Penile Transplantation As an Appropriate Response to Botched Traditional Circumcisions in South Africa: an Argument Against Keymanthri Moodley,1 Stuart Rennie2
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Clinical ethics J Med Ethics: first published as 10.1136/medethics-2016-103515 on 29 July 2017. Downloaded from PAPER Penile transplantation as an appropriate response to botched traditional circumcisions in South Africa: an argument against Keymanthri Moodley,1 Stuart Rennie2 1Department of Medicine, ABSTRact On 11 December 2014, a team of South African Centre for Medical Ethics and Traditional male circumcision is a deeply entrenched urologists and reconstructive surgeons at Tygerberg Law, Stellenbosch University, Hospital in South Africa performed what was hailed Stellenbosch, Western Cape, cultural practice in South Africa. In recent times, there South Africa have been increasing numbers of botched circumcisions as the first successful penile transplant in the world 2Department of Social Medicine, by untrained and unscrupulous practitioners, leading on a 21-year-old victim of a botched traditional UNC Center for Bioethics, to genital mutilation and often, the need for penile circumcision.8 While the long-term success of the University of North Carolina- amputation. Hailed as a world’s first, a team of surgeons operation remains to be seen, the patient’s sexual Chapel Hill, Chapel Hill, North Carolina, USA conducted the first successful penile transplant in Cape function appears to have been restored, given that his Town, South Africa in 2015. Despite the euphoria of this girlfriend has reportedly become pregnant.9 Techni- Correspondence to surgical victory, concerns about the use of this costly cally, however, this was not a first. In 2006, a penile Professor Keymanthri Moodley, intervention in a context of severe resource constraints transplant was conducted in Guangzhou, China. Department of Medicine, Centre have been raised. In this paper, we explore some of the After the operation, the Chinese patient resumed for Medical Ethics and Law, ethical implications of penile transplants as a clinical and normal urinary function, and there were no signs Stellenbosch University, P.O. Box 2400, Cape Town, 8000, South public health response to the adverse consequences of of infection or tissue rejection. However, 2 weeks Africa; km@ sun. ac. za traditional male circumcision. Given the current fiscal later, the patient experienced significant psycho- deficits in healthcare and public health sectors, how logical distress, and the transplant was reversed by Received 5 March 2016 can one justify costly, high-technology interventions for the surgical team at the patient’s request.10 More Revised 23 September 2016 conditions affecting a small section of the population? recently, reports emerged in the New York Times Accepted 9 June 2017 Since botched traditional male circumcisions are about proposed penile transplant surgery to be Published Online First 29 July 2017 preventable, is a focus on penile transplantation as a form offered in the USA to wounded war veterans who of treatment reasonable? Finally, do such interventions suffered genitourinary injuries in Iraq and Afghan- create undue expectations and false hope among a highly istan.4 On 8 May 2016, the first US penile trans- vulnerable and stigmatised group of young men? In this plantation took place with a patient with cancer in paper, we argue that given limited healthcare resources in Massachusetts General Hospital.11 More recently, South Africa and competing healthcare needs, prevention on 21 April 2017, the surgical team of Prof. Van http://jme.bmj.com/ is a more appropriate response to botched traditional der Merwe at Tygerberg Hospital conducted a circumcisions than penile transplants. second penile replacement operation.12 In our view, advances in penile transplantation in South Africa and elsewhere should not be an occasion for simple INTRODUCTION medical triumphalism. What significance does the Every year in South Africa, as has probably been ability to perform penile transplants have for young the case for centuries, young men undergo circum- men in rural South Africa mutilated by traditional on September 29, 2021 by guest. Protected copyright. cisions as part of traditional rites of passage. circumcision rites? In what follows, we will first However, over the past few decades there has been present arguments in favour of promoting penile a reported rise of botched circumcisions leading to transplantation—including the use of public health a number of complications, including penile ampu- funding—as a response to cases of severe penile tation and death.1–3 Currently, it is estimated that injury in developed country settings. We will then roughly 250 traditional circumcisions lead to penile present counterarguments and reasons for scepti- amputation