Grunt: The Curious Science of Humans at War

5. IT COULD GET WEIRD A Salute to Genital Transplants

THE ELDERLY DEAD—THE MEN, anyway—always seem to need a shave. Maybe it’s because their demise so often unfolds over a span of days. While dying leaves plenty of unscheduled time one could use for shaving, for trimming one’s toenails or arranging one’s hair, there is little energy for sprucing up and really no call. The two dead men lying on gurneys in the cadaver lab of the Maryland State Anatomy Board this morning share the look—stubble and bed hair—but aside from that, they appear nothing alike. One is fleshy and barrel-chested. His legs are splayed at the hip with knees bent, one higher than the other. The carefree legs of a man dancing a jig. The other cadaver is rigid and lean. His legs lie pressed together like chopsticks. You could almost slide him under a teller window. One body has a tattoo, the other has none.

One is circumcised, and one is not. Given that the surgery being worked out this morning is a penis transplant—a lead-up to the first such operation in the United States—this is the difference that stands out. Though of course it doesn’t matter. The recipient will never wake to see his new endowment. Thus the cadavers weren’t chosen for any particular genital attribute. “They are whoever happened to be on hand,” says Rick Redett, the surgeon heading up the session, “and male.”

Redett and the plastic and reconstructive surgeons assisting him—Damon Cooney and Sami Tuffaha—are from down the road, at Johns Hopkins University. The Hopkins School of Medicine, with funding from the Defense Department, has been the setting for a lot of innovation in the field of transplantation over the past decade. The members of the surgical team that performed the first double-hand and the first above-elbow transplant in the United States are there now. Hopkins transplanters helped refine a technique called marrow infusion, which greatly reduces the likelihood that a patient’s body will reject its new parts. This is especially helpful with transplants of composite tissue. A face or hand—unlike a liver or kidney—is a variety pack of skin, muscle, mucous membrane. If you’re talking about a penis, add erectile tissue to the list. The body may accept one or two kinds of tissue and reject another. Skin is especially problematic because it’s a protective barrier; immunologically, it’s on high alert. To fool the body’s sentries, patients receive an infusion of the donor’s bone marrow—marrow being a generator of immune cells. The donor’s marrow doesn’t replace the patient’s own, but it reprograms the immune agenda to an extent. The body may glower suspiciously at its new parts but stops short of wholesale eviction. A lower risk of rejection means fewer immune-suppressant drugs are needed, and at lower doses. That, in turn, means fewer side effects and healthier patients.

New techniques like marrow infusion have tipped the ethical balance for transplants that are non-life-saving. The benefits of a face or hand—and maybe a penis—transplant have begun to outweigh the drawbacks. (Legs are a less appealing type of transplant, partly because the nerves have so far to regrow. For now, prosthetics present a better option.)

Redett heads the Johns Hopkins transplant team’s reconstructive and plastic surgery arm, and, like me writing this sentence, will stick a body part most anywhere. Earlier he described separating a set of conjoined twins. The sentence ran like this: “…so we transplanted the dying sister’s leg and buttocks and a little bit of her pelvis and then we took her aorta and plugged it into…” Redett’s own features are solidly After-photo: the face well balanced, the nose small to average-sized, the eyes pleasingly spaced. His voice is the stand-out element. He sounds just like the actor James Spader.

Redett pulls on a surgical cap cut like a knight’s chain mail: all the way down over the ears and low across the forehead—the better to ward off cadaver lab smell. (He has a lunch meeting.) Cooney’s cap is a bright green luck-of-the-Irish clover-print number that belonged to his dad. Flashes of gray hair can be seen below it, at his temples, though you would not use the word distinguished to describe him. Adorable you might use. He is forty but looks thirty. He also, in tribute, wears the old man’s magnifying loupes, which are too big for his face and keep sliding down his nose. Today he has a cold, well timed given the odors of the morning.

Veterans from Walter Reed often come to Johns Hopkins for phalloplasty—a penis reconstruction made from a cannoli roll of their own forearm skin implanted with saline-inflatable rods. The resulting “neopenis” is impressively natural looking. It is a testament to Redett’s skill that some of the pictures on his phone could be mistaken for Anthony Wiener–style selfies.

