Amy Bloom: Normal

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.

“He was my first. I had just come over from Stanford to spend time with Dr. Laub. Reconstructive breast surgery was my strong interest, and he’s incredibly good at that. He says to me, ‘How do you feel about working with transsexuals?’ And I said, ‘Oh, fine.’ Because I had no idea — I went to Berkeley, I figure I’m open-minded, it’ll be all right. Dr. Laub points me to one of the examining rooms, and I go in and find a middle-aged couple. I don’t even know who the patient is, but I look at the chart and I see it’s him. I ask him how he’s doing, he says, ‘Not too bad,’ and I’m trying to make an educated guess, to figure out what’s wrong, what kind of cosmetic surgery he’s here for. Finally I ask him, ‘Have you had any previous surgeries?’ and he says, ‘Why, yes, the double mastectomy and the hysterectomy.’ And I thought, But you’re a man. People outside the field always say, ‘He, she, whatever,’ in that tone of voice, you know the tone I mean. But that question never arises once you meet them, once you open yourself up to the danger.”

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.”