Phantom Penis: Extrapolating Neuroscience and Employing Imagination for Trans Male Sexual Embodiment

ABSTRACT

This article investigates transgender men’s phantom penis experience with respect to several contexts: historical reportage and medical explanations of phantom limbs and phantom penises following amputation; body dysphoria and “melancholic strength”; all renditions of trans penis including the testosterone-morphed clitoris; phenomenology and prosthetic incorporation; the neurobiology of metoidioplasty and phalloplasty; and neuroscience research on cortical mapping, hard-wired gender, proprioception, brain plasticity, epiphenomenal orgasm, the rubber hand illusion (RHI), virtual reality (VR) embodiment, and mirror neurons. Although a unique phantom instantiation, trans men’s phantom penises are instructively related to congenital aplasia, visual and motor neural simulation, and cis men’s phantom penises. I examine three aspects of trans men’s phantom penis: phantom presence of a penis, phantom penile erogenous sensation, and the volitional phantom penis. An emphasis on function over visibility, pleasure over presence, and synthesis over staidness enables an understanding of phantom penis sensation as the neurological underpinning of all erogenous penile perception and therefore a desirable asset for trans men’s sexuality. In that vein, cognitive imagination is deployed to postulate volitional phantom penises.

To become thus again conscious of a ghostly bit of yourself which had been laid for years must certainly be somewhat surprising to the least emotional of men.—Silas Weir Mitchell, “Phantom Limbs,” 1871

Introduction

When I first heard two trans men talking about phantom penises, they did not use the word “phantom.” They used the word “penis.” They described their penises in concrete terms and referred to specific physical sensations. Moreover, the characteristic they most often attributed to their penises was presence. Although it is common for trans masculine people to use phallic language to talk about their genitals, these men were talking about another phenomenon—the sensorially felt experience of a penis that is not actually part of the physical body. Their conversation did not evoke anything phantasmatic. Nor, at the time, did the word “phantom” occur to me, even though I had previously read about phantom limbs. This, I believe, is because the salient relation between trans men and their phantom penises is aliveness. Trans men experience their phantom penises as alive, and phantom penises make trans men feel more alive.

When any of us sees a phantom, perhaps of a recently lost loved one—a not uncommon experience—our loved one is not present, yet has a presence. The phantom does not equal absence. It seems to merge presence and absence. Because our loved ones are part of us, the “passage” of time loses authority. The phantom is a re-presentation that brings historical fact back to the grieving subject. To study and describe a phantom fully requires a precise openness to experiential knowledge, whether one’s own or that of others. Thus, the conversation to which I was privy was both matter-of-fact and affirming. These qualities guided my thinking as I researched the history and science of phantom experience for this essay.

Although phantom penises were reported as early as the mid 1700s, there is still today a near-total absence of scholarly and clinical attention to them. My initial inquiry thus relied almost entirely on the literature on phantom limbs. The history of phantom limbs includes curiosity, incredulity, dismissal, and neglect, and is most often focused on the phenomenon of phantom pain. The research literature is also replete with gaps, restarts, speculation, science, and insufficiency. In this regard, the second section of this essay summarizes my journey through that literature, a cyclical search that was, for me, fascinating, informative, and frustrating. Although finally legitimizing phantom limbs, 150 years of study can still not fully explain them.

The modern theorization of phantoms and their causation has been primarily a collaboration of philosophy, psychology, and neuroscience. Certainly, trans men’s phantom experiences can offer generative questions, ideas, and qualifications to this enterprise. To this end, as already suggested, my consideration of trans phantom penises foregrounds presence, function, and desire. In the third section, I conceptualize trans men’s lasting desire for a penis as a “trans tense” that engages “melancholic strength.” In the fourth section, I bring the scant study of phantom penises in conversation with other neuroscientific studies that investigate the brain’s active role in perception and body consciousness. I suggest the possible relations and relevance of these studies, while cautioning against metaphoric leaps and reductive applications to phantom penises. In the fifth section, I build upon the synergy between phantom limbs and prosthetics to posit the phantom penis as a conduit for trans male embodiment. I elaborate this with an inclusive list of trans penises, including hormone nurtured, surgically molded, and futuristically engineered. In the sixth section, I turn to the body’s peripheral nervous system and, more particularly, to the erogenous function of trans phalloplasties. Orgasm provides a strong case for the phantom’s operative presence in brain–body circuitry. Throughout this essay, I not only value but also advocate for the sensate phantom penis, and in the seventh section, I speculate about how it might be intentionally developed through cognitive imagination, cross-modal perception, mirror mechanisms, and bodily agency. Here, my humanities “voice” comes to bear on what is at stake: trans men’s embodiment and sexual pleasure. For those without phantom experience, I rhetorically theorize a bricolage of will, affect, mentalizing, seeing-as, attunement, motor imagination, feeling-as, temporally fluid episodic memory, and metaphoric belief for conjuring the phantom penis. Ultimately, I understand erogenous phantom sensation as a usual physiological process and thus posit the trans man’s phantom penis as, at once, the epitome of penile enhancement and unremarkable among penises.

Phantom penises within a long but spotty history of phantoms

The phenomenon in which an absent body part is nevertheless felt to be present as part of the body—the “phantom”—is most associated with the loss of limbs in war. The persistent pain in phantom limbs that many soldiers experienced after amputation presented the phenomenon to military doctors and then to the purview of medicine at large, especially following World Wars I and II. Prior to the 1930s, there is scant literature on phantom limbs. René Descartes, Aaron Lemos, and Charles Bell, in 1641, 1798, and 1820–1830s, respectively, wrote about the phenomenon of pain perceived after limb loss but not phantom limbs per se (Heller-Roazen, 2007, pp. 261–262). Silas Weir Mitchell coined the term in his 1871 article “Phantom Limbs,” written after observing American Civil War soldiers at Stump Hospital in Philadelphia. Mitchell described many characteristics and variables that still lack definitive explanations today.

Phantom limbs can present with or without accompanying pain, continually or intermittently, and in various locations and postures. They can be rigid or mobile, and their shape and size can alter. Often they shrink over time, develop gaps, or undergo an effect called telescoping, in which the most distal part (e.g., the hand in the case of a phantom arm) relocates to meet the corporeal boundary (the body’s shoulder) while in-between parts of the phantom (forearm, upper arm) vanish. Even after prolonged existence, phantoms can completely desist, only to return at a later time in some cases. Phantom limbs can disappear when the person begins using a prosthetic limb, or the prosthetic can revitalize a disappeared phantom. Finally, the phantom is not generally mistaken for a real body part. (For a systematic description of phantom limbs and phantom limb pain, see Sunderland [1978, pp. 424–447].)

Mitchell’s article briefly mentioned Ambroise Paré, a French military surgeon whose two brief references in 1551–1552 are believed the sole prior reportage of ghostly limbs after amputation. However, given that amputations have occurred since ancient time, Price and Twombly sought evidence of phantom limbs in folkloric texts dating back to the 10th century. In 75 medieval (and 11 modern) stories of the miraculous recovery of lost body parts, they find descriptions that sufficiently resemble the symptoms of phantom limbs to conclude that the stories are metaphoric representations of actual phantom limb experiences during an age predisposed to superstitions and miracles. Price and Twombly thus extend the history of phantom limbs back to medieval time (1978, pp. xiii–xix).

In 1887, inspired by Mitchell’s reportage, William James distributed a circular of questions and conducted interviews to obtain information from 185 amputated persons in an attempt to explain the variations of phantom experience. Although his results fell short of that goal, many insightful remarks and propositions put forth by James in “The Consciousness of Lost Limbs” remain salient to contemporary research, with the most prescient being his assertion that the brain participates in the generation of phantoms. While discussing the illusion of voluntary movements in lost parts, James states:

In these illusions the mind, sensibly impressed by what seems a part of a certain probable fact, forthwith perceives that fact in its entirety. The parts supplied by the mind are in these cases no whit inferior in vividness and reality to those actually impressing the sense. In all perception, indeed, but half of the object comes from without. The larger half usually comes out of our head. (1887, n.p.)

Why are phantom limbs so rare in the literature prior to the 20th century? Perhaps the answer lies in the suspect status of phantoms in general as figments of the imagination. It is unfortunate that terminology inherited from centuries ago mistakenly suggests that the common phantom is otherworldly and nonscientific. Scientific disbelief in the actuality of phantoms could make patients hesitant to describe their unexplainable sensations of invisible body parts. For patients and doctors alike, speaking seriously about phantoms might solicit doubts of their reasonableness, even their sanity. Indeed, Mitchell first described symptoms of phantom limbs anonymously in a fictional story (see Heller-Roazen, 2007, pp. 253–261; Wade and Finger, 2010, p. 300). More recently, many of the 648 veterans and 436 civilian subjects surveyed by Sherman and Sherman (1983, 1985) reported a strong impression that the physicians with whom they discussed their phantom pain considered them insane.

Not until the early 20th century did scholarly interest in phantom limbs proliferate and persist. The ensuing interest gathered shifting etiologies. Prior to World War II, phantoms were widely considered to be psychogenic. Post World War II neurologic etiology attributed phantoms to peripheral nerve irritation from amputation or prior injury. In 1950, Schilder concurred that phantoms depended on peripheral nerve pain, but argued too, as James had earlier, that the central nervous system was also involved. “We should not ask whether a phenomenon is peripheral or central, but rather, ‘What are the peripheral and what are the central components in a phantom?’” (1950, p. 66). The protean understanding of phantoms supported a proliferation of phantom body parts (from limbs to noses, tongues, jaws, breasts, and penises) during the 1950s, an epidemic of phantom pain during the 1970s, and the remission of phantom pain during the 2000s despite the ineffectiveness of treatments. In 1983 Sherman and Sherman reported that many veterans no longer mentioned their phantom pain to doctors because they had heard about “some of the invasive procedures unsuccessfully used … . Virtually all commented that they would be interested only if an efficacious mode were available” (1983, p. 233). In 1985 Sherman and Sherman reported very low effectiveness of phantom pain treatments. “The success rate for reported treatments of our [648] military respondents [questioned in 1983] was a dismal 1.1% who achieved lasting major benefit … . Our [436] civilians reported very similar results” (1985, 96). As Cassandra Crawford concludes,

The morphology of phantoms, their bizarre and idiosyncratic ways, their biomedical facticity and “realness,” their very existence has always been at least partly dependent on which knowledge claims were deemed legitimate and why. (2014, p. 229)

It seems wise then, when it comes to descriptions of phantom experiences, not to displace earlier accounts but rather to give continued consideration to testimonies and reports from all eras and situations, even when contradictory. (Figure 1)

Figure 1. The Sensory Homunculus (left) and the Motor Homunculus (right), from Penfield and Rasmussen (1968, pp. 214–215)

Throughout the 20th century, neuroscientists became increasingly convinced that phantom limbs derive from activity in specific areas of the brain that previously had been devoted to now missing limbs. Various “mappings” that correlate sensory and motor activities of the body’s surface and external parts to particular cortical regions in the brain, such as Penfield and Rasmussen’s Homunculus, were deduced from observed effects of accidental brain injuries and intentional brain stimulation. Over the 20th century, cortical mapping included Head and Holmes’s body schema in 1911, Penfield’s homunculus in 1937 with later renditions in 1951 and 1958, and Melzack’s neuromatrix in 1997 (see Crawford, 2014). Interruptions of sensory neural flow from periphery to brain, such as occurs in spinal cord injuries (e.g., quadriplegia and paraplegia) and major nerve breakage (e.g., brachial plexus avulsion), were also recognized to produce phantoms. Modern technology that excites and tracks brain activity, such as transcranial magnetic stimulation (TMS), magnetoencephalogram (MEG), and functional magnetic resonance imaging (fMRI), has produced additional maps and elaborated possible relations between brain and body. Melzack (1989) describes the neuromatrix as a genetically determined, highly complex neural network engaging multiple areas of the brain with synaptic changes constantly occurring due to environment and experience. Nevertheless, ambiguity remains as to how these relations operate to produce the wide variety of phantom limb phenomenon.

