Of Eunuchs and Wannabes

Transcript and audio of WPATH symposium on eunuch identity

The World Professional Association for Transgender Health’s 27th Scientific Symposium, which was held between September 16-20 in Montreal, was the site of a number of extraordinary developments whose impact will be felt for a long time. Among them was a presentation by Thomas W. Johnson, a professor emeritus of anthropology at California State University, discussing a chapter in the new Standards of Care issued by the organization which designates “those who identify as eunuchs” suffering from “Male-to-Eunuch Gender Dysphoria” as subjects with a need for “gender-affirming care” as a part of the “gender diverse umbrella.” Johnson is, among other things, the author of a remarkable op-ed published in the Washington Post advising ISIS to cease beheading and begin castrating prisoners so as to create a class of eunuchs who will replicate the purportedly crucial role their predecessors played in the original Caliphate acting as “infertile functionaries to enact the authority of the state.” His remarks effectively convey the tone and atmosphere of the event and the baseline assumptions held by those helping to define the organization’s mission and priorities. They are worth listening to and reading in full and constitute a notable document of our times. These are the people exercising influence over the organization setting standards for gender affirming care.

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

Chapter 9. Eunuchs (Page No. S88)

WPATH 27TH SCIENTIFIC SYMPOSIUM

MONTREAL, QUEBEC, CANADA

TUESDAY, SEPTEMBER 20, 2022 • MAIN CONFERENCE

2:10pm - 3:10pm

Session A - Grand Salon

SOC8 Session - Eunuch

Thomas W. Johnson, PhD; Michael S. Irwig, MD

Thomas W. Johnson, PhD: —where we'll be doing, first, the Eunuch chapter, and this will be followed by a video on the Intersex chapter. So, I'm Tom Johnson, part of this committee, and I'll be joined by Michael Irwig, who will do the second half of our presentation. I'm going to be talking, my set—there we go—is the people that we're dealing with, and then Michael, how do we help them, what do we do to work with them. Somewhere, that’s it—

Tom Johnson: First, I'd like to do a little history. Eunuch is the oldest recognized gender outside the binary, it's in the Bible, it’s in all kinds of sources. People know something about the history, some of it accurate, some of it very inaccurate. And their knowledge of that history, of course, then affects how they will be treating their patients, how they will react to the eunuchs in the modern world. Castration was, of course, an important discovery for the history of domestication: castration of large animals. In early civilization, Sumer, for example, slaves were just another domestic animal. In the Sumerian cuneiforms, slaves and pigs were counted together, and separately from goats, sheep, and donkeys. And the slaves were treated the same way as other domestic animals; you castrate the non-breeding population. 

But very quickly, it was discovered that, just like in other animals, there are some personality differences that come with this. And they soon started moving into various administrative positions, into all kinds of jobs that required the skills that eunuchs were then better suited for. And by the time of the Assyrians, they were so embedded in the bureaucracy that important families were castrating younger sons so that they would move into the bureaucracy. Some of the Assyrian kings who had access to many, many women— had 100 or more children—most of the boys would be castrated, so they were no longer contenders for the throne, but still part of the royal entourage and worked in the palace. It became the standard route into bureaucracy for religious hierarchy, military, and district administrators throughout the Eurasian landmass. 

And in early Christianity, a great many of the early saints were eunuchs, as created to maintain celibacy. Several of the patriarchs of the Eastern Orthodox Church were eunuchs. They were simply widespread across culture in lots of positions where the standard stereotype today doesn't place them. We would more likely think of the old gentleman at the bottom there, he —that was a photo from seven years ago, one of the Guardians of the Tomb of the Prophet in Medina. There was a photo exhibit in London of a number of the eunuchs who are there, guarding the tomb; they are still prominent in that role. 

Tom Johnson: Eunuchs today, though, are mostly an invisible gender. There's no real way to present as eunuch in the Western world. Most present publicly as male. They're indistinguishable from anyone else you see on the street. Sometimes they try to appear androgynous, but there is really no way they demonstrate publicly that they are other than male. And we estimate there are eight to ten thousand self-identified voluntary eunuchs in North America today. The photos are five that I've interviewed who have given me permission to use their photos in presentations like this. Yes, all–four of the five are in the United—or three of the five are in the United States, one is Canadian, one is British. 

