Personal Health

The Complicated Ethics of Penis Transplants

What to know about a groundbreaking clinical trial.

Photo Credit: Sara Heinrichs/Flickr Creative Commons

A decade ago, doctors in China attempted the first penis transplant in history. Using a penis harvested from a 22-year-old brain-dead donor, they attempted the surgery on a 44-year-old man who’d lost his genitalia due to a traumatic injury.

They ultimately failed—after 14 days, the donor penis was removed because of the severely adverse psychological effects the transplanted penis had on the recipient and his wife, due in part to significant post-transplantation swelling. Researchers at Johns Hopkins University determined that the swelling was a result of a failure to connect certain blood vessels that have since been deemed essential to the surgery.

Two years ago, another transplant was attempted—and this time, the results were successful. The surgery took place on a 21-year-old South African man who underwent a botched circumcision. Years of attempts to find a donor were unsuccessful, in part because families were unwilling to leave their deceased relative without a penis. Eventually, a donor was found, and the team in South Africa constructed something that looked like a penis using skin from the donor’s arm, which met the approval of his family. The penis transplant recipient has since regained full urinary and sexual function.

Now, on the heels of that success, researchers at Johns Hopkins University are set to oversee the world’s first large-scale penis transplant clinical trial. The first recipient has been selected, and the initial procedure could happen within weeks or months, depending on the availability of a donor. The trial will involve 60 wounded veterans, with the goal of restoring their urinary and sexual function.

If proven successful, the trial could open the door to a surgery with the potential to improve the lives of men who’ve lost not only certain bodily functions, but also something central to their sexual identity.

But, as with most new medical procedures, it doesn’t come without questions of ethics—or in this case, of sexual and gender identity.

Penis Transplants: A Primer

It may surprise some to hear how common penile injuries are. According to the Journal of the American Medical Association(JAMA), between 2001 and 2013, more than 1,300 servicemen suffered urogenital injuries, 86 of which were classified as severe penile injuries, occurring at the average age of 24.

Arthur L. Burnett II, M.D., M.B.A., a professor of urology at John Hopkins University, noted that there are increasing numbers of servicemen returning with urogenital injuries because improvements in medical care mean that veterans are surviving injuries that may have killed them in the past. According to theJoint Theater Trauma Registry, the majority of these injuries were to the scrotum (29%), followed by the kidney (22.9%), bladder (21.3%), penis (14.2%), testicle (9.1%), ureter (2.7%), and urethra (0.8%). Injury to external genitalia accounted for more than 70% of urogenital injuries in servicemen. More than half of these injuries(65%) were results of explosions, while 14.8% were caused by firearms, 10.6% from blunt trauma, and 1.2% from burns.

It’s not just servicemen who suffer such incidents: Though not usually serious enough to warrant surgery, penile trauma can also result from car or machine accidents, gunshot wounds, burns, sports, or even sex. Men may also have their penis removed during penile cancer surgery, and some men are born without a penis.

The number of people the surgery could potentially help, then, is not insignificant.

As for the how of the transplant—well, it’s complicated. While it is technically possible to create a penis using tissue from other parts of the body—an operation that is increasingly being done on transgender men—the trial at Johns Hopkins will involve penis transplants from deceased donors. One potential reason for this is that a penis created using tissue from the recipient’s own body is incapable of spontaneous erection on its own and requires a prosthetic implant, which comes with a higher rate of infection. Although this is a feasible option for some, many servicemen also do not have sufficient viable tissue from other parts of their bodies from which to reconstruct a penis.  

According to the team at Johns Hopkins, donor penises are being evaluated based on a variety of factors specific to the recipient, including blood type, age (within five to 10 years), and skin tone. At this stage, researchers only have approval to conduct penis transplants on wounded servicemen, and in addition to military service, there are strict selection criteria for transplant candidates—including not being a candidate for more traditional genital reconstruction, being mentally healthy, having sufficient family support, and being fully aware of the potential need for additional surgeries and a lifetime of immunosuppressive drugs.

In an attempt to minimize the need for immunosuppressive medication, the team at Johns Hopkins will utilize a protocoldeveloped for hand transplants, in which the patient receives an infusion of the donor’s bone marrow, resulting in the patient’s bone marrow containing their own stem cells as well as those of the donor.

Doctors anticipate it taking between six months and one year for recipients to achieve urinary and sexual function. Of course, like any other organ transplant, the recipient’s body could possibly reject the donor penis, and there is no guarantee of the extent of urinary or sexual function, including the ability to have an erection, successfully engage in sexual intercourse, or biologically father children.

Ethical Considerations

As a society, we are used to talking about organ transplants, as well as the loss of limbs or other body parts as a result of military service. But the exceptionally personal nature of missing or malformed genitalia makes this surgery more fraught than the typical reparative procedure. It’s no secret that genitalia is culturally tied, quite strongly, to ideas of masculinity and femininity; some men who have had prostate or testicular cancer, for example, have expressed a diminished sense of agency

Likely in part because of this stigmatization, the team at Johns Hopkins is currently in discussions with various organ procurement organizations in order to determine how best to approach possible donor families, being upfront about the procedure in a way that does not scare them away from penis donation.

Anne Paschke, spokesperson for the United Network for Organ Sharing, has also noted that individuals who have indicated their willingness to donate organs on a driver’s license or registry should not be concerned: “Rest assured,” she told the Philadelphia Inquirer, “when you sign up to become an organ, eye, and tissue donor it does not include the face, hands, uterus, or penis. There has to be a separate request and consent for those.”

In being so tightly bound to sexual and, in some cases, gender identity, penis transplants are similar to uterus transplants, which have also been in the news of late. The two even share a primarily ethical concern—both are classified as “life-enhancing” rather than “life-saving.” As a result, both medical professionals and potential recipients must seriously consider the risks of undergoing the non-life-saving major surgery. In addition to possible complications with the procedure itself, the surgery could result in rejection of the transplanted penis and a lifetime of immunosuppression medication, which could be accompanied bydiminished immunoresponse.

On the other hand, there are potentially very significant benefits to recipients of penis transplants. In addition to potentially enabling men to regain urinary and sexual function and father children, the surgery could have significant psychological benefits for those whose identity is threatened by the loss of their penis.

Also similar to the discussion surrounding uterus transplants, it is important to note that eventually, if proven successful, penis transplant procedures may be used on transgender men as part ofgender-affirming surgery—though at this stage, that is only being discussed as a future possibility, once the procedure is proven to be safe and effective.

Perhaps the most pressing potential ethical concern with this particular trial is that these procedures are first being performed on wounded servicemen—a decision saddled with historical baggage. Members of the military are no strangers to being participants in experimental treatments, both with and without their consent. In some instances, new procedures were utilized by military doctors as a last resort, which eventually became used in regular clinical practice. There are other situations, however, when soldiers were used as human guinea pigs, testing the effects of certain chemicals and treatments without their knowledge and consent. However, unlike some experimental procedures of the past, the servicemen who will undergo the penis transplants will do so only after granting their informed consent.

While this clinical trial will initially be limited to veterans, it has the potential for significant and lasting implications for many who—by injury, illness, or birth—are lacking an integral part of their body and identity.

Elizabeth Yuko is a bioethicist and writer who specializes in reproductive and sexual health ethics, the ethics of human enhancement, and the intersection of bioethics and popular culture. Her work has appeared in publications such as The Atlantic, Salon, and Bitch, and she hosts a monthly show called Let's Get Ethical! at Q.E.D. in Astoria, Queens.

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