CHAPTER 9 Eunuchs
Among the many people who benefit from gender-affirming medical care, those who identify as eunuchs are among the least visible. The 8th version of the Standards of Care (SOC) includes a discussion of eunuch individuals because of their unique presentation and their need for medically necessary gender-affirming care (see Chapter 2—Global Applicability, Statement 2.1).
Eunuch individuals are those assigned male at birth (AMAB) and wish to eliminate masculine physical features, masculine genitals, or genital functioning. They also include those whose testicles have been surgically removed or rendered nonfunctional by chemical or physical means and who identify as eunuch. This identity-based definition for those who embrace the term eunuch does not include others, such as men who have been treated for advanced prostate cancer and reject the designation of eunuch. We focus here on those who identify as eunuchs as part of the gender diverse umbrella.
As with other gender diverse individuals, eunuchs may also seek castration to better align their bodies with their gender identity. As such, eunuch individuals are gender nonconforming individuals who have needs requiring medically necessary gender-affirming care (Brett et al., 2007; Johnson et al., 2007; Roberts et al., 2008).
Eunuch individuals identify their gender identities in various ways. Many eunuch individuals see their status as eunuch as their distinct gender identity with no other gender or transgender affiliation. The focus of this chapter is on the treatment and care for those who identify as eunuchs. Health care professionals (HCPs) will encounter eunuchs requesting hormonal interventions, castration, or both to become eunuchs. These individuals may also benefit from a eunuch community because of the identification—with or without actual castration.
While there is a 4000-year history of eunuchs in society, the greatest wealth of information about contemporary eunuch-identified people is found within the large online peer-support community that congregates on sites such as the Eunuch Archive (www.eunuch.org), which was established in 1998. The moderators of this site attempt to maintain both medical and historical accuracy in its discussion forums, although there is certainly misinformation as well. According to the website, as of January 2022, there have been over 130,000 registered members from various parts of the world and frequently over 90% of those reading the site are “guests” rather than members. The website lists over 23,000 threads and nearly 220,000 posts. For example, two threads giving instructions for self-castration by injection of different toxins directly into the testicles have about 2,500 posts each, and each has been read well over one million times. Beginning in 2001, there have been 20 annual international gatherings of the Eunuch Archive community in Minneapolis in addition to many regional gatherings elsewhere. While the topic of castration is of interest to the great majority of people who participate in the discussions, it is a minority of the membership who seriously seek or have undergone castration. Many former Eunuch Archive members have achieved their goals and no longer participate.
Because of misconceptions and prejudice about historic eunuchs, the invisibility of contemporary eunuchs, and the social stigma that affects all gender and sexual minorities, few eunuch individuals come out publicly as eunuch and many will tell no one and will share only with like-minded people in an online community or are known as such only to close family and friends (Wassersug & Lieberman, 2010). The stereotypes of eunuchs are often highly negative (Lieberman 2018), and eunuchs may suffer the same minority stress as other stigmatized groups (Wassersug & Lieberman, 2010). Research into minority stress affecting gender diverse people should therefore include eunuchs.
Statements of Recommendations
9.1- We recommend health care professionals and other users of the standards of Care 8th guidelines should apply the recommendations in ways that meet the needs of eunuch individuals
9.2- We recommend health care professionals should consider medical intervention, surgical intervention, or both for eunuch individuals when there is a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones.
9.3- We recommend health care professionals who are assessing eunuch individuals for treatment have demonstrated competency in assessing them.
9.4- We suggest health care professionals providing care to eunuch individuals include sexuality education and counseling.
