Orchidectomy As A First Stage Towards Gender Reassignment: A Positive Option.

Dr. Russell Reid M.B., ChB, FRC Psych.

Consultant Psychiatrist, Hillingdon Hospital & Private Practice London Institute of Human Sexuality, GT Assoc. Trustee Beaumont Trust.
Gendys Conference, 1996

This study follows on from my paper "Orchidectomy as a Preliminary Procedure Prior to Gender Reassignment Surgery" presented at the 3rd Gendys Conference at the University of Manchester in September 1994. In this study a group of 14 patients, of whom 13 presented as Transsexual, Male to Female, had requested orchidectomy as a first stage toward full gender reassignment surgery. (The 14th patient was gender dysphoric with a high libido which he wished to have reduced). Within the UK it has never been the accepted practise to offer orchidectomy in place of anti-androgen therapy, indeed the use of GnRH analogues including Goserelin, and Prostap SR by subcutaneous injection into the abdomen may well be preferable, not least because such treatment is reversible. Goserelin or Prostap may be used in gender dysphoric pre-pubertal boys to delay the onset of the masculinising changes of adolescence.

Obviously bilateral orchidectomy is not an option when gender reassignment surgery is contemplated within 6-12 months, or when an alternative anti-androgen, including Androcur, is effective.

However, an increasing number of patients have found the side effects of Androcur (cyproterone acetate) sufficiently unpleasant that these, combined with a wish to be free of their testes, have led them to request bilateral orchidectomy.

The side effects of Androcur complained of were:

• extreme lassitude,
• alteration of sleep pattern,
• mood swings,
• headaches,
• depression,
• hot and cold sweats, and
• intolerance to alcohol (particularly red wine).

It is significant that Androcur has never been licensed for use in the USA, presumably because of its hepato-toxicity and tendency to cause depression, fatigue, weight gain, osteoporosis and thrombosis and embolism.

The Study.

All the patients who had undergone bilateral orchidectomy over the last 5 years were contacted by letter enclosing a questionnaire and those who returned the questionnaire were then also personally interviewed.

The youngest patient was 24, the oldest 66, with an average age of 46. All patients underwent surgery privately. Three operations were carried out under local anaesthesia as day cases, and 11 under general anaesthesia with an overnight stay in hospital. Three patients has post-operative complications, two of which were an abscess/infection, and one was a healing problem with the suture line.

We asked why patients wished to undergo orchidectomy, giving them a number of choices and allowing them to choose a combination of reasons. Eleven patients stated that they disliked having testicles, one had testicular pain, nine had difficulties with Androcur, twelve wished to prevent further masculinisation, and six gave other reasons, including:

"I had young adult children and felt that I had to proceed by degrees to help them adjust to my transition."

"To lessen my mental conflict."

"As a testing ground to judge my response as a precursor to eventual gender reassignment surgery."

"Prolonged use of Androcur and concerns about liver damage."

"Discomfort wearing tight under-wear/swimwear."

We asked these patients whether or not they were pleased with the orchidectomy from a psychological and physical point of view. All 14 said they were pleased on both counts. (One person was initially unhappy from a psychological point of view and said it had taken 6 months for him to settle down and feel balanced. He is now very happy and settled, although has not proceeded with gender reassignment surgery). 50% of the group gave other reasons for being pleased with the outcome of orchidectomy, including an increased sense of self-confidence, lessening facial hair, improved attitude of family and friends, no further testicle pain, and feeling generally happier.

Seven of the group have now undergone GRS. The waiting time between orchidectomy and GRS varied between 3 months and 34 months, with an average of 16.7 months. We looked at whether orchidectomy increased or decreased the need for GRS. Seven said that it made no difference, 5 said that it increased or confirmed their need for GRS, and in 2 patients it decreased their need for GRS.

Of the patients who subsequently underwent GRS none had surgical complications or complaints about vaginal depth as a result of orchidectomy.

Of the 50% of patients who had not yet had GRS, 3 had not yet changed gender role. Two are currently on the waiting list for GRS, and one is waiting for NHS funding. The other does not wish to have GRS.

The following comments were listed by patients following orchidectomy:

"It produced a wonderful reduction in tension."

"It prepared me for more radical surgery."

"It consolidated my position as a woman amongst family and friends."

"I have become more confident with an increase in my self-esteem."

"It enabled me to stop taking Androcur."

"I am able to get on with every day living without being so pre-occupied with my gender conflict." (This was the patient who decided not to proceed with GRS).

"Greatly enhanced confidence in female role enabling me to participate fully as a woman in public situations."

"The removal of something unsightly and unwanted."

"It really did stop me feeling male which I desperately needed to do, enabling me to live with myself as my treatment progressed."

"I feel much more at peace, and more feminine, more caring, more weepy, softer, more understanding and happier."

"It made me feel that my consultant and counsellor believed in me and thus it confirmed my transsexuality and my road to full reassignment surgery."

"It confirmed my inner sense of self."

"A positive step, with positive results on the route to GRS."

Conclusion.

This study suggests that orchidectomy is a valuable option prior to eventual gender reassignment surgery in persons with gender dysphoria who are intolerant to Androcur, have a particular revulsion for their testes, or are for whatever reason, unable to proceed with GRS within a reasonable period of time.

Since bilateral orchidectomy can and should be considered when gender dysphoric persons are not in a position to start their real life test, this clearly breaches the present Harry Benjamin Guidelines which I would suggest need urgent revision because of this. In view of the fact that this procedure has had a controversial history, and may be considered inappropriate on moral or ethical grounds, it is necessary to obtain the written approval of two psychiatrists or mental health workers beforehand. It is also necessary to obtain the written consent from the patient's wife, together with the consent of the patient, to the effect that bilateral orchidectomy causes impotence with erectile failure, permanent sterility, and the need for indefinite hormone maintenance to prevent osteoporosis in the long term. These are necessary Medico-Legal requirements. On a more positive note however, it is said that bilateral orchidectomy protects against coronary artery disease, cerebrovascular disease and effectively increases the life span by an average of 5 years.

It should be noted that there may be a change in temperament with docility, sluggishness and lethargy, as well as reduced energy, weight gain, and after several years reduced face and body hair.

In the UK bilateral orchidectomy is available privately as a cost of approximately £1500 when done under General Anaesthesia with an overnight stay in hospital. The cost is significantly reduced when done under local anaesthesia as a day case. It should be noted that even under local anaesthesia, the procedure is extremely painful for a short while, and so this is not for the squeamish. The effects of bilateral orchidectomy can be partially reversed in the sense that realistic prosthetic testes can be reinserted in the scrotum, and replacement testosterone in the form of Sustanon injections every two or three weeks can restore physiological levels of testosterone along with the restoration of libido and potency. Obviously sperm production stops completely which results in permanent sterility.