Mary Roach - Grunt

Jezior narrates with simple anatomical vocabulary, but I can’t always parse what I’m seeing in a way that matches the words. I can’t even see person in some of these images. I see butcher shop . Bandages protect the psyche, too; some of these soldiers never saw what I’m seeing. Jezior had a patient who didn’t see the injuries to his penis for three weeks. He clicks ahead to a slide from this man’s arrival at the hospital, a close-up of the weapon-target interaction, as they say in ballistics circles. How do you prepare a patient like this for the unveiling? “We used to try to sound optimistic,” Jezior says. “But when this guy finally saw it, he was like, ‘Oh, my God.’ It was another devastation, a second loss.” Now they’re blunter. “I’ll say, ‘It’s a severe injury. You’ll have to see it.’” If there’s going to be a surprise, let it be a positive one.

What can be done for these men? A lot. The art of phalloplasty—crafting a working penis from other parts of a patient’s body—has come a long way (thanks in no small part to the transgender community). To build a penis, Jezior begins with an arm. A rectangular flap of skin on the underside of the forearm is planed into two thinner layers. The inner one is rolled to form a urethra; the outer becomes the shaft. This tube within a tube is left in place, nourished by the arm’s blood supply. When what remains of the original organ heals, the new model is detached from the arm and reattached farther south.

Erectile tissue is the challenge. While spongiform erectile tissue exists in other parts of the male anatomy—along the urethra and in the sinus cavity (congestion being an erection of the nasal turbinates)—there isn’t much of it, and no one has tried to transplant it. And while there are eye banks and sperm banks and brain banks, no one is banking noses. So in place of the corpora cavernosa—the two parallel cylinders of erectile tissue—surgeons install a pair of inflatable silicone implants. (To get erect, the patient—or his friend—squeezes a little silicone bulb implanted in the scrotum that pumps saline from a receptacle in the bladder.) Hook up the tubes and let the nerves regrow, and in time orgasm and ejaculation are back on track.

Jezior continues with his slides. “This is a brigade commander. A sniper shot him across the top of the groin. Took out the middle part of his penis.” Losing the whole penis—and surviving the blast—is rare. Among Grade 3 and higher (the worst) cases of Dismounted Complex Blast Injury, 20 percent suffer damage to the penis, but only 4 percent lose everything.

You have to wonder: Was the sniper off his game, or was the shot intentional? Are there some who aim for the crotch? Jezior thinks that there are. He’s heard stories from World War II. Dale C. Smith, a professor of military medicine and history at the nearby Uniformed Services University of the Health Sciences (USUHS), has also heard those stories, but knows of no evidence to back them up. Smith points out that the secondary goal of a sniper is to sow fear. In that sense, the crotch is an effective shot. However, Smith said in an email, it is also a risky shot, in that a sniper is looking for a “high percentage return” on the tactical effort and risk of getting into position. The pelvis is not considered a “kill shot.”

Another gunshot case follows, this one through the scrotum and rectum. “This is half his anus here. Here’s his scrotum up here. This is the insides of the testes. ” The horrid Cubism of modern warfare. The reconstruction in this case was done by Rob Dean, Walter Reed’s director of andrology. The andrologist’s beat is reproduction, not excretion: testes and scrotums, hormones and fertility. Dean is joining Jezior and me in a few minutes for lunch, in a sandwich place downstairs. The two served four months together in Iraq.

Jezior closes the photo file and leads me out through the urology waiting area, toward the stairs. “Patient Jackson?” calls a receptionist. As though “patient” were the man’s rank. I guess in a sense it is. He may be a major or a colonel and the man across from him may be a private, but here everyone’s a patient. In a culture defined by rank and hierarchy, Walter Reed can seem—to an outsider, anyway—endearingly egalitarian.

Dean is already in the line to order sandwiches. He, too, is extremely busy, which, in the grand and ghastly scheme of war, is a good thing. It means more men are surviving bigger explosions. If funding and research lag behind, it’s partly because of the general cultural discomfort that surrounds all things sexual—including the poor organs themselves. On a much simpler level, Jezior says, it’s a case of out of sight, out of mind. “When some celebrity comes to Walter Reed and visits you in your room…”

Dean jumps in. They finish each other’s thoughts like an old married couple. “…Right, the President doesn’t pull down the sheet and go…”

“…‘That’s terrible, look at that. His penis is gone. Let’s get some money flowing for that.’”

Walter Reed Medical Center pays for phalloplasty, although there was initially some resistance. (The implants alone cost about $10,000.) Erections were thought of as “icing on the cake,” Dean says. “They’d say, ‘Oh, people don’t really need that.’ I’m like, ‘Well, the guy with the amputated legs doesn’t need prostheses. Put him in a wheelchair!’ And they’d go, ‘Oh, no! It’s important that they walk!’ I’d say, ‘Okay, well, most people think it’s important to have sex.’ Can I get a Caprese sandwich and a Coke Zero?”

Dean has expressive hands and eyes and prominent arching eyebrows, and when he talks and laughs, the whole lot of them join the fun. In this business, humor and candor are a therapy on their own. Dean has been known to put a ruler to a discouraged patient’s penis and hoot, “You’ve got six inches! How much more do you need?”

Don’t be fooled by the jolly tone. Dean is a bulldog for his patients. He was a force behind the push to get the VA to cover in vitro fertilization for soldiers whose injuries left them sterile. He gives talks to USUHS students about sexual health issues among injured service members and answers questions at veterans support groups. He helped colleague Christine DesLauriers found the Walter Reed Sexual Health and Intimacy Workgroup: a dozen-plus local medical providers and social workers who gather periodically to plot strategy and share resources. For instance: Sex and Intimacy for Wounded Veterans , a book by DC-area occupational therapists Kathryn Ellis and Caitlin Dennison. These two do not flinch. Here are sexual positioning tips for triple amputees. Ways to modify a vibrator for a patient who’s lost both arms below the elbow. I second the sentiments of the title page endorsement (if not the precise phrasing): “We should put a copy of this manual in the hands of every patient, spouse, and medical provider…”

Especially the medical providers. “It’s amazing,” says DesLauriers, “how many of them are frightened to bring it up.” She told me about a Marine she’d worked with who said to her, “Christine, I’ve had thirty-six surgeries on my penis, I’ve had my shaft completely reconstructed, and not one damn person told me how I’m going to go home and use the thing on my wife.”

Few talk to the wives, either. “It’s depressing watching some of them interact,” says Jezior. “In your mind you’re going, ‘She’s going to leave him.’” When I asked DesLauriers what the divorce rate is, she said, “Divorce rate? How about suicide rate. And what a shame to lose them after they’ve made it back. We keep them alive, but we don’t teach them how to live.” Walter Reed has no full-time sex educators or sex therapists on its payroll. The Internal Medicine Clinic offers appointments in “sexual health and intimacy,” but only one nurse is set up to handle them.