“This is a soldier who was hit with an RPG in Afghanistan. Lost his testes and scrotum and penis. There’s the flap being raised on his arm.” Redett swipes through photos like a proud parent. “We made a scrotum using a tissue expander in his perineum. Here it is with the artificial testes. He has total sensation now.” After nine months to a year, a patient’s penile nerves regrow in the tissue formerly known as arm, supplying normal penile sensations and triggering orgasm very much as they used to.

So why would a man opt for a transplant? Especially since transplants still—even with the marrow infusion—require some degree of immunosuppression. And not only does immunosuppression diminish the body’s defenses, opening the door to infections and cancers, but the drugs it requires have hefty side effects. Why not stick with phalloplasty?

“Here’s the problem.” Redett steps over to a whiteboard on the wall and draws a penis. For a moment, it looks like fifth graders had the run of the place. The problem is extrusion: implants poking through the tip of the penis, typically during intercourse. Penile implants were designed for men with erectile dysfunction (severe cases that Cialis won’t help). In these men, the inflatable rods are inserted into tough fibrous sheaths that line the erectile chambers (two of which run the length of the shaft like the barrels of a gun). Phalloplasty patients have no sheaths, just skin—which is easier to poke through. Think of holding a restaurant drinking straw in your fist and pulling down the wrapper until the straw pushes out the top. It’s that kind of situation. The extrusion rate has been reported to be as high as 40 percent (though sheathing the implants with Dacron or cadaveric tissue sleeves has helped somewhat). Also, as mentioned in the previous chapter, urethras made from forearm skin sometimes prune up and deteriorate in a moist environment.

Besides, a man might like to have a natural, no-pumping-needed erection. (To get hard, a man with implants has to squeeze a bulb inside the scrotum that pumps saline.) A man might also, when he’s finished with that erection, wish to have a less bulky, more retractable organ. Uninflated penile implants are less rigid but no shorter. “Right?”

Cooney glances over his loupes. “In general, Mary? Men don’t complain about it being too big.”

AS YOU read this, Redett’s team may have undertaken their first transplant. When I last checked in, in February 2016, a wounded veteran had been selected and was awaiting a suitable donor. In addition to the matching criteria used with internal organs, a penis must also, Redett said in an email, be a good match visually: “Skin color and… age.” And size, I wrote back? This he shrewdly ignored.

Their first won’t be the world’s first. That took place in China in 2006, at the hospital of the Guangzhou Military Command. In the case study, the surgeons describe the recipient not as a soldier but as the victim of an unspecified “unfortunate traumatic accident.” Additional trauma ensued: The new penis “regretfully had to be cut off” after two weeks. The man’s body didn’t reject it, but his wife did. No details were supplied other than to say that there was a “severe psychological problem… beyond our and the patient’s imagination.” Swelling was mentioned, and some necrotic tissue.

Necrosis happens when tissue is deprived of oxygen—in this case, because someone’s transplant surgeon didn’t hook up the necessary arteries. The skin turns black and leathery and eventually falls off.

“Necrotic means dead,” explains Cooney. “Surgeons don’t like to say dead.”

Even without necrosis, a transplanted appendage has a taint of death. It’s not dead, but it is a bit resurrected. You can imagine how a patient might be uncomfortable with it. With internal organs like kidneys or lungs, the psychological consequences are generally mild: out of sight, out of mind. “But it is not so easy to use and see… a dead person’s hands, nor is it easy to look in a mirror and see a dead person’s face,” wrote Jean-Michel Dubernard, the surgeon who successfully transplanted the first hand—which was later removed, the patient believing it to be evil. (The hand was swollen and inflamed, though not from evil. The recipient had stopped taking his immunosuppresants.)

Cooney’s experience has been otherwise. “People really thought that with the hand and face transplants, conversion”—the psychological assimilation of another person’s body part—“was going to be an issue.” It has not been. “I realized that that is the whole person’s hubris: You and I have two hands, so having another hand would feel unnatural. But having a missing hand is more unnatural.” Cooney’s experience with all six of the hand transplant patients his team has worked on is that the instant they wake up, even though they can’t yet feel or even see their new hand, it feels like their own. This has been true even in cases where the hand was from a person of a different gender or with a slightly different skin color.

Receiving a stranger’s face has also proved less disturbing than people had imagined, because the alternative is no face at all. “Patients say, ‘I don’t care whose face I get,’” says Cooney. “Having a face is being human. Not having a face is being some movie monster.”