Gallagher et al. (1998) offered two plausible causes for the phenomenon of “forgetting,” in which a person with a phantom limb forgets they have lost their original limb. Such a person, for example, might confidently step out of bed, only to collapse on the floor. One explanation is that present-tense cortex-generating sensations of the phantom leg are so strongly perceived that the person forgets that the phantom is not real. A second explanation is that the original corporeal limb is remembered so strongly in the body schema, a (somewhat permanent) mental representation of one’s body that allows a person to move through space without needing to look at their body parts, that the person forgets it is gone. From the 1990s to the present, scores of assorted experiments utilizing phantom experience (including phantom-sensation-evoked via deafferentation) have been designed to elucidate and theorize the bases and operations of body image, body schema, consciousness, self, embodiment, peri-personal space, prosthetic incorporation, pain, illusion, and extrabody experience.

Phantom penises appear even more rarely in the literature than do phantom limbs. Wade and Finger (2010) provide valuable research identifying reports of a total of four phantom-like penises by Scottish doctors Hunter, Marshal, and Bell working in London in the mid 1700s. A century later, in his 1872 book, Mitchell included a footnote referencing an unpublished case of a phantom penis that was subject to erection, mentioned to him by U.S. Naval physician Rauschenberger (Mitchell, 1872, p. 350). Wade and Finger list additional phantom penises occurring during the 20th century, including two phantom penises (and a phantom testis) reported by Heusner in 1950, seven phantom penises among 12 patients whose penises were amputated due to cancer reported by Crone-Münzebrock in 1951, and another phantom penis after total penectomy due to cancer, reported by Fisher in 1999 (Wade and Finger, 2010, p. 300).

Phantom penises are notable in the literature because they can present with erections and pleasurable sensations. Fisher’s patient described his phantom penis, which was only noticeable when erect, as resembling its precedent organ in size, shape, and sexual feeling, which still could be prompted by the sight of a pretty woman. Researching the occurrence of 27 phantom penises among 50 paraplegics, Bors (1951, as reported in Fisher, 1999, p. 56) reported 8 erect-only, 13 non-erect-only, and 6 phantom penises that were experienced in both states. Crone-Münzebrock’s seven patients with phantom penises reported them only to be sensate when erect (reported in Fisher, 1999, p. 53). Much rarer is the lack of erogenous sensation in phantom erections, evidenced by one of the cases reported by Heusner (1950, p. 129). Generally, the erections and erotic sensations of phantom penises diverge significantly from phantom limbs’ frequent occurrences of telescoping and pain. The cases of two penis phantoms and one testis phantom reported by Heusner (1950) are exceptions in that the patients experienced pain. However, it may be relevant that the pain was referred to the organ from elsewhere already existing before amputation. In the few other reported cases in which phantom penises were accompanied by pain, similar pain had already been present before amputation. The associations between preexisting pain, genital phantoms, and phantom pain, although not predictable, continue to interest researchers. Of 238 men surveyed by Pünse et al. (2010) who had one testis amputated between 1995 and 2005, approximately 50% experienced phantoms and 25% experienced phantom pain. Subjects who did not experience phantoms were less likely to have endured pain preoperatively (p. e216). It is also interesting that those 5 of Crone-Münzebrock’s 12 penectomy patients who did not experience phantoms had lost their libido before the operation (Fisher, 1999, p. 53).

Obvious differences between limbs and penises should be noted, lest we overconfidently deduce the phantom penis from the better known phantom limb. Most importantly, although limbs are draped upon both sensory and motor sides of Penfield and Rasmussen’s Homunculus, the penis is represented only on the sensory side. The penis is a relatively passive organ. By contrast, arms and legs, with their muscles and joints, are highly dedicated to body locomotion, so movement (or the lack thereof) is a significant variable in their phantoms. Many investigative experiments with phantom limbs test for neuromuscular activity in remaining muscles proximal to the amputation site.

Although limbs are bilateral, the penis is located axially. Treatments that mirror or manipulate a surviving opposite limb in order to coach a phantom from a rigid position are irrelevant to phantom penises. Limbs make frequent, forceful contact with the concrete world. When their distal ends are used for grasping or standing, rigid bone length maximizes the physical encounter. Similarly, the impacting of material objects and surfaces by pinchers and canes aids the incorporation of such prosthetics into the body image. The flaccid penis is less active and less direction motivated, except during urination, when it projects body fluids outward.

During sexual activity, the penis stiffens and extends in length. However, the visible penis has no bone or voluntary muscle. Although the penis appears to move itself, it is passively moved by adjacent muscles and a hydraulic system. Its erotic momentum calls on the forceful movement by hips and torso or being moved upon. Several smooth (involuntary) muscles, under the influence of the autonomic nervous system, are located in the (proximal, internal) root of the penis. The ischiocavernosus muscles aid in the increased inflow and decreased outflow of blood to achieve and sustain erection—that primary accomplishment of the penis, which announces itself proprioceptively via a high density of stretch receptors. Involuntary rhythmic motions of the bulbocavernosous muscles aid ejaculation. In a discussion following Heusner’s article on phantom penises, Yakovlev succinctly elucidates the motor mediocrity of the axial penis: “The genitalia are not outjuttings of the body wall, but rather viscera extruded … . The testicle and penis are endowed with only what may be called cremasteric motion of pulling up—a motion of a part of the body upon the body, with the fulcrum in the body” (1950, p. 132).

The repeated focus on erections in the preceding descriptions of phantom penises insists on a second characteristic of the penis important to the study of phantoms. In addition to the proprioceptive signaling of presence that occurs in limbs, perception of the penis serves up erogenous pleasure. Finally, in addition to such somatoperception in one’s body, the penis is a special object of what Longo, Azañon, and Haggard (2010) term “somatorepresentation,” which acknowledges salient emotions and attitudes cognitively directed at one’s penis. It should not surprise if phantom penises are found to veer away from phantom limbs in terms of presence, timing, position, movement, sensation, and appraisal.

Trans tense: claim to a penis

Many trans men live in a state that I term “should-have-been” tense. Should-have-been is a perfect verb with a conditional auxiliary. The perfect tense of “have been” indicates a completed action (in the past), but it focuses attention on the resulting circumstance (the now). The conditional auxiliary, “should,” expresses a futurity, a probability, an obligation. In other words, the present situation of trans men who live in this tense is that, when born, they were meant to have a penis. This resembles what Bettcher (2016), following Harold Garfinkel’s discussion of genital mutilation, has termed “moral genitalia”: penises and vaginas that people were meant to have (p. 422).

This is not an instance of mourning, in which one comes to accept the loss of someone (which was considered by Freud [1917] the healthier process), but rather something more like melancholia in which loss is not accepted: One refuses to give up what was supposedly lost. In the case of these trans men, it is not another person whom one insistently embraces; rather, it is a (promised) part of oneself. As Henry Rubin asserts about transsexual men who ignore their female anatomy and fantasize male genitals,

This ignorance/knowledge is the assertion of the I committed to remaining active in the world and to working on a life project … . [D]iscursive approaches … slide all too easily from analyzing social formations into erasing transsexual subjectivity and passing moral judgments on transsexual subjects, who should somehow know better than to “believe” in gender (while letting nontranssexuals off the hook). (1998, p. 271)

The “wrong body” description of transsexual experience has been considered medically dictated, a product of false consciousness, pathologizing, and politically incorrect. Self-understandings, over time, have accrued political dimensions. Critical debate among trans scholars about the meanings and ramifications of personal desires regarding gender transition dates back at least to Sandy Stone’s “The Empire Strikes Back: A Posttranssexual Manifesto” (Stone, 1991/2006) and Leslie Feinberg’s Transgender Warriors: Making History from Joan of Arc to RuPaul (1996), which contributed to the development of “transgender” as an inclusive cultural identity. Extensive scholarship has extended the discussion to the present day, generating multiple positions. Within some positions, terms such as “medicalization” and “normativity” suggest that personal dispositions, such as wanting gender-affirming surgery (GAS), are overdetermined by dominant institutions and ideology (see Johnson, 2015). Other positions have argued that a transgender umbrella elides important issues foregrounded by transsexualism, including body specificity (see Connell, 2012). I am less interested in dismissals or prescriptions (from any quarters) than in investigating the feelings and desires that many trans people have, and the shapes through which they defend and pursue them.

Addressing debates that pit social constructionism against biological determinism and dichotomize transgenderism as subversive versus transsexualism as conservative, Riki Lane (2009) proffers biology as an active producer of diversity. Embracing new materialism, he understands biology as a nonlinear becoming, rather than a constraint. With recognition of biological contingency, research on brain sex and phantom etiology is not to be dismissed as simply essentialist. Nor is transsexualism. “Re-reading biological research on trans can mean seeing the drive to alter the sexed body as having a clear neurological correlate that is not dichotomous but diverse” (Lane 2009, p. 150).

Many trans people endure an existential state that Havi Carel (2016), discussing illness, calls bodily doubt, in which one has lost a prereflective certainty in one’s body, that underlying sense of “I can” that all intentional actions presuppose (pp. 90–91). For a person experiencing illness, the inability to take one’s body for granted creates a “disruption of one’s sense of belonging to the world” (p. 101). I contend that for transsexuals (and many who identify as transgender or gender nonconforming), an existential, always-already experience of non-belongingness conjures an agential preexistence, a “should have been.”

Trans desire is constitutive. It launches from mental subjectivity and bodily intention, both of which are agential and generative. Both contribute to the constitution and care of phantom penises. Desire can seed itself in the past as well as the future. It affects not only what we do but what we are. For trans people, desire can make what is materially unobtainable phenomenologically useable. Trans people differ in their desires, experiences, and choices, and there is no formula to determine what is the healthy choice for all trans persons. For some, accepting the forward authority of linear temporality opens a proactive acceptance that allows for a more livable self. But for others, desire moves corporeal existence backward as well as forward, invigorating trans tense, and to give up on this desire is to lose the bastion of melancholic strength. Phantom penises—as expressed desire, as bodily claim, as realization—can be self-authenticating. Furthermore, they can be pleasurable. They are worth appreciating by those who have them and worth pursuing by those who don’t.

My favorite example of generative biology comes from Karen Barad’s discussion of how research at Tufts University, merging the fields of bioelectricity and molecular biology to study developmental and regenerative biology, produced a startling discovery: Bioelectrical patterning is crucial to morphological development. Biologists Michael Levin and Dany Adams were studying early tadpole development when Adams observed an electric potential, generated by an ion transporter in the tadpole embryo, a flash on the surface of the embryo depicting the pattern of its future face. The genes generally thought to determine facial morphology had not yet been activated. This image of a not-yet-existing face was evident before cell differentiation had occurred. The agency of bioelectric coding predated that of genetic coding. Using bioelectric patterning, Levin’s laboratory has been able not only to regenerate organs, but also to grow new organs in new bodily locations (Barad, 2015). Barad appreciates the relevance of this research to trans bodies, desires, and imaginaries:

Nature is agential trans*materiality/trans-matter-reality in its ongoing re(con)figuring, where trans is not a matter of changing in time, from this to that, but an undoing of ‘this’ and ‘that,’ an ongoing reconfiguring of spacetimemattering in an iterative reworking of past, present, future integral to the play of the indeterminacy of being-time.

The electric body—at all scales, atmospheric, subatomic, molecular, organismic—is a quantum phenomenon generating new imaginaries, new lines of research, new possibilities. The (re)generative possibilities are endless. Fodder for potent trans* imaginaries for reconfiguring future/past lived realities, for regenerating what never was but might yet have been. (Barad, 2015, p. 411)

Although the trans phantom penis gathers meaning and value from personal and social existence in present “reality,” when research points to pre-embryological and pregenetic determinants, we cannot rely on conventional science or insist on conscious memories for explanation. Perhaps the heterogeneity in phantom “symptoms” is less needing explanation than providing clues.

