Why the first genital transplant is so important for war veterans

For every visible scar that a U.S. war veteran carries, there are dozens of wounds you can’t see. There are lost limbs concealed by prosthetics and psychiatric disorders discussed behind closed doors. But there’s another — perhaps even lesser known — wound that rarely gets attention: loss of genitals. Due to the nature of improvised explosive devices (IEDs), severe damage to the genitals is not a rare occurrence for male soldiers, and it’s a particularly devastating injury to face.

In an article on this phenomenon for the Huffington Post in 2013, senior military correspondent David Wood called it the “deepest fear” among soldiers. “Makeshift bombs known as IEDs are taking a frightening toll in Afghanistan, the blasts shearing off arms and legs, ripping through soft flesh, crushing organs and bone, and driving dirt, rocks and filth deep into torn flesh — often leaving the genitals shredded or missing,” Wood writes. “Some guys said they’d rather be dead.”

For men who have either experienced this or fear it while on the battlefield, the news from Johns Hopkins that doctors have succeeded in doing the first penis and scrotum transplant was uniquely comforting.

A statement from Johns Hopkins Medicine described the historic transplant as a “14-hour procedure” led by a team of nine plastic surgeons and two urological surgeons. In it, the entire penis, scrotum, and partial abdominal wall were removed from the deceased donor and then reconstructed onto the wounded soldier. At the time of the announcement, the soldier had been in the hospital for two weeks.

An Afghanistan veteran who wishes to remain anonymous, the soldier described to Johns Hopkins the intimate nature of the injury — and transplant. “It’s a real mind-boggling injury to suffer, it is not an easy one to accept,” he told the hospital. “When I first woke up, I felt finally more normal … [with] a level of confidence as well. Confidence … like finally I’m OK now.”

During a conference call with reporters Monday night, the team from Johns Hopkins said the matching process for this transplant was “much more involved and complicated,” requiring not only a match in blood type but also a match in age and skin tone. They also noted that the decision not to transplant the testicles was intentional and the result of ethical concerns about attaching another man’s sperm.

Richard Redett, MD, clinical director of Johns Hopkins’s genital urinary transplant program, said on the call that the feat took years of preparation. “This procedure represents the culmination of more than five years of research and collaboration across multiple disciplines to address the logistical, procedural, and ethical considerations of doing such a transplant,” Redett said. “It is our hope that such a life-enhancing transplant will allow him to regain urinary and sexual function and lead a more normal life. It is also our goal to offer the procedure in the future to other suitable patients.”

Given testimonials from soldiers who have lost genitals, there will be no shortage of candidates. Despite a lack of media coverage, injuries to genitals are a major topic in the military. To spread awareness about this, veterans joined the Bob Woodruff Foundation — a nonprofit in honor of the journalist — to host a conference about the issue. At the multiday event in Washington, D.C., doctors and veterans testified about the need for better treatment in the aftermath of sexual injuries, and the toll that they take on individuals’ lives.

The 25-page report about the conference, titled Intimacy After Injury, offers in-depth information about the prevalence of the injury, and the mental, physical, and financial toll that it takes. Based on the 2014 report, the military recorded 1,378 “genitourinary injuries” among male service members between 2001 and 2013, 75 percent of which resulted from explosions. “Severe penile and testicular injuries present huge reconstructive surgical challenges as well as related psychological problems,” the report says.

Margaret Rukstalis, MD, an associate professor in the Wake Forest department of psychiatry, explained the significance of the injuries in the report. “Sexual health, relationships, body competence, and fitness all affect body image … For men, weight, muscularity, height, and penis size are often related to overall appearance, sexual prowess, and self-esteem,” Rukstalis said. “While there is little qualitative data regarding the impact of genital injury on body image, scientists have identified regions in the brain related to body image. If penis transplants are undertaken in the future, it may be possible to develop multidisciplinary therapies and treatments to maximize psychological resilience and help the individual accept a transplanted penis.”

For the thousands of wounded soldiers who lost the ability to live normal lives in the wake of war, this news is not only exciting — it is also potentially life-changing. But as Alexandra Glazier, president and CEO of New England Donor Services, said on Monday night’s call with Johns Hopkins, it wouldn’t even be possible without the donor. “We thank the family for their remarkable decision,” Glazier said. “[It] has changed forever the life of someone unknown to them, but who they knew was in need.”

Glazier, whose organization located the donor, ended the call with a statement from the family: “To the recipient, we are all very proud that our loved one was able to help a young man that served this country. … He would be honored to know he provided such a special gift to you.”

The statement continued: “As a family, we are very supportive of all the men and women who serve our country, and grateful for the job you did for this nation. Please know that this is truly a heartfelt statement, as we have several veterans in the family. We hope you can return to better health soon and we continue to wish you a speedy recovery.”

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