The current set of recommendations is directed at professionals working with individuals who identify as eunuchs (Johnson & Wassersug, 2016; Vale et al., 2010) requesting medically necessary gender-affirming medical and/or surgical treatments (GAMSTs). Although not a specific diagnostic category in the ICD or DSM, eunuch is a useful construct as it speaks to the specifics of eunuch experience while also connecting it to the experience of gender incongruence more broadly. Eunuch individuals will present themselves clinically in various ways. They wish for a body that is compatible with their eunuch identity—a body that does not have fully functional male genitalia. Some other eunuch individuals feel acute discomfort with their male genitals and need to have them removed to feel comfortable in their bodies (Johnson et al., 2007; Roberts et al., 2008). Others are indifferent to having male external genitalia as long as they are only physically present and do not function to produce androgens and male secondary sexual features (Brett et al., 2007). Hormonal means may be used to suppress the production of androgens, although orchiectomy provides a permanent solution for those not wishing genital functioning (Wibowo et al., 2016). Some eunuch individuals desire lower testosterone levels achieved with orchiectomy, but many will elect some form of hormone replacement to prevent adverse effects associated with hypogonadism. Most who elect hormone therapy choose either a full or partial replacement dose of testosterone. A smaller number elect estrogen.
All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.
We recommend health care professionals and other users of the Standards of Care, Version 8 guidelines should apply the recommendations in ways that meet the needs of eunuch individuals.
Eunuch individuals are part of the population of gender diverse people who experience gender incongruence and may also seek gender-affirming care. Like other transgender and gender diverse (TGD) individuals, eunuchs require access to affirming care to gain comfort with their gendered self. Each section of the SOC addresses the needs of diverse individuals, and eunuchs can be included within that group. They may have commonality with some nonbinary individuals in that social transition may not be a desired option, and hormone therapy may not play the same role as it might in a social transition or transition within the binary (Wassersug & Lieberman, 2010).
Like other gender diverse individuals, eunuch individuals may be aware of their identity in childhood or adolescence. Due to the lack of research into the treatment of children who may identify as eunuchs, we refrain from making specific suggestions.
Eunuch individuals may seek medical or surgical care (hormone suppression, orchiectomy, and, in some cases, penectomy) to achieve physical, psychological, or sexual changes (Wassersug & Johnson, 2007). It is important all patients, including both eunuchs and those seeking castration, establish and maintain a relationship with an HCP that is built upon trust and mutual understanding. Given a lack of awareness of eunuchs within the general medical community and the fear among many individuals seeking castration they will not be accepted, many do not receive appropriate primary care and screening tests (Jäggi et al., 2018). Increased awareness and education among medical providers will help address the need to be informed about the need to include eunuchs in discussions of gender diversity (Deutsch, 2016a). It goes without saying that eunuchs require and deserve the same primary care services as the general population. The topic of screening tests for cancers, such as prostate and breast, is an important area for discussion as the risks of hormone-related cancers are likely different among male-assigned people whose testosterone and estrogen levels are not in the male range. Due to a lack of studies looking at the prevalence and incidence of hormone-related cancers in the eunuch population, there is no evidence to guide how often to screen for hormone-related cancers with prostate exams, PSA measurements, mammograms, etcetera.
The large literature on prostate cancer patients who have been medically or surgically castrated provides information about some of the effects of post-pubertal castration (such as potential osteoporosis, depression, or metabolic syndrome), but voluntary eunuchs may interpret the results very differently from those castrated for medical reasons. Chemical or surgical castration may be experienced as a source of distress to cis men with prostate cancer, while the same treatment may be affirming and a source of comfort for eunuch individuals. Similarly, transmasculine people who have a mastectomy to gain comfort with their bodies experience that surgery differently from ciswomen who undergo mastectomy to treat breast cancer (Koçan & Gürsoy, 2016; van de Grift et al., 2016). The prostate cancer information is well summarized by Wassersug et al. (2021) who provide references that explore the large literature on the subject. Such information on the effects of castration should be made available to those seeking castration.
Following an assessment as per the SOC-8, medical options requested by the patient can be considered and prescribed, if appropriate. These options can be tailored to the individual to create a plan that reflects their specific needs and preferences. The number and type of interventions applied and the order in which these take place may differ from person to person. These options are consistent with both the assessment and surgery chapters of the SOC-8. Treatment options for eunuchs to consider include:
Hormone suppression to explore the effects of androgen deficiency for eunuch individuals wishing to become asexual, nonsexual, or androgynous;
Orchiectomy to stop testicular production of testosterone;
Orchiectomy with or without penectomy to alter their body to match their self-image;
Orchiectomy followed by hormone replacement with testosterone or estrogen.
