Choosing Castration: A Thematic Analysis of the Perceived Pros and Cons of Genital Injuries and Ablation by Men Who Voluntarily Sought Castration.

Some men elect castration voluntarily without any clear medical reason. Here we aim to document their perception of genital ablation and injuries to better understand their motivations for castration. Participants completed an online survey with open-ended questions related to their perspectives on castration, genital ablation, and genital injuries. Thematic analyses were performed on the responses to these questions. Responses were obtained from 208 male castrated individuals (51.9 ± 16.0 years old). Among these, 154 were physically castrated, 36 chemically castrated, and 18 nullified (had testicles and penis removed). The majority learned about castration from media (55.8%) or animal castration (23.4%). The circumstances when they first wanted to be castrated varied greatly. Most (46.3%) wished to achieve an idealized self motivated by gender dysphoria, body integrity dysphoria, or wanting to be conspicuously non-sexual. The top themes we identified related to the respondents' perceptions of the pros of genital ablation were physical appearance, psychological benefit (i.e., a "eunuch calm"), and being non-sexual. Conversely, themes related to the cons they saw in having no genitals ranged from no disadvantages to loss of sexual/reproductive capability. Some perceived performing genital injury as a step toward ultimate castration or nullification. The respondents similarly varied in whether they saw any loss in having non-functional testicles. Perceptions in this regard appeared to differ depending on whether the respondents were taking supplemental androgens post-