Most of the reported series were comprised of patients with gender dysphoria. Men requiring TPR for penile loss after ritual circumcision differ radically from most cases in the literature, in that these young men were subjected to a life-threatening event, often under peer pressure. Apart from the physical disfigurement, there is severe psychosocial debilitation resulting from the loss of sexual function and fertility. The reality in South African state hospitals is that the operative time and resources to provide free flap TPR for these patients is rarely available. If such surgery is performed, it is rarely followed by prosthesis placement, due to the high cost and the risk of complications such as extrusion and infection. Consequently, many mutilated young men face a future with severe sexual and psychosocial problems.