Tom Johnson: Men today are also castrated for medical reasons. At least a half-million men in North America are currently castrated, whether chemically or surgically, as treatment for prostate cancer. Some small number of men lose their testicles for other medical reasons, or because of accidents of various sort. And men are castrated for all kinds of other reasons. But those who are castrated for medical reasons very seldom identify as eunuchs. In Standards of Care Version 8, eunuch refers only to those who identify as eunuchs. So we're not including the prostate cancer patients, we're not including those who do not wish to have that identity. 

Tom Johnson: And who are these people? Who seeks voluntary castration? One type is men with extreme gender dysphoria; they desire to be not male, to be emasculated, but don't want to be female either. They have a male-to-eunuch gender dysphoria now part of the SOC8. There are others who have a feeling that their genitals are not a part of their—proper part of their body—body integrity dysphoria. This is in the SOC8. It's also an ICD-11; it's classification 6C21. So it's there in the ICD as well as the Standards of Care. Or they have an extreme fetish or paraphilic disorder, of which there's a wide variety, and they're not in the SOC8. That's something separate, most of that is religious based. In the Western world, it tends to be based on Matthew 19:12, where Jesus talks about the three types of eunuchs: those who “made themselves eunuchs for heaven's sake.” There are quite a number of those as well, but they don't fall under our purview here. 

Tom Johnson: Many of them out there are seeking what they term “eunuch calm.” And we see this in many of their online posts, and questions that they have. It includes at least these two items: one is reduced libido—not necessarily eliminated, but significantly reduced; and they significantly reduce reactive aggression. This is the road rage, the bar fights, the loss of control, losing one's temper easily. Proactive aggression is unchanged by loss of testosterone; reactive aggression is. And it's this part, which is part of why they were so prominent in past governance. They make excellent military commanders, they can sit back and carefully plan and organize a campaign without getting caught up in the immediate emotions of it with reactive aggression. In the long term warfare between the Byzantine state and the emerging Muslim caliphate, in many of the battles, the commanders on both sides were eunuchs. 

In order to decide to become a eunuch, many–most of them are well aware of it as an option. They don't just come into this, they know about it. We have found in looking at the population out there, that a great many of them are very well-educated. A lot of them have farm backgrounds, rural backgrounds, that they have witnessed or participated in animal castration, so they know what the procedure is. They have observed the changes that take place in the animals they’re working with. And they—actually a scary number of them have been threatened with castration by an adult in their life, most likely a parent.

There’s educational attainment– U.S. average: 30.44 percent of those 25-and-up have a bachelor's degree. Among the eunuchs, 48.24 percent. The wannabes, those who have–who are seeking castration, seeking safe castration, 49 percent—much more educated than the average in the population. At the doctoral or professional degree level: 3 percent of the general population, 8.25 or 6.75 [percent] of the eunuchs and the wannabes–much more educated than the average of the population. 

Growing up on a working farm, the U.S. Census for 1970 was 2.48 percent. Looking back at when our sample would have been growing up, 18 percent of the eunuchs grew up on a farm compared to 2.5 percent of the general population. Much more likely to have been of rural background where they have seen castration, seen the effects of it around them. And we have no idea how many people as children participated in castration as a child.  If I were doing this at a university audience, I'd ask, okay, how many of you—raise your hands—how many of you helped to castrate an animal when you were a child. And sometimes I’d get a hand. That's not something that's common. Close to 30% of both the eunuchs and the wannabes had practical experience with the castration of an animal. They know what the procedure is, they know the results that occur. 

Tom Johnson: And what I usually ask—but don't ask for a show of hands—is how many of the males here were threatened with castration by an adult when they were a child. Here's our effect with the eunuch population. I think of that as a very high number, but there's nothing to compare it with.

