by Ava Kofman; Photography by Philip Cheung, special to ProPublica
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They wanted it because they’d just gone through a bad breakup and needed an edge in the volatile dating market; because porn had warped their sense of scale; because they’d been in a car accident, or were looking to fix a curve, or were hoping for a little “software upgrade”; because they were not having a midlife crisis; because they were, “and it was cheaper than a Bugatti Veyron”; because, after five kids, their wife couldn’t feel them anymore; because they’d been molested as a child and still remembered the laughter of the adults in the room; because they couldn’t forget a passing comment their spouse made in 1975; because, despite the objections of their couples therapist, they believed it would bring them closer to their “sex obsessed” husband (who then had an affair that precipitated their divorce); because they’d stopped changing in locker rooms, stopped peeing in urinals, stopped having sex; because who wouldn’t want it?
Mick (his middle name) wanted a bigger penis because he believed it would allow him to look in the mirror and feel satisfied. He had trouble imagining what shape the satisfaction would take, since it was something he’d never actually experienced. Small and dark haired, he’d found his adolescence to be a gantlet of humiliating comparisons: to classmates who were blond and blue-eyed; to his half brothers, who were older and taller and heterosexual; to the hirsute men in his stepfather’s Hasidic community, who wore big beards and billowing frock coats. After he reached puberty — late, in his estimation — he grew an impressive beard of his own, and his feelings of inadequacy concentrated on his genitals.
None of Mick’s romantic partners ever commented on his size, but his preoccupation had a way of short-circuiting the mood. He tried several kinds of self-acceptance therapy, without success; whenever he went to the bathroom, there it was, mocking him. “Like an evil root,” he said of the fixation. “It gets in there and grows like a tree. But I think everybody has that on some level about something.”
After high school, Mick decided to study art and moved to Berkeley, California, where his mother had spent her hippie years. Eventually landing in Seattle, he supported his life as an artist by working in the hospitality industry. His paintings often depicted a human body glowing, as if transfigured, in a geometric landscape.
Over the years, Mick kept up with advances in male augmentation but wasn’t thrilled by the options. The gains from a vacuum pump were fleeting; hanging weights from the end of his shaft seemed like a painful investment for an uncertain result; and having a surgeon snip his suspensory ligament, which promised an additional inch or so, could lead to wobblier erections. It wasn’t until the spring of 2019, when he was 36, that he came across something appealing: a silicone implant shaped like a hotdog bun that could be inserted just under the skin of the penis to increase its girth and flaccid length.
The device, called the Penuma, had been invented by James Elist — a silver-haired urologist who has been described on TMZ as “the Thomas Edison of penis surgery.” Elist’s procedure was touted as reversible, and, according to a rapturous article in GQ, more than a thousand men had already undergone it. It was also, as far as Mick could tell, the only genital enhancement on the market to have received the blessing of the Food and Drug Administration.
The basic operation would cost $15,000 — roughly half of Mick’s life savings — though he added in a pair of discounted testicular implants, at seven grand more. He put down a deposit, told his long-distance boyfriend that he was taking a work trip and, on a sunny morning in September, arrived at Elist’s office, in Beverly Hills. A framed copy of the GQ story — cover line: “We Have Huge News About Your Manhood” — hung on the wall of the exam room. Elist strode in, directed Mick to drop his pants and rolled Mick’s scrotal sac appraisingly between his fingers, as though it were a piece of fruit at a market stall.
Elist’s hands seemed reassuringly delicate, but Mick wanted to see the implant before it was put inside him. The surgeon clicked open a briefcase containing three translucent sheaths: Large, Extra Large and Extra Extra Large. The device felt stiff to Mick’s touch, but Elist told him that over time it would soften to the consistency of a gummy bear.
The consultation lasted about five minutes, Mick recalled. He signed a stack of consent forms and releases, including one that said his consultation had lasted more than an hour, and another promising “not to disclose, under any circumstance,” his “relationship with Dr. James J. Elist.” The operation took place the same morning in an outpatient clinic up the street. In the preop room, awaiting his turn, he watched “Rush Hour” in its entirety on a flat-screen TV.
