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.

Introduction

There are men who seek and obtain genital ablations outside proper medical facilities for reasons other than medical necessity, such as testicular or metastatic prostate cancer 1–5. Some of these men identify as male-to-female transsexuals and seek orchiectomy and/or penectomy as part of sexual reassignment surgery but have been unable to receive the proper psychiatric diagnosis for elective surgery. There are others who are driven to genital ablation from psychological distress and may have a diagnosis of xenomelia or Body Integrity Identity Disorder, which is not associated with a gender dysphoria 6–8. Some men have socially challenging paraphilic interests and seek castration as a means of libido control. There are also individuals who desire castration because they do not feel comfortable identifying as female or male and prefer a gender identity outside the gender binary currently recognized in the contemporary western world 1,9–11.

Individuals who wish to be emasculated but do not identify as female have few options for medical assistance. There is a lack of formal standards of care for “male-to-eunuch” unlike those provided for male-to-female transsexuals in the Standards of Care of the World Professional Association for Transgender Health (see [12,13]). As a result, these individuals are unable to find appropriate medical care and may seek services outside of the medical community for their genital surgeries [2,3,14].

As part of our ongoing study of modern-day eunuchs in the western world, we have previously explored the motivation for, and consequences of, castration [1,2,14,15]. In the present study, we attempt to characterize individuals who perform or assist in genital ablations that occur outside of the healthcare system. In the eunuch.org community, a forum for those interested in the subject of human castration, these individuals are referred to as “cutters.”

In 2008, we posted a request for survey respondents on the eunuch.org website in order to better understand the motivations of those who seek voluntary castration. There were just over 3,000 respondents and close to 100 individuals who reported having assisted in human castrations outside the medical framework. Among the other respondents, there were individuals who had already been either chemically or physically castrated, or who expressed an interest in the subject with or without any expressed desire to become castrated. Although voluntary eunuchs have received some previous research attention, there are no studies that profile the unlicensed providers of human castration 1–3,16.

Our concern is about the safety of the “clients” of the cutters, and of the cutters themselves, who work outside of the healthcare system. Individuals, who perform surgeries without a license, put themselves at serious legal risk … in addition to putting their clients at great physical risk. In striving to characterize the cutters, we hope to better inform healthcare providers about this population so that they can identify individuals attracted to the activity and intercede appropriately.

Aim

Our goal was to characterize the cutter population and identify any features that distinguished them from their “clients.” We hypothesized that cutters, castrated or not, form a distinct and definable subset of individuals with extreme castration ideations. In characterizing the cutters, we aim to inform healthcare providers of their existence. We wish to help profile individuals, who may be at high risk of illegal activities and physical injury to themselves and others.

Definitions

In order to characterize the population, we define cutters as any respondents, castrated or not, who indicated that they had assisted in the castration of another person. We compared the cutters with other subgroups within our larger surveyed population. We focused on three groups for comparison (see Figure 1). First, we compared them with noncutters in our larger population of online survey respondents. This included all individuals who had expressed an interest in castration independent of whether or not they have been chemically or physically castrated but who had not participated in the castration of others. Next, we looked more extensively at the subpopulation of survey respondents who had been physically castrated (i.e., eunuchs, many of whom were clients of cutters). As many of the cutters were themselves castrated, we divided this physically castrated group into eunuch cutters and eunuch noncutters for a third comparison.

Figure 1

Illustration of subgroups used for each of our three statistical comparisons. The overall sample size of all comparisons, following removal of the biological females, underage and fraudulent responses is 2,871.

Methods

Our questionnaire was created using the SurveyMonkey template (http://www.surveymonkey.com). It was posted on the Eunuch Archive website (http://www.eunuch.org, an online community interested in “testicles, testosterone, castration, eunuchs and related topics”) for 6 months from July through December 2008. All participants provided informed consent consistent with review board approval from Dalhousie University, Halifax, Nova Scotia. The survey was announced on the “front page” of the site, and participation was invited. Some members wrote favorable comments on the site after completing the survey, which aided recruitment. No compensation was provided for participation. Participants were anonymous and were not required to answer all of the survey questions, resulting in slight differences in the number of responses to each question. Eligible participants were 18 years of age or older and had computer access to the Eunuch Archives website. There were 3,015 individuals who responded to the survey. Because Eunuch.org is a website specifically for individuals with an interest in castration, there was no separate control group of fully disinterested individuals to which the cutters or their clients could be compared.

