Variation in perceptions of genital ablation between aspiring eunuchs and individuals with paraphilic sexual fantasies

Abstract

Background

Although uncommon, some individuals assigned male at birth (AMAB) seek voluntary genital ablative procedures, and others fantasize about it.

Aim

To learn more about the views of genital ablation and injuries in those who aspire to be castrated as compared with those who only fantasize about it.

Methods

A survey was run on the Eunuch Archive internet community. Content analysis was conducted on the responses of 342 AMAB individuals with castration fantasy but no desire for actual surgery (fantasizers) vs 294 AMAB individuals who expressed a desire for genital ablation (aspiring).

Outcomes

Study outcomes were responses to open-ended questions about genital ablations and injury.

Results

Aspiring individuals were more likely to perceive a “physical appearance benefit” from orchiectomy, but fewer could recall how they first learned about the procedure. Some reasons that aspiring persons gave for desiring an orchiectomy included “achieving preferred self” and “health reasons.” Fantasizers, in contrast, worried about the potential side effects of orchiectomy, and more believed there to be no benefit to it.

Clinical Implications

Psychiatrists and other clinicians need to understand their patients’ views on genital ablation to properly diagnose and provide the best personalized care.

Strengths and Limitations

Strengths include a large sample of respondents. Limitations include the accuracy of the anonymous survey data.

Conclusions

This study demonstrates divergent interests on genital ablation among AMAB individuals who have not had an any genital ablation yet have intense interest in the topic.

Introduction

Genital ablation refers to any procedure that removes or renders nonfunctional a part of the external genitalia. In rare cases, some individuals assigned male at birth (AMAB) have a strong desire for genital ablation without medical need or a diagnosis of male-to-female gender dysphoria.^1,2 They may experience significant dysphoria from their genitals or feel that their genitals do not belong to their body and wish to have them removed. Past studies have labeled persons who desire orchiectomy but have not yet undergone the procedure as “wannabes,”^1,3 but a more proper clinical term may be aspiring. Others do not want genital ablations but have sexual fantasies about receiving genital ablation. They are recognized here as fantasizers.¹

Terminology

Psychiatry and sexology researchers have a long history of creating labels and terms that may not align with the language and terminology used by the populations whom they are treating.⁴ In many cases, certain terms are stigmatizing and pathologizing and do not affirm the wide range of naturally occurring sexual and gender diversity within a population.⁵ As psychiatry and other disciplines have gained greater scientific understanding and cultural competency, they have attempted to adopt the terminology and language of the communities that they treat.⁶

Sometimes, the language used by a community may at first glance appear pejorative or shocking but may in fact be reappropriation. For example, in the queer community, the word queer was historically used as a slur but now may have positive connotations within the LGBTQIA+ community (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual).⁷ This is also true within the modern eunuch community.⁸

The term eunuch has been around for thousands of years.⁹ For many outside the eunuch community, the term remains associated with historical eunuchs who often had little choice in their genital ablations.¹⁰ In most cases, modern eunuchs are eunuchs by choice, although there is evidence of some who lost their testicles due to accidents or medical treatment and come to identify with the label.¹¹

Another term that is often used by the eunuch community is castration, which it uses in an image-positive way to describe the orchiectomy procedure.¹² This term, which frequently appears in the veterinary and oncologic literature, is often perceived as negative when applied to humans in the psychiatric or medical context.¹² In this article, the words orchiectomy and castration are used in keeping with the language used by the medical as well as eunuch communities.

We avoid the term emasculation because it is often used in various and inconsistent ways in the medical and sociologic literature.¹²  Masculinity itself is a term that has varying meanings to different people, including eunuchs and aspiring eunuchs, and is thus also avoided.¹³ While most people who are interested in genital ablation self-identify as men, a smaller proportion will align with identities such as eunuch or genderqueer.¹⁴

Modern eunuch community

The internet has allowed eunuchs and others interested in genital ablation to connect and create community in ways previously unavailable. The Eunuch Archive internet community (www.eunuch.org) is perhaps the largest and most studied, with close to 6000 active members who have provided personal information to register on the site. Topic threads on the Eunuch Archive are wide ranging, from creative fiction about eunuchs to methods of performing orchiectomy. Similar to other health-oriented internet communities, members of the Eunuch Archive share resources, including information on surgeons and other providers who are supportive of their needs.