And penises? “I’ve been trying to think,” says Cooney, straightening a row of surgical instruments laid out on the big guy’s belly. “What’s different about the penis? It’s not part of one’s identity in the way a face or even hands are. But there’s something about it. It’s more personal, in a way, because no one sees it.”

And in this case, everyone will want to. The media spotlight will be intense and especially uncomfortable. “When you’ve got somebody sitting there in a wheelchair with bilateral arm transplants, it’s easy to look at him and say, ‘Wow, that is really something,’” says Redett, from his work station at the other gurney. “But when you’ve got a guy sitting there in a hospital gown, saying, ‘Yup, everything went well…,’ you know what everyone’s thinking: Does it work? Can we see it?”

Cooney makes a deep cut, the big man’s penis springing open, kielbasa-like, under the blade. When pressed, he will allow that this is, as a male, an uncomfortable act. And then change the topic.

“So this is the spongy tissue of the corpus cavernosum.” He indicates one of the twin erectile chambers. He squeezes the stump, and blood appears like water from a sponge.

Because blood is the substance of erection, hooking up the right arteries is doubly important: not only to avoid necrosis, but to facilitate sexual function. The Chinese surgeons didn’t reattach the cavernosal arteries, which run down the center of each erectile chamber and supply much of the blood for erections. One reason, perhaps, for the wifely discontent.

Meanwhile, one gurney over, an artery in the skin on the lean cadaver’s abdomen is being hooked up to a tube running down from an IV bag. The fluid in the bag is dyed indigo, and when it begins to flow, a patch of skin will blush blue, revealing the precise territory fed by the artery. In this way, Redett and his colleagues are able to pinpoint which vessels are critical for the transplant. There will be no necrosis when the Americans move their first penis.

The IV isn’t a drip but a rapid infusion, a setup used in emergency rooms to replenish blood volume quickly. “The first time we tried this, it was a disaster,” says Sami Tuffaha, who has been researching penile vasculature as part of his residency. “Dye all over the place.” Irritated janitor. Ruined loafers. He sticks out a foot. “They’re my cadaver shoes now.”

From off behind us comes the voice of James Spader. “If you don’t have a pair of cadaver shoes, you’re not doing enough research.”

In a previous session in the same lab, Tuffaha located a vessel coming off the femoral artery that perfuses the skin of the lower abdomen just above the penis. They’re rechecking this, to be sure it wasn’t an anomaly. Tuffaha reaches up to open the valve on the IV. Within seconds, a time-lapse bruise unfolds. The area expands and darkens, its boundaries made clear. “This is great,” says Redett. “We can take this whole area as part of the transplant.” Transplanting a penis is like transplanting a tree. You don’t just lop it off at the trunk. You take the ground around it and the roots that nourish it. In all, three to four veins, a like number of arteries, and two nerves will need to be connected.

The donor cadaver, the lean one, lies on his back, one forearm draped across his waist. It’s a relaxed pose, a movie pose—postcoital, maybe, or poolside chaise longue. It’s an odd visual, given the proceedings. Tuffaha and Redett have by now disconnected the whole package: penis, scrotum, and a peninsula of flesh above and to the side, which contains that critical artery Tuffaha found.

Redett needs photographs for an upcoming conference presentation. Tuffaha obliges by holding the unit in front of the camera. With thumbs and forefingers he dangles it by the two top corners of skin, then reverses it, so Redett can document the back side. Imagine a mother-to-be at a shower, holding up a baby sweater for guests to admire. It’s of similar size and floppiness, is what I mean. Possibly there was a better comparison to be made, but let’s move on.

I later asked Ronn Wade, who runs Maryland’s body donor program out of an office down the hall from the lab, what he would say in the event he was contacted by a family member wanting to know how this cadaver was used. He answered that he would tell them it was a “multi-use clinical/surgical specimen.” Having seen what I’ve seen, I understand the need for vagueness. Before you could expect a body donor’s family to accept the specifics of the research under way today, they would need to understand the specifics of its promise. They’d need to have a sense of what it’s like to be a soldier or Marine who wakes up from surgery after an IED blasts a hole in his life. They’d need to appreciate that the procedure being developed in this windowless horror movie of a room has the potential to restore the wholeness of a young man: his future, his relationships, his well-being. More graceful, I think, to leave the particulars of the gift unspoken.