We deleted 38 responses from individuals claiming to be under the age of 18. To screen out fraudulent responses, we deleted all submissions with inconsistencies (e.g., age—question #2—that did not match date of birth—question #477, as in one case, a respondent claimed to have been castrated before puberty yet had biological children). In order to reduce the chances of receiving multiple submissions from a single individual, we only accepted a single submission from any one IP address. Three independent researchers assessed all submissions that had questionable authenticity and/or data. Responses were excluded if two of the three reviewers doubted their authenticity. We eliminated an additional 28 responses as possibly fraudulent. A small number of women completed the questionnaire (75 “just interested” respondents and three cutters). Being male was not a requirement to complete the survey; however, we excluded these women from our analyses, as there were too few women respondents to analyze as a separate group. It is noteworthy that some women perform underground castration. Within the eunuch community, female cutters are referred to as “castratrixes.” The total number of valid, 18+, males left in the sample was 2,871.

Chi-squared tests were conducted to assess the significance of the differences between the cutters and other groups, with P < 0.05 taken as significant. Independent samples t-tests were used to compare the ages of the groups. All analyses were completed using SPSS Statistics software, version 21 (SPSS Inc., Chicago, IL, USA).

Main Outcome Measures

The survey contained questions pertaining to: (i) general demographic information (e.g., age, country of residence, education level, current marital status, and annual income), (ii) gender identity and presentation, (iii) childhood experiences such as abuse and witnessing animal castration, (iv) history of aggressive behaviors, (v) self-harming behaviors, (vi) sexually offensive behaviors, and (vii) hospitalization history. Self-harm was explored further with questions regarding a history of body modification, i.e., if participants had any tattoos or piercings. A closer look at the survey methods as well as a more detailed presentation of demographic information for the total study population can be found in Vale et al. [14].

Results

Of the 2,871 individuals in our core sample, 278 reported that they had been physically castrated and were eunuchs, and 98 reported an involvement in performing human castration.

The majority of respondents reported that they resided in the United States and the rest were from the United Kingdom, Canada, Australia, or Germany (approximately 5–10% from each) or one of 60 other countries, mostly from Europe. The majority of respondents (88.2%, n = 1,786) identified as white. Additional sample demographics are presented in Table 1.

Table 1

Sample demographics

	Overall sample (n = 2,871)	Cutters (n = 98)	Noncutters (n = 2,773)	Physically castrated (n = 278)
Age at time of survey	44.1	43.8	44.5	45.8
Location
United States	59% (1,569)	60% (55)	59% (1,391)	64% (169)
United Kingdom	10% (261)	1% (1)	10% (240)	6% (16)
Canada	6% (154)	7% (6)	6% (132)	6% (15)
Germany	5% (134)	7% (6)	5% (108)	5% (12)
Ethnicity
White	88% (1,786)	74% (56)	89% (1,590)	86% (172)
East Asian	3% (51)	5% (4)	2% (37)	1% (2)
European	2% (47)	3% (2)	2% (42)	6% (12)
Education level
Graduate degree/MD etc.	23% (657)	31% (30)	23% (583)	17% (57)
All or part of an undergraduate degree	53% (1,518)	36% (35)	54% (1,347)	53% (146)
Vocational or trade school	7% (186)	11% (11)	6% (155)	6% (17)
All or part of a high school diploma	17% (494)	22% (22)	16% (406)	20% (56)
Salary (U.S. dollars)
<25,000	23% (623)	33% (29)	25% (587)	26% (60)
25,000–50,000	30% (744)	17% (15)	31% (721)	34% (78)
50,000–100,000	31% (755)	25% (22)	31% (724)	28% (65)
>100,000	14% (336)	26% (23)	13% (310)	12% (28)
Marital status
Divorced/separated	9% (263)	17% (16)	9% (223)	11% (30)
Married	36% (1,002)	29% (28)	37% (890)	36% (94)
Partnered	14% (403)	24% (23)	14% (339)	17% (44)
Single	40% (1,124)	30% (29)	40% (981)	37% (97)
Cutters	4% (98)	—	—	18% (44)
Physically castrated	10% (278)	45% (44)	8% (196)	—

The number of responses is given in parentheses after the percentages.