They have thought about it, they know about it. It's not something that they simply run into as an adult. They–this is a long-ish process. In our work with the eunuchs, we find it's many years before their decision to–that they want to be castrated before they actually manage it at this point. They–simply looking for safe surgery takes a long while today. And we hope that the Standards of Care will help with that. And there's greater interest than most of us are aware of. There is a website where many of them congregate. This is a screen print from their opening page. At the time I took this, there were 2,613 people reading about eunuchs on this website, of whom only 11 were registered members and the rest were guests. Anyone can read, you have to give personal information to register, which is required to post or ask questions. But most of the readers at any given time [inaudible]-teen thousand people, at once, were reading the site. Average month, according to the internet provider, is between 100 and 200 thousand unique IP addresses read the site per month. So there's a lot of interest out there that is not being taken care of.

Michael will tell you about what we do.

Michael S. Irwig, MD: Great. Thank you, Tom. And so my name is Michael Irwig, and I'm an adult endocrinologist at Beth Israel Deaconess Medical Center in Boston. Just two quick disclosures: one is I don't accept any money from any of the pharmaceutical companies, so I can say pretty much whatever I want about testosterone, estrogen, and the products. The second big disclosure, which is probably the more important one, is that I am by no means an expert in this field. I was involved in this chapter for the medical portion of it, because a lot of eunuchs do get castrated, so to talk about the hypogonadism and management of it, and the mitigation of it. I was actually introduced to this field by Tom when we collaborated on a paper in 2013, 2014. But it's a real honor to be part of this chapter because it really is making history. As Tom has mentioned, eunuchs and eunuch wannabes—this is probably one of the most marginalized and stigmatized communities in any culture anywhere across the world, and so it's really making history to have a eunuch chapter in the SOC8 to increase awareness of this population, so that we can provide the best of care to them. 

Alright, so I'm going to be running through a list of the statements that we have in our chapter. So Statement 1 is –We recommend that health care professionals and other users of the Standard of Care Version 8 guidelines should apply the recommendations in ways that meet the needs of eunuch individuals. So basically, given a lack of awareness of eunuchs within the general medical community and the fear among many individuals seeking castration that they will not be accepted, many avoid and do not receive appropriate medical and psychological care. And it's important that all patients including both eunuchs and those seeking castration establish and maintain a relationship with a healthcare professional that is built upon trust and mutual understanding. 

Michael Irwig: Statement 2– We recommend health care professionals should consider medical and/or surgical intervention to 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 can affect hormones. So this was from a review article. Tom knows a lot more about this than I do. But there are—there have been so many different ways that people have performed self-castrations, or have somebody done it to them who is not qualified to do castrations. These happen to be instruments used to castrate animals.

Michael Irwig: So one of the big take home messages here is, simply like we do for all of our patients, just to create a welcoming environment. That's the big first step here. And if somebody has been castrated, or they're contemplating castration, then you do want to explore various options with them, whether it be medical or surgical. So before getting castrated physically, you can actually do a chemical castration, kind of, as a trial. So there are ways to suppress testosterone levels, through hormonal suppression, to explore the effects of androgen deficiency for eunuch individuals wishing to become, for example, asexual or nonsexual or androgynous. Orchiectomy is a very simple surgical procedure that can be performed by pretty much any urologist, which is going to decrease–and basically eliminate–testicular production of testosterone. Some eunuchs will undergo an orchiectomy, with or without penectomy, to alter their body to match their self-image. And finally, there's orchiectomy followed by hormone replacement with testosterone or estrogen to mitigate some of the effects of the hypogonadism. So hypogonadism basically refers to the lack of producing the endogenous sex steroids–which would be estrogen and testosterone–which do have important roles in the body, particularly in bone density, for example, and bone strength. But also in body composition with muscle-to-fat ratios, strength, and a lot of other effects as well. 

Statement 3 is– We recommend health care professionals who are assessing eunuch individuals for treatment have demonstrated capac—competency in assessing them. So due to the stigma they may not voluntarily disclose their identity and desires to their medical or mental health providers. Health care professionals may be involved in assessment, psychotherapy, if desired, preparation and follow-up for medical and surgical gender affirmation—affirming interventions. and eunuch-identifying 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 the Education chapters of SOC. 

Statement 4–We suggest health care professionals providing care to eunuch individuals include sexuality education and counseling. And research has shown that there's a great diversity among eunuchs regarding their level of desire, type of preferred physical or sexual contact, and nature of preferred relationships. And this basically just goes back to the basics for any of our patients–is we just don't make assumptions in this area. 

