Grunt: The Curious Science of Humans at War

by Mary Roach

  What can be done for these men? A lot. The art of phalloplasty—crafting a working penis from other parts of a patient’s body—has come a long way (thanks in no small part to the transgender community). To build a penis, Jezior begins with an arm. A rectangular flap of skin on the underside of the forearm is planed into two thinner layers. The inner one is rolled to form a urethra; the outer becomes the shaft. This tube within a tube is left in place, nourished by the arm’s blood supply. When what remains of the original organ heals, the new model is detached from the arm and reattached farther south.

  Erectile tissue is the challenge. While spongiform erectile tissue exists in other parts of the male anatomy—along the urethra and in the sinus cavity (congestion being an erection of the nasal turbinates)—there isn’t much of it, and no one has tried to transplant it. And while there are eye banks and sperm banks and brain banks, no one is banking noses. So in place of the corpora cavernosa—the two parallel cylinders of erectile tissue—surgeons install a pair of inflatable silicone implants. (To get erect, the patient—or his friend—squeezes a little silicone bulb implanted in the scrotum that pumps saline from a receptacle in the bladder.) Hook up the tubes and let the nerves regrow, and in time orgasm and ejaculation are back on track.

  Jezior continues with his slides. “This is a brigade commander. A sniper shot him across the top of the groin. Took out the middle part of his penis.” Losing the whole penis—and surviving the blast—is rare. Among Grade 3 and higher (the worst) cases of Dismounted Complex Blast Injury, 20 percent suffer damage to the penis, but only 4 percent lose everything.

  You have to wonder: Was the sniper off his game, or was the shot intentional? Are there some who aim for the crotch? Jezior thinks that there are. He’s heard stories from World War II. Dale C. Smith, a professor of military medicine and history at the nearby Uniformed Services University of the Health Sciences (USUHS), has also heard those stories, but knows of no evidence to back them up. Smith points out that the secondary goal of a sniper is to sow fear. In that sense, the crotch is an effective shot. However, Smith said in an email, it is also a risky shot, in that a sniper is looking for a “high percentage return” on the tactical effort and risk of getting into position. The pelvis is not considered a “kill shot.”

  Another gunshot case follows, this one through the scrotum and rectum. “This is half his anus here. Here’s his scrotum up here. This is the insides of the testes. ” The horrid Cubism of modern warfare. The reconstruction in this case was done by Rob Dean, Walter Reed’s director of andrology. The andrologist’s beat is reproduction, not excretion: testes and scrotums, hormones and fertility. Dean is joining Jezior and me in a few minutes for lunch, in a sandwich place downstairs. The two served four months together in Iraq.

  Jezior closes the photo file and leads me out through the urology waiting area, toward the stairs. “Patient Jackson?” calls a receptionist. As though “patient” were the man’s rank. I guess in a sense it is. He may be a major or a colonel and the man across from him may be a private, but here everyone’s a patient. In a culture defined by rank and hierarchy, Walter Reed can seem—to an outsider, anyway—endearingly egalitarian.

  Dean is already in the line to order sandwiches. He, too, is extremely busy, which, in the grand and ghastly scheme of war, is a good thing. It means more men are surviving bigger explosions. If funding and research lag behind, it’s partly because of the general cultural discomfort that surrounds all things sexual—including the poor organs themselves. On a much simpler level, Jezior says, it’s a case of out of sight, out of mind. “When some celebrity comes to Walter Reed and visits you in your room . . .”

  Dean jumps in. They finish each other’s thoughts like an old married couple. “. . . Right, the President doesn’t pull down the sheet and go . . .”

  “. . . ‘That’s terrible, look at that. His penis is gone. Let’s get some money flowing for that.’”

  Walter Reed Medical Center pays for phalloplasty, although there was initially some resistance. (The implants alone cost about $10,000.) Erections were thought of as “icing on the cake,” Dean says. “They’d say, ‘Oh, people don’t really need that.’ I’m like, ‘Well, the guy with the amputated legs doesn’t need prostheses. Put him in a wheelchair!’ And they’d go, ‘Oh, no! It’s important that they walk!’ I’d say, ‘Okay, well, most people think it’s important to have sex.’ Can I get a Caprese sandwich and a Coke Zero?”