Situating trans phantom penises within neuroscientific research

Attention to trans phantom penises can be credited to Ramachandran and McGeoch (2008), Case and Ramachandran (2012), and, among trans scholars, Prosser (1998), Rubin (1998), and Langer (2016, 2019). Ramachandran and McGeoch reported that of 29 interviewed “female-to-male transsexuals,” 18 (62%) had experienced phantom penises. They state:

This finding provides a striking vindication of the hypothesis that there is a hard-wired, neural basis for an individual’s gender-specific body image down to the precise details of external sexual anatomy. It is especially remarkable that, in these individuals, the sensation of having a phantom penis has survived a lifetime of contrary visual feedback, enculturation and being raised as a girl. In two of the cases the phantom first made its appearance shortly after starting hormone (testosterone) therapy, suggesting dormant “male-body image” brain circuits that only required a hormonal trigger for re-activation. (Ramachandran and McGeoch, 2008, p. 1003)

In contemporary neuroscience, the assertion of a hard-wired brain does not preclude brain plasticity. Ramachandran and colleagues have also contributed salient research regarding cortical remapping, which supports an understanding of the brain as changeable. That is, the brain adapts in response to its environment, whether that be the rest of the body or the outer world. To dichotomize hard-wired and plastic modes is to oversimplify both theoretical avenues. As Pitts-Taylor (2016) states in a considered discussion of neuroplasticity, with critical attention to social factors, the sexing of brains, new materialism, nonhuman agency, and material performativity: “How can [plasticity’s] promise be understood when plasticity so neatly coincides with dominant ideologies and practices, or when it threatens the body-subject with techniques of governmentality?” (p. 18) “The specificity of matter must be explored without accepting the naïve position that what neuroscience research uncovers is given by nature alone” (p. 41).

Ramachandran has demonstrated remapping of the homunculus in adults after limb amputation. He speculated that when the now absent limb no longer sends (afferent) sensory information to the cortical region associated with it, the region is invaded by neurons sprouting from adjacent areas serving other body parts. Hence a person whose arm has been amputated may feel a (phantom) hand whenever their face is touched (Ramachandran and Blakeslee, 1999, pp. 28–33). In their multifocal model, Ramachandran and Hirstein (1998) also consider that such perceptual mislocation might result from neural redundancy in the brain. In this case, already existing neural connections from the face to the hand’s cortical area, which formerly were masked by input from the limb, now are able to stimulate the hand’s cortical area, producing a phantom hand. A third possible explanation is that when body movements are mentally commanded, utilizing a retained image of the body, the motor cortex simultaneously sends data to the sensory cortex (and spinal cord), which incites perception of the involved (but absent) limb (Ramachandran and Hirstein, 1998; Inui, 2016, pp. 2–3).

Armel and Ramachandran (2003) have demonstrated that people with the relevant body parts intact can also be made to experience phantom limbs using the rubber hand illusion (RHI). The subject sits at a table, positioning one of their hands out of sight underneath the tabletop or behind a screen. A rubber hand is placed in a corresponding position on top the table. The experimenter then congruently strokes the visible rubber hand and the subject’s unseen corporeal hand. This procedure soon causes the subject to feel the stroking where they see it, that is, in the rubber hand, which they experience as their own hand. During this experiment, the subject loses track of their actual hand and incorporates, via phantom sensation, the rubber hand into their body image and experience—so much so that injury to the rubber hand is felt as pain by the subject. Ramachandran’s experiments with the rubber hand illusion (RHI) and mirror therapy foreshadowed contemporary experiments with virtual reality (VR) that produce temporary phantom bodies. The bodily self can exceed the person’s corporeal body.

Langer has suggested a similar procedure, with a sexual prosthetic and partner collaboration, for trans men to experience a phantom penis.

For some trans men, I believe we could apply the RHI. The visual of wearing a prosthetic can be helpful to reduce the prediction error of the expectation of seeing a penis … . The RHI could be applied during masturbation or with a partner. The individual needs to be able to touch his own material penis while touching the prosthetic or have someone else touch his body and prosthetic … . Synchronizing touch on the prosthetic and on his body, he may be able to provoke the remapping of his body and feel sensation in the prosthetic. (Langer, 2016, pp. 163–164)

While Armel and Ramachandran use the RHI to demonstrate one’s ability to feel an extrabody presence and its pain, Langer’s proposition seeks a fuller body presence and its erotic pleasure. This difference should be kept in mind. Ramachandran and Hirstein (1998) acknowledge the importance not only of synesthesia, but also of modal specificity. In each of the already-described uses of RHI, the particular sensation is primarily determined, not by the target object, but rather by the specialized body part from which it is projected. In each case the object from which sensation seems to arise is experienced as one’s own body. However, these otherwise parallel experiences of presence can produce different affective results. Although the subject of the RHI will likely be astounded by their temporary incorporation of an inauthentic hand, Langer’s trans man may well feel validated by his newly realized penis. This prompts the question of whether the phantom penises that (some) trans men experience in everyday life compare to or diverge from phantom penises experienced by (some) cis men who have lost their penis to amputation or disease. Both sets of men lack visible penises, but other anatomical differences might influence the character of their phantoms. Trans men likely have intact genitals, whereas depending on the site of amputation, cis men may or may not have a penile “stump” containing genital tissue. Trans men lack male reproductive capacity, whereas genitally injured cis men may or may not have sperm-producing testicles. With different internal anatomy, both trans and cis men may seek phalloplastic surgery to supplement their extant external anatomy. Perhaps the most important question concerns what anatomy is represented on the cerebral cortex of trans and cis men.

Research on two additional groups who experience phantom limbs—people born without limbs (congenital aplasia) and stroke patients with paralysis (e.g., hemiplegia)—may lend insight to trans phantom penises. Because trans men were assigned female at birth (AFAB) and are understood to be born without penises, it might be doubted that their phantom penis sensation is the same as that of cis men, who experienced having a penis throughout life until it was removed, or that it is even genuine. How can a phantom penis exist when the subject has not previously experienced a corporeal penis, when the brain has never received afferent proprioceptive messaging from a preexisting penis? To some extent, this doubt is logically countered if a person born without a limb can nevertheless experience such limb as a phantom. Research into the possibility of phantoms in people with congenital aplasia has drawn conflicting conclusions. As Crawford (2014) puts it, “Whether or not phantoms do or can appear in cases of congenital absence is one of the longest running and most acrimonious debates within the phantom literature over the twentieth century and into the twenty-first. Phantom limb in cases of congenital amputation reemerges throughout the history of phantom etiology as one of the most persuasive ways of either buttressing claims or undermining them” (pp. 115–116) (see also Weinstein and Sersen, 1961; Flor et al., 1998). The tendency to accept the possibility of phantoms resulting from congenital aplasia supports a prenatal hardwiring similar to that asserted by Ramachandran and McGeoch (as already described) in trans men.

Regarding their study of 15 children born limb-deficit and 26 children who had limbs amputated before age 6, Melzack et al. state:

These cases provide evidence that phantom limbs are experienced by at least 20% of congenitally limb-deficient subjects and by 50% of subjects who underwent amputations before the age of 6 years … . It is argued that these phantom experiences provide evidence of a distributed neural representation of the body that is part genetically determined. (Melzack et al., 1997, p. 1603)

Other investigators have similarly concluded that some inborn neural substrate exists even when a person is born without the relevant limb, and that genetic and epigenetic influences probably coexist for aplasic phantoms. Gallagher et al. (1998) observed that hand-to-mouth movements related to hunger and feeding behaviors of newborns are already evident at weeks 12–15 of gestation. Thus, the occurrence of phantom hands in persons with congenital hand aplasia is supported by prenatal neural circuitry linking hand to mouth. The natal mouth begins a circuit that presumes a hand. Brugger et al. (2000) used TMS, fMRI, and implicit reaching testing to provide an empirical foundation for the self-reported vivid phantoms of a woman born without forearms and legs. They showed that phantoms do not depend on the cortex remembering previously present parts. While maintaining that their study neither confirms nor contradicts an innate component of the body schema, they provide convincing evidence that phantoms of congenitally missing limbs do occur.

Perhaps trans men’s phantom penises similarly derive from prenatal neural preparations for a never-developed penis. But first we must ask: Are phantom limbs following congenital aplasia a reasonable basis for validating trans phantom penises? The answer is complex. The term “congenital aplasia” is imprecise. Its usage often includes both cases where the limb is completely missing anatomically and cases where it is simply imperceptible by gross visual inspection. In other words, the term does not specify whether or not there exists a beginning growth regardless of how minimal, for example, proximal bone matter of the humerus or femur. Does this matter? If proximal portions of limbs can be felt or moved, even if not seen, might they have provided early afferent sensations that are now “remembered”? Do phantoms depend solely on a visual-based experience of one’s body? Could the fact that not all people with congenital aplasia have phantoms reflect the use of a vague term? Melzack et al. relied not on x-rays but rather on subjects’ self-descriptions of missing limbs (a subjective all-or-none appraisal of body parts that many trans men mistakenly share regarding the penis). Sunderland (1978) states that, until age 6 years, a child has insufficiently experienced the environment and their own body to develop a stable body image (p. 442). This implies that without an already established body image, a phantom limb cannot appear. Because of the roles of vision and temporality in the development of self, psychoanalysts might appreciate Melzack’s grouping together children with congenital aplasia and children whose limbs were amputated at an early age. Perhaps by age 6 years, trans children are already unconsciously haggling about body images, instinctively maintaining instability. But this discussion also points to a meta question: Does the proclivity for reasoning based on one’s gross visible experience, which founds psychological theory, enable or limit neuroscientific research design?

The term “congenital aplasia” is imprecise also because it generally addresses limb status at birth without regard for presence or absence of embryonic precursors. A more precise term, “amelia,” is defined as the complete absence of limb at birth due to the lack or eradication of the embryonic anlage/tubercle from which a limb otherwise would have developed in the fetus. Amelia, therefore, includes only those congenital aplasias caused during the earliest stages of embryonic generation. Although not believed to be genetic, amelia points to total anatomical absence of limb not only at birth but also during prefetal development. Bermejo-Sánchez et al. (2011) describe amelia even more strictly, distinguishing between never-present tubercles and those instances when a limb bud briefly exists before being extinguished within the embryo by interuterine amputation or insufficient blood supply. These are important distinctions for research as long as etiology and variety of phantoms remain unexplained. Do people with congenital amelia resulting from lack of anlage have phantoms? For philosophers, neuroscientists, and neuropsychologists, this distinction might seem relevant to speculations about a “primordial” aspect (Ramachandran and Hirstein, 1998, p. 1625). As was obvious in the previous section, transsexuals also speculate about primordiality.

The term for a totally missing penis is “aphallia.” Congenital aphallia is very rare, and I am aware of no published report of an aphallic man that discusses presence or absence of a phantom penis. In aphallia, the (nonbinary) rudimentary bud for genitals was either absent or eradicated before it began embryological development into clitoris/penis. By contrast, in trans men, the rudimentary bud for genitals has indeed developed, just not into a penis. Penis and clitoris are embryonically homologous genital components. To a large degree, they are located similarly on somatosensory maps (Cazala et al., 2015). Cis men (or women) with congenital aphallia lack this genital component (whether it would have been directed into either clitoris or penis), while trans men have the genital component (developed into a clitoris). To equate trans men and aphallic cis men would risk defining female genitals as “lacking” (this genital component), a bedrock position of the patriarchal unconscious that feminist, queer, trans, and nonbinary theory and politics have worked to denaturalize. Congenital aphallia and congenital amelia may have no representation on the somatosensory cortex. The simultaneous presence of birth genitals and absence of penis in trans men thus complicates phantom etiology that depends on a binary of occupied versus empty cortical areas.

