The sexuality and social performance of androgen-deprived (castrated) men throughout history: implications for modern day cancer patients

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

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.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Prostate Cancer From a Sex and Gender Perspective: A Review

INTRODUCTION

Factors influencing patient behavior regarding risk of prostate cancer (PCa) and outcomes of PCa treatments are poorly understood. Similarly, how PCa treatments affect patient sexual function and sense of their masculinity has not been fully investigated. A better understanding of the relationship between sex and gender for patients with PCa could significantly improve their care and quality of life.

OBJECTIVES

To review how concerns about sex and gender influence men's attitudes toward PCa screening, diagnosis, and treatment. To explore how PCa influences sexual function and self-perceived masculine identity. To examine contexts for PSA screening for transgender individuals.

METHODS

We reviewed biomedical and sociological literature exploring the impact of PCa on patient sexual function and self-perceived masculinity using OVID, PubMed, and other databases. We similarly reviewed how masculine gender norms influence patient willingness to engage with PCa screening, diagnoses, and treatment.

RESULTS

Gender norms and sexual function concerns influence patient engagement in all aspects of PCa care. This includes PSA screening, digital rectal examinations, active surveillance, and androgen deprivation therapy (ADT) amongst others. ADT is particularly challenging to sexual function, self-esteem, and masculine identity. Our research suggests that sex and gender are not separate concepts, but rather tightly intertwined, particularly when dealing with the realities experienced by patients with PCa.

CONCLUSION

Interventions to help patients deal with the challenges of PCa and its treatment are likely to be most effective if they concurrently address patients' sexual needs and understanding of gender norms. PSA screening should be considered for transgender individuals who are at greater risk of cancer and on long-term hormone therapy. More research is needed on how concerns over sex and gender influence PCa screening, diagnosis, and treatment. There is also a need for long term data on the oncological outcomes of prolonged exposure to hormone therapy for patients who are transgender. Muermann MM, Wassersug RJ. Prostate Cancer From a Sex and Gender Perspective: A Review. Sex Med Rev 2021;XX:XXX-XXX.

A qualitative exploration of South African men's perceived effects of Androgen Deprivation Therapy (ADT) as a treatment for advanced prostate cancer

OBJECTIVE

We undertake qualitative research with men treated in a Pretoria, South Africa Oncology clinic to address men's self-reported experiences on androgen deprivation therapy (ADT).

METHODS

Analyses rely upon 22 men's responses to open-ended questions during interviews. These men were 63-78 years of age, and almost all married (three widowed), had children and were no longer engaged in paid work.

RESULTS

In addressing questions about the anticipated and experienced positive and broader side effects of ADT, men referred to its treatment for prostate cancer, with several generally specifying health or life. Patients also referred to a variety of more specific effects such as pain, nausea, difficulties urinating, gaining weight, low energy and sleep disruptions that appeared to reflect a mixture of influences of prostate cancer, ADT and oncological treatment. In addressing a question about the effects of ADT on romantic/sex life, 16 of 19 married men referred to deleterious impacts on their sex lives. With respect to perceived family, work or broader social life impacts, some men noted others' worries and social support.

CONCLUSION

Findings are situated within discussions of existing research on ADT largely from North American or European samples, and broader views of testosterone and male social behavior.

Sadomasochistic erotica and the sexual response cycle: Insights from the Eunuch Archives

The Eunuch Archive (EA) is a website where registered members can post for others to read and rate sexual fantasies that involve genital mutilation and ablation. The EA includes over 8,000 stories. We have previously explored common features of 100 top-rated EA stories. We reasoned that understanding such fantasies may be a step toward recognizing who is at risk of irreversible injury should they act out their fantasies. Here we explore the top-rated EA stories in the context of well-established models for human sexual response. We argue the archetypal storyline from these fantasies, which are characterized by extreme sadomasochism (SM), can be interpreted and understood within the context of these established sexual response models, but we note several ways the fantasies diverge from such models. The stories closely fit the classic Masters and Johnson model, but with a protracted plateau phase resolved with pleasure and pain heightened. Even though the central character in all the stories is a male, the stories align well with the Basson intimacy-based model more characteristic of female motivations to be sexually active. In the fantasies, the central character is willing to sacrifice everything short of his life to develop or strengthen a dyadic relationship. In all the stories, castration is depicted with a sensory intensity equivalent to orgasm. The stories reveal what is both natural and pathological in extreme SM fantasies. They also reveal similarities between female sexual desire and the desire for genital ablation which has not, to the best of our knowledge, been previously elucidated.

