PHALLIC PERFORMANCE: Phalloplasty and the techniques of sex Vernon Rosario, MD, PhD UCLA Neuropsychiatric Institute
In Second Skins: The Body Narratives of Transsexuality, Jay Prosser (1998)
criticizes the tendency of postmodernist, queer theorists--specifically Judith
Butler (1990 and 1993)--to reduce the body to a sign: bodies and their sex become
the discursive effects of cultural power dynamics. Thomas Csordas (1994) also
points out how this semiotic reduction entails a phenomenological neglect of the
experience of existing in a body.
Given the attention queer theory has paid to gender performance and performativity,
I would like to examine them as techniques of sex: bodily performances that connote
gender and constitute the experience of being sexed. I am alluding to Marcel Mauss's
notion of technique du corps (techniques of the body), which Bourdieu adapted in his theorization of habitus (1972). Mauss noted that even the most "natural" bodily
activities--such as walking, swimming, or birthing--were diverse and culturally
transmitted. Equally importantly, he argued that the techniques of the body could be adequately studied only through a three pronged approach: paying attention to their
cultural, biological, and psychological aspects (1936, 369).
The experience of transsexuality particularly demands this tripartite analysis, since,
as Prosser argues,"transsexuality reveals the extent to which embodiment is as much
about feeling one inhabits material flesh as the flesh itself" (1998, 7). I want to return
to the flesh in all its bloody, fatty, sensuous materiality, not in transsexual narratives
but in surgical ones about phalloplasty. These reveal techniques of sex as constructed
(quite literally) by male surgeons and urologists, and also as construed as general
cultural expectations of the performance of sex.
Plastic surgeons often claim that phalloplasty is considered to be one of the most challenging procedures in reconstructive surgery (Hage, Bloem and Suliman 1993, 1093).
Surgeons certainly perceive phalloplasty to be a more formidable operation than
vaginoplasty. In part, this is due to their perception of the vagina as simply a passive receptacle for the penis. One pediatric surgeon stated it quite bluntly when he exclaimed,
"It's easier to poke a hole than build a pole." Surgeons have higher expectations of
the penis and its surgical simulacrum. Dr. J. Joris Hage and his colleagues of the
Department of Plastic and Reconstructive Surgery in Amsterdam, one of the most distinguished and experienced sex reassignment teams in the world, summarize the
challenge of constructing a fully functional phallus or "peniplastica totalis":
The surgeons ideal goals in performing phalloplasty in transsexuals have been
repeatedly described. These goals include the construction in a one-stage operation
of an aesthetically appealing neophallus with erogenous and tactile sensation,
permitting the patient to void standing up and to have sexual intercourse like a
natural male. The meatus should be at the tip of the penis and a urine stream,
not a spray, should break cleanly from it. The phallus should be in the midline
just below the pubis and should be of an appropriate size and shape. (Hage, Bout,
et al. 1993, 323)
They explicitly invoke a number of performance challenges as well as implicitly
evoke a variety of performative challenges. First off is the surgeon's own performance:
the anatomical and procedural planning of a fairly rare surgical intervention,
the technical prowess of accomplishing it, and the post-operative management
and corrective surgeries to obtain optimal functioning and prevent surgical failure.
The second part of the challenge is achieving the "surgeon's ideal goals" or the material projection of male doctors penis ideal. While some of these ideals seem mainly cosmetic
(e.g., the size and shape of the penis and the sculpturing of a glans [Hage, de Gaaf, et al.
1993]), on closer examination they are also elements of phallic performance including
matters such as urination in a standing position, erection, tactile and erotic sensation. A
and a capacity for vaginal coitus. The cosmetic aspects are essential to how the penis
or phallus performs as an exhibition object --whether veiled in undergarments or
exposed bare.
This is clear given the rising popularity of penis enlargement surgeries. As Randy
Sue Klein points out in her research on the subject, the majority of men who undergo
these procedures are heterosexuals who are most concerned about other men's perception
of their penis, for example, in locker rooms or at the beach. This also appears to be a
concern of FTM transsexuals--or at least it is a significant projected concern of surgeons.
In the one published survey on "Phalloplasty in female-to-male-transsexuals: What do our patients ask for?" conducted by the Dutch team, subjects were specifically asked if they desired a phalloplasty "to be able to wear a tight swimming suit without being "spotted"
as nonmales." And 91% replied in the affirmative (Hage, Bout, Bloem, and Megens 1993, 324).
