In the late 1970s, Sheldon Burman, the chief cardiothoracic surgeon at the Veterans Administration Hospital in North Chicago, started to notice something about his patients, veterans who were candidates for heart surgery. In their arteriograms-x-ray images of the arteries that provide a picture of the patient's blood flow-many of these men had significant blockage in the pathways to the penis. For a man to get an erection, blood has to rush to the penis, so Burman started to question his patients about the quality of their sex lives.

It turned out most of them had trouble. In those days long before Mike Ditka and Bob Dole were on TV touting drugs for erectile dysfunction, many of Burman's patients suffered serious, secret anxiety. "I was astonished to find that many of them were more devastated by their lost erectile ability than they were by the problem they were actually in the hospital for," Burman recalls.

Within a few years, Burman had shifted his professional attention from the heart to the penis, opening a male sexual dysfunction clinic and treating, by his count, more than 58,000 men over the next 25 years. Although he performed vasectomies and a variety of other procedures, he became a pioneer in one specialty that is particularly controversial: phalloplasty, surgery to enlarge the penis.

The national body of urologists has repeatedly declined to endorse phalloplasty, saying that it has not been found to be safe or effective. In the face of that opposition, Burman helped found the American Academy of Phalloplasty Surgeons, and he estimates he performed the operation more than 2,500 times after first doing it in 1992. Most of the procedures weren't absolutely necessary, he acknowledges: nobody he worked with needed a bigger penis to stay alive. "But I gave these men what they wanted," he says. "To my knowledge, no man has ever wished for a smaller penis."

Burman is no longer performing the procedure. He has been dogged by malpractice claims, many involving the enlargement surgery and some by men who claim the procedure left their penises deformed and scarred. In April 2005, Burman closed his Male Sexual Dysfunction Clinic on Chicago's Northwest Side, retiring at age 78.

But the book isn't closed on his practice. In August 2006, the Illinois Department of Financial and Professional Regulation began the process of determining whether to revoke Burman's medical license for a pattern of practice that it said might be found to be both incompetent and fraudulent. Two malpractice cases are pending against him now, and a third was settled in February for an amount the patient's lawyer, Robert Karr, would not disclose. (Burman's attorneys, Daniel Mills and Robert Sidkey at the firm Pretzel & Stouffer, did not respond to requests for an interview.)

As for Burman's statement that he was merely giving patients what they wanted, Kevin McVary, a professor of urology at Northwestern University's Feinberg School of Medicine, asks, "Is this Kmart or medical care? As a physician, you have to advocate for your patient, take the total view of his health and protect him, sometimes from marketing campaigns and sometimes from himself."

Some observers have wondered why it took the Department of Financial and Professional Regulation so long to investigate Burman's practice. "Obviously the process is not doing what it should be doing," says Christos Galanopoulos, who as head of surgery at Grant Hospital in the early 2000s sat on a committee that fought to keep Burman from being allowed to operate there. (Galanopoulos now works in California.) "The process is silly, and that means we [doctors] have to police ourselves better."
 

The question of penis size in attracting and satisfying sexual partners is, of course, a very old one. As Burman himself wrote in an article for Muscle & Fitness, "The penile erection has been celebrated and revered for thousands of years. Native and tribal art from all over the world features young men with prominent erections. The man with the big, erect penis could win more battles, impregnate more women and subdue his male rivals. His children, his females and his turf were more secure because of his splendid erect organ."

Studies in the 20th century by Kinsey, Masters and Johnson, and others suggest that this notion is largely myth. (There's some evidence that women derive more satisfaction from a partner with a thicker penis, but not a longer one.) And yet, "even though there is no evidence that men with bigger penises are more powerful or more attractive, there's still this false idea in most societies that the size of the penis is a measure of masculinity," says Ira Sharlip, a San Francisco urologist who is the spokesman for the American Urological Association. "So probably most men wish their penises were a little bigger than they are, but it's not a big enough wish to bring them to having surgery done."

It's not known how many doctors in the United States perform phalloplasty, but the American Academy of Cosmetic Surgery found in 2005 that at least 54 of its 1,800 members performed some kind of penis enhancement. (Burman is not a member of the AACS.) Surgical procedures are not regulated by a federal authority, as drugs are; but only an accredited surgeon like Burman would be able to get privileges at a hospital or surgicenter to do the operation.