THE DONOR’S work is done. Where his penis was,[18] there’s a crimson rectangle, a loincloth of his own tidy gore. The testes, skinned, have been pulled off to the side of the hips. “You’re not taking these?” I ask Redett. As though he were packing for a trip. I’m thinking now of combatants whose injuries leave them unable to generate sperm. It might be nice to give them, along with a functioning penis, a reproductive future. What’s a few more ducts and tubes to hook up?

It’s trouble. That’s what it is. Hook up the testes, and now the penis donor is also a sperm donor. If the transplant recipient impregnates someone using the dead donor’s testes—and, more to the point, his genes—whose offspring will that child be? What if the donor’s widow tries to lay claim to her dead husband’s sperm, now being generated inside a different man? What if the dead man’s parents want a relationship with their biological grandchild? Cooney looks up from the stump: “It could get weird.”

I asked Ray Madoff about this. Madoff is a professor at Boston College Law School and the author of Immortality and the Law, the go-to book on the legal rights of the dead. “It’s no weirder a problem than we already have,” she said, meaning that the United States years ago entered the uncharted waters of donor sperm and donor dads. “Some countries, sensible countries, have statutes and regulations about what happens to the sperm of dead men.” The United States isn’t there yet. It’s a place where judges have ordered sperm donors to pay child support, and rapists have been granted visitation rights to a victim’s child.

For now, more practical matters stand in the way. It’s enough of a challenge to find people who’d be willing to let Rick Redett take the penis from their brain-dead, respirator-oxygenated loved one and stitch it onto another man. Taking the cellular lineage, too, would, as Cooney says, “be beyond the normal donation that most people would consider.” In the meantime, simpler options exist. The military could, as a matter of course, bank sperm from each male soldier prior to deployment.

Rob Dean, the Walter Reed andrologist from chapter 4, counters that even that isn’t simple. “It’s an elective procedure,” he said when I visited. “The military can’t say, ‘Line up, we’re going to make you donate sperm.’” There’s also a cost-benefit issue. Maybe three hundred veterans from Operation Enduring Freedom suffered injuries that left them infertile. “So for those three hundred you’re going to bank sperm for a hundred fifty thousand men?” In the current climate of Defense Department budget cuts, it’s a tough sell. Madoff surmised that military budgeteers might have an additional concern. A widow who uses a dead veteran’s banked sperm may be creating not just a baby but a government beneficiary.

A third option exists. Sperm typically live about forty-eight hours, so it’s possible—if things look testicularly dire—to extract the last batch, the soldier’s last shot at biological fatherhood, in the operating room. “But again,” said Dean. “If they haven’t consented, I can’t do it. I don’t know if this guy wanted to be a father, now or ever. I need to know that, or have a [prior] directive from a legal guardian or next of kin. The wives and girlfriends get upset, but it’s not their body.”

So education is what’s being done. Information about sperm banks is sent to service members before they deploy, so that at the very least they’re aware it’s an option.

Not good enough, says Stacy Fidler, a veterans’ reproductive rights advocate I spoke to at Walter Reed. With support from a national infertility nonprofit called Resolve, Fidler is pushing for on-base sperm banks. She lives with her son Mark, a Marine who has been recuperating in an apartment at Walter Reed National Military Medical Center since the propulsion charges on three grenades on his belt were set off by a nearby IED. Mark lost all of both legs and both buttocks. Although, quoting Stacy, “the big boy’s fine,” there was some damage to the testes, and the family doesn’t know whether Mark will be fertile once he heals.

MARK WAS on his bed when I arrived. It was midafternoon, and the curtains were closed. The Big Bang Theory was playing through a projector set up on his bedside table. I sat down in the one chair available, in the path of the projector’s beam. The actors sniped at each other on the side of my head until Mark reached for a remote and shut them down. Pressure sores made it too painful for him to sit upright. Without the cushioning of buttock muscle, the bony points of the pelvis can wear through the skin. Mark’s bed had become his couch, his office, and his dining table. Within arm’s reach were three remotes, an iPad, a plate of donuts, and that simplest of prostheses, the rattan back scratcher.