Differences Between Cutters and All Noncutters

More cutters self-identified as “eunuch,” “third gender,” or “other” compared with the noncutters (see Table 2 for significant differences between cutters and noncutters). The two groups also differed significantly in their current public gender presentations, with a greater proportion of the cutters reporting that they present as “very masculine” (P < 0.01) despite their propensity toward a third gender identity. Furthermore, significantly more of the cutters indicated that their longest sexual relationship was with a male compared with the noncutters (P < 0.01). There was no significant difference in age between the two groups (P = 0.65).

Table 2

Differences between cutters (n = 98) and all noncutters (n = 2,773) who participated in the eunuch.org survey

	Cutters	Noncutters	P value
Age at time of survey	43.8	44.4	0.65
Self-identify as “eunuch,” “third gender,” or “other”	41% (40)	18% (447)	<0.01
Present publicly as “very masculine”	37% (36)	25% (606)	<0.01
Marital status			0.001
1) Divorced/separated	17% (16)	9% (223)
2) Married	29% (28)	37% (890)
3) Partnered (not married)	24% (23)	14% (339)
4) Single	30% (29)	40% (981)
Annual income			0.01
1) More than $100,000	26% (23)	13% (310)
2) $50,000–100,000	25% (22)	31% (724)
3) $25,000–50,000	17% (15)	31% (721)
4) Less than $25,000	33% (29)	25% (587)
Education level			<0.001
1) Doctoral or other advanced degree	17% (17)	7% (183)
2) Master's degree or equivalent	13% (13)	16% (400)
3) Finished university (4/5 year degree)	18% (18)	27% (677)
4) Some college or a 2-year degree	17% (17)	27% (670)
5) Vocational or trade school	11% (11)	6% (155)
6) Finished high school	11% (11)	12% (297)
7) Some high school or less	11% (11)	4% (109)
Primarily raised …			0.003
1) In a large city (over 250,000)	29% (28)	19% (467)
2) In a medium-sized city (50,000–250,000)	21% (20)	17% (415)
3) In a small city or town (under 50,000)	16% (15)	27% (674)
4) In a suburb near a large city	9% (9)	14% (346
5) In open country, but not on a farm	7% (7)	12% (302)
6) On a farm	19% (18)	11% (281)
Observed or assisted in animal castration	52% (47)	27% (635)	<0.01
Threatened with genital mutilation or castration in childhood	24% (23)	14% (346)	0.006
More than three hospitalizations following genital injuries	5% (3)	1% (9)	<0.01
Injuries to the:
1) Penis	39% (38)	25% (627)	<0.01
2) Scrotum	50% (49)	23% (575)	<0.01
3) Testicles	57% (56)	25% (621)	<0.01
History of deliberate self-harm	32% (30)	12% (304)	<0.01
Thinking about sex never makes them feel guilty	64% (57)	50% (1,219)	<0.01
Longest sexual relationship has been with a male	31% (30)	25% (628)	<0.01
Seven or more alcoholic drinks per week	21% (21)	20% (500)	0.87
Recreational drug use (any)	20% (19)	11% (281)	0.013
Sexually inappropriate behavior
Concerned that they might commit …	43% (40)	34% (823)	0.78
Concern with committing … increased interest in castration	20% (18)	12% (273)	0.068
Accused	19% (17)	11% (253)	0.57
Charged	9% (8)	3% (61)	<0.01
Convicted	13% (12)	2% (49)	<0.001
Abused or assaulted as a child	30% (29)	23% (579)	0.314
One or more tattoos	31% (30)	26% (426)	0.002
Have or had any piercings	52% (50)	33% (827)	<0.001
History of aggressiveness or aggressive display	18% (17)	15% (377)	0.78
Have ever fantasized about castrating others	64% (61)	34% (824)	<0.001
Handedness			0.38
1) Right	71% (68)	77% (1,906)
2) Left	18% (17)	14% (348)
3) Ambidextrous	11% (11)	9% (222)
Parent's religiosity rated “very devout”	14% (13)	8% (200)	0.07
Religion raised			<0.001
1) Christian (other than Catholic)	35% (34)	50% (1,234)
2) None	21% (20)	17% (409)

