: “The Vagina Bible,” “The Great Wall of Vagina,” “A Celebration of Vulva Diversity.” Bluebond-Langner does three vaginas for every one penis. She sometimes finishes three vaginas in a day; each penis usually takes at least two surgeries, but often four or more. “The demand is far higher for vaginoplasty,” she said. “I think this goes back to the fact that it’s a reductive, single-stage procedure. The risks are lower.”‘
The N.Y.U. program has performed just over 150 phalloplasties to date. At the initial surgical consultation, Bluebond-Langner tries to understand what kind of sex the patient likes to have, to better recommend what combination of procedures might best improve quality of life while minimizing risk of complications. In the early days of formalized transgender medicine in the United States — a period between roughly 1960 and 1980 — phalloplasty was rare and pretty much one-size-fits-all, with its goal being to replicate the idealized form and function of an imagined standard American penis. While this is still the hope of many individual patients, Bluebond-Langner herself, and medicine at large, have begun to move away from this benchmark as an objective measure of surgical success.
Transgender surgery is designated as a treatment for gender dysphoria, not the condition of not being cisgender. There are partial interventions that can help achieve this goal while also minimizing risk. One patient, for instance, might choose to pursue standing urination but have no practical use for an erectile implant. Another might experience dysphoria as mainly visual but still enjoy vaginal receptive intercourse; phalloplasty without vaginectomy could meet this need with fewer procedures. “You can do glansplasty, no glansplasty. Scrotoplasty, no scrotoplasty. You can really do a whole mix-and-match thing to meet your goals,” Bluebond-Langner said.
Despite these improvements in patient-centered care, phalloplasty has a long way to go. Even as the frequency of surgery increases, the patient pool is not yet large enough to know empirically what cuts down on complications or leads to satisfaction in the course of an entire life. Bluebond-Langner’s phalloplasty patients are generally young, between roughly 18 and 32. The F.D.A.-approved erectile implants are designed for the bodies of cisgender men. The one trans-specific implant is not approved in the United States, but even if it were, there is not yet a standard way to measure or report what makes for good surgical outcomes. Cases between doctors are rarely comparable because of differences in technique.
“We need to improve the operation,” Bluebond-Langner said. “It’s an imperfect operation.” In this case, she says, the risks are justified only by the overwhelming impact on quality of life. “People understand the trade-off,” she said. “But we wouldn’t accept this rate of complication necessarily in other procedures.”
Ben after his final surgery and a revision to his ”top surgery” in March. From start to finish, Ben’s penis took four years to complete.Credit…Elle Perez for The New York Times
The main specialties of gender-affirming care — endocrinology and plastic surgery — were founded in the early 1900s, not as a means of transmogrifying gender but rather as tools for reifying it. Eugen Steinach’s experiments with hormones, conducted on rodents throughout the 1910s, gave rise to the Steinach rejuvenation method, a 20-minute partial vasectomy that he claimed could change decrepit aging men into “men of vigorous bloom who threw away their glasses, shaved twice a day, dragged loads up to 220 pounds and even indulged in such youthful follies as buying land in Florida.” (W.B. Yeats and Sigmund Freud both got “Steinached.”)
The basic techniques of plastic surgery stretch back more than two millenniums, but the discipline matured in the course of World War I as a means of restoring the bodies of blast victims so that they might better rejoin the world as men and husbands. Harold Gillies, an early British plastic surgeon, popularized the tubed pedicle, a general technique for moving tissue across the body by shaping a flap of skin into a tube and inching it toward the site of injury through periodic cutting and reattachment. “Deformities,” Gillies wrote in his 1920 book, “Plastic Surgery of the Face,” “are not only the constant source of the greatest distress and anguish, but materially lower the market value of the individual.” In 1939, the British Ministry of Health, foreseeing the mass disfigurement of World War II, called on Gillies to found Rooksdown House, a plastic-surgery hospital. It was there that he would meet Lawrence Michael Dillon, the man on whom he eventually performed the world’s first known gender-affirming phalloplasty.
