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Voluntary Genital Ablations: Contrasting the Cutters and Their Clients

Sex Med. 2014 Aug; 2(3): 121–132.

Published online 2014 Jul 17. doi: 10.1002/sm2.33

Robyn A Jackowich, BA,*Rachel Vale, MD,Kayla Vale, MD,§Richard J Wassersug, PhD,** and Thomas W Johnson, PhD††

Robyn A Jackowich

*Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada

Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada

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Rachel Vale

Division of Dermatology, University of Toronto, Toronto, ON, Canada

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Kayla Vale

§Department of Family Medicine, McMaster University, Vancouver, BC, Canada

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Richard J Wassersug

Department of Medical Neuroscience, Halifax, Nova Scotia, Canada

**Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Vic., Australia

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Thomas W Johnson

††Department of Anthropology (Emeritus), California State University-Chico, Fulton, CA, USA

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Author informationCopyright and License informationDisclaimer

*Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada

Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada

Division of Dermatology, University of Toronto, Toronto, ON, Canada

§Department of Family Medicine, McMaster University, Vancouver, BC, Canada

Department of Medical Neuroscience, Halifax, Nova Scotia, Canada

**Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Vic., Australia

††Department of Anthropology (Emeritus), California State University-Chico, Fulton, CA, USA

Corresponding Author: Thomas W. Johnson, PhD, Department of Anthropology (Emeritus), California State University, Chico, P.O. Box 50, Fulton, CA 95439-0050, USA. Tel: +1 (707) 528-7725; E-mail: [email protected]

Copyright © 2014 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

This article has been cited by other articles in PMC.

Abstract

Introduction

Some healthy males voluntarily seek castration without a recognized medical need. There are currently no standards of care for these individuals, which cause many of them to obtain surgery outside of a licensed medical setting. We seek to understand who performs these surgeries.

Aim

This study aims to characterize individuals who perform or assist in genital ablations outside of the healthcare system.

Methods

A cross-sectional Internet survey posted on eunuch.org received 2,871 responses. We identified individuals who had performed or assisted in human castrations (“cutters”; n = 98) and compared this group with all other survey respondents (n = 2,773), who had not assisted in castrations. Next we compared the cutters with the voluntary eunuchs. Lastly, because many of the cutters have themselves been castrated, we also divided the physically castrated population (n = 278) into cutters (n = 44) and noncutters (n = 234) and compared them.

Main Outcome Measures

Self-reported questionnaires were used to collect demographic information, gender identity and presentation, selected childhood experiences, and history of aggressive behaviors, self-harming behaviors, and hospitalization.

Results

Distinguishing characteristics of cutters included: (i) presenting themselves as very masculine, (ii) having had their longest sexual relationship with a man, (iii) growing up on a farm, (iv) witnessing animal castrations, (v) having a history of sexually inappropriate behavior, (vi) having been threatened with genital mutilation as a child, (vii) having a history of self-harm, (viii) being raised in a devoutly Christian household, (ix) having had an underground castration themselves, and (x) having body piercings and/or tattoos.

Conclusions

This study may help identify individuals who are at risk of performing illegal castrations. That information may help healthcare providers protect individuals with extreme castration ideations from injuring themselves or others. Jackowich RA, Vale R, Vale K, Wassersug RJ, and Johnson TW. Voluntary genital ablations: Contrasting the cutters and their clients. Sex Med 2014;2:121–132.

Keywords: Castration, Genitals, Eunuch, Gender, Body Modification, Eunuch Archive

Introduction

There are men who seek and obtain genital ablations outside proper medical facilities for reasons other than medical necessity, such as testicular or metastatic prostate cancer 1–5. Some of these men identify as male-to-female transsexuals and seek orchiectomy and/or penectomy as part of sexual reassignment surgery but have been unable to receive the proper psychiatric diagnosis for elective surgery. There are others who are driven to genital ablation from psychological distress and may have a diagnosis of xenomelia or Body Integrity Identity Disorder, which is not associated with a gender dysphoria 6–8. Some men have socially challenging paraphilic interests and seek castration as a means of libido control. There are also individuals who desire castration because they do not feel comfortable identifying as female or male and prefer a gender identity outside the gender binary currently recognized in the contemporary western world 1,9–11.

Individuals who wish to be emasculated but do not identify as female have few options for medical assistance. There is a lack of formal standards of care for “male-to-eunuch” unlike those provided for male-to-female transsexuals in the Standards of Care of the World Professional Association for Transgender Health (see [12,13]). As a result, these individuals are unable to find appropriate medical care and may seek services outside of the medical community for their genital surgeries [2,3,14].

As part of our ongoing study of modern-day eunuchs in the western world, we have previously explored the motivation for, and consequences of, castration [1,2,14,15]. In the present study, we attempt to characterize individuals who perform or assist in genital ablations that occur outside of the healthcare system. In the eunuch.org community, a forum for those interested in the subject of human castration, these individuals are referred to as “cutters.”

In 2008, we posted a request for survey respondents on the eunuch.org website in order to better understand the motivations of those who seek voluntary castration. There were just over 3,000 respondents and close to 100 individuals who reported having assisted in human castrations outside the medical framework. Among the other respondents, there were individuals who had already been either chemically or physically castrated, or who expressed an interest in the subject with or without any expressed desire to become castrated. Although voluntary eunuchs have received some previous research attention, there are no studies that profile the unlicensed providers of human castration 1–3,16.

Our concern is about the safety of the “clients” of the cutters, and of the cutters themselves, who work outside of the healthcare system. Individuals, who perform surgeries without a license, put themselves at serious legal risk … in addition to putting their clients at great physical risk. In striving to characterize the cutters, we hope to better inform healthcare providers about this population so that they can identify individuals attracted to the activity and intercede appropriately.

Aim

Our goal was to characterize the cutter population and identify any features that distinguished them from their “clients.” We hypothesized that cutters, castrated or not, form a distinct and definable subset of individuals with extreme castration ideations. In characterizing the cutters, we aim to inform healthcare providers of their existence. We wish to help profile individuals, who may be at high risk of illegal activities and physical injury to themselves and others.

Definitions

In order to characterize the population, we define cutters as any respondents, castrated or not, who indicated that they had assisted in the castration of another person. We compared the cutters with other subgroups within our larger surveyed population. We focused on three groups for comparison (see Figure ​1). First, we compared them with noncutters in our larger population of online survey respondents. This included all individuals who had expressed an interest in castration independent of whether or not they have been chemically or physically castrated but who had not participated in the castration of others. Next, we looked more extensively at the subpopulation of survey respondents who had been physically castrated (i.e., eunuchs, many of whom were clients of cutters). As many of the cutters were themselves castrated, we divided this physically castrated group into eunuch cutters and eunuch noncutters for a third comparison.

Methods

Our questionnaire was created using the SurveyMonkey template (http://www.surveymonkey.com). It was posted on the Eunuch Archive website (http://www.eunuch.org, an online community interested in “testicles, testosterone, castration, eunuchs and related topics”) for 6 months from July through December 2008. All participants provided informed consent consistent with review board approval from Dalhousie University, Halifax, Nova Scotia. The survey was announced on the “front page” of the site, and participation was invited. Some members wrote favorable comments on the site after completing the survey, which aided recruitment. No compensation was provided for participation. Participants were anonymous and were not required to answer all of the survey questions, resulting in slight differences in the number of responses to each question. Eligible participants were 18 years of age or older and had computer access to the Eunuch Archives website. There were 3,015 individuals who responded to the survey. Because Eunuch.org is a website specifically for individuals with an interest in castration, there was no separate control group of fully disinterested individuals to which the cutters or their clients could be compared.

We deleted 38 responses from individuals claiming to be under the age of 18. To screen out fraudulent responses, we deleted all submissions with inconsistencies (e.g., age—question #2—that did not match date of birth—question #477, as in one case, a respondent claimed to have been castrated before puberty yet had biological children). In order to reduce the chances of receiving multiple submissions from a single individual, we only accepted a single submission from any one IP address. Three independent researchers assessed all submissions that had questionable authenticity and/or data. Responses were excluded if two of the three reviewers doubted their authenticity. We eliminated an additional 28 responses as possibly fraudulent. A small number of women completed the questionnaire (75 “just interested” respondents and three cutters). Being male was not a requirement to complete the survey; however, we excluded these women from our analyses, as there were too few women respondents to analyze as a separate group. It is noteworthy that some women perform underground castration. Within the eunuch community, female cutters are referred to as “castratrixes.” The total number of valid, 18+, males left in the sample was 2,871.

Chi-squared tests were conducted to assess the significance of the differences between the cutters and other groups, with P < 0.05 taken as significant. Independent samples t-tests were used to compare the ages of the groups. All analyses were completed using SPSS Statistics software, version 21 (SPSS Inc., Chicago, IL, USA).

Main Outcome Measures

The survey contained questions pertaining to: (i) general demographic information (e.g., age, country of residence, education level, current marital status, and annual income), (ii) gender identity and presentation, (iii) childhood experiences such as abuse and witnessing animal castration, (iv) history of aggressive behaviors, (v) self-harming behaviors, (vi) sexually offensive behaviors, and (vii) hospitalization history. Self-harm was explored further with questions regarding a history of body modification, i.e., if participants had any tattoos or piercings. A closer look at the survey methods as well as a more detailed presentation of demographic information for the total study population can be found in Vale et al. [14].

Results

Of the 2,871 individuals in our core sample, 278 reported that they had been physically castrated and were eunuchs, and 98 reported an involvement in performing human castration.

The majority of respondents reported that they resided in the United States and the rest were from the United Kingdom, Canada, Australia, or Germany (approximately 5–10% from each) or one of 60 other countries, mostly from Europe. The majority of respondents (88.2%, n = 1,786) identified as white. Additional sample demographics are presented in Table ​1.