All the preceding situations of “absent” body parts are unique, and the differences matter. Trans men’s genital instantiation at birth differs from that of people with amputated or missing limbs, cis men with amputated or wounded penises, and people born without genitals. The trans man is uniquely prepared for a phantom penis. Probably his closest comparison is either to a cis man with sensory penile tissue remaining after amputation or to a cis man with rudimentary development despite congenital lack of a visible penis. However, considering the limits of available research regarding those two subjects, the pragmatic comparison defaults to persons with gross congenital aplasia but having some internal anatomy. Still, other factors raised here remain relevant to future research, including the relation of the genital tubercle, or even its blastocyst precursor, to “primordial agency.” Most importantly, when considering trans men’s situation in relation to congenital aplasia, one should keep in mind (a) differences between penis and limb, (b) differences between gross absence and complete lack of development, and (c) differences between lack of penis and lack of genitals. Theorizing trans phantom penises also must appreciate feelings of loss, feelings of potential, and feelings of something having gone wrong. Considering these, it is not wide of the mark to analogize trans phantom penises to congenital aplasic (limb) phantoms, especially because gross absence biases the subjective experiences of both. Further interdisciplinary research is needed that exceeds binaries of presence versus absence, that considers genetic and epigenetic factors together, that explores multisensory subjectivity, that attunes to both propensity and variety in processes and outcomes, and that, without hubris, is willing to go out on a ghostly limb.

The second body of research relevant to trans phantom penises concerns stroke patients. Working with stroke patients who experience temporary paralysis, behavioral neuroscientist Edward Taub has shown that a cortical area shrinks with nonuse of an affected limb but then can expand when the limb is increasingly used again (Taub, personal communication, 2005, reported in Crawford, 2014, p. 184). Thus, it seems that a cortical area is both able to give space over to another use, for example, in the case described by Ramachandran and Blakeslee already discussed, in which stimulation of the face incites phantom hand feeling, and able to retain latent allegiance to its originally associated limb, as suggested by Ramachandran and McGeoch as already discussed, when discussing the existence of trans men’s phantom penises despite their upbringing as girls. To me, such yielding integrity suggests that, for some trans men, the homologous clitoris may function as a penis stakeholder in the cortical map.

In the late 20th century, some cortical areas previously considered “dead zones” were “recharacterized as pockets of allegiance, atrophied homuncular areas that retained at least some of their original sensory and motor function” (Crawford, 2014, p. 183). Doetsch proffered:

Activation of a set of cortical neurons appears to retain its original meaning! … The trick is to identify the positive and negative features of brain plasticity, and to develop ways (physiological, pharmacological, behavioral, etc.) to enhance the former and diminish the latter. (Doetsch, 1977, quoted in Crawford, 2014, p. 183)

This recalls Ramachandran and McGeoch’s report, already described, that some trans men first experience phantom penises after beginning testosterone therapy. In a review of recent neuroimaging studies of gender incongruent persons, Kreukels and Guillamon (2016) report that intake of exogenous testosterone changes the size and/or microstructure of certain morphological sites in the brain, as do many other sex hormone therapies for trans and cis people. “If the brain is already sensitive to endogenous levels of sex hormones during the menstrual cycle and puberty, one can imagine that the administration of pharmaceutical doses of these hormones will have an effect as well” (p. 6). Some trans men describe genital growth and/or changed genital sensitivity and orgasm with testosterone intake (see Van de Grift et al., 2019; Irwig, 2017). For example, one FtM (female-to-male) interviewed by Doorduin and van Berlo (2014) reported shorter but more intense orgasms (p. 661). Given that testosterone intake changes trans men’s brain morphology and genital size, influences orgasmic sensation, and perhaps beckons phantom penises from “dead zones,” a complex conception of body plasticity as well as brain plasticity is in order.

In his discussion of core gender, Langer (2016) steers our attention away from primary and secondary sex characteristics to the body’s internal gender, away from visual and verbal perceptions to interoception, reminding us that afferent sensation from viscera is important to a sense of body ownership. Rather than body image, he foregrounds the body matrix, a multisensory, neural body model. Further, he considers interoception not as a straightforward viscera-to-brain afferent flow, but rather as subject to a process of efferent brain predictions. Here, he posits a dissonance experienced by trans people in that the brain expects different gender data than their viscera send. Unlike in other instances of dissonance, which initiate homeostatic adjustments, Langer argues that gender is a hyperprior, which means the brain’s prediction holds steady, perhaps because it is genetically coded. He then links the somatic changes that trans people experience from cross-sex hormone therapy to a changed visceral interoception that lessens gender dissonance (2016, pp. 21–29, 36–44). Recalling Yakovlev’s description (provided earlier) of the penis as viscera extruded, the effect of testosterone—not only on the trans man’s penis but also on his phantom penis—might be understood as producing a correction of afferent bodily information.

Brugger et al. (2013) promote a model of “social neuroscience” that “unifies neurological, psychological, and sociological approaches to bodily self-consciousness” (p. 1). What Case and Ramachandran (2012) have named alternating gender incongruity (AGI) calls for such methodology. They interviewed a subgroup of bigender-identified individuals who experience involuntary (and sometimes distressing) swinging between gender states. These gender states include a feeling of being male or female. When occupying a transgender state (that is out of alignment with their birth anatomy), some persons with AGI experience phantoms of the (transgender) parts that are expected but missing. For example, when an AGI person assigned male at birth (AMAB) switches into a female gender, they can experience phantom breasts; when an AGI person assigned female at birth (AFAB) swings into male gender, they can experience a phantom penis. AGI suggests cortical (or other brain) generation (or disruption) of identity or unstable plural identities (in contrast to nonbinary, queer, or gender-fluid identity). The authors suggest that a biological basis for AGI might relate to the coexistence of two (differently sexed) body images or of one body image with both male and female parts that are turned on and off with shifting hemispheric dominance. They expect this will be identified as a neuropsychological condition. It requires no great leap to add sociology to the mix. The subjective experience of AGI would certainly differ in social environments open to versus stigmatizing of nonbinary expression.

Neuroscientists are quick to remind us of how little is known of the human brain. For example, when considering whether cortical mapping processes include both sprouting from intact neurons and unmasking of silent neurons, Taub is cautious. “One doesn’t know … . What I really believe is that there are a number of mechanisms that no one has thought of that may be more important than anything that anyone has been talking about recently” (Taub interview, 2005, quoted in Crawford, 2014, p. 258).

In this essay, therefore, I extrapolate from the meager accumulated knowledge and research, which are also, to a degree, engaged in extrapolation. Reported cases, research studies, and subjects in those studies are few in number. Hence we need to proceed with caution when theorizing trans men’s phantom penises. But indeed we need to proceed. Rather than declarative, I hope this paper is generative.

After an accident in 1974 that necessitated that his left leg be immobilized for two weeks, neuroscientist Oliver Sacks experienced the leg as alien, as not his own. Although some of his fellow patients described similar experiences, Sacks’s surgeon was unknowing. Searching the literature nearly in vain, Sacks came upon Mitchell’s writing on phantom limbs and negative phantoms, with the latter being Sacks’s experience. Why was the literature so scanty for something that is experienced by numerous patients with neural injuries? Sacks likened this situation to a neurological scotoma, a scientific “hiatus in perception” similar to a blind spot (Sacks, 2017, p. 196). As to why the medical literature has been blind to such conditions, Sacks noted, in relation to his alien leg, “Such a scotoma is literally unimaginable unless one is actually experiencing it” (Sacks, 2017, p. 197). For Sacks, the personal, internal nature of phantoms and alien limbs contributes to “forgetting and neglect in science” (Sacks, 2017, p. 185). Thankfully, Sacks provided valuable elaboration and analysis of his personal experience in his 1984 book, A Leg to Stand On (1984).

Perhaps what trans men most have to offer to the developing discourse about phantom penises—which has importance to trans health care and relevance to additional populations—are their personal testimonies, extrapolations of spotty research, and reasonable questions.

Deploying the phantom to embody trans men’s penises, with pleasure

Unlike phantom limbs, phantom penises are more associated with pleasure than pain. This is good news for trans men, for whom, I contend, phantom penises are both useful and desirable. The phantom is sensate. By this I mean that when accompanied by pain or pleasure, the phantom, although immaterial, is where its sensation is located. It is also felt to be the source of sensation and in this respect seems assertive. We can think of this as a type of agency.

In the rubber hand illusion (RHI) described in the preceding, visual perception is key. The subject’s brain receives tactile perception (from their own hand) simultaneous with visual perception (of the rubber hand). The brain prioritizes the visual data. Visual perception has a stronger effect on the brain than tactile perception and proprioception. That is why the RHI subject attributes the feeling of being touched (the tactile data) to the visual site and experiences the rubber hand as being their own hand.

This is possible because the sensate body is epiphenomenal, a product of the brain. The body does not feel itself. The RHI (as well as the naturally occurring phantom) demonstrates that the brain produces the feeling of a body. Melzack states that the body “is not essential for any of the qualities of experience … from excruciating pain to orgasm” (Melzack, 1989, p. 9, quoted in Crawford, 2014, p. 159). In the case of the RHI, it is what the brain does with incoming visual and tactile perception that creates the sensation in the rubber hand.

The brain did not create the rubber hand. It created the feeling located coincident with the rubber hand. Obviously, the rubber hand has helped trick the brain. But, in fact, no actual hand or surrogate hand need exist at all for us to experience having a hand that is not actually our hand, that is, a phantom hand. The rubber hand is not equal to the phantom. It is part of an apparatus that has produced phantom feeling in an extrabody object. In the case of amputees with phantoms, brains have made phantom limbs coincident with thin air. How the brain does this is a subject of neuroscience. That we can encourage and exploit the phantom penis is my subject. As a condition of being sensate, the immaterial phantom penis wants to touch and to be touched.

Boehme et al. (2019) hold that a coherent sense of self depends on one’s ability to distinguish between self-touch and touch by others. Testing for touch activation of multiple areas in brain and spinal cord, they found that subjects reacted more strongly to other-touch than to self-touch. During self-touch, sensitivity to the area being touched is widely deactivated in the brain. Perhaps, they suggest, this is because the subject is causing the touching and thus knows they are going to be touched. The authors then point to a pragmatic application. People feeling pain in their body can lessen it by massaging that area themselves, like people often do when they accidentally bump into something. A phantom limb cannot be self-touched. Perhaps, this is partly why phantom limb pain can be so lasting and severe. When an embodied prosthetic concretizes the phantom, however, the phantom becomes able not only to touch its environment but also to be itself touched. It is well known that use of a prosthetic often eases phantom limb pain. Perhaps when a person knows the possibility of self-touch, even if not skin to skin, the pain in their sensate phantom can be eased. Boehme et al. consider slow caressing (other-touch), such as occurs in interaction with loved ones. Unfortunately, they do not specifically consider orgasmic caressing, and indeed erogenous sensation may veer from their model. Research on discriminating fine touch leaves open questions about sexual touch. Much too little is known about erogenous sensation.

There is a strong suitability between phantoms and prosthetics. The collaboration between a phantom leg and a prosthetic leg enables the amputee, walking once again, to feel and function as fully bodied. More precisely, the person is fully bodied if the prosthesis becomes incorporated into the body image. At this stage, the prosthetic leg does not need to be seen in order to be felt. The person with a prosthetic leg generally knows where it is without looking for it, especially when moving it in space and using it to contact the outer world. At this stage, the prosthesis itself no longer belongs to the outer world. It is embodied, often because the phantom has made it sensate.

