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Contemporary castration: why the modern day eunuch remains invisible

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4509 (Published 18 August 2010) Cite this as: BMJ 2010;341:c4509
  1. Richard J Wassersug, professor of anatomy and neurobiology, Dalhousie University, Halifax, Nova Scotia, and visiting professor, Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne,
  2. Tucker Lieberman, independent author, Boston, Massachusetts
  1. Correspondence to: R J Wassersug Richard.Wassersug{at}dal.ca

    Let’s study emasculation. No, we don’t mean the loss of political power. That’s a metaphorical sense. We mean the real thing: the removal or chemical destruction of a man’s testes. And here we refer not to the manufacturing of courtiers in Constantinople, nor to the construction of a caste of opera singers, but to modern day emasculations.

    Although to many people castration signifies a barbarism that disappeared with the demise of the Ottoman empire, the Chinese dynasties, and the castrati movement in European music, there are surely more men living with removed or functionally arrested testes today than at any other time in history. A minority either identify as women and have sex reassignment surgery or sought castration simply to suppress their libidos.1 2 By far the majority, though, are prostate cancer patients, and it’s this group that we focus on here.

    Chemically shutting down or surgically removing the main source of testosterone—the testes—can slow the spread of prostate cancer. Castration, of course, has extensive side effects.3 A castrated adult male will lose muscle but gain fat.4 He can expect hot flushes like those that women have at menopause.5 He will lose body hair, and his penis will shrink. Erections will be rare and weak, if they occur at all.3 He will be sterile.

    Castrated men also often experience changes in cognitive function and affect, although the nature of those changes is poorly understood. Recent reviews of the topic have yielded contradictory results.6 7 8 9 10 11

    Right now, in North America, as many as 600 000 patients with prostate cancer are coping with the effects of medical emasculation.12 But unless such a man tells you what has happened to him, his physical and mental changes may not be apparent to you.

    Most of those patients are on a short term course of androgen suppressing drugs and believe that their testosterone titres will recover once they stop taking the drugs. However, the longer they are taking these compounds, the longer it takes for their testes to recover; and even with short term use the effects are not always completely reversible.13

    Inaccurate, antiquated, and negative stereotypes of castrated men—implicitly illustrated by the misuse of the term “eunuch” to indicate a completely powerless person—are perpetuated because of society’s general ignorance of contemporary castrations. The language of emasculation remains pejorative and shameful.14 Fearing such shame, many patients hide their medically modified morphology and deny that they feel any different.15 Thus they remain invisible,16 and their condition is poorly understood.

    Emasculation is arguably as distressing for men as mastectomy is for women. Nevertheless a search in PubMed on “castration” and “mastectomy” matched with various words indicative of psychological effects indicates that mastectomy has received over 50% more attention in that domain. Data from open ended discussions with men taking androgen deprivation treatments show that many are distressed yet can’t fully articulate how they feel about the changes they are experiencing.17 In trying to preserve residual masculinity, most are reticent on the subject of their transformation.

    It is crucial that the psychosocial impact of castration receives more attention so that those who are androgen deprived can be helped to adapt to the changes they experience, whatever those changes may be. Recognising the side effects of any medical treatment is a prelude to developing effective coping strategies. This is particularly true when the treatment affects the personality. Although emasculated males may continue to present outwardly as men, they must come to terms with their diminished biological maleness. How they adapt to such changes is inevitably influenced by social context. As long as society remains largely unaware of who is emasculated and how common castration is, we can expect little curiosity about its consequences. Thus there is a paucity of scholarship on modern day emasculation. This lack of research is regrettable, as it hampers efforts to help medically emasculated men overcome the more emotionally challenging side effects of their treatment and leaves androgen deprived patients little or no social context with which to accept the changes they experience.

    So where should you go to learn more about the psychosocial effects of androgen deprivation? Despite the fact that eunuchs have been the most common gender variant throughout history,18 they are rarely mentioned in university courses. Even when castration is discussed in the field of “gender studies,” it tends to be metaphorical, as exemplified by the title of Germaine Greer’s famous book The Female Eunuch.

    The only academic terrain in which contemporary castration is regularly explored is in departments of urology, where physicians are trained to do orchidectomies and administer castrating drugs to patients with cancer. Even there, physicians shy away from using terms such as “castrated,” “emasculated,” and “neutered,” because they sound like what they are: mutilating procedures with profound psychological and social impact. Typically physicians relabel androgen depriving treatments, including orchidectomy, as “hormonal therapy.” This may make it easier for them to diminish, if not dismiss, the consequences of the treatment—easing their own angst, if not that of their patients. This, however, leaves the scholarly exploration of emasculation in academic no man’s land.

    Genital ablation has never been merely a metaphor. Everyone should be aware that a multitude of men are either chemically or surgically castrated for a variety of reasons in contemporary Western society. Until doctors, scholars, and researchers are forthright with their language, the emasculated will remain invisible. This invisibility, in turn, castrates the study of emasculation.

    Notes

    Cite this as: BMJ 2010;341:c4509

    Footnotes

    • All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: RJW and TL have support from the Australian Research Centre in Sex, Health and Society for the submitted work; no relationships with companies that might have an interest in the submitted work in the previous three years; and no non-financial interests that may be relevant to the submitted work.

    References