Table 1

Sample demographics

Overall sample (n = 2,871)Cutters (n = 98)Noncutters (n = 2,773)Physically castrated (n = 278)
Age at time of survey44.143.844.545.8
Location
 United States59% (1,569)60% (55)59% (1,391)64% (169)
 United Kingdom10% (261)1% (1)10% (240)6% (16)
 Canada6% (154)7% (6)6% (132)6% (15)
 Germany5% (134)7% (6)5% (108)5% (12)
Ethnicity
 White88% (1,786)74% (56)89% (1,590)86% (172)
 East Asian3% (51)5% (4)2% (37)1% (2)
 European2% (47)3% (2)2% (42)6% (12)
Education level
 Graduate degree/MD etc.23% (657)31% (30)23% (583)17% (57)
 All or part of an undergraduate degree53% (1,518)36% (35)54% (1,347)53% (146)
 Vocational or trade school7% (186)11% (11)6% (155)6% (17)
 All or part of a high school diploma17% (494)22% (22)16% (406)20% (56)
Salary (U.S. dollars)
 <25,00023% (623)33% (29)25% (587)26% (60)
 25,000–50,00030% (744)17% (15)31% (721)34% (78)
 50,000–100,00031% (755)25% (22)31% (724)28% (65)
 >100,00014% (336)26% (23)13% (310)12% (28)
Marital status
 Divorced/separated9% (263)17% (16)9% (223)11% (30)
 Married36% (1,002)29% (28)37% (890)36% (94)
 Partnered14% (403)24% (23)14% (339)17% (44)
 Single40% (1,124)30% (29)40% (981)37% (97)
Cutters4% (98)18% (44)
Physically castrated10% (278)45% (44)8% (196)

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Differences Between Cutters and All Noncutters

More cutters self-identified as “eunuch,” “third gender,” or “other” compared with the noncutters (see Table ​2 for significant differences between cutters and noncutters). The two groups also differed significantly in their current public gender presentations, with a greater proportion of the cutters reporting that they present as “very masculine” (P < 0.01) despite their propensity toward a third gender identity. Furthermore, significantly more of the cutters indicated that their longest sexual relationship was with a male compared with the noncutters (P < 0.01). There was no significant difference in age between the two groups (P = 0.65).

Table 2

Differences between cutters (n = 98) and all noncutters (n = 2,773) who participated in the eunuch.org survey

CuttersNoncuttersP value
Age at time of survey43.844.40.65
Self-identify as “eunuch,” “third gender,” or “other”41% (40)18% (447)<0.01
Present publicly as “very masculine”37% (36)25% (606)<0.01
Marital status0.001
 1) Divorced/separated17% (16)9% (223)
 2) Married29% (28)37% (890)
 3) Partnered (not married)24% (23)14% (339)
 4) Single30% (29)40% (981)
Annual income0.01
 1) More than $100,00026% (23)13% (310)
 2) $50,000–100,00025% (22)31% (724)
 3) $25,000–50,00017% (15)31% (721)
 4) Less than $25,00033% (29)25% (587)
Education level<0.001
 1) Doctoral or other advanced degree17% (17)7% (183)
 2) Master's degree or equivalent13% (13)16% (400)
 3) Finished university (4/5 year degree)18% (18)27% (677)
 4) Some college or a 2-year degree17% (17)27% (670)
 5) Vocational or trade school11% (11)6% (155)
 6) Finished high school11% (11)12% (297)
 7) Some high school or less11% (11)4% (109)
Primarily raised …0.003
 1) In a large city (over 250,000)29% (28)19% (467)
 2) In a medium-sized city (50,000–250,000)21% (20)17% (415)
 3) In a small city or town (under 50,000)16% (15)27% (674)
 4) In a suburb near a large city9% (9)14% (346
 5) In open country, but not on a farm7% (7)12% (302)
 6) On a farm19% (18)11% (281)
Observed or assisted in animal castration52% (47)27% (635)<0.01
Threatened with genital mutilation or castration in childhood24% (23)14% (346)0.006
More than three hospitalizations following genital injuries5% (3)1% (9)<0.01
Injuries to the:
 1) Penis39% (38)25% (627)<0.01
 2) Scrotum50% (49)23% (575)<0.01
 3) Testicles57% (56)25% (621)<0.01
History of deliberate self-harm32% (30)12% (304)<0.01
Thinking about sex never makes them feel guilty64% (57)50% (1,219)<0.01
Longest sexual relationship has been with a male31% (30)25% (628)<0.01
Seven or more alcoholic drinks per week21% (21)20% (500)0.87
Recreational drug use (any)20% (19)11% (281)0.013
Sexually inappropriate behavior
 Concerned that they might commit …43% (40)34% (823)0.78
 Concern with committing … increased interest in castration20% (18)12% (273)0.068
 Accused19% (17)11% (253)0.57
 Charged9% (8)3% (61)<0.01
 Convicted13% (12)2% (49)<0.001
Abused or assaulted as a child30% (29)23% (579)0.314
One or more tattoos31% (30)26% (426)0.002
Have or had any piercings52% (50)33% (827)<0.001
History of aggressiveness or aggressive display18% (17)15% (377)0.78
Have ever fantasized about castrating others64% (61)34% (824)<0.001
Handedness0.38
 1) Right71% (68)77% (1,906)
 2) Left18% (17)14% (348)
 3) Ambidextrous11% (11)9% (222)
Parent's religiosity rated “very devout”14% (13)8% (200)0.07
Religion raised<0.001
 1) Christian (other than Catholic)35% (34)50% (1,234)
 2) None21% (20)17% (409)

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There were a higher proportion of cutters at both the upper and lower ends of the education scale when compared with noncutters. This was reflected in their reported annual incomes as significantly more cutters reported annual incomes in both the lowest and highest income brackets (P < 0.01). Of the cutters, a third earned less than $25,000, and about a quarter said that they earned more than $100,000 annually. More than twice as many cutters as noncutters have completed a doctoral or equivalent degree.

A greater proportion of cutters than noncutters indicated that they were raised on farms (P < 0.003) though the majority of cutters reported being raised in a large city. Consistent with being raised on farms, almost double the proportion of cutters than noncutters indicated that they had assisted in or observed the castration(s) of farm animals and/or pets (P < 0.01). Of the cutters, only 19% grew up on farms but 52% had participated in the castration of farm animals.

Significant differences between the cutters and the noncutters were evident in the self-reported histories of sexually inappropriate behavior. The proportion of cutters who had been charged with sexually inappropriate behavior was three times greater than that of the noncutters (P < 0.01). The proportion of cutters who indicated that they had been convicted of sexually inappropriate behavior was six times greater than that of the noncutters (P < 0.001). Although the groups did not differ on whether they were concerned about committing sexually inappropriate acts (P = 0.78), more cutters than noncutters (approaching significance) endorsed the idea that their concern with committing sexually inappropriate behavior increased their interest in castration (P = 0.068).

Significantly more cutters than noncutters had a history of being threatened with genital mutilation or castration in childhood (P < 0.006). Although large numbers of both cutters (30%, n = 29) and noncutters (23%, n = 579) report instances of abuse or assault during childhood, the difference between these two groups was not significant. Cutters and noncutters do not report a significant difference in alcohol use (P = 0.87), but cutters report significantly higher recreational drug use (P = 0.013). Furthermore, cutters were over two times more likely to have a history of deliberate self-harm, genital or other (P < 0.01).

Approximately two-thirds of cutters indicated that they had fantasized about castrating others (P < 0.001), compared with only one-third of noncutters. Cutters report significantly more body modifications, including tattoos (P = 0.002) and piercings (P < 0.001) compared with noncutters. Almost two-thirds of cutters reported that they do not feel guilty when thinking about sex, whereas only half of noncutters (P < 0.01) shared this sentiment.

Consistent with this result, the number of reported hospital visits due to genital injuries was greater for the cutters (P < 0.05). The proportion of the cutters that reported more than three hospitalizations following genital injuries was four times that of the noncutters. Conversely, 78% of the noncutters reported never having been hospitalized due to genital injury, compared with 58% of the cutters. As well, a significantly greater percentage of the cutters reported having injuries to their penis, scrotum, or testicles than the noncutters, although the survey did not differentiate accidental from deliberate injuries.

Difference Between Cutters and Physically Castrated Individuals

Our most notable finding was the overall similarity between the cutters and their “clients,” i.e., those whom they cut, the physically castrated individuals. In all of the parameters we measured, there were no statistically significant differences between all cutters and all those who had been physically castrated. This is not surprising, as 45% (n = 44) of the cutters reported being physically castrated, providing a large overlap in membership between the two groups. However, in comparing specifically cutters and noncutters within the greater community of the physically castrated, significant differences emerged. These are addressed below.

Differences Between Cutters and Noncutters Within the Physically Castrated (Eunuch) Population

Similar to the overall sample, the majority of both eunuch cutters and eunuch noncutters in the physically castrated sample reported being of white ethnicity and currently residing in North America (Ps > 0.10). There was no significant difference between the two groups on age at the time of completing the survey (P = 0.14) or age at the time of castration (P = 0.68; see Table ​3). The physically castrated cutters and noncutters did differ on a few demographic variables. Almost half of all cutters reported an annual income of less than $25,000 compared with only a quarter of noncutters (P = 0.03). However, contrary to the lower incomes they report, significantly more cutters reported having a Masters or PhD level of education (P = 0.01). Significantly more cutters reported being divorced or separated (21%, n = 9) than noncutters (9%, n = 16), and more noncutters reported being single (40%, n = 76; P = 0.01). Cutters were more than twice as likely to have been raised in large cities (40%, n = 17) than were noncutters (17%, n = 33; P = 0.01). The two groups were, though, equally likely to have been raised on farms (cutters 16%, n = 7; noncutters 17%, n = 34). Despite that, eunuch cutters were almost twice as likely to report having participated in animal castrations (40%, n = 17) than were eunuch noncutters (23%, n = 41; P = 0.02).

Table 3

Differences between physically castrated (i.e., eunuch) cutters (n = 44) and physically castrated eunuchs who are noncutters (n = 234)