Per statement 5.6 in Chapter 5—Assessment of Adults, eunuch individuals seeking gonadectomy consider a minimum of 6 months of hormone therapy as appropriate to the TGD person’s gender goals before the TGD person undergoes irreversible surgical intervention (unless hormones are not clinically indicated for the individual).
We recommend health care professionals consider medical intervention, surgical intervention, or both for eunuch individuals when there is a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones.
The same assessment process recommended in the SOC-8 ought to apply to eunuchs (see Chapter 5—Assessment of Adults). The Eunuch Archive has a large number of posts from individuals finding great difficulty in seeking medical providers who will perform castration surgery. There are a large number of eunuch individuals who have performed self-surgery or have had surgery performed by people who are not credentialed medical providers (Johnson & Irwig, 2014). There are also clinical reports of eunuch individuals who have self-castrated and accounts of patients who have misled medical providers to obtain castration (Hermann & Thorstenson, 2015; Mukhopadhyay & Chowdhury, 2009). There is no doubt when members of this population are denied access to quality medical treatment, they will take actions that may cause them great harm, such as bleeding and infection that may require hospital admission (Hay, 2021; Jackowich et al., 2014; Johnson & Irwig, 2014). Because of these serious problems and harm caused through self-surgery, surgery by unqualified practitioners or the unsupervised use of medications that affect hormones, it is important health care providers create a welcoming environment and consider various treatment options after careful assessment to avoid the problems that lack of access to treatment and withholding treatment will cause.
When desired, castration can be achieved either chemically or surgically. For some, chemical castration can be an appropriate trial prior to undergoing surgical castration to determine how the individual feels when hypogonadal (Vale et al., 2010). Chemical castration is usually reversible if the medications are discontinued (Wassersug et al., 2021). The most common types of medications used to lower testosterone levels are antiandrogens and estrogen.
The two most commonly used antiandrogens, cyproterone acetate and spironolactone, are oral. Estrogen is sometimes prescribed for prostate cancer patients to lower serum testosterone levels via negative feedback at the hypothalamus and pituitary gland. Estrogens and antiandrogens may not fully suppress testosterone levels into the female or castrate range, and oral estrogens increase the risk of venous thromboembolism. Although not commonly used due to cost, gonadotropin releasing hormone (GnRH) agonists are a very effective method for suppressing the production of sex steroids and fertility (Hembree et al., 2017). When selecting a medication, we advise using those which have been studied in multiple transgender populations (i.e., estrogen, cyproterone acetate, GnRH agonists) rather than medications with little to no peer-reviewed scientific studies (i.e., bicalutamide, rectal progesterone, etc.) (Angus et al., 2021; Butler et al., 2017; Efstathiou et al., 2019; Tosun et al., 2019).
Many eunuch individuals pursue hormone replacement therapy following castration as they do not desire the complete suppression of hormone levels and consequent problems, such as the increased risk of osteoporosis. The two main options for replacement of sex steroids are testosterone and estrogen that may be used in full or partial replacement doses. The majority elect testosterone as they present as male and are not interested in feminization. A minority elect estrogen at a high enough dose to prevent osteoporosis, but low enough avoid most feminization. They may identify as nonbinary, agender, or other (Johnson et al., 2007; Johnson & Wassersug, 2016).
Although studies on hormone replacement therapy in eunuchs are lacking, findings from cisgender men treated for prostate cancer can be informative regarding the effects of hormone therapy. In a randomized controlled trial of 1,694 cisgender men treated for locally advanced or metastatic prostate cancer, one group received a GnRH agonist and the other received transdermal estrogen (Langley et al., 2021). Cisgender men who received the GnRH agonist developed signs and symptoms of both androgen and estrogen deficiency, whereas men who received the estrogen patch only developed androgen-depleting symptoms. Both groups had high rates of sexual side effects (91%), and weight gain was similar among the groups. Compared with cisgender men receiving the GnRH agonist, cisgender men treated with estrogen patches had a higher self-reported quality of life, lower rates of hot flushes (35% vs. 86%), and higher rates of gynecomastia (86% vs. 38%). Metabolically, cisgender men receiving estrogen patches had favorable changes with a lower mean fasting glucose, fasting total cholesterol, systolic and diastolic blood pressure. Conversely, cisgender men receiving the GnRH agonist experienced the opposite effects. Based on this study, eunuchs may consider a low dose of transdermal estrogen therapy to avoid adverse estrogen-depleting effects, which include hot flashes, fatigue, metabolic effects, and loss of bone mineral density (Hembree et al., 2017; Langley et al., 2021). For further information see Chapter 12—Hormone Therapy.