The number of responses is given in parentheses after the percentages. Bold texts indicate significant comparisons.

There were a higher proportion of cutters at both the upper and lower ends of the education scale when compared with noncutters. This was reflected in their reported annual incomes as significantly more cutters reported annual incomes in both the lowest and highest income brackets (P < 0.01). Of the cutters, a third earned less than $25,000, and about a quarter said that they earned more than $100,000 annually. More than twice as many cutters as noncutters have completed a doctoral or equivalent degree.

A greater proportion of cutters than noncutters indicated that they were raised on farms (P < 0.003) though the majority of cutters reported being raised in a large city. Consistent with being raised on farms, almost double the proportion of cutters than noncutters indicated that they had assisted in or observed the castration(s) of farm animals and/or pets (P < 0.01). Of the cutters, only 19% grew up on farms but 52% had participated in the castration of farm animals.

Significant differences between the cutters and the noncutters were evident in the self-reported histories of sexually inappropriate behavior. The proportion of cutters who had been charged with sexually inappropriate behavior was three times greater than that of the noncutters (P < 0.01). The proportion of cutters who indicated that they had been convicted of sexually inappropriate behavior was six times greater than that of the noncutters (P < 0.001). Although the groups did not differ on whether they were concerned about committing sexually inappropriate acts (P = 0.78), more cutters than noncutters (approaching significance) endorsed the idea that their concern with committing sexually inappropriate behavior increased their interest in castration (P = 0.068).

Significantly more cutters than noncutters had a history of being threatened with genital mutilation or castration in childhood (P < 0.006). Although large numbers of both cutters (30%, n = 29) and noncutters (23%, n = 579) report instances of abuse or assault during childhood, the difference between these two groups was not significant. Cutters and noncutters do not report a significant difference in alcohol use (P = 0.87), but cutters report significantly higher recreational drug use (P = 0.013). Furthermore, cutters were over two times more likely to have a history of deliberate self-harm, genital or other (P < 0.01).

Approximately two-thirds of cutters indicated that they had fantasized about castrating others (P < 0.001), compared with only one-third of noncutters. Cutters report significantly more body modifications, including tattoos (P = 0.002) and piercings (P < 0.001) compared with noncutters. Almost two-thirds of cutters reported that they do not feel guilty when thinking about sex, whereas only half of noncutters (P < 0.01) shared this sentiment.

Consistent with this result, the number of reported hospital visits due to genital injuries was greater for the cutters (P < 0.05). The proportion of the cutters that reported more than three hospitalizations following genital injuries was four times that of the noncutters. Conversely, 78% of the noncutters reported never having been hospitalized due to genital injury, compared with 58% of the cutters. As well, a significantly greater percentage of the cutters reported having injuries to their penis, scrotum, or testicles than the noncutters, although the survey did not differentiate accidental from deliberate injuries.

Difference Between Cutters and Physically Castrated Individuals

Our most notable finding was the overall similarity between the cutters and their “clients,” i.e., those whom they cut, the physically castrated individuals. In all of the parameters we measured, there were no statistically significant differences between all cutters and all those who had been physically castrated. This is not surprising, as 45% (n = 44) of the cutters reported being physically castrated, providing a large overlap in membership between the two groups. However, in comparing specifically cutters and noncutters within the greater community of the physically castrated, significant differences emerged. These are addressed below.

