by Amy Bloom
At Don Laub’s surgical center in Palo Alto, I stand in the doorway of the waiting room, observing two women in the courtyard, wondering if they are “genetically female,” and wondering if I can bring myself to ask such a rude question. But if I believe, as I now find myself believing, that transsexual men and women are men and women, what would make the question rude? The implication that something tipped me off, that their femininity was imperfect, that there was some trace of the masculine in their appearance? I have been noticing traces of the imperfect, traces of the other gender in people, for two days now, ever since I met with Lyle and Jessie and with the guys at James’s condo.
The person on the side of the courtyard nearest me is blond, pretty, curvy, lightly made up in suitable-for-blonds colors. Conservative navy dress, white trim. Suntan hose and navy pumps. Could be, I think. Good makeup, but maybe just a bit stereotypically feminine, maybe a little overboard. She gestures to her companion forcefully, and I think, Ah, those hands. Very strong, even at a distance. I look at the companion. Thin and angular, in loose black pants and a loose black-and-ivory shirt. No visible curves at all. Reddish wavy hair gathered back tightly from a long, shining, intense, and makeupless face. But the narrowness of the forehead, the size and shape and prominence of the eyes. I don’t think so. And she laughs, showing her braces, and I think, Can’t be. This red-haired person, although not particularly feminine or womanly, is a genetic female.
I go into the courtyard, and the blond calls my name and introduces herself: Dr. Gail Lebovic, Dr. Laub’s associate. She introduces me to Selena, a visiting medical student. We sit in the courtyard a while longer, waiting for Don Laub, and I watch for tall, big-handed women, short, wide-hipped men with scraggly facial hair. A broad-shouldered, potbellied woman with a bad dye job comes through the courtyard, bandy-legged and squat. The cleaning lady. Genetic female. There’s a slim, wispy-mustached young man in the corridor. Sean, the new office worker. Genetic male.
We are joined by Dr. Laub, graying and clean-shaven, utterly conventional and conservative in a dark-suited, reptie way, except for eyes so brightly intense they seem silver rather than blue-gray. He went to Jesuit schools, has been married forever to the same woman, and has five children, one of whom is a microsurgeon in Vermont, and one a registered nurse. He is also the founder of Interplast, a charitable organization that sends plastic surgeons to poor countries to provide free corrective surgery for children and adults. As of this writing, Laub’s center has done 798 female-to-male surgeries, most performed by Laub himself before he retired in 2001. Of that number, two female-to-male transsexuals asked to have their phalloplasties reversed and to return to female bodies. Although both reported that they were happy in their lives as men, they had become born-again Christians, and had been advised that their sex change surgeries were not God’s will.
Don Laub and Gail Lebovic show me some photograph albums of their female-to-male patients—dozens of head shots, before, during, and after hormone treatments. It begins to seem to me that what we take as the immutable biological fact of our existence is, after all, largely hormonal and unnervingly fluid. Many of the pictures of the same patient at various stages of his transformation look like family portraits—younger, middle, and eldest brother. The faces broaden; the foreheads slope forward and down more roughly to the eyebrows from receding hairlines; the necks and shoulders widen. Strength training is recommended for female-to-male transsexuals, to deal with the weight gain, but many of the men in the photographs are somewhere between stocky and fat. A few of them are handsome, more than a few are attractive, most are average. One guy looks like Don Ho, another looks like Don Knotts, another like Richard Gere. Some are homely, with bad skin, bad haircuts, cheap eyeglasses and overwashed shirts, ugly mustaches, pouchy eyes, jowly necks. But no one in his right mind would take them for women.
Lebovic clears her throat and shows me the other pictures. I’ve seen them before, the pictures Don Laub sent me of phalloplasties and metoidioplasties; I flipped through them at home and tried to study them, but they were black-and-white photocopies. The originals are in brutal, Polaroid-type color, in which brown skin has a dappled, froglike quality, and white skin has the sheen and color of bad pork.
Lebovic occasionally points out items of interest. “See, with this surgery”—the phalloplasty—“we keep the clitoris. Here, underneath, just above the scrotum, so when the penis is either rubbing against it or pulled out of the way, there’s full sexual response. Isn’t that great? We make the scrotum with the labia, by inserting skin expanders, just a little bit, week by week. After the skin has expanded, we insert the testicular implants, stitch it up the middle a bit, to create the look. Otherwise you just have one big ball, like this. Picture a small deflated balloon—that’s the expander. We put one in each labium, sew the labia together, and expand each compartment so it’s just like testicles. Then we put in the implants, just silicone balls.”
She describes the painful electrolysis of the abdominal area (all hair must be removed from the skin that will be used to make the phallus), and then the surgery. Two vertical incisions are made, three inches apart, stopping short of the navel. The surgeon lifts up the skin and soft tissue while it’s still attached at the ends, and rolls it up lengthwise into a tube. This inside-out tube is covered with a skin graft from the hip. The soft, skin-covered tube is still attached in two places, at the navel and the bikini line, and will be left that way, a pulsing hot dog growing on the abdominal field, for at least three months, so that it will develop its own blood supply. The second stage requires detaching the tube at the navel end and allowing the newly developed phallus to drop down. Function, of course, in the form of urination and ejaculation, is another matter. Urination through the phallus can be arranged, but the production and ejaculation of sperm is not yet possible.
