Orchidectomy as a preliminary procedure prior to gender reassignment surgery.

Dr. Russell W. Reid.

M.B., ChB, M.R.C.Psych., Consultant Psychiatrist. Hillingdon Hospital, The London Institute. Gender Trust Associate, Trustee Beaumont Trust.
Gendys Conference, 1994

The hypothesis which I am proposing is that bilateral orchidectomy, for whichever endocrinological or psychological reason, reduces the subjective intensity and severity of the gender dysphoria in some persons with Gender Identity Disorder.

This is based on my clinical impressions from some 20 Gender disordered patients who have undergone this operation.

The reasons given by patients for requesting bilateral orchidectomy, or physical castration, include the following:

1. An intolerance to the effects of Androcur, (Cyproterone acetate). Androcur does seem to have certain `toxic effects' over and above its anti-androgenic effect in some persons.

2. Many gender dysphoric patients have a particular revulsion of their testicles. Patients say their testicles feel alien or foreign to them, and their idealised feminine body image doesn't allow for the presence of testicles. They complain that they get in the way, or that they are painful.

In the WHO Classification ICD 10, Transsexualism is defined as "A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have hormonal treatment and surgery to make ones body as congruent as possible with the preferred sex."

Integral to this definition is the sense of discomfort with, or inappropriateness of, one's anatomy sex ie. one's genitals.

3. They complain that they produce the male hormone testosterone, which they regard, correctly, as the essence of maleness and all things masculine. They complain about the inexorable masculinising and ageing effect of Testosterone. (Female hormones do in fact improve skin texture by improving skin elasticity and reducing wrinkling of the skin).

4. Gender dysphoric persons associate their testicles with masculine aggression, competitiveness and sexuality. Undoubtedly they are right. Testosterone is the hormone responsible for male libido, (as well as female libido). It is no accident that 95% of convicted sexual offenders are males, all of whom have testosterone secreting testicles.

Rightly or wrongly, they focus everything bad about themselves on to their testes, and not surprisingly want them removed. Occasionally, fortunately rarely, gender dysphoric patients threaten self-mutilation, and sometimes even carry this out.

There are similarities in patients suffering from Dysmorphophobia, where a person, usually a young lady, has a neurotic and sometimes psychotic fixation that some part of their body is deformed and requires surgical correction. It can be the nose, the chin or the size of breasts. Such patients invariably find their way to a plastic surgeon to undergo corrective surgery. They may or may not be satisfied with the end result. The danger is that they will become `poly-surgery patients' and continue to plague plastic surgeons for "Just a little more to be whittled away from my nose." I recall one American dysmorphobic patient who was preoccupied to the point of being obsessed with having his foreskin restored surgically, which I understand is technically a very difficult, if not impossible, procedure.

Pre-operative preparations.

The effects of bilateral orchidectomy need to be carefully explained to the patient. The obvious effects includes:

1.Reduced libido, or sex-drive.

2.Sterilization.

3. Almost certain permanent impotence (erections do still occur occasionally, although they are unlikely to be associated with sexual arousal).

4. Menopausal symptoms with uncomfortable hot flushes, sweats and anxiety symptoms may follow orchidectomy, but usually settle down after a month or two, particularly with HRT.

The need for indefinite Hormonal Replacement Therapy to prevent osteoporosis in the long term (bone density slowly diminishes over many years without HRT).

5. Lethargy and sluggishness may occur, as well as weight-gain, fluid retention and hypertension.

Legal Considerations.

1. Obviously the patient needs to provide written consent for this procedure to be performed on him, with the likely effects, side-effects and long-term consequences explained carefully beforehand.

2. If married, the wife needs to consent in writing for her husband to undergo orchidectomy.

3. The medical ethics of the operation are reasonably straightforward, since there is already a body of medical opinion which approves such surgery, as there is also a body of medical opinion which approves Gender Reassignment Surgery, provided the Harry Benjamin Standards of Care are followed.

4. Provided the patient is mentally competent, and therefore able to give valid consent to the procedure, and there is no suggestion of coercion, then provided two psychiatric opinions are obtained, both of which recommend the procedure as being in the patient's interests, surgical referral is both appropriate and legitimate.

Outcome.

In 19 of the 20 patients I have followed, all but one have been very satisfied with the outcome.

Case anecdote:

One patient in particular was seen 5 years ago, at the age of 20, with severe distressing gender dysphoria, which was interfering with his enjoyment of life. He was extremely depressed and threatening that he must have a "surgical sex-change," or he would commit suicide. At the time he was so desperate that there seemed no other choice for him.

I lost touch with him, but in the meantime his GP had referred him for bilateral orchidectomy. When I saw him 5 years later, about 6 months ago, he explained that after a difficult month post-operatively, when he experienced `menopausal' symptoms with lability of mood, hot flushes, as well as periods of anxiety and depression, he eventually settled down, reviewed his priorities, started his Registered Nursing Training, which he completed successfully in 3 years. His depression lifted, he was no longer suicidal, and most importantly the gender dysphoria faded very much into the background. He continued low dose feminising hormones, but remained living in the male role all the time. It seemed as if his feminine side had faded very much into the background, and was no longer a problem to him. He explained in a matter-of-fact quite believable way, that he knew he was still transsexual and one of these days will probably get round to changing gender role, and maybe even undergoing gender reassignment surgery. It seemed as if his gender conflicts had subsided following orchidectomy and the worrying obsession to either castrate or kill himself completely disappeared.