Due to social and cultural stigma, many modern-day eunuchs choose to remain anonymous on the Eunuch Archive and share their eunuch identity and interests only with close friends and family.⁸ Some members are more open and meet yearly in person, where they socialize and share their experiences. Previous surveys of Eunuch Archive members demonstrate that they represent a psychosocially diverse group whose interest and goals related to genital ablation are divergent and diagnostically varied.¹⁵

Diagnostics

Diagnostically, the desire for genital ablation can be categorized in different ways.¹⁵ Some may experience dysphoria related to their testicles in a manner similar to other gender-diverse people.^15-17 These individuals may desire a “smooth” appearance to their perineum as well as having no testicles.¹⁸ They may also desire the psychological effects of low testosterone.¹⁹ Others may have intense feelings of physical inappropriateness about their testicles and do not wish to be castrated.²⁰ They may, for example, see no benefit to having lower testosterone and may often perceive it as negative.¹⁴ Still, others may simply fantasize intensely about performing or receiving genital ablation.^1,14

Individuals who eroticize orchiectomy and other forms of genital ablation may present with a different set of characteristics and diagnostic profile.¹ They may not actually desire orchiectomy or feel any persistent bodily incongruence related to their genitals. Instead, they may have intense sexual fantasies about castration, consistent with a paraphilic diagnosis.²¹ Even so, their distress may be significant, and some may seek orchiectomy as a means of controlling clinically significant symptoms that impair daily function.¹⁴ Properly assessing one’s interest and/or desire for genital ablation can be helpful for providing the best treatment and supports to meet these patients’ needs.¹⁵

Male-to-eunuch gender dysphoria

Previous research suggests many people who have undergone voluntary orchiectomy or desire it (aspiring) will fit into this diagnostic category.^1,2 Individuals with male-to-eunuch (MtE) gender dysphoria often experience emotional and/or physical dysphoria from a body with functional testicles.^15,16 Some may also feel dysphoria related to the secondary sexual characteristics that arise as a result of exposure to testosterone.¹⁵ In some cases, their dysphoria is specific to the psychosexual effects of testosterone and not to any aspect of their physical appearance or gender presentation.¹⁵ These persons may have their first desire for genital ablation in childhood or adolescence when the changes associated with puberty trigger the incongruence.²²

Diagnostically, this group has gender dysphoria without a desire for feminization.^15,16 Their primary gender identities are man or eunuch.⁹ Similar to those with other forms of gender-related dysphoria, individuals with MtE gender dysphoria may have very different presentation and treatment goals.²³ For example, even though they may identify as eunuchs, they may choose divergent gender expressions, with the predominant gender expression being masculine.¹⁵ Treatment options are varied and may include supportive psychotherapy, hormonal interventions (androgen blockade and/or hormonal replacement), or surgery (orchiectomy).^15,23 In all cases, the goal of these interventions is to provide relief of gender dysphoria.²³

Body integrity dysphoria

Another group that may seek genital ablation are people with body integrity dysphoria (BID): “intense feelings of inappropriateness concerning current non-disabled body configuration.”²⁴ Individuals with BID may feel that their genitals do not belong to their body and so wish to have them removed to improve body perception.^2,17 They may share the same desire for genital ablation as those with MtE gender dysphoria but not a desire for the psychoneuroendocrinologic side effects of orchiectomy, such as suppressed libido.¹⁴ They may express a desire for genital ablation but remain otherwise masculine.