When the surgery was over, Mick, still groggy from the general anesthesia, took an Uber to a Motel 6 near the airport, where he spent the next five days alone on his back, his penis mummy-wrapped in gauze. Morning erections were excruciating. Sharp jolts seized his crotch whenever he peed, which he could do only by leaning over the bathtub. He’d anticipated some discomfort, but when he changed his gauze, he was startled to see the corners of the implant protruding under the skin, like a misplaced bone.
Back in Seattle, the Penuma’s edges continued to jut out, particularly on the right side, although the testicular implants looked fine. He decided not to tell his boyfriend about the operation: talking to him would only make it seem more real, and he wasn’t yet prepared to entertain the possibility that he’d made a terrible mistake. When he emailed Elist’s clinic the staff urged patience, counseling him that he was “continuing to heal as we expect.” Then he began to lose sensation.
“I know it’s been just three weeks and I’m following by the letter all the instructions but I’m a bit concerned about the look of it as you have seen in the pictures,” he wrote Elist.
“It’s been 70 days since surgery and yet it feels like a shrimp,” he wrote in November.
“I’m so sorry for another email,” he wrote in December, “but I am freaking out about the fact I have zero sensitivity in my penis!”
“Being totally numb is normal as mention[ed] in the past correct?” he asked later that month. “It will pass correct?”
After Mick received a cosmetic penile implant, he lost sensation in his penis. (This photo has been darkened to protect Mick’s identity.)
For much of the 20th century, urologists devoted themselves to the prostate, testes, kidneys and bladder. A man’s sexual function, or lack thereof, was largely considered a matter for psychoanalysts to puzzle over. It wasn’t until the late 1970s that a handful of researchers began demonstrating that erectile troubles, though occasionally psychogenic, were primarily vascular in cause. Their discoveries transformed the mercurial penis — John Updike’s “demon of sorts ... whose performance is erratic and whose errands seem, at times, ridiculous” — into a tamable medical object.
It was at this moment of upheaval that Elist entered the clannish, hypermasculine world of American urology. Raised in a Sephardic family in Iran, he completed a residency in Washington, D.C., just before the 1979 Islamic Revolution. Instead of going home, he remained in the States and went into private practice in Beverly Hills. There, he joined the vanguard of physicians who were treating impotence with a suite of novel procedures, such as injections and inflatable penile prostheses. “If the penis is the antenna to a man’s soul, then James Elist must be the Marconi of medicine,” Hustler announced in a 1993 profile. Larry Flynt, the magazine’s publisher, was among his celebrity clientele.
Dr. James Elist, a urologist in Beverly Hills, received his first Food and Drug Administration clearance for his invention, the Penuma, in 2004.
With the blockbuster launch of Viagra, in 1998, Elist feared that demand for surgical cures for erectile dysfunction would fall, and decided it was time to diversify. Over the years, many of his patients had asked if he could make them bigger while he was down there. Walking around the 90210 ZIP code, where the median breast size seemed to balloon by the day, Elist realized that his next move was staring him in the face.
As he toyed with an early prototype for the Penuma, other doctors were dismissive. The penis — a tentacle that shrinks and swells with an exquisite sensitivity — was nothing like the breast; it wouldn’t be possible, they told him, to put something static under its elastic skin.
Because the FDA requires the pharmaceutical industry to conduct clinical studies of new drugs, it is often assumed that the same is required of medical device manufacturers. However, a loophole known as the 510(k) process allows companies to implant untested products in patients as long as they can demonstrate that the devices are “substantially equivalent” to those already on the market. In September 2004, not long after Elist convinced the U.S. Patent and Trademark Office of the novelty of his invention, he informed the FDA that his “silicone block” was comparable to calf and butt implants. A month later, when the agency cleared the device for the “cosmetic correction of soft tissue deformities,” the word “penis” did not appear in its indications for use.
Despite the FDA imprimatur, persuading men to get the implant was a challenge, even after one of his patients, Bryan, a 20-something with biceps the size of porterhouse steaks, began modeling it for prospective customers. Bryan, who later referred to himself as Elist’s “spokespenis,” told me he also moderated content on My New Size, an online forum for male enhancement, where Elist’s invention was often extolled. Still, by 2014, the doctor was averaging barely 100 implant surgeries a year. It wasn’t until the 2016 GQ article that his device — newly christened the Penuma, an acronym for Penis New Man — was propelled from the margins to the mainstream. (The New Yorker, like GQ, is owned by Condé Nast.) By the end of the year, Elist was doing roughly 60 Penuma procedures a month, and his oldest son, Jonathan, left a job at McKinsey to become the CEO of International Medical Devices, as they called their family firm.