It seemed to me that the decision this patient took to undergo orchidectomy was certainly correct for him at that time, and it remains to be seen just what happens in the future. My guess is that he will remain reasonably happy in the status quo, leading a decent and fulfilling life.

Case anecdote:

This is about 45 year-old man, married with two children, still living with his family, in a rather tense household, mainly because of his own and his family's ambivalence to his gender dysphoria, and his attempts to periodically change gender role. His two daughters particularly have little respect for him as a father, and even less as a wouldbe transsexual. He is aware of this antipathy and is sensitive to their criticism. It may be significant that despite a poor marital relationship his wife insisted on paying for his orchidectomy (I suspect she had ulterior motives). He has always been sensitive to small doses of hormones, he couldn't tolerate Androcur at all. As well, he was subject to a variety of neurotic symptoms, including depression, anxiety and panic attacks, as well as odd physical symptoms. He had had one possible bout of depersonalisation verging on a fugue state.

The orchidectomy was carried out six months ago, and since then he has been off work more often than he has worked. The family problems, as well as his general misery persist, and he now blames the orchidectomy for everything that has gone wrong with him and his family. In retrospect it was clearly a mistake for this man to have been castrated.

Orchidectomy in its Historical Context.

Any discussion about castration is bound to provoke an emotional response. Castration is reminiscent of the brutal treatment of sexual offenders during the Nazi period from 1933-45. Anyone viewing sexuality as a positive and delightful aspect of human existence will react primarily with aversion to the thought of surgical desexualisation.

Animal breeders of earlier times were probably the first to notice the change of behaviour and the domesticating effects of orchidectomy on horses and cattle. In the 30's the connection between hormone status, and sexual behaviour following castration, was the subject of research. In 1970 Beach summarised the results of Endocrinological studies on castrated animals. The review implied that the activity of gonadal hormones influences sexual behaviour, but that this may not be regarded as more than one of many influencing factors. Beach 1977, proposed that there are "multiple determinants of sex-related behaviour," and many non-hormonal factors can be named, but the actual extent to which these factors influence behaviour patterns is still obscure. Although there are multiple determinants of human sexual behaviour as well, conclusions generalised from animals to human beings, are often problematic, especially as far as sexual behaviour is concerned.

Myths tell of human victors gaining the characteristics of the defeated by symbolically devouring their hearts, brains or testicles. On removing the testicles, the masculine strength and dangerousness of the defeated was broken. Following the commandment of the Old Testament and the widespread legal-historical principle of Talion - Eye for an Eye, Tooth for a Tooth - it seemed a psychologically appropriate consequence in those days to punish the sex offender on "his sinful member."

By 250BC, the stoic philosophers were aware of the detachment of passion and emotions by castration. Self-emasculation, for religious ascetic reasons, was no rarity among priests and patriarchs, including early Christian Fathers, even though several early Christian Councils condemned this practice vigorously. From the 16th. Century until the beginning of this Century, castrate choirs performed in Roman Catholic churches in order to keep females away from liturgic services and to create beautiful voices (Castratio Euphonica).

First castration laws were enacted in the middle of the last century in the Southern States of America. Castration laws, including some calling for forced orchidectomy of sex offenders, have been operative since the beginning of this century in Scandinavia and in Continental Europe, but not in the Mediterranean countries. There have been many forensic/psychiatric publications since the 1930's on the Psychic and Behavioural effects of castration. Although these authors mention the spectrum of effects from castration, ie. general decrease in libido, erection, ejaculation, and intercourse, the results are by no means homogeneous. Very much in dispute are the range and number of mental effects, such as depressive reactions, suicidal tendencies, emotional lability, loss of interest, general sadness, and indifference to life. This range of results, in part at least, relates to the profession reporting on castration. Something considered pertinent by an Endocrine physician may be described by Psychologists as irrelevant for human sexual behaviour. Often the soft characteristics, like adjustment to the castration, post-operative quality of life or social conduct, are ignored, as is the pre-operative state of the patient.

The Skoptic Syndrome: castration and genital self-mutilation as an example of sexual body-image pathology.

This is summarized from Dr. John Money's paper published in the Journal of Psychology and Human Sexuality, Volume 1 1988:

Castration, with or without amputation of the penis, was a secret rite of the Russian Skoptic Sect which originated early in the 18th Century and existed for 200 years, until presumably they died out through lack of regenerative capacity, at least amongst the male members. (My understanding is that the Skoptic's central tenet of faith involved the belief that the genitals, particularly the testes, were considered the organs of lust, wickedness, impurity and evil and, in order to enter the Kingdom of God, members of this sect needed to be purified by completely ablating the genitals, including penis and testes). The same rite is practised by the contemporary Hijras of India, a sect comprised of men who live as women and worship the goddess, Behuchara Mata. The practice of becoming a eunuch is sporadic in the annals of today's medical sexology and sex therapy. It represents a renunciation to sex, with or without a Transsexual implication. It is a Sexual Body-image Syndrome, with three degrees of severity: fixation, neurosis or psychosis.