Paraphilic disorder

Paraphilic disorders are classified as “persistent and intense patterns of atypical sexual arousal” that may include “sexual thoughts, fantasies, urges, or behaviours” acted upon or directed toward those who are “unwilling or unable to consent” and cause marked distress or involve solitary behaviours or activities with consenting adults that can lead to a “significant risk of injury or death.”²⁵ Individuals with paraphilic attractions are more likely to engage in sexual behaviors related to those attractions.^14,26-28

For those with a paraphilic interest in genital ablation, they may not express an actual desire for orchiectomy but may nevertheless engage in behaviors that could indirectly result in genital injury.²⁰ They do not experience gender dysphoria or an intense sense of inappropriateness from their genitals. Their interest in genital ablation is predominantly erotic; thus, they would not see a benefit physically, psychologically, or emotionally from the loss of their genitals, although they may eroticize those effects.^14,20

Current study

We explore here the views of genital injuries and ablation of aspiring eunuchs and fantasizers. Specifically, we analyze the responses to open-ended questions in an anonymous survey for readers of the Eunuch Archive. Our goal was to answer the following question: are aspiring individuals more likely than fantasizers to perceive benefits from genital injury, having nonfunctional testicles, and/or having no genitals? We hypothesize that aspiring individuals will perceive greater benefits to genital injury, having nonfunctional testicles, and/or having no genitals. Understanding one’s interests and motivations for genital ablation can help clinicians formulate assessments and treatment plans.

Methods

Participants and procedures

Participants were recruited from a convenience sample in the Eunuch Archive internet community between October 2016 and June 2017. The research study was approved by the institutional review board of California State University, Chico, and the Eunuch Archive Steering Committee. Because data collection involved anonymous survey data, the study was exempt from full committee review. We built the survey on the SurveyMonkey platform, and the study link was posted online.

The landing page has an initial statement: “The survey is for eunuchs, eunuch wannabes [ie, intact natal males who are considering orchiectomy], and any others who may have interests in orchiectomy, whether as fantasy or academic interest.” Only individuals who consented to the study were able to access the full survey, which required approximately 30 to 40 minutes to complete. Respondents were not compensated for participating in the study.

There were 1023 participants in the study. Respondents were asked their age when they began the survey, and this was verified by asking for their date of birth near the end of the survey. Those whose age did not match their date of birth by 1 year were excluded. Other exclusion criteria were (1) age <18 years, (2) not biologically male or with unspecified biological sex, (3) formerly taking chemically castrating agents but not currently, (4) castration, (5) penectomized without castration, and (6) failure to indicate castration status. Of the remaining surveys, we analyzed data from 342 respondents who reported having orchiectomy fantasy but expressed no desire for actual surgery (fantasizers) and 294 who stated a desire for an orchiectomy without having obtained genital ablation (aspiring).

That classification was drawn from participants’ answers to the question “What is your current castration status or interest in castration?” The two relevant options were “Get sexual pleasure from thinking about castration or for ‘play castration’” and “Would like to be castrated and/or searching for ways to be castrated.”

Measures

Demographics

Participants completed standard demographic questions, including age, ethnicity, relationship status, marital status, education, income, gender, country of residence, partner’s gender, handedness, and sexual attraction based on the Kinsey Scale. The answer options for sexual attraction were as follows:²⁹

• X –Asexual or nonsexual (no interest in sexual activity with others)

• 0 –Exclusively heterosexual with no homosexual attraction

• 1 –Predominantly heterosexual, only incidentally homosexual

• 2 –Predominantly heterosexual, but more than incidentally homosexual

• 3 –Bisexual (equal heterosexual and homosexual attraction)

• 4 –Predominantly homosexual, but more than incidentally heterosexual

• 5 –Predominantly homosexual, only incidentally heterosexual

• 6 –Exclusively homosexual

Open-ended questions

Participants responded to the following open-ended questions (Table 2):

• How did you first learn about castration?

• What were the circumstances when you first thought that you might want to be castrated?

• What do you believe are the advantages of not having genitals?

• What do you believe are the disadvantages of not having genitals?

• What do you believe are the advantages of injuring genitals?

• What do you believe are the disadvantages of injuring genitals?

• What do you believe are the advantages of having nonfunctional testicles?

• What do you believe are the disadvantages of having nonfunctional testicles?