Prominent urologists had long seen penile enlargement as the remit of cowboys and regarded Elist as such, insofar as they regarded him at all. As part of Penuma’s gentrification campaign, Elist got the FDA to explicitly clear his implant for the penile region in 2017, noting in his application that the “unique anatomy, physiology, and function of the penis does not increase the overall potential risks.” At conferences of the Sexual Medicine Society of North America, his company also began to recruit “key opinion leaders,” as Jonathan put it, to advise the company and join its new board.
Among the KOLs in the field of sexual medicine are those who install the highest number of prostheses to restore erectile function, typically in prostate cancer patients or in men with diabetes. So entrenched is this hierarchy that specialists to whom I spoke frequently rattled off their colleagues’ stats. “It’s all about who has the biggest whatever and who has the bigger numbers,” Faysal Yafi, the director of Men’s Health at the University of California, Irvine, and himself a high-volume implanter, explained.
Elist’s first big catch was Steven Wilson, formerly a professor of urology at the University of Arkansas, who, until his apparent unseating by Paul Perito, a spirited upstart in Miami, was feted as the highest volume implanter in the country. (“Our Tom Brady,” Yafi said of Wilson, admiringly.) Wilson, a paid consultant for Elist’s company, helped vet skilled surgeons around the country who could be trained to perform the Penuma procedure. “The cosmetic revolution of the flaccid penis,” Wilson said, is urology’s “last frontier.”
On the conference circuit, where the goals of the revolution were the subject of fervid debate, Penuma surgeons argued that urologists were at a crossroads. They could cede the augmentation market to quacks and overconfident plastic surgeons, or they could embrace their vocation as the so-called champions of the penis, and in their hygienic, well-lit clinics provide patients with what they’d been asking for and might otherwise find an unsafe way to secure. When the tabloids reported in March 2019 that a Belgian Israeli billionaire had died on a Parisian operating table while getting an unknown substance injected into his penis, it seemed to prove their point. A month later, Laurence Levine, a past president of the Sexual Medicine Society of North America and a professor at Chicago’s Rush University Medical Center, successfully performed the first Penuma procedure outside Beverly Hills, kicking off the implant’s national expansion.
Soon afterward, the pandemic began fueling a boom in the male augmentation market — a development its pioneers attribute to an uptick in porn consumption, work-from-home policies that let patients recover in private and important refinements of technique. The fringe penoplasty fads of the ’90s — primitive fat injections, cadaver-skin grafts — had now been surpassed not just by implants but by injectable fillers. In Las Vegas, Ed Zimmerman, who trained as a family practitioner, is now known for his proprietary HapPenis injections; he saw a 69% jump in enhancement clients after rebranding himself in 2021 as TikTok’s “Dick Doc.” In Manhattan, the plastic surgeon David Shafer estimates that his signature SWAG shot — short for “Shafer Width and Girth” — accounts for half of his practice. The treatment starts at $10,000, doesn’t require general anesthesia and can be reversed with the injection of an enzyme. In Atlanta, Prometheus by Dr. Malik, a fillers clinic, has been fielding requests from private equity investors.
Elist’s first book, “Put Impotency In Your Past,” published in 1991
In a business that’s often reduced to a punchline, enhancement entrepreneurs are unusually vocal about the perceived or actual chicanery of their rivals, whom they see as posing a threat to their fledgling legitimacy. “What can we do to keep patients out of the hands of these charlatans?” Paul Perito, who developed a popular filler named UroFill, asked colleagues at a recent webinar attended by doctors across the world. He displayed a slide highlighting an ad by Victor Loria, an osteopath and erstwhile hair transplant specialist headquartered in Miami, whose permanent penile filler injections were on sale for $14,950. Loria’s concoction, mixed in-house, includes liquid silicone oil, which is typically used to refill damaged eyeballs. Perito described Loria’s methods as “practically criminal,” but Loria, who self-identifies as the highest volume permanent penile filler administrator in the nation, denies unethical conduct, defends the safety record of his product and told me that Perito and his “bandits” were just upset that he’d stepped into the urologists’ sandbox.