Its etiology is obscure. It is subject to mis-diagnosis, and to treatment that proves ineffective. Once the status of eunuch has been achieved, the prognosis is from guarded to good. Dr. Money goes on to describe an autobiographical case report of self-castration to illustrate a variant of the Syndrome which proved to be self-limiting, and with a good prognosis.

Dr. Money states that, in the science of psychology and human sexuality, there are still unclassified syndromes that need to be reported as detailed sexological case biographies. Eventually it may be possible to assemble them into homogeneous groups according to syndrome, and compare each group with the comparisonal control group. Dr. Money described a case in which the sexual body-image pathology was directed toward the eradication of genital eroticism and orgasm as "a threat to identity." It entailed a progressive programme of self-castration and denervation of the penis, after which the man's life stabilised in the role of eunuch. Self-castration may signify either the renunciation of sexuality or, when related to transsexualism, the renunciation of masculinity and the assumption of femininity, partial or complete. Self-castration is a cross-cultural phenomenon.

The etiology or cause of sexual body-image pathology has not yet been discovered. It is not difficult to recognise an intellectually superior but obsessional and self-absorbed cognitional history. The diagnosis is usually missed since Body-image Syndromes are not recognised in the official nomenclature. Treatment is often complicated by non-compliance, which is intrinsic to the syndrome, and this may be manifested as 'clinic shopping' which entails that cure eludes even the most famous experts who are consulted consecutively. In this respect the syndrome resembles, but isn't identical with, Munchausen's Syndrome, and also Munchausen's Syndrome by proxy.

Dr. Money then goes on to quote at length the patient's bizarre biography obtained by letters and telephone calls, describing in detail this man's prolonged method of self-castration, with the aim and object of totally eliminating all sexuality from his life. He took for granted the absoluteness of the postulate that sexuality must be eradicated, and with absolute conviction proceeded accordingly.

In some, although not all, cases of elective castration, there is an indication that the threat of sexuality in general masks a more specific threat of having a gender transposition syndrome. In the case described, the patient conceptualized his problem as being related to gender identity, but as a repudiation of masculine eroticism, not as its transposition towards femininity. In another case, of a man who applied for castration, there was a gender transposition component, namely a phobia of becoming overtly homosexual. Initially this phobia was masked behind the rationale of castration as being imperative to arrest the progress of baldness. He was becoming, like his father, prematurely bald in his 20's. The rational for not being bald was that it would traumatize his entire future existence.

The relationship of castration to gender transposition is undisguised in the case of the extreme and chronic form of transposition, namely, the Syndrome of Transsexualism in males. To be rid of the male genitalia takes priority over vaginoplasty in this syndrome. In some cases to become a eunuch is the sole demand. In others the procedure of surgical sex reassignment, from male to female, has proven to be preliminary to living as a lesbian, and yet others to living as a male who is a eunuch. Cross-culturally, the ideal of becoming a eunuch is evident amongst the Hijras of India. Hijras are a counterpart of male to female transsexualism in the West. For centuries their leaders have trained their successors in the surgery of amputation of the penis, scrotum and testes, minus vaginoplasty, and minus hormonal treatment with female hormones.

There is no evidence that being a eunuch through self-castration represents a special instance of the paraphilic syndrome of masochism. In paraphilic masochism, pain and injury, plus or minus humiliation, are prerequisite to eroto-sexual arousal, erection of the penis in the male, and the attainment of orgasm.

Castration according to Camille Paglia.

Paglia suggests that castration has prehistoric origins, by virtue of the fact that only stone tools could be used for ritual castrations; bronze or iron was forbidden. She suggests that castration was passed from culture to culture, and altered over time to circumcision, and that the celibacy of Catholic priests is a substitute for castration. She suggests that the shaved heads of Priests of Isis is a lesser self-mutilation. By castration the devotee subordinated himself to the female life-force. Self-castration was a one-way road to ritual impersonation. In the mystery religions, which influenced Christianity, the devotee imitated and sought union with his God. The Priest of the Great Mother changed sex in order to become Her.

The phenomenon called Shamanism migrated northwards to Central Asia and has been reported in North and South America, and Polynesia. Frazer describes the Shaman's stages of sexual transformation, which resemble those of our candidates for sex reassignment surgery. The religious call may come as a dream in which the man is "possessed by a female spirit." He adopts female speech, hairstyle and clothing, and finally takes a husband. The Siberian Shaman, who wears a woman's caftan sewn with large round discs as female breasts, is an example of "ritual androgyny" symbolizing the reconciliation of opposites. Inspired the Shaman goes into a trance and falls unconscious. He may disappear, either to fly over distant land, or to die and be resurrected. The Shaman is an archaic prototype of the artist, who also crosses sexes and commands space and time. How many modern transsexuals are unacknowledged Shamans? Perhaps it is to poets they should go for counsel, rather than psychiatrists.