The last two questions were included because some voluntary eunuchs reported having injected toxins into their testes to make them nonfunctional and as a way to make them warrant surgical removal through the medical system.²

Data analysis

Data were analyzed with SPSS version 26 (IBM). Demographic data were compared between the fantasizers and aspiring groups via t-test for continuous variables or chi-square test for categorical variables. We analyzed responses to the open-ended questions using the content analyses framework outlined by Braun and Clarke.³⁰ Qualitative responses were organized on Microsoft Excel. Data were read and coded by E.W. The themes were coded at the semantic level, and we framed the thematic analyses within an essentialist epistemology. Initial codes were collated and categorized into themes. Most themes were based on the ones used in our previous study.¹⁴ However, a few new themes were identified. Direct quotes are provided only for newly identified themes. Multiple themes may be identified from 1 response. The content of each code was reviewed for each theme, and each theme was named and defined. For each theme, the number and proportion in relation to the total number of responses for each question are listed in Table 2.

Results

Demographic

Table 1 shows demographic data from the two groups. There were significant differences in the proportions for gender identity (χ²[6] = 54.2, P < .001), education background (χ²[6] = 19.7, P < .01), sexual attraction (χ²[8] = 17.4, P < .05), and handedness (χ²[7] = 16.8, P < .05). The aspiring group had a lower proportion who identified as male (70.7% vs 91.8%) but a higher proportion who identified as eunuchs (9.9% vs 0.9%) vs the fantasizers. Both groups were well educated; however, the fantasizers had more members with a university education (60.8% vs 46.9%) than the aspiring group. The proportion of sexual attraction was similar for both groups, except that the aspiring group had more asexual respondents (9.9% vs 3.2%). In addition, the aspiring group had fewer individuals who were strongly right-handed (52.7% vs 67.3%).

Content comparison for responses to open-ended questions

How did you first learn about castration?

Participants from both groups reported similar proportions of most themes on how they first learned about castration. The top three were through various media, from becoming aware of animal castration (eg, pet or living on a farm), and from interaction with another person. The fantasizers, however, were more likely than the aspiring group to remember how they first learned about castration (7.1% vs 3.0%, χ²[1] = 4.6, P < .05).

What were the circumstances when you first thought you might want to be castrated?

Four themes for the circumstance when participants first thought of wanting to be castrated differed between the fantasizers and aspiring group. The aspiring group was more likely to report “achieving preferred self” (χ²[1] = 52.4, P < .001) and “health reasons” (χ²[1] = 7.9, P < .01). Yet, the fantasizers were more likely to indicate “eroticizing castration” (χ²[1] = 28.7, P < .001) and “nonerotic castration fantasy” (χ²[1] = 24.2, P < .001), the latter of which was cited by 14.7% of the fantasizers but only 2.1% of the aspiring group. For example, two fantasizers stated the following: “I saw a parade one day. The majorette looked so smooth in genital area. I had a lot of [fantasies] about not having male genitals” (P961), and “[I] picked up an elastrator out of a tool box, and wondered how much it would hurt if the neighbour girl ripped my testicles out like I had done to the bull” (P150). Two from the aspiring group reported “amputation fantasies” (P901) and “When I was ten years old, I would go into the kitchen late at night, put my penis on a cutting board, and hold a carving knife against it—fantasizing about not having a penis anymore and daring myself to do it” (P13).

Having no genitals

In terms of their perception of the advantages of having no genitals, the aspiring group had a higher proportion of participants reporting physical benefit (χ²[1] = 8.6, P < .01) but a lower proportion citing no benefit (χ²[1] = 18.6, P < .001) as compared with the fantasizers.

The latter theme (no advantage) was noted by 16.5% of the fantasizers but only 4.3% of the aspiring group. For example, two fantasizers stated that they “don’t believe there are advantages” (P373) and “can’t think of any” (P576). Two from the aspiring group reported “none I can think of” (P612) and “none” (P951).

The proportions for most themes on the disadvantages of lacking genitals differed between the aspiring group and the fantasizers. Specifically, the aspiring group was more likely to report no disadvantages (χ²[1] = 20.9, P < .001), side effects associated with androgen loss (χ²[1] = 5.9, P < .05), and urinating problems (χ²[1] = 4.2, P < .05). However, the fantasizers were more likely to cite concerns associated with sexual or reproductive problems as the disadvantages for not having genitals (χ²[1] = 36.6, P < .001).