  Dean has expressive hands and eyes and prominent arching eyebrows, and when he talks and laughs, the whole lot of them join the fun. In this business, humor and candor are a therapy on their own. Dean has been known to put a ruler to a discouraged patient’s penis and hoot, “You’ve got six inches! How much more do you need?”

  Don’t be fooled by the jolly tone. Dean is a bulldog for his patients. He was a force behind the push to get the VA to cover in vitro fertilization for soldiers whose injuries left them sterile. He gives talks to USUHS students about sexual health issues among injured service members and answers questions at veterans support groups. He helped colleague Christine DesLauriers found the Walter Reed Sexual Health and Intimacy Workgroup: a dozen-plus local medical providers and social workers who gather periodically to plot strategy and share resources. For instance: Sex and Intimacy for Wounded Veterans, a book by DC-area occupational therapists Kathryn Ellis and Caitlin Dennison. These two do not flinch. Here are sexual positioning tips for triple amputees. Ways to modify a vibrator for a patient who’s lost both arms below the elbow. I second the sentiments of the title page endorsement (if not the precise phrasing): “We should put a copy of this manual in the hands of every patient, spouse, and medical provider . . .”

  Especially the medical providers. “It’s amazing,” says DesLauriers, “how many of them are frightened to bring it up.” She told me about a Marine she’d worked with who said to her, “Christine, I’ve had thirty-six surgeries on my penis, I’ve had my shaft completely reconstructed, and not one damn person told me how I’m going to go home and use the thing on my wife.”

  Few talk to the wives, either. “It’s depressing watching some of them interact,” says Jezior. “In your mind you’re going, ‘She’s going to leave him.’” When I asked DesLauriers what the divorce rate is, she said, “Divorce rate? How about suicide rate. And what a shame to lose them after they’ve made it back. We keep them alive, but we don’t teach them how to live.” Walter Reed has no full-time sex educators or sex therapists on its payroll. The Internal Medicine Clinic offers appointments in “sexual health and intimacy,” but only one nurse is set up to handle them.

  “It’s not,” Jezior says when the topic comes up, “as well situated as we’d like it to be . . .”

  Dean cuts through it. “There’s nothing. There’s a vacuum.”

  DesLauriers’ workgroup has spent seven years meeting with military boards, trying to get Defense Department funding for an on-staff sex therapist at Walter Reed. She gets lots of support, almost entirely verbal. The problem isn’t just budget cuts. “The problem is getting the US government to embrace sex.” She told me about a meeting several years ago with an admiral who headed up Walter Reed. “He said, ‘I don’t understand what we are teaching someone who doesn’t have a penis. What exactly are you going to help that person with?’”

  There are so many things DesLauriers could have said to the admiral. She could have said, “Strap-ons, sir? Thigh riders?” She could have quoted from Ellis and Dennison’s book. “‘Incorporation of a residual limb in creative ways, such as stimulating a female partner’s clitoris,’ sir?” “‘Exploration of other areas that could provide more pleasure (e.g., nipples, neck, ears, prostate, rectum),’ sir?” She went with something more basic: “I said, ‘Sir, if I can be very candid with you. Does he have a tongue, and can he be taught?’”

  “The other thing to keep in mind,” Jezior says, “is that in the early stages after a major injury, there’s a lot going on that makes sexual intimacy not nece
ssarily the priority . . .”

  Dean, nodding: “Like, Can I brush my own teeth now?”

  “And they’re heavily medicated to get them through this period.” Narcotics, nerve stabilizers, antidepressants. “So if they’re not getting a good erection, you say, ‘Let’s get you through this, get you off the pain meds, and then see how you’re doing.’”

  Or, if you’re Christine DesLauriers, you say, “Can you handle a bit of pain? Cut back on the meds for four hours, have sex, go back on the meds.” Catheter in the way? Fold it back and put on a condom. “Absolutely you can have sex with an indwelling catheter!”

  Aside from Christine DesLauriers, are there other promising developments? What’s on the urotrauma horizon? What about penis transplants? I’m only half-serious, but Jezior starts talking about experimental work going on at Johns Hopkins.

  “Wait, they’re going to transplant a penis?” Some extraneous decibels on that. A couple look up from their paninis.

  Jezior says, “Yeah”—the kind of yeah you give someone who’s asked if you want your receipt, or fries with that, like it’s nothing. He adds that one of the patients in the photographs we were looking at is a candidate. Though it won’t happen for at least six months. “They’re doing some cadaver work right now.”

  “Really.”

  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.