Growing Pains

Not surprisingly, his wife, Kathy, is disappointed. She also is hurt. "I'm just not as trusting as I used to be," she says. "I wish we could go back in time."

Dr. H.L. Safford III is more upbeat. But then, he has performed almost 500 surgeries for the benefit of men who crave longer, wider--more macho--members. (About 10,000 such operations have been performed across the country.) "I constantly have made improvements," Dr. Safford says enthusiastically from his fifth-floor office in midtown Denver. "I'm having fewer and fewer complications and better results."

A fourth-generation physician, the grandson of one of the country's pioneering urologists and a board-certified urologist himself for a quarter-century, Safford underwent a professional transformation three years ago. He abandoned an apparently successful and locally esteemed practice dedicated to standard penis and prostate problems to begin a new career as the only practitioner of surgical penile enhancement--officially called phalloplasty--between Chicago and Las Vegas.

Cynics might carp that Safford did it for the money, pointing out that 500 operations multiplied by $7,000--what he charges for the inflationary surgery--comes out to a tidy $3.5 million over less than three years, a salary dreamland for most urologists. Patrick Haley, a local urologist and colleague of Safford's, suspects Safford did it to escape meddling insurance companies. But Safford will tell you that none of this is so.

He says that his new practice has been personally rewarding and that, when the medical changes of a grander penis are combined with the patient's psychological advances, penile-enhancement work has been more satisfying than the procedures he labored over as a traditional urologist.

"Before, when I did regular urology, removing cancers and so on, people walked out of my office and they were relieved," he says. "Now people walk out of my door and they're proud."

But what sort of man walks in Dr. Safford's door? What leads a man, even a man's man--Glen Rains is an auto mechanic--to voluntarily place his most private privates at the mercy of cold surgical tools? And why would one of Denver's most highly regarded urologists veer off the road of professional respectability to pursue a procedure that for years women have been assuring men is unnecessary?

HL. Safford III is a pale man with a long face, rimless glasses, gray-blue eyes with heavy lids, and close-cropped graying hair that makes him look exactly like one of those ageless Army veterans, which he is. He is tall and gangly, and his green surgical scrubs don't quite reach his ankles.

One wall of his small office is covered with diplomas, certifications and photos of mentors and idols, including an old picture of Dr. Michael DeBakey, the famous heart surgeon. Another wall holds his model train collection. A Xeroxed "Far Side" cartoon shows several cowboys sitting manfully around a campfire. One of them has his legs crossed, talk-show-guest style. "Frank...don't do that," one of the other cowboys tells him.

Although he is operating on what many physicians would consider the fringe of established medicine, Safford prefers to position himself differently. He suggests he is the latest in a line of misunderstood medical pioneers who endured vigorous public opposition before history and science vindicated them.

His grandfather, family doctor T. Leon Howard, practiced urology in Alabama at the turn of the century before helping found the American Board of Urology. Safford himself graduated from Baylor College of Medicine in 1968. He served in the Army for several years ("They used to call me the White Tornado because I was always in the front office arguing about quality of medical care," he remembers); upon his honorable discharge, he practiced mainstream urology for the next two decades. Among other prestigious appointments, he held the title of chief of urology for St. Joseph's Hospital in Denver. He performed his first penile-enhancement surgery just over three years ago, and he has done about 425 more since then.

During that time, Safford also has become a historian. He's in the process of writing a book about big penises through the ages. "People have been thinking about this for thousands and thousands of years," he says, citing, for example, the practice among some primitive tribes of tying rocks to boys' privates. "By the time they're young adults," he reports, "their penis is two feet long."

In America, surgical penile enhancement grew out of work first done in the beginning of the century on infant boys born with what doctors considered congenitally small penises (in adult sizes, that translates to less than three inches erect). Initially, it involved simply cutting the ligament above the penis, which permitted the penis to fall away from the pubic bone and thus lengthen. In the early 1980s that technique was combined with new procedures being used to reshape parts of a person's body by moving fat from one part, usually the legs or buttocks, to another, such as the lips or breasts.

Like other urologists who later began performing the surgery, Safford started by watching the work of Dr. Harold Reed. Reed, who had imported certain surgical techniques to his Miami practice from China in 1991, was claiming to elongate penises by as much as two inches and increase their girth by 30 percent or more. While the surgery also saw its share of medical setbacks (in 1993 a Miami lounge singer had his penis enlarged as a nice surprise for his wife but died instead), Safford became convinced of the operation's potential.

"I watched Dr. Reed for four or five years," he recalls. "I wanted to make sure he was honest and professional. I determined he was. Then, in February 1993, I went and spent time with him and watched him work personally."

