For boys growing up in the Xhosa tribe in South Africa, the journey to manhood begins painfully.
Xhosa boys, some as young as 12, undergo a ritual circumcision -- or ukwaluka -- then are isolated in mountain huts for weeks at a time, according to National Geographic. Those who "cry, show discomfort, run away or go to a hospital" risk being branded as "boys" for as long as they live, according to the Los Angeles Times.
Tribal tradition demands that the foreskins must be buried to prevent sorcerers from using them in witchcraft, according to National Geographic.
The most dangerous part of the ritual is not necessarily the procedure -- which is often carried out by a traditional surgeon wielding a blade or knife -- but the arduous, weeks-long recovery, National Geographic reports. That's when the initiate's penis is wrapped with strips of goatskin, according to the Times, and the boy is forbidden from eating food or drinking water.
The risk for infection is high, but the fear of being shunned may be even greater.
"If they wrap it too tight, the blood supply will be cut off," Andre Van der Merwe, head of urology at Stellenbosch University in the Western Cape, told the Times. "They also dehydrate the guys. ... You've got a dehydrated patient with a necrotic penis and septicemia [bacteria or other pathogens in the blood stream]. Those kidneys go and you have got a death. If they don't die, it [the penis] falls off anyway."
By the time victims go to a hospital, it's often too late, according to Van der Merwe. At that point, he said, doctors are focused on trying to save lives.
"I'll never forget some of those young guys' faces," Van der Merwe told the Times. "The guy asks, 'When will it grow back?' You have got to tell them it's never going to grow back. They just go completely blank. It's just like they can't believe it."
But last month, Van der Merwe offered a glimmer of hope: The world's first successful penis transplant.
In a nine-hour surgery, a South African medical team successfully transplanted the penis of a dead donor to a young man who had lost his penis because of complications from a ritual circumcision years earlier.
The difficult surgery, which was practiced on cadavers prior to the operation, took place in December, but the team delayed announcing it while waiting to see how the patient would recover, according to CBS.
Van der Merwe told the 21-year-old patient that it might take two years for him to fully regain his sexual function; he was shocked to learn that the man -- who has a girlfriend -- needed just five weeks.
There are 5 million members of the Xhosa ethnic group, and thousands of Xhosa boys -- mostly teenagers -- undergo the "secretive rite of passage" each year, according to the Guardian.
Nelson Mandela, a Xhosa, wrote about his own circumcision in his autobiography, the newspaper noted:
"Without a word, he took my foreskin, pulled it forward, and then, in a single motion, brought down his assegai," he writes. "I felt as if fire was shooting through my veins; the pain was so intense that I buried my chin in my chest.
"Many seconds seemed to pass before I remembered the cry, and then I recovered and called out, 'Ndiyindoda!' [I am a man!]"
But doctors believe untold numbers of Xhosa men have been living without penises for years. According to government statistics, at least 38 boys died and 10 lost their penises last year, the Los Angeles Times noted. The year before that, the paper reported, about 40 died.
In 2012, according to the Guardian, human rights activists in South Africa demanded change after 42 Xhosa boys died in three weeks "from badly performed rite-of-passage" circumcision procedures.
Even for those who survive, Van der Merwe said, a botched circumcision can be the beginning of the end.
"The thing that happens is they commit suicide," he told the Times. "They buy food and poison and just go into the bush and have that last meal."
Nine men remain on a transplant waiting list, but the expensive operations may require outside funding to continue, according to the Times. Another obstacle doctors face, the paper reported, is finding patients. Van der Merwe told the Times he believes many victims who have lost all or part of their penises are too ashamed to seek help.
For those on the waiting list, shame has been superseded by possibility.
"This transplant project has given them hope," he said. "One guy told me he'll never stress in his life again, because he knows what real stress is."
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