At this point in my life I can say with confidence that I have seen a lot of penises. I have seen penises that are circumcised and uncircumcised. I have seen penises that are long, that are short, that are wide, that are narrow. I have seen penises with weird things growing off of them, with weird holes cut into them, that have been broken into a few different pieces, that have swollen up to three times their normal size. I have seen penises without any skin on them (protip: do not google image search “Fournier’s Gangrene”), penises turning green or black or purple, penises oozing pus. I have seen them cut open on the operating table, with insides splayed out like Prometheus on the rock.
In a similar vein, I have seen a lot of vaginas. Vaginas, being internal organs, are not as readily exhibited as penises, and require a great deal more assistance to display. No matter how good of a lover you think you are, I can guarantee you haven’t really seen a vagina until you’ve seen it in the OR. There are long labia, and short labia, and large clitorises, and small clitorises, and people with lots of hair and people with little hair, but once you pull the folds aside with a special surgical instrument called a Lone Star retractor (another thing you do not want to Google Image search), they all look mostly the same. There’s a lot of mucosal tissue, and eventually you get to a cervix. There’s not much modesty when you’re in the OR, legs in stirrups, draped in blue towels covering everything but your genitals, everything swabbed with iodine, two to three big surgical lights as bright as spotlights pointed directly at your crotch. Your face is totally covered. Your genitals are the star.
Americans feel weird about genitals. Are they supposed to have hair? How much? What color? Is it supposed to go up the shaft, or down into the labia minora? What are they supposed to look like? How big is big enough? How much skin is too much skin? And even if you reach a point in life where you feel comfortable with your genitals, there’s always some hesitancy about showing them to someone else, because you never know if that person might think something looks weird. This is America, and we’re weird about our junk. Usually genital aesthetics are confined to changing style or amount of hair, but more extreme options—from external pumps, implantable rods, or surgical nip & tuck of loose skin—still appear on side bars of all disreputable websites. Devices or surgeries to cosmetically alter the vagina are less common. While labioplasties (surgery to decrease the size of the labia majora or minora) are performed as surgical alterations to the vagina, most genital-modifying devices and surgeries are usually marketed to one specific group: people who want bigger penises.
The first penis surgery I ever saw was an implantable penile prosthesis (IPP, in surgical jargon). There are several different types of penile prostheses, but the two most common flavors are a pump or a malleable. The ‘pump’ is composed of two cylinders sewn into the shaft of the penis, connected by a suction line to a reservoir tucked away in the abdomen. This suction line is activated by means of a squeezeable plastic bulb (the pump itself), which is tucked down in the scrotal sack. A malleable is a lot simpler—just two malleable rods which get inserted. Bend down for everyday life, bend up for action.
The malleable kind
As a student, penis surgery was the first surgery I got really excited about. This sounds weird. Most urologic surgeries are done laproscopically, which means we cut holes in your belly, pump it full of air, and then stick a camera and surgical instruments inside and do the entire surgery on camera, video-game style. Laproscopic surgeries are good for patients—smaller incisions take less time to heal, require less pain medication, and usually have shorter hospital stays than open surgeries. However, when you’re a bright-eyed med student, sitting in the back of the operating room watching a screen for four hours does not feel like doing surgery. If you’re a student, you want open cases. Open cases are what laypeople picture when you think of surgery: someone is lying on a table with part of their body cut open, and surgeons standing around them with surgical tools, operating. If you’re a med student, you want to see real surgery, and that means open surgery. You want to be in there, holding back organs, watching blood spurt out of somebody’s abdomen and cauterizing the bleeders. I’m not saying that I want anyone to bleed profusely in the operating room, but if someone were to start spewing blood, I’ll be circling like a hawk with talons full of gauze. After watching a few days of mostly laproscopic surgeries, falling asleep in a darkened OR while people more important than me (trained surgeons) manipulated instruments inside someone else’s peritoneum, I wanted to get my hands dirty. So I signed up for the IPP.
If you’re thinking about getting a penis implant, here are some things you should know. They’re done by urologists. They are not a first-line therapy for erectile dysfunction; we only use them as a last resort, after Viagra, injections, and all other treatments fail. We more frequently use them in people who have traumatic injuries, or prostate cancer, or severe priapism (if you have an erection lasting six days, we might be seeing you). They only allow you to achieve an erection; they do not affect ejaculation or orgasm. They don’t make your penis larger; we specifically use an implant that will match the size of the organ you already have. They take around two hours, maybe as long as four or five. The surgery is covered by Medicare, as long as you have documented erectile dysfunction. You will lose a fair amount of blood—not as much as a car wreck with a long bone fracture, but more than a kidney transplant. Penises and scrotums have a lot of blood vessels.