CuttersNoncuttersP value
Age at time of survey45.646.90.14
Age at time of castration38.239.30.68
Self-identify as “eunuch,”, “third gender,” or “other”72% (31)63% (123)0.30
Present publicly as “very masculine”27% (12)20% (39)0.73
Marital status0.01
 1) Divorced/separated21% (9)9% (16)
 2) Married25% (11)39% (73)
 3) Partnered (not married)25% (11)12% (23)
 4) Single29% (13)40% (76)
Annual income0.03
 1) More than $100,00014% (3)12% (22)
 2) $50,000–100,00024% (10)30% (55)
 3) $25,000–50,00019% (8)36% (66)
 4) Less than $25,00043% (18)23% (42)
Education level0.01
 1) Doctoral or other advanced degree14% (6)7% (13)
 2) Master's degree or equivalent23% (10)12% (23)
 3) Finished university (4/5 year degree)18% (8)28% (55)
 4) Some college or a 2-year degree14% (6)33% (64)
 5) Vocational or trade school11% (5)4% (8)
 6) Finished high school11% (5)13% (26)
 7) Some high school or less9% (4)4% (7)
Primarily raised …0.01
 1) In a large city (over 250,000)40% (17)17% (33)
 2) In a medium-sized city (50,000–250,000)16% (7)14% (27)
 3) In a small city or town (under 50,000)16% (7)26% (50)
 4) In a suburb near a large city2% (1)13% (25)
 5) In open country, but not on a farm9% (4)14% (27)
 6) On a farm16% (7)17% (34)
Observed or assisted in animal castration40% (17)23% (41)0.02
Threatened with genital mutilation or castration in childhood21% (9)15% (29)0.36
More than three hospitalizations following genital injuries0% (0)4% (5)0.812
History of deliberate self-harm33% (14)18% (35)0.89
Thinking about sex never makes them feel guilty67% (24)66% (117)0.77
Longest sexual relationship has been with a male34% (15)23% (45)0.22
Seven or more alcoholic drinks per week27% (12)21% (40)0.46
Recreational drug use (any)16% (7)13% (25)0.29
Sexually inappropriate behavior
 Concerned that they might commit …26% (11)16% (31)0.14
 Concern with committing … increased interest in castration10% (4)12% (21)0.93
 Accused21% (9)15% (28)0.65
 Charged12% (5)4% (8)0.063
 Convicted14% (6)3% (6)0.005
Abused or assaulted as a child27% (12)34% (66)0.70
Have ever fantasized about castrating others61% (26)23% (45)<0.001
One or more tattoos50% (22)30% (58)0.03
Have or had any piercings64% (28)40% (78)0.02
History of aggressiveness or aggressive display14% (6)16% (30)0.89
Handedness0.35
 1) Right71% (31)75% (145)
 2) Left23% (10)15% (28)
 3) Ambidextrous7% (3)10% (20)
Parent's religiosity rated “very devout”14% (6)13% (25)0.96
Religion raised0.60
 1) Christian (other than Catholic)43% (19)48% (94)
 2) None18% (8)17% (34)
Hormone replacement therapy0.15
 1) Full testosterone replacement41% (17)29% (55)
 2) No or low HRT45% (19)62% (117)
 3) Transitional (high) estrogen14% (6)10% (18)
Friend or lover performed their castration30% (13)6% (11)0.001
Underground cutter performed their castration25% (11)6% (11)0.001
Self-castrated9% (4)19% (38)0.10
Personal castration performed by an MD11% (5)48% (94)<0.001

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Cutters, who are physically castrated, were significantly less likely (P < 0.001) to have had their castration performed by an MD compared with noncutters who were physically castrated. Alternatively, significantly more physically castrated cutters reported having had a friend or lover (P < 0.001) or another underground cutter (P < 0.001) perform their castration compared with physically castrated individuals who are noncutters. Although not statistically significant (P = 0.15), cutters were more likely to take a replacement dose of testosterone (41%, n = 17) than were noncutters (29%, n = 55) and, conversely, the noncutters were more likely to use either no hormone replacement therapy or a low dose of estrogen or testosterone at a level thought to ward off osteoporosis and hot flashes (62%, n = 117) than were the cutters (45%, n = 19).

When it came to body modifications, almost two-thirds of the physically castrated, who are themselves cutters, report having (or ever having) piercings compared with less than half of the physically castrated who are noncutters, and this difference is significant (P = 0.02). Half of physically castrated cutters reported having tattoos, which is significantly more than the 30% of physically castrated noncutters (P = 0.03).

In terms of committing sexually inappropriate acts, the physically castrated cutters and noncutters differed more as the consequences increased, with significantly more cutters reporting a conviction (14%, n = 6, P = 0.005). No differences were found between the two groups on their concerns about committing sexually inappropriate behaviour, or whether this concern was their motivation for seeking castration. The majority of physically castrated cutters reported having fantasized about castrating others, compared with just below one quarter of noncutters (P < 0.001).

Discussion

Based on previous survey data, Johnson et al. [2] suggested that there were specific risk factors for extreme castration ideations leading to voluntary genital ablations. These included: (i) a history of childhood abuse, (ii) being threatened as a child with genital mutilation, (iii) being raised in a devoutly Christian home, (iv) having witnessed or participated in physical castration(s) of animals, and (v) homosexuality or bisexuality. Vale et al. [14] confirmed that these are true risk factors for obtaining voluntarily castration. We have identified these to also be risk factors for individuals participating in nonmedical genital ablations, i.e., our cutters. As many of the cutters are themselves castrated, it is not surprising that the risk factors for cutters overlap with those for becoming physically castrated.

It is unclear how influential these risk factors are in terms of promoting a desire to castrate others. Open-ended questions in our survey regarding reasons for interest in castration frequently brought forth reports of witnessing animal castration(s) [14]. Unfortunately, there are no prevalence rates for how many individuals in society at large have witnessed animal castrations as a point of comparison. Interestingly, despite the similar proportion of cutters and noncutters that grew up on farms, more cutters reported to have witnessed animal castrations than noncutters.

Having been threatened with genital mutilation was identified as a more common experience in those seeking castration. Nearly one quarter of both the cutters and the physically castrated said that they had been threatened with genital mutilation as children. Several of our participants reported that their mothers had held a knife or scissors to their penis and threatened to cut it off after finding them masturbating. One respondent wrote a long account of being held by his father while his uncle pulled down his pants, held a knife to his scrotum, and offered to castrate him just like the pigs he had been watching them castrate.

A notable percentage of both the cutters and the physically castrated participants reported having been raised in “very devout” households that possibly condemned certain sexual activities and behaviors (see [14]). Children raised in devoutly religious homes are often taught that sexual activities for pleasure, such as masturbation, or certain sexual orientations and partnerships, such as homosexuality, are sinful. Among our respondents, 34% of cutters and 23% of noncutters reported their longest sexual relationship was with a male. As children threatened with genital mutilation, they may have come to believe that castration is a method to control undesirable sexual thoughts and activities. Indeed an association between devout religiosity, being threatened with genital mutilation, and being physically castrated is evidenced in our data and discussed in Vale et al. [14]. These risk factors may synergistically lead to a desire for castration. However, it is less obvious how they contribute to a desire to castrate others, as significant differences in these variables were not seen between the cutters and the physically castrated subgroup.

Perhaps contradictory to this is the finding that 67% of physically castrated cutters and 66% of physically castrated noncutters reported that thinking about sex never makes them feel guilty. Also, 41% of all cutters report identifying as “eunuch,” “third gender,” or “other,” while despite this, 37% of all cutters report presenting as “very masculine.” Regrettably we did not ask explicitly about the motivation for castrating others. Nor did we ask about the number of castrations the cutter had participated in. Without such additional data, it is impossible to tell if these are contradictory risk factors (i.e., self-identifying as being “very masculine,” yet identify as outside the gender binary), or hints of subgroups within the larger cutter population.

Our comparison of the subgroup of physically castrated cutters to physically castrated noncutters sought to identify additional risk factors beyond those discussed in Vale et al. [14], i.e., contrasting cutters and their clients. Many of the significant differences that we found between cutters and noncutters are no longer significant when we compare cutters with noncutter eunuchs. It appears that the risk factors for becoming a cutter are essentially risk factors for obtaining castration rather than performing it. Similarly, they suggest that physically castrated cutters are a distinguishable group within the population of cutters.

One notable difference in the physically castrated subgroup of cutters relates to who performed their castrations. More physically castrated cutters had a friend, or loved one perform their castration. Conversely, the majority of physically castrated noncutters performed self-surgery, or had a medical professional perform their surgery if that option was available to them. This difference may be the result of the different motivations for seeking castration, i.e., whether they seek castration to become compatible with their gender identity, or to fulfill a sexual fantasy.

In addition, more than two-thirds of the cutter population have piercings and or tattoos. This may suggest a greater interest in body modification. In the overall comparison of all cutters vs. noncutters, significantly more cutters report being charged and convicted for sexually inappropriate behavior. Within the physically castrated subgroup, the cutters remain significantly more likely to be convicted of sexually inappropriate behavior. However, there is no difference between the two groups in whether their concern about committing an inappropriate behavior increased their interest in castration.

Given the nature of our data, we cannot say which characteristics or experiences are most related to the desire to perform castrations on one's self or others. However, we can examine where the largest differences lie between these groups (Figure ​2). Looking only at the significant differences, the greatest proportional difference between cutters and noncutters are in: (i) being physically castrated themselves, (ii) fantasizing about castrating others, and (iii) witnessing animal castrations—with the cutters reporting larger proportions for all three.

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Figure 2

The plots above are designed to help visualize the most significant differences in the comparison between (i) all cutters (n = 98) vs. all noncutters (n = 2,773) who responded to our survey (top) and (ii) all eunuch cutters (n = 44) vs. eunuch noncutters (n = 234) (bottom). Along the X-axis are the percentage difference in a particular trait between the two groups compared. In all of these cases the greater percentage is with the cutters. The traits that are compared are arranged along the Y-axis and listed in order of the traits with the most to least difference between the compared groups. Only features that were different in the statistical analyses at P < 0.05 are plotted here. The level of statistical difference is given in Table ​1 and Table ​2, respectively.

When looking specifically at the physically castrated population, the greatest proportional difference between eunuch cutters and eunuch noncutters are in the following features with the cutters reporting the largest proportion: (i) castration performed by another cutter/friend or lover, (ii) castration performed by a non-MD, and (iii) has or had piercings. Although this comparison cannot show which feature is most predictive of a person becoming a cutter, it highlights the greatest differences between these populations.

In sum, there may be no singular, invariant psychological profile of the cutter, who is himself castrated. However, the general picture that emerges, as noted above, is of someone who both sought out injury for himself and is willing to injure others.

Limitations

There were several limitations to the study. First, in order to recruit a sufficient sample size an anonymous survey was used, and thus the veracity of responses could not be monitored. The questionnaire was limited to English-speaking individuals with access to the Internet, and caution should be used when generalizing these findings. In addition, we could not have a control group comprised of individuals without an interest in castration, as all members of the Eunuch Archive website expressed some interest in this topic. To assess risk factors, participants were asked questions about their childhood and past experiences. Therefore, many questions relied on participants' retrospection. As well, we did not separate those who have assisted in/performed a single or a few castration(s) from those who have performed many. That information may help identify the strength of the association between certain risk factors and participants involvement in illegal surgeries. In order to gain a deeper understanding of the motivating factors for cutters, a survey that specifically targets the cutters would need to be undertaken. Future research should also assess comorbid disorders, such as Borderline Personality Disorder, that may share some common features with extreme castration ideations.

Legal and Medical Implications

Inflicting trauma or permanent injury on a nonconsenting person is a crime. However, the morality and legality of someone allowing himself to be permanently injured raises the question of whether full consent can be given in such a scenario.