Orchiectomy and letrozole differentially regulate synaptic plasticity and spatial memory in a manner that is mediated by SRC-1 in the hippocampus of male mice

Hippocampal synaptic plasticity is the basis of spatial memory and cognition and is strongly regulated by both testicular androgens (testosterone, T) and hippocampal estrogens (17β-estradiol, E2) converted from T by aromatase, which is inhibited by letrozole (LET), but the contribution of each pathway to spatial memory and the associated mechanisms are unclear. In this study, we first used orchiectomy (ORX) and LET injection to investigate the effects of T and hippocampal E2 on spatial memory and hippocampal synaptic plasticity. Next, we examined the changes in steroid receptors and steroid receptor coactivator-1 (SRC-1) under these treatments. Finally, we constructed an SRC-1 RNA interference lentivirus and an AROM overexpression lentivirus to explore the roles of SRC-1 under T replacement and AROM overexpression. The results revealed spatial memory impairment only after LET. LET induced more actin depolymerization and greater losses of spines, synapses, and postsynaptic proteins compared with ORX. Moreover, although ERα and ERβ were affected by LET and ORX at similar levels, AR, GPR30, and SRC-1 were dramatically decreased by LET compared with ORX. Finally, the T and AROM overexpression-induced changes in synaptic proteins and actin polymerization were blocked by SRC-1 inhibition. These results demonstrate that testicular androgens play a limited role, whereas local E2 is more important for cognition, which may explain why castrated men such as eunuchs usually do not have cognitive disorders. These results also suggest a pivotal role of SRC-1 in the action of steroids; thus, SRC-1 may serve as a novel therapeutic target for cognitive disorders.

Maintaining intimacy for prostate cancer patients on androgen deprivation therapy

PURPOSE OF REVIEW

Androgen deprivation therapy (ADT) causes erectile dysfunction and increases patients' emotionality while diminishing their sexual interest. ADT has been linked to erosion of spousal bonds; however, this is not an invariant outcome. Understanding the factors that lead to these various outcomes may help couples deal with ADT.

RECENT FINDINGS

A subset of couples report that they became closer as a result of the patients going on ADT. Recent data suggest that what helps couples most is preemptive awareness of ADT's side-effects and congruence in how patients and their partners understand and accept the psychosexual impact of ADT. Sex therapy for prostate cancer patients divides along gendered lines, with distinctly 'male' (recovery of erections) and 'female' (promoting sexual practices that are not erection dependent) approaches. Unfortunately, neither is very effective for couples when the patient is on ADT. Options beyond the standard gendered framework, such as use of an external penile prosthesis, may be worth offering to ADT patients trying to find a 'new normal' that is sexually rewarding for them.

SUMMARY

Intimacy is sharing something with someone that one shares with no one else. Exploring novel sexual practices can help couples stay intimate, even when the patient is on ADT.

Searching for wisdom in oncology care: A scoping review

OBJECTIVE

The concept of "wisdom" is beginning to emerge in the oncology literature, raising questions concerning: (1) how the concept of wisdom is used in oncology literature; (2) the ways in which wisdom has been a focus of inquiry within oncology care; and (3) how wisdom is characterized when the term is used.

METHOD

A scoping review, using Arksey and O'Malley's five-step framework, was undertaken to address these questions. In consultation with oncology reference librarians, "wisdom"- and "oncology"-related search terms were identified, and four electronic databases were searched: CINAHL, SocINDEX, PubMed, and PsychINFO. After removal of duplicates and application of inclusion and exclusion criteria, 58 records were identified and included for analysis.