Differences Between Cutters and Noncutters Within the Physically Castrated (Eunuch) Population

Similar to the overall sample, the majority of both eunuch cutters and eunuch noncutters in the physically castrated sample reported being of white ethnicity and currently residing in North America (Ps > 0.10). There was no significant difference between the two groups on age at the time of completing the survey (P = 0.14) or age at the time of castration (P = 0.68; see Table 3). The physically castrated cutters and noncutters did differ on a few demographic variables. Almost half of all cutters reported an annual income of less than $25,000 compared with only a quarter of noncutters (P = 0.03). However, contrary to the lower incomes they report, significantly more cutters reported having a Masters or PhD level of education (P = 0.01). Significantly more cutters reported being divorced or separated (21%, n = 9) than noncutters (9%, n = 16), and more noncutters reported being single (40%, n = 76; P = 0.01). Cutters were more than twice as likely to have been raised in large cities (40%, n = 17) than were noncutters (17%, n = 33; P = 0.01). The two groups were, though, equally likely to have been raised on farms (cutters 16%, n = 7; noncutters 17%, n = 34). Despite that, eunuch cutters were almost twice as likely to report having participated in animal castrations (40%, n = 17) than were eunuch noncutters (23%, n = 41; P = 0.02).

Table 3

Differences between physically castrated (i.e., eunuch) cutters (n = 44) and physically castrated eunuchs who are noncutters (n = 234)

	Cutters	Noncutters	P value
Age at time of survey	45.6	46.9	0.14
Age at time of castration	38.2	39.3	0.68
Self-identify as “eunuch,”, “third gender,” or “other”	72% (31)	63% (123)	0.30
Present publicly as “very masculine”	27% (12)	20% (39)	0.73
Marital status			0.01
1) Divorced/separated	21% (9)	9% (16)
2) Married	25% (11)	39% (73)
3) Partnered (not married)	25% (11)	12% (23)
4) Single	29% (13)	40% (76)
Annual income			0.03
1) More than $100,000	14% (3)	12% (22)
2) $50,000–100,000	24% (10)	30% (55)
3) $25,000–50,000	19% (8)	36% (66)
4) Less than $25,000	43% (18)	23% (42)
Education level			0.01
1) Doctoral or other advanced degree	14% (6)	7% (13)
2) Master's degree or equivalent	23% (10)	12% (23)
3) Finished university (4/5 year degree)	18% (8)	28% (55)
4) Some college or a 2-year degree	14% (6)	33% (64)
5) Vocational or trade school	11% (5)	4% (8)
6) Finished high school	11% (5)	13% (26)
7) Some high school or less	9% (4)	4% (7)
Primarily raised …			0.01
1) In a large city (over 250,000)	40% (17)	17% (33)
2) In a medium-sized city (50,000–250,000)	16% (7)	14% (27)
3) In a small city or town (under 50,000)	16% (7)	26% (50)
4) In a suburb near a large city	2% (1)	13% (25)
5) In open country, but not on a farm	9% (4)	14% (27)
6) On a farm	16% (7)	17% (34)
Observed or assisted in animal castration	40% (17)	23% (41)	0.02
Threatened with genital mutilation or castration in childhood	21% (9)	15% (29)	0.36
More than three hospitalizations following genital injuries	0% (0)	4% (5)	0.812
History of deliberate self-harm	33% (14)	18% (35)	0.89
Thinking about sex never makes them feel guilty	67% (24)	66% (117)	0.77
Longest sexual relationship has been with a male	34% (15)	23% (45)	0.22
Seven or more alcoholic drinks per week	27% (12)	21% (40)	0.46
Recreational drug use (any)	16% (7)	13% (25)	0.29
Sexually inappropriate behavior
Concerned that they might commit …	26% (11)	16% (31)	0.14
Concern with committing … increased interest in castration	10% (4)	12% (21)	0.93
Accused	21% (9)	15% (28)	0.65
Charged	12% (5)	4% (8)	0.063
Convicted	14% (6)	3% (6)	0.005
Abused or assaulted as a child	27% (12)	34% (66)	0.70
Have ever fantasized about castrating others	61% (26)	23% (45)	<0.001
One or more tattoos	50% (22)	30% (58)	0.03
Have or had any piercings	64% (28)	40% (78)	0.02
History of aggressiveness or aggressive display	14% (6)	16% (30)	0.89
Handedness			0.35
1) Right	71% (31)	75% (145)
2) Left	23% (10)	15% (28)
3) Ambidextrous	7% (3)	10% (20)
Parent's religiosity rated “very devout”	14% (6)	13% (25)	0.96
Religion raised			0.60
1) Christian (other than Catholic)	43% (19)	48% (94)
2) None	18% (8)	17% (34)
Hormone replacement therapy			0.15
1) Full testosterone replacement	41% (17)	29% (55)
2) No or low HRT	45% (19)	62% (117)
3) Transitional (high) estrogen	14% (6)	10% (18)
Friend or lover performed their castration	30% (13)	6% (11)	0.001
Underground cutter performed their castration	25% (11)	6% (11)	0.001
Self-castrated	9% (4)	19% (38)	0.10
Personal castration performed by an MD	11% (5)	48% (94)	<0.001

