The Oransky Journal

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Transsexual woman castrates herself: What one person did when insurance wouldn’t pay

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Warning: This will likely be a painful read. Unlike many of the posts elsewhere on this blog, there are no jokes in it, because poking fun at this kind of pathos is really in poor taste. At least as importantly, ridicule would obscure the fact that there’s a real and desperate human being in this story who made a choice that actually seemed like the best one at the time, given her options.

In a report in the Journal of Sexual Medicine, Michael Irwig and colleagues from the George Washington University describe a transsexual woman in her 40s who decided that she should castrate herself rather than than have the procedure done by surgeons:

Elective outpatient orchiectomy is often out of reach for many patients, primarily due to cost but also due to waiting times, local laws prohibiting such surgeries, and cultural disapproval of transsexualism in certain countries [2,3]. In some locations, patients may lack access to a surgeon willing to perform the operation out of fear of destroying normal tissue, legal consequences, or undesirable publicity [4]. In the United Sates, elective orchiectomy is often not covered by healthcare insurance plans and patients would be responsible for all costs, which are typically in the thousands of dollars. Medical and surgical costs vary widely by country, and some patients travel internationally to have surgery performed for a significantly lower price than in their home country. Nonetheless, the above barriers to surgery have prompted some transsexual women to resort to self-castration [2,3,5,6]. Self-castration rarely results in death, but significant risks are present, which include hemorrhage, disfigurement, infection, urinary fistulae, and nerve damage [2,3]. Many patients who perform or attempt to perform self-castration subsequently seek care at a hospital emergency department, often for bleeding.

Neither private insurance nor Medicaid typically pays for the procedure, Irwig tells The Oransky Journal. Here’s a description of how she carried out the operation:

Prior to performing this procedure, the patient had researched relevant male anatomy and “banding” on Internet Web sites. Although she read about constricting the blood supply to the scrotum to promote dry necrosis, she wished to avoid the odor of dead tissue. The night prior to presentation, the patient used rubbing alcohol to “sterilize” a set of elastic hair ties which she placed around the scrotum. She also self-medicated with benzodiazepines. After approximately 7 hours of “banding,” she used a pair of pink garden shears, specifically purchased for this purpose, to excise part of the scrotum and both testes. She chose to make the incision as distal as possible to preserve tissue for future vaginoplasty. She promptly flushed the testes and excised tissue down the toilet to prevent reattachment. Shortly thereafter, the hair ties slipped off and pulsatile bleeding ensued. Attempts to stop the bleeding were unsuccessful, prompting the patient to travel by public transportation to the Emergency Department.

The episode cost taxpayers nearly $15,000, which is nearly four times the $4,000 the authors estimate an elective surgery would have cost:

The patient was admitted to the psychiatric service for a 3-day hospitalization to clarify her psychiatric conditions, to assure safety, and to modify her endocrine treatment. The total cost was US $14,923. The fee breakdown was US $6,210 for room charges, US $5,574 for the surgeon, US $1,320 for the anesthesiologist, and US $1,819 for pharmacy medications, lab tests, and various consults. The patient’s health insurance was Medicaid, a plan that covers low-income residents in the United States and varies by state. Consequently, she was not responsible for the hospital bill.

What’s clear from the report is that this woman was making a clear and informed choice:

At the time of her presentation, her mental status examination revealed no psychotic symptoms. Her speech and affect modulation were normal and her intellectual functioning was average. She did not exhibit suicidal thoughts or any other self-destructive or harmful ideations. She did not define her self-castration as a form of self-harm; she interpreted it as an action necessary to decrease the risks associated with a high dose of estrogen and to hasten the pace of her physical transition. She had a fairly good understanding of the medical options to suppress androgens and their limitations. She was spending a large percentage of her limited income on dermabrasion and electrolysis, and she saw the act as partly a way to decrease the cost of maintaining a female appearance.

In fact, her health care team had what turned out to be a wince-inducing warning:

Prior to the admission, she stated to a mental health professional that her fatigue was “nothing a pair of garden shears couldn’t fix.”

It’s not clear how often this sort of thing happens. The authors found 109 cases in the scientific literature, but only 10 of those were transsexuals. Irwig told me he hasn’t seen any other cases:

One of my colleagues/friends who has treated over 1000 transgendered individuals also noted to me that it is quite rare.

Fortunately, the woman in this case does not have any long-term effects of her operation, and is doing well, Irwig said. He and his co-authors conclude:

…many male-to-female transsexuals lack access to affordable elective orchiectomy. Some patients, particularly those with underlying psychiatric conditions, have resorted to self-castration out of frustration. Providers of transsexual women should make sure to discuss the risks of self-castration with their patients, particularly those at high risk. On a local level, providers can help to identify surgeons with the expertise and willingness to perform surgery on transsexuals. In this case, the costs to the health care system of a self-castration were almost four times that of an elective orchiectomy. Further research is needed to explore the economics of self-castration in a series of patients and in different health care systems which have different financial models.

Written by Ivan Oransky

February 1, 2012 at 9:30 am

Posted in Uncategorized

4 Responses

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  1. For those interested in more information on self-castration:


    February 1, 2012 at 10:04 am

  2. Please tell me where in the U.S. a bilateral orchiectomy would cost only $4000.00? My grandson just had 4 teeth extracted under general anesthesia as a day surgery. The hospital charge alone was $17,000.00. This did not include the fee for the oral surgeon or the anesthesiologist.

    Skeptical Scalpel

    February 1, 2012 at 10:22 am

  3. @Scalpel, I think orchiectomies are often performed out of a hospital setting, e.g. in a doctor’s private office, due to the Catholic-backed hospital system being unwilling to support orchiectomies. This probably makes them a little cheaper; I’ve heard of some doctors offering them in the $2300 price range. It may also be that the anesthetics are cheaper.


    February 4, 2012 at 2:11 am

  4. Here’s a true story for you… I live near central USA. So it’s hard to find someone that can do the procedure of removing the testicles from my body. So, I actually attempted to cut mine off. It was December 25, 2004 and I had rational thought to proceed with what I was doing. I had all the items to do it with: disinfecting, cutting, burning, sewing, etc.. Except that I chose not to use any type of numbing. That is how I messed up my castration. I got as far as holding one my problems( testicle) in my hand and could not cut it due to too much pain. I didn’t realize the pain from the tubes that held on to the testicles had just as, if not more sensitivity than the testicles themselves. By then it was too late to try to numb it so I decided to rethink my situation. I decided that I couldn’t cut it slow. The tubes would have to be pinched by hemostats and then have a swift and direct cut to the part with the testes to detach them. Then have to be burned and cauterized to stop the bleeding. But I never got that far. I only had a surgical blade and it was not big enough for the swift cut that I presumed I needed. So I stuck my problem back in the scrotum and stitched it back together. I decided to try again tomorrow. However; I didn’t think about the swelling and didn’t want to further the chance of infection so I halted the castration part and let it heal and try again in the future. I had swelling for about 2 and a half months along with a leakage of fluid draining from between the stitches for an additional month. I had videotaped the procedure but I erased it later that week from fear that someone find it and post it somewhere.
    But if you think that that failing attempt has stopped me, you are wrong. I plan to finish what I started. The next time I do it I will have help and more equipment for the procedure. I already have one friend willing to help me, and maybe a second one. I do plan to record and document it again, but this time for more reasons than just my own.


    October 21, 2012 at 1:19 am

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