In performing a phalloplasty, Burman would remove a small amount of fat from the patient's abdominal wall or buttocks by liposuction and transplant it into the penis, essentially wrapping the cylindrical shaft with fat. (Other surgeons use decellularized skin, sometimes from a cadaver.) Burman's clinic claimed on its Web site that patients' penises gained 50 percent in diameter.

Burman's second step involved cutting two "suspensory" ligaments that connect the base of the penis to the pubic bone, so that the organ hangs out farther when not erect. "Nobody knows what those ligaments are there for," Burman says. "You can cut them without any impact on penis wobbling or anything else." Burman's Web site (length andgirth.com; it's now closed down) said that cutting the ligaments added an inch and a half to the length of a penis, although Harold Reed, a Miami urologist who performs the procedure, says a patient normally gains about three-eighths of an inch.

Burman typically performed the phalloplasty procedure on an outpatient basis at a small hospital or surgicenter in about an hour. After the surgery, the patient's penis was bound snugly for seven to ten days in surgical wrap. Burman explains that this was to hold the transplanted fat in place so it could "revascularize," or grow nourishing blood vessels. For 16 weeks, the patient had to wear a penis stretcher, a small, flat device that prevented scar tissue from pulling the penis back in toward the body. Patients were told to refrain from intercourse or masturbation for six weeks after surgery.

Burman promoted his services with ads in Chicago newspapers, men's weight-training magazines, on the radio, and on the Internet. And the price of the procedure? In 2004, the Male Sexual Dysfunction Clinic's price for phalloplasty was more than $8,000, according to a press release. But in December of that year, the clinic announced a Christmas special "for the man who has everything": a discount to $6,999.
 

Burman told me during the course of four lengthy telephone interviews that of the thousands of phalloplasties he had performed, only a relative few resulted in malpractice suits. The problems, he says, came from former patients who had unrealistic expectations or who didn't follow the recommended care of their penises in the weeks after surgery, and that, he says, opened the door to predatory medical malpractice attorneys. Although patients are not supposed to have intercourse or masturbate for weeks after the surgery, he explains, "sometimes they can't resist, with what they now have."

Burman adds that every phalloplasty patient had to sign a form that stated clearly that the procedure had not been proven safe or effective, and that it "should be regarded as experimental surgery."

The doctor says he has many satisfied patients, and he put me in touch with one. This man went to Burman around 2001 to discuss getting a vasectomy and wound up learning about phalloplasty from the doctor. (Because of the intimate nature of the procedure, this man, as well as other patients interviewed for this story, asked not to be identified.) The patient says that before going to see Burman, he considered his penis adequate when erect, but in repose "it disappeared, and when a woman sees you like that, she wonders what you got." The patient was initially skeptical about Burman's length and girth operation, but ultimately decided to go for it because, he says, "Dr. Burman earned my confidence. There was no hard selling from him, just talking about how it works."

Five years after the operation, the patient says the increased size of his penis (he would not divulge the dimensions) "gives you a higher sense of self-esteem." His large penis, he says, "can be an aphrodisiac if used properly."

The malpractice suits tell far sorrier stories. "He robbed me," one former patient says of Burman, who in 2001 performed phalloplasty on this 61-year-old father of eight who lives in the western suburbs. The day after the surgery, the man, an immigrant who speaks little English, ended up in intensive care, where he remained for seven days while doctors repaired his punctured small intestine. A jury awarded the man $454,000, believing that Burman made the puncture with his liposuction equipment-although Burman's defense was that the puncture was the intestine's spontaneous response to chronic overuse of aspirin. Today, the man's penis appears ordinary in size, but his abdomen bears a huge scar, and when he lies down, a mass of herniated flesh the size of a fist rises up on his stomach. "This is why I don't see doctors ever again," he told me.

In the case that was settled in February, a patient claimed that Burman operated on him 13 times between January 2000 and September 2004, all to make the man's penis longer and fatter or to correct problems from prior procedures. The goal was for the man, a 40-year-old truck driver in the western suburbs, to "have the largest possible penis that would please both him and his partner," according to Burman's own operating notes. Today, in photos shown to me by Robert Karr, the patient's attorney, the man's penis is misshapen and swollen and looks more like a sweet potato.

Several lawyers who have brought cases against Burman argue that the doctor played on men's insecurities and, as one complaint alleges, performed phalloplasty "for reasons that were not consistent with accepted medical practices."

