Doctors can now transplant penises. What does this mean for transgender men?

After three years without a functioning penis, Thomas Manning has one again—only it’s not his. A serious work accident in 2012 lead doctors to discover he had a rare, aggressive, and potentially fatal penile cancer, and in order to save the 64-year-old’s life, they were forced to remove most of Manning’s penis. After a lengthy surgery performed by staff volunteering their time at Massachusetts General Hospital in Boston, Manning just became the first American to receive what appears to be a successful penis transplant.

Prior to May 8th of this year, if you lived in this country and had your penis removed (accidentally or on purpose), your options were slim—the chances you’d be able to urinate standing up again or reproduce through sex seemed like a pipe dream. But the new experimental transplant procedure performed on Manning could change everything. And while the initial focus of the surgery has been on cancer patients and military veterans who have lost a penis due to traumatic injuries and are not able to have theirs repaired or reconstructed, the longterm impact could be felt by an entirely different population: transgender men.

For many men, feeling like a “real” man is inextricably linked with having a phallus. Most of the military vets who have suffered from what doctors call “genitourinary injuries”—1,367 in Iraq or Afghanistan from 2001 to 2013, according to the Department of Defense—are under 35 years old and report feeling completely stripped of their manhood. But for transgender men who were not born with a penis, having one could be the final step in their transformation into what it means to be physically male.

“As a trans guy, I’m thrilled to see the incredible strides being taken in the medical community,” Kade Clark, one of the founders of online transgender health resource My Trans Health, told me via email on Monday. “These transplant programs are of vital importance.”

But according to Dr. Dicken Ko, one of the team leaders in Manning’s transplant, he and his colleagues will not be offering a similar procedure to transgender men just yet. So what’s stopping them?

Well, a lot of things.

Dr. Loren Schechter is a Chicago-based surgeon who has been performing gender confirmation surgeries for 15 years. He’s heavily involved with the World Professional Organization for Transgender Health and was one of the authors of the organization’s 7th Edition of The Standards of Care—basically, he’s helping to write the book on the future of transgender medicine. That’s why it may be disappointing for some transgender men to hear that Schechter doesn’t see the penis implant as a viable option in the near future.

Schechter told me in a phone conversation on Monday that “there’s just not enough data yet to make an assessment” about what Manning’s transplant, and a similar successful 2014 procedure in South Africa, means for the community he serves. From his perspective, it’s a matter of waiting for more results from cancer and trauma patients, and providing the best options currently available for transgender men seeking a penis.

“I don’t think we’re ready for a transplant for a trans male because it would be a little bit different in terms of the tissue requirement,” Schechter explained. A transgender transplant recipient would require extensive urethral reconstruction, reconstruction of the scrotum, and removal of the vagina, on top of what’s involved with a non-transgender patient—attaching blood vessels, nerves, the urethra, and erectile tissue. “While it may be possible at some point, I think it certainly requires further study…I don’t think it’s quite yet ready for the transgender population.”

For now, Schechter’s focus remains on phalloplasty, the procedure he performs for transgender men who’d like to have some of the main functions of a biological penis. Before the procedure, the patient must have a hysterectomy and have the vagina removed. With the phalloplasty, the surgeon then lengthens the urethra, constructs a scrotum and creates the shape of the penis. Later, a urologist will put in a penile implant and erectile device.

One upside of the phalloplasty, as opposed to the transplant, is that the body won’t reject it: An attempted 2006 penis transplant in China failed because the man’s body rejected the transplant. Transplant recipients, like Manning and the 60 future experimental procedures that Johns Hopkins has permission to perform, will need to take anti-rejection, or immunosuppression, medication for the rest of their lives. But even with these treatments, there’s no guarantee the body will take to the transplant.

While the result of the phalloplasty may look like a real penis and allow certain functions like urinating standing up and penetrative intercourse, because recipients don’t have testicles, they can’t ejaculate—and therefore can’t use the phalloplasty for reproduction. The man who received the transplant in South Africa (after a botched circumcision) was reportedly able to reproduce, but until testicular implants are available, a penis implant for a transgender man would still be largely ornamental.

That’s not to say there are no alternatives in the works—albeit, the labor may not bear fruit for years, or even decades.

“For the transgender male, this is a new era giving options that allow a quality of life with a truer sense of gender and sexual identity on a psychosocial level,” Dima Elissa, CEO and founder of VisMed 3D, a Chicago-based company looking at the future of 3D-printed body parts, told me in an email. The 3D-printed anatomical parts that Elissa and her team are working on could be the more viable genital solution for transgender men in the shorter term.

“A transplant naturally has similar risks as any other organ transplant: rejection, infection, or transmitted diseases,” she told me. Not only that, but the “cost, time and talent resources needed to execute a complex penis transplant are steep, making it challenging for members of a disenfranchised community, or youth wanting to benefit from such a procedure to afford it. With 3D printing, I believe it will be years not decades, when we will realize and replicate anatomical parts at a much reduced cost, and a more tailored personal solution.”

Clearly she has a vested interest in promoting the promise of 3D printing, but Schecter did not rule out the possibility of the technology making its way to trans men before the transplants.

“The goal is to accelerate the use of 3D technology through proven standards, which don’t really exist today, that would make the production of body parts, penis or otherwise, a real and affordable possibility for all,” she said.

The challenge of transgender men receiving transplants may not just be anatomical. In order for a penis to be donated from a deceased male, the family must give special permission—it’s not enough to just say “organ donor” on your driver’s license.

At the “Intimacy After Injury” conference put on by the Bob Woodruff Foundation in 2014 to discuss the research for veteran penile transplants being conducted at Johns Hopkins University School of Medicine, Dr. Jeffrey Kahn, a bioethicist at the school, addressed whether the potential procedure would extend to transgender male candidates.

“Once this becomes public and there’s some sense that this is successful and a good therapy, there will be all sorts of questions about whether you will do it for gender reassignment,” Kahn reportedly said at the conference. “What do you say to the donor? A 23-year-old wounded in the line of duty has a very different sound than somebody who is seeking gender reassignment.”

While this sounds like a moral judgement, there’s no denying that even if doctors can find a way around the physiological hurdles, transgender people in the U.S. are currently at the center of a cultural war. Communities all over the country are battling over so-called “bathroom bills” regarding which public restrooms transgender people should be allowed to use, and with U.S. Attorney General Loretta Lynch declaring last week that “There is no room in our schools for discrimination of any kind, including discrimination against transgender students on the basis of their sex,” transgender issues have become as politicized as abortion and same-sex marriage.

But if an actual penis is what it will take to quiet transgender rights opponents’ standby argument that transgender men aren’t “real” men, then perhaps it’s time these opponents refocus their energies on raising money for transplant research.

Marisa Kabas is a Sex + Life reporter based in New York City. She loves baseball, bunnies and bagels.