The photograph Don Laub shows me next must be a picture of something gone wrong. Underneath the penis is a huge, brownish, fuzzy red ball, a little bigger than a tennis ball. Nothing wrong, Lebovic says a little dubiously, it must just be a fresh post-op. Laub reassures me later that there wasn’t anything wrong in the case, just something a little unusual.
“This was a very macho Mexican guy, and he felt that he really needed it—them—to be big, so I expanded the labia way out so the scrotum would hang properly large.”
We come to some terrible pictures. These are of men, genetic men, who’ve had penises created after disease or trauma. “Burn, cancer, tree shredder,” Lebovic says gently.
Next we look at an album of various completed phalloplasties, which is much easier than looking at the squirming reds and yellows and acres of flaccid, anesthetized skin in the surgical procedures used to construct them. The penises here are long, blobby tubes with no real heads, no color.
“These are the early ones,” Lebovic says. “You see the shape is not so great. And of course, Dr. Laub was making them huge. I mean, really.” She shows me a photograph with a ruler held up to the penis. I’m reluctant to lean closer to read the number of inches. “Nine,” she says, laughing. “Well, Dr. Laub is a guy. I guess he figured that if you want one, you may as well get a big one. Now they’re a little closer to average. And there’s no erectile tissue, so you wouldn’t want it too small.”
The penises are starting to look more familiar, more penis-like. I’m getting used to the black, hard-looking stitches. The guys in the photo album are predominantly white, but transsexuals come in every ethnic and racial group.
On to the metoidioplasties—a surgery sometimes called clitoral release. These penises look, just as Laub’s articles say they do, like the penises of small boys, or like “what you’d see in a men’s locker room on a chilly day,” as he writes. “I don’t really understand why anyone has this surgery,” Lebovic says. “I mean, if you’re going to have a penis …”
She flips back to the first photo album and points to a WASPy middle-aged businessman with the silver flattop I associate with California Rotarians.
What danger?
“The danger of questioning everything we take for granted. The danger of questioning yourself.”
I arrange to meet Don Laub again in New York City, at the Harry Benjamin International Gender Dysphoria Symposium. Harry Benjamin came from Germany in 1913 to do his residency in endocrinology; he stayed in America and began a private practice, pursuing his fascination with the aging process and the study of glands. Alfred Kinsey, wanting an endocrinological assessment of a puzzling young man, sent Benjamin his first transsexual patient, in 1948, and changed the focus of Benjamin’s career. In 1966, Benjamin published The Transsexual Phenomenon, still widely used as a reference. He was, by all reports, the most lovable of men. He retired at ninety and died in 1986 at a hundred and one.
I haven’t yet understood the mechanics of all the intricate surgical procedures, and at my request Laub is going to explain them to me again. The conference is being held at the Marriott Marquis Hotel, and we sit down at a little table in a corridor that also functions as a lounge. Laub demonstrates the various genital surgeries for female-to-male transsexuals on lined yellow paper, using his pen point as a scalpel.
The four options are the basic phalloplasty, with external devices for erection and urination; two deluxe models, both of which provide the capacity to urinate in the typical male position (one also affords some physical sensation); and the metoidioplasty. All four are major surgeries, with more than one step. Mastectomies almost always precede the genital surgeries, which include hysterectomies and testicular implants.
Before long, Laub and I are surrounded by large and small yellow penises and one Red Grooms–style paper sculpture, with which Laub has walked me through three stages of the deluxe phalloplasty that includes the removal of a nerve from the forearm and its placement within the newly created phallus, running from the glans of the new penis to the nerves of the still existing clitoris and allowing a full range of sensation.
“I call this the postmodern one. Like those buildings over there.” He waves vaguely toward the newer architecture of Times Square.
I’ve heard transsexual patients and others—especially Stanley Biber, the grandfather-king of male-to-female surgery—talk about the horrifying scarring of the forearm when the skin and nerve are used to make the tube for the phallus. Laub shows me just how much of the forearm is taken for the standard flap, and I cringe as he runs his pen over most of the underside of my arm.
“I don’t do the standard flap. The goal is always, in surgery, the least ‘expensive,’ meaning least traumatic, donor site.” He describes stretching the thin, hairless skin of the forearm with tissue expanders so that when the skin and nerve and an artery are removed there’s only a thin incision, nothing worse. “It’s less than two inches across,” he assures me, “and then you’ve got urinary function and sensitivity. I got tired of other people making presentations, and showing the basic phalloplasty with the baculum [one of the devices used to maintain erections] and the urinary assist device, and saying, ‘Well, here’s the traditional method, as used by Don Laub.’ That’s still the one most patients choose. It’s functional, it’s much less expensive, in both senses, and you don’t burn any bridges. I’ve done about a hundred and fifty of those. A hundred and forty-eight. You can always go back and reconstruct at a later date.”