What the Penuma promised the urologists was effectively what it promised patients: the chance to make it even bigger. Even as costs soar, physician reimbursement rates from Medicare for complex operations have declined. Inserting an inflatable penile prosthesis to treat erectile dysfunction brings a surgeon around $800. For the Penuma procedure, which is not covered by insurance, that same surgeon can pocket six times as much.
During a call in January 2020, four months after Mick’s Penuma surgery, Elist told him that the sensation in his penis would return in time. Having invested so much, financially and psychologically, in the implant, Mick felt grateful for the doctor’s assurances and tried to focus on his paintings, producing several large acrylic canvases in which forlorn human figures appeared to be tossed about by waves. But the numbness of his penis reminded him of having a limb fall asleep, indefinitely.
In the paperwork Mick had initialed on the day of the surgery, a clause said, “The clinic highly discourages seeking information elsewhere as the information provided can be false, misleading, and inaccurate.” One day, though, Mick opened Google and searched “Elist,” “Penuma,” “numb.”
“I was looking for people to tell me, ‘Oh, yeah, I waited three months, and now everything’s fine, I am very happy,’” he said. Those people were hard to find.
A truck driver whose device dug into his pubic bone told me that he felt like a “prisoner in my own body.” An executive at an adhesive company, who hid his newly bulging crotch behind a shopping bag when walking the dog, began to have nightmares in which he castrated himself. A sales specialist at an industrial supply store sent me his diary, which imagined Elist as its addressee. “I wish you would have told me I would lose erect length,” he wrote. “I wish you would have told me it could shift and pinch my urethra and make it difficult to urinate.”
It was tricky to bend over to tie the laces of winter boots, tricky to slip on a condom, tricky to sleep in a comfortable position, tricky to stretch, tricky to spoon. “It makes you look like you’re always semi-erect,” a health-spa vice president said of his Penuma. “I couldn’t let my kids sit on my lap. I couldn’t jump on the trampoline with them. I even felt like a pervert hugging my friends. And God forbid you get an actual erection, because then you have to run and hide it.”
Not everyone minded. Kaelan Strouse, a 35-year-old life coach, was thrilled by both the “restaurant-size pepper mill” between his legs and the kilts he began wearing to accommodate it. Richard Hague Jr., a 74-year-old pastor at a Baptist church in Niagara Falls, said his implant made him feel like “a wild stallion.” Contented customers told me they were feeling better about their bodies and having better sex, too. But even they acknowledged that getting a Penuma could require adjusting not just to a different appendage but to a different way of life. As one pleased Elist patient counseled others, “You have to treat your penis like a Rolex.”
For dozens of Penuma patients who spoke to me, the shock of the new was the prelude to graver troubles. Some, like Mick, lost sensation. Others said they experienced stabbing pains in the shower or during sex. Seroma, or excess fluid, was not uncommon. When a defense-and- intelligence contractor’s girlfriend, a registered nurse, aspirated his seroma with a sterile needle, a cup of amber fluid oozed out. The one time they tried to have sex, she told me, the corners of his implant felt like “someone sticking a butter knife inside you.”
Some implants got infected or detached. Others buckled at the corners. Occasionally these protrusions broke through the skin, forming holes that would fester. The hole of the health-spa vice president was so tiny that he originally mistook its fermented odor for an STD. An engineer with gallows humor played me a video of the snorting crunch his penis made when air moved through a hole. He had two holes, and the skin between them eventually eroded so that a corner of the implant emerged, pearlescent.
A Penuma removed from a patient
Later, doctors unaffiliated with the Penuma would compare such penises to “a torpedo,” “a penguin,” “a pig in a blanket,” “a beer can with a mushroom sticking out on the top” and “the tipped-down nose of the Concorde.” But the imperturbable assistants at Elist’s clinic, besieged by photographs documenting these phenomena, told patients that they were “healing as expected” and “continuing to heal well!” It was only after months had passed and the men insisted they weren’t healing well at all that Elist would sometimes suggest that an “upgrade” to a bigger size would resolve their problems. (Elist said in a deposition that upgrades are “part of the process of the procedure,” noting that some patients “might need the upgrade with the larger implant or the longer implant, and that happens often.”) Faced with the prospect of more surgery, some men began, quietly, to seek other advice.
