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

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.