All right, so I have a few minutes before we delve into the questions, and I'll just share with you my clinical experience. So I've only actually taken care of two eunuch or eunuch wannabe patients. And what I wanted to convey is that neither of these individuals came to me saying, I'm here because I'm a eunuch or a eunuch wannabe, this is what I want. I deduced it just because it was on my radar. So my first patient was back when I was in Washington, D.C.--actually both of them were. My first patient was a 19-year-old who was struggling in school; his family sent him out of the country; he came back into the country; he was kind of living in their basement, playing video games; wasn't working; getting on the internet; may have been on the autism Asperger's spectrum, but it wasn't for formally evaluated for that; very smart. And he basically told his psychiatrist, I'm going on the internet, and I want to buy estrogen, and I want to get finasteride, and I want to get progesterone. And the psychiatrist said, timeout, I want you to see the endocrinologist; don't go buying all these hormones off of the internet. And when I chatted with him, it was very clear that he was not a transgender woman; you know, he did not want feminization, he did not want breasts. He basically wanted to be pre-pubertal; he wanted a low testosterone level. And that's why he wanted to take progesterone and estrogen; it was more to lower his testosterone levels. So I kind of deduced that he, kind of, fell into this population. 

And my second patient was actually interesting in a different way. This was a guy who was probably in his 40s, who came to see me with a referral letter from a therapist in the community who was just, kind of, copying-and-pasting the same template for every patient, and basically referred this supposedly transgender woman for hormone therapy for gender-affirming care. And when I took a history, I realized that this patient was not interested in feminization at all. It was really not a transgender woman. So this particular individual was a gay man, who injected his testicles—he iatrogenically damaged one of his testicles to get them removed. So he feigned an illness; he went to the urologist. The urologist did an ultrasound and said, oh my God, I've never seen a testicle looking like that, and I don't know what this could be. Maybe this is a cancer. Let me take it out. Let me just protect everybody here because I've never seen this. This looks suspicious. And the patient said, by the way, can you please take out the other testicle, too, while you're down there. So he actually became male hypogonadal, and he was on a full dose testosterone when he came to see me, because he obviously had no sex steroid productions. And he came to see me to get on estrogen because he wanted to see if it would help him with his depression and his mood; he just wasn't feeling good on testosterone, and that was more—and then I realized that, you know, he was a eunuch, too. Now, he didn't come out and mention any of this stuff to me. He definitely told me that he was on the testosterone, because he had his testicles removed, but he didn't mention any of the other things. I only discovered this because I obtained his outside medical records, where I had pieced this together. And I did have a frank discussion with him. I said, oh by the way, I got your old records, and I saw that there was an abnormality seen on the ultrasound, which is what led to you having the castration. And he was so ashamed. He was just like, you know, I really just don't want to talk about it. So you can even see the level of stigma and embarrassment and being ashamed is just so high here. So, yes. 

So yeah, that's actually the end of my clinical scenarios. But I think we have about seven minutes; and Tom and I will answer questions. I apologize, I do have a flight, so I'm going to be leaving in about seven minutes. But we'll open this up to questions.

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Speaker 3: I'm so sorry to say that I'm horrified. We have medical language for those that are desiring the removal of their genitals, and it's orchiectomy, [inaudible] or penectomy. And I feel that it's very stigmatizing to say, oh, these folks are so stigmatized, but then use the language of castration that we literally use for animals. Enslaved people being treated as animals is a terrible introduction to this chapter– that was genital mutilation. That was not a choice. Please don't use that for an example.

Christine Wheeler: Christine Wheeler, founder and charter member of this organization, and congratulations to all the writers of this particular chapter, however it evolves eventually. I'm interested to know if the castrati are a part of your sample, whatsoever, because their motivation is really to maintain exquisite voice, to continue performing [inaudible] who, in fact, are gender binary.

Tom Johnson: They are so seldom out, but we know that they're out there. And we know back historically, during the height of the popularity of the castrati, particularly in Italy, but all through Europe, and even in Brazil, we know of a couple—though it was through the European system– that there were those boys who went and sought castration. We have documents from some of the Italian duchies of boys coming and requesting the funds to pay the doctor to get castration, and of the funds being granted. They did fall into this as voluntary, as well, even though they were minors at the time –that was not a consideration in the 17th, 18th century.