If the phantom brings sensation to the prosthesis, what does the prosthesis bring to the phantom? Materiality. The phantom limb is immaterial, ghostly. It seems to be there, but one can pass their hand right through it. Indeed, trying to touch the phantom can temporarily quash it. However, when the phantom inhabits or is inhabited by a prosthetic, it gains substance and obtains firm boundaries. Schilder (1950) described a phantom as entering into a rigid object (p. 64), and Melzack (1989) described a phantom as fleshing out the prosthesis (p. 2). If these opposite internal–external relations distinguish actual experiences, rather than differently describing the same felt fusion of immaterial phantom and material prosthesis, they invite a comparative psychological and phenomenological investigation. In any case, the phantom paired with the prosthesis now can feel the tangible force of other objects and exert pressure upon them. A phantom limb typically is most sensitive at the distal end, as if seeking to feel contact with the material world. By giving it materiality, the prosthetic enables that execution.

Following this symbiotic effect, I contend that phantom penises can augment trans men’s use of sexual prostheses, making them sensate, and that sexual prostheses can augment the functionality of phantoms penises, allowing them to affect and be affected by the environment, whether that be through packing, urinating, masturbating, or interacting sexually with others. (Although they are no doubt related, I am prioritizing, for my purpose here, the private realm rather than the experience and function of trans identity in the public realm.) Furthermore, I recruit to this prosthetic role all trans penises ranging from renamed birth anatomy, to hormonally nurtured birth anatomy, to surgically reconstructed genital anatomy, to bionic penises, to penis transplants, to tissue-engineered penises.

We can understand this phantom–prosthesis symbiosis as a process of embodiment. Vivian Sobchack utilized phenomenology to analyze her experience after leg amputation. Her description of embodiment dramatizes the phantom–prosthetic symbiosis:

Phenomenologically, it is not a contradiction to say that my corporeal figuration was, at once, both new and renewed. Radically transformed in its perceived shape, my diffused “phantom” both figuratively and functionally elongated and grew into the hollow of my prosthetic socket—occupying, thickening and substantiating it, finally “grasping” it so that it made sense to me and became corporeally integrated and lived as my own body. And as my diffused “phantom” again took form so as to substantiate and animate the prosthesis, the prosthesis reciprocally “grasped” my lived body’s intentional directedness as animation and materially articulated it in the long-familiar gestures of standing and walking on the concrete ground of my world. (Sobchack, 2010, p. 63)

Having previously shortened through the common processes of gapping and telescoping, Sobchack’s phantom leg here achieves, by way of the prosthesis, a length that equals that of her (lost) leg, reaching the ground. And, as her prosthetic leg grasps her corporality, it is met by an intention to stand. I understand such grasping and intentional directedness as bodily agency.

Many trans men choose various medical paths for physical transition, including exogenous testosterone therapy, surgical chest reconstruction, and surgical genital reconstruction. They resignify their genitals not only via testosterone-induced growth and phalloplasty and metoidioplasty surgeries but also psychologically, technologically, and discursively. What I term “trans future medicine” may soon offer additional means.

It is my contention that all trans penises need optimal embodiment for optimal function, and that the phantom is advantageous for erogenous sensation in the penises of trans men. For my purpose here, I consider all trans penises as conceptually “prosthetic” because they all enact formal bodily completion and they all present functional challenges, that is, gaps between proclivity and fulfillment. In every case, the phantom penis can offer a valuable bridge.

Trans Male Penises

Rearticulated original anatomy (linguistically claimed).

Testosterone nurtured original anatomy (growing and libidinal).

Penile prosthetic (inorganic; temporary augmentation).

Bionic prosthetic (inorganic–organic collaboration; temporary or permanent augmentation).

Metoidioplasty/meta (one’s own “alike” tissue, i.e., genital for genital).

Phalloplasty/phallo (partly one’s own unalike tissue, e.g., arm to penis; partly one’s own alike tissue).

Penis transplant (another’s alike tissue, i.e., donor penis to recipient; futuristic for trans men).

Tissue-engineered penis (one’s own alike penis; futuristic).

Penile prosthetics are material penis-appearing tools/toys/stand-ins, including those that are packed inside underwear for visual and/or tactile effect and those that are strapped onto the body using a harness or attached with adhesive. Again, a prosthetic offers materiality to the phantom, which in turn provides sensation to the prosthetic. When I conceptualize all trans penises as prosthetic, I am advocating for this synergism throughout trans penis variety.

Original anatomy with or without testosterone nurturance, and metoidioplasties are the most sensorially rigorous of neo-penises. This is despite the fact that metoidioplasties do entail significant cutting of suspensory ligaments and surface tissues of the clitoral hood. In a March 30, 2019, conversation with me, at the Psychotherapy Center for Gender and Sexuality (PCGS) conference in New York City, Dr. Loren Schechter stated that even when the clitoris and its neural structures remain intact, a phalloplasty is probably slightly less sensorially rigorous than the testosterone-nurtured neo-penis or the metoidioplasty because current phalloplasty procedure embeds the clitoris beneath an extra layer of skin. Van de Grift et al. (2019) confirmed decreased orgasmic capacity in a significant minority of 38 trans men in a clinical follow-up to phalloplasty, “possibly because genital stimulation is more difficult with a buried clitoris” (p. 203). In a systematic review of 11 articles on radial forearm flap phalloplasty (RFFP) and 7 on metoidioplasty, Frey et al. (2016) found that 69% of RFFP patients had erogenous sensation, compared to 100% of metoidioplasty patients (p. 3). Nevertheless, we must also consider that metoidioplasties are vulnerable to a normative critical gaze due to their lesser size. Such a critical gaze can challenge embodiment even of one’s own tissue, causing what phenomenologists term excorporation. Can the phantom penis produce an attitude to confront the critical gaze?

To date, there have been four successful penis transplantations worldwide (all from cis men to cis men). Transplants offer “alike” (penis for penis) tissues; that is, an actual penis is donated to the recipient’s body. But in other ways, transplants introduce difference. The recipient may have a physiological and/or psychological reaction against incorporating an organ from another person (see Straayer, 2018.) Might the phantom penis facilitate compatibility with a transplant?

Tissue-engineered penises are futuristic for humans, but during the past 6 years Dr. Antony Atala, of Wake Forrest Institute of Regenerative Medicine, has been growing rabbit penises (see Kime, 2016). Of 12 (male) rabbits implanted with laboratory-grown penises, all were able to mate, 8 ejaculated, and 4 produced offspring. Atala is planning to soon grow human penises (see Chen et al., 2010). Organ engineering involves seeding an organ-shaped scaffold with the recipient’s own cells, which then grow into the organ. The cells that are seeded have the potential to develop into the variety of tissues needed to compose the particular organ. The tissue-engineered penis, then, is, to a great degree, a product of individual bodily intention. However, the design of the scaffold will likely resemble a generic human penis. Perhaps if a trans man’s experience of his individual phantom penis could be represented, and that depiction used to design his scaffold, the engineered neo-penis would more heartily grow into its intended aspect.

A bionic penis is in development. Transthetics, a trans-owned company that develops and markets “innovative prosthetics for trans men et al.,” has been working with engineering students at Denver University (in 2018–2019), Colorado University Boulder (in 2018), and Colorado School of Mines (in 2019), to design its Bionic Deluxe*: a packer, stand to pee (STP), and sexually functional penis. It will be able to move between flaccid and erect states, stimulate the wearer’s erogenous zone, and ejaculate. It will have a natural countenance, including skin that feels like human skin, registers touch to activate erection, and moves back from the glans during an erect state. Magnets on the device will align with magnets that are embedded in the wearer’s skin (like embedded jewelry). Batteries located in the testes will fuel the device (see Transthetics, n.d.; Straayer, 2020). Will trans men be ready to “grasp” the bionic penis with their phantoms?

The sensate phalloplasty

For Jay Prosser, phantomization reveals a body’s “struggle not to forget its original body image,” while gender affirming surgery (GAS) is the “recovery of what was not” (Prosser, 1998, p. 84). He argues that the postsurgery transsexual’s ability to incorporate new body parts suggests that those parts were already phantomized. While recognizing the enabling effects of phantoms for amputees using prosthetics, Prosser posits GAS as an “antidote” to the transsexual’s phantomized state, replacing the phantom with corporeal substance. “For the surgery-opting transsexual, however potent, the fantasized sex is insufficient in and of itself to transform the meaning of bodily matter” (pp. 85–86). Even as Prosser likens GAS embodiment to a return home (to one’s originally correct body), he credits surgery for a concluding achievement in relation to the (past) phantom. But we know from Ramachandran and McGeoch’s study that trans men can have phantom penises both before and after genital surgery, and that phalloplasty does not necessarily replace a phantom penis (2008). We also know that in some cases phantom parts vanish with the use of a prosthetic limb, and in other cases they continue with prosthetic use or can emerge with new organ presence. For example, Case and Ramachandran (2012) report that a bigender individual’s phantom breasts vanished when they grew tiny breasts on estrogen (p. 628), and Melzack (1989) reports on a phantom enhanced by a prosthetic (p. 2). In this section, I advocate for the continuance of a phantom penis after phalloplasty because the phantom’s erogenous sensation can benefit the phalloplasty. I shift focus now from presence to function.

If emphasizing presence, it seems common sense that the “one’s-own-flesh” phalloplasty has an either–or relation to a penile prosthetic. In that sense, it might seem ill directed for me to include phalloplasty in this discussion. However, in basic practice, this phalloplasty versus prosthetic, either–or thinking doesn’t hold up. One trans subject with a phallo interviewed by Doorduin and van Berlo (2014) reported that “although he had an erection prosthesis implant, his penis could not get sufficiently stiff for penetration, so he used an exterior prosthesis” (p. 662). No doubt a variety of cis men for a variety of reasons also use penile prosthetics for sexual interactions. I conceptualize every trans penis as prosthetic, not to challenge its verity, but rather to emphasize how the brain can augment its pleasurable function. I offer that erogenous phantom sensation helps achieve a reasonable goal of phalloplasty. And, again, one can easily extend this to many cis men, whose penises might benefit from phantom feelings.

A phalloplasty does not replicate the entire penile anatomy. This is not meant to imply that the cis male organ is the ideal. Indeed, the glans clitoris has a much higher density of erotic nerve endings. And the postphalloplasty trans man brings to his orgasm not only the proprioception and erotic sensation available via his phalloplasty (including the embedded clitoris) but also expansive interconnections within his lower internal anatomy and availability of the vagus nerve. Nonetheless, in contrast to the metoidioplasty, the phalloplasty is not constructed entirely from “alike” tissue. (For an overview of trans related surgeries within a trans health care context, see Schechter and Safa [2018].) Because there is insufficient tissue available from the patient’s original genital morphology to form a full-sized phallo, phalloplastic surgery must repurpose skin, blood vessels, and nerves from other body sites, most frequently an arm. Nerve fibers and sensory receptors vary in type throughout the body. The skin of different body locations varies greatly in terms of the types and density of sensory elements. For example, the glabrous (nonhairy) skin of the penis, labia minora, lips, tongue, and so on lacks the hair follicles in the nonglabrous (hairy) skin of arms, legs, belly, face, and so on. Further, the glabrous fingertips have a higher density of mechanoreceptors than does the glabrous palm, enabling their sophisticated haptic perception and object manipulation. The skin of the glans penis differs from that of the penile shaft. After extensive microscopic examination of neural fibers and sensory receptors, Halata and Munger conclude, “The sensory innervation of the glans is unlike any other cutaneous area of the human body” (1986, p. 227).

