by Craig Klugman, Ph.D.
This weekend, doctors in South Africa announced a new first—a successful penis transplant. The 9-hour operation took place in December 2014. After three months of recovery, the recipient is able to urinate, achieve an erection and a sexual response. As of yet, the recipient does not have full sensation in the organ.
The recipient was 18 years old when he underwent a ritual circumcision that went wrong and left him with 1cm of the original penis. Estimates are that dozens to hundreds of men are maimed each year as a result of these rituals.
This was not the first attempted transplant. That honor goes to China in 2006. The patient had the penis removed after he and his wife described psychological distress and strange swelling.
A BBC report said that the South African surgeons spent time asking whether this operation was ethical. After all, the recipient will be on anti-rejection drugs for the rest of his life and a penis may be psychologically and reproductively important, but it is not life supporting in the way that a heart or liver would be. Using needle aspiration and in vitro fertilization, these men could father children. Alternative methods can be fashioned to allow the elimination of urine. Sexual function though, is clearly compromised.
A 2010 article in the Asian Journal of Andrology discussed the ethical issues of penile transplant. These included surgical risks, informed consent, body image, and privacy. For the donor family, the authors identified concerns with assessing the suitability of a donor, privacy, and the consent process.
After the first attempt in China, the Guangzhou General Hospital of Guangzhou Military Command outlined guidelines for penile transplants: (1) only on patients with severe penile damage, (2) under certified institutions with IRBs, (3) institution must have the necessary expertise, (4) create selection criteria, (5) have special consent documents, (6) potential recipients should undergo both physical and psychological evaluations, (7) patients with diagnoses of mental illness or coping problems or noncompliance should not be considered, (8) apply the new process carefully and learn from surgeries, (9) peer review of the procedure, (10) carefully weigh the risks and benefits. These seem to be reasonable guidelines and are similar to guidelines for hand and face transplants.
A female friend I was mentioning this news item to immediately responded, “are they going to do vagina transplants next?” My friend’s comment came out of a sense that perhaps the time, money and other resources put into this program could have more productively been spent elsewhere such as in preventive health campaigns. There is a notion of male privilege in thinking about this issue. Looking at the various functions of the penis separately provides analogies that lend insight. As the male reproductive instrument, what would the female analogy be. The answer would be the uterus where an embryo implants and gestates. Consider that uterus transplants already happen. In Fall 2014, a 36-year-old woman with a transplanted uterus did give birth. She had ovaries and thus could produce eggs. The embryo was created using IVF techniques and then transferred to the transplanted uterus. Nine women have had these transplants.
The answer to my friend’s question of disbelief (and dismissiveness) is that between 2005 and 2008 four women received transplanted vaginas that were grown from their stem cells in a laboratory. These women were born without a vagina. This procedure did not generate as much news as the penile transplants have which may have a lot to do with male privilege in medicine and society.
A male friend talked about the cosmetic and psychological elements. He said that without his penis, he would feel incomplete and would understand the desire for one. Thus, perhaps the reason for the transplant is a cosmetic one. Is the risk of the surgery outweighed by benefits to self-esteem or appearance? This seems somewhat similar to debates over face transplants, which although started as ethically troubling, are becoming more accepted as more face transplant programs open. Of course one major difference is that one’s face is publicly shown all the time, while a penis is ideally not shown publicly.
Several people I discussed the case with snickered a bit and then made some jokes about being able to trade their penises for other ones. One even asked if he could choose his donor. All jokes aside, penis transplants potentially fall into the debate of therapy versus enhancement. The surgeries that have been done and are planned fall into the therapeutic category—returning a person to male normal functioning after a trauma. This is similar to rebuilding a breast for a woman after mastectomy (although breast reconstruction is far simpler because there is no need to reconnect blood supplies and nerves as in the penis, which is a mechanical device). While breast reconstruction is fully accepted and viewed as ethical, cosmetic breast enhancement is viewed as elective and not physiologically necessary. Between therapy and enhancement though lies this question: What about the woman who needs a reconstruction but asks to be given larger breasts than she originally had? This is generally accepted because the risk is that of surgery is the same whether there is a replacement or an enhancement or both.
Penis transplant for reconstructive or therapeutic purposes seems to hold fewer ethical qualms. When this surgery becomes more regular and less risky, could a man request an enhancement surgery? Literally, if a desirable donor is found, could one request a transplant to increase size? Could a man donate his organ after death to someone else? Such ideas seem like the makings of a comedic science fiction movie, but are ones that we may face very soon.
One could argue that the analogy between breasts and penises is a faulty one because much of the breast enhancement is done using artificial devices that are bio-nonreactive and thus pose few risks for rejection. However, Wake Forest University is actually growing penises in the lab similar to the processes used to create vaginas. Although only done in animals at the moment, the process consists of taking cells from the various tissues in a person’s penis and then seeding these cells onto a collagen scaffold. Eventually, a new penis that is genetically the same as the donor is created. The process in animals has been successful and avoids the need for taking anti-rejection drugs.
Thus, the need for transplanting penises may not exist for long, although the techniques used in this surgery would be invaluable in attaching the engineered penis. Once the risk of rejection is removed though, the possibility of ordering an enhanced version may no longer be the realm of comedy but of cosmetic surgery.
Ethically, this surgery is nothing new. The issues raised are no different than those that have been investigated in hand, face, vaginal, and uterine transplants. The difference is symbolic. The penis is viewed as the seat of masculinity, a sign of virility, a tool of subjugation and an important part of a man’s sense of himself. Our reactions to this news may be more interesting than the actual surgical feat itself.