According to American criminal law, the consent to bodily harm is not a valid defense against a charge of battery; however, this legal principle has sparked controversy [17]. The “mainstreaming” of body piercing indicates a relaxation of cultural attitudes toward consent to body harm, although the legal system does not appear to be changing to reflect current practice. The question of consent becomes more complicated in the context of our research because human castration is drastic, irreversible and, when performed by nonmedical professionals, carries a high risk of pain, infection, and even death by exsanguination. As such, to remove the risk associated with nonmedical surgeries, some have argued for the medical community to provide amputations of healthy limbs for individuals experiencing extreme xenomelia or body integrity identity disorder (see discussion in 18–20). We would extend this argument to genitals to encompass those individuals who seek a eunuch or “third gender” identity. It might be argued that the great difficulty in finding effective psychiatric counseling and medically qualified surgeons for this population may result in greater harm than an absolute adherence to the Hippocratic creed of “do no harm.” Within the community of eunuchs and those wishing to be castrated, who frequent the Eunuch Archive website, there is strong opposition both to self-castration and to the use of cutters. However, there are many discussions of “safer” ways to obtain castrations from surgeons. Some now inject toxins directly into the testicles in order to produce sufficient damage that a surgeon will perform an orchiectomy for damage control [21].

As with castrations for sexual reassignment, we favor standards of care for males with extreme castration ideations (i.e., the potential clients of the cutters) that would provide safe options beyond self-castration or seeking the service of cutters [2,10,14]. However, we do stress that the treatment of these individuals and the decision whether to perform the procedure should lie with the discretion and clinical judgment of treating physicians. Healthcare professionals must take individuals who disclose castration fantasies seriously, particularly if risk factors (e.g., history of sexual abuse, having been threatened with genital mutilation, and having witnessing animal castrations) are identified.

Conclusion

Our research helps to characterize individuals who perform underground genital ablations. We have identified a number of distinguishing characteristics of cutters, including: (i) presenting themselves as very masculine, (ii) having had their longest sexual relationship with a man, (iii) growing up on a farm, (iv) witnessing animal castrations, (v) having a history of sexually inappropriate behavior, (vi) having been threatened with genital mutilation as a child, (vii) having a history of self-harm, (viii) being raised in a devoutly Christian household, (ix) having had an underground castration themselves, and (x) having body piercings and/or tattoos. Few individuals have all these risk factors, and we cannot comment on which risk factors are dominant in the development of extreme castration ideations.

Unfortunately, individuals with a collection of these risk factors seldom present to their family doctors, psychiatrists, or other healthcare providers. It is important, however, that healthcare professionals recognize that these individuals exist. Our study may help healthcare providers identify individuals who are at the greatest risk of injuring their own genitals and the genitals of others.

Conflict of Interest

The author(s) report no conflicts of interest.

References

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Long-Term Consequences of Castration in Men: Lessons from the Skoptzy and the Eunuchs of the Chinese and Ottoman Courts

Castration of men and males of other species was almost certainly the first experiment in endocrinology (if not in zoology), and the literature on the subject is vast. Indeed, the Cumming Manuscript Collection of the New York Academy of Medicine Library contains more than 1200 references, abstracts, and documents concerning the early history of human castration (1). In antiquity the procedure was performed for several reasons, including as punishment for prisoners of war (2), and by the time of Aristotle in the fourth century BC the physiological consequences of male castration were understood with remarkable exactitude (3). “Some animals change their form and character, not only at certain ages and at certain seasons, but in consequence of being castrated; and all animals possessed of testicles may be submitted to this operation. Birds have their testicles inside, and oviparous quadrupeds close to the loins; and of viviparous animals that walk some have them inside, and most have them outside, but all have them at the lower end of the belly. Birds are castrated at the rump at the part where the two sexes unite in copulation. If you burn this twice or thrice with hot irons, then, if the bird be full-grown, his crest grows sallow, he ceases to crow, and forgoes sexual activity; but if you castrate the bird when young, none of these male attributes or propensities will come to him as he grows up. The case is the same with men; if you mutilate them in boyhood, the later-growing hair never comes, and the voice never changes but remains high-pitched; if they be mutilated in early manhood, the later growth of hair quit them except the growth on the groin, and that diminishes, but does not entirely depart. The congenital growth of hair never falls out, for a eunuch never goes bald. In the case of all castrated or mutilated male quadrupeds the voice changes to the feminine voice… All animals, if operated on when they are young, become bigger and better looking than their unmutilated fellows; if they be mutilated when full-grown, they do not take on any increase of size. If stags be mutilated when, by reason of their age, they have as yet no horns, they never grow horns at all; if they be mutilated when they have horns, the horns remain unchanged in size, and the animal does not lose them… As a general rule, mutilated animals grow to a greater length than the unmutilated (3).”

In contrast to the rapidity and sophistication of the early advances, studies of the physiological effects of castration in more recent times have been relatively limited (presumably because fewer castrated men are available for study), and most studies of androgen deficiency focus on hypogonadal states rather than castration (4). However, in the 1940s, Hamilton and his colleagues did pioneering work in the United States on mentally deficient men who were castrated as a consequence of eugenics laws, quantifying the effects on skeletal development, hemoglobin production, and metabolism (5), and Bremer subsequently defined the relation between testicular secretions and male sexual drive and function in men who were castrated in Norway because of sexual offenses (6). Most studies of castration in men have involved relatively short term experiences (usually men who had been castrated for less than a decade), but in the 20th century the effects of long term castration have been studied in three groups of men: the Skoptzy and the court eunuchs of the Chinese and Ottoman empires (Table 1). According to Penzer (7) three varieties of eunuchs were recognized in antiquity: 1) castrati, clean-cut, both penis and testicles were removed; 2) spadones, testicles only were removed; and 3) thlibiae, testicles were bruised and/or crushed. The three groups of eunuchs under consideration in this review fall into the castrati category.

Table 1.

Medical studies of men after long term castration

Group . Author(s) and Ref. . Date of publication . No. of subjects . Average age (yr) . Average duration of castration (yr) . 
Skoptzy Tandler and Grosz (12) 1910 30 18 
Koch (13) 1921 13 64 30 
Chinese court eunuchs Wagenseil (19) 1933 31 57 38 
Wu and Gu (25, 26) 1987, 1991 26 72 54 
Ottoman court eunuchs Wagenseil (33) 1927 10 43 34 
Group . Author(s) and Ref. . Date of publication . No. of subjects . Average age (yr) . Average duration of castration (yr) . 
Skoptzy Tandler and Grosz (12) 1910 30 18 
Koch (13) 1921 13 64 30 
Chinese court eunuchs Wagenseil (19) 1933 31 57 38 
Wu and Gu (25, 26) 1987, 1991 26 72 54 
Ottoman court eunuchs Wagenseil (33) 1927 10 43 34 

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Table 1.

Medical studies of men after long term castration

Group . Author(s) and Ref. . Date of publication . No. of subjects . Average age (yr) . Average duration of castration (yr) . 
Skoptzy Tandler and Grosz (12) 1910 30 18 
Koch (13) 1921 13 64 30 
Chinese court eunuchs Wagenseil (19) 1933 31 57 38 
Wu and Gu (25, 26) 1987, 1991 26 72 54 
Ottoman court eunuchs Wagenseil (33) 1927 10 43 34 
Group . Author(s) and Ref. . Date of publication . No. of subjects . Average age (yr) . Average duration of castration (yr) . 
Skoptzy Tandler and Grosz (12) 1910 30 18 
Koch (13) 1921 13 64 30 
Chinese court eunuchs Wagenseil (19) 1933 31 57 38 
Wu and Gu (25, 26) 1987, 1991 26 72 54 
Ottoman court eunuchs Wagenseil (33) 1927 10 43 34 

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The Skoptzy

The Skoptzy (or Skoptsy, meaning the castrated), also called the White Doves, were a Christian sect whose male members, to attain their ideal of sanctity, subjected themselves to castration. Their origin in the 18th century, their spread through a large part of Russia and into Romania and Bessarabia, the attempts by the Russian government to suppress the movement, and the theological underpinnings of the religion were described by Pelikan (8), Grass (9), and Pittard (10). Because they believed that the second coming of Christ would occur only when the number of Skoptzys reached the apocalyptic number of 144,000, they became ardent proselytizers. Their critics claimed that they used coercion among children and prisoners, a charge that seems warranted in view of the fact that many were castrated below the age of 10 yr, but others were religious enthusiasts who underwent the procedure voluntarily as adults. Male members of the sect were encouraged to take either the “great seal” (removal of the penis, the scrotum, and the testes) or the “lesser seal” (removal of the scrotum and testes, leaving the penis intact). Women were not castrated, but were subjected to mutilation of the breasts and external genitalia. In men the procedure was of great simplicity; namely, the operator seized the parts to be removed with one hand and struck them off with the other. In the early years of the sect the surgical instrument was a red-hot iron rod or poker (hence the expression baptism of fire), but instruments of castration included pieces of glass, razors, and knives. A cicatrix formed, with healing in 4–6 weeks (Fig. 1). In some instances the procedure was performed in stages (taking the lesser seal before the great seal). When the penis was removed, nails were inserted into the urethra to avoid strictures, and such men were said to urinate while sitting or squatting. Many Skoptzys were deported to Siberia, where they formed settlements, and the sect continued to perform castrations as late as 1927 (11). Persecution of the Skoptzys persisted into the Soviet era, and during the antireligious fervor in 1929–1930 they were subjected to sensational public trials and publicity. It was estimated that there were between 1000 and 2000 Skoptzy in Soviet Russia in 1930, 500 of whom lived in Moscow, but by 1962 none were thought to be alive (11).

Figure 1.

Anatomical preparation of the external genitalia of a Skoptzy man who had received the greater seal. Reprinted from Koch (13 ).

Figure 1.

Anatomical preparation of the external genitalia of a Skoptzy man who had received the greater seal. Reprinted from Koch (13 ).

Medical studies on the Skoptzy. Medical studies were performed on the Skoptzy by at least three different groups of investigators. At the turn of the century Pittard made measurements in 30 Skoptzy men in 1 Romanian village and noted that they appeared to be taller than their peers (10). In 1907 Tandler and Grosz examined 5 Skoptzy men in Bucharest whose average age was 30 yr and who had been castrated between ages 5–21 yr (12). Subsequently, during the German occupation of Romania in the First World War Walter Koch studied 13 Skoptzy men, all between 50 and 94 yr of age (averaging 64 yr), who had been castrated for an average of 46 yr (13). A variety of anthropomorphic measurements were made, and skull x-rays were obtained in some (13).

The eunuchs of the Chinese court

The practice of employing eunuchs as court functionaries in China and in other oriental countries goes back into prehistory (14). The procedure by which the Chinese court eunuchs were castrated in the late 19th century during the Qing dynasty was described in some detail by Stent in 1878 (15), and subsequent descriptions of the practice, including those by Korasow (16), Matignon (17), and Wong and Wu (18), appear to be paraphrases of Stent (15). However, on the basis of published interviews of surviving eunuchs, the surgical procedure appears to have been essentially the same in the later days of the dynasty (14). Possession and employment of eunuchs as servants in China were reserved for the imperial family and the 8 hereditary princes. The emperor maintained approximately 2000 in his service, the imperial princes and princesses each had about 30, and various family members were allowed 10 or so eunuchs each. On occasion, the castration was punitive, as in prisoners of war, but most were performed voluntarily in adults who, because of poverty or laziness, underwent castration to gain employment (usually as young adults, but sometimes in men after having born children) or in children under compulsion who were sold by their parents for the purpose of castration (15).