Within months of returning to Denver, Safford hired a public-relations expert to notify local media of his plans to offer penile-enchancement surgery. He began advertising heavily in local papers and, in September 1993, started cutting.

The procedure takes about two hours, during which time fat is extracted from the man's buttocks or legs and then injected into his penis. Patients can resume sex in five weeks. Sometimes, as part of his follow-up care, Safford recommends that men use the P.L.D. Hangman, a weighted device that hangs from the post-operative penis and ensures maximum lengthening. "You're not well-hung until you've been hung by the Hangman," is the company's trademarked slogan.

Safford originally performed the operation as a sideline to his urology practice. Soon, though, he was handling fewer routine urology cases and more elective cosmetic sur-geries; today they make up about 90 percent of his work. Some of his penile surgeries, he adds, remain medically necessitated repair work as the result of accidents rather than cosmetic considerations. Locally, Safford's dramatic shift in professional focus was like Wolfgang Puck agreeing to hawk Olestra or Carl Sagan writing an astrology column, and there has been some fallout. "People don't like medical pioneers, and Denver is a conservative community," he says. "There are people who want to see me fail.

"For the past three years I've put my heart and my soul and my own money into this project, and I don't want anything to jeopardize it," he adds. "I'm working hard to make this work. I'm pioneering a whole new area here."

But even Safford will concede that exploring new frontiers can lead to some surprises. Seeking synergy, for instance, he started off by liposuctioning patients' flanks for the fat to be injected into the penis. While this pleased men concerned about their penis size and their love handles, it turned out that side fat was not very compatible with penises. "I ended up doing more touchups than I expected," Safford says.

Despite such early setbacks, though, the sur-geries have had their financial rewards. Safford has opened a second office in Houston, his hometown; he maintains a monopoly on the procedure in Colorado, and many patients come here from out of state. Each pays upwards of $7,000 for the operation ($1,700 nonrefundable deposit, personal checks not accepted, financing available). Recently, he began performing cosmetic liposuction for men in addition to his penis work.

Safford says his rising success can be traced to more liberal attitudes toward men and their emotional needs, which have been too long neglected. "There's been a change in society, where men can now go in and do something to feel good about themselves," he explains. "Traditionally, men have been unable to express themselves, to women and to other men." Some of this is the fault of women. "Men can hurt you physically," he says. "Women can destroy you mentally. They leave scars on these guys.

"The biggest motivating factor I see among men coming in for this procedure is low self-esteem," he continues. "I've got Fortune 500 executives running big, powerful companies who are being eaten alive on the inside by terrible self-esteem."

Safford, who distributes writings by self-image guru (and cosmetic surgeon) Dr. Maxwell Maltz to prospective patients, offers himself as a prime example. He says that years of neglecting an earlier weightlifting habit left him with saggy breasts and, consequently, feelings of social embarrassment and self-doubt. The lamentable result: "I've never been able to wear alligator shirts," he says. He adds that he hopes to have his breasts and his self-esteem surgically repaired when he has time.

Bigger penises also seem to cure this sort of thing, and Safford is filled with stories of happiness, hope and size. There is the one about the "blue-collar guy" whose business was failing; enhanced, his outlook improved, and today his business is growing at an unprecedented rate.

There is the "LSU student" who struggled along as a "B or C student." Now his penis is bigger and he gets straight A's. And the Army recruit who couldn't bear the closeness and scrutiny of barracks life before his personal amplification. "When I last spoke to his drill sergeant two years ago, he told me now they're thinking of throwing him out of the Army for being an exhibitionist," Safford says.

"I'm exaggerating, of course," he adds, smiling. "It's not that bad."
Doctors whose business it is to make men's penises bigger often find themselves justifying why they do what they do. The party line on penile enhancements is that, regardless of where the knife actually goes in, the primary benefit is in the brain: A larger penis is a sure way for a man to improve his self-image or boost his confidence.

Still, the purpose of the operation is to increase a man's penis size, and satisfied patients will brag on occasion. Take, for instance, the middle-aged man who had been celibate for forty years.

"He told me that the closest thing he had gotten to sex during that time was going to a titty bar," Safford recalls. "But after the operation, he came into my office and leaned over my desk and whispered, 'Doc, guess what! I've got three steady girlfriends and a fourth on the way. I go to bars and women give me their phone numbers, and I don't even know who they are!'"

And a letter that Safford distributes to potential patients reads: "I can't thank you enough for the wonderful results. My erections are completely rigid compared to the semi-hardness I was experiencing. That, combined with the extra girth and length, leaves a real smile on the wife's face. She really gets excited as do I! Our sessions last for over an hour now and I can experience ejaculation twice in the same session (not to mention my wife!)."