The subculture of penile enhancement remains shrouded in stigma, because for a man to admit that he wants to be bigger suggests that he isn’t big enough. In February, the rapper 50 Cent settled his claims against the Shade Room, a gossip blog he’d sued for falsely insinuating that he’d had work done on his penis and subjecting him “to ridicule.” Only six of the 49 enlargement patients I spoke to agreed to have their last names printed, also fearing ridicule. In such a taboo and information-poor environment, anonymous testimonials can take on the authority of peer-reviewed journal articles.
Elist understood this dynamic. In addition to encouraging Bryan, the spokespenis, to post positive comments on My New Size, Elist tracked his own mentions on PhalloBoards and Thunder’s Place, other online forums for male enhancement, demanding that their moderators stop harboring “defamatory” statements. He offered a PhalloBoards user, after an abscess had formed, $5,000 for deleting his posts about the procedure and releasing the clinic from liability, according to a settlement agreement I reviewed. (Elist said through a spokesperson that the patient didn’t follow post-op advice, and that, while he was not able to respond to some of the accounts in this story because men had requested anonymity, complications were rare.)
A sign in Elist’s waiting room instructed patients not to speak to one another about medical issues (the better to protect their privacy, Elist said through the spokesperson). But Elist could only do so much to disrupt the communities of unhappy men coalescing online. As Mick pored over hundreds of posts, he was horrified to discover that he had been acting out a well-worn script. The others had also read the GQ article about the Penuma, learned that the implant was “reversible” and, heartened by the FDA’s clearance, put down their deposit. They, too, felt that their consultations were rushed and that they hadn’t had enough time to review the cascade of consent forms they’d signed alerting them to potential complications.
Emmanuel Jackson, then 26, was a model who had grown up in foster homes outside of Boston. He won a free Penuma in a contest in 2013, as part of a marketing campaign involving the rapper Master P. According to a complaint by the Medical Board of California, Jackson said he was given scripted answers for a promotional video, which later appeared on Elist’s YouTube channel. (Elist’s spokesperson said Jackson volunteered his positive comments in the video, and Master P, who once featured Elist on his Playboy Radio show, said through his own spokesperson that he was not involved with any YouTube testimonials for the implant.)
Emmanuel Jackson’s Penuma fractured into pieces.
Jackson didn’t find the other men online until 2018, around the time a doctor at the Cleveland Clinic told him his implant had fractured into pieces that were floating under his skin. A young Iraq War veteran whom Jackson met through PhalloBoards warned him that having the implant out could be even worse than having it in. “He told me, ‘Manny, you’re going to lose your mind,’” Jackson recalled. “He was right.” Medical records show that, not long after the fragments were removed, Jackson attempted suicide.
“I’ve been threatened for saying the things I’m telling you,” Mark Solomon said when I visited him in his waiting room, in Los Angeles, this spring. A plastic surgeon with an elegant Roman nose and a crisp white lab coat over a brown cashmere sweater, he’d learned the techne of male enhancement in Vienna in the ’90s. But he never imagined that, one day, nearly half his male practice would involve fixing the handiwork of other practitioners. Now, as much as he liked to joke that the last thing Beverly Hills needed was another plastic surgeon, he was doing such brisk business repairing Penuma complications that he’d relocated his practice from Philadelphia to an office down the street from Elist’s clinic.
As the number of Penuma procedures increased, a cottage industry emerged to treat what Solomon describes as a new class of “penile cripples.” William Brant, a reconstructive urologist in Salt Lake City, who told me he sees about 10 Penuma patients a month, noted “the deep despair of men who can’t unring the bell.” Gordon Muir, a urologist in London, said that he’s been taking out Penumas “all the way across the bloody pond.” But other reconstructive surgeons asked to speak confidentially, because they were afraid of being sued. Solomon had received a cease and desist letter from Elist’s lawyers arguing that the mere mention of Penuma on his website infringed on the implant’s trademark. (Solomon now notes his expertise in treating complications from “penis enlargement implants” instead.)
Part of plastic surgeon Dr. Mark Solomon’s practice consists of repairing Penuma complications.