Specialists (termed knifers) performed the operation in an establishment maintained outside one of the palace gates in the imperial city, and the trade was handed down from father to son. The subject reclined on a broad bench, and the genitalia were anaesthetized with a secret agent known only to the surgeon. Two assistants held the spread legs, and a third assistant secured the arms. The surgeon stood between the legs armed with a curved knife (Fig. 2a), grasped the scrotum and penis with his left hand, and asked the candidate or his parents to consent to the procedure. If the answer was yes, the genitalia (scrotum, penis, and testes) were removed with a single cut. A plug made of pewter (Fig. 2b) was introduced into the urethra to prevent stricture formation. The wound was washed three times with a solution of boiled pepper and covered with a piece of soft, moistened paper. With the support of two assistants the subject was made to walk around the room for 2–3 h. For the following 3 days, the subject was not allowed to drink liquids or to urinate. On the fourth day, the dressing and plug were removed, and if the subject was able to urinate the operation was considered a success. Healing took approximately 100 days, and eventually all that was left was a contracted scar (Fig. 3). Urinary retention was treated with drugs, and if it persisted the surgeon beat the patient on each visit. Complications included hemorrhage, infection, and extravasation of urine, but death was rare (estimated at around 2%). Until convalescence was completed the pewter plug was only removed to allow urination. With time the opening of the urethra could become narrowed despite the use of dilators, resulting in urinary dribbling or retention, urinary tract infection, and bladder stones. Urinary incontinence was said to be common and caused a characteristic odor in the unfortunate victims. The stoma sometimes required dilatation long after the castration (16–18). [According to Wagenseil, other castration techniques were sometimes used, each involving the removal of all the external genitalia (19).]

Figure 2.

Some of the instruments used for creating and treating eunuchs. a, Scalpel used by knifers for the removal of the external genitalia of the Chinese eunuchs (the blade is described as 3.7 in. in length, and the handle as 2 in. in length.) Redrawn from Wong and Wu (18 ). b, A urethral dilator for insertion into the urethra of the Chinese eunuchs (3 cm long and 0.9 cm in the widest portion of the plug). Redrawn from Matignon (17 ). c, A urethral plug used to prevent incontinence in the Ottoman Court eunuchs (5 cm long). A string was placed in the eye to prevent it from slipping into the bladder. Redrawn from Millant (31 ).

Figure 2.

Some of the instruments used for creating and treating eunuchs. a, Scalpel used by knifers for the removal of the external genitalia of the Chinese eunuchs (the blade is described as 3.7 in. in length, and the handle as 2 in. in length.) Redrawn from Wong and Wu (18 ). b, A urethral dilator for insertion into the urethra of the Chinese eunuchs (3 cm long and 0.9 cm in the widest portion of the plug). Redrawn from Matignon (17 ). c, A urethral plug used to prevent incontinence in the Ottoman Court eunuchs (5 cm long). A string was placed in the eye to prevent it from slipping into the bladder. Redrawn from Millant (31 ).

The amputated penis, testes, and scrotum, termed “the precious” or“ the treasures,” were preserved in alcohol and either stored by the knifer or kept by the subject (15, 16). Genitalia retained by the knifers were kept in jars labeled to indicate from whom they came and when the amputation was performed. The eunuchs were required to show the preserved genitalia to a special court official at each promotion (“inspection of the precious”) to document the completeness of the operation, and eunuchs who, through carelessness or misadventure, lost the items had to borrow or rent them for display at the time of promotion. Each eunuch was buried with the preserved genitalia, because of the religious need to be as complete as possible when departing into another world.

The palace eunuchs were divided into 48 departments (for looking after gardens, courtyards, kitchens, armory, furniture, etc.) Each department had a superintendent, usually of the sixth grade, and a chief eunuch served over the entire complement of eunuchs. At least in the last phase of the Qing dynasty, eunuchs were subject to the Imperial Household Department, which was not headed by a eunuch (20). Most Chinese eunuchs were castrated as adults, but eunuchs castrated before the age of 10 yr were considered ‘thoroughly pure’ and were prized as personal servants. All eunuchs received a regular stipend as well as room and board. Most lived in the palaces until they were released from service in old age. Some spent their final days in monasteries. Those who had families and children before castration rejoined their families, and others married and adopted children. The most frequent marriage partners were palace maids; such wives were referred to as ‘companions sitting at meals’ to indicate a platonic relationship (21). [George Kates, an American, rented a house in the Imperial City in Beijing from one such couple in the 1930s, the wife having been a maid to the dowager empress (22). This couple survived until the Cultural Revolution of 1966–76, the wife dying of malnutrition, and the husband disappearing after being deported to the countryside (23).]

After the revolution of 1911 the emperor Pu Yi retained figurehead status and continued to reside in the Forbidden City. According to the articles of agreement with the new government, the existing eunuchs continued to be employed in the Imperial Household Department (20). However, on July 15, 1923, the entire staff of eunuchs (with the exception of about 50 household servants of elderly members of the imperial family) was expelled from the Forbidden City because they were suspected of stealing and selling furniture and works of art and were believed to have burned a portion of the edifice as a protest against a planned inventory of the palace treasures (20). Although there is disagreement as to whether the eunuchs were responsible (14, 20), corruption in the Imperial Household Department was pervasive.

Medical studies on the Chinese court eunuchs. The expulsion of the eunuchs from the Forbidden City left most unemployed and many destitute. Ferdinand Wagenseil, from the Institute of Anatomy at Freiburg but then at Tungchi University in Shanghai, conducted anthropometric studies on normal men from northern China (24), and in 1930 he examined 31 eunuchs at the German Hospital in Beijing (19). The technique of study involved measurements of height, weight, and a variety of skeletal dimensions, radiographic studies of the skull, and descriptions of skin and body hair. The average age in this group was 57 yr, and the average duration of castration was 38 yr. In 1960 Wu and Gu (25, 26) performed careful physical examinations, including palpation of the prostate in 26 eunuchs (5 of whom had been castrated after the revolution of 1911) who lived in Beijing. The average age in the latter study was 72 yr, and the average duration of castration was 54 yr.

The eunuchs of the Ottoman court

The practice of employing eunuchs as palace functionaries in Constantinople (Istanbul) apparently began during the reign of the Emperor Justinian in the latter days of the Roman Empire and persisted through the Byzantine (27) and Ottoman eras (7). In contrast to China, ownership of eunuchs in Turkey was not limited to the royal palaces; any citizen who could afford the purchase price was entitled. Some eunuchs of the Ottoman Empire were from Russia or the Balkans, but from the 16th century black eunuchs were in charge of the harem in the Ottoman court, most commonly individuals from Ethiopia or Sudan who had been castrated as children (28). Slave dealers kidnapped some, and some were sold into slavery by their parents. According to Penzer, stopping points were used by the slave exporters, and it was during the halts at such places that the castration of the boys took place (7). According to other reports many of the boys were castrated at a monastery in Upper Egypt where Coptic priests performed the operation (29, 30). The child was restrained on a chair; the phallus and scrotum were tied with a cord which was pulled taught, and the phallus, scrotum, and testes were removed as close as possible with a single stroke of a razor. Bleeding was stopped with boiling oil, and the wound was dressed with an extract of wax and tallow. In some instances hemostasis was achieved with hot sand, and the wound was dressed with an extract of acacia bark. The mortality was said to be high, only about one in three surviving. As in the case of the Skoptzy and the Chinese court eunuchs, a nail was introduced into the urethra to prevent stricture formation. The eunuchs squatted to urinate, and both urethral strictures and incontinence must have been common, because some eunuchs carried silver quills for self-catheterization, presumably because of strictures (7), and others used a removable plug (Fig. 2c) to prevent incontinence (31). Owing to the high death rate, the survivors were sold at high prices either to Turkey or to Persia (29). The physicians to the harem inspected the eunuchs on arrival to be certain that both penis and testes had been removed and reexamined them every few years to be certain that nothing was amiss (7). The eunuchs entered the court service at the lowest rank and passed successively through the grades of novice, middle grade, and highest rank. Strict rules of behavior were enforced for the eunuchs’ guild. Some took to learning and literature and served as tutors to the royal children; others rose to high administrative ranks (28). Some 200 eunuchs were said to have lived in the palace of Topkapi in Istanbul after the royal family had moved to other palaces (28), and after the Turkish revolution the eunuchs continued to be devoted servants until the royal family was sent into exile in March of 1924 (32).

Medical studies on the Ottoman court eunuchs. Hikmet and Regnault appear to have made the first medical observations on the eunuchs in Istanbul in 1901 (30). During the first world war Ferdinand Wagenseil had been assigned as a physician to the German Red Cross Hospital in Istanbul, where he took care of a 40-yr-old eunuch from the harem who died after a febrile illness (presumably typhus) and subsequently examined 10 additional eunuchs, most of whom had voiding difficulties (33). An autopsy was performed on the man who died; the others (average age, 43 yr; average duration of castration, 34 yr) were subjected to detailed anthropological measurements and physical examinations, and skull x-rays were obtained on four of them.

The medical consequences of long term castration

Because the findings in the various studies overlap and are complementary, they will be discussed together.

Enlargement of the pituitary. Tandler and Grosz obtained an x-ray of the skull in a 20-yr-old Skoptzy man, who had been castrated at age 10 yr and observed that the sella turcica was grossly enlarged (12). Koch obtained x-rays of the skull in 10 Skoptzy men and reported that the pituitary glands were normal in size in 3, enlarged in 4, and“ particularly” enlarged in 3 (13). In the latter group, there was also erosion of the dorsum sellae of the pituitary (“sattellehne”). The average duration of castration was the same in the 3 groups studied by Koch (46 yr), but the average age at which the castration was performed (11 yr) was younger in the group with the largest pituitaries. In his Istanbul study Wagenseil reported that 2 of 4 skull x-rays obtained revealed enlargement of the pituitary with thinning of the dorsum sella; the average age at castration was 11 yr, and the average duration of castration was 44 yr in these 2 men (33). In the same study the pituitary was normal at autopsy in the 40-yr-old man who had been castrated for an uncertain duration (33). In his Beijing study Wagenseil obtained skull x-rays on 27 eunuchs and had them reviewed at the University of Bonn where “enlargement of the sella turcica could not be found generally” (19). The reason for the apparent discrepancy between the findings in the Chinese eunuchs and those in the Skoptzy and the Ottoman eunuchs is not clear, but it is of interest that the average age at which castration was performed was older in the Chinese group (average age at castration, 18 yr; less than a fourth had been castrated before age 14 yr). Subsequently, reactive hyperplasia of the pituitary was described in hypogonadal men (34–36), including men with Klinefelter’s syndrome (37). There is in addition at least one instance in which a large gonadotropin-secreting pituitary adenoma developed 35 yr after a man was castrated for cryptorchidism (38).