Including the mastectomy, the whole procedure for the basic sex change surgery costs twenty thousand dollars; if your insurance company is persuaded that you truly have the psychiatric disorder of transsexualism, for which surgery is a necessary part of the treatment, you might get reimbursement from them—after you’ve agreed to go through life with an official diagnosis probably comparable in many people’s minds to necrophilia. The prices at Laub’s surgical center haven’t gone up for years, and are a little lower than those of some other surgeons, including many who are still learning the techniques.
“This other kind of phalloplasty, which allows for natural, unassisted urination, calls for a year of electrolysis in a very sensitive place, the pubic region and lower stomach. And sometimes even then the hair grows back. But you see”—he quickly makes an incision in the paper and rolls up the tube—“you can’t have urination through the tunnel if there’s hair. The skin has to be hairless, so you either have to find hairless skin”—he taps my forearm—“or make it.”
He draws a long spoon. “With the first kind of phalloplasty, the one I’ve done the most often, this [urinary assist] device is what they use. You slip it in from the meatus [the opening for urination] right through the phallus. It’s very soft, flexible plastic. And after all, in men’s bathrooms, men are like this.” Don Laub stands up, hand placed over his belt buckle, and stares ahead with slight trepidation. His eyes dart from left to right and then fasten on the opposite wall. “The norm is not to look. With peripheral vision, all they’re going to see is some guy fumbling with his shorts and then urinating. That’s all. It works.
“Now, the metoidioplasty—it’s from meta, meaning ‘toward,’ oidio, for the male genitals, and plasty, ‘change.’ ” He draws and dissects another set of female genitalia, carving out a small penis and folding over the lips of the labia majora to make a very neat, actually rather cute scrotum. “I don’t think the patients really prefer this—I mean, if money were no object. Maybe some, some who are not such high-intensity transsexuals. Sometimes their wives don’t want the penises—they’ve been married eight, ten years, and I’m showing them the choices. I sit there like an encyclopedia salesman, showing them the different models, and maybe the wife says, ‘We want the metoidioplasty.’ And the husband says, ‘We do? I don’t think so, honey. I want the phalloplasty.’ And that relationship is in trouble. Because, for the most part—again, if money’s no object and this is a younger man—he wants a penis. Men want penises. But the metoidioplasty mimics nature, and that’s appealing. The testosterone enlarges the clitoris. It’s the way men and women both are in utero—an enlarged clitoris, which does or doesn’t become a penis. And it’s one-stage surgery, less expensive than the other, and obviously sexual and urinary functioning is intact and they can go on having sex however they had it. Like lesbians do.”
“You mean sex without intercourse? That’s all that they don’t get, right? No penile penetration.”
Laub pauses. “Well, yes. It’s only about an inch and a half, maybe two inches. So they can go on having the kind of sex they had before. Dildos, whatever.”
Laub next describes the four different devices that allow the men to have erections (a minority of those who have the forearm flap surgery won’t even need a device). The devices fall into two categories: pumps and inserts. One pump, the most discreet, is small, ball-like, and implanted in the scrotum. When activated, it pumps fluid from inside the ball into the penis, which remains erect for about ten minutes. There is also a syringelike external pump, which is attached to a condom. When activated, the pump evacuates the air from the hollow tube of the penis, forming a vacuum within it and hardening the o
uter casing—“like making Styrofoam,” Laub says. Of the two inserts, one is permanent, and the other is used only as needed. Laub is wary of the permanent implant, a woven silver-wire tube within a silicone sheath, which gives the penis some rigidity, whether pointed up or down. “It’s dangerous to have implants where you have no feeling,” Laub says. He recommends the baculum, slightly thicker than a ballpoint pen, coated with Teflon, and tailor-made, rather inexpensively, for each patient. It is inserted before intercourse, extends from the tip of the penis back to the clitoris, and allows for tireless intercourse and full sensation from the pressure on the clitoris, now located above the scrotum.
Laub is more comfortable with the men who choose penises and intercourse and who have clear-cut, easily identifiable heterosexual preferences, but he not only does the metoidioplasties, he does them extremely well and teaches other surgeons to do them. Still, as is so commonly the case in the medical world, the doctors and the patients involved in these procedures often understand their relationships in radically different ways. The doctors are trained to believe that they know, not only how, but also what and why and for whom. Patients, whether they have breast cancer or AIDS or colds, often want to be active partners in a treatment process marked by dialogue and exploration. At worst, patients see doctors as arrogant technicians; doctors see patients as self-endangering fools. Many of the men I interviewed preferred metoidioplasties, but never for the reasons offered in the literature or by the surgeons. The gender professionals say that patients choose metoidioplasties because they’re older and don’t want to go through the more complicated surgery, or because they have other medical conditions that contraindicate surgery, or because they were lesbians before transition and their partners don’t like the idea of sex with a man (as though if your partner had a beard, a deep voice, and no breasts, you would think you were in bed with a woman). But every transsexual man I spoke to who’d chosen metoidioplasty said, in essence, “I don’t need a big, expensive penis; this little one does just fine, and I can use the money to enhance my life.” It was like interviewing a bunch of proud and content but slightly bewildered Volkswagen owners and, across town, some slightly miffed and equally bewildered Mercedes dealers.
