December 15, 2016
Seema Yasmin | Dallas News
Five months after his 32nd birthday, Aaron Causey stepped on a bomb. The newlywed from Alabama was on his second overseas Army deployment, working as an explosives technician in Afghanistan. That morning in 2011, Aaron was on the hunt, peering inside tunnels for improvised explosive devices.
Before he saw the small bundle of plastic and copper wires, he had stepped on it. The blast ripped off his legs and traveled through his groin. One testicle was destroyed, only two-thirds of the other remained.
Four days later in a German hospital, Kat Causey walked into her husband’s hospital room. "Don’t throw up. Don’t throw up," she told herself. The words repeated in her head as she stared at Aaron. How can he still be alive, she wondered. Her husband was in pieces. Surely their plans for having a baby were shattered.
The blast from an IED hits from below. It can hollow out a soldier’s pelvis, shredding the shaft of the penis, obliterating testicles and destroying the bladder and the tubes that carry urine and sperm.
Fighting on the front lines in Afghanistan means hopping out of trucks to walk on foot in terrain too rugged for military vehicles. Experts say service members are more vulnerable to IED blasts than ever before.
That could explain why more than 1,400 U.S. troops suffered injuries to the penis, testicles or bladder from 2001 to 2013 while serving in Afghanistan and Iraq. Their average age was 24. Experts describe the rise of genital injuries from combat as “unprecedented.”
Blasts powerful enough to amputate legs and genitalia used to mean almost certain death. These days, advanced medical care in the field and quick evacuation to specialist trauma centers means soldiers who suffer severe blast injuries have a better chance of surviving.
Surviving means repeat surgeries, re-imagining relationships and wondering if you’ll ever enjoy sex or have children. And while there are more conversations about brain injuries and post-traumatic stress disorder in troops, experts and families say there’s not enough discussion about the men who return home with the most taboo of injuries.
Counting the injured
At his office in the San Antonio Military Medical Center, Army Maj. Steven Hudak tracks the number of wounded military service members. When he’s not treating the injured — Dr. Hudak is a reconstructive urologist — he studies the Department of Defense Trauma Registry to learn what kinds of injuries are afflicting military members across the services.
In a recent paper published in the Journal of Urology, Hudak and colleagues wrote that there are more U.S. service members surviving with genitourinary injuries than ever before in the history of war. They described the different types of genital trauma suffered by young military men and said the range of trauma to the penis and testicles is varied.
“There’s no characteristic pattern among the men who have penile injuries. Really every service member that I’ve treated for a penile injury had a different kind of injury.” More than 1,400 men suffered injuries to the genitals while serving in Iraq and Afghanistan over a 12-year period. Seventy-five men died from their wounds and were excluded from the analysis.
Hudak found that of 1,367 wounded service members who survived, 3 out of 4 had injuries to the penis, scrotum or testicles. A third had injuries that were classified as severe and 84 suffered severe injuries to the penis.
In a separate study of soldiers injured in Operations Enduring Freedom and Iraqi Freedom between 2001 and 2011, Hudak's team found 501 men suffered genital and urinary system injuries and that 1 in 5 of them had an injury to the penis.
Overall, the greatest number of severe injuries were among those who had testicular damage, says Hudak. “That obviously has a different set of ramifications with regards to long-term fertility potential.”
Aaron Causey with his daughter Alexandra Jayne, or "A.J.," at home just outside of Birmingham, Ala. Causey suffered genital injuries along with amputation of both legs and some fingers and a traumatic brain injury while on active duty in the Army in Afghanistan in 2011. (For the Dallas Morning News/Photo by Bernard Troncale)
Dreaming of a family
If a service member's testicles are badly damaged or amputated and he can no longer produce sperm, the only way to have a child is to use a sperm donor. That process is costly and is not a covered benefit for service members or veterans.
In-vitro fertilization is covered but requires that the service member produce sperm themselves. Some service members report paying $30,000 for civilian IVF because they were not active duty at the time they were trying to conceive.
Officials from TRICARE, the health care program of the Department of Defense, said in-vitro fertilization is specifically excluded from coverage under the basic TRICARE benefit by federal regulation. A TRICARE spokesperson said, "It's excluded because it is an elective procedure and doesn't diagnose or treat a disease or injury."
IVF is available through separate services to those who suffer what the military terms "catastrophic injury or illness." But still, use of donor sperm is not permitted.
Kat Causey recalls talking to a doctor about her dream of having a baby with Aaron. “They told me, ‘If you really want to have a baby you’ll need IVF, and you’re going to have to think about how you’ll pay for it.'
"And I'm thinking, my husband is amputated above the knees, he's on 13 medications, his body is chopped up to pieces and you're telling me how to not get in debt over having a baby?"
— Kat Causey
Lawmakers have been debating which fertility treatments should be offered to those with combat injuries. One procedure being discussed is sperm salvage. That’s the process of sifting through a wounded testicle to look for sperm. If the testicle is ultimately amputated, saving any sperm and freezing it beforehand means the injured soldier can later attempt to have children.
