Bonk (13 page)

By his own description, Hsu is something of a “queer bird.” He once inserted a Foley catheter into his own urethra, “just to feel what patients feel.” He self-medicates with acupuncture, sometimes walking around his clinic with a needle protruding from the side of his head. I have heard him use a translation of one of Chiang Kai-Shek’s names (“central uprightness”) to make a point about penile curvature.
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Today finds him wearing blue plastic wraparound sunglasses as he operates. He explains that this is because he suffered a seizure some years back, which left him sensitive to glare. His face is still partly paralyzed. This is noticeable only when he smiles, which he does with just one side of his face, in the manner of a dramatics-club mask.

The next step in the operation Dr. Hsu has named the “inside-out maneuver.” Though it is not so much “inside-out” as just “out.” Using his gloved fingers, Dr. Hsu pulls the man’s penis up and out of its skin, through the three-inch slit, by its midshaft. The protruding skinless portion is doubled over inchworm-style. (The skin at the head of the penis has been left attached.) I ask Dr. Hsu what this maneuver would feel like without anesthesia. His answer: “Like the way to treat a spy.”

For the next three hours, Dr. Hsu isolates the veins he is after, ties off the blood supply with sutures half again as fine as a strand of his hair, and then snips the veins away. He begins with the deep dorsal vein, the fattest. Bit by bit, he frees it from its moorings. As he works, he pulls the vein taut and holds it out away from the penis, like a robin pulling on a worm.

t
o understand why removing veins from a penis can help it stay erect, you need to understand how it gets that way in the first place. Erections are all about blood. Blood is the backbone of a stiff penis. Though it was a long time before anyone figured this out. In the Middle Ages, the erect male member was thought to be filled with pressurized air, a miniature skin blimp. It was Leonardo da Vinci who made the breakthrough. Cadavers available for anatomy study back then were typically those of executed murderers. Because they’d been hanged, the dead criminals had erections, and because Leonardo was dissecting them, he noticed that their penises were, in his very own words, “full of a large quantity of blood.”

The blood resides in a pair of cylindrical chambers—the corpora cavernosa—which lie side by side like a diver’s tanks. The chambers are filled with smooth-muscle erectile tissue, full of thousands of tiny hollow spaces, like a sponge. When the smooth-muscle tissue relaxes—which it does at the behest of an enzyme activated when the brain perceives a sexual stimulus—it expands. (Smooth muscle, unlike the striated muscles of your arms and legs, is operated by the autonomic nervous system; this is why men can’t simply will themselves erect—or unerect.) The relaxation of the erectile tissue allows blood to rush in and fill out the spongy hollows. Drugs like Viagra enhance the erection process by knocking out a substance nicknamed PDE5, which inhibits smooth-muscle relaxation. They inhibit the inhibitor. (Thus, they’re called PDE5 inhibitors.)

So now we have
achieved,
in the parlance of ED experts, an erection. It is a respectable achievement, but it is not enough. An erection, like a motorcycle or a lawn, must also be
maintained
. The blood that has filled the two erection chambers
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must be trapped there, otherwise the erection wilts. This is tricky, as the chambers are equipped with drainage veins along their surface. What keeps the blood from leaking out via these veins? The miracle of passive venous occlusion. (Stay with me here.) These drainage veins lie outside the erection chambers but inside the stiff outer membrane (called the tunica) that protects the erectile tissue. When the chambers expand with blood, they slam up against the tunica—which also expands, but not as much—and this pressure squeezes shut the veins caught in between. If all goes well, the blood stays trapped until a postorgasm chemical messenger tells the smooth-muscle tissue to stop relaxing.

When a man is impotent, very often it’s because the erectile tissue isn’t expanding as vigorously as it needs to squeeze shut the veins, and some of the blood seeps out. The result: “Like a tire! Flat!” Dr. Hsu relies on a lively repertoire of metaphors and analogies to explain the various functions and dysfunctions of the male genitalia. One particularly ambitious explanation, delivered earlier today, involved a Christmas tree and an elephant’s trunk. A diver was diving into a pool, and an aircraft was taking off. I felt like ducking under the table.

