Boys from the Xhosa tribe who have undergone a circumcision ceremony sit near Qunu on June 30, 2013.

For Male Circumcisions Gone Wrong, a Pioneering Transplant Surgery

Though transplants are almost always done under immense pressure and less than ideal circumstances, this one felt a little extreme to the four doctors involved. The difficulty started with the donor, a 21-year-old man who was admitted this past April to Tygerberg Hospital in Cape Town, South Africa, for a severe asthma attack. The incident left him brain dead, and his family initially consented to making his penis available for a transplant — a procedure that had been successfully carried out on just two previous occasions: in Boston last year, and here at Tygerberg, where doctors accomplished the first successful penis transplant in 2014.

But as often happens in such cases, the man’s family vacillated for hours, first granting permission for the penis donation, then retracting it. It is one thing to donate a loved one’s unseen organs (the family had agreed to donate his kidneys), but it is quite another to donate a visible appendage like a hand or penis, forever altering one’s final memory of the body. Five hours later, though, the family had another change of heart. The penis transplant would take place after all — and the medical staff had to quickly reanimate all the logistical levers required for an operation of such complexity.

“By that time the patient was so unstable his heart nearly stopped,” said André van der Merwe, lead surgeon on the case. If the patient’s heart were to completely cease, that would starve the organs of blood, causing them to die and making them impossible to transplant.

Shortly before midnight, two groups of surgeons got to work. One sought to harvest the kidneys while another tried to get the penis (the respective organs were intended for separate recipients). With the patient’s diminishing blood pressure serving as a constant reminder of how little time he had, van der Merwe was forced to sever the vessels a lot closer to the tip of the penis than he would have preferred. This would later prove to be a big problem. If the donor’s and recipient’s blood vessels are not matched perfectly, the blood crossing the threshold at which they are conjoined may be subject to turbulence, which could trigger clotting and ultimately a rejection of the organ.

Van der Merwe knew how significant this setback was because he had overseen the hospital’s landmark penis transplant three years before. In that instance, he had more time to harvest the penis and could achieve more congruence among the vessels. Now, knowing how much the world responded to that first transplant, the possibility of failure taunted him. “I just thought everyone’s going to [say] the first one was luck and you couldn’t do the second one,” van der Merwe told me as he recounted the recent late-night surgery. “But nobody would have known how difficult it was because of the small-diameter blood vessels.”

Eventually the team managed to complete the harvesting just in time. “As we removed the kidneys, the heart stopped,” van der Merwe said. “It was a very tense situation.”

That South Africa is at the vanguard of this delicate and novel surgery is a testament to some grim realities. While the actual number is difficult to come by, experts in the country believe South Africa has the highest rate of penis amputations in the world, in large part because of the persistence of traditional male circumcision in many communities — particularly the amaXhosa, the second largest ethnic group in South Africa. The traditional procedure leads to dozens of South African men’s deaths each year — many from dehydration or septicemia. As many as 46 initiates died in the Eastern Cape in the 2015-2016 season alone. Attempts to reduce the number of deaths through legislation like the Application of Health Standards in Traditional Circumcision Act of 2001 have had little impact, and among those who survive botched circumcisions, complete amputation is often the only recourse.

In this case, the harvested organ is destined for a 40 year-old isiXhosa-speaking man who posed formidable medical challenges of his own. Since losing his penis in a botched traditional circumcision 17 years ago, he had begun to abuse alcohol and other drugs — common pathologies among amputees. Not only is their sense of masculinity deeply shaken by the loss, but they often face ostracism from their communities.

An undocumented number of them make attempts on their lives.

“The guys that I interviewed, they all had the same sort of methodology when they considered suicide,” van der Merwe said. “And that is to take poison — put it in food and go back into the bushes in the area where they’d been circumcised — they just never come out of it again. That is, sort of, the most dignified way for men to exit the situation.”

The prospect of giving this man peace — and an alternative future — weighed heavily on van der Merwe’s shoulders that night in Cape Town. So with the penis successfully removed, the surgeon rinsed it in a solution and, at 4 in the morning on April 21, turned his attention to what remains one of the rarest and most difficult transplants in modern medicine.

Boys from the Xhosa tribe who have undergone a circumcision ceremony walk near Qunu in South Africa’s Eastern Cape province. Visual: CARL DE SOUZA/AFP/Getty Images

Roughly 48,000 traditional circumcisions took place nationally in 2015, according to government estimates, with most occurring in the Eastern Cape — the poorest province in the country. Local activists estimate that about 3,500 circumcisions take place twice a year in the most rural parts of that province, an area formerly known as the Transkei. Euphemistically designated a “homeland” by the apartheid government, it was part of the only 7 percent of the nation in which black people were legally allowed to own property — the rest of the land was reserved for white citizens only.

This is the home of Azola Nkqinqa, a young man not unlike the patient who had come under the care of van der Merwe’s transplant team in April. When the time came for Nkqinqa to get circumcised at age 18, he had no male family members left who could guide him through the process. His father had long ceased to be a feature in his life and two uncles had been murdered. Patrick Dakwa, a local community activist who runs training events to improve safety during initiation ceremonies, offered to take responsibility for Nkqinqa during the ritual.

Nkqinqa remembers being taken to an assembly point where, on a warm December afternoon in 2013, his journey to manhood began. Other men who have already undergone the process are sworn to secrecy about the details of the rite, so, beyond the fact of the circumcision, Nkqinqa had no idea what would happen.