From his satchel, Solomon produced a couple of biohazard bags. One held two sheaths of silicone stitched together with a blue thread: an early edition of the Penuma that he’d removed from a patient. The other contained a modern Penuma, a single piece with a built-in crease. “Once this goes in, these men are never going to be the same again, because their penis is never the same again,” he said.
When a foreign object is placed in the body, the body reacts by forming an envelope of tissue around it. In the penis, a retractable organ, this new tissue can distort shape and mobility, causing the penis to shorten and curve. The disfigurement can be exacerbated if the Penuma is removed, Solomon explained, since the penis can contract to seal up the vacuum of space — a phenomenon that patients have called the “mini-dick” or “dicklet” phase.
To counteract retraction and scarring after removal, some men engage in an elaborate penile rehab regimen. Solomon directs his patients to wear a condom with a metal weight at its tip six hours a day. Other doctors who remove the device — explanters, in the parlance — prescribe RestoreX, a contraption whose painful clamp and extension rods its users compare to a medieval rack. These daily stretching routines are sometimes accompanied by further revision procedures, as well as by prescriptions for Viagra and antidepressants. The great irony — lost on few — was that, after getting surgery to stop thinking about their penises, these men were now thinking about their penises all the time.
At conferences and in case reports, urologists across the country cautioned that, although they were seeing only the subset of patients unhappy enough to seek them out, the complications those patients presented (“significant penoscrotal edema,” severe erectile dysfunction “necessitating placement of an inflatable penile implant during removal”) could be “devastating” and “uncorrectable.” Penuma surgeons, meanwhile, were collecting their own data, which showed that the complication rate was both low and comparable to that of other procedures. In the largest study to date, published in The Journal of Sexual Medicine, Elist’s clinic surveyed 400 of the 526 patients who’d received a Penuma between 2009 and 2014. Eighty-one percent of the subjects who responded to the questionnaire indicated “high” or “very high” levels of satisfaction. Other surgeons told me they wouldn’t be associated with Elist’s invention if most of their patients (some of whom, they added, were urologists themselves) weren’t similarly pleased. On his website, one of the Penuma doctors dismissed PhalloBoards as being populated by patients who ignored post-op instructions and said it was propped up by “opportunistic” competitors. (Solomon is among a dozen doctors who sponsor PhalloBoards.)
Elist’s consent forms included a provision releasing the clinic from “any liability” if a patient receives post-op treatment elsewhere, but Mick, confused about whom to trust, online or off, decided to seek out a second professional opinion — and then a third, a fourth and a fifth. Some of the physicians he consulted were, as Elist had forewarned, baffled by the alien device. But Thomas Walsh, a reconstructive urologist and director of the Men’s Health Center at the University of Washington, was not. He was struck that Mick, like other Penuma patients, had the misapprehension that the device was easily “reversible,” as Elist and his network had advertised. “To fully consent to a procedure, the patient needs someone to tell him everything,” Walsh said. “He doesn’t need a salesman. The problem here is that you’ve got someone who is inventing and manufacturing and selling the device. That personal investment can create a tremendous conflict of interest.” (Elist, through his spokesperson, said his expertise with the device outweighs the conflict, which he freely discloses.)
Reconstructive urologist Dr. Thomas Walsh removed Mick’s Penuma.
Before removing Mick’s implant, in May 2020, Walsh ordered an MRI, which suggested that the device was impinging on the nerves and arteries at the head of his penis. Walsh also sent Mick to a neurologist, who, after prodding Mick’s shaft with a sharp metal tool, declared the glans to have lost “total” sensation.
There was no guarantee it would return. The challenge of removing a Penuma, Walsh told Mick, can lie in the detachment of a rectangular piece of mesh from the tip of the penis. Mesh prompts the body to create scar tissue, which binds together everything in its vicinity; to help the implant adhere, Penuma doctors stitched some near the head, an area dense with arborized nerves and blood vessels. Despite carefully planning the explantation, Walsh found himself disconcerted in surgery by the sight of his patient’s erogenous zone ensnared by the patch of plastic. “I feel like it’s sacrilege, wrapping a man’s neurovascular bundle in mesh,” Walsh later said. “How would anyone want to do that?”
It has been hypothesized that a longer penis confers an evolutionary edge in launching the reproductive payload into the vaginal canal. But, as the journalist David Friedman recounts in “A Mind of Its Own,” a cultural history of the male sex organ, some primatologists who have seen male apes brandish their genitals during a fight have posited that its purpose, if any, is simpler: to impress and intimidate rivals.