We recommend health care professionals who are assessing eunuch individuals for treatment have demonstrated competency in assessing them.
A frequent topic on the discussion boards of the Eunuch Archive is the difficulty of finding practitioners who are able to understand their needs. Eunuchs and those seeking castration usually are less visible than other gender minorities (Wassersug & Lieberman, 2010). Due to stigma and fear of rejection by the medical community, they may not voluntarily disclose their identity and desires to their medical or mental health providers. In some environments, medical providers may not be aware eunuchs exist and may not even know they have treated eunuch-identified patients.
The SOC section on assessment is applicable to eunuch individuals. Like other gender diverse individuals, those seeking castration can engage in an informed consent process in which qualified providers conduct assessments to ensure individuals are capable of providing informed consent prior to medical interventions and to ensure a mental health problem is not the etiology of the desire. As with other sexual and gender minorities, working with eunuchs requires an understanding that they are a diverse population, and that each person is eunuch in their own way (Johnson et al., 2007). The person seeking services benefits from the professional’s accepting stance, open inquiry, suspension of judgment, and flexible expectations, combined with professional competency and expertise.
To provide appropriate treatment, providers must establish trust and respect by creating an inclusive environment for eunuch-identified people. For eunuch-identified individuals, the ideal intake form would ask the assigned sex and identified gender and offer multiple gender options, including “eunuch” and “other.” Individuals may identify with more than one option and should be able to select more than one.
HCPs may be involved in the assessment, psychotherapy (if desired), preparation, and follow-up for medical and surgical gender-affirming interventions. They may also provide support for partners and families. Eunuch-identified individuals who want the support of a qualified mental health provider will benefit from a therapist who meets the experience and criteria set out in Chapter 4—Education.
While some individuals seeking or considering castration come to counseling or therapy because they want emotional support or help with decision-making, many come to providers for an assessment in preparation for specific medical interventions (Vale et al., 2010).
We suggest health care professionals providing care to eunuch individuals include sexuality education and counseling.
Several research studies have contributed to our knowledge of contemporary eunuch-identified people and have explored demographic characteristics and sexuality (Handy et al., 2015; Vale et al., 2013; Wibowo et al., 2012, 2016). Medical and MHPs should assume eunuchs are sexual people capable of sexual activity, pleasure, and relationships, unless they report otherwise (Wibowo et al., 2021). Research has shown there is great diversity among eunuchs regarding the level of desire, type of preferred physical or sexual contact, and nature of preferred relationships (Brett et al., 2007; Johnson et al., 2007; Roberts et al., 2008). While some enjoy active sex lives with or without romantic relationships, others identify as asexual or aromantic and are relieved by the loss of libido achieved through surgical or chemical castration (Brett et al., 2007). Each person is different, and one’s genital status does not determine sexual or romantic attraction (Walton et al., 2016; Yule et al., 2015).
Regardless of the type of chemical suppression or surgery a person has undergone, they may be capable of sexual pleasure and sexual activity. Contrary to popular belief, eunuchs are not necessarily asexual or nonsexual (Aucoin & Wassersug, 2006). Safe sex education is necessary for all people who engage in sexual activity that could involve an exchange of body fluids. See Chapter 17—Sexual Health for information regarding sex education and safe sex options for people with diverse genders and sexualities. In addition, fertility preservation should be discussed when considering medical interventions that might impact the possibilities for future parenthood. For more considerations see Chapter 16— Reproductive Health.