If you’re thinking of DIYing some penis implants (never never never do this), the first thing you do is arrange the penis for surgery. To use a Lone Star retractor, you put about five or six hooks through the glans and the scrotal sac and pin them into place so you’re looking at the underside of the penis. You make a two or three inch incision in the scrotum, and then pull that incision open so you have a hole you can almost fit your hand through. You reach up through the inguinal ring (that’s the space where testicles descend out of the abdomen and into the scrotal sac), and you have to dissect away enough fascia (essentially the packing peanuts of your body, all the stuff between your organs) to make a pouch to hold the reservoir.
Then comes the fun part—you have to make space in the penis for the implants. To do this you take a series of dilators, metal rods of successively larger diameter, and shove them up each side of the shaft. Make sure you don’t hit the urethra, lest your quarry forfeit the cherished ability to urinate. To really get it in there, you have to hold the shaft up by the glans and shove as hard as you can to get the big metal rod all the way to the tip. Then repeat, only with another metal dilator which is larger around. After the hole in the shaft is large enough, you’ll have to put the implants up through the shaft. The implants also have to be anchored to something, so you take those same metal dilators and make two more holes, going through the scrotum down to the pelvic bone. Push the dilators to make sure they’re all the way down to pubic bone. Listen for the thump.
Then you begin to implant the prosthesis itself. To get the prosthesis up in the shaft, a threaded needle is attached to the top of the implant. Stick that needle up the shaft until it comes out of the glans, then pull on the thread to situate the inflatable cylinder all the way up the shaft, secured just under the glans. Insert the other end of the implant down next to the pubic bone, to anchor it. Repeat, inserting the shaft implant and bone anchor, for the other side. Then you insert the reservoir (which is just a plastic balloon filled with about a half cup of fluid) into that space you made in the abdomen. Attached to the implants is a little pump, which has a button in the middle. You take the tubing from the reservoir and hook it up to the pump, then hook up the tubing going from the pump to the implants.
To make sure it works, give it a squeeze. (This was the part my all-male operating staff made me do.) When you squeeze the pump, the inflatable cylinders fill with fluid, and up it goes. Push the button, and the fluid drains out of the cylinders back into the reservoir. Down it goes. In the operating room, full of male staff, they made jokes about the device. “Look, you’ve got his attention,” they said, when the cylinders were full, and laughed. “Pull harder, it won’t bite,” they said, when I didn’t hold the shaft tightly enough during the catheter insertion. “It’s like a llama. It’ll just spit a little.” They laughed. I laughed, too. “His wife will be happier now,” our scrub nurse said.
As someone who appreciates a little misandry now and then, watching penis implants is grossly satisfying. Cut open the scrotum! Yeah! Shove big metal rods up the shaft! Oooh, that’s a lot of blood. But I was also upset. The first patient I saw get an IPP had lost his prostate to cancer, and was unable to ejaculate or achieve erection. Later in the week, I watched my second IPP—this time for a young man who took too much Viagra and got a blood clot in his superficial penile veins. The clot turned into scar, which would permanently disable his ability to achieve erection on his own, without the implant. In both cases insurance covered the surgeries.
Implantable penile prostheses are not just covered by insurance in case of disease or trauma, like the patients above. Medicare covers implantable devices for anyone who had documented history of erectile dysfunction. I live in a country where insurance will cover penis pumps if you can’t get it up, but not my birth control. The pleasure of middle aged men who can’t achieve an erection on their own is more important than my right as a woman to control hormones in my own body.
Is it right? Is it right that insurance (and not just private insurance, but Medicare, government-funded insurance) will pay for penis surgery? Well, it’s okay for the first patient, because he had cancer. Cancer is bad. It took away his sex life. We’re just fixing the consequences of cancer. He’s a nice man, with a beautiful wife, who was always kind, and courteous, and his bones stuck out from his chemotherapy. But what about the guy who drunkenly took too much Viagra and got a blood clot in his penis? Unlike our cancer patient, he was terrible to us—rude to the nurses, mean to the doctors, always asking for increased pain medication. He kept cases of Mountain Dew in his room, and had already, before age 45, lost his top teeth. Does that change the way you think about his right to health care? What about the man the next week, who was going too hard from behind and ripped his corpus cavernosum? Is it right that most insurance will pay for a surgery so that he can engage in intercourse again, but won’t cover Plan B if I drunkenly use a condom wrong?