“They notice the penis of a brother or playmate, strikingly visible and of large proportions, at once recognize it as the superior counterpart of their own small and inconspicuous organ, and from that time forward fall a victim to envy for the penis,” Freud wrote in 1925. He was referring to the “momentous discovery which little girls are destined to make” about their lack of a phallus, but his description more precisely captures the “penis envy” that some men told me they’d felt after catching a glimpse of the competition. As John Mulcahy, a clinical professor of urology at the University of Arizona, put it, “It’s more of a locker room thing than a bedroom thing.”
Yet, after biological explanations for impotence triumphed and urologists wrested the penis away from the psychoanalysts, they seemed to overlook the man and the society to which it was attached. Critics of male enhancement said they had no desire to body shame men in search of something extra, noting that women who get breast implants can do so without provoking a moral panic. But, especially in the case of men with an unrealistic self-image, the critics worried that doctors seemed too eager to pitch a risky surgical procedure for what is a cultural, and, in some instances, a psychiatric, phenomenon.
What surgeons continually emphasized — the implanters with pride, the explanters with dismay — was that most of the men they were seeing had been of at least average size before going under the knife. (The photographic evidence men sent to me over text and email supported this contention.) “Most don’t have anything physically wrong with them at all, so what they don’t need is vultures preying on them, which is almost always a disaster,” Muir, the London urologist, said.
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 counseling 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.
An anatomical model at the Men’s Health Center at the University of Washington
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 MD 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 2020, 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 CEO 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 CEO 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 20% of the patients in his 2018 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 2021, 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’s 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 FBI agent in his early 30s 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 traveled 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 FBI, 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 specializes in class-action complaints. Last year, a Texas man accused International Medical Devices of falsely advertising the Penuma as FDA 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 10 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 35 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, centimeter by centimeter, 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 theater 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 part way and snipped a bit off the bottom. Pushing it into the shaft, he wagged it back and forth. “OK,” 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.
The office building in Beverly Hills where Elist’s clinic is located
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 website and of a book he self-published in 2015, “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 LA 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 FDA.”
At least 23 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 prosthesis 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 40 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 MO. 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 65-year-old property manager and auto detailer who filed a malpractice case in 2021, told me that a consultant at Elist’s clinic had encouraged him to get the Penuma by reassuring him that Elist had one himself.
Elist’s spokesperson told me that Duette’s allegations and the claims in the other lawsuits are false; that Elist does not have a Penuma; and that Elist is a gifted, responsive and exacting surgeon, supported by conscientious employees, who does not rush his patients and performs additional surgery only when medically appropriate. The spokesperson said Elist was not aware of any patients suffering extreme dissatisfaction or sleeplessness or mental health crises as a result of Penuma surgery, and noted that complications were more likely when patients failed to comply with post-op instructions. The spokesperson disputed some particulars of Mick’s account (Mick waived his medical privacy rights so that Elist could discuss his records) and said this article “cherry-picks and sensationalizes” outlier cases.
Elist told me that what his critics failed to grasp, whether by dint of envy or closed mindedness, was that for every dissatisfied customer there were many more whose lives had improved immeasurably. Nobody hears about the happy implantees, he said, because “unfortunately people are not willing to come out and talk about penile enlargement.”
All nine deeply satisfied Penuma patients I spoke to, several on the recommendation of Elist and his associates, said they would do it again. “I can give someone pleasure and see it in their eyes,” an industrial designer said. “That’s the part that makes me almost cry.” But hearing some of their stories I found myself wondering whether the difference between happy and unhappy customers was less a matter of experience than of its interpretation. Two men said they’d needed a second surgery to replace their implants when complications arose, and one continued to volunteer as a patient advocate even though he’d had his Extra Extra Large removed. He explained: “It was very uncomfortable for my wife. She was getting microtears and was considering getting a procedure done to enlarge that opening.”
Elist emphasized to me that “the best advantage of Penuma over any other procedure” was how easy it was to remove. He said that some patients even gained length upon removal. Last year, Penuma’s monthly newsletter, “Inching Towards Greatness,” featured the YouTube testimonial of a man who, after his removal, said that the procedure had still been “worth every cent.” This patient — who described his Penuma to me as a “life-ruiner” — said that he’d been under the influence of drugs the clinic had prescribed at the time. Elist, through his spokesperson, declined to comment on the matter; the video is no longer available.