Skeletal changes. Tandler and Grosz described failure of closure of the epiphyses in the skeleton of a eunuch (39) and subsequently in a 35-yr-old Ottoman eunuch who had been castrated at age 8 yr (12) Koch reported that thinning of the bones of the skull was evident by x-ray in all of the Skoptzy men examined and that kyphosis was common (Fig. 4) (13). Likewise, Wagenseil observed that 20 of the 31 Chinese eunuchs had kyphosis of the spine (Fig. 5) (18). These observations appear to have been made before it was recognized that kyphosis is a manifestation of severe osteoporosis in women (40). In the Wagenseil study, men with kyphosis averaged 59 yr of age and had an average duration of castration of 42 yr, whereas the men who did not have kyphosis were slightly younger (average age, 54 yr) and had a slightly somewhat shorter average duration of castration (33 yr) (18). Involvement of the spine is common in men with osteoporosis of various etiologies (41), and in view of the fact that bone mineral density decreases progressively with time after castration, particularly in the first few years (42), it is surprising that kyphosis was not even more common in the Chinese eunuchs and the Skoptzy. Furthermore, an increased incidence of fractures does not appear to have been reported in the eunuchs, and Wagenseil had not observed kyphosis in his earlier study of eunuchs in Istanbul (33). The reason for the discrepancy between the Turkish study and the other studies is not clear. The Turkish eunuchs were somewhat younger (average age, 44 yr), and were either Ethiopian or Sudanese in origin and might have had higher initial bone densities (43). Alternatively, osteomalacia due to vitamin D deficiency was common in Northern China in the early years of this century (44), and vitamin D deficiency might have contributed to osteopenia in the Chinese eunuchs (and possibly in the Skoptzy).

Figure 4.

Photograph demonstrating kyphosis in a 54-yr-old Skoptzy man who had been castrated at age 15 yr. Reprinted from Koch (13 ).

Figure 4.

Photograph demonstrating kyphosis in a 54-yr-old Skoptzy man who had been castrated at age 15 yr. Reprinted from Koch (13 ).

Figure 5.

Photograph demonstrating kyphosis and gynecomastia in eight Chinese eunuchs. The average age of these men was 56 yr, and the average time lapsed since castration was 38 yr. Reprinted from Wagenseil (19 ).

Figure 5.

Photograph demonstrating kyphosis and gynecomastia in eight Chinese eunuchs. The average age of these men was 56 yr, and the average time lapsed since castration was 38 yr. Reprinted from Wagenseil (19 ).

Gynecomastia. Hikmet and Regnault reported that the breasts in the Ottoman court eunuchs became large and pendulous (30) Although not commented on by either author, gynecomastia is also evident in 5 of 9 photographs of Skoptzy men published by Koch (13) and in 7 of 14 photographs of Chinese eunuchs published by Wagenseil (19) (Fig. 5). Furthermore, Wu and Gu reported that 9 of the 26 subjects in their study had breast enlargement (25, 26). These observations of gynecomastia in castrated men are in keeping with the subsequent report by Heller, Nelson, and Roth that approximately half of men with functional prepubertal hypogonadism develop gynecomastia (45). In hypogonadal men, gynecomastia develops when estrogen formed by extraglandular aromatization of adrenal androgens is sufficient to cause breast enlargement in the face of profoundly low testosterone values (46). The reason that gynecomastia develops in some but not all men with primary hypogonadism is not known.

Apparent disappearance of the prostate. Androgen action is required for the development of the prostate gland during embryogenesis (47), and the prostate does not develop in men with mutations that profoundly impair the function of the androgen receptor (48) or of steroid 5α-reductase-2 (49). Furthermore, it has been known since the 19th century that prostatic hyperplasia does not develop in prepubertal castrates and that castration causes regression of the hyperplastic prostate (50). Hikmet and Regnault reported that the prostate became atrophic in the Ottoman court eunuchs (30). Likewise, in Wagonseil’s description of the autopsy of a 40-yr-old eunuch, the prostate gland was prepubertal in size (16 × 24 × 13 mm, corresponding to a weight of approximately 4 g) (33), a finding that is hardly surprising. However, the report by Wu and Gu that the prostate was completely impalpable in 21 of 26 Chinese eunuchs (and very small in the other 5) (25, 26) was unexpected and implies that viability of the gland throughout life requires the continued presence of gonadal hormones, presumably androgens. It is possible that very small prostates were missed on physical examination by Wu and Gu (25, 26).

Alternatively, it is possible that disappearance of the prostate is a function of time after castration, as the duration of castration in their study was much longer than that in any other report, recognizing that the duration of castration in the subset of men with barely palpable prostates (55 yr) did not differ from that of the group overall (54 yr).

Comment

Hopefully, it will never again be possible to repeat the studies reviewed in this paper, as in more recent times we have used different means of expressing man’s inhumanity to man. It is to the credit of the pioneering physician scientists involved that useful medical information was obtained about the long term effects of castration, under circumstances that must have been difficult, from the study of these now extinct groups of castrated men, and it is impressive that all their findings (osteoporosis, failure of closure of the epiphyses, reactive pituitary hyperplasia, shrinkage of the prostate, and development of gynecomastia) have been confirmed subsequently by studies of individuals or small groups of individuals with various forms of hypogonadism.

One question of interest concerning castration in men cannot be resolved from the available data, namely the issue as to whether the life span of men is shorter than that of women because of the presence of testes or the absence of ovaries (and menstruation) (5). Indeed, there are no valid data indicating that castration has any effect on life span of men.

It is of some interest that no mention appears to have been made of the relation between castration and singing in any of the literature concerning the Chinese, Ottoman, or Skoptzy eunuchs, whereas there was a long tradition in Italy that associated the castrated state with phenomenal singing by men both in choirs and the opera (2). The probable reasons for this apparent discrepancy are several. First, the so-called castrati singers were, in fact, a heterogeneous group consisting of women who posed as castrated men, men with hypogonadism and/or cryptorchidism, men with intact testes who probably sang as counter tenors or falsetto, and a few singers who either had their testes removed or crushed (51). Consequently, it is difficult to interpret the literature on the subject in medical terms. Second, in the instances in which castration was performed, only boys with extraordinary singing ability were chosen for such a procedure, and it is likely that singing ability would be no different in men selected for castration using other criteria than in the population at large.

Acknowledgements

Cindy Karolikowski, Reference Librarian of the Shiffman Medical Library in Detroit, provided invaluable assistance in the initiation of these studies, and the assistance of Caroline Duroselle-Melish, Reference Librarian in the Historical Collections of the New York Academy of Medicine Library, made it possible for us to broaden their scope. We are also grateful to reference librarians at the New York Public Library and at the University of Texas Southwestern Medical Center. Translations from German were made by one of the authors (C.R.), and we are indebted to Philippe E. Zimmern for aid with the French translations.

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Sours: https://academic.oup.com/jcem/article/84/12/4324/2864451
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Surgical Castration

The procedure is done for the treatment of advanced prostate cancer and rarely for some bilateral cancers of the testes. Sometimes it maybe necessary to remove both the testis where there is a severe injury to the scrotum.(1)

Surgical Castration Procedure

Surgical castration has been often carried out in history for other reasons too. It has been used as a form of punishment for rapists, homosexuals, as well as for prisoners of war. There has been a renewed demand in the recent past to introduce surgical castration in sexual offenders specially rapists. However, most countries have given up surgical castration for habitual sexual offenders and opt for voluntary medical castration instead, where a chemical drug is injected or a tablet is given regularly.

During surgical castration, a small incision is made in the scrotum under anesthesia and both the testes are removed. Sometimes, prostheses are placed in the scrotum to replace the testes. Following surgical castration, due to removal of testes, the person cannot father any children. Due to lack of testosterone following the procedure, the person loses sexual drive. However, it has been observed that the sexual drive is not lost immediately in all those castrated. Also, the sexual drive can be restored by taking testosterone injection. Thus, surgical castration may not be the treatment of choice in habitual sexual offenders.(2)

Side effects of the procedure include:

  • Changes in physical appearance: The person loses body hair and the skin softens akin to that in females. The body weight may increase.
  • Changes in organs: The calcium content of the bones may reduce; the hemoglobin levels in the blood may come down; proteins from the body may be lost.
  • Psychological effects: Perhaps the most disastrous effects following surgical castration take place on the psychology of the person.(3)
Side Effects of the Surgical Castration Procedure

Surgical castration is a permanent procedure, which not only affects the sexual function of a male, but also causes changes in the appearance and important parts of the body. The person may get depressed and even attempt suicide. Its use in habitual sexual offenders raises ethical issues. On the other hand, the use of medical castration which causes temporary effects may be more justifiable in these cases.

Reference:

  1. Castration Anxiety - (https://slate.com/news-and-politics/2007/12/can-a-sex-offender-still-have-sex-after-he-s-been-castrated.html)
  2. Surgical Castration of Sex Offenders and its Legality: The Case of the Czech Republic - (http://www.iusetsocietas.cz/fileadmin/user_upload/Vitezne_prace/Stojanovski.pdf)
  3. Hormone Therapy For Prostate Cancer - (https://www.texasoncology.com/types-of-cancer/prostate-cancer/hormonal-therapy-for-prostate-cancer)

Published on Jan 29, 2013
Last Updated on Dec 13, 2019

Latest Publications and Research on Surgical Castration

Sours: https://www.medindia.net/patients/patientinfo/surgical-castration.htm
This Is What a Goat Sounds Like After Being Castrated

The Case

An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persistent aching in his left scrotal area, with no identifiable exacerbating or alleviating factors. He noted no change in bowel or bladder habits and reported taking a stool softener. No history was elicited or offered regarding prior genital surgery. Physical examination showed a 20-centimeter left groin mass with some superficial skin ulcerations. The mass was non-tender and was not reducible. The right groin and scrotum were unremarkable.

The patient underwent surgery with a preoperative diagnosis of direct left inguinal hernia versus left hydrocele. Although preoperative ultrasound might have allowed this differentiation, it was not performed. Exploration of the left groin revealed a relatively small direct hernia and large left-sided hydrocele (Figure). The planned repair of the direct hernia was carried out, but an intra-operative decision was made to perform complete excision of the hydrocele, spermatic cord, and testicle on the left. The operation was completed without complication.