Dillon was born in 1915 and raised as a girl by two morose aunts on a shabby estate near Dover. At St. Anne’s, a women’s college at Oxford, he spent most of his time rowing crew and wore his hair in the Eton crop — a short and slicked-down hairstyle, popular with lesbians on campus. Though Dillon liked girls, he did not think of himself as a lesbian; he dreamed of being taken to the blacksmith and somehow melted down into a man. Around the outbreak of World War II, he went to see a doctor who specialized in sex, who prescribed him tablets of testosterone. He had a mastectomy a few years later. This surgeon suggested he go see Gillies about a penis.
Gillies, at Rooksdown, was busy with the war but told Dillon to come back after it ended. In 1945, he returned and began a series of either 13 or 17 operations. (His and Gillies’s papers disagree.) Dillon’s penis was constructed using Gillies’s tubed-pedicle method, which here involved lifting a flap of skin, shaping it into a phallus and letting it heal while attached at both ends, dangling from the abdomen like a suitcase handle. While healing in this state, Dillon finished medical school. Some time after the pedicle reached its intended destination, he quit medicine, bounced around a series of Buddhist monasteries in India, changed his name to Jivaka and settled down to write his autobiography. Of the completed penis, he wrote only: “How different was life now! I could walk past anyone and not fear to hear any comments for no one looked at me twice.” Gillies was happy with the surgery too. He documented the case, with substantial editorial liberties, in his 1957 textbook, “The Principles and Art of Plastic Surgery”: “Provided thus with the new organ, the patient’s life has been a social success; he has become an active and successful business man and is very anxious to have everything done that would make it justifiable for him to marry.”
Dillon/Jivaka did not go on to marry, but the specter of marriage and social success would come to play a significant role in how gender-affirming medical care was conceived of and administered in the decades that followed. Formalized transgender medicine arrived in the United States between roughly 1960 and 1980, with the advent of the university-based “gender-identity clinic.” In the name of progressing medical research, these programs took on people who sought to change their sex, subjecting them to years of psychological study in exchange for a chance at hormones and surgery. Admission was limited to patients with the greatest chances of succeeding in life as employed heterosexual men or women. These candidates were almost always white. “The big benchmark was, ‘Could you disappear into a crowd?'” says Jules Gill-Peterson, associate professor of history at Johns Hopkins and author of “Histories of the Transgender Child.” “Medicine was not trying to make trans people happy. Medicine was trying to make trans people compliant.”
At the gender-identity clinics, trans women were typically prescribed hormones, breast augmentation and vaginoplasty. For trans men, testosterone and mastectomy were common, but genital surgeries remained rare, in part because phalloplasty had only minimally evolved beyond Gillies’s tubed pedicle of the 1940s. In a 1978 paper, “Construction of Male Genitalia,” researchers from Stanford’s gender clinic wrote, “In the female-to-male transsexual, the objective of the surgical program is to construct a penis and all the external male genitalia including the scrotum, with implantation of testicular prostheses.” By this standard — and often the standards of the patients themselves — the penises of the late midcentury could hardly be described as a success. They rarely allowed for standing urination, and sexual sensation was regarded as incidental. For those who wanted one anyway, the barriers were nearly insurmountable. In the gender-clinic era, care was free, but only to model patients. With the demise of the clinics, surgery became available on the free market, but only to those with the necessary cash and time to negotiate bureaucracy. A domestic phalloplasty in that time cost more than most people’s annual salary.
‘Healing is a weird thing in general, but especially when you have this big open wound on something as important and sensitive as your genitals.’
Nevertheless, the procedure itself began to improve in the ’80s with the gradual advancement of microsurgery. By linking blood vessels on a microscopic scale, it opened the door for phalloplasty with a lower rate of loss and an increased capacity for both sexual and tactile sensation. By this point, trans men had begun communicating with one another through a small but robust network of newsletters — FTM Newsletter, Twenty Minutes — which covered these medical advancements with great hope. Progress was slow and often disappointing. Microsurgical technique would not truly mature until the period after 1998, when the Women’s Health and Cancer Rights Act began requiring insurance coverage for post-mastectomy breast reconstruction. The enormous increase in free-flap breast surgeries — arguably itself a form of gender-affirming care — advanced microsurgery’s sophistication, allowing the modern phalloplasty to be born.
