The next patient is a young man, looking down nervously at his traditional Burmese lungi; his gelled hair obscuring his face. He hands over his notes, glancing round at the crowd of people in the operating room, wondering, like us, who they all are. We register his limp and various differentials flick through our overheated heads.
He is told to undress which he does so sheepishly before jumping on the table, which is still wet from wiping off the blood of the previous patient.
Another instruction is barked in Burmese and he reluctantly takes off his underwear too, desperately pulling at his shirt to try and cover himself. Everyone gathers round and gasps. Some people get out their phones and take pictures. The patient lies back on the table, defeated.
Eight days ago he injected his penis with coconut oil, as a self-inflicted ‘enhancement’ process. We are shocked. Yet the local medics giggle at our wide eyes and open mouths. This is very common here apparently, ‘like malaria’. His village was visited by a mysterious man, and he was assured, over several glasses of homemade whisky, that he could improve his marital relations for a fee of ‘just’ 500 Thai Baht (around £10) and a small injection.
He has certainly achieved enlargement to some extent we think, looking on at the swollen, red, oozing mass before us. He cries out as the first local anaesthetic goes in; there is no other anaesthesia available. To start the procedure, incisions are made around the base, shaft, and finally tip of the foreskin, to facilitate removal of the skin. After 10 days of iodine dressings to the bare muscle, a skin graft from his upper thigh will replace the original skin that was removed. This man will apparently have a ‘fully functioning’ penis again within 6 months, which seems hard to believe at the moment. He is clearly still in pain despite the anaesthetic.
An hour later he sits up, looking drained. The surgeons are still wiping the dried blood that grips the hair on his thighs, sticking him to the table where it has dripped down. The crowd of spectators (all trainee medics we later learn) move aside. He looks exhausted as he stumbles out into the rain, his limp even worse, clutching his sweat, blood, and tear-stained lungi; he had not tied it properly in his haste to leave. It will be a while before he can wear trousers again.
The clinic’s attempts at deterring locals from ‘Karen Viagra’ include a fine to the patient of 1000 Thai Baht (£20) and literature in several local languages complete with gruesome photos. Stigma and embarrassment maintain ignorance however, and only two patients (in the last 10 years) have approached the surgeon for advice regarding having the procedure, and promptly changed their minds. They often don’t hear the horror stories until it is too late, as complications can take up to 5 years to develop.
By the end of our 8 weeks at Mae Tao we think back with fond nostalgia about the horror experienced on that first day. By now ‘penis operations’ are a bi-weekly occurrence, and no longer a shock, almost equivalent to another case of a common condition, like peptic ulcers or dengue fever. But it should still be shocking. This is a huge, completely avoidable public health problem but despite the clinic’s best efforts, the message is not getting through to the local people. We certainly have a new differential to add to our list next time we see a patient with a limp.
The Mae Tao Clinic
Mae Tao clinic is an exceptional healthcare facility located on the border of Northwest Thailand and the Karen state of Burma. Karen refugees and migrant workers come to the clinic on the Thai border to receive free health care. The clinic also trains medics, some of whom remain at the clinic, while others return to their villages in Burma to work as healthcare professionals.
- © British Journal of General Practice 2013