RESULTS

The concept of wisdom was employed with a breadth of meanings, and 58 records were schematized into 7 genres, including: (1) empirical research with wisdom foregrounded as a study focus (n = 2); (2) empirical research articles where "wisdom" appears in the findings (n = 16); (3) a quality-improvement project where wisdom is an embedded concept (n = 1); (4) essays where wisdom is an aspect of the discussion (n = 5); (5) commentary/opinion pieces where wisdom is an aspect of its focus (n = 6); (6) personal stories describing wisdom as something gleaned from lived experience with cancer (n = 2); and (7) everyday/taken-for-granted uses of wisdom (n = 26).

SIGNIFICANCE OF RESULTS

The notion of wisdom has a taken-for-granted presence in the published oncology literature and holds promise for future research into patient and clinician wisdom in oncology care. Nonetheless, the terminology is varied and unclear. A scholarly focus on wisdom has not been brought to bear in cancer care to the degree it has in other fields, and research is in the early stages. Various characterizations of wisdom are present. If such a resource as "wisdom" exists, dwelling in human experiences and practices, there may be benefit in recognizing wisdom as informing the epistemologies of practice in oncology care.

Gender Preference in the Sexual Attractions, Fantasies, and Relationships of Voluntarily Castrated Men

Introduction

Some men seek castration outside a clear medical need. This study explored how their sexuality changed after castration.

Aim

To explore changes in preferred gender(s) of sexual attraction, fantasy, and relationships in voluntarily castrated men with or without gonadal hormone therapy.

Methods

A questionnaire was posted at http://www.eunuch.org that yielded data on men who had been voluntarily castrated physically (n = 198) or chemically (n = 96).

Main Outcome Measures

Respondents were asked to report retrospectively on their sexuality, including their sexual activity and which gender(s) they were sexually attracted to, fantasized about, or had sexual relations with 6 months to 1 year before and after castration.

Results

A substantial proportion of men remained sexually active after castration; 37% had sex at least several times per week. Most respondents did not report a change in preferred gender(s) of attraction (65%, n = 181), fantasies (62%, n = 169), or sexual relationships (66%, n = 163), although approximately 20% to 30% of respondents did report such changes and 8% to 11% became non-sexual after castration. Respondents who were attracted to and fantasized about “only men” or who had sexual relationship with “only women” before castration were the least likely to report a change subsequent to castration. Respondents who were taking neither supplemental testosterone nor estrogen were more likely to report (i) becoming attracted to no one, (ii) fantasizing about no one, and (iii) becoming sexually inactive.

Conclusion

Sexual changes in voluntarily castrated men vary and can be influenced by various factors including the use of supplemental testosterone or estrogen therapy.

Co-constructing sexual recovery after prostate cancer: a qualitative study with couples

Background

Men are likely to experience deterioration in sexual functioning as a consequence of treatment for prostate cancer. Indeed, sexual difficulties are common across all treatment modalities.

Objective

To determine the impact of treatment for prostate cancer on intimacy and sexual expression/relationships from the perspective of couples.

Methods

An observational study was conducted including in-depth interviews with 18 people affected by prostate cancer; comprising eight couples and two individual men.

Results

Four categories were identified that illustrated the impact of prostate cancer on intimacy and sexual recovery. These related to social influences and language used to describe the loss or recovery of sexual activities; difficulties in discussing sexual activity with clinicians; the clash of individual impact of prostate cancer recovery versus the impact on the couple, and the re-integration of sexual activities into the relationship.

Conclusions

Though only one person in a partnership experiences cancer, these data indicated the extent to which prostate cancer treatment also impacts on partners. The study indicates that adjustment to erectile dysfunction (ED) takes time, but is a highly significant event in couples’ lives and its importance should not be under-estimated. Consequently, we suggest that relational models of care should be considered, whereby side-effects are recognised as impacting on both members of the partnership (for example ED, or lack or ejaculate). Supportive care in this context, therefore, may best be based on a relational approach using language and interventions that are appropriate to the patient and their situation.