The number of responses is given in parentheses after the percentages. Bold text indicates significant comparisons.

Cutters, who are physically castrated, were significantly less likely (P < 0.001) to have had their castration performed by an MD compared with noncutters who were physically castrated. Alternatively, significantly more physically castrated cutters reported having had a friend or lover (P < 0.001) or another underground cutter (P < 0.001) perform their castration compared with physically castrated individuals who are noncutters. Although not statistically significant (P = 0.15), cutters were more likely to take a replacement dose of testosterone (41%, n = 17) than were noncutters (29%, n = 55) and, conversely, the noncutters were more likely to use either no hormone replacement therapy or a low dose of estrogen or testosterone at a level thought to ward off osteoporosis and hot flashes (62%, n = 117) than were the cutters (45%, n = 19).

When it came to body modifications, almost two-thirds of the physically castrated, who are themselves cutters, report having (or ever having) piercings compared with less than half of the physically castrated who are noncutters, and this difference is significant (P = 0.02). Half of physically castrated cutters reported having tattoos, which is significantly more than the 30% of physically castrated noncutters (P = 0.03).

In terms of committing sexually inappropriate acts, the physically castrated cutters and noncutters differed more as the consequences increased, with significantly more cutters reporting a conviction (14%, n = 6, P = 0.005). No differences were found between the two groups on their concerns about committing sexually inappropriate behaviour, or whether this concern was their motivation for seeking castration. The majority of physically castrated cutters reported having fantasized about castrating others, compared with just below one quarter of noncutters (P < 0.001).

Discussion

Based on previous survey data, Johnson et al. [2] suggested that there were specific risk factors for extreme castration ideations leading to voluntary genital ablations. These included: (i) a history of childhood abuse, (ii) being threatened as a child with genital mutilation, (iii) being raised in a devoutly Christian home, (iv) having witnessed or participated in physical castration(s) of animals, and (v) homosexuality or bisexuality. Vale et al. [14] confirmed that these are true risk factors for obtaining voluntarily castration. We have identified these to also be risk factors for individuals participating in nonmedical genital ablations, i.e., our cutters. As many of the cutters are themselves castrated, it is not surprising that the risk factors for cutters overlap with those for becoming physically castrated.

It is unclear how influential these risk factors are in terms of promoting a desire to castrate others. Open-ended questions in our survey regarding reasons for interest in castration frequently brought forth reports of witnessing animal castration(s) [14]. Unfortunately, there are no prevalence rates for how many individuals in society at large have witnessed animal castrations as a point of comparison. Interestingly, despite the similar proportion of cutters and noncutters that grew up on farms, more cutters reported to have witnessed animal castrations than noncutters.

