When servicemen back from Iraq and Afghanistan with grievous groin injuries asked about penis transplants, doctors had to tell them it wasn't possible. That gnawed at Johns Hopkins Hospital surgeons who were performing penis reconstruction surgery, but only when injuries left enough tissue on the arms, legs or backs to use for the procedure.
With other successful transplants of limbs and the men's sacrifices on their minds, the surgeons organized a team about five years ago to study the organ so central to male identity and to devise a penis transplant procedure.
The surgeons are now ready to perform the first penis transplant in the United States. They and their first patient, a young serviceman who was wounded in Afghanistan, are awaiting a donor.
Not surprisingly, such an operation raises questions about costs and necessity.
"Maybe there are people who think we shouldn't do this because it's not life-saving," said Dr. Richard Redett, a Hopkins transplant surgeon and director of pediatric plastic and reconstructive surgery.
"I don't know if people realize how important this is to these wounded warriors. Doctors who treat them say the first thing they do when they're hurt is look at their pelvis. It's the first thing they ask about."
U.S. soldiers fighting in Afghanistan and Iraq suffered a spate of such injuries, largely from improvised explosive devices. From 2001 to 2013, about 1,367 male service members were placed on the Department of Defense Trauma Registry with so-called genitourinary injuries, which includes injuries to the genitals.
Nonetheless there is little public discussion about groin injuries, let alone penis transplants. There's stigma and embarrassment associated with loss of sexual function from physical or mental trauma, said Dr. Elspeth Cameron Ritchie, a retired Army psychiatrist who is working on a book about intimacy after injury.
When considering a new procedure such as a penis transplant, doctors, ethicists, safety monitors and other officials pore over the risks and benefits. Such considerations become heightened when the surgery isn't considered life-saving and can result in serious complications such as rejection of the organ, infection or illness stemming from the immunosuppressant drugs patients must take for the rest of their lives.
A penis transplant also raises a host of questions. How would hospitals gain approval from donors or their loved ones who surely didn't consider such a possibility? What alternatives to penis donations do recipients have? How much consideration should be given to the feelings of the intimate partners of the wounded servicemen?
Then there is the considerable expense — between $200,000 and $400,000 — for an operation never before performed in the United States and not covered by any insurance.
An internal Hopkins review board was satisfied these issues could be addressed and approved 60 penis transplants, said Jeffrey Kahn, a professor of bioethics and public policy at Hopkins' Berman Institute of Bioethics who helped with the review. Kahn said donors would be asked to sign a separate consent for a penis transplant, as they have done for hand transplants or a face transplant expected to be done at Hopkins.
Hopkins agreed to cover the cost of the operating room for the first surgery and doctors donated their time, while officials asked the Department of Defense to consider funding future transplants. The Department of Veterans Affairs confirmed it would provide follow-up care.
Defense officials already declined two proposals for related research funding in fiscal 2014 because other proposals were determined to have greater scientific merit and relevance, said Maj. Ben Sakrisson, a Defense Department spokesman. He said significant evidence of success would be needed before the military would consider routine coverage of a medical procedure, though severely injured service members can sometimes get waivers for procedures done as part of a clinical trial.
The primary alternative to a transplant is penis reconstruction, which involves cutting a flap of skin along with blood vessels and nerves from elsewhere on the body and shaping it into a penis. While doctors have performed such procedures on patients born with defects, or who have been injured, or are undergoing gender reassignment, Hopkins doctors say it's imperfect. Men need an implant for an erection and normal urination can be difficult.
The case for transplants becomes stronger because reconstruction isn't always an option for servicemen when large areas of their bodies are burned or amputated, Kahn said.
"These are young men in the prime of life fighting for our country, and that combination is quite powerful," he said.
"I have come to believe that it's a quite easily justified risk balance."
Doctors made sure the initial candidate, who did not want to be identified, understood the risks and possible outcomes of a procedure successfully performed only once — in 2014 on a man in South Africa who had his penis amputated after a botched circumcision. That man was reportedly able to father a child last year, though a penis transplant wouldn't affect fertility as only intact testes would be needed.
For now, Hopkins is considering only injured servicemen for the transplants, not transgender individuals or those born with defects. That doesn't mean these other groups wouldn't have access to transplants eventually, said Robert Veatch, a professor emeritus of medical ethics from Georgetown University's Kennedy School of Ethics and an expert on transplant issues.
Life-saving organs such as kidneys and livers are allocated based largely on medical need and nationally coordinated waiting lists, which now include more than 121,000 people. Merit is not a consideration, and Veatch considers it a "dangerous path" because it would be hard to establish who is most worthy.
There are no official waiting lists for hands, faces, or penises because there isn't the same competition for these body parts, which come from deceased donors, said Veatch, who serves on a panel guiding such transplants at the United Network for Organ Sharing, the national body regulating the U.S. transplant system. Deciding who gets these transplants will be at the discretion of performing hospitals, with allocation rules possibly coming in the future, Veatch said.
Military service shouldn't be a factor, he said, even if some people think it ought to be. More likely, the surgeries would be available to those with the ability to pay, he said.
"I agree that casualties in the line of duty normally command a societal obligation to pay the costs of rehabilitation," Veatch said. "We are not very good at covering those costs, surely we should."
For now, being first means being a research subject, as the long-term effectiveness of penis transplants is not proven, said Ana S. Iltis, director of the Center for Bioethics, Health and Society and a professor of philosophy at Wake Forest University. That will strike people in different ways, she said. Some may not think the risks are justified, though she said many servicemen surely would think otherwise.
"There is no single point of view from which to judge risks and benefits," Iltis said.