"Burman was targeting the less sophisticated [men,] the lower socioeconomic [class], and certainly the more gullible and more likely to come in really anxious to have something done," says Eugene Pavalon, a medical malpractice attorney. Pavalon settled two phalloplasty cases against Burman out of court for about $175,000 each as part of a 2001 "aggregate settlement," in which Burman's insurer gave its total liability coverage of $2 million to be divided among about ten plaintiffs, most of them for phalloplasty. With his partner John J. Simonetti, Pavalon has another case against Burman now.

Pavalon contends that Burman hurried his patients to have phalloplasty and, according to his complaint, failed to perform a complete preoperative evaluation. "If you come to a doctor and you need a procedure because you have a life-threatening problem, they rush you into surgery even if the risk is great," Pavalon says. "But these surgeries are elective. The patients could live without it."

Burman says he never targeted any one segment of the population, and never rushed a patient to sign up for the surgery. Not only would either of those practices have been wrong, he says; "it's not necessary when you have a procedure that so many men are asking to have done."

But he acknowledges that virtually all his phalloplasty patients came to him with penises in the range of normal (when erect, five to seven inches long and four to six inches around); the men worried, though, that they were too small. Burman says one patient arrived with his wife in tow; she showed the doctor a plastic sex toy and said she wanted her husband's penis to be made the same size.
 

Sheldon Burman was born in 1926, the son of Aaron Burman, who practiced medicine in Syracuse, New York, for 52 years. "I am my father's son," Sheldon says. "He taught me to adhere to principles I believe are proper and correct, and to be an integral part of the civic life of my community. I'm not the back-alley abortionist you might think. I've been a pioneer in two fields."

The first was cardiothoracic surgery, in which Burman scored a pivotal breakthrough 40 years ago. Burman had graduated cum laude from Syracuse University in 1947 and earned his medical degree at the State University of New York/Syracuse in 1951. In 1967, he performed the first successful transplant of an animal's heart valve into a human being, using the aortic valve of a calf. He then spent two years as the chairman of thoracic and cardiovascular surgery at the University of Sherbrooke in Quebec, before moving with his wife, Diane, to Chicago in 1970. He spent five years as a University of Illinois professor of surgery and the assistant chief of surgery at the West Side VA Hospital (now called Jesse Brown Medical Center), before becoming the chief of thoracic and cardiovascular surgery at what is now the North Chicago VA Medical Center and a professor of surgery and head of the cardiothoracic surgery division at the Chicago Medical School (now part of Rosalind Franklin University), also in North Chicago.

In 1973 the Burmans, who have been married since 1961 and have two daughters and a son, bought an impressive Italianate house in Highland Park on a large lot a few blocks from the lake; they still live there today. On a Saturday morning in December 1981, the couple were crossing a downtown Highland Park street when a car struck them. Burman convalesced for almost a year and eventually realized, he says, he "would not go back to cardiac surgery. The male sexual dysfunction thing was pulling me. The push was that accident."

With all the training and certification it entails to switch specialties, few physicians would do so at 55 years of age. Burman was trying something even more rare: he would go from the well-trodden realm of heart surgery to a little-known and less widely discussed field, men's erectile problems. At the time, Burman says, there were no urology programs in the United States with specialty training in erectile dysfunction or sexual health, so he made his own way.

Burman "apprenticed" himself to the chief of urology at the Chicago Medical School for a year and visited specialists at nine major medical centers around the country, "spending a few days with each one picking their brains." At the Chicago Medical School, he read every article or book he could in the library, he says, about the penis. Thus was he prepared, he believes, to launch a new specialty, male sexual dysfunction. "I've always been on the fringe, and I'm not afraid to be," he says.

Burman contends his lack of board certification in urology has irked his detractors, who believe that work on the penis is rightly part of that specialty. "They have never forgiven me," Burman says.

Northwestern's McVary says, though, that "Dr. Burman's troubles have nothing to do with turf issues." In February 2006, the American Urological Association reaffirmed its position that both injection of fat cells to make the penis wider and cutting the suspensory ligaments to make it longer are "procedures that [have] not been shown to be safe or efficacious." Ira Sharlip, of the Urological Association, says the issue is not whether Burman is a urologist: "Most of the people who do this surgery are urologists, and we have the same attitude about anyone doing the surgery."