But speed is crucial. Delaying sperm salvage lowers the chances of finding viable sperm. In the United Kingdom, sperm is taken from service members as soon as possible after a genital injury. Even if a soldier is unconscious and unable to consent, doctors will search for sperm and save it in case he later chooses to have a family.
That’s not the case in the U.S., where doctors wait for a service member to regain consciousness and give consent. For the Causeys, that meant an 11-day wait before doctors would look to see if Aaron’s remaining testicle, of which one third was destroyed, could make sperm.
"I remember sitting on the floor, and the doctor had to sit on the floor next to me, and he said: 'There's no sperm, I'm sorry.' This was worse than them taking his fingers. They were taking our babies."— Kat Causey
Kat says the U.K. could do much to improve care for wounded service members, “but their fertility care is light years ahead of America.”
The couple did eventually have a child. Alexandra Jayne was conceived soon after they began IVF process but before the insemination part. Aaron put off retirement to undergo the procedure since only active duty military are eligible for IVF.
“It’s not fair. The problem is that people are serving their country thinking they’ll get taken care of for all of their injuries and that’s not happening," says Kat. "Aaron went to war and stepped on a bomb serving his country, so why can’t we get IVF?”
Another way to protect future fertility is to freeze sperm before deployment. Some clinics in the United Kingdom offer half-price rates to British troops who want to freeze sperm. In January, a pilot program to cover the cost of freezing sperm and eggs for active-duty U.S. service members was launched by the Pentagon.
Legal quandaries such as what should happen to the sperm if the soldier dies in combat and how long samples should be stored have complicated this decision. Advocates say soldiers should be able to freeze sperm before deployment in the same way that cancer patients do before chemotherapy or surgery.
Frozen sperm samples can be useful even if a soldier does not suffer a genital injury. Combat can lower sperm counts in other ways, including through post-traumatic stress disorder and depression.
Injured service members not thinking about starting a family may be thinking about intimate relationships. There was new hope earlier this year when the first U.S. penis transplant was performed at Massachusetts General Hospital.
Using new techniques, a team of more than 50 surgeons attached a donor penis to the body of a man who lost his penis to cancer. The procedure involved surgically joining the nerves and blood vessels of the donor penis to the nerves and vessels of the recipient.
The first successful penis transplant was performed in 2014 in Cape Town, South Africa. The patient, a 21-year-old man, had his penis amputated after suffering complications from ritual circumcision. Six months after the surgery, he was able to get his girlfriend pregnant.
The first ever penis transplant was not so straightforward. In 2005, surgeons at Guangzhou General Hospital in China attached a donor penis to a man who lost most of the organ after an accident. The injury had left him unable to urinate or have sex.
Two weeks after the surgery, doctors had to remove the transplant — not because the surgery was a failure but “because of a severe psychological problem of the recipient and his wife,” a surgeon told journalists. His wife reportedly could not tolerate the idea of penetration with a deceased donor’s penis.
Sex is as much psychological as it is physical. While we’re making strides in attaching donor penises and implanting prosthetic testicles, there’s not enough discussion about sexual intimacy, says Kat.
Let’s talk about sex (and testosterone)
“We can talk about function and biology but there’s a different aspect that we’re not talking about,” she says, pointing to her head. “No one talks to us about this sex organ.” In the weeks and months following Aaron's accident, she says, medical staff were sometimes reluctant to talk about sex.
“Things were so hectic and the staff are busy, and they’re like, 'OK, you have a penis and it’s erect. Thank you, goodbye.'” What the couple needed was someone to talk to about ways they could enjoy sex during and after Aaron’s recovery.
"We needed someone to tell us 'Don't compare your new sex life to your old sex life,' things like that."— Kat Causey
She found help in talking to a psychologist who works with people with physical disabilities. He showed the couple sex positions for amputees and wheelchair users. Kat says she learned to broaden her definition of sex. “Now when I talk to caregivers, I say you can have sex without penetration and intimacy without sex. You can take showers together, cuddle while naked, wear something really slutty for your husband.”
She feels lucky that Aaron did not lose his penis in the blast and that they are able to enjoy intercourse. But because the blast led to the complete loss of one testicle and part of the other, his testosterone levels are low. And that can also be a problem.
Testosterone regulates sperm production and affects energy levels and libido. But levels have to be carefully balanced. If Aaron takes too high a dose of his testosterone supplements, his sperm production actually decreases. If he doesn’t take enough testosterone, he feels lethargic and is not in the mood for sex. “It’s a juggling act,” says Kat. “We try to see how little ‘T’ he can get away with.”
Kat and Aaron advocate for broader access to fertility treatments for service members injured in combat. While genital injuries are on the rise, Kat believes a culture of silence leaves military families unprepared for this nightmare.
“They tell you what will happen if your service member dies. Down to the hour they tell you what will happen. If your soldier dies. If your Marine dies. If your Navy SEAL dies. They tell you what will happen if they send them back in a box.
"But they don’t tell you what to do when they send them back in pieces.”
Dr. Seema Yasmin, a physician and former CDC epidemiologist, is a professor at the University of Texas at Dallas and a staff writer at The Dallas Morning News.