“Listen,” said Mark. “I know how a grunt’s mind works. They’re not thinking about having kids. They don’t have wives, most of them.” He was shirtless under a gray fleece throw, his body a round form that stopped too soon. He pointed out that the sperm bank nearest to the Marine Corps training base at Twentynine Palms was probably in Los Angeles, three hours away. “You can give them all the information you want; they’re not going to do it.”

His mom joined the conversation. Stacy Fidler wore jeans and a red shirt with a Marine Corps insignia and was perched on the edge of Mark’s prone cart, a joystick-operated, wheeled table that he’s been using to get around. “It should be available right there on base,” she said. “And if you don’t want to, you don’t have to.”

“No,” countered Mark. “You have to make them do it. Honestly, in Afghanistan we talked nearly every day about getting blown up. But the most we ever talked about, injury-wise, was losing maybe above the knees, both legs. You never think about the genitals. Don’t give them a single chance to go, ‘Aaaaa, forget it.’”

If the military were to pay for predeployment sperm-banking for every male recruit, wouldn’t they also need to pay for extracting and freezing eggs—a costlier and more involved undertaking? Stacy shakes her head no. “If a girl gets her ovaries blown up, she’s not going to be here.” Meaning that an explosion that blows up a woman’s ovaries is likely to be lethal. “That’s a whole different ball game,” she said, intending no word play.

Mark has radar for whatever frame of mind a person has brought along into his room: unease, medical detachment, in my case curiosity. With little warning, he rolled onto his belly, pulled the blanket off and slid down the back of his Jockeys. Pointing to where his buttocks used to be, he said, “This right here is my lap.” Was, he means. His surgeons took skin from the front of his thighs, thighs they were removing anyway, and covered the crater made by the grenades. A dressing as big as a gas cap covered a pressure sore.

Once the sores heal, he said, he wants to try skydiving, horseback riding, calf roping. He wants to act in zombie movies and wrestle alligators. For some reason, it was the next one that made me go gooey: “I want to see Paris.” To this day, when I think of Mark, I picture him, cigarette behind one ear, rolling way too fast down Boulevard Saint-Germain.

As I write this, there’s been chatter in the media about the ultimate composite-tissue transplant: a whole body. If it were possible to regrow spinal nerves, you could, in theory, sever a soldier’s head from his severely mangled body and surgically transplant it—hooking up the arteries, veins, and nerves—onto a freshly decapitated beating-heart cadaver whose tissues have been kept oxygenated via a respirator. A rough version of the procedure was performed by Cleveland surgeon Robert White in the 1960s, using pairs of rhesus monkeys. The heads with their new bodies survived for a few days, paralyzed and unable to breathe on their own. Then rejection issues set in. Vastly better immunosuppressant protocols have brought the whole Frankenstein tale closer to reality, though it still resides in the realm of speculation. Spinal nerves are far more complicated than peripheral nerves. Peripheral nerves, which serve the extremities, are like telephone wires in a sheath. When the wire is cut, the signal stops at that point. But if you reattach the axon it will regrow along the pathway of its sheath. With spinal nerves, the analogy is no longer telephone wires; now you’re cutting the wires in a sophisticated computer network. The nerves don’t know what they’re supposed to reconnect to, which way to regrow, what paths to follow to restore function. The optic nerve is similarly complex. That is one reason no one, not even Rick Redett, has successfully transplanted an eye.[19]

THE THIN cadaver’s penis lies on the big cadaver’s belly while Cooney finishes isolating nerves and vessels on the stump. They’re not going to hook them up this time, because that takes six to ten hours, four to six surgeons, and a microscope on wheels. And was not the point of today’s endeavor.

When Cooney is done, Redett picks up the organ and drapes it in place over the larger cadaver’s stump. In the way a shopper previews the fit of a shirt by holding it to his shoulders, we have a sense of what this body would look like with the other’s penis. Redett steps away to get his camera. I am not preparing a presentation, but I, too, take some photographs. As though I could ever forget the sight.

Redett finishes and sets down his camera. He zips the big man’s body bag. It resembles a tuxedo bag and has a space for the cadaver’s name, which has been filled in with black marker. When I get back to my hotel, I find an online obituary for him. There are a number of interactive options. One of them causes me to make a strangled barking sound. “Please add a photo and share in the life story of ________.” Another option invites me to add a memory to the online guest book. “If you need help finding the right words, view our suggested entries.” Nothing seems to fit.