Sharlip, McVary, and others say that there is no scientific study supporting the safety of phalloplasty. Burman relies on a survey he did of patient satisfaction (published in 1996 in the Proceedings of the International Symposium on Penile Disorders, in Hamburg, Germany). After his first 700 surgeries, Burman wrote, on an ascending scale of 1 to 10, "we judge patient satisfaction to be around 7." That was up from his previous paper, a 1994 report on the first 162 patients, where he had pegged satisfaction at 5 to 6. He also reported that when asked months after the surgery if the patients would do it again, "about 75% said yes."

But Burman noted something else about his practice: "Many of our patients are bodybuilders and weightlifters who are committed to attaining a highly developed, idealized vision of themselves. Many men come seeking the operation who are obsessed with the most minute details of their appearance," he wrote. "Our experience is that no matter the results, these patients will never be satisfied. No matter how perfect you make their penis, it will never be perfect enough."

Burman ran into problems with non-phalloplasty cases, too-since 1980, he has been sued at least 26 times for malpractice. (In 2001, an AMA survey found that, among physicians who have been sued for malpractice, the average is about two cases.) His record raises several questions: If he is performing a questionable operation, why would hospitals and surgicenters give him surgery privileges? And why didn't state regulators step in earlier to investigate?

Over the years, Burman worked at several small hospitals, including Doctors Hospital in Hyde Park (which has since closed) and Our Lady of the Resurrection Medical Center in Portage Park, and at surgicenters in Rogers Park and Vernon Hills. Because of Burman's estimable surgical pedigree, getting privileges to perform operations was relatively straightforward, says Christos Galanopoulos. He was head of credentialing at Lincoln Park's Grant Hospital when Burman applied for surgical privileges there in the early years of this decade. (Grant has since closed and been replaced in the facility by Lincoln Park Hospital.) Burman "has credentials, and blocking him from having privileges can be tough, because there's a risk he'll say you're putting unreasonable restrictions on his trade," Galanopoulos says. Nevertheless, Galanopoulos says, when the hospital ran a background check, "we noticed [Burman] had a significant number of lawsuits. We also had a bylaw that said urological surgery could only be performed by a board-certified urologist." After a contentious meeting with Burman, the credentialing committee rejected him. "But there were other hospitals whose rules didn't prohibit him from working," Galanopoulos says.

State licensers, meanwhile, gained new power to investigate malpractice cases when, in 2005, the legislature passed a medical malpractice reform package. Included in the law was a new statute of limitations that allowed investigators from the Department of Financial and Professional Regulation to go back ten years from the date a complaint was filed to prove a "pattern of practice" demonstrating incompetence or fraud. The new statute allowed investigators to look deeper into Burman's past and bolster their case against him.

In March of this year, the department had another status hearing on Burman's case. His license is intact unless and until the agency finds cause to suspend it. But he's retired and 80 years old, so why bother? Several attorneys in cases against him note that Burman is still vital; with a license, he could always go back to work. Burman responds that he has no intention of working anymore.

Burman closed his clinic in April 2005, four months before the medical malpractice reform package became law. "I just wanted to retire quietly," he told me. "I've spent 54 years as a surgeon, and I want to retire with my dignity and my reputation unsullied." While defending the lawsuits and the Department of Financial and Professional Regulation proceedings, Burman has kept busy with other things. He has long been active in Democratic politics, civil rights groups, Lake County health organizations, and other civic groups. After retiring, he was named to the Dean's International Council, a policy advisory board, at the Harris School of Public Policy at the University of Chicago. (His official biography, posted on the school's Web site, emphasizes his accomplishments in cardiothoracic surgery, never mentioning his career since 1981.) He has his memoirs and a biography of his father to write. He works out three times a week and says, "If you saw me, you'd think I was 20 or 30 years younger." (Though we talked on the phone, he would not meet me in person.)

Although he has been embattled since retirement, Burman told me several times that he has neither shame nor regret about his work in penis enhancement. "I loved my work. I loved getting up every day and doing this," he says. "These men would come to me in agony. Maybe [the patient's] fiancée had left, and on the way out said, ‘By the way, you're not much of a man.' [Or the patient] had been laughed at in the locker room. Or-this is common-he was a competitive bodybuilder and felt he needed to have in the Speedo something that was visible, that showed how strong he was.

"And I gave these guys what they wanted."