The most common explanation for ED is that the erectile tissue is simply getting old. “As we age, we lose elastic fibers, we lose smooth muscle, our tissues become more rigid,” explains Gerry Brock, a professor of urology at the University of Western Ontario who sits on the board of the
Journal of Andrology
. In an offshoot of aging called fibrosis, some of the muscle cells in the erectile chambers are gradually replaced by fibers of connective tissue that don’t have the elasticity that youthful smooth-muscle tissue has. When erectile tissue loses its stretch, it no longer expands fully and presses hard against the walls of the tunica. Thus, the veins aren’t squeezed shut, and blood leaks out. If you were to tie off and remove some of those veins, it would prevent—or at least slow—the leakage.

Because the largest of these drainage tubes, the dorsal vein, runs just under the skin along the top of the penis, it’s possible to effect a crude version of Hsu’s surgery by simply constricting the thing with an elasticized band or clamp. A surprising amount of this went on in the pre-Viagra era, long before the cock ring entered modern vernacular. There are so many patents on file for erector rings
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that they earn their own chapter in Hoag Levins’s diverting book
American Sex Machines: The Hidden History of Sex at the U.S. Patent Office
. Levins traces the ring’s evolution, from the handsome steel clamps of the circa 1900 metal-machining era clear through to a 1989 model with a hand-held remote, stopping along the way for a double-page spread of “Penile Ring Clamp Patents of the Post-WWII Years.” Though very few of the early patent titles contain the words
penile
or
erection
. Many employ the unhelpful rubric “Appliance for Assisting Anatomical Organs.” A 1900 patent is coyly titled “A Boon to Men.” Descriptions are similarly vague. One 1897 clamp is for use on male organs that “fail to perform their office,” leaving it unclear, at first glance, whether the device is intended to aid the organ or court-martial it.

Dr. Hsu was not the first surgeon to realize that limiting venous drainage could be a ticket to newfound potency. A Dr. Joe Wooten tied off a man’s dorsal vein with catgut in 1902. The high risk of infection—penicillin hadn’t yet been discovered—probably kept most of Wooten’s colleagues from taking up the scalpel, but it might also have been Wooten’s flummoxing conclusion in a
Texas Medical Journal
article from that year: “It has now been about four months since the operation, and the party reported to me…that he had had for the first time in nearly three years complete and satisfactory coitus and was now willing to stop trying.”

It was Hsu’s mentor and fellowship advisor Tom Lue,
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a professor of urological surgery at the University of California, San Francisco, who refined and championed the procedure in the late eighties. Alas, a long-term cure proved elusive—the success rate dropping in one study from 62 percent after three months to 31 percent after forty-five months. Why would this happen? The logical reason, say Brock and others, is that the body tends to compensate when someone or something destroys or blocks a vein. It grows new veins, and/or the remaining ones get bigger. Lue ultimately distanced himself from the procedure, and others followed suit.

Most everyone but Dr. Hsu. In a 2005 paper published in the
Journal of Andrology
, twenty-one of Hsu’s patients who underwent an early version of penile venous stripping surgery in 1986 were contacted for a follow-up. They filled out the same questionnaire they had filled out before the surgery: the International Index of Erectile Function (IIEF). Their mean preoperative score had been 10 (out of a possible 25), and their follow-up score was 19. Hsu saw no evidence that the penises had grown new veins.

“See the difference?” says Dr. Hsu, who is by now closing up the incision. “Already. Look how engorged.” The organ is visibly larger than it was when it walked in. Dr. Hsu says many of his patients report that their penis is mildly engorged all the time. He adds that many enjoy this, that it makes them feel more confident.

“So this guy. Now ready to make a home run. Like a baseball bat!”

Why would Dr. Hsu be able to cure so many men, when other competent urologists who undertake the procedure have seen, for the most part, only short-term benefits for their patients? “I can’t for the life of me answer that question,” says Gerry Brock. “I’ve seen Geng’s surgery, and he does a good job. He’s an honest guy, a great guy. But I have a hard time understanding, from a physiologic basis, how his results can be so distinctly different from those of others.” One possibility is that Taiwanese patients are more polite—or more timid—than Western patients. Perhaps Dr. Hsu’s patients are hesitant to report that the surgery’s effects are fading.

