Introduction

Male-to-female transsexuals diagnosed with gender dysphoria often request castration as part of their transition to a different gender, to promote demasculinization and change their physical appearance. However, other biological males seek to have their testicles removed or destroyed without the transition to female gender.1,2 Some of these men have a strong desire to be “some alternative gender different from [their] assigned gender”, although not female, according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).3 This condition is classified as male-to-eunuch gender dysphoria.4 Prior to the recently released DSM-5, only a desire to be the 'opposite gender' was recognized as a gender identity disorder. Other men have xenomelia, a neurological disorder of the sensory cortex of the right parietal lobe, which makes them feel that their male sexual organs do not belong on their body and should be physically removed.5,6,7 This condition has been termed body integrity identity disorder (BIID) in the psychiatric literature, although it has not yet been accepted into the DSM. Here, we report on a community of biological males who desire emasculation and are successful in removing or destroying their own testicles. We consider the heterogeneity of this community and describe methods by which eunuchs injure or remove their testicular tissue. In addition to raising awareness of this topic, we hope that practicing urologists will consider the ethical issues of whether to perform voluntary castration.

Epidemiology of self-castration

Although thousands of men share a common desire for castration, eunuchs and 'eunuch wannabes' (individuals who desire, or are planning, voluntary castration)1,2 represent a heterogeneous community that is difficult to characterize for several reasons. Firstly, many of the men in this community live their lives 'under the radar', meaning that they have not revealed their true gender identity and eunuch status to others. For example, according to one survey of voluntarily castrated males who identified themselves as eunuchs, only 30% and 11% had divulged this fact to close friends and family, respectively.2 Unsurprisingly, many individuals who desire castration do not disclose these desires to urologists and other medical professionals owing to fear of embarrassment or rejection. Secondly, much of the published data relating to eunuchs has been extracted from surveys with potential selection bias, such as recruitment after visits to emergency departments for genital self-mutilation, which is frequently performed during a psychotic episode. Despite these limitations, important data have been gathered on voluntarily castrated males that provide insight into this community.1,2 According to these data, the most common reasons given for pursuing voluntary castration are to reduce libido, correct a vision of their dysmorphic genitalia, or fulfill a sexual fantasy.

Available data also reveal that after castration, less than one-third of eunuchs continue to consider themselves as male, most consider themselves to be neither male nor female, and a few identify themselves as female (Table 1).1,3 Less than one-third (32.0%) describe their sexual orientation as straight, whereas most identify themselves as gay (21.4%), bisexual (39.8%), or asexual (4.5%) (Table 1). Over one-fifth of eunuchs report a change in their sexual orientation after castration. Although only a very small percentage of Americans live on farms (2.5% in the 1970 US census, when the average survey respondent was a child), a very high percentage of both eunuch wannabes (11.2%) and castrated eunuchs (18.3%) grew up on farms. An even higher percentage of both groups participated in the castration of animals as children—29.5% of the eunuch wannabes and 29.7% of those already castrated.8 In addition, 48.2% of eunuchs and 49.0% of eunuch wannabes hold at least a bachelor's degree compared with only 30.4% of the US population aged >25 years. In the general population, 10.9% hold university degrees beyond the bachelor's, compared with 22.4% of eunuchs and 22.2% of eunuch wannabes (Table 1). Although we cannot explain why both eunuchs and eunuch wannabes seem to be educated to a higher level than the general populace, we speculate that greater knowledge might lead to awareness of possibilities outside the gender binary.

Table 1 Demographic characteristics of eunuchs and eunuch wannabes in the USA
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The Eunuch Archive

The Eunuch Archive (www.eunuch.org)9 is an internet site that is frequented by individuals who have already been castrated, are actively seeking castration, or are especially interested in the subject. This website contains first-hand accounts of castration, including both successful and unsuccessful attempts, as reported by its members. Since its launch in 1998, it has attracted over 70,000 registered members, approximately 12,000 of whom remain active today. Over the past dozen years, the site has been accessed via approximately 350,000 unique internet protocol addresses per month, by individuals who do not need to register in order to read the site. In addition, gatherings of members of the Eunuch Archive community have been held in various locations across the USA.