Evolution of sexually dimorphic longevity in humans

Why do humans live longer than other higher primates? Why do women live longer than men? What is the significance of the menopause? Answers to these questions may be sought by reference to the mechanisms by which human aging might have evolved. Here, an evolutionary hypothesis is presented that could answer all three questions, based on the following suppositions. First, that the evolution of increased human longevity was driven by increased late-life reproduction by men in polygynous primordial societies. Second, that the lack of a corresponding increase in female reproductive lifespan reflects evolutionary constraint on late-life oocyte production. Third, that antagonistic pleiotropy acting on androgen-generated secondary sexual characteristics in men increased reproductive success earlier in life, but shortened lifespan. That the gender gap in aging is attributable to androgens appears more likely given a recent report of exceptional longevity in eunuchs. Yet androgen depletion therapy, now used to treat prostatic hyperplasia, appears to accelerate other aspects of aging (e.g. cardiovascular disease). One possibility is that low levels of androgens throughout life reduces aging rate, but late-life androgen depletion does not.

Voluntary genital ablations: contrasting the cutters and their clients

INTRODUCTION

Some healthy males voluntarily seek castration without a recognized medical need. There are currently no standards of care for these individuals, which cause many of them to obtain surgery outside of a licensed medical setting. We seek to understand who performs these surgeries.

AIM

This study aims to characterize individuals who perform or assist in genital ablations outside of the healthcare system.

METHODS

A cross-sectional Internet survey posted on eunuch.org received 2,871 responses. We identified individuals who had performed or assisted in human castrations ("cutters"; n = 98) and compared this group with all other survey respondents (n = 2,773), who had not assisted in castrations. Next we compared the cutters with the voluntary eunuchs. Lastly, because many of the cutters have themselves been castrated, we also divided the physically castrated population (n = 278) into cutters (n = 44) and noncutters (n = 234) and compared them.

MAIN OUTCOME MEASURES

Self-reported questionnaires were used to collect demographic information, gender identity and presentation, selected childhood experiences, and history of aggressive behaviors, self-harming behaviors, and hospitalization.

RESULTS

DISTINGUISHING CHARACTERISTICS OF CUTTERS INCLUDED: (i) presenting themselves as very masculine, (ii) having had their longest sexual relationship with a man, (iii) growing up on a farm, (iv) witnessing animal castrations, (v) having a history of sexually inappropriate behavior, (vi) having been threatened with genital mutilation as a child, (vii) having a history of self-harm, (viii) being raised in a devoutly Christian household, (ix) having had an underground castration themselves, and (x) having body piercings and/or tattoos.

CONCLUSIONS

This study may help identify individuals who are at risk of performing illegal castrations. That information may help healthcare providers protect individuals with extreme castration ideations from injuring themselves or others. Jackowich RA, Vale R, Vale K, Wassersug RJ, and Johnson TW. Voluntary genital ablations: Contrasting the cutters and their clients. Sex Med 2014;2:121-132.

Sexuality and Intimacy After Definitive Treatment and Subsequent Androgen Deprivation Therapy for Prostate Cancer

There are more than 2 million prostate cancer survivors in the United States. Primary therapy with surgery or radiation results in permanent changes in sexual function. More than half of these men are subsequently treated with androgen deprivation therapy (ADT) at some point. The addition of ADT further compromises sexuality, intimacy, and a couple's relationship. This review will highlight the challenges faced by patients and couples and reveal the tremendous need for better education of physicians, patients, and couples as well as for more research in sexuality and intimacy with the goal of improving quality of life for this large population of survivors. Suggestions for clinicians to better help patients and their partners regarding sexuality and intimacy are offered.

The language of prostate cancer treatments and implications for informed decision making by patients

Previous research has shown that cancer patients lack knowledge about treatments particularly for reproductive system cancers. Focusing on prostate cancer, we explored how the language used to describe treatments and their side effects is understood by both men and women. Since the language around prostate cancer is often euphemised to reduce distress and stigma, our aim was to elucidate how language (e.g. hormone therapy vs. androgen deprivation therapy) affects both patients' and partners' attitudes towards treatment decision making. We surveyed 690 male and female cancer patients and non-patients through an online questionnaire. A large proportion of participants did not understand the terminology used to describe prostate cancer treatments. Most did not know that the terms 'chemical castration', 'hormonal therapy' and 'androgen deprivation' are synonymous. Male respondents stated that they would more readily agree to hormonal therapy than to castration to treat prostate cancer and felt significantly more strongly than women about how androgen deprivation therapy, described in various terms, affected masculinity. Men and women differed substantially in their opinion about the impact of androgen deprivation. For patients and partners to make informed decisions and cope effectively with treatment side effects, it is important that healthcare practitioners provide accurate information using language that is unambiguous.