In the penis, as in many other glabrous and nonglabrous tissues, numerous nerves end in microscopic corpuscular receptors that are highly sensitive to light touch, which allows one to perceive pressure with location accuracy. The penis has an especially high density of mechanoreceptors that are specifically sensitive to intermittent pressure. Further, the penis has a very high density of free nerve endings (FNE) and genital end bulbs (GEB) that facilitate feelings of erogenous pleasure. Penis skin differs from other surface skin in that most of its axons are of small diameter like C-fibers (Cazala et al., 2015, n.p.; Longo, Azañon and Haggard, 2010, p. 662). The glans penis differs even more from other surface skin. For example, it lacks (sensitive, slowly adapting) Merkel cells and (low-threshold, rapidly adapting) Meissner corpuscles (Halata and Munger, 1986, p. 227). Histologically, the glans clitoris closely resembles the glans penis. In a comparison of tissues from the glans clitoris and glans penis, Shih et al. (2013) concluded, “The glans clitoris is densely innervated with cutaneous corpuscular receptors. These receptors are morphologically similar to the corpuscular receptors of the glans penis” (p. 1788). The primary difference between the glans clitoris and the glans penis is that the glans clitoris has greater variability in the density of these corpuscles. The penis/clitoris is a highly complex organ that discerns two kinds of sensation: epicritic (discriminating fine touch) and protopathic (affective crude touch, sensing both pleasure and pain). This is phenomenologically significant. As Cazala et al. state, “Genital sensations are first and foremost pleasure sensations rather than fine touch sensations. These two kinds of sensations should be clearly distinguished” (2015, n.p.).

Tactile sensitivity is important for protecting the phalloplasty because if a person cannot feel trauma to the penis, they will not withdraw defensively. Phalloplastic microsurgery generally can achieve epicritic (tactile) sensitivity through the length of the trans penis by connecting one of the nerves harvested from the donor flap to one branch of the dorsal nerve of the clitoris (DNC) (which extends from the more proximal pudendal nerve) or to the iliolinguinal nerve (which, before being surgically severed, sent filaments to the skin of external genitalia). During subsequent months, the donor nerve grows throughout the flap tissue of the phalloplasty. But it should be noted that tactile sensitivity is not always achieved. Both surgical execution and physiological robustness vary, as do outcomes. Some trans men have described lasting or permanent tactile insensitivity in their otherwise successful phalloplasties. This possibility is acknowledged when the Mayo Foundation for Medical Education and Research (1998–2019) website lists “changes in skin sensation” such as “persistent pain, tingling, [and] reduced sensation or numbness” among the risks for all masculinizing surgeries. Further documentation is provided by a 2016 systematic review of 11 articles on radial forearm flap phalloplasty by Frey et al., finding that [only] 77% of patients reported tactile sensation (2016, p. 3).

Although the results of individual surgeons vary, state-of-the-art phalloplasty techniques can often obtain postsurgery orgasmic ability for trans men. Selvaggi et al. (2007) report 100% orgasmic ability in trans men following their phalloplasty technique. Attempting to retain all original erogenous tissue, most contemporary surgeons embed the clitoris at the base of the phallic shaft, utilize the labia minora for urethral extension, use the labia majora to form the scrotum, and incorporate the clitoral hood into the scrotum. Remembering that male and female genitalia are embryologically homologous, we can appreciate that these original erogenous components, including their neuroreceptors, are essentially “alike” tissue, whereas the skin donated from other body areas to create the penis shaft and glans, although one’s own, is “unalike.” One might wonder whether the donor skin will be challenged by the lower concentration and different type of nerve receptors that it offers for sensation. Additionally, one wonders whether the choice of which in situ nerve to use for neurorrhaphy (nerve to nerve suture) matters. In a March 30, 2019, conversation with me at the PCGS conference in New York City, Dr. Loren Schechter stated that he now connects the ilioinguinal nerve to the donor nerve in order to keep intact both branches of the DNC to best ensure sensation of the embedded clitoris.

The (still open) question is whether or not (and, if so, how) any current phalloplasty technique can achieve erotic sensation throughout the entire trans penis. At the 2018 Philadelphia Trans Wellness Conference, gender affirmation surgeon Dr. Marci Bowers expressed strong doubt that orgasmic sensation would entail the length of a phalloplasty, which was followed by contrary testimony by a trans man in the audience affirming full-length erotic sensation. On the other hand, one trans subject with a phalloplasty interviewed by Doorduin and van Berlo (2014) reported that “he was content with the looks of his ‘phallo,’ but less with its erotic sensitivity. Although he could have an orgasm, it felt to him as if his sensitive parts were ‘covered’ under a layer of skin, so that it took longer to orgasm” (p. 662).

It is impressive indeed that microsurgeons are able to preserve orgasmic function for trans men who choose phalloplasty, and no doubt surgical techniques will continue to improve. Nevertheless, it is understandable that trans men want not just tactile but also erotic sensation throughout the length of their phalloplasty. Gottlieb (2018) states that “at 6 to 9 months, [post phalloplasty] patients are usually able to stimulate the shaft of the neophallus to orgasm” (p. 397). Without more detailed and candid follow-up questions about erogenous and orgasmic experience, we cannot know for sure whether the shaft stimulation by those patients includes deliberate (targeted) rhythmic pressure on the embedded clitoris. Trans men often prefer to use conventionally male-associated terms (shaft) while avoiding female-associated terms (clitoris), which might lead to imprecise (only anatomically, not experientially) client reportage, including where their orgasms are stimulated and felt (see Zimman, 2014; Edelman, 2015). This is not to insist that clitoral-focused stimulation necessarily delimits the orgasm to the clitoral site. It remains unclear whether (or how often) these men’s felt orgasm is localized in the embedded clitoris or felt throughout the phalloplasty. Certainly the experiences of trans men after phalloplasty vary widely, but this particular question deserves a systematic study.

I follow a rigorous definition of erogenous sensitivity: the condition to build pleasurably toward orgasm in genital sexual activities (adapted from Selvaggi et al., 2007, n.p..). For my discussion here, it is important to insist on the specificity of orgasm, as opposed to the more general “satisfaction” criteria often queried in trans surgery outcome surveys. Phalloplasty qualifies as what Agar (2013) terms “well-being technology.” Subjective well-being consists of both cognitive judgment about how good one’s life is and affective experience of positive feelings. The former can be obtained by surveys, while the latter is better measured via periodic self-ratings of happiness (pp. 13–15). Of course, “satisfaction” with phalloplasty does not entirely or always depend on orgasmic ability. Trans men’s stated satisfaction after surgery can also refer to self-esteem, gendered image/presence, and nonorgasmic intimate pleasure, any of which can be equally but differently valuable. Cotten’s (2012) interviews with trans men after phalloplastic surgery give witness to a wide variety of experiences within the realm of erotic and sexual satisfaction, including orgasm. For my purpose here, however, I am concerned precisely with the enjoyment of sexual-orgasmic experiences. Taghipour et al. (2018) offer a succinct summary of orgasm production: “The main tract involved works through tactile stimulation of the genitals, which reaches the spinal cord via pudendal nerve and is relayed through spinoreticular tract to the [ventral tegmental nucleus] VTN in midbrain (part of anterior spinothalamic tract which is well known to carry the sensation of fine touch, tickling and itching to the thalamus). Activation of the VTN is followed by firing of dopaminergic neurons toward [nucleus accumbens] NAc in ventral striatum. A dopamine surge in the milieu of NAc is related to the prefrontal cortex which constitutes the neurochemical basis of orgasm” (p. 492). Obviously, phalloplastic surgery faces a fastidious test.

Several questions are relevant. Can the “unalike” skin of a trans man’s phallo, which is missing (or underpopulated by) specific erogenous receptors such as genital end bulbs and free nerve endings, support shaft orgasm? Considering this more widely, what determines erogenous (rather than tactile only) sensation in a phalloplasty: the type of receptors that produce afferent sensory data, the proximal nerves that relay data to the brain, the brain’s response to afferent data, the brain’s production of physical sensation, or particular interactions among these? Can peripheral tactile perception by the phalloplasty inspire the brain cortex to produce erogenous sensation? This would, of course, be a phantom sensation itself, not of morphological presence but of protopathic sensation—like phantom pain, but in this case pleasure. Gilbert et al. (1988), who report erogenous sensibility and ability to masturbate to orgasm in twelve 1-year postphalloplasty cis and trans men, despite the phalloplasty’s much-increased thresholds to vibratory stimulation, posit two nonexclusive possibilities:

These apparent incongruous findings indicate a tremendous cortical adaptation and reeducation basic to any sensory reconstruction but even more important in the case of erogenous stimuli … . The cortex “feels what it wants to feel” despite a relative paucity of somatosensory input, particularly when nonglabrous skin replaces the highly specialized glabrous skin of the penis. Do the mucocutaneous and hair follicle [tactile] receptors of the nonglabrous skin replace the genital corpuscles of the glans penis as erogenous receptors? … The return of erogenous sensibility may be owing to “dissociated sensibility”, that is the ability of the brain to interpret other peripheral stimuli as erogenous in nature. (p. 299)

Only one fMRI has been performed on a trans man post phalloplasty, to my knowledge. Doria-Medina et al. (2017) utilized fMRI to ”assess the cortical activation after clitoris stimulation” (p. 1). To stimulate the embedded clitoris, doctors “poked” the left and right sides of the phalloplasty and the right groin with a plastic pen, while checking for patterns in (SI) cortical regions. The results were somewhat ambiguous in that one of the locations associated with sexually pleasurable perception was activated, while the other one was not. An (SII) cortical region associated with conscious perception of sexual stimulation also showed activation. The fMRI imagery therefore confirmed that the brain received afferent data, that is, that the neurorrhaphy was successful, and indicated that at least some of the data were erogenous sensation (Doria-Medina et al., 2017). However, the patient was not asked to describe his subjective experience of erogenous sensation, nor was any attempt made by experimenters or patient to produce an orgasm for the purpose of cortical imaging (Selvaggi, 2018). Also unfortunately for our inquiry, the experimenters did not differentially test for erogenous sensation throughout the penile shaft. Previous to the fMRI, the patient had reported erogenous sensation from his trans phallus during masturbation and penetrative sex, but no more specific description was reported (Doria-Medina et al., 2017). Further fMRI research is needed to more precisely determine capacity for phalloplasty shaft orgasm currently and to guide surgical advances.

This article does not include a discussion of existing research asserting male versus female sexed brains or research that extends from there to describe trans brains. (For a review of brain studies of trans people, see Kreukels and Guillamon [2016]. For cautions about sexing brains, see Jordan-Young [2010].) However, three discussions regarding brain representation of genital presence and erogenous sensation are interesting for my project. First, in a meta-analysis of cortical representation of epicritic and protopathic genital sensation, Cazala et al. (2015) report that, despite certain discrepancies in reported cortical locations, the clitoris and penis generally map together. But they also remind readers that clitoris, vagina, and cervix are different components of female sexual anatomy, as are penis and scrotum of male sexual anatomy. They recommend that future studies map genital components separately. Second, it seems that genital morphology (presence) and orgasm (function) stimulate different locations on sensory maps. Cazala et al. (2015) suggest that epicritic fine touch sensation relating to morphological presence corresponds more to the primary somatosensory cortex (SI), while protopathic affective, erotic sensation corresponds more to the secondary somatosensory cortex (SII) and posterior insula, with SI and SII interactive in some ways. Further, they suggest that sensation resulting from stimulation of the penis’s superficial skin may map differently than perception of tumescence (p. 10). Third, comparing brain responses in heterosexual men and women, Georgiadis et al. (2009) demonstrated that “gender differences were most prominent during tactile genital stimulation, while gender similarities were observed during orgasm. It is highly unlikely that differences measured during sexual tactile genital stimulation were caused by sexual dimorphism of cerebral structures” (p. 3096). “This could mean that men and women have different ways to reach orgasm while undergoing tactile simulation, but that their orgasmic experience is largely similar” (p. 3099). All of these points speak to the complexity of designing future research to locate erogenous sensitivity and orgasmic sensation in trans men’s phalloplasties.