A survey of 236 already-castrated members of the Eunuch Archive (unpublished data, T. W. Johnson) found that 31% of these individuals were taking a full replacement dose of testosterone, indicating that they were probably experiencing xenomelia, rather than gender dysphoria. Only 12% of survey respondents had received oestrogen at a level that would facilitate a transition to female gender. Of the remaining eunuchs, 35% received no hormone replacement therapy (HRT) and 22% self-administered a small dose of either testosterone or oestrogen at a level that is thought, within the community, to minimize hot flashes and prevent osteoporosis. Those taking no HRT, or very low doses of HRT, are more likely to experience male-to-eunuch gender dysphoria than those taking high doses. A similar survey of 145 castrated men1 found that the average age of first interest in castration was 22.5 years, with 38% of respondents reporting an interest before age 14 years. The average age of actual castration was 41.7 years; the youngest castration was performed at age 17 years (by the individual's boyfriend). The average age of the population at the time of the survey was 48.2 years.8

Incidence of self-castration

The number of men who have undergone voluntary castration or testicular damage in the USA is unknown, but might be more than 10,000 based upon postings on the Eunuch Archive website. Many of the men who request help from their urologist with voluntary castration state that they are unable to find a qualified surgeon who is willing to perform this procedure. Hence, many resort to chemical castrating agents purchased over the internet, undertake self-surgery, or seek surgery from unqualified self-described 'cutters'. Although these operations are dangerous and illegal, many of the cutters who perform them have some background in surgery, gaining such experience as nurses or veterinary assistants. A survey of 113 cutters found that 21% of them were raised on a farm and 58% had experience with animal castration.8 Of those cutters who come to the attention of the authorities for practicing medicine without a license, many have already performed several successful castrations (without causing medical emergencies) according to posts on the Eunuch Archive.10,11 Much of the medical literature that addresses the desire for castration is based on individuals who present at emergency rooms after genital self-mutilation,12,13,14,15,16 providing little evidence for the actual incidence of voluntary orchiectomies, as many of these individuals never come to the attention of medical professionals. In one paper, Greilsheimer and Groves17 stated that “intentional self-mutilation of the genitals in males is exceedingly rare”, as they found only 53 cases reported in the medical literature worldwide between 1901 and 1977. However, Romilly and Isaac18 identified an additional 44 cases in the literature published since 1900. Additionally, Aboseif et al.19 identified 14 cases in a single hospital in San Francisco over a 10-year period.

In much of the medical literature, it is presumed that “[men] who intentionally mutilate or remove their own genitals are likely to be psychotic at the time of the act”.17 However, much of this research was conducted in an era when there was less awareness and understanding of transsexualism. Romilly and Isaac18 suggested that “about two-thirds of male genital self-mutilators are psychotic”; Aboseif et al.19 similarly characterized 65% of the men in their study as psychotic. However, most of the mutilations deemed to be psychotic acts were focused primarily on the penis. By contrast, the population under consideration here consists largely of men who seek to remove only their testicles, after long and careful planning. As such, they are less likely to self-castrate as an impulsive and psychotic act and present as patients to emergency departments.

Methods of self-castration

New visitors to the Eunuch Archive site seeking information on how to self-castrate are strongly advised by the moderators and other long-term members of the site to undertake a 'trial run' with a reversible chemical castrating agent before doing anything more permanent. Internet sources for obtaining antiandrogens (such as progesterones and cyproterone acetate) and other chemically castrating pharmaceuticals are posted on the site and various suppliers are rated for reliability and price. Strong warnings are also given that surgical castration by anyone other than a trained surgeon is highly dangerous. Nonetheless, there are long discussions of methods for self-castration.

Clamps and rings

One method of physical self-castration involves the use of a Burdizzo clamp, which was designed for the castration of beef cattle (Box 1; Figure 1a). The Burdizzo clamp crushes the spermatic cord and disrupts blood flow to the testicles. Men who have attempted self-castration with a Burdizzo clamp report it as extremely painful and seldom successful. Another method uses an elastrator, a device originally designed to castrate young lambs and goats (Box 1; Figure 1b). The elastrator is used to place a tight rubber ring around the scrotum above the testicles to restrict the blood supply until the testicles and scrotum necrotize. According to members of the Eunuch Archive community, castration with the elastrator is even more painful and dangerous than castration with the Burdizzo clamp.

Figure 1: Methods of self-castration.
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a | The Burdizzo clamp was designed for the castration of beef cattle. It can be used to crush the spermatic cord and disrupt blood flow to the testicles. b | The elastrator was originally designed to castrate young lambs and goats. It is used to place a tight rubber ring around the scrotum above the testicles to restrict the blood supply until the testicles and scrotum necrotize.

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Surgical orchiectomy

The other method for physical castration is surgical orchiectomy (Box 1). The necessary supplies (including anaesthesia, scalpels, and suture materials) can all be purchased online. Orchiectomies can then be performed as either self-surgery or by others. Reports circulating on the Eunuch Archive, and on other internet sites concerned with body modification, tell of cutters who have performed many castrations without any medical follow-up care. Indeed, according to self-reports posted on the Eunuch Archive, most men who perform self-surgery are successful and do not require treatment in emergency rooms. Nonetheless, a botched self-castration or orchiectomy by a cutter might necessitate expensive treatment, often resulting in hospital admission.20

Injection of toxins

One recent thread on the Eunuch Archive website discusses the injection of ethyl alcohol—which has a known necrotizing effect on male reproductive tissue21—directly into the testicles to gradually destroy them (Box 1). The thread has been accessed over 400,000 times since the first comment was posted in October 2009. It includes detailed instructions for injection, with recommended sources of ethyl alcohol and associated materials that are available either locally or online. Everclear® (95.6% ethanol) is the alcohol preparation of choice for most men in the USA. Vodka containing 50% ethanol is commonly used as the fallback ethanol source when Everclear is unavailable. Polish spirytus (96% ethanol) is available throughout much of Europe, according to European Eunuch Archive members who have used it. Links to web addresses for online videos of the procedure are also provided within the thread.

