Amy Bloom - Normal

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 outer 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.

James Green said, “I chose this because, well, I don’t really feel the need for a big one and I like having the range of feeling I always did. This form of sexual pleasure is fine for me and for my girlfriend. And the other costs a lot of money. A lot of money.”

Loren Cameron said, “It’s not all or nothing. I can live this way, as a man with a vagina. If I could get a fully functioning penis, I’d have the surgery. But I’m not prepared to go through more surgery, all of these procedures, to wind up with a pair of plastic testicles and not much more. I know who I am.”

I don’t think the idea of a man choosing to keep his vagina would make sense to Don Laub, although Loren would never find a more skillful or compassionate surgeon.

During the Harry Benjamin symposium, I talk to other doctors besides Laub, and to psychologists, psychiatrists, even psychoanalysts, people who collectively have worked with a thousand transsexuals and their families, in the United States and in northern Europe. Among them is Dr. Leah Schaefer, who is a psychologist, a genetic female, and a past president of the Harry Benjamin Association, and has treated hundreds of people like Loren, James, Luis, and Lyle. She is small and rounded, the right kind of Mittel-europa figure for full skirts, big belts, and a lace fichu at the neck. We meet at her Manhattan office, which is in her home and is itself homey, haimish —dried flowers, ceramic birds, carved boxes, family photographs, and a little sculpture of an Orthodox Jewish man studying Torah. I didn’t expect the mezuzah on the doorway, or that she would have spent twelve years singing professionally, or that we would end up talking about her closetful of shoes, talking with the same shared enthusiasm and tenderness you hear in the voices of boat enthusiasts, golfers, and transsexuals comparing surgical work.

“There are probably more than five thousand postoperative transsexuals in the United States now. You have small-town surgeons setting up shop just like the well-known ones, the ones with years of training. I’ve seen over five hundred people, but no researchers have ever interviewed me or asked for my statistics when they’re gathering information. There’s not a good statistics bank here in America. I’m afraid I don’t know where people get their numbers.”

Later, she brightens when she thinks of “a very wonderful scientist” to tell me about.

“Friedemann Pfafflin’s everything — an M.D., a psychoanalyst, a practicing clinician. He has a better vantage point than a lot of researchers. He’s just wonderful.”