When Bluebond-Langner began his rounds, he says, older surgeons warned, “Be careful what you’re famous for.” Unheard, she began assembling the training she would need to perform upper surgeries, vaginoplasty, phalloplasty, and metoidoplasty (a less involved surgery that builds a smaller penis using only native clitoral tissue). This training took her around the world: to Thailand and Canada to study vaginoplasty and to Mexico City, where she learned microsurgery, the technique that facilitates the transfer of the skin flap 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 such-affirmative phalloplasty. The operation, as far as you know, was a success. (She and the patient lost contact after two years.) A few years earlier, Rodriguez had moved to NYU Langone to be president of the plastic surgery department. Eventually, she recruited Bluebond-Langner to start a transgender surgery program.
NYU’s transgender surgery program occupies its suite on the sixth floor of a glass office building in Manhattan. I went to see him for the first time in March 2021. Stepping out of the elevator, I immediately noticed how extravagant everything was. In the waiting room there were Keurig machines and orchids in pots and iPads with futuristic fingerprint scanners. Far from the age of the separate secret website, the names of the benefactors were pasted on the wall. Sitting on the mid-century sofa (or leather swivel couch or chrome chair), a transgender journalist could be forgiven for feeling more than just a cynic. Trans people in America are in a complex relationship with the medical establishment: on the one hand, there is a call to expand and improve the treatments that have historically been denied; on the other hand, most of us aren’t blind to our bodies doing good business in a for-profit system. “We are paid,” Bluebond-Langner said, explaining that he doesn’t get more money for more patients. “Even if they give us a little incentive. They will give us more resources. “
Bluebond-Langner is smiling and direct and generally immune to the surgical god complex. When she came to NYU in 2017 to begin the program, she only had 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 navigational nurses. More than helped the team identify as trans, including two surgeons in training, which Bluebond-Langner hopes will one day succeed herself and Zhao.
Medical transition is an endless list of things to do. To be approved for phalloplasty, applicants must secure separate referrals from two mental health providers. They need laser hair removal at the donor site of the skin flap and support during the recurrent (and often immobilizing) phases of healing. “Unfortunately, many of our patients have been marginalized,” Bluebond-Langner said. They can’t always depend on their jobs or their families for support. You see the program’s care team as the key to achieving a good surgical outcome. Although trans rights have progressed on paper, many of her patients still experience adversity – poverty, unstable housing, social ostracization – making recovery more difficult. “If it’s hard to get a job because you’re trans, it won’t help you with the surgery.”
‘People understand compromise. But we wouldn’t necessarily accept this complication rate in other procedures. ‘
Walking down the aisle to Bluebond-Langner’s private office, we pushed past the people rushing back and forth in NYU Gender Surgery’s custom suit jackets. (The program’s logo is a shy fig leaf.) Inside, on a reference table, hung an autographed poster of “Pose” actress Dominique Jackson. On a shelf, the back issues of Plastic and Reconstructive Surgery were placed next to a stack of desk books: “The Bible of the Vagina”, “The Great Wall of the Vagina”, “A Celebration of the Diversity of Vulva.” Bluebond-Langner makes three vaginas for each penis. Sometimes she finishes three vaginas in one day; each penis usually requires at least two surgeries, but often four or more. “The demand is much higher for vaginoplasty,” she said. “I think this is due to the fact that it is a reductive, one-step procedure. The risks are lower. “‘
The NYU program has performed just over 150 phalloplasty to date. At the initial surgical visit, Bluebond-Langner tries to understand what kind of sex the patient likes to have, to better advise which combination of procedures could best improve the quality of life while minimizing the risk of complications. In the early days of formalized transgender medicine in the United States – a period between about 1960 and 1980 – phalloplasty was rare and virtually unique, with the aim of replicating the idealized shape and function of an imagined American penis standard. While this is still the hope of many individual patients, Bluebond-Langner herself, and medicine in general, have begun to move away from this benchmark as an objective measure of surgical success.