Neuroscience has determined that the feeling of orgasm is generated from the brain. Some people with spinal cord injury that prevents afferent sensory communication from the genitals nevertheless experience orgasm. Phantom erections in males with quadriplegia were reported by Melzack (1989, p. 4), and in cis men with functional penises were reported in 2007 by Anstis (referenced in Ramachandran and McGeoch, 2008, p. 8). Orgasms are known to occur in body sites other than the genitals (Komisaruk, Beyer-Flores, and Whipple, 2006, pp. 204–216). Perhaps we should be calling these phantom orgasms inventions of an omnipotent brain. On the other hand, there are also many instances in which bodily damage has permanently curtailed or eliminated orgasmic ability. To accept that the body is epiphenomenal does not equate with independence from the body. It does not translate to the dismissal of peripheral physiology. This may be especially so in the case of orgasm. Although direct stimulation of the somatosensory cortex (and other areas of the brain) has produced a variety of sensations at correlative sites in the peripheral body, no similar direct brain stimulation thus far has produced erogenous sensation (Turnbull et al., 2014). This suggests but does not ascertain that orgasm is not epiphenomenal. Taghipour et al. (2018) hypothesize that deep brain stimulation at the site of the nucleus accumbens (NAc) could produce the experience of orgasm in patients with spinal cord injury. Nonetheless, trans men seeking phalloplasty can hardly be nonchalant about their surgeon’s ability and intent to preserve the integrity and functionality of their peripheral nerve elements. It seems that erogenous sensation and orgasm in humans are both adaptable and fragile, with their sensory pathways multiple and their experienced outcomes unpredictable. A process that is both perceptive and epiphenomenal need not be contradictory. Rather, it demonstrates reciprocity between the complex apparatus of the brain and the complex apparatus of the peripheral nervous system. For trans men, the phantom penis can augment the central–peripheral system by serving as a conduit. Might the phantom penis, produced by the genital area of the cortical homunculus and responding to the grasping phalloplasty, spread erogenous sensation throughout a trans man’s penis? For such a process requiring both body and brain, the phantom penis is perfectly fit to facilitate. Very likely, shaft orgasm in phalloplasties is phantom sensation itself.

Erogenous sensation, phantom and/or physically based, seems to lubricate the similarity between penis and phantom penis. Phantom orgasm boosts the trans penis, and erectile tissue boosts the phantom penis. Some trans women experience a phantom penis for several weeks after their GAS, which includes penectomy. Namba et al. (2008) reported on a trans woman who still experienced a phantom erectile penis 6 months after GAS. After a second surgery was performed to excise the bulbocavernosus muscle and the bulbar corpus spongiosum penis, thus reducing the remaining erectile tissue, the phantom ceased. Namba et al. concluded, “Based on our experience with this one patient, the continued existence of the bulbocavernosus muscle and bulbar corpus spongiosum penis postoperatively might be the cause of the phantom erectile penis” (p. 216). This case is interesting in that it points to the presence of internal proximal penile tissues, rather than to the absence of the external penis, as a possible cause for the persistent phantom erectile penis.

Fisher (1999) reported on a patient with an erotically sensitive erect-only phantom penis after a “total” penis amputation in which “there was no stump projecting anterior to the pubis.” However, despite describing the patient as having a complete amputation, Fisher considered that his patient probably still had remnants of corpus cavernosa (pp. 53–54). Once again, we suffer from an imprecise definition. Does “penis” refer to a discrete, grossly visible, external organ or to an inclusive penis with internal as well as external parts? Longo, Azañon, and Haggard (2010) summarize several different relations that comprise the conventional organization of body semantics: partonomy (e.g., the hand is part of the arm), contiguity and spatial (the hand is connected to the arm), and functional information (the hand is a tool) (p. 662). In what various ways might such semantics prompt us to consider the phallo’s embedded clitoris? Is it a rudimentary part of the trans penis? Is it a proximal stump “left behind?” Does it produce a penile orgasm?

Wilson (1998) offers an elucidating description of the hand that can help us conceptualize the inclusive penis. “From the perspective of classical surface anatomy, the hand extends from the wrist to the fingers. But under the skin, this boundary is just an abstraction” (p. 8). From a biomechanical perspective, the hand includes the entire arm, the shoulder, and upper chest. From a physiological or functional anatomy perspective, the hand includes muscles that connect to tendons and nerves that connect to the spinal cord. From a neurobehavioral perspective, the hand includes parts of the brain that not only control but also are shaped by its use (pp. 8–9). “Although we understand what is meant conventionally by the simple anatomic term, we can no longer say with any certainty where the hand itself, or its control or influence, begins or ends in the body” (p. 9).

Considering the phallo alongside Wilson’s hand, we must understand a trans man’s inclusive penis to encompass the external phalloplasty with both “alike” and “unalike” tissues; the internal genital and paragenital anatomy such as the clitoral crura and the urethra; the peripheral nervous system including nerves, nerve fibers, and neural receptors; and the central nervous system of spinal cord and brain with cerebral cortex and neural matrix. Furthermore, the circulatory system participates in erection; the voluntary muscles of hips, legs, buttocks, and lower back participate in thrusting; and the endocrine system with testosterone receptors participates in libido and orgasmic ability. Following Wilson’s model, the inclusive trans penis is a genital apparatus that overrides partonomy and embraces connectivity.

It is within this context of connectivity that I understand the clitoris as having provided a placeholder for the trans man’s phantom penis. From the similar erogenous receptors of the glans clitoris and glans penis (Shih et al. 2013) to the similar mappings of clitoral and penile orgasms in the sensory cortex (Georgiadis et al. 2009), the trans phantom penis leans forward. Because trans men have a unique relation to both phantom and penis, we should bear in mind that the phantom can produce a variety of sensations. Phantom presence differs from phantom pain, which also differs from erogenous feeling. These differ affectively, and also their cortical neural processes differ. In the case of limb amputations, the absence of afferent sensory information due to the lack of limb (and/or the traumatically changed afferent information from damaged tissue and nerve breakage) allows for cortical reorganization (invasion by other body representations) at the limb’s representational site. Cortical reorganization highly correlates with phantom limb pain, which assumes phantom limb presence. It has been demonstrated that early use of a prosthetic limb can prevent or reduce these changes (Lotze et al., 1999). Similarly, in the case of trans men’s phantom penises, if we consider the clitoris a cortical surrogate for the meant-to-be penis, we would predict no reorganization in the genital somatosensory area for genitals and thus no phantom pain. The intact clitoris correlates with pleasure rather than pain and maintains the meant-to-be penis’s erogenous functionality. Although both differ from epicritic touch, the central processes of pain and sexual pleasure are not equivalent. Further study of pain and pleasure is needed to understand why the prosthetic limb weakens the presence of phantom limb, while the clitoral placeholder supports the trans man’s phantom penis. Perhaps the answer lies in the cavernosal erectile tissue in the clitoris and/or the corpus spongiosum erectile tissue in the vulva.

Another approach to the clitoris as penis placeholder might consider how erogenous use of the clitoris throughout one’s life could enlarge the representation of genitals in the somatosensory cortex. Brain studies related to skill learning show that repeated performance of a particular activity increases the cortical representations of the body parts utilized. Furthermore, attention to a repeated movement aids such representational enlargement by reducing cortical inhibition to change (Tremere et al., 2003, pp. 309–310). In a study of congenital one-handers, Hahamy et al. (2017) showed that the missing hand’s intended (representational) area on the sensorimotor cortex had been taken up by (representations of) those body parts that were compensating for the hand’s missing function. Function, not proximity on the cortical map, determined their access. The authors reported extensive brain reorganization with widespread connectivity throughout, linking to the missing hand’s area. “Our findings suggest that [in congenital one-handers] the typical hand territory may not represent the hand per se, but rather any other body part that can mimic the missing hand’s functionality” (p. 1353). Long prior to phalloplasty, the clitoris was sending afferent signals of presence to a place on the cortical map reserved for the trans man’s penis. Unlike a penis lost to amputation or disease, leaving traumatized tissues behind to alarm the somatosensory cortex, the clitoris has served all along within the trans inclusive penile apparatus, provoking erogenous sensation in what some may argue was a melancholic tense. Hence, the clitoris stood in not only with its presence but also with its functionality, both of which prepared the trans man for a phantom penis and spared him from phantom pain. After GAS, it continues to contribute, embedded/embodied within/as phallo/prosthetic.

Wilson’s beyond-the-surface approach to anatomy and physiology reveals a penis–brain connectivity that is reciprocally agential. This complexity suggests to me that although the phantom presence only becomes noticeable in the case of amputation or other bodily needs, it may index a continuous suturing process that regularly operates in all bodies: intact as well as fragmented, surgically constructed as well as “strapped on,” cis as well as trans. Regardless of the type of neo-penis that a trans man has, when we consider not only its external anatomy but also its internal anatomy, we understand that its major portion is original anatomy. I don’t consider the original anatomy strictly female, not only because of genital homology, but also because it has been inflected by trans subjectivity, including “trans tense.” After all, this anatomy functions within a particular man’s body so, like the brain, it exists phenomenologically. Melzack (1989) proffers that it is precisely because of the phantom limb’s quality of being real that some people with paraplegia still feel their legs and lower body to the extent that they deny having a phantom (p. 3). Further, “the experience of phantom limb has the quality of reality because it is provided by the same brain processes that underlie the experience of the body when it is intact” (p. 4). Phantom erogenous sensation is no more and no less than a body’s usual orgasmic function. It is always operating during orgasm, whomever experiences it, wherever in their body, whether noticed or unnoticed. I have elaborated on the phalloplastic trans penis in order to investigate the surgical enabling of peripheral function in tandem with the pleasure producing brain. But this interplay is in the interests of all trans penises. Through its vital realness the phantom provides the trans man self-realization. Phalloplasty does not discard the phantom penis anymore than it does the clitoris. Erogenous phantom sensation achieves for trans men a sensate penis, just like it does for cis men.

Volitional phantoms by way of volitional imagination

I have argued the benefit of the phantom penis for trans men’s sexuality. I have described its usefulness for the body’s incorporation of trans penises of all kinds. The affiliation between phantom and prosthetic—whether that prosthetic be inorganic, fleshy, or bionic—allows trans men to embrace and maximize penile sexual pleasure. These positive attributes characterize the phantom penis as a desirable asset for trans men. Given the still limited ability of brain science to explain the neural processes underlying the varieties of phantom limb experience, as well as the rarity of research on phantom penises, I consider there is much room yet, not only for speculative thinking about trans men’s phantom penises, but also for strategic initiatives. As mentioned earlier, Ramachandran and McGeoch reported that 62% of the trans men they interviewed said they had phantom penises. Furthermore, Ramachandran and McGeoch believed them. “Whilst this phenomenon is astonishing … there is no a priori reason for rejecting the self-reported phantom penises in FtMs” (2008, p. 11). Now, what of the other 38%? Wouldn’t they want phantom penises too?

Consider the following three quotations:

One cannot simply ‘wish away’ or ‘wish for’ a phantom. (Ramachandran and McGeoch, 2008, p. 11)

When my [phantom] foot first lost definition, I could voluntarily will it into sensed existence or, describing it to curious others with the focus demanded by description, I would involuntarily feel the foot reassert its self-presence with my words. Later still, even these acts (voluntary or involuntary) became corporeally impossible to realize. (Sobchack, 2010, p. 54)

Imagination is a capacity subject to the will. (Crowther, 2013, p. 101)

Ramachandran and McGeoch state that one cannot simply will a phantom into existence. But allow me to read against the grain of their statement by emphasizing the word “simply.” I think this is justified when one considers Ramachandran’s larger body of work. One only has to read the chapter on false pregnancy in Phantoms of the Brain to witness respect for the unknowns (and knowns) of mind–body medicine (Ramachandran and Blakeslee, 1999). “If the human mind can conjure up something as complex as pregnancy, what else can the brain do to or for the body” (p. 215)? The authors reject blind faith, but insufficiently explained cases like this, in which a “highly specific wish” (p. 217) produces phantom pregnancy, “illustrate our ignorance and illuminate the need for conducting experiments on topics that most people have ignored for no obvious reason” (p. 221). As Sobchack’s testimony indicates, the relation of volition to phantoms is surely less than absolute. Phantoms are protean and have proven themselves, to doctors and patients alike, hardly predictable and ultimately uncontrollable, yet there are times when they bend to the conscious mind. How might trans men harness cognition to the task not only of influencing but also creating phantom penises? Crowther argues that imagination is both generative and subject to the will in a way that perception is not. To the degree that any image that one imagines is styled by personal history, one’s imagination is volitional.