Genital injury

Responses for their views on the disadvantages of genital injury were comparable between the aspiring group and fantasizers, with health risks, no disadvantage, and social disadvantages as the top three identified themes. Yet, there were some differences in perceptions on the advantages of genital injury between groups. Aspiring eunuchs had a higher proportion of participants reporting that genital injury would be a way for them to obtain genital ablation (χ²[1] = 28.0, P < .001). However, the fantasizers were more likely to cite sexual pleasure or erotic pain as an advantage of injuring their genitals (χ²[1] = 15.6, P < .001).

Having nonfunctional testicles

The aspiring group was more likely than the fantasizers to perceive that having nonfunctional testicles would help achieve genital ablation and its desired side effects (χ²[1] = 34.0, P < .001). However, the fantasizers were more likely than participants in the aspiring group to think that there was no benefit of having nonfunctional testicles (χ²[1] = 18.3, P < .001).

Similarly, the aspiring group had higher proportions reporting no disadvantage of having nonfunctional testicles (χ²[1] = 15.3, P < .001). In contrast, the aspiring group had a lower proportion indicating sexual and reproductive problems associated with having nonfunctional testicles (χ²[1] = 49.9, P < .001). When compared with fantasizers, the aspiring group considered having intact testicles (χ²[1] = 9.7, P < .01) as a disadvantage because the testicles were still present.

Discussion

In this study, we compared the characteristics of individuals AMAB who have sexual fantasies about castration (fantasizers) vs those wishing to be castrated (aspiring). The responses of aspiring eunuchs paralleled responses found in previous studies of those already castrated.¹⁴ When compared with fantasizers, aspiring eunuchs are more likely to view genital injuries as a step toward their goal of eventual genital ablation. A higher proportion of aspiring eunuchs consider there to be advantages to having no testicles, such as a step toward a smooth physical appearance. As a group, they are more likely to report no disadvantages to not having testicles and are less concerned about sexual function, reproduction, side effects of androgen loss, and potential urination problems.^1,14

Many eunuchs and aspiring eunuchs do not wish to undergo androgen replacement therapy after orchiectomy because of the perceived beneficial psychological and physiologic effects of androgen suppression.²¹ They may seek a “eunuch calm,” understood as a state of having reduced libido and lower reactive aggression.^14,19 Others may see lowered libido and other side effects of androgen deprivation, such as increased risk of osteoporosis, as a problem.

In keeping with this goal—to achieve a lower libido as part of a eunuch calm—many aspiring eunuchs were more likely to identify as asexual (9.9%) when compared with fantasizers (3.2%), who have a similar rate of asexuality to the general population.³¹ Both groups are aware of the potential risks associated with genital injury, such as pain, infection, and sexual dysfunction.

Aspiring eunuchs in our sample were more likely to describe benefits of having nonfunctional testicles in line with their desire for an orchiectomy, such as the physiologic and psychological effects of androgen loss and as a step toward genital ablation. They were more likely to consider the physical appearance or presence of testicles to be a disadvantage. Conversely, fantasizers were more likely to report no benefit to nonfunctional testicles or genital ablation and to see the loss of sexual and reproductive effects, such as the loss of erections, sexual desire, and fertility, as a disadvantage.

Learning about orchiectomy

In line with another recent study of eunuchs,¹⁴ the most commonly reported pathway for learning about castration for aspiring eunuchs and fantasizers was via media or through knowledge of animal castration. When compared with aspiring eunuchs, fantasizers were more likely to remember how they first learned about genital ablation. For fantasizers, exposure to a specific, intensely erotic event may have precipitated a sustained sexual interest in castration. In contrast, aspiring eunuchs may gradually develop an interest in castration as they explore their gender identity. In this way, their interest in genital ablation procedures is a long-term medical decision that is not tied to a specific salient event.