Which leads to the sticky issue of women and their opinions of big penises. Despite what they've been telling men since the beginning of time about the non-relationship between size and satisfaction, women apparently are very pleased with Safford's work. (There are indications the sexes still aren't on the same page, however. When it comes to enhancement, Safford says, "Men like the length and women like the girth.") The story of the staunch Baptist woman is typical.

"Sex is not a language that these people speak," Safford starts off. "But I was at my Houston clinic, on the floor on my knees, checking out this woman's husband. She was sitting next to us, with her very tightly coiffed hair and a dress reaching down to her ankles, sitting very primly. I was surprised she wasn't wearing white gloves. And she reached over and tapped me on the shoulder and said--with just a little hint of a smile, but still looking straight ahead--'Dr. Safford, ever since you've done this surgery, I come every time we have sex.'"

Safford leans back in his chair, nodding. "Now, that's the most satisfying part of this job," he says.

With penis enhancement, it seems, there is a fine line between self-esteem, which is desired, and self-aggrandizement, which is wrong. Dr. Safford must walk it every time a new patient walks into his office. "When I started doing the procedure," he says, "I saw a lot of emotionally unbalanced people.

"I won't do someone who wants to be another John Holmes," he continues, referring to the well-known and well-hung late porn star. "If all they want to do is create a bigger penis to hammer somebody, I won't do it.

"I'm really a psychiatrist who happens to be a surgeon," he adds. Safford says he turns down about one-fifth of the men who come into his office seeking enlarged sex organs.

Some people wish he were even more selective.

There are only a few procedures we won't cover," says Dr. Robert Brittain, risk manager for Copic Insurance Company, which writes medical-malpractice policies for about 85 percent of Colorado's physicians. The company will not cover doctors who perform transsexual surgery; doctors who inject chymopapain drugs into spinal disks; chelation therapy as a treatment for anything other than using heavy metals to leach lead out of children's bodies; and privately run sperm banks. Copic also won't insure doctors who perform penile-enhancement surgery.

The reasons an insurance company won't cover a procedure vary. Sometimes underwriters shy away from a surgery or technique because it's too risky. A miscalculation half the thinness of a dime during a chymopapain injection, for instance, could cause instant paralysis.

In other cases, insufficient research will cause Copic to reject coverage. For example, in the late 1970s Copic refused to provide malpractice insurance to physicians who treated patients with drugs derived from peach pits, Brittain says. It also initially refrained from covering ophthalmologists who performed radial keratotomy surgery, although Copic now does.

Brittain concedes that some research has been done regarding penile-enhancement surgery, but he and his company are concerned about its validity. Specifically, he explains, "The majority of the research on the fat-injection penile enlargement was done by a doctor who stood to make a profit from it." (That would be Dr. Reed, in Florida.) Until objective scientists at an uninvolved university can prove that injecting fat into a penis is worthwhile, effective and not dangerous, he adds, doctors who insist on performing the operation should not come to Copic for their insurance coverage.

A second worry for insurance companies considering penile-enhancement surgery is the presumed volatility of the patients. "We are a company of doctors, by doctors," begins Dr. Mark Gorney, executive vice-president for Medical Affairs of The Doctor's Co., based in California, the second of the three major insurance companies that write most of the medical-malpractice insurance in the state of Colorado.

"We firmly believe that we should not dictate medicine to doctors--up to a point," he continues. "And that point is crystal clear. We will not cover experimental, novel or dangerous procedures, particularly dealing with sexuality."

That definition becomes tricky when discussing, say, the difference between breast augmentation for women--which The Doctor's Co. will insure physicians for--and penile enhancement, which it won't. Much of the discussion could be summarized like this: Women who want larger breasts are normal; men who want bigger penises may not be.

"Having breasts, which can be seen, is a primary evidence of womanhood, a primary item of sexual attraction," Gorney explains. "But with men, I like to say, 'It's not how you're built, it's how you're wired.' Unless you're dancing naked, nobody goes about exposing their genitalia, except in their boudoir or bathroom."

He concludes: "Whoever comes looking for that kind of procedure [penile enhancement] has a problem with his masculinity. And that's just courting disaster in terms of liability. What you have is a patient who is unstable to begin with." Translation: Lawsuit danger. Translation: No coverage.

The third company that provides medical-malpractice insurance for Colorado physicians is Minnesota's St. Paul Insurance. How comprehensively it covers Safford is a point of debate. Safford insists he is covered. "I am very careful about that," he says. "We have a sixteen-page consent form I go over very carefully with my patients explaining all the risks. But I definitely am covered. I have a special, symbiotic relationship with St. Paul's."