In terms of its psychological generation imagination involves deliberative activity. It is something we can both choose to do, and, when appropriate, do thoughtfully—either through visualizing some described state of affairs, or through paying close attention to what we are imagining. (Crowther, 2013, p. 106)

Crowther describes the will as a “decision-making capacity—an intentional nexus—that is emergent from a broader, constantly transforming flux of desires, beliefs, attitudes, and experiences” (2013, p. 108). Imagination is what we intend. The image, created by imagination, differs from the percept, which is created by perception. What one imagines, unlike what one perceives, is volitional.

I propose that imagination is vital for obtaining a phantom penis, that is, for willing one into existence. The visual perception of a rubber hand being touched was essential to creating a phantom in the RHI. Might trans men substitute an image for the percept in this illusion-making process, to create a phantom penis—which eventually they can make persist and thus can more consistently rely on? Admittedly, holding forth the phantom by willful imagination can entail considerable mental labor.

Here stands our volitional project. Trans men want a phantom in order to proprioceptively perceive the penis as present and to enjoy its erogenous function. Adding a prosthetic to the body can provide cognitive modification for completed body presence but not seamless perceptual modification. So we are trying to create a bridge between cognitive and perceptual realms, which would be tantamount to consciously enlisting processes underlying the phantom. Thus, using imagination as a wedge, we will do what we can to tweak the processes of perception and cognition. Imagination—haptic as well as visual—will be our means to feeling and knowing our bodies. We will try on the natal man’s penis via mirroring, link it to our body via the mirror neurons of voluntary muscles within our inclusive penile apparatus, map it onto our brain through procedural memory, and then believe it is ours, as it should have been.

First, let’s establish that cognitive and perceptual processes are not entirely segregated. For example, tactile perception of size always involves consulting a reference. Our perceptual system includes no afferent data for size. We don’t feel the size of our body parts. Rather, we rely on remembered knowledge of our body metrics. Longo, Azañon, and Haggard (2010) assert that, in addition to expressionist maps like the homunculus with its gigantic index finger and lips, there are realist maps that represent the body as we experience it visually in everyday life. The first map represents the present-tense status of the body informed by immediate sensation, for example, the immense sensation in our lips when kissing, while the second represents a consistent body remembered over time, including the visual experience of our body parts. Both of these maps are used to determine the size of objects contacting the body. The first can tactilely perceive an object held between one’s finger and thumb, while the second, which knows the lengths of finger and thumb and the width of palm, provides a reference for calculating the size of the object. Interpretation of size is thus a collaborative enterprise of perception and cognition. Hence these processes are not always independent. This invites trans men to utilize willful cognition alongside perception to conjure the phantom penis.

When a trans man sees his sexual prosthetic as a penis, he is engaged in what McGinn (2004) terms “seeing-as,” a hybrid form of imagination and perception, in which the image permeates the percept. Usually the image that one imagines is located in an imaginary space. However, the fusion obtained by “seeing-as” locates it within the subject’s current visual field. In this case, the trans man sees his prosthetic as a penis on his actual body. “Seeing-as” is driven by affect (pp. 48–51). Desire (for a penis) fuels trans men’s imaginative engagement with a sexual prosthetic. But “seeing-as” is not delusional. The image never totally displaces the percept. Unfortunately, for many trans men, perception of the prosthetic produces a disturbingly realistic counter-affect that incites disengagement. Procuring an effective phantom would benefit from more stability. Is there another mode for “seeing-as,” in which the perception of realness is less disturbing?

What happens when trans men watch images of nude cis male bodies, for example, those occurring in mainstream movies (rarely), art photography, or pornography? Sensory and motor activities are integrated in a neural system that Gallese and Ebisch (2013) term “mirror mechanisms.” This neural system is activated both when executing an action and when observing someone else executing an action (p. 396). In other words, watching someone else do something engages the same neurons that doing it oneself would engage. Especially (although not only) in the case of a moving image, the trans man can vicariously experience body integrity, just like people with congenital aplasia can incorporate an otherwise missing limb into their body image by watching the gestures of other people. The trans man’s body mirrors the cis man’s body in what Gallese and Ebisch term “embodied simulation” (Gallese and Ebisch, 2013). During such mirroring, relevant muscles in the observer’s body are neurologically activated even though they are not themselves moving. “Visual imagery is equivalent to simulating an actual visual experience, and motor imagery is equivalent to simulating an actual motor experience” (Gallese, 2011, p. 64). In the case of viewing explicit sexual imagery, the trans man’s neurons related to those muscles that are mirroring the cis man’s movements—those muscles of trunk, buttocks, and legs that Wilson has led us to understand as part of an inclusive penile system—can predispose a phantom penis. This assertion is supported by observations that mirror mechanisms are most responsive to goal-oriented movement. It should be noted that cis men also engage in such mirroring when they watch pornography and see other cis men engaging in sexual activities. Trans men’s “use” of pornography, therefore, is a vicarious activity shared by cis men. For trans men, the goal of this “feeling as” action is not only erogenous sensation, but also body realization—in the form and function of a phantom penis. For Brugger et al. (2000), phantom limbs are “the phenomenal correlate of planning actions” (p. 6172).

Embodied simulation has been described as a biological substrate of empathy (Gallese and Ebisch, 2013, 274) with claims of social benefits following. I make no lofty claims for the trans man’s embodied simulation. In my scenario, the trans man is deploying attunement to secure a displacement. As with his earlier seeing-as, this visually initiated simulation does not delude him. But with his eyes on the nude male image, he avoids the prosthetic’s disruption by bringing the cis man’s penis-imagined-as-his-own penis into his space via “feeling-as.” The trans man deliberately harnesses this mirroring apparatus, not for biology-based brotherhood, but for corporeal masculinization, which in his case is self-realization. Keysers and Gazzola (2009) “embrace the fact that vicarious activations in the motor, somatosensory, emotional system interact and sometimes depend on other, more cognitive brain systems involved in attention, mentalizing, and cognitive control” (p. 669). We need these ingredients to invigorate our imagined phantoms.

We know from the RHI that visual perception more strongly entices the brain than does tactile perception. But for the trans man, visual perception of the prosthetic is not always available or pleasant. During penetrative sex, when the penis is hidden from view, only tactile perception is present or chosen. This does not impede functionality because, like the amputated person using a prosthetic leg, the trans man does not need to see his embodied penile prosthetic to know where it is. The concrete prosthetic’s contact with other body surfaces facilitates proprioceptive sensation, which aids its embodiment. Moreover, the trans man’s inclusive penis involves the kinesthetic feelings of weight produced by the dangling penile prosthetic, movement as it swings, and muscle contractions as it thrusts. The trans man can append these dynamics of the inclusive penis by imagining his penis’s erection, its swelling, stiffening, pulsating, and ejaculating. In his study of trans men viewers of XTube, Edelman (2015) reported how trans men “phenomenologically manage” their genitals to “destabilize hegemonic notions of maleness” (p. 150), for example, by “framing vaginal secretions in the same manner as ejaculation” (p. 157). As Gallese (2016) explains, “Motor imagery does qualify as a further form of embodied simulation, since it implies reusing our motor apparatus to imagine actions that are not actual, and to simulate situations that are not real” (p. 241). Feeling-as and motor imagination grant steadfastness to the volitional phantom penis.

We know that cortical maps have a basic resistance to change because represented body parts on the homunculus generally stay in place for life. In the drastic events of amputation and paralysis, a decrease in afferent signals results in a disinhibition of cortical change. Tremere et al. (2003) propose that repeated sustained attention during skill learning, such as violin practice, can also trigger a state of disinhibition that allows plastic changes in the cortex. This permits the practiced skill to lay down a “memory” that enlarges the representations of the body parts utilized (p. 309). To me, this not only supports the possibility that clitoral use can have maintained a genital representation on the trans man’s somatosensory map(s), but also suggests that subsequent concerted (cognitive) attention during sexual prosthetic use may facilitate cortical change, thus inducing the phantom penis. Given the nature of prosthetic use, its own “muscle memory” may strengthen the phantom that embodies and (pleasurably) sensitizes the trans penis.

In addition to seeing-as, some trans men ”imagine-that.” McGinn (2004) defends both: “Images and imaginings are not the poor relatives of percepts and beliefs; they have their own distinctive characteristics and place in the mind” (p. 134). McGinn explains that cognitive imagination differs from belief. Unlike belief, imagination is evidence indifferent. Unlike imagination, belief cannot be chosen. One either believes something or doesn’t. However, cognitive imagination and belief can combine in what McGill terms “metaphorical belief.” Metaphorical belief can be chosen because one chooses their metaphors. As Connell (2012) states, transsexuals often explain their belief in their body’s intention through metaphors.

Transsexual women reach for one metaphor after another to describe their experience: having a man’s body and a woman’s body at the same time, or one body emerging from the other, or (most traditionally) being trapped in the wrong body … . Indeed, no metaphor is adequate. But all these have the merit of pointing to the agency of the body. (p. 867)

Metaphorical belief combines imaginative and literal components so that imagination permeates belief. Although belief asserts the actual, “imagination is what brings a possibility to mind” (McGinn, 2004, p. 137). I understand trans tense and the phantom penis as metaphorical beliefs, together stretching memory backward and forward.

Memory and imagination are linked. No one remembers everything, even of a single scene or event. What we reconstruct when remembering does not equal past reality. In this way, memory is like imagination and in fact may require it. Imagination is especially important in episodic memory when we try to remember what a past experience felt like, as opposed to just the facts. As Crowther states: “The role of imagination allows us to … own our memories from the inside” (2013, p. 110). For some trans men (as well as some neuroscientists) the phantom penis signals a prenatal past traced in the brain’s cortical area, DNA, or something further primordial. When the penis remains stagnant in the past, some trans men suffer from a forgotten feeling. Might remembering it through an imagination that permeates perception and belief free the trans man’s phantom penis into the event of living? And what could a trans man do with that memory of a meant-to-be body? Would we be so cocky as to proclaim embodiment?

I have seldom seen a more plausible lot of evidence of the view that imagination and sensation are but differences of vividness in an identical process, than these confessions, taking them altogether, contain. Many patients say they can hardly tell whether they feel or fancy the limb.—William James, 1887, “The Consciousness of Lost Limbs”

Acknowledgments

Thanks to Katherine Rachlin, SJ Langer, and Vivian Sobchack for discussion and advice helpful to this essay.

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Notes on contributors

Chris Straayer

Chris Straayer, Ph.D., an associate professor in the Department of Cinema Studies at New York University, is the author of Deviant Eyes, Deviant Bodies (Columbia University Press) and, most recently, “Trans Men’s Stealth Aesthetics: Navigating Penile Prosthetics and ‘Gender Fraud’” (Journal of Visual Culture, 19(2)). He serves on the editorial board of TSQ: Transgender Studies Quarterly, for which he co-edited (with Eric Plemons) TSQ 5(2), The Surgery Issue. Straayer’s research is interdisciplinary, combining trans and queer studies with interests in science, social science, art, and cultural studies. His current works-in-progress include “Trans Phantom Penis: A Qualitative Analysis of Interviews with Trans and Gender Non Conforming Individuals” (with Katherine Rachlin) and Trans-Physicalities, which addresses transgender desires for a biological basis, neurological renditions of sexual corporeality, and trans-future medicine.