Over dinner in Los Angeles, the narrator meets Dr. Maurice Garcia, director of the Cedars-Sinai Transgender Surgery and Health Program. They discuss his team’s 2017 adaptation of a vaginoplasty, which uses part of the patient’s colon instead of inverting their penis, the usual technique. Garcia explains why he chooses the colon over other parts of the digestive system: it is wide, has strong blood flow, and is more mobile. He weighs functional trade-offs: Losing eight inches of colon does not typically cause chronic diarrhea, but some patients develop colitis-like symptoms inside the neovagina. He suspects that the relocated tissue lacks nutrients it normally derives from the fecal stream. He instructs his patients to perform monthly douching with half-and-half (which contains short-chain fatty acids) to improve symptoms.

Garcia explains that even though colon tissue might appear to be self-lubricating, like a vagina,  the mucus is too continuous and thick to make it a real advantage. The operation also involves the construction of a neoclitoris, using nerve-rich glans tissue. Garcia emphasizes that patients must prioritize postoperative care, including dilation three times daily for three months. He holds a patent on an extra-long hollow dilator that also functions as a douche. 

Garcia reports that many of his patients do not have the surgery out of a desire for vaginal intercourse. Instead, they simply prioritize eliminating male anatomy; for this reason, about one-third choose to get a vulvoplasty alone (an external vulva without a canal) to avoid ongoing care and higher complication risks. He criticizes an inclination among some surgeons to prescribe what they think patients should want instead of fairly presenting all the options. He offers one example of this: Surgeons who perform oversized reconstructions during phalloplasties, which end up complicating intercourse. He also condemns risky choices like reconstructing the penis by inserting a bone for rigidity, as it can erode through the skin. A 2002 Russian case report describes the use of a patient’s finger in penile reconstruction. Roach is so intrigued that she decides to investigate the surgeon who performed it. She sets off for Tbilisi, Georgia, where the surgeon practices.

In Tbilisi, Roach and her friend Steph arrive at the Kuzanov Clinic to learn about finger-to-penis reconstruction. Dr. Iva Kuzanov is away, but the clinic staff agree to show them the case files. On Kuzanov’s computer, they review a penile reconstruction for a cancer patient. The technique uses the patient’s skinned middle finger—including bones—as an internal rigid strut, around which a skin flap is wrapped. X-rays show the internal bone, and photos document a reconstructed urethra that allows standing urination. A demonstration photo shows the neopenis supporting a hanging pitcher to illustrate its rigidity. The surgery leaves patients without a glans or clitoral tissue, but Roach notes that studies show people can still develop new erotic zones over time.

Roach contrasts this autograft approach with the idea of an allotransplantation: “[I]f you’re committed to using a finger in this way, might it be better to transplant one from a deceased donor?” (77). This is difficult because the body tends to reject foreign tissue, and a finger contains multiple types of tissues (skin, bone, and muscle), making it an even more complex composite transplant. 

Roach consults Dr. Branko Bojovic, a plastic surgeon at Massachusetts General, who describes how early optimism about composite transplants has cooled. He details persistent long-term risks: cancers under immunosuppression, infections, rejection, a chronic vasculitis that stiffens grafts, and kidney damage. Some hand transplant recipients request removal, and face transplant recipients sometimes opt to go back on the waiting list for re-transplantation. Funding has dwindled, and insurers do not cover such procedures. Bojovic adds that slow nerve regrowth in muscles prohibits the viability of leg transplants, and advances in modern prosthetics often outweigh the risks of transplantation, unless a transplant can clearly exceed state-of-the-art reconstructive outcomes.

Roach attends the Amputee Coalition National Conference with Judy Berna, an elective amputee born with spina bifida, which twisted her left foot. She experienced chronic pain her entire life despite decades of surgeries. Berna eventually chose amputation and now wears a prosthesis covered in the Seattle Seahawks logo. 

They meet Clayton Frech, who runs Angel City Sports, and his son, Ezra Frech, a Paralympic gold medalist who has a prosthetic leg. Ezra uses a variety of different sport-specific prosthetic devices depending on the activity he’s doing. In the exhibitor hall, prosthetist Kevin Carroll argues that some patients do better with earlier amputation than years of limb salvage surgeries. Surgeons remain cautious due to professional bias, liability, and reimbursement hurdles.

Judy tells Roach about high-tech myoelectric hands, which use sensors in the patient’s muscles to detect activity and react accordingly. Though the idea is promising, in reality, they are heavy, slow, and exhausting to use. Many arm amputees prefer body-powered devices or no device at all. Roach also studies the central role of the socket in leg prostheses. This is the part attached to the patient’s remaining limb, where the prosthetic connects. Prosthetists constantly adjust fit to prevent skin breakdown, and users manage perspiration and liners. 

Judy and Roach then evaluate osseointegration, a new, fringe procedure that anchors a prosthesis directly to the bone, shifting weight-bearing to the skeleton and delivering osseoperception. Glenn Bedwell, an above-knee amputee, switched from sockets to osseointegration, and now he reports better control and endurance after 21 years using sockets. However, he also has side effects like early infections and minor ongoing skin issues. Roach questions how common infection is in osseointegration, but she finds that reported infection rates vary widely across studies. She does discover that the procedure is likely most promising for arm amputees. Teams pair osseointegration with targeted muscle reinnervation to amplify nerve signals, though only a few US patients have received the combined system. Judy declined osseointegration due to infection risk.

Months later, infection in Judy’s remaining foot leads to hospitalization with sepsis, and she chooses a second amputation. She receives basic, comfortable new prostheses, reports strong function, and sends Roach a video of herself walking with her toddler grandson.