Then again, the possibility exists that no one who does this technique is as good at it as Dr. Hsu. Few urologists seem as lovingly immersed in the anatomy of the penis as Geng-Long Hsu. He publishes papers on the tunica, the deep dorsal vein, the distal ligament. He has a standing order for “leftovers” at the dissection lab of the anatomy department of Taiwan Adventist Hospital: “Please give all the penises to me.” Some years back, a lab tech threw away a box containing seventy-three penises that Dr. Hsu had collected from researchers and anatomy labs over the years and stored in a freezer. The memory pains him to this day.

The next time a cadaver becomes available, Dr. Hsu plans to make a detailed examination of the penile veins to see which ones account for what percentage of the drainage. He wants to know which are most critical to remove, and which make little difference, in terms of erectile function. Which begs the question, Can a dead man get an erection? He can. I have seen it myself, on a DVD of a previous research operation,
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which Dr. Hsu sent me before I came to Taiwan. Standing in for blood was saline, being pumped in at more or less the same rate that the heart pumps in blood during a normal erection.

One day this week, Dr. Hsu and I walked to a temple high on a hill behind his apartment complex. He said he regularly walks the two-mile road to the top (stopping to pick up litter along the way), and when he gets there, he jogs up and down the flights of steps to the temple door fifteen times. He explained that because he feels an obligation to help as many men as he can, he does not want poor health to cut short his life.

Geng-Long Hsu is a man on a mission. He feels he has a cure for ED and wants it to be used throughout the world, but is, well, impotent to make it happen. Until other surgeons are able to replicate his success rates, the procedure will likely remain shelved everywhere but in his clinic.

g
eng-Long Hsu is typical among modern urologists in his enthusiasm for the medical and surgical treatment of what had long been considered a psychological problem. In
The Rise of Viagra
, Meika Loe makes the case that urology pretty much stole impotence out from under psychology’s nose. (Loe, a sociology professor, earned my abiding respect by waitressing undercover at Hooters as part of a graduate research project in gender studies.) From the heyday of Freud all the way through the behavior therapy era of the fifties and sixties, the causes of impotence were thought to dwell in the psyche. Penises went limp from unresolved neuroses, deep-seated anxieties, distraction, obsession. If you wanted help, you turned to a shrink.

All that began to change in 1980. Loe cites as the turning point the publication of a contentious
JAMA
article entitled “Impotence Is Not All Psychogenic,” as well as the introduction of the vacuum pump and the penile implant, neither of which your therapist was likely to have on hand. The medicalization of impotence was underway.

Viagra sealed the deal. In 1998, Pfizer—with a cadre of media-savvy urologists in tow—launched a massive publicity campaign to announce an exciting new approach to impotence. Only it wasn’t called impotence anymore; it was “erectile dysfunction.” The stigma of the psychological had been removed. Impotence had morphed into a tidy biological problem treatable with a harmless pill. There wasn’t something wrong with the man, there was something wrong with the plumbing. Pfizer craftily introduced three categories of ED: mild, moderate, severe. Heck, it now seemed, everyone has it sometimes, to some degree, even Bob Dole. No need to be embarrassed. Urologists—most of them consultants for Pfizer—began appearing on talk shows, chatting about “ED” as casually as the last guest had chatted about his wheat-free cookbook.

In truth, plenty of cases of psychologically based impotence exist, and it’s relatively simple to sort out which ones they are. If a man is medically impotent—because his smooth-muscle tissue is damaged, say, or there’s a problem with his nerves—then he won’t get erections in his sleep. If the problem is purely psychological, he will. That is why diagnosis is sometimes done by checking for nighttime erections with gizmos like the RigiScan-Plus Rigidity Assessment System (with Self-Calibrating Penile Loops). Once upon a time, it was done by having a nurse watch your penis as you slept. The next generation of “nocturnal penile tumescence monitoring,” as it is officially known, took the form of a strip of old-fashioned perforated postage stamps slipped around the organ at bedtime and either torn or not torn during the night. The advantage of the “postage stamp tumescence test”
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was that it could be done in the privacy of one’s home and—thankfully or disappointingly—no longer involved anyone in a nurse’s uniform.