Estrogens in men: clinical implications for sexual function and the treatment of testosterone deficiency

INTRODUCTION

The role of estrogens in male sexual function and the pathogenesis of testosterone deficiency remain controversial and poorly understood.

AIMS

To review the distribution of estrogens in normal and testosterone deficient men, their potential role in sexual function, and the clinical implications of elevated estrogens during testosterone therapy.

METHODS

A comprehensive, broad-based literature review was conducted on the role of estrogens in male sexual function and testosterone deficiency.

RESULTS

Estrogens elicit a variety of physiological responses in men and may contribute to modulation of sexual function. In the absence of testosterone deficiency, elevations in estrogens do not appear to be harmful and estrogens may help maintain some, but not all, sexual function in castrated men. While the therapeutic use of estrogens at pharmacologic doses has been used to suppress serum testosterone, naturally occurring elevations of estrogens do not appear to be a cause of low testosterone. During testosterone replacement, estrogens may rise and occasionally reach elevated levels. There is a lack of evidence that treatment of elevated estrogen levels during testosterone replacement has benefit in terms of male sexuality.

CONCLUSION

Further research on the importance of estrogens in male sexual function is needed. Current evidence does not support a role of naturally occurring estrogen elevations in testosterone deficiency or the treatment of elevated estrogens during testosterone therapy.

Role of estrogen in normal male function: clinical implications for patients with prostate cancer on androgen deprivation therapy

PURPOSE

Patients with prostate cancer on androgen deprivation therapy with luteinizing hormone-releasing hormone agonists experience deleterious side effects, including sexual dysfunction, hot flashes and osteoporosis. Estrogen may relieve or reduce some of these side effects. We explore the role of estrogen in normal male function, emphasizing sexual interest and performance.

MATERIALS AND METHODS

We reviewed the literature on androgen deprivation therapy, estrogen and sexual function in males using PubMed® and other sources.

RESULTS

Estrogen receptors are present in tissues involved in sexual behavior including several brain centers and pelvic floor muscles. Exogenous estrogens can restore some sexual interest to greater than castrate level in castrated animals. This has also been reported for certain androgen deprived patients (eg voluntarily castrated men, male-to-female transsexuals) who take exogenous estrogens and others who are on high dose antiandrogens which increase endogenous estradiol levels. Estrogen also helps prevent hot flashes and bone mineral loss, which commonly occur with luteinizing hormone-releasing hormone agonist treatment. However, estrogen may cause gynecomastia and increases the risk of breast cancer. Thus, patients with prostate cancer should be informed about the pros and cons of estrogen therapy before starting androgen deprivation therapy. Based on these data estrogen is likely to have maximal benefits in men if initiated simultaneously with androgen deprivation therapy. Because estrogen autoregulates its own receptors, a constant dose of estrogen will not likely produce a constant serum concentration, suggesting that its effectiveness could be optimized if administered cyclically.

CONCLUSIONS

Prospective studies on the ability of parenteral estrogen to preserve sexual interest at greater than castrate level in patients with prostate cancer are warranted.

Passing through the wall: on outings, exodus, angels, and the ark

Classicists have argued that angels in Christian theology were modeled on the eunuchs of antiquity; with angels providing the same services to the Lord in Heaven that eunuchs provided to emperors on Earth. I apply this idea toward understanding the cherubim on the ark in Exodus 25 and the death of Aaron's sons in Leviticus 10. I also suggest that the angel-eunuch analogy can help us understand the psychological impact of androgen deprivation therapy on modern prostate cancer patients. Appreciating this analogy can help prostate cancer patients accept and adapt to the changes they experience.

A passion for castration: characterizing men who are fascinated with castration, but have not been castrated

INTRODUCTION

A number of men have extreme castration ideations. Many only fantasize about castration; others actualize their fantasies.