Maybe the comparison isn’t fair. But being able to generate an erection for sex is so important that it is covered by most insurance companies, and there is little controversy. It’s also complicated to parse out what is and isn’t covered—all private insurance is a little different, and government-funded Medicare part D (the part that pays for prescriptions) recently cut funding for all ED drugs, but Medicare will still pay for an implantable penile prosthesis for a patient with the same diagnosis. Earlier this year, when Hobby Lobby made a big stink about covering Plan B and IUDs, opponents were quick to point out that they still covered Viagra and vasectomies. But there was no Supreme Court case where these were challenged. There are no Christians lobbying Congress to cut Medicare funding for IPPs so older white men can get it up. There is little or no public controversy about who’s paying for men to have sex. No lobby group is trying to control male sexuality. When it comes to an IPP, no one is asking: “Well, did he have cancer? Or did he do this to himself?” because the male right to an erection is unquestioned. There is no other medical reason to get an IPP—it doesn’t, for example, stabilize mood swings, decrease the incidence of ovarian cysts, help prevent endometrial overgrowth, or even treat acne, all of which oral contraception pills do. Why does the controversy only come up when women and sex are involved?
The patient did well. The next day, in his hospital room, his wife thanked us as we signed his discharge paperwork. Later, the surgeon in charge of the case awkwardly admitted that he should be more professional, and that it was a bad idea to make lewd jokes in front of med students. He gave me a good grade. In the next case, instead of just holding retraction and mopping up blood with gauze, they let me attach the connectors to the pump—it sounds like a small gesture, but with an expensive surgical implantable device which requires correct connections to work properly, is way more important than wiping up the dirty spots. My urology rotation finished uneventfully. Every resident and attending I met asked me the same question: “What do you want to do?” And each time, I gave the same answer—gynecology. “It’s very similar,” they said. Unspoken but true, which I thought every time, was but urologists make more money. Eventually my sex drive came back, but I don’t know if I’ll ever be able to see a penis without thinking of what it looks like cut open. And I’ll never see penis enhancement spam the same way again.
I did not expect this to go where it did, but it was SO DAMN GOOD.
As a non-penis haver, I was intrigued, but read the entire thing with my legs crossed and kind of wincing.
This is amazing, THANK YOU!
Lovely article, thankyou.
I kind of wish we did know where it was going earlier, because I’ve always thought, when people talk about insurance covering penis pumps, they meant those corny plastic devices from Austin Powers. It takes so long to get to the crux, that I feel like a ton of people will bail out of the article, and miss that crucial paragraph. I come from a medical family, so I like this stuff, but I’m a lot less squeamish than most. Dang, this comment has a ton of parenthetical clauses.
To be clear– I did enjoy the post.
This was great, even though I had to skim the surgery descriptions (being a delicate flower like that). I wonder why urology is “urinary tract + male genitals” and gynecology is “female genitals” — like why aren’t those three things rather than two? (I guess I know the answer, in general terms, but I wonder about the specific medical history of the development of those specializations.)
Urology covers the urinary tract from the kidneys to where the urine exists the body. In penis-havers, that’s at the tip of the penis; in people without penises, that’s right above the vaginal introitus.
So that’s why urology covers XY genitalia more than XX. There’s just more XY genitalia involved with the urinary tract. I guess we also cover the scrotum and testicles, which are of course analogous to the labia minors and ovaries and have nothing to do with the urinary tract. I think that’s because a) they’re right there! not tucked away like XX gonads, and b) they’d be an orphan organ otherwise. I suspect there isn’t a separate “andro” speciality because of the way the male body has always been seen as the default. Teh ladiez are wereeiiiiiiirrrddd and need their own speciality. Dudes are normal.
That said, I’m a urology NP and I do a LOT of XX-specific work. Incontinence? Bladder pain? Those are majority-XX-haver concerns and they are my bread and butter.
I read the first page sort of hiding my eyes behind my fingers, looking at the words from out of the corners of my eyes, and also clenching very hard. Re: the second page, if you look at most American institutions from a broader perspective, they’re all about retaining power (whether for men, the rich, the white, or all three), so… that’s my standard answer to almost everything having to do with inequality and religion and politics.
Every word of this is perfect.
<3 anatomical misandry.
This should be required reading for All Men.