every year in South Africa4; for 2015, cism relative to the South African context. there were 57 deaths during the summer circumci- sion season and 44 deaths during the winter season,5 Promoting penile transplantation: reasons in and 27 initiates died during the summer of 2016.6 favour The South African government’s official position An argument in support of penile transplantation is one of deep concern. The Ministry of Health starts from a recognition of the extensive physical has made it mandatory for traditional surgeons and psychosocial suffering of men and boys with to register with the Department of Health. The severe genitourinary injuries. Damage to the genital Ministry of Co-operative Governance and Tradi- area can result in impairment of excretion, urinary tional Affairs has started to visit initiation schools incontinence, sexual dysfunction, hormonal imbal- and some arrests have been made.7 Despite these ance and infertility.13 Those who have sustained measures, traditional circumcisions by unqualified penile injuries also commonly suffer from feelings To cite: Moodley K, Rennie S. J Med Ethics 2018;44:86–90. practitioners, some leading to permanent injury and of emasculation, suicidality and post-traumatic death, continue unabated. stress disorder.14 While penile transplantation (like 86 Moodley K, Rennie S. J Med Ethics 2018;44:86–90. doi:10.1136/medethics-2016-103515 Clinical ethics J Med Ethics: first published as 10.1136/medethics-2016-103515 on 29 July 2017. Downloaded from its facial counterpart)15 is life-enhancing rather than life-saving, but who experience themselves as men with a functional penis. successful transplantations could nevertheless substantially The surgical procedures will be riskier and more complex than improve quality of life. In countries like the USA, three key bene- other cases, due to the transplant being preceded by extensive ficiary groups stand out: wounded military personnel, patients urethral reconstruction, reconstruction of the scrotum and with cancer, accident victims and transgender men. removal of the vagina. Arguments in favour of supporting and In the case of soldiers wounded in war, one could argue that promoting penis transplantation here are unlikely to be based the government has a clear obligation to support penile trans- on reciprocity or disability, but rather human rights to (sexual) plantation experimentation and successful interventions that health. The surgical alignment of genital anatomy with gender result. This would presumably fall under a government obliga- identity would have to be regarded not as cosmetic or as a form tion to provide compensation to those wounded during service of enhancement, but as fundamental to the well-being of trans- for their country. The special obligation would be based on reci- gender men. procity, that is, veterans with genitourinary injuries should be If penile transplantation proves safe and effective, no doubt it cared for in exchange for the sacrifices they made in the line will be gradually integrated within healthcare systems in devel- of duty. This obligation is stronger in regard to a conscription oped countries. No doubt, too, this will be accompanied by army where soldiers are coerced to fight and risk injury, but a ethical challenges, as some have already pointed out.21 22 These reciprocity-based obligation to provide healthcare also remains include: risks of the procedure, including physical risks such in force in the case of volunteer armies.16 Further, this kind of as cancer and death—as has been the case with the first facial obligation cannot be fulfilled by providing any sort of compen- transplant patient on life-long immunosuppression,23 as well as sation. As Nancy Jecker puts it: “We cannot give reparation for psychosocial risks; enhanced consent processes including infor- the loss of a leg by providing a soldier with a financial bonus, mation on risk of graft failure and need to take immunosup- better housing, or an expensive car. Reparation instead requires pressant drugs for life; need to explicitly inform potential organ that we provide benefits, such as prosthetic devices and physical donors and family members of donors of the possibility of genital therapy, designed to make the soldier whole, i.e., to restore the donation; responsible inclusion of first recipients in early penis soldier as much as possible to the state that existed prior to the transplant trials; provision of long-term postoperative psychoso- injury.”17 The special relationship of reciprocity yields at least cial support; and last but not least, increasing equitable access to a prima facie obligation on the part of government to provide what will initially be a prohibitively expensive intervention, like penile transplantation for injured soldiers who meet medical and other vascularised composite allotransplantation procedures.24