AIMS

We wish to identify factors that distinguish those who merely fantasize about being castrated from those who are at the greatest risk of genital mutilation.

METHODS

Seven hundred thirty-one individuals, who were not castrated, responded to a survey posted on http://www.eunuch.org. We compared the responses of these "wannabes" to those of 92 men who were voluntarily castrated and responded to a companion survey. Main Outcome Measures. Respondents answered the questionnaire items relating to demographics, origin of interest in castration, and ambition toward eunuchdom.

RESULTS

Two categories of wannabes emerged. A large proportion ( approximately 40%) of wannabes' interest in castration was singularly of a fetishistic nature, and these men appeared to be at a relatively low risk of irreversible genital mutilation. Approximately 20% of the men, however, appeared to be at great risk of genital mutilation. They showed a greater desire to reduce libido, change their genital appearance, transition out of male, and prevent sexually offensive behavior. Nineteen percent of all wannabes have attempted self-castration, yet only 10% have sought medical assistance.

CONCLUSIONS

We identify several motivating factors for extreme castration ideations and provide a classification for reasons why some males desire orchiectomies. Castration ideations fall under several categories of the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV), most notably a Gender Identity Disorder other than male-to-female (MtF) transsexual (i.e., male-to-eunuch) and a Body Identity Integrity Disorder. Physicians need to be aware of males who have strong desires for emasculation without a traditional MtF transsexual identity.

Management of complications of androgen deprivation therapy in the older man

Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.

The social context for psychological distress from iatrogenic gynecomastia with suggestions for its management

INTRODUCTION

Gynecomastia (breast development in males) is a side effect of androgen deprivation therapy (ADT) for prostate cancer (PCa). Medical interventions to prevent or treat gynecomastia carry risk of additional detrimental side effects. However, untreated gynecomastia can be physically uncomfortable and psychologically distressing. Shame from gynecomastia can lead patients to stop otherwise beneficial exercise.

AIMS

Our first aim is to explore the social context for gynecomastia and how it is interpreted by men with the condition, as well as by others, both male and female. Subsequently, we use our understanding of why gynecomastia is psychologically distressing to propose psychosocial interventions that could help men accept this side effect of ADT.

METHODS

We draw on academic literature, media accounts, and web-based testimonials from men with gynecomastia, to understand how gynecomastia is perceived by both patients and the medical community. We examine these resources in light of gynecomastia's impact on sex roles, sexuality, and gender identity issues.

MAIN OUTCOME MEASURES

By exploring what breasts in a male mean to the individual, we produce an understanding of the social context for distress from gynecomastia. From this understanding, we derive hypotheses about who might be most distressed from gynecomastia and strategies for alleviating this distress.

RESULTS

The shame and stigma of gynecomastia is linked to the objectification of women. We suggest that men fear that their breasts will marginalize and subordinate them within gender hierarchies. There is little evidence that breasts on a male erotically attract either men or women. Novel options for living with gynecomastia are contrasted with medicalized strategies including mastectomy.

CONCLUSION

Assessment instruments need to be developed to identify patients most likely to experience distress from gynecomastia and seek out medical interventions. Surgical, radiological, or pharmacological interventions may not be universally necessary if greater acceptance of gynecomastia is made available through psychosocial support programs. For example, PCa patients may learn to accept gynecomastia through reconceptualizing their breasts as autoerotic. Support programs modeled on those of the breast cancer community, including Encore and dragon boat racing, may also help to build communities to serve patients with gynecomastia while defending individuals against shame, isolation, and loss of self-esteem.