…D’you know, it genuinely never occurred to me that implants existed outside of phalloplasty? This was actually really interesting for me. (And yes, I totally googled all those things. I did not know you could stretch genitals that far. Bodies are AMAZING.)
That anecdote about the jokes they were making really bothers me. I think because I’m dumb enough to buy into the bullshit arguments of men, so when I do realize how lame it is, I’m like, shit, man, that’s messed up, did everyone else already know how shitty that is? Because I think guys are often making excuses like, Oh, it’s just a jovial, fun, lewd environment, we can’t have a little fun, and we won’t even know when we cross the line because we are so busy making hilarious important jokes, and then how it is OUR FAULT if we didn’t REALIZE it was offensive, what if we get punished for something EVERYONE was doing and seemed okay with?!
And like, somehow that seems reasonable to us (or maybe just me? hopefully?), like oh man, yeah, I want everyone to just be able to joke around to a reasonable degree, I’m not a killjoy harpy. But the truth is, it’s obvious when you are being inappropriate and it never improves the work environment, and we never lose anything by discouraging those types of jokes. Like, even in this anecdote, you can tell it’s harmless, not minded by anyone, but…still. Why do we always have to be okay with it?
Like, something like that happened to me. I was showing a group of guys at work how to do maintenance/repair work on a Very Important and Sensitive Science Machine, and I was, well, literally polishing a rod, and they made the obvious joke, and I laughed and was a little embarrassed but kind of pleased I got it and played along…and I’ve never resented it or been mad about it or even thought about it much, but now I just feel like…fuck them and fuck that.
It bothered me as well, but also from the perspective of the patient. I hate the idea of being in such a vulnerable position and having people look at my body with anything other than professionalism and compassion.
“…the male right to an erection is unquestioned”
YUP. Meanwhile, women who want birth control are big ol’ slutty sluts.
(Why yes, I do rant and rave when ads for ED medications come on TV!)
But ED medication is about proving to your wife that you love her! The doctors just want to help you nurture and fulfill your wife, the most important person in your whole world.
I googled the things you said not to google.
D:
D:
D:
grrrrrr the complete hypocrisy of Medicare (beautifully elucidated, or graphically so, here) is making me angry! WTF.
Erections are more important than ensuring all children are wanted children, through funded birth control?
I feel lucky to live in the UK where even a Tory govt wouldnt dream of stopping free contraception.
But back to the grrrrrrr: the US rules make me angry, there should totally be a case about this hypocrisy, Supreme Court style.
I enjoyed this, both the gory surgical stuff and the political angle. Believe me, next birth control coverage debate I get into, the 45-year-old Mountain Dew guy’s unquestioned coverage is getting brought up. Also, when I was an undergrad in gross anatomy, one of the cadaver donors had an implanted penis pump. It was pretty wild — but I had no idea that the surgery to get it in there required so much … elbow grease. Ouch.
I did both image searches, and can report that the Fournier’s Gangrene one, while gory and gross, caused me not an iota of disturbance. Meanwhile, the Lone Star retractor, an important medical aid rather than any sort of disease or illness, flooded me with visceral terror, and caused me to both shriek and curl my legs up in my office chair to protect myself in case it leapt off the screen at me.
Learn from my experiences!
I totally read this as being by Hamilton Nolan. I was very confused.
I just really love all of this. Cheers to science, cheers to challenging sexism and hypocrisy (and baby cheers to the doctor apologizing to you, even if only out of fear of repercussions of his assholery), cheers all over the place.
I have seen them cut open on the operating table like the evening spread out against the sky.
Also: I read this while eating oatmeal. Next, I have a package of bite-size salami nuggets. Just wanted to share.
“Why shouldn’t insurance companies be mandated to cover birth control?”
“Because fertility isn’t a disease to be medicated! Women should be able to have children at any time! It’s a natural state!”
“So when old guys can’t get boners anymore, that’s not nature telling them that their days of horndoggery are over?”
“No, because PENIS PENIS PENIS MY PENIS IS BETTER THAN YOUR BAGINA NEENER NEENER NEENER.”
Viagra should only be covered by insurance if a man under a certain age signs a contract swearing that it will be used solely in the context of married hetero sex for the purposes of reproduction.
Subject to in-person audit 24/7 by any woman who has ever been denied coverage for reproductive/contraceptive/etc. health care.