The injection process is described as extremely painful, and must be repeated 10 or more times on each testicle at intervals of 1–2 weeks to be successful. Nevertheless, many members of the Eunuch Archive describe success with this procedure, which usually ends with a urologist removing the damaged testicles. Many of the Eunuch Archive posts on this thread are warnings that individuals should try reversible chemical castrating agents for 6–12 months before contemplating anything more permanent. Readers are also advised to seek the help of a fully trained and qualified surgeon, rather than performing self-castration by injecting toxins into the testicles.

Ethyl alcohol is not the only toxin that has been discussed on the Eunuch Archive for self-castration by intratesticular injection. Other toxins include lactic acid, which is available commercially as Chemcast® GP (Total Plastics, Inc., USA) in the USA, Australia, and Canada for castrating beef cattle,22,23 zinc gluconate, which is sold as Neutersol® (Addison Laboratories, USA) for the permanent sterilization of young dogs (aged 3–10 months),24 and calcium chloride, which is commonly used to castrate stray dogs in India.25,26

An active thread concerning calcium chloride injection has been read more than 100,000 times since it was first posted in October 2012. Food-grade calcium chloride dihydrate is readily available in supermarkets as Pickle Crisp® (TMs Ball Corporation, USA), which is produced by the makers of Ball® canning jars. Several men have posted descriptions of their success using this toxin, having found a qualified surgeon to perform an orchiectomy after permanently damaging their testicles with calcium chloride.

Men have injected ethyl alcohol or calcium chloride to damage their testicles in order to feign testicular cancer so that a urologist would perform an orchiectomy. One young man provided a detailed description of how injections led to testicular abnormalities on ultrasonography, and posted the following description of his follow-up urology consultation: “[the urologist] looked a little guilty, as if he felt bad he had to remove my testicles. The pathology report stated that there were several spots of 'focal necrosis', and they could not figure out why. He asked me if I had any recent sexually transmitted diseases or infections, any sort of trauma, and I told him not that I was aware of, just the onset of sudden pain at one point and swelling (the truth, technically). He said it could have been some sort of serious acute infection, but that other than that he was clueless. I told him “that's fine, I'm happy”.” Later, the man admitted to feeling bad for “leading everyone on” and deceiving the urologist into thinking that he had cancer, but wrote: “what choice did I have? I couldn't tell them the truth.”

Conclusions

As pointed out by St Peter et al.,20 even men with the more generally accepted diagnosis of male-to-female transsexualism might have difficulty in persuading a licensed surgeon to perform an orchiectomy. Men with the less widely recognized male-to-eunuch gender dysphoria have far more difficulty with obtaining castration through the proper medical channels and are more likely to resort to self-surgery, enlist the help of cutters, or inject toxins. A common goal of injecting toxins is to injure the testicles so that a surgeon will remove them safely. If a qualified and willing surgeon cannot be found, men with extreme castration urges are likely to resort to unsafe self-surgery or the services of a cutter found online.

BIID or xenomelia is rarely considered to be a valid diagnosis for surgery and, when it is, it generally refers only to the desire for amputation of a lateral appendage (most frequently, the left lower limb). However, in a survey of the medical literature on BIID, Swindell and St Lawrence27 found that approximately one-third of the cases reported involved amputation of male genitals. Some bioethicists have argued that, provided the individual is legally sane, he should be allowed to have healthy tissue amputated by a surgeon.28 However, legal scholars debate the basis for any right to an action resulting in self-harm. Bergelson29 points out that, although some forms of self-harm are prohibited, others are clearly permitted. What is permissible also changes over time; for example, body piercing and tattooing (which was only made legal in New York City in 1997) have gained wider acceptance recently.

Physicians—urologists, in particular—need to be aware of the growing popularity of self-castration and self-inflicted damage to the testicles. A misdiagnosis of bilateral testicular cancer will lead to costly blood tests and imaging studies, possibly resulting in an inguinal orchiectomy, which is much more expensive than a simple trans-scrotal orchiectomy under local anesthesia. It also has the potential to cause psychological distress for the surgeon who might feel guilty for removing potentially healthy testicles that were noncancerous on pathology.