In April, Mick received a letter from the office of California’s attorney general, notifying him of a hearing this October on Elist’s conduct. Since Mick had filed his complaint, the California medical board had investigated the surgeon’s treatment of 10 other Penuma patients, including the contest winner Emmanuel Jackson and other men I interviewed. Alleging gross negligence and incompetence, the board accused Elist of, among other lapses, recommending that patients treat what appeared to be post-op infections with Neosporin, aloe vera and a bloodflow ointment; asking them to remove their own sutures; and deterring them from seeking outside medical care. Elist said through his attorney that innovative procedures like his are routinely reviewed by regulators; that many specifics in the complaint are false; and that a previous medical board complaint against him was resolved in 2019, when he agreed to improve his recordkeeping.
Reading the letter from the attorney general’s office dredged up “dark thoughts from the ditch where I’d been burying them,” Mick said. In the three years since his Penuma removal, he estimates that he’s regained about 80% of the sensation in his penis, but his anger and sense of powerlessness have remained. In one of his last emails to Elist’s office, he wrote that he’d felt like “a testing mouse.” Given a recent expansion of Elist’s empire, the possibility that the surgeon might be censured, fined or lose his license now seemed to Mick beside the point. “They should have cut down the tree before it grew,” he said. “It’s too big now.”
The Medical Board of California is investigating Elist’s treatment of Mick and 10 other Penuma patients. A hearing is scheduled for October.
In Times Square, a billboard recently appeared: “MANHOOD REDEFINED,” it said, beside the URL for the Penuma website. A few weeks after Elist and his lawyer were served by the office of the California attorney general, Elist was traveling on the East Coast, training new recruits to his network. He has also been pitching interested parties in the United Arab Emirates, Qatar, Kuwait and South Korea, the world capital for cosmetic surgery. Colombia was already a go. “The Penuma is going to be the only procedure that surgeons not just in the United States but worldwide are going to accept,” Elist told me.
In June, his company rebranded the updated Penuma as the Himplant, and the Augmenta trial unfolded in a federal courthouse in downtown Los Angeles. Elist testified with brio about his victimization at the hands of Cornell, who’d violated “the sanctuary” of his operating theater; the judge ruled with Penuma’s attorneys that the negative experiences of patients like Mick were irrelevant to the question of theft at hand. On June 16, the jury returned a verdict in Elist’s favor and invalidated Cornell’s patents.
Not long ago, I met Bryan, Elist’s former penis model, at a coffee shop in Orange County. He had undergone multiple surgeries with Elist, with two different iterations of the implant. He said he’d experienced complications and, in 2011, he’d had his second implant removed. The following year, Bryan ended up flying to Philadelphia for the first in a series of revision and enhancement procedures with Solomon, whom he’d learned about on PhalloBoards.
This spring, he was released from prison, where he’d served time for participating in a car theft ring that a prosecutor described as highly sophisticated and that Bryan described to me as a matter of “incorrectly filled-out paperwork.” When he returned home, he got back into the enlargement scene. He now works as a paid patient advocate for Solomon — a role that involves fielding inquiries from men struggling with the fallout from unsatisfactory operations. The week before we met, Bryan had spent hours on the phone with Kevin (his middle name), an aspiring actor. Kevin said that he had undergone five surgeries with Elist, including two upgrades, a revision and a removal, and his penis no longer functioned.
Still, Kevin had always found the surgeon to be caring, if a little preoccupied. “He reminded me of Doctor Frankenstein — the intensity of him wanting this thing to come to life,” Kevin told me. It sounded strange, he acknowledged, but before each operation he’d been filled with excitement. “You just feel relieved that you’re fixing something,” he said.
At an appointment earlier this year, Kevin said, Elist promised to fix him again with a sixth procedure, but one of the surgeon’s assistants discreetly advised against it. Kevin thought he could spot “the other experiments” in the clinic from their loose-fitting sweatpants and the awkward way they walked. There were so many men waiting to see the doctor that they spilled into the hallway.
Kirsten Berg contributed research.
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