Excellent analysis of the insurability of the penis above the vagina. And by that I mean RAGE RAGE RAGE RAGE RAGE.
my favorite part was when it got sociopolitical, both because that section was excellent and important, and also because it gave me something to think about besides getting a curtain rod in my penis
/sideshow bob noise
yes.
all of the above.
and all the commentary.
Thank you for writing this.
I really appreciated the use of words in this.
That’s a bad description of what I mean. But the medical terms are there and correct, but not completely inaccessible. You talk about “vaginas” then describe the clitoris and labia, then point out that they are not the same thing as a vagina, without explicitly saying those words. It’s a little thing to latch onto (I really enjoyed reading the entire essay! and also learning more about male genitalia), but the words you chose – I really appreciated that.
My one (and only) caveat to all of this is that Viagra isn’t always covered. My husband and I were practically still newlyweds when my husband started taking the anti-depressants needed for his anxiety and depression, and the SSRIs worked the best. They also caused sexual dysfunction as a side effect, enough that it seriously cramped our sex life (also, the teeny little fact that we were trying to start a family). His doctor prescribed Viagra, but our insurance (a well known, national insurer) refused coverage. We paid $200 for ten tablets.
We spent the next few years figuring out dietary/supplemental alternatives, but it’s always frustrated me that the system hung him out to dry.
This was so amazing. Agreed with all the above commenters about your wonderful use of language, perfect anecdotes, and beautiful change of mood on the second page. What a perfect article. Thank you.
i have a sadistic streak and i loves me some CBT but i got to “..listen for the thump…” and now i’m all D: D: D: D: D: D: D: at my desk.
i… uummmmm… maybe later… *sips tea*
Came for the bloody surgical details, stayed for the fascinating perspective on gender politics. Awesome piece.
(sorry for the late comment, but I had to wait until I got home from work to read this particular article…)
I’m a nursing student and I got to watch two laparoscopic robotic vaginal mesh surgeries last year (both for prolapsed, one post-hysterectomy and one included a hysterectomy). Everyone in the room but the anesthesiologist, one surgical tech, and a rep for the uterus manipulation device, was female. I counted and there were thirteen people in the room. Someone else in my mostly-female class mentioned how nice it was to see a room full of women in charge like that.
I saw a caesarean delivery this semester and could hardly see anything because there were so many people in the room; in the laparoscopic surgeries I could see everything on screen and it was easy to forget this was a real human body- which helped me to really see exactly how dehumanizing surgery can be, and develop empathy for what my patients had gone through. I am truly grateful for the experience.
I fainted.
There is little or no public controversy about who’s paying for men to have sex. No lobby group is trying to control male sexuality. When it comes to an IPP, no one is asking: “Well, did he have cancer? Or did he do this to himself?” because the male right to an erection is unquestioned.
To my knowledge, this is really really not true. Older men are getting penis pumps through Medicare as a last resort, because they *can’t* get Viagra or Cialis through Medicare. Because Medicare Part D explicitly excludes erectile dysfunction drugs from coverage. Due to a 2005 amendment to Part D, which was sponsored and championed by…Republicans. The lead sponsor complained about the unfairness of “taxing those young people[…]to subsidize Grandpa’s recreational sex.” Yet Medicare does cover treatments for female sexual dysfunction–mostly vaginal estrogen–and to my knowledge, Republicans haven’t publicly targeted *that*.
As knopetastic pointed out above, many private providers don’t cover erectile dysfunction drugs either. Mine doesn’t, nor does it cover penis pumps or, basically, anything to do with men’s–or women’s–sexual dysfunction. Nor does it cover vasectomies or tubal ligation.
And now we have the ACA’s contraceptive mandate, which does not cover vasectomies or any other sort of male contraception at all.
So, yes, Republican lawmakers and conservative lobby groups are absolutely trying to control men’s sexuality. They’re trying to control *everybody’s* sexuality. And Democratic lawmakers are generally willing to push back against this in the arena of women’s sexual health, but not men’s.
Should contraceptive coverage for women be higher priority than ED coverage for men? Yes, absolutely. But at the national level, it’s been that way for decades now. Women still don’t have sufficient access to contraception, but that’s not because the government is busy doing an awesome job of helping old men get their boners back.
(That’s not to say that you can’t find private insurers and lobbyist groups that aren’t way phallocentric on sexual health, of course. The conservative Catholic lobbies want ED treatments but not contraception because Babies. And Hobby Lobby covers both vasectomies and Viagra but not female contraception because…well, because they hate women having control over their bodies, I guess? There’s not really an alternative interpretation of that policy.)