The importance of the penis to men's technique of sex is also underscored by the fact
that phalloplasty was developed in the early part of this century not for sex-reassignment
surgery but for the treatment of congenital-men with penile atresia (Gilles 1948)
deformities of the urethra (McIndoe 1948), and traumatic loss of the penis from war or
circumcision injuries, or from radical penectomies secondary to cancer (Gelb, Malamet,
and LoVerme 1959). More recently, microsurgeons have advocated pediatric phalloplasty
for XY-genotype individuals born with intersexed micropenises or penile deformities in
order to "preserve" their male gender (Gilbert et al. 1993). Early penile reconstructions
did not even provide a urethra which would allow for urination (since neo-urethras are a major source of complications); however, surgeons still labored to create a meatal dimple and they circumcised the neophallus to create the appearance of a coronal ridge (Munawar
1957, Puckett and Montie 1978). So, while these neophalluses could not perform the
function of urination they could perform cosmetically. Two Brazilian surgeons in 1954 poignantly explained the significance of the cosmetic:
The great importance of the penis in man depends not only on its functions but also
on the appearance of the organ. . . . We should consider it as a very important organ
from a cosmetic point of view. It is really very humiliating for a man with all the
secondary sexual characteristics, to show himself without a penis. It is a very severe mutilation which leads sometimes to psychic complications. (Farina and Freire 1954, 351)
Imagine then the psychic distress of a transsexual man with no penis, let alone a small or deformed penis.
Simply to construct a phallus, surgeons have deployed a variety of techniques
which parallel the evolution of reconstructive surgery itself (Hage, Bloem and Suliman
1993). Tissue from one part of the body (the abdomen, thigh, or forearm) is harvested
turned into a tube, and positioned at the pubis. A major reason individuals avoid
phalloplasty is because of the resulting disfigurement of the donor site.
Early phalloplasties had to be performed in several stages to allow tissue to heal
and for blood vessels to grow in. Thus, various waltzing procedures were devised,
whereby the tube would first be formed on the forearm, later transferred to the groin,
and finally detached from the forearm (Gelb et al., 1959). A dozen techniques have beendevised to concurrently or subsequently create a urethral meatus at the tip, as
well as the appearance of a circumcised or non-circumcised glans-like end.
This surgical supplement to the phallus is not just aesthetically important,
but is functionally essential for producing a vigorous jet of urine that breaks
cleanly from the phallusrather than dribbling or spraying (Hage et al. 1993, 157).
The phalloplastic literature abounds with images of phalluses captured in midstream.
Public urinal performance, the lively sound of urine streaming into the toilet, and
standing to project one's bodily fluids in a clean, golden arch is paramount in surgeons'
phallic ideals and visible proof of a phalloplastic surgeon's craftsmanship. Indeed, fashioning a viable neourethra remains a major surgical challenge due to the development�@
of infections, constriction, and fistulas. The Dutch survey of transsexuals' phallic
desiderata suggests that erect voiding is also transsexuals' number one expectation
from phalloplasty (Hage, Bout, Bloem, and Megens 1993, 324). However, the broader
import of urinary stream to male gender performativity is evidenced by men's concern
with urinary trickle since it suggests prostatic disease associated with advancing age,
cancer, and the specter of prostatic surgery that could result in impotence.
The achievement of erection, while highly coveted by surgeons, remains a secondary
goal--even for the Dutch transsexuals surveyed. No doubt this is because it remains
so great a surgical challenge. Numerous ingenious methods for achieving rigidity in theneophallus have been tried, from incorporation of a strip of rib cartilage (in an uncannily
inverted Adamic genesis of gender) to the deployment of existing implants and external
devices already developed for treating male impotence. Again, given the seismic cultural
impact of Viagra, failure of phallic rigidity is not just a concern of transsexuals.
However,the Dutch team and others have found that all the surgical techniques have,
as yet, an unduly high rate of failure due to infection, rejection, and extrusion, and
therefore they avoid prostheses (Hage, Bloe, and Bouman 1993). Erection, particularly physiological erection, thus remains the Holy Grail of phalloplasty, further
valorizing and mystifying penetrative performance as the ultimate masculine
gender and surgical performative.
A major reason for the high failure rate of erectile prostheses is poor sensation
in the neophallus. Early surgeries using free flaps would provide for no innervation.
But thanks to current microsurgical techniques, nerves in the neophallic tissue can be connected to nerves of the groin so that tactile sensation develops in about six months. Surgeons comment, however, that erogenous sensation does not develop in the neophallus
but is still obtained from the clitoris which is imbedded into the base of the neophallus. Presumably these sensory distinctions are elicited from their FTM patients who,
in published studies at least, report greater sexual satisfaction and orgiastic capacity
after phalloplasty (Gordon 1991, Lief and Hubschman 1993).
That a FTM transsexual should feel that a tube of tissue harvested from the forearm
is the true materialization of a internally sensed penis that can finally stimulate a
masculine orgasm through an incorporated clitoris or coapted groin innervation, points
out the complex interaction between psychological and somatic factors in the performance
of sexed behaviors that constitute masculinity--for FTM's as well as born males.
Whether it is in erection, penetration, urination, or simply flaccid display, the penis
is more than a cosmetic sign--a static icon of gender--but a complex, physiological
signifier, whose appropriate deployment in gendered techniques of sex is central to
gender performativity.
References and Illustrations
Benglis, Lynda. 1974. [Advertisement.] Artforum (November): 1-2.
Blum, V. (1938). A case of plastic restoration of the penis. J. of
the Mount Sinai Hospital 4: 506-11.
Borgoras, N. 1936. Uber die volle plastische Wiederherstellung eines
zum koitusfahigen Penis (Penisplastica Totalis). Zentralblatt Chirurgie 63:1271.
