Along with other urologists and psychiatrists, at King’s College and the University of Turin, Muir conducted a literature review called “Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size.” The research showed that men dissatisfied with their penises respond well to educational counselling about the average size, which is 3.6 inches long when flaccid, and 5.2 inches erect. (The average girth is 3.5 inches flaccid, and 4.6 inches erect.) For men who have an excessive and distorted preoccupation with the appearance of their genitals—a form of body dysmorphic disorder—Muir said that cognitive-behavioral therapy and medications may also be necessary.
Penuma surgeons told me they use educational videos, intake surveys, and sexual-health therapists to make sure that the men they operate on have realistic expectations and to screen for those with body dysmorphia, though only a handful of the patients I spoke to recalled being referred to a therapist before their surgery.
Shortly before the pandemic, Elist received a Google alert for “penile implant” and noticed something strange: a Houston urologist, Robert Cornell, had been issued a patent for the Augmenta, a device that bore an uncanny resemblance to his own. The previous year, Cornell had asked to learn about the Penuma “expeditiously,” saying that he saw a “real opportunity to expand the level of service” he offered to patients. Run Wang, a Penuma board member and a professor at the University of Texas M. D. Anderson Cancer Center, in Houston, had cautioned Elist that Cornell could be a bit of a snake, according to Jonathan Elist. But father and son chalked up Wang’s warning to the machismo of the Texas urological market, and Elist invited Cornell to shadow him as he performed four Penuma procedures. Now, as Elist thumbed through Cornell’s patent, he was startled to see his future plans for the Penuma, which he said he recalled discussing with Cornell, incorporated into the Augmenta’s design.
In April, 2src2src, Elist and his company sued Cornell, alleging that his visit to Beverly Hills was “a ruse” to steal trade secrets. Later that year, when Elist discovered that Wang was listed as the Augmenta C.E.O. and had assisted the penile startup with its cadaver studies, Elist and his company added Wang as a party to the suit. (Cornell and Wang did not comment for this story, though Wang denied through his counsel that he’d called Cornell a snake and said in court filings that he’d been named C.E.O. without his consent.)
When deposed, Cornell said that he’d talked to Elist about marketing strategies, not proprietary specifics, and that his invention had been spurred by potential hazards he’d observed during the surgeries, particularly the use of mesh. As both teams began conscripting high-volume implanters as allies and expert witnesses, the fraternity of sexual medicine was sundered into warring camps. “This is a tiny smear of people, and they are fucking cutthroat,” one high-volume implanter told me of the intellectual-property dispute. “It’s vicious because there’s so much money to make.”
Augmenta’s team endeavored to put the safety record of the Penuma on trial, securing Elist’s confirmation in a deposition that twenty per cent of the patients in his 2src18 study had reported at least one adverse post-surgical event. Foster Johnson, one of the Augmenta attorneys, also tracked down some of the patients who’d posted horror stories online. In 2src21, he reached out to Mick.
A year had passed since Mick’s explant, and he’d entered a serious depression. He’d barely noticed when pandemic restrictions were lifted, because he’d continued to stay in his bed. Originally six and a half inches erect, he had lost an inch of length. Whenever he caught sight of himself in the mirror, he felt desperate.
So did other post-removal patients. An F.B.I. agent in his early thirties said that he was afraid he would never date again, let alone start a family, because his penis had shrunk to a stub. A Hollywood executive who’d undergone multiple surgeries with Elist told me, “It’s like he also snipped the possibility of intimacy away from me.” The defense-and-intelligence contractor, who’d travelled the country to consult six reconstructive surgeons, said he’d tucked a Glock in his waistband before one appointment, thinking he might kill himself if the doctor couldn’t help.
Mick had come to believe that the only thing more humiliating than being a satisfied penile-enhancement patient was being a dissatisfied one. Still, he tried to alert local news stations, the Better Business Bureau, the F.B.I., the district attorney, malpractice lawyers, the California medical board. No one returned his calls—“Who could blame them when it almost sounds like a joke?”—apart from an investigator with the medical board, who didn’t treat his distress as a laughing matter.
Neither did Johnson, who decided to tip off a Houston-based firm that specialized in class-action complaints. Last year, a Texas man accused International Medical Devices of falsely advertising the Penuma as F.D.A.-cleared for “cosmetic enhancement” when it was, until recently, cleared only for cosmetic correction of soft-tissue deformities. Jonathan Elist called the lawsuit, which awaits class certification, meritless. “It’s not medical malpractice,” he said. “And it’s not a product-liability case, either, which is what one might expect from something like this.” His expectations proved prescient when, in March, a personal-injury law firm in Ohio brought the first of what are now eight product-liability suits against the company. The lawsuits, all of which Elist’s spokesperson called “frivolous,” feature ten John Does.
Every surgical revolution is bloody by definition. When I met Elist, earlier this year, he underscored how many taken-for-granted medical breakthroughs had emerged from tweaks and stepwise developments. The breast implant had been dogged by ruptures and leaks in its early days. Even the celebrated penile pump—the object around which the egos of many eminent urologists now orbit—had taken years to overcome high rates of removals. Two decades of innovation had led to the current Penuma procedure, he noted, and during that time nearly everything about it had improved, from the deployment of a drain to the placement of the incision. “This procedure is like any other procedure,” he told me. “It has its own evolution.”
Recently, the Penuma procedure evolved again. Elist had got rid of the vexing patch of mesh, and the company was shipping out a new model. He invited me to shadow him as he implanted it.