First orchiectomy thoughts

Aspiring eunuchs differed significantly from fantasizers in relation to circumstances when they first considered an orchiectomy or other forms of genital ablation. Specifically, aspiring eunuchs identified the onset of gender dysphoria and/or a desire to achieve one’s preferred self as significant circumstances that triggered orchiectomy thoughts. Fantasizers, however, were more likely to identify exposure to material or situations that eroticized castration as a leading circumstance to trigger their first castration fantasy. In rare circumstances, health reasons such as testicular torsion, testicular pain, and prostate cancer triggered first orchiectomy thoughts, which were found more in aspiring eunuchs than fantasizers in our analysis. Nonerotic fantasies or dreams were also more highly cited by the fantasizers.

Genital injuries

Genital injury is common among individuals who have a desire for or fantasize about genital ablation. Some of the most popular threads on the Eunuch Archive are related to testicular self-injury. A common way to achieve this is to inject toxins² in the hope that it will lead to nonfunctional testicles or as a means for obtaining medical intervention leading to a proper orchiectomy.¹⁴ The two most popular threads on injection of toxins on the Eunuch Archive have been accessed nearly 3 million times as of December 31, 2023.

A majority of the respondents in both groups were aware of the potential health risks associated with injuring their genitals. Despite knowledge of these risks, both groups saw advantages to injuring their genitals, although they were not the same. For example, a higher proportion of aspiring eunuchs saw genital injury as a step toward full genital ablation, while a greater proportion of fantasizers saw it as a means for sexual pleasure. The data on aspiring eunuchs collected in this study are in keeping with previous studies on eunuchs who injured their genitals to access proper medical treatment and care.^2,14

The World Professional Association for Transgender Health’s Standards of Care version 8 (SOC8) identifies the need to offer medical and surgical interventions to those who are at high risk for self-injury through such practices as “self-surgery, surgery by unqualified practitioners,” and other practices that may lead to harm.²³ This is true for those with MtE gender dysphoria, BID, or extreme paraphilias. These individuals may all qualify for such interventions.

Nonfunctional testicles

Perceptions on the advantages and disadvantages of having nonfunctional testicles were distinctly different in the 2 populations. Aspiring eunuchs were more likely to consider the effects of genital ablation—low testosterone, infertility, and a smooth genital area—as advantages, whereas a greater proportion of fantasizers considered there to be no benefit. Interestingly, nearly a third of both groups considered being nonsexual or having a low libido as an advantage.

This desire to be asexual may lead some who eroticize orchiectomy to eventually receive surgical genital ablations.^32,33 As noted by Wibowo et al,¹⁴ individuals with extreme paraphilias may seek orchiectomy and other ablative procedures as part of their sexual desire. Alternatively, they may want to get control of that same paraphilia when it leads to repeated genital self-injury and is causing clinically significant distress in their lives.

The groups differed in what they considered disadvantages of having nonfunctional testicles. Aspiring eunuchs were more likely to see no disadvantages, as many also desired the physiologic effects of orchiectomy. As noted, the aspiring eunuchs found the physical appearance of nonfunctional testes as a disadvantage as compared with fantasizers because many aspiring eunuchs preferred a smooth appearance.

Gender dysphoria, paraphilia, or BID

Aspiring eunuchs and fantasizers share some similar but divergent beliefs related to genital ablation. Previous research has shown that aspiring eunuchs share many, if not most, characteristics with actual eunuchs,¹⁴ most profoundly in experiencing MtE gender dysphoria. As with the dysphoria felt by male-to-female, female-to-male, and nonbinary individuals, those with MtE gender dysphoria may experience an incongruence between natal sex and gender. This may be manifested as feeling burdened or unhappy with the effects of testosterone on their libido, physiology, and/or emotional state, leading to clinically significant levels of distress. This is consistent with previous data showing that interest in genital ablation in this population often manifests in childhood and adolescence.¹⁸ Note that access to gender-affirming hormonal or surgical care may not only reduce the risk of self-harm but may also alleviate gender dysphoria for those with MtE gender dysphoria.²³

An additional reason why some desire genital ablation appears to be as sexual fantasy that eroticizes castration.^14,32,33 Those who fantasize about genital ablation would be eligible for orchiectomy under the current SOC8 guidelines given the risk that these individuals face as a result of genital injury and other high-risk behaviors meant to reduce clinically significant distress.²³ However, as we would expect and as noted by Wong et al,¹ the desire for actual castration for fantasizers is lower than that of aspiring eunuchs. Thus, differentiating aspiring eunuchs from fantasizers is a helpful construct for psychiatrists and other medical providers to understand their patients beyond the diagnostic framework.

