The patient, who also lost both of his legs when he stepped on an improvised explosive device in 2010, is one of more than 1,300 US soldiers to suffer genital injuries in Afghanistan and Iraq between 2001 and 2013. For many, the wounds take a brutal psychological toll. Returning from war, soldiers face a bleak future where they may never father biological children, and forming intimate relationships or experiencing sexual pleasure seems impossible. Making matters worse, some see discussing their injuries as taboo. W.P. Andrew Lee, the head of plastic and reconstructive surgery at Johns Hopkins School of Medicine, has termed the condition an "unspoken injury of war." In a recent article in the MIT Technology Review, the wounded veteran, who asked to be called by a pseudonym, "Ray," said that losing his legs hadn't particularly bothered him. He quickly learned to walk on prosthetic legs, and had no problem going out in public in a pair of shorts. But he largely kept his other injury a secret, telling no one but his family. Ray, who is now in his 30s, had the option of a phalloplasty, which involves using skin from other parts of the body to create an artificial penis and would require him to use a pump before sexual intercourse. But doctors at Johns Hopkins suggested something bolder - grafting a penis, scrotum and abdominal wall from a deceased donor, which would mean also transplanting the connected nerves, muscles and blood vessels.

Before Ray's operation in Baltimore in March 2018, four other medical teams had reported conducting successful penis transplants. One, which took place in China, was later reversed because the recipient and his wife found it only caused them more psychological distress. In nnother case, in South Africa, the recipient fathered a child just six months after the surgery. But the transplant performed on the wounded veteran was far more extensive because of the severity of his injuries. Talking to the Los Angeles Times, Curtis Cetrulo, a Massachusetts transplant surgeon who in 2016 performed the first penis transplant in the US, called it "a real quantum leap." The procedure was significantly more complicated than a liver or kidney transplant, which typically involves replacing only one type of tissue. A penis transplant, the Review reported, "is a chaotic amalgamation that entails stitching millimetres-wide blood vessels and nerves with minuscule sutures." The 14-hour surgery involved a team of roughly three dozen medical professionals. Loading Replay Replay video Play video Play video The groundbreaking operation also forced doctors to contend with complex ethical questions. If the donor's testes were transplanted during the procedure, the recipient potentially could have fathered a child with the other man's genetic material. Ultimately, after consulting with bioethicists, the Johns Hopkins team decided against doing so.

Loading The transplant comes with some long-term complications. The recipient will likely have to take anti-rejection drugs for the rest of his life, which could put him at risk for infections, kidney problems and certain types of cancers, the Times reported. The immunosuppressants that prevent his body from rejecting the transplant can weaken his overall immune system, which means that he has to wash his hands constantly. But Ray shrugged off those concerns, telling the Review that agreeing to the transplant was "one of the best decisions I ever made." The procedure hugely improved his quality of life, he said, and gave him renewed confidence to go out and meet new people. "This surgery was a way for me to overcome that little subconscious voice or whatever it was that would always keep me feeling different from everyone else," Ray told the Review. "It was one of those injuries that really stresses you out and you think, 'Why would I keep going?' I guess I always just kept this real hope that there's an answer out there." For now, the prohibitive cost of the procedure makes it out of reach for most wounded veterans. As The Washington Post's Eli Rosenberg reported last year, the transplant was not covered by insurance. The hospital covered most of the costs, estimated at $US300,000 to $US400,000 ($430,000 to $575,000).

Finding organ donors has also been a challenge, especially given the awkwardness of asking grieving families about their recently deceased relative's genitals. In Ray's case, doctors were intent on finding a donor who was young and healthy, had a similar skin tone and was only two hours from the hospital. It took five years before one came along. The family who made Ray's transplant possible requested to remain anonymous, but said in a statement through Johns Hopkins last year that they were "very proud that our loved one was able to help a young man that served his country." While only men with genital injuries have been recipients of penis transplants, there remains a possibility that eventually the same surgical technique could be used for sex reassignment surgery on transgender men. That prospect is still far in the future, however, with doctors at Johns Hopkins saying that they plan to first perfect the procedure on wounded veterans. The Washington Post