The first operation of the day complete, Elist was in a giddy, expansive mood. As his next patient was put under anesthesia, Elist sat behind an imposing desk in a borrowed office and spoke about his forthcoming book, a collection of parables for spiritually minded surgeons titled “Operating with God.” His ghostwriter had rendered his voice so skillfully, he said, that he’d found himself moved to tears while reading it. Beside a gilt statue of a jaguar in the corner of the room, someone had propped a mirror with an image of Jesus etched at its center. As Elist recounted passages from his book, his merry face, crowned by a hairnet, hovered next to Christ’s.
The surgery, which Elist said was supposed to take approximately thirty-five minutes, lasted twice as long. A surgical technician had covered the patient’s body in sheets until only his penis, gleaming beneath the overhead lamp, was visible. With a purple marker, Elist drew a dotted line close to where the scrotum met the shaft. A clamp pulled the skin taut, and he began to cut along the line. The scrotal skin gave easily, like something ripe, and a few seconds later, the man on the table let out a high-pitched sound.
To stop the bleeding, Elist applied a cautery pencil that beeped each time it singed the skin, giving off smoke and a whiff of burned flesh. Alternating between his cautery tool and a pair of scissors, he deepened the incision, centimetre by centimetre, revealing the chalky tissue below, until he approached the pubic bone. Then, in a stage known as “degloving,” he began to flip the penis inside out through the hole he’d created at its base. Wearing the marbled interior flesh around his fingers, he trimmed the soft tissue and cauterized a series of superficial blood vessels, speckling the interior of the shaft with dark dots. For a few moments, a quivering red sphere popped up like a jellyfish surfacing at sea—an inverted testicle, he explained.
A nurse unwrapped an Extra Large implant from its box and handed it to Elist, who used curved scissors to smooth its top corners. With a hook-shaped needle, he began to sew the implant into the inverted penis, and he asked his surgical tech to tie a “double lateral” knot. He barked the word “lateral” several times and sighed. “She’s never seen this procedure,” he told me. When he asked for wet gauze a few minutes later, she handed him a piece they’d discarded. “You know that it’s dirty,” he reprimanded her in Farsi. “It was on the skin. And you bring it for me?”
I recalled that Zimmerman, the “Dick Doc’’ of Las Vegas, had compared his own visit to Elist’s operating theatre to being “in the presence of a master conductor who can bring the whole orchestra together.” But as Elist chided his tech for being “a troublemaker”—she’d handed him the wrong size of sutures, an unnecessary needle, the wrong end of the drain, the wrong kind of scissors—it felt like watching the stumble-through of a student ensemble.
Elist cauterized more tissue by the pubic bone to make sure the implant would fit there, and at this the patient’s breaths rose into a moan. Elist regloved the penis with the Penuma tucked under its skin. Too long, he decided. He slid the implant out partway and snipped a bit off the bottom. Pushing it into the shaft, he wagged it back and forth. “O.K.,” he said. It was done. The patient, who had arrived that morning average-sized—four inches in length by four inches in girth—was now six by five. Later, through his spokesperson, Elist would say that the patient’s outcome was excellent. In the room, talk turned to preparing the table for the next man.
Elist has always been keen to distance himself from other purveyors of controversial penile-enhancement techniques—“gimmick” surgeons, he has called them. At one point during our conversations, which were punctuated by lively digressions, he said that some of his unscrupulous rivals reminded him of Josef Mengele, the Nazi doctor who conducted lethal experiments on prisoners at Auschwitz. “How do you allow yourself to put something on the patient’s body that you know gets infected?” he asked, as though addressing them directly. Sections of his Web site and of a book he self-published in 2src15, “A Matter of Size,” are devoted to chronicling the macabre complications that can result from skin grafts and fat injections to the penis.
When I reviewed old files in an underground archive for the Los Angeles County courts, however, I saw that, a decade before the Penuma came into being, Elist had been part of a coterie of L.A. surgeons promoting the very methods he now decried, with coverage in Hustler, Penthouse, Penis Power Quarterly, and local newspapers like the Korea Central Daily and the Korea Times. One ad, in Korean, for the surgery center where Elist operated sounded a familiar note, promising a “life-changing” procedure with no complications and “guaranteed results,” performed by “the Highest Authority in Urology in Beverly Hills,” “approved by the state government,” and “authorized by the F.D.A.”
At least twenty-three malpractice lawsuits have been filed against Elist in Los Angeles since 1993. (He has also been named as a defendant in product-liability lawsuits regarding inflatable penile prostheses brought by plaintiffs Dick Glass and Semen Brodsky.) The dockets indicate that some of the complaints were settled confidentially out of court, a few were dismissed, and in one of two trials a jury ruled in Elist’s favor.
It is not unusual for a doctor practicing for more than forty years to be accused of malpractice, and it is not unusual, either, for patients to be self-serving in their recollections of informed consent, but as I scrolled through the microfilm I was surprised to see how many of Elist’s past patients—who’d received cosmetic surgeries, medical procedures, or both—described the same M.O. Three men alleged that they’d been asked to sign consent forms after being injected with Demerol, a fast-acting narcotic. A number of foreign-born patients seeking treatment for erectile dysfunction alleged that they were given forms in English, which they couldn’t read, and some of those same patients, who said they’d thought they were undergoing a vein-cleaning procedure, alleged that they awoke from surgery to find themselves implanted with a penile prosthesis for erectile dysfunction. Multiple patients who said they’d turned to Elist for a functional issue alleged that they’d been upsold enhancement procedures that resulted in their disfigurement. Ronald Duette, a sixty-five-year-old property manager and auto detailer who filed a malpractice case in 2src21, told me that a consultant at Elist’s clinic had encouraged him to get the Penuma by reassuring him that Elist had one himself.