While there are distinct characteristics that separate persons with gender dysphoria, paraphilia, and BID, there is also significant overlap (Figure 1). For instance, those with gender dysphoria and BID may desire to have a smooth genital appearance that lacks testicles.^2,17 Even aspiring eunuchs and those who only fantasize about genital ablation showed significant overlap in survey responses, leading to many nonsignificant response comparisons despite significant proportions of each group. For example, nearly 40% of each group saw no advantage to injuring its genitals. More than 65% of each group recognized the health risks of injuring its genitals. In addition, more than a third of each group thought that there would be psychological benefits for not having genitals.

These cumulative results emphasize the importance of individualized assessments that focus on getting to know the patients and their desires without attempting to define and treat them by rigid categorizations. This approach will build trust, safety, and the space to apply the informed consent model of collaborative decision making that serves patients best.

Clinical significance

Some men have unusually strong interests in genital ablation. Here we provide a framework for understanding the different motivations of those who fantasize about vs aspire to have genital ablation. Fantasizers and aspiring eunuchs may feel stigmatized and misunderstood by medical providers. As a result, many have resorted to genital self-injury as a means of accessing care. For clinicians with no previous exposure to this population, this study provides a helpful framework for the differential diagnosis and treatment of persons who experience this kind of dysphoria.

Limitations

This study has several limitations. Due to the online data collection, some respondents’ responses may not be accurate (eg, whether the participant received an orchiectomy). Some participants may also have reluctance to disclose sexually related information (eg, if their orchiectomy desire has a sexual component). To help confirm if participants answered truthfully, we asked for participants’ age at the start of the survey and their year of birth at the end. If the data did not match, the survey was removed from the analysis.

In addition, our data collection was done from a website dedicated to eunuchs and those interested in genital ablations; therefore, our data may be generalizable only to people with heightened genital ablation interests. Last, only one of us coded the data; thus, we could not indicate interrater reliability.

Future studies could use interviews to gain more insights and clarify details of individuals’ histories worthy of further exploration. For example, future research could explore the onset of gender dysphoria and castration interest for persons who meet the criteria for MtE gender dysphoria. Additionally, future studies could determine the impact of access to care since the World Professional Association for Transgender Health’s SOC8 was released and whether this has led to a decrease in genital self-injury.

Conclusion

The motivations for genital injuries and ablations vary among individuals. Fantasizers and aspiring eunuchs hold divergent views on the pros and cons of orchiectomy, genital injuries, and having nonfunctional testicles. For aspiring eunuchs, a majority considers genital injury a step toward eventually obtaining medically safe ablative surgery. This speaks to the profound dysphoria and desperation experienced by this group.

Patients desiring an orchiectomy and other interventions for gender dysphoria may benefit from interventions that are individualized, and these may include surgery, hormone replacement therapies, mental health support, and aftercare planning that fit a patient’s goals and aspirations.^15,23

For those who pursue an orchiectomy, a process of informed consent and shared decision making that respects a patient’s autonomy, while mitigating harm, is prudent. This approach offers the greatest benefit to the patient and the clinician, which is to provide nonjudgmental access to care that optimizes psychological well-being, physical health, and self-fulfillment.

Acknowledgments

We thank the Eunuch Archive Steering Committee for helping us post our survey on eunuch.org and Samantha Wong for help with data collection.

Author contributions

Conceptualization: E.W., T.W.J., R.J.W. Formal analysis: E.W. Funding acquisition: R.J.W. Investigation: E.W., T.W.J., R.J.W. Methodology: E.W., T.W.J., R.J.W. Project administration: T.W.J. Resources: R.J.W. Supervision: R.J.W., T.W.J. Writing–original draft: J.A., E.W. Writing–review and editing: J.A., E.W., T.W.J., R.J.W.

Funding

This research was supported in part by a Natural Sciences and Engineering Research Council of Canada grant to R.J.W. (RGPIN/8194-2012).

Conflicts of interest

None declared.

References