As Ben prepared for Stage 1 surgery, he told only his family and close friends. He knew that acceptance from some people in his life would hinge on every step going smoothly, and found himself acutely aware of a mandate to justify his desires. Though surgery today can construct a penis, it cannot reconcile millenniums of phallic anxiety: the tangled bond between penises and manhood; the supposedly inherent violence of the penis; the sense of the vagina as its wanting opposite; the feminist call to destroy gender essentialism. Even among trans men themselves, phalloplasty remains a highly scrutinized desire. It is easy to stand up for some vague and glittery right to gender self-determination; fighting for the penis is like rooting for the Yankees.
“In the back of my mind, when I thought of complications, there was always somebody saying to me: ‘See? That’s why you shouldn’t go against nature,'” Ben says. “I did not ever want to come across an ‘I told you so.'”
On the day of the surgery, Ben woke up in a hotel and checked into the hospital, where he changed into a gown and sat watching the Cartoon Network. He felt as if he were waiting forever. At 12:30 p.m., he was taken into the operating room and put under anesthesia. Six hours later, Stage 1 was done. Despite all the poking and prodding from doctors, and the swelling, and the wound on his thigh, and the drugs, the new penis felt like his right away. “I’d never had a penis before,” he says, “but once I had it, it just made sense that it was there.” The next few days were mostly pain and small achievements: first time standing up (May 11), removal of the catheter (May 13), discharge from the hospital (May 14). Even simple tasks were made better by the presence of his newly formed appendage. “Shower was AWESOME!!!” he posted to Facebook. “I got to hold my dick a bunch of times.”
After leaving the hospital, Ben spent two weeks recovering in a long-term-stay hotel in New Jersey. At his first post-op appointment with Bluebond-Langner and Zhao, he handed out bubble-gum “It’s a boy!” cigars. At that point, his penis was really just a tube — as featureless and smooth as a sea cucumber. In Stage 2, five months later, the team began laying the groundwork for an organ with increased functionality. This surgery began with Bluebond-Langner’s removing Ben’s vagina. (He’d already had a hysterectomy in preparation for Stage 1.) Next, in what is perhaps the surgery’s most gruesome stage, she sliced his penis lengthwise up the underside and lined the open face with more tissue from his thigh. This surface would someday form his new urethra, but first this tissue graft had to heal. Ben’s recovery coincided with the arrival of the pandemic, and he lived for more than seven months with his penis splayed open. “The ‘hot-dog bun’ stage was the hardest stage for me,” he said. “Healing is a weird thing in general, but especially when you have this big open wound on something as important and sensitive as your genitals. It can be scary. You’re seeing lots of colors. You’re seeing lots of fluids. You’re smelling lots of things.”
In May 2020, Bluebond-Langner stitched up the channel, connecting his existing urethra to his new one. At age 28, Ben was potty-trained again, teaching himself to pee standing up with a children’s urinal suctioned to the wall of his shower. (“When you hit the target,” he told me, “it would spin.”) He first used a public urinal a few months later, on crab-leg night at a restaurant in his hometown. (“My stepdad was like: ‘Oh, yeah! Go, Ben!'”) A few months later, in the Port Authority Bus Terminal, a stranger wondered aloud if he was in the wrong bathroom. “I was like, ‘Want to see my dick, bro?'” The man apologized, and Ben relieved himself, relieved. By this measure alone, the surgery was a success. Moreover, Ben’s goals had been drastically exceeded.
Ben with his mother and stepfather.Credit…Elle Perez for The New York Times
“The best 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, or the next surgery, or any sort of dissatisfaction,” he says. “If the world ended right then, I would forget that I was a trans man living in a trans body. I was just existing.”
I spoke to Ben on and off over those months. Though he did not yet have his erectile implant, he was starting to feel optimistic about his future sex life. Through various “American Pie”-style experiments involving multiple condoms for stability and a sex toy from an online store called Cherry Pie, he already knew he could feel a few sensations — hot, cold, tactile, erogenous. The implant he wanted, the Coloplast Titan pump, would allow him to elicit an erection on demand by a squeezing a device inside his scrotal sack. Ben hoped to get the implant — and a matching silicon testicle — sometime in early 2022, but before that he wanted to address two complications. First, his urine stream had grown weak, and he worried he might have a urethral stricture. Second, his penis was still very thick — far too thick to put his hand around.
In March 2021, Ben took an overnight bus to New York to consult with Bluebond-Langner and Zhao about these post-surgical concerns. I met him at the hospital at 8 a.m., each of us clutching a giant iced coffee. Even after a bad night’s sleep across two bus seats, Ben had a game and smooth-talking air, making wholesome, flirty chitchat with everyone he met. We went upstairs to the waiting room, where he handed out cupcakes to the office staff.