The advised method for removing a foreskin is to use disposable razors. But Nkqinqa’s ritual was performed in an unsanctioned facility where a knife was used — and the same knife was used for all 13 boys in his cohort, a highly dangerous practice because of the risk of HIV transmission.

After his foreskin was removed, his wound was dressed with some traditional medicinal leaves and left to heal. Nkqinqa says he experienced intense pain — more than his peers seemed to be going through. When Patrick Dakwa came to check in, he was alarmed by Nkqinqa’s condition. “I discovered that this guy [is] suffering dehydration,” Dakwa said. Traditionally, initiates are not permitted to drink water for up to eight days after the circumcision, though temperatures in the area can reach 95 degrees Fahrenheit. Then Dakwa noticed the penis was changing color and shape, an early sign of gangrene. “Even the urine found a way of exiting — not where it’s supposed to,” Dakwa said.

The decision to take Nkqinqa away was a weighty one. Any initiate who prematurely breaks off the full ritual — normally a monthlong affair that includes the circumcision, recovery, and cultural teachings — would likely be ridiculed as a “half-man.” Nonetheless, Dakwa insisted that Nkqinqa be taken to a medical facility. “If he [had been] there for the next 12 hours, he might be one of the statistics, counted as a dead person,” Dakwa concluded.

He convinced a community member with a van to drive Nkqinqa to hospital where he was admitted immediately. The young man awoke the following day, confused about how he came to be in a strange bed, wearing a white gown dappled with blue dots. Groggily he looked down the front of his gown at the gaping absence where his penis had once been.

“Seeing this thing, that there’s nothing here, so I felt like, I felt like I lost my mind,” Nkqinqa recalled.

Even compared with other traumatic causes of amputations — soldiers injured by improvised explosive devices, for example, or the thousands of victims of penis cancer globally each year — those arising from botched circumcisions in South Africa can seem particularly bitter. Not only is there tragic irony in the fact that the very rite of passage meant to usher a boy into manhood is the reason for the loss of one of the key identifiers of manhood, but there is the double whammy of social stigma added on.

Before his circumcision, Nkqinqa was well known in the community as being helpful and polite. After the amputation, his personality wilted. He dropped out of school for two years and became a recluse. “I started to drink alcohol a lot,” he told me.

Nkqinqa doubts he will ever be able to have a child, but if he does, he says he would not allow his son to participate in traditional circumcision.

Stellenbosch University’s André van der Merwe discusses South Africa’s second successful penile transplant.

Despite the late hour of the looming transplant in April, van der Merwe said he eschewed caffeinated drinks before beginning what would ultimately prove to be a nine-hour procedure — weighing the benefit of mental stimulation against the possibility of the caffeine causing a tremor in his hand. Every inch of his body had to be completely still for the microscopic surgery, during which he, at times, rested his arms against the patient, his body against the bed and his head on the microscope.

Since the first kidney transplant in 1954, solid organ transplants have been done many times around the world. Penis transplants, however, fall into a category with face or hand transplants known as “vascularized composite allografts” or VCAs. These are relatively new — the first face transplant was completed in 2005 — and more intricate because they involve several kinds of tissue: skin, blood vessels, muscle, and nerves. “With these transplants, complex parts of the body are reconstructed in function and appearance,” said Dr. Alexander Zühlke, the lead plastic surgeon on this and the first penis transplant back in 2014. That first operation was so remarkable because it allowed the patient to regain full urological and reproductive functions, including the ability to father a child, which he did in 2015.

As van der Merwe made the first incisions and his fears about the small blood vessels were confirmed, the probability of this operation turning out to be a similar success receded into the distance. They were so tiny that he was not able to reconnect one of the four main arteries feeding blood to the organ. “It was very difficult for me. I really thought that this one is not going to work,” van der Merwe recalled. He and his team connected the skin, nerves, and as many of the vessels as they could. Then, under a cloud of despondency, they closed the patient up and went home for the night.

The next day, as van der Merwe checked on the dressing, he was shocked to find that the coloration of the wound looked promising. He pinched the tip of the penis to perform a capillary test. To his delight the blood rushed back into the spot where his fingers had been, suggesting that the circulation was normal.

Several months later, van der Merwe proudly reported that the second penis transplant recipient is still doing well — though there are a few challenges that remain: For one thing, the donor was white and the patient black. At the time of the operation this seemed like a minor detail, he was happy to receive any penis on offer, but after looking at the organ for an extended period of time, he has requested corrective medical tattooing so that the penis matches his skin tone.

Another of the physical costs is his now lifelong dependence on immunosuppressive drugs, the medication that all transplantees need to take to prevent their bodies from rejecting the new flesh. In the long term, these drugs can be very taxing, in some cases resulting in kidney damage. But according to reports from his doctors, the most recent transplantee, who has thus far declined media interviews, considers these costs manageable compared with life without a penis.

Other recipients appear to agree. Tom Manning, the Boston resident who received a penis in 2016, articulated the significance of the transplant in an interview with Esquire magazine: “You ask every guy, of every ethnicity, ‘What makes you a man?’ I bet the penis would be the first thing.”

These are sentiments that van der Merwe and his fellow surgeons take seriously.

“If you don’t have a penis, you are essentially dead,” van der Merwe said at a press conference celebrating the first transplant. “If you give a penis back, you can bring them back to life.”

T.L. Andrews is a freelance journalist from South Africa. His work has appeared in The Guardian, Al Jazeera, and Quartz magazine, among other publications. His areas of interest include economics, science, and art.