Pe­nis trans­plant pro­vides hope

Af­ter the first suc­cess, vic­tims of botched rit­ual cir­cum­ci­sions in South Africa line up for the pro­ce­dure.

Los Angeles Times - - THE WORLD - By Robyn Dixon robyn.dixon@la­times.com

JO­HAN­NES­BURG, South Africa — In the deep of win­ter high in the moun­tains of South Africa’s Eastern Cape, teenage boys clad only in blan­kets, with white clay painted on their faces, un­dergo ag­o­niz­ing tra­di­tional cir­cum­ci­sions. Hun­dreds have died as a re­sult of the rit­ual, and hun­dreds more have lost their penises when in­fec­tion set in, ac­cord­ing to the South African Health Min­istry.

For years, Dr. An­dre van der Merwe, head of urol­ogy at Stel­len­bosch Uni­ver­sity in the West­ern Cape, has lis­tened to the heart­break­ing sto­ries of dozens of vic­tims, many of whom were sui­ci­dal. In 2010, he de­cided to de­ter­mine how to per­form a pe­nile trans­plant.

“I thought it would be sim­ple. How wrong I was.”

It took Van der Merwe and a team of sur­geons nine hours to con­duct what is be­ing called the world’s first suc­cess­ful pe­nile trans­plant, in De­cem­ber at Tyger­berg Hos­pi­tal in Cape Town. It was a tense day, in­volv­ing hours strug­gling to tease out del­i­cate nerve end­ings and blood ves­sels from the pa­tient’s hard­ened scar tis­sue and graft on a pe­nis taken from the ca­daver of an or­gan donor.

“We were not stand­ing around that op­er­at­ing ta­ble for nine hours telling jokes,” he said in an in­ter­view. “The amount of scar tis­sue that had been cre­ated around the area was huge. It was very dif­fi­cult to get the nerves out. We couldn’t get the blood ves­sels out. We had to aban­don that ef­fort in the end.” Doc­tors even­tu­ally used an­other nearby blood ves­sel.

The re­sult ex­ceeded Van der Merwe’s wildest hopes: He had ad­vised his 21-yearold pa­tient that he might re­cover his sex­ual func­tion af­ter per­haps two years. To his as­ton­ish­ment, the man, who has a girl­friend, be­came sex­u­ally ac­tive within five weeks.

“We’re sit­ting on num­bers of young men who are with­out penises and their lives have been dev­as­tated. They’re all young men. Some have been living with­out their pe­nis for 10 years.

“The thing that hap­pens is they com­mit sui­cide. They buy food and poi­son and just go into the bush and have that last meal.”

The is­sue is limited to the 5-mil­lion-strong Xhosa eth­nic group on the Eastern Cape, which per­forms a risky form of tra­di­tional cir­cum­ci­sion — or uk­waluka — on teenage boys, who are oth­er­wise shunned and ridiculed.

The boys, some as young as 12, wear only blan­kets in the freez­ing night, and live in huts high in the moun­tains for three to four weeks. The rules gov­ern­ing the deeply se­cre­tive rit­ual for­bid them to cry, show dis­com­fort, run away or go to a hos­pi­tal af­ter­ward. Those who do are branded as weak fail­ures and “boys” for the rest of their lives.

In the moun­tains, they are taught by el­ders how to be­have in the com­mu­nity, build­ing huts from sticks and grass for shel­ter. They’re for­bid­den to dis­cuss the rit­ual with out­siders.

Van der Merwe said the most danger­ous part of the eth­nic rit­ual oc­curs af­ter the fore­skin is re­moved with a blade or knife. The pe­nis is then tightly wrapped with strips of goatskin for a week or more, a painful and harm­ful pro­ce­dure, par­tic­u­larly be­cause ini­ti­ates are also not al­lowed to drink wa­ter and are per­mit­ted only tiny amounts of dry food.

“If they wrap it too tight, the blood sup­ply will be cut off. They also de­hy­drate the guys.... You’ve got a de­hy­drated pa­tient with a necrotic pe­nis and sep­ticemia. Those kid­neys go and you have got a death. If they don’t die, it [the pe­nis] falls off any­way.”

Adding to the prob­lem is that some prac­ti­tion­ers who con­duct the cir­cum­ci­sions have vir­tu­ally no ex­pe­ri­ence other than hav­ing un­der­gone the pro­ce­dure them­selves.

By the time vic­tims seek med­i­cal help, their penises are be­yond sav­ing, say Van der Merwe and other doc­tors. The pri­or­ity is to save their lives.

“I’ll never for­get some of those young guys’ faces. The guy asks, ‘When will it grow back?’ You have got to tell them it’s never go­ing to grow back. They just go com­pletely blank. It’s just like they can’t be­lieve it.

“They blame them­selves, be­cause the com­mu­nity thinks they’re too weak.”

There are now nine men on a wait­ing list for trans­plants, and later in the year, the hos­pi­tal will an­a­lyze whether fur­ther op­er­a­tions can be funded with­out ex­ter­nal help.

The gov­ern­ment in June de­clared zero tol­er­ance for un­safe ini­ti­a­tions, but the deaths haven’t stopped.

At least 38 boys died and 10 lost their penises dur­ing last year’s ini­ti­a­tion sea­son, from May to July, ac­cord­ing to gov­ern­ment statis­tics. The pre­vi­ous year, about 40 died.

In Au­gust, a group of sci­en­tists and public health pro­fes­sion­als called for a ban on tra­di­tional cir­cum­ci­sions. They said many boys and young men “paid the ul­ti­mate penalty of death for tak­ing part in cul­tural prac­tices that had out­lived their value in to­day’s South Africa.”

Tra­di­tional lead­ers re­jected the call for a ban, but said they sup­ported moves to es­tab­lish safer cir­cum­ci­sions.

Van der Merwe said the pe­nile trans­plant pro­ce­dure had to be prac­ticed care­fully on ca­dav­ers be­fore that op­er­a­tion in De­cem­ber. Be­cause of the acute cul­tural sen­si­tiv­ity, he also con­sulted tra­di­tional el­ders on whether they thought the op­er­a­tion would be ap­pro­pri­ate.

“They said, ‘If you can do it, please, go ahead. It will be like bring­ing some­one back from the dead,’ ” he said.

One ma­jor dif­fi­culty is find­ing donors for the trans­plants, be­cause of strong cul­tural re­sis­tance to or­gan do­na­tion in South Africa.

Be­cause most vic­tims avoid hos­pi­tals, Van der Merwe be­lieves that many young men who lost part or all of their penises re­main in the com­mu­nity, too ashamed, fear­ful or trau­ma­tized to seek help.

Some mem­bers of South Africa’s trans­plant med­i­cal fra­ter­nity have not been en­thu­si­as­tic about the pro­ce­dure, view­ing it as un­nec­es­sary be­cause it doesn’t di­rectly save a life.

But for the young man who un­der­went the na­tion’s first suc­cess­ful pe­nile trans­plant, it means the world, Van der Merwe said. Other pa­tients have ea­gerly fol­lowed his progress, hop­ing that their turn will be next.

“This trans­plant project has given them hope. One guy told me he’ll never stress in his life again, be­cause he knows what real stress is.”

AFP/Getty Images

“THEIR LIVES have been dev­as­tated. They’re all young men,” says Dr. An­dre van der Merwe, head of urol­ogy at Stel­len­bosch Uni­ver­sity in South Africa.

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