Having been threatened with genital mutilation was identified as a more common experience in those seeking castration. Nearly one quarter of both the cutters and the physically castrated said that they had been threatened with genital mutilation as children. Several of our participants reported that their mothers had held a knife or scissors to their penis and threatened to cut it off after finding them masturbating. One respondent wrote a long account of being held by his father while his uncle pulled down his pants, held a knife to his scrotum, and offered to castrate him just like the pigs he had been watching them castrate.

A notable percentage of both the cutters and the physically castrated participants reported having been raised in “very devout” households that possibly condemned certain sexual activities and behaviors (see [14]). Children raised in devoutly religious homes are often taught that sexual activities for pleasure, such as masturbation, or certain sexual orientations and partnerships, such as homosexuality, are sinful. Among our respondents, 34% of cutters and 23% of noncutters reported their longest sexual relationship was with a male. As children threatened with genital mutilation, they may have come to believe that castration is a method to control undesirable sexual thoughts and activities. Indeed an association between devout religiosity, being threatened with genital mutilation, and being physically castrated is evidenced in our data and discussed in Vale et al. [14]. These risk factors may synergistically lead to a desire for castration. However, it is less obvious how they contribute to a desire to castrate others, as significant differences in these variables were not seen between the cutters and the physically castrated subgroup.

Perhaps contradictory to this is the finding that 67% of physically castrated cutters and 66% of physically castrated noncutters reported that thinking about sex never makes them feel guilty. Also, 41% of all cutters report identifying as “eunuch,” “third gender,” or “other,” while despite this, 37% of all cutters report presenting as “very masculine.” Regrettably we did not ask explicitly about the motivation for castrating others. Nor did we ask about the number of castrations the cutter had participated in. Without such additional data, it is impossible to tell if these are contradictory risk factors (i.e., self-identifying as being “very masculine,” yet identify as outside the gender binary), or hints of subgroups within the larger cutter population.

Our comparison of the subgroup of physically castrated cutters to physically castrated noncutters sought to identify additional risk factors beyond those discussed in Vale et al. [14], i.e., contrasting cutters and their clients. Many of the significant differences that we found between cutters and noncutters are no longer significant when we compare cutters with noncutter eunuchs. It appears that the risk factors for becoming a cutter are essentially risk factors for obtaining castration rather than performing it. Similarly, they suggest that physically castrated cutters are a distinguishable group within the population of cutters.

One notable difference in the physically castrated subgroup of cutters relates to who performed their castrations. More physically castrated cutters had a friend, or loved one perform their castration. Conversely, the majority of physically castrated noncutters performed self-surgery, or had a medical professional perform their surgery if that option was available to them. This difference may be the result of the different motivations for seeking castration, i.e., whether they seek castration to become compatible with their gender identity, or to fulfill a sexual fantasy.

In addition, more than two-thirds of the cutter population have piercings and or tattoos. This may suggest a greater interest in body modification. In the overall comparison of all cutters vs. noncutters, significantly more cutters report being charged and convicted for sexually inappropriate behavior. Within the physically castrated subgroup, the cutters remain significantly more likely to be convicted of sexually inappropriate behavior. However, there is no difference between the two groups in whether their concern about committing an inappropriate behavior increased their interest in castration.

Given the nature of our data, we cannot say which characteristics or experiences are most related to the desire to perform castrations on one's self or others. However, we can examine where the largest differences lie between these groups (Figure 2). Looking only at the significant differences, the greatest proportional difference between cutters and noncutters are in: (i) being physically castrated themselves, (ii) fantasizing about castrating others, and (iii) witnessing animal castrations—with the cutters reporting larger proportions for all three.

Figure 2

The plots above are designed to help visualize the most significant differences in the comparison between (i) all cutters (n = 98) vs. all noncutters (n = 2,773) who responded to our survey (top) and (ii) all eunuch cutters (n = 44) vs. eunuch noncutters (n = 234) (bottom). Along the X-axis are the percentage difference in a particular trait between the two groups compared. In all of these cases the greater percentage is with the cutters. The traits that are compared are arranged along the Y-axis and listed in order of the traits with the most to least difference between the compared groups. Only features that were different in the statistical analyses at P < 0.05 are plotted here. The level of statistical difference is given in Table 1 and Table 2, respectively.