One person familiar with Safford's business insists equally forcefully that the doctor does not--or at least at one time did not--have insurance coverage for the number of procedures he does, about twenty a month. St. Paul itself is unwilling to clarify. "In this instance, we are going to decline comment," says Barry Johnson, communications director for St. Paul.

For Glen Rains and his bumpy penis, Safford's unclear insurance situation has been troublesome. Rains says he has contemplated suing Safford for malpractice, but each time he met with attorneys, the lawyers were uninterested. Their reason: Recovering damages from a physician is more difficult when a lawyer must pursue a doctor's personal assets rather than negotiate with his insurance company for a settlement. Other attorneys specializing in medical cases also point out the difficulty of finding a jury sympathetic to a man who paid $7,000 to obtain a larger penis.

Penile-enhancement surgery has begun to gain a measure of professional acceptance. "I'm balding, and I have no intention of getting a hair transplant. I used to feel that way about all cosmetic surgery," says Patrick Haley, the Denver urologist. But, he adds, "I've decided that if people want to change their body image, then go ahead." He sees some of Safford's patients when Safford is unavailable, and he says he has been impressed with the doctor's work.

Many traditional medical organizations remain unreceptive, however. Their objections have less to do with actuarial risk than with technical concerns, such as the fact that the fat injected into the penis to widen it sometimes doesn't take. This can result in a bumpy, misshapen--in short, an unsightly--penis. (One recent study in The American Journal of Cosmetic Surgery warned doctors contemplating the procedure about problem patients: "Touch-ups may be required especially by fastidious patients who seek a perfectly cylindrical result.")

There is also no consensus as to the best method to surgically enlarge a penis, either. Fat injections are the method of choice among most penis-builders because the procedure is relatively simple and quick. It's not the only way, however. Gary Alter, a Beverly Hills urologist and plastic surgeon and a clinical professor at UCLA, does penis enhancements. But instead of injecting fat, he wraps a dermal fat graft around the shaft to increase girth. Alter says it's a more time-consuming, invasive--and successful--technique.

"When you're trying to sculpt a perfectly cylindrical penis, [fat injections] are a little unpredictable," he says. Alter also does not do any lengthening procedures: He says that in his experience, the standard technique--cutting the ligament--produces no appreciable difference in size. "This is still a new field, and patients need to understand that," he adds.

Still, many physicians continue to dismiss the idea of enhanced penises. Among other doubts, there are lingering concerns over post-operative performance problems such as impotence and loss of erection.

Safford says he is laboring to overcome such unfounded biases, not only by maintaining his own quality work but also by starting (like his grandfather, the pioneering urologist) his own legitimate professional organization. He hopes the two-year-old American Academy of Phalloplasty Surgeons' thirty-odd members can inject some legitimacy and professional review into the controversial procedure.

It will be a struggle. This past fall the young organization met for only the second time, at Aspen's Little Nell Hotel. While many hours were set aside for seminars featuring scientific debate, technique sharing and professional networking, the entire Saturday of the conference was designated "Lawyer's Day." It featured a presentation titled "Evaluation & Profile of Happy People; Happy Patients, Happy Couples: Evaluation of Unhappy People; Litigious, Sociopaths, & Angry" and starred attorneys for Melvin Rosenstein.

Before he lost his license to practice medicine this past February, Rosenstein was the highest-profile and most prolific practitioner of penile enhancement in the country. Operating out of his bustling office in image-conscious Southern California, Rosenstein performed up to a dozen surgeries a day and, according to court documents, collected revenues of $7.4 million in the first six months of 1994.

He became a surgical celebrity. In 1995 he enhanced John Wayne Bobbitt's previously mangled member. He later stood by his work, literally, when he made a cameo appearance in one of Bobbitt's recent film projects, Frankenpenis.

Despite such heady success, though, Rosenstein's dissatisfied customers eventually caught up with him. By the beginning of this year, dozens of complaints had been lodged against him with California medical regulators. Rosenstein denied any malpractice, but a month later the state pulled his license.

Whether or not any of his former patients recover their money will be decided in many future court cases. But Rosenstein's work already has begun to take its place in an up-and-coming subspecialty of penile-enhancement surgery: penile-enhancement repair.

"I've had to repair some of Dr. Rosenstein's work," confides Safford.

I'm thinking of going to Florida to have Dr. Reed repair Dr. Safford's work," Glen Rains says.

"We talked about it first about two or three years ago," recalls Kathy Rains of her husband's surgery. "He just flat-out asked me, 'What do you think about me having it done?' Mostly it was just the look that he wanted that wasn't there to begin with. Also, he wanted a little more size. But not much more. Fuller, I guess, but with a little more length.