Thomas Satterwhite: Hi there, excuse me, my name is Thomas Satterwhite. I stayed out way too late last night, but—I’m Thomas Satterwhite, I’m a plastic surgeon in San Francisco, you've been—

Tom Johnson: Yeah, you’ve done some wonderful work—

Thomas Satterwhite: —general surgery in the past eight years. And Dr. Johnson, I met you in the beginning of my career, albeit my career is quite short, but I did meet you about seven or eight years ago, because the first patient—one of the first patients who came to me was an individual who identified as cisgender male, gay, wanted to move forward with penectomy and scrotectomy or [inaudible]. And I, myself, had my own discomfort, and a lot of it was at an emotional level. And you definitely assisted me in the process. And since then, I do perform a fair number of these procedures, as well as other forms of genital and gender-affirming surgery, that's quote-unquote non-standard and less frequently asked for. So I do appreciate that. So what is it that, you know, can be done—how do we get more surgeons on board, I suppose? Because during the surgeon symposium, I was open about my—what I do, and certainly got mixed responses. And there's certainly folks out there who say, no, I would never do it, right. And the other thing is, how do we —what conversations should we, as surgeons, be having, you know, with our patients, to ensure that we are appropriately addressing their needs and concerns? I mean, I know for me, I'm very open when I'm chatting with my patients, and for those who are pursuing a scrotectomy, penectomy, orchiectomy– they're oftentimes, you know, surprisingly relieved when I even bring that up as an option. So I think that could certainly be part of the discussion. But any thoughts you might have?

Tom Johnson: First of all, I remember our conversation. And the key thing is exactly what you were— open to new ideas and being willing to talk about what was best for the patient. How do you best serve the needs of the patient. And that openness was so very refreshing. And we need to find more of that out there. I'm hoping that having the chapter in the Standards of Care will open the possibilities; surgeons will see this and say, yep, this is something that I ought to be willing to consider. Michael, you're in a medical school, you have any thoughts on that?

Michael Irwig: So I think having this in the SOC is so huge, because it's now in the official guidelines. And a lot of doctors and surgeons, you know, they don't want to be seen as, you know, being rogue, and doing things that are—may get them into trouble, or that they may get their licenses pulled on. So now that there's a chapter in the SOC8 saying, here's this population, here are the services that they're looking for, this is an appropriate, you know, management— it helps alleviate some of their concerns, I think. And it also will lead to, I think, more education. You know, now, I think maybe at the urology meetings across the country, and surgery meetings, you know, there can be sessions on this, and more symposiums. The more sessions like this we have, the more educated people will get, and then we'll get more people like you to be able to do this. 

Tom Johnson: Okay great, we have—we're running out of time before we have to go to the movie, so—

Speaker 6:  Ok, really fast. Thank you [inaudible] from France. Thank you so much for this chapter that put some light about, like, several clinical situation. My question is quite naive, but pretty simple. Like, what about dealing with—I had the case of, like, dealing with an acute, masochistic paraphilia with a long and clinical history of genital self-mutilation. What goes with that kind of surgery demands, and how—do you have like any advice of like clinical management about this? Thank you.

Tom Johnson: Ok, for that it’s a medical [inaudible].

Michael Irwig: So, I mean, basically, you know, like a lot of our care, this is multidisciplinary, and on teamwork. And so you know, this is where you really want to have a qualified mental health care practitioner, who knows about the LGBTQIA community, who's versed in the Standards of Care; who you can have a conversation with and say, okay, I saw this patient, this is what they told me, this is what their history is, and then collaborate, to move forward. And you know, particularly if this is a clinical scenario that you've never experienced in your career before, because I think that's the tendency—when you first see somebody who's a eunuch, you know, you've never encountered this. The initial reaction is oh, this is outside of my comfort zone. Oh, this is strange. This person is crazy. But now that we realize that, you know, there's this whole community out there, then we get more and more comfortable with this.

Alright, we're out of time. And it's a real pleasure to have been at this conference and to have met you all. We look forward to continuing discussions. Thank you.

Tom Johnson: And sorry to leave a couple of people out. I will stay around long after this. And anyone who's interested, I brought a couple of handouts that will be available after the next session.