Prostate cancer prevention: past, present, and future

Prostate cancer is the most common male malignancy and the second or third leading cause of cancer death among men in the West. The descriptive epidemiology of prostate cancer suggests that it is a preventable disease. Prevention has the theoretical advantage of not only saving lives, but also reduce the morbidity of radical prostate cancer therapy. This article reviews the past, present, and future of prostate cancer prevention. In particular, the evidence and scientific data of a variety of prevention strategies are reviewed. Strategies reviewed include dietary fat reduction and supplementation with vitamins D and E, and selenium. Dietary intake of soy, green tea, and tomato-rich products (lycopene) are also reviewed. Data regarding pharmacological intervention with cyclo-oxygenease inhibitors, antiestrogens, and in particular 5-alpha reductase inhibitors are reviewed. The results of the Prostate Cancer Prevention Trial including the controversy surrounding higher-grade cancers among men randomized to finasteride are also summarized. Finally, a variety of trial designs as well as a roster of current phase 2 trials are presented. Probably no cancer is being investigated more thoroughly in the context of prevention as prostate cancer in 2007. Definitive answers to pivotal phase 3 trials will be available in the coming 2 to 7 years.

Eunuchs in contemporary society: characterizing men who are voluntarily castrated (part I)

INTRODUCTION

Some males desire to be emasculated for no medical reason. These individuals are often secretive about their desires and little is known about their background and motivation.

AIMS

We sought to characterize these modern eunuchs and to identify risk factors for genital self-mutilation or self-administered chemical castration.

METHODS

We posted a questionnaire on the Eunuch Archive ( http://www.eunuch.org) that was responded to by 135 voluntarily castrated males. Questionnaire data were supplemented by accompanying narrative responses and several personal interviews.

MAIN OUTCOME MEASURES

Participants answered questionnaire items pertaining to their knowledge about androgen deprivation, the nature of their castration, and the length of time between initial presentation of castration paraphilia and castration. These questionnaire data allowed us to compare and contrast voluntary chemical and physical eunuchs.

RESULTS

The physical castrations were largely premeditated, with an average of 18 years from the time that an individual developed interest in being a eunuch to the time of their actual castration. We identified four factors that may promote castration ideations: (i) abuse sustained during childhood, including parental threats of castration; (ii) homosexuality; (iii) exposure to animal castration during youth; and (iv) religious condemnation of sexuality. Chemical eunuchs were more likely to have sought castration for libido control or to advance transition from male to female (P < 0.05). Physical eunuchs had a nonsignificant tendency to have masochistic paraphilia involving genital mutilation in advance of their castration (P < 0.1). Both Body Integrity Identity Disorder and Gender Identity Disorders occur among those who self-identify as eunuch.

CONCLUSIONS

We present evidence that the majority of self-identified voluntary eunuchs are not male-to-female transsexuals. Whereas the majority identify as male, many view themselves as in an alternate nonmale, nonfemale, gender space. We therefore suggest that male-to-eunuch is a valid transgender identity.

Eunuchs in Contemporary Society: Expectations, Consequences, and Adjustments to Castration (Part II)

INTRODUCTION

There are men in the Western world who are voluntarily castrated and are not male-to-female transsexuals.

AIMS

We surveyed members of this group to understand their responses to androgen deprivation (AD) and how their experiences matched their expectations of AD.

METHODS

We posted a questionnaire on the Eunuch Archive (http://www.eunuch.org) that received responses from 92 voluntarily orchiectomized males who identified as eunuchs. Data from this questionnaire were supplemented with interviews with 19 of the eunuchs.

MAIN OUTCOME MEASURES

Participants completed questionnaire items regarding: (i) the side effects they expected and experienced; (ii) their current physical and psychological condition; (iii) their level of regret; (iv) what they appreciated most about their castrated status; and (v) who performed their orchiectomies.

RESULTS

The most appreciated aspect of castration was the sense of control over sexual urges and appetite (52%). The major side effects experienced were loss of libido (66%), hot flashes (63%), and genital shrinkage (55%). The population had high self-rated sociability, and mental and physical health. Although there was an insignificant reduction in depression after castration, the overall level of self-reported obsessive-compulsive disorders decreased significantly (P < 0.01). Twenty-two percent of the population reported a change in sexual orientation. Many respondents (60%) took supplemental hormone treatments to counteract the side effects of AD. The use of both supplemental testosterone and high-dose estrogen correlated with a significant increase in self-reported sexual desire and activity above the agonadal level (P < 0.001). The majority of the castrations (53%) were not performed by medical professionals.

CONCLUSION

The medical community needs to be aware of men at risk of unsafe castrations in order to provide them with more information on the side effects of AD and access to safe orchiectomies.