In the recovery room, the surgeon discussed the changes to the planned procedure with the patient's wife, who informed the surgeon that the patient's right testicle had been removed after a traumatic injury many years earlier. In subsequent discussions with both the patient and his wife about hormonal replacement, the patient revealed that he had not been sexually active for several years. The patient was informed of the benefits of hormonal replacement—on energy level, muscle mass, and bone density—regardless of sexual activity. He elected to receive periodic, intramuscularly injected testosterone.

Adverse events occur during 3%-39% of all surgical admissions, with the operating room being the most common site for errors in care.(1-3) The extent to which faulty communication or planning contributes to this unacceptably high rate of medical injury remains poorly studied.

Several patient safety issues are raised by this case, in which an elderly man with a scrotal mass suffered a medical injury when his only remaining testicle was removed to (inappropriately) treat a hydrocele, resulting in iatrogenic castration. However, without a dispassionate human factors oriented investigation, it is hard to say what really happened. Following a catastrophic accident, a faulty "first story" often emerges that blames the 'sharp end' worker for a failure in vigilance after only a cursory review of the facts.(4) Perhaps just as horrifying as the injury in this case is the reality that workers in the surgical domain commonly avoid similar occurrences by only the narrowest of margins.

Accident Investigation

The case description contains insufficient information to identify the specific safety barriers breached. We do not know the exact setting for the medical injury—urban or rural, community practice or academia, group or solo surgeon—all factors that greatly influence how surgical care is delivered. Likewise, it would be helpful to have information about the extent to which the operating surgeon was involved in the preoperative evaluation process, the availability of consultants, or the intra-operative findings that led the operating surgeon to suspect malignancy as the etiology for the resected mass (which is why I suspect he performed the much larger-than-planned resection). We know nothing of this surgeon's training, the time of day the injury occurred, or pertinent environmental data.

Answers to these questions should be considered essential to medical accident investigation. After sentinel events occur, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates use of varying tools for root-cause analysis, and the Department of Veterans' Affairs (VA) hospitals widely use such tools to investigate accidents and near misses.(5,6) However, such tools are rarely, if ever, used to investigate intra-operative occurrences that don't rise to the level of "sentinel event."

Decision Support

From my reading of the case description, I've inferred that the orchiectomy was probably performed by a general surgeon, apparently without urologic consultation. This procedure may have occurred in a hospital where an urologist was not immediately available, a situation common in smaller community hospitals, and one that cannot be solved by inserting subspecialty consultants in every hospital. In the face of this reality, clinicians and investigators at several universities (and NASA) envision opportunities for multi-media telemedicine, which will allow rural hospitals (or even long-distance space missions) to obtain remote consultation.(7) If my suspicion is correct and this surgeon believed that the mass was potentially a testicular malignancy or did not know how to definitively exclude the possibility of hydrocele, such remote consultation, were it available on-demand in the OR, may have enabled him to acquire the opinion of an expert urologist and subsequently perform drainage or excision of this patient's hydrocele rather than orchiectomy.

Wrong-site Surgery and Other Cognitive Errors

In this case, the surgeon almost certainly never considered the possibility of absence of the contralateral testicle. In this regard, this misalignment of the stars links this case and many other common intra-operative adverse events involving wrong-site surgery.(8,9) This patient had his testicle surgically removed, but similar disasters have occurred in situations involving patients' only remaining kidneys, adrenal glands, or parathyroids. Moreover, similar cognitive errors—failing to systematically rule out unusual but critical issues before plowing forward with a planned procedure or therapy—lead clinicians to fail to recognize and act upon critical patient-specific factors such as drug allergies, potential medication interactions, and religious preferences, as well as how such factors interact with comorbid illnesses.

Similar to other fast-paced, high-risk endeavors, most clinicians committing cognitive errors would take appropriate action had they accurately comprehended the situation—a state generally known as "situation awareness."(10) In medical accidents, gaps in situation awareness and experience, rather than lack of medical knowledge, are often to blame.(11) Combating cognitive errors and supporting situation awareness requires procedures and systems that recognize the frailties of normal human cognition. When complex, multi-step tasks are performed in any high-risk arena, the use of memory aids, checklists, and other fault-tolerant practices, such as placing mission-critical data (eg, the history and physical, operative plan, and diagrams) in the environment, is recommended.

Team Building

The prevailing model for surgical teams tends to designate the surgeon as 'supreme commander,' with sole responsibility for the safe functioning of the team, with some indirect monitoring and occasional modification by the anesthesiologist.(12) Roles of other participants are largely based on experience and familiarity, with numerous critical, yet often unspoken, rules. In this anachronistic model, the non-surgeon physician, resident, nurse, and technician team members are subordinate, with extremely limited capability to crosscheck mission-critical facts or stop the procedure if something goes awry. Unfortunately, another common feature is an even more subordinate level for the patient, who is often expected to behave somewhat like inanimate cargo, even before he or she is anesthetized. Simple strategies emerging from human-factors research, such as pre-operative "pauses" or team-briefings, have the capacity to efficiently orient team members to the task at hand and enable them to "speak up" or challenge something that seems to fall outside standard of care by suggesting alternative courses of action.(13)

An absence of a pre-procedure team meeting, along with the low likelihood that the surgeon or other team members ever participated in simulator training, may have contributed to the safety breakdown that led to this patient's castration. A direct link between such practices and enhanced safety does not yet exist, but indirect evidence supports the common-sense notion that these practices could bolster medical safety. Mandatory team briefings, with invitations by the team leader for participants to step back and speak up if they perceive a gap in safety, are simple, non-resource-consuming interventions that harness the abilities of operating room personnel to help surgeons protect patients.

Prevention of similar events may depend on our ability to adopt more effective human-factors-oriented approaches in accident investigations and Morbidity and Mortality (M & M) conferences, and to explore the potential benefits of adding team building to the list of mandatory competencies for practicing surgeons.

J. Forrest Calland, MD Resident in Surgery Research Fellow and Co-Founder, Surgical Technology and Safety Laboratory University of Virginia Health System

References

1. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66-75.[ go to PubMed ]

2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-6.[ go to PubMed ]

3. Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349:309-13.[ go to PubMed ]

4. Cook RI, Woods DD, Miller C. A tale of two stories: contrasting views of patient safety. National Patient Safety Foundation Web site. Available at: [ go to related site ]. Accessed November 3, 2003.

5. Wald H, Shojania KG. Incident reporting and root cause analysis. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making health care safer: a critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001: 41-56. AHRQ publication 01-E058. Evidence report/technology assessment. no. 43. [ go to related site ]; [ go to related site ]

6. Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv. 2002;28:531-45.[ go to PubMed ]

7. Eadie LH, Seifalian AM, Davidson BR. Telemedicine in surgery. Br J Surg. 2003;90:647-58.[ go to PubMed ]

8. Wald H, Shojania KG. Strategies to avoid wrong-site surgery. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making health care safer: a critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001: 494-500. AHRQ publication 01-E058. Evidence report/technology assessment. no. 43. [ go to related site ]

9. Vincent C. The other side. AHRQ WebM&M [serial online]. October 2003. Available at: [ go to commentary ]. Accessed December 5, 2003.

10. Baumann MR, Sniezek JA, Buerkle CA. Self-evaluation, stress, and performance: a model of decision making under acute stress. In Salas E, Klein G, eds. Linking expertise and naturalistic decision making. Mahwah, NJ: Lawrence Erlbaum Associates; 2001:139-58.

11. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614-21.[ go to PubMed ]

12. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745-49.[ go to PubMed ]

13. Rouse WB, Cannon-Bowers JA, Salas E. The role of mental models in team performance in complex systems. IEEE Transactions on Systems, Man, and Cybernetics. 1992;22:1296-1308. [ go to related site ]

Figure

Figure. Anatomy of the Groin. (Illustration by Chris Gralapp)

Figure Anatomy of the Groin
Sours: https://psnet.ahrq.gov/web-mm/inadvertent-castration

Services human castration

What Is Chemical Castration?

Chemical castration is the use of drugs to lower the production of hormones in your testicles.

Doctors use this method to treat hormone-related cancers, such as prostate cancer. Other names for chemical castration are:

  • hormone therapy
  • androgen suppression therapy
  • androgen depressive therapy

Let’s take a closer look at how chemical castration works, what the long-term risks are, and if it can be reversed.

What is chemical castration?

The purpose of chemical castration is to lower the levels of male hormones, or androgens.

The main androgens are testosterone and dihydrotestosterone (DHT). According to a 2012 research review, about of androgens are made in your testicles. The rest come from your adrenal glands.

Luteinizing hormone-releasing hormone (LHRH) comes from your pituitary gland. This hormone tells your testicles to make testosterone.

That’s where LHRH agonists come in. They work by stimulating the production of luteinizing hormone (LH). That’s why when you first take them, LHRH agonists cause testosterone levels to rise.

This effect only lasts a few weeks, though. And taking anti-androgens such as bicalutamide for a few weeks can relieve this concern.

When LH levels are higher, your pituitary gland stops making it. It no longer tells your testicles to make androgens. As a result, circulating testosterone is reduced to very low levels, similar to surgical castration.

About LHRH agonists

Some LHRH agonists are:

  • goserelin (Zoladex)
  • histrelin (Vantas)
  • leuprolide (Lupron, Eligard)
  • triptorelin (Trelstar)

LHRH agonists are also known as gonadotropin-releasing hormones (GnRH) agonists. They don’t directly affect the production of androgens in your adrenal glands, as anti-androgens do.

Treatment is ongoing

Chemical castration is not a one-time treatment. Your doctor administers the drugs by injection or implants them under your skin.

Depending on the drug and the dose, this must be repeated as often as once a month or as seldom as once a year.

For advanced prostate cancer, your doctor may recommend LHRH antagonists instead. They work faster than LHRH agonists, but don’t cause an increase in testosterone levels. Some of these medicines are:

  • degarelix (Firmagon), a monthly injection
  • relugolix (Orgovyx), a daily pill

What are the side effects of chemical castration?

Side effects of chemical castration can include:

Over the long term, chemical castration may also lead to:

According to a , side effects and complications may increase the longer you’re in treatment. Your doctor may recommend other therapies to prevent or ease these side effects.

Other potential risks

There are also concerns that men treated with hormone therapy may be at an increased risk of:

According to the , not all studies have reached the same conclusions about these risks. More research is needed to fully understand the relationship between chemical castration and these conditions.

How long does chemical castration last?

Chemical castration lasts as long as you continue to take the drugs. Once you stop taking them, hormone production returns to normal.

The effects are generally reversible. But if you’ve been taking the medications for a long time, some side effects may continue.

What’s the difference between chemical and surgical castration? 

Chemical castration is administered with oral medication, injections, or an implant under your skin. This affects hormone levels, but there’s no immediate change in the appearance of your testicles.

However, they may shrink over time. In some cases, your testicles can become so small that you can’t feel them.

The effects last as long as you stay in treatment. Once you stop, they’re generally reversible.