When looking specifically at the physically castrated population, the greatest proportional difference between eunuch cutters and eunuch noncutters are in the following features with the cutters reporting the largest proportion: (i) castration performed by another cutter/friend or lover, (ii) castration performed by a non-MD, and (iii) has or had piercings. Although this comparison cannot show which feature is most predictive of a person becoming a cutter, it highlights the greatest differences between these populations.

In sum, there may be no singular, invariant psychological profile of the cutter, who is himself castrated. However, the general picture that emerges, as noted above, is of someone who both sought out injury for himself and is willing to injure others.

Limitations

There were several limitations to the study. First, in order to recruit a sufficient sample size an anonymous survey was used, and thus the veracity of responses could not be monitored. The questionnaire was limited to English-speaking individuals with access to the Internet, and caution should be used when generalizing these findings. In addition, we could not have a control group comprised of individuals without an interest in castration, as all members of the Eunuch Archive website expressed some interest in this topic. To assess risk factors, participants were asked questions about their childhood and past experiences. Therefore, many questions relied on participants' retrospection. As well, we did not separate those who have assisted in/performed a single or a few castration(s) from those who have performed many. That information may help identify the strength of the association between certain risk factors and participants involvement in illegal surgeries. In order to gain a deeper understanding of the motivating factors for cutters, a survey that specifically targets the cutters would need to be undertaken. Future research should also assess comorbid disorders, such as Borderline Personality Disorder, that may share some common features with extreme castration ideations.

Legal and Medical Implications

Inflicting trauma or permanent injury on a nonconsenting person is a crime. However, the morality and legality of someone allowing himself to be permanently injured raises the question of whether full consent can be given in such a scenario.

According to American criminal law, the consent to bodily harm is not a valid defense against a charge of battery; however, this legal principle has sparked controversy [17]. The “mainstreaming” of body piercing indicates a relaxation of cultural attitudes toward consent to body harm, although the legal system does not appear to be changing to reflect current practice. The question of consent becomes more complicated in the context of our research because human castration is drastic, irreversible and, when performed by nonmedical professionals, carries a high risk of pain, infection, and even death by exsanguination. As such, to remove the risk associated with nonmedical surgeries, some have argued for the medical community to provide amputations of healthy limbs for individuals experiencing extreme xenomelia or body integrity identity disorder (see discussion in 18–20). We would extend this argument to genitals to encompass those individuals who seek a eunuch or “third gender” identity. It might be argued that the great difficulty in finding effective psychiatric counseling and medically qualified surgeons for this population may result in greater harm than an absolute adherence to the Hippocratic creed of “do no harm.” Within the community of eunuchs and those wishing to be castrated, who frequent the Eunuch Archive website, there is strong opposition both to self-castration and to the use of cutters. However, there are many discussions of “safer” ways to obtain castrations from surgeons. Some now inject toxins directly into the testicles in order to produce sufficient damage that a surgeon will perform an orchiectomy for damage control [21].

As with castrations for sexual reassignment, we favor standards of care for males with extreme castration ideations (i.e., the potential clients of the cutters) that would provide safe options beyond self-castration or seeking the service of cutters [2,10,14]. However, we do stress that the treatment of these individuals and the decision whether to perform the procedure should lie with the discretion and clinical judgment of treating physicians. Healthcare professionals must take individuals who disclose castration fantasies seriously, particularly if risk factors (e.g., history of sexual abuse, having been threatened with genital mutilation, and having witnessing animal castrations) are identified.

Conclusion

Our research helps to characterize individuals who perform underground genital ablations. We have identified a number of distinguishing characteristics of cutters, including: (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. Few individuals have all these risk factors, and we cannot comment on which risk factors are dominant in the development of extreme castration ideations.

Unfortunately, individuals with a collection of these risk factors seldom present to their family doctors, psychiatrists, or other healthcare providers. It is important, however, that healthcare professionals recognize that these individuals exist. Our study may help healthcare providers identify individuals who are at the greatest risk of injuring their own genitals and the genitals of others.