Inside the examination room, a nurse instructed Ben to get undressed from the waist down. I offered to excuse myself, but Ben said it was fine to stay. He dropped his pants and pulled on a gown. His penis was a respectable length by any measure. It was thicker and paler than any I had personally seen, but it otherwise looked unremarkably handsome.
Bluebond-Langner appeared in the door, followed by a pod of white-coated observers. Before Ben could say hello, she crouched down. “Looking good!” she exclaimed. “Did we take photos?” She took out her phone and snapped a few shots while listening to Ben’s concerns about his girth. She agreed they should excise some fat before implanting his erectile device. Ben stood up and put on his clothes. I followed him to another exam room, where Zhao would look inside his penis with a camera. A nurse produced a syringe of numbing gel and shot it up the length of Ben’s urethra. As he sat waiting for his penis to go numb, he asked me to pass him his cup of iced coffee.
Zhao threaded the camera inside, and soon Ben’s urethra appeared across four screens. Ben pointed at some squiggles. “Are those hairs?” he asked. Zhao said they were, from what used to be his thigh, but they weren’t thick enough to affect the flow of urine. He fished the camera deeper until he met resistance. “There’s just a tiny bit of a narrowing,” he said. It was only scar tissue. Massaging the spot from the outside would help break it up and improve his urine flow. This was all good news. Ben put on his clothes and tossed his drained iced coffee in the trash.
Ben went in for his “debulking” procedure that summer. His penis didn’t turn out as slender as he wanted, but finally he could grasp it in one hand. Describing the risks of further debulking, he repeated to me what Zhao had said to him: “Better is the enemy of good.” In March of this year, he returned for his final implant surgery and emerged from the hospital semi-erect; his penis had to heal with the pump partly inflated. By April, when we met again at N.Y.U. Langone, he was excited to get hard, but more excited to go soft. A month at half-staff had been somewhat awkward.
Zhao was waiting in the examination room for a post-op lesson in inflating and deflating. He put on a pair of purple nitrile gloves and lifted Ben’s penis up with his right hand. With the other, he gently grasped Ben’s scrotum and started to explain how the implant was designed. There was now a small reservoir filled with saline embedded in Ben’s groin. Inside his scrotum was a testicle-shaped bulb, which pushed the saline into a tube running down the length of his penis.
Zhao pinched the bottom of the pump a couple of times, and Ben’s penis stiffened. He moved the skin back and forth a little bit, to show how robust the whole mechanism was. “Now let’s try to deflate it,” Zhao said. Ben squeezed the pump inside his scrotum with his right hand. With the left, he began to compress his shaft like an accordion, pushing the saline back into the reservoir. Zhao said he should feel a “whooshing” sensation. After a few seconds, he gave a final push, and the penis flopped over, triumphantly flaccid.
“I believe that Liberace had one of these,” Zhao said.
With the clinical and congratulatory tone of a wedding officiant, Zhao cleared Ben for sexual activity. A few minutes later, Ben took out his phone and put on King Missile’s college-radio standard, “Detachable Penis,” which he said reminded him of his life before phalloplasty. He reflected on how surgery had changed him. The whole thing had taken just over four years, and in that time, his confidence improved. His relationship with his family had changed. His penis had improved his relationship to manhood, allowing him to inhabit the role with much less friction. He had told me in another conversation that this made sense for a small-town guy like him, but half-joked that it made him “a bad trans.”
When Ben set out in pursuit of phalloplasty, his one and only goal had been safety. Along the way, he grew in touch with a desire to stand naked in front of the mirror and look at his body without any snag of dysphoria. I wondered aloud if the point of surgery was to grant him the freedom to stop thinking about his penis.
“No,” Ben said, correcting me. “I think about it all the time. Touch it all the time. Look at it all the time. It’s my favorite thing to do.”
Jamie Lauren Keiles is a contributing writer for the magazine. They are currently working on a book about the rise of gender-neutral pronouns and nonbinary identity in America. Elle Perez is an artist who primarily works in photography and video. A solo exhibition of their most recent body of work, “Devotions,” is currently on view at the Baltimore Museum of Art through next spring.