Surgical castration, also called orchiectomy, is the removal of one or both testicles. It can be considered a surgical form of hormone therapy.

According to the National Cancer Institute, this procedure can lower testosterone in your blood by .

Surgical castration is generally done on an outpatient basis. But once it’s done, it cannot be reversed, so you should consider it permanent.

A procedure called subcapsular orchiectomy involves removing your tissue that produces androgens instead of your entire testicle. This keeps your scrotum intact. If desired, artificial testicles can be inserted into your scrotum.

Medical uses of chemical castration

Chemical castration is used to treat hormone-dependent cancers, such as prostate cancer. Lowering androgens can help slow cancer growth and metastasis.

Chemical castration may be beneficial for prostate cancer that has spread or recurred after first-line treatment.

Prostate cancers tend to be castration-sensitive early on. Over time, they can become castration-resistant, but may still be responsive to:

Chemical castration can also be used to slow the progression of male breast cancer.

Takeaway

Chemical castration is the use of medication to lower levels of male hormones. It has the same effect as the surgical removal of your testicles, except that it’s not permanent.

There are significant side effects to chemical castration, such as:

  • loss of libido
  • hot flashes
  • shrinking testicles

Once you stop the treatment, androgen production should return to normal. But some side effects, such as osteoporosis, can become long-term concerns.

Chemical castration is primarily used to treat hormone-dependent conditions, such as prostate cancer.

Sours: https://www.healthline.com/health/chemically-castrating
Your Castration Questions Answered!

Study finds castration most cost-effective for prostate cancer


graphic

WASHINGTON (Reuters) -- Surgical castration is the most cost-effective treatment for advanced prostate cancer, but it may be hard for many men to overcome their horror of it, researchers said on Tuesday.

The team of Canadian, British and U.S. researchers said their analysis showed the surgery gives patients not only a longer life but also a better one.

Prostate cancer is the second-biggest cancer killer of men in the United States and many other industrialized countries, after lung cancer. It is expected to kill 31,000 men this year in the United States alone.

Prostate cancer is easily cured if caught early, but once it has spread it is incurable. Because it is a hormone-related cancer, eliminating the male hormones can slow its spread and help patients live longer and healthier lives.

Dr. Ahmed Bayoumi of the University of Toronto and St. Michael's Hospital and colleagues at Britain's Oxford University and Stanford University in California reviewed six treatments for prostate cancer that has spread.

They looked at how well each treatment worked, the side-effects it caused, such as diarrhea and liver failure, and quality of life.

Some men, they said, think that having their testicles removed is disfiguring, while others prefer it to living with the side-effects of medical castration -- using drugs to dry up the supply of hormones.

"The important thing to understand is that the medications chemically castrate people, so that everybody is castrated," Bayoumi said in a telephone interview.

"Medical castration means having to take injections in some cases and long-term pills and being subjected to side-effects," Bayoumi added.

"The base case was assumed to be a 65-year-old man with a clinically evident, local recurrence of prostate cancer," the researchers wrote in their report published in the Journal of the National Cancer Institute.

"DES, the least expensive therapy, had a discounted lifetime cost of $3,600 and the lowest quality-adjusted survival, 4.6 quality-adjusted life-years."

Surgical castration, on the other hand, costs $7,000 but led to 5.1 quality adjusted years of survival, the researchers found.

DES is a synthetic estrogen that counteracts the effects of testosterone. Quality adjustment has to do not only with lifestyle but also with the immediate value that people put on having a nice life now as opposed to more years in an uncertain future, Bayoumi said.

Without such adjustments, looking at average life expectancy alone, Bayoumi said a patient treated with DES cold expect to live 6.9 years and one treated by surgical castration could expect to live 7.5 years.

Of course, he added, some men live longer and others die sooner.

"Our analysis calls into question the cost-effectiveness of widespread use of expensive androgen-suppression strategies for men with advanced prostate cancer," they wrote.

"Since Medicare spent more than $477 million on (hormone-suppressing drugs) in 1994, the potential for cost-savings are considerable."

Bruce Hillner and John Roberts of Virginia Commonwealth University agreed. "Medicare payments for prostate cancer treatment were estimated to be $1.4 billion in 1994," they wrote in a commentary.

"From a societal and Medicare perspective, the obvious preferred strategy is orchiectomy (surgical castration) based on lower cost."

Copyright 2000 Reuters. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.



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The final cut

Some people can identify a defining moment in their childhood - an incident that brings an idea to mind which is then indelibly fixed in the psyche. For Gelding - an adopted alias for the American internet guru to all wanna-be eunuchs - that moment came when he was 12 years old and thrown against an older boy in a packed bus. "Do that again and I'll crush 'em," said the older boy, grabbing his genitals. The pain was as piercing as the pleasure. And so began a lifetime's quest to be castrated.

In the UK, self-motivated castration mainly exists only in the most extreme S&M scene, while in America those aspiring to be castrated comprise a burgeoning and divergent tribe made up of both gay and straight men. Men who want to be castrated fit no stereotype, have no common neuroses or childhood experience. Some are androgynous types (thin and underdeveloped) who want to remain in a prepubescent, asexual phase, others are eroto-phobes who don't like to feel driven by their libidos and want to become surgically tranquillised. Some want to be feminised, a few - known as nullos or smoothies - want to become nullified by having their penis removed along with their testicles.

In Gelding's experience a quarter of those who get castrated continue to regulate their libidos with testosterone, which allows them to have full sex. But what compulsion drives grown men to be castrated in the first place? According to Gelding, for most men the desire to be castrated stems from puberty but does not develop into a fixation for at least 10 years.

This was certainly his experience. Now in his early 50s, he has been without his testicles for six years and is keen to point out that he has no desire to be feminised. Growing up in rural New York State, he knew he was gay from childhood, but it was only in his mid-20s, while working for the military in a top security position, that he discovered the gay S&M scene and a world where castration was honoured rather than abhorred.

One of his first boyfriends was a cutter - a man who worked in the netherworld of the gay S&M scene, cutting off men's testicles, consensually and safely. By 1991 Gelding's testicles had become an unbearable affront to him. The idea of cutting aroused him sexually, but more than that, there was an aching need to be rid of something that had begun to take a stranglehold of his life.

At first he tried to cut off the offending items himself by using rubber bands as a tourniquet and drenching his balls in ice water. But after an hour he ran out of adrenaline and went into clinical shock. In hospital a horrified A&E surgeon castigated him for trying to remove healthy tissue. Three years later he went to a cutter in California and got rid of them safely and efficiently. "I've never felt more myself, more complete or happy," he says, unemotionally.

In order to receive the testosterone that he requires to keep him functioning as a man (he has occasional erectile problems but can still ejaculate) he has devised a cover story which makes him eligible for medical treatment. The story is posted up on the web and tells how he lost his balls against his will in a gay S&M episode which went horribly wrong. "My cover story also means that if someone finds out I'm castrated they view me as a victim, or a brave stalwart rather than a deviant or psychotic person," he explains. As well as resurrecting the libido, testosterone prevents osteoporosis and reduces the flab that castration causes to the hips and breasts. (On the down side, it also increases the risk of prostate cancer.)

A self-confessed mother hen, Gelding has for four years been dispensing advice on his website to men who want, or think they want, to be castrated. In that time he's had 5,000 enquiries from both gay and straight men, all believing that their obsession is unique. Consultant psychiatrist Dr Russell Reid, of Hillingdon Hospital in west London, identifies castration fixation as "highly disturbed behaviour, in mainly gay men, whose self-hatred is directed towards their genitals".

Gelding's response to this interpretation is equivocal. "Yes, it's true that no normal person would do that, but then given that homosexuality has always been called a sickness, what's normal?" Reid's experience of this tender topic is predominantly with transsexuals (some of whom even castrate themselves) as well as with men who are hypersexed. "These men are led by their erect penises and some are driven to offend. Being castrated can be a huge release because they become pre-pubital, and sex is no longer an overwhelming preoccupation."

He finds the origins of the fixation perplexing but speculates that it might be a case of the fear of castration turned on its head to become a uncontrollable craving.

But eunuchs are nothing new. For 4,000 years they have represented some of the most marginalised and most honoured in society. In ancient India, eunuchs advised princes and guarded their harems, and the Biblical Daniel was a eunuch who rose to become prime minister of Babylon and later Persia. More recently there have been the Italian castrati of the 19th century - boys who sacrificed their manhood for the sake of singing careers in the opera houses of Europe. Today there are the cross-dressing Hijras in India and religious extremists such as members of the Russian Skoptsy sect who see the testicles as an organ of weakness. The medical profession understands this "syndrome" only in relation to transgender reassignment surgery or as part of body dysmorphia (a syndrome in which people become fixated with having a limb amputated). But Gelding disregards the connection with the body modification scene, believing the desire to be castrated is far more complex.

Nor can he relate to the transgendered, "some of whom get castrated just to get on to a gender reassignment programme". He is also reluctant to help those whose desire to be castrated hinges on the ritual of cutting: "Because if that's the overriding issue then most of these people are into fantasy and role play and don't have a true fixation." When castration is a true fixation, Gelding believes it is vital that surgeons treat the problem in a much more educated fashion. "There isn't a doctor in the world informed in this area, because nothing will justify to a physician the removal of healthy tissue."

There are several doctors in the US who will surgically remove testicles, but seldom before getting their patients to sign a consent form saying it is for gender reassignment. Dr Felix Spector, who advertises castration on his business card, has become something of a celebrity in the murky world of eunochdom, having performed his first castration in 1957. But the vast majority are amateur cutters, subject to prosecution for practising medicine without a licence, and desperately sought after on the net by men in urgent need.

Although these cutters offer a necessary service (reducing the instance of self-castration), for the most part they too find the act of cutting erotic. Talking about doing a DIY castration, one cutter described the "lovely crunching sound" a Burdizzo (a castration device) makes "like biting into fresh celery". Burdizzos, elastators and other animal castration devices can all be purchased on the net. The internet has become a sanctuary to these would-be eunuchs. There are numerous websites providing information, and chat lines link men from all over the world who share this compulsion.

When Gelding was delivering himself into the hands of the cutter there were no such support services and perhaps that's why it wasn't until he was in his 40s that he finally did what he had always wanted to do. Since then, he says, he has found some kind of inner peace, but at a price. He would have preferred to have been one of those who rationalised their way out of it, something he encourages all his correspondents to do. He considers those who manage it to be the lucky ones.

The others must join him among one of the most disenfranchised of groups. Men who are ridiculed, despised and misunderstood by a society which will never be able to make any sense of why they feel incomplete with their testicles and yet complete without them.

• Hidden Love: Modern Day Eunuchs is on Channel 4 next Tuesday at 10pm

Sours: https://www.theguardian.com/theguardian/2000/oct/13/features11.g22


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