Bourdieu, Pierre. 1972. Esquisse d'une thorie de la pratique. Geneva: Droz.
Butler, Judith. 1990. Gender Trouble: Feminism and the Subversion of Identity.
New York: Routledge.
Butler, Judith. 1993. Bodies That Matter: On the Discursive Limits of "Sex".
New York: Rouledge.
Csordas, Thomas J. 1994. Intorduction: the body as representation and
being-in-the-world. In Embodiment and Experience: The Existential Ground
of Culture and Self, ed. Thomas Csordas, 1-24. Cambridge: Cambridge, University Press.
Fang, Rong-Hwang, Jin-Teh Lin, Shiuh Ma. 1994. Phalloplasty for female to male
transsexuals with sensate free forarm flab. Microsurgery 15:349-52.
Gilbert, D. A., G. H. Jordan, C. J. Devine, Jr., B. H. Winslow, S. M. Schlossberg. 1993. Phallic construction in prepubertal and adolescent boys. Journal of Urology 149: 1521-26.
Gordon, Eric B. 1991. Transsexual healing: Medicaid funding of sex reassignment surgery. Arch. Sex. Behav. 20: 61- 74.
Hage, J. J. 1992. From Peniplastica Totalis to Reassignment Surgery of the
External Genitalia in Female-to-Male Transsexuals. Amsterdam: V. U. Press.
Hage, J. J., J. J. A. M. Bloem, F. G. Bouman. 1993. Obtaining rigidity in the
neophallus of female-to-male transsexuals: A Review of the literature.
Annals of Plastic Surgery 30: 327-33.
Hage, J. J., J. J. A. M. Bloem, and H. M. Suliman. 1993. Review of the literature
on techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. Journal of Urology 150: 1093-98.
Hage, J. J., C. A. Bout, J. J. A. M. Bloem, , J. A. J. Megens. 1993. Phalloplasty in
female-to-male transsexuals: What do our patients ask for? Annals of Plastic
Surgery 30:323-26.
Hage, J. J., F. H. de Graaf, F. G. Bouman. J. J. A. M. Bloem. 1993. Sculpturing the
glans in phalloplasty. Plastic and Reconstructive Surgery 92: 157-61.
Lief, Harold & Lynn Hubschman. 1993. Orgasm in postoperative transsexuals.
Arch. Sex. Behav. 22: 145-155.
Mauss, Marcel. [1936] 1985. Les Techniques du corps. Sociologie et anthropologie,
363-86. Paris: Presses Universitaires de France.
Munawar, A. 1957. Surgical treatment of male genitalia. Journal of the International
College of Surgeons 27: 352.
Prosser, Jay. 1998. Second Skins: The Body Narratives of Transsexuality.
New York Columbia University Press.
Puckett, C. L., and J. E. Montie. 1978. Construction of male genitalia in
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SLIDES
Benglis, Lynda. 1974. [Advertisement.] Artforum (November): 1-2.
Fang, Rong-Hwang, Jin-Teh Lin, Shiuh Ma. 1994. Phalloplasty for female to
male transsexuals with sensate free forarm flab. Microsurgery 15:349-52.
Fig. 1 & 2. Patient voiding. Tubed vaginal mucosa graft over forearm.
Fig. 3. Patient voiding while standing.
Gilles, Harold. (1948). Congenital absence of the penis. British Journal of
Plastic Surgery 1: 8-28.
Fig. 6. Marking of abdominal flaps.
Fig. 8. Forming abdominal tube.
Fig. 9. Abdominal graft.
Fig. 15. Hanging phallus.
Fig. 24 & 25. Formation of skin tunnel. Pedicle transposed over it.
fig. 26. Abdominal pedicle completed.
Fig. 27. Pedicle waltzed to scrotum.
Gelb, Jerome, Maxwell Malament, and Stephen LoVerme. 1959.
Total reconstruction of the penis. Plastic and Reconstructive Surgery 24:62-73.
Fig. 2. Presurgical view, total penile amputation
Fig. 5. Abdominal pedicle--side view.
Fig. 7. Forearm pedicle anastomosed to groin.
Fig. 8. Closure of urethral fistula
Fig. 10. Reconstructed penis urinating.
Perovic, Sava. 1995. Phalloplasty in children and adolescents using the
extended pedicle island groin flap. Journal of Urology 154:848-53.
Fig. 1. Design of pedicle goin flap.
Fig. 2-3. Elevation of graoin flap. De-epithelialization of flap.
Fig. 4. Tubularizing flap to form neourethra and neophallus.
Fig. 5. Transfer of neophallus. Mobilizing clitoris.
Fig. 6. A, Transfer of neophallus and urethral anastomosis. B, Coronoplasty.
Fig. 7. 12-year-old boy with exstrophy-epispadias complex, before and after surgery.
Fig. 8. 17-year-old man with complete traumatic amputation of genitalia,
before and after surgery.
Figure of Sigmund Freud with cigar. (Courtesy of the Louise Darling Biomedical Library, UCLA.).