"So I said to him, 'Are you absolutely sure about this? Because it's definitely for you and not for me--it's not an issue for me.'"

It made sense for Glen to ask Kathy. Not only was she his wife of two decades; she'd also had enhancement surgery of her own. "It helped with my self-esteem a whole bunch," she says, "a whole bunch. When you look at your family and they're 'all there' and you're not, you're left saying, 'What happened?'"

The feelings of inadequacy got worse as she got older and so, in 1988, Kathy had silicone implants. "It's been fantastic!" she says. "Never had an ounce of problem."

Given that, Glen, a 39-year-old auto mechanic who recently opened his own repair business, remembers thinking his wife was harboring a double standard. "She said to me, 'You're fucking crazy!'" he recalls.

By last year, though, he'd made up his mind. "I guess more than anything else, I felt inadequate," he says. "I wanted to do it for me." After seeing an ad for Safford in the Rocky Mountain News, Rains says he "jumped on the bandwagon and went in and got screened."

During the time leading up to the surgery, Rains's moods swung back and forth from anxiety to hope. There were the warnings of possible infections and other unlikely complications. "Dr. Safford said it was possible that some of the fat wouldn't take and he'd need to retouch it," Glen recalls. But there was also that hope of one to two inches in additional length and a 30 to 50 percent increase in mass.

Anything more than that would just be greedy. Besides, says Glen, "If you go much higher than that, Dr. Safford told me it gets to looking grotesque and it won't work properly."

On the day of the operation--September 13, 1995--Rains and his wife drove to the Aurora Outpatient Surgical Center. He was given general anesthesia. He woke up a couple of hours later feeling hung over and sore. Kathy stopped at McDonald's on the way home and bought him two milkshakes.

When Glen got home, "I was worried because of the swelling and the bruising," says Kathy. "Boy, it was not just unsightly. It was blue." Safford's office told them such an appearance was common after the operation, and Kathy calmed down. "But then," she adds, "the infections started."

Post-surgery infections are hardly unheard of. Still, one of the most commonly reported complications of penile-enhancement procedures is penile infections, and Glen's seemed particularly bad.

Within three days, Glen's penis was in such rough shape that he had to return to Safford's office, where he was given antibiotics. He came in each day after that for nearly a week. On the weekend, one of Safford's assistants went to the Rainses' home to administer the shots.

The infection lasted nearly three weeks, Glen and Kathy say. They requested that Glen be sent to a hospital, they add, but Safford advised against it. Even after Glen's fever finally retreated, there were problems. For instance, Kathy says, "sexually, he was totally incapacitated. There was just no way. It was too painful for him. But it was also worrisome for me."

Worse, Glen's penis remained misshapen. Most studies recommend patients wait at least three months for the injected fat to settle. Even then, though, when Glen looked down, he was disappointed. "It worked okay, but cosmetically, it didn't look correct," he says. "It's constricted in the middle where the fat didn't take. It's like a bicycle tube you're putting a patch on, and then it bulges in one place and is smaller in another."

Although his penis had undoubtedly gotten larger--Glen estimates a one-inch length gain and a 30 percent girth increase where the fat injections did stay put--"it was not what I expected," he says.

Glen felt his business with Safford wasn't over. Speaking from his garage, he finds an analogy: "If I goof somebody's engine up when I work on it, I have to stand behind my work. I'll repair it."

Touch-up work on enhanced penises is not uncommon, and some of Glen's member probably could have been repaired (although his long infection likely left some permanent scars). But over the next several months, relations between Safford's office and the Rainses deteriorated into emotional shouting matches and threats of legal action--the sort of thing medical-malpractice insurers fear most from the penilely enhanced. Glen and Kathy admit that, on occasion, they were aggressive, loud and demanding, a result of their frustration. Today they are not on speaking terms with Safford.

Meanwhile, on his own, Glen went in search of a repair shop. He returned to the source. Harold Reed, considered the founder of penile enhancement, still works in Miami, where a portion of his business is now surgery done to repair the unsatisfactory work of other doctors.

Reed told Glen that to smooth out the bulges, divots and cysts remaining on his penis would cost between $3,900 and $6,000. That's not including plane fare to Florida, three nights in a hotel (Reed's clinic will provide bus service between the hotel and the clinic) and other expenses.

It's a lot of money, but Glen has begun to save. Kathy explains: "It would be like if you had this really huge nose, and you went in for surgery and it came out worse than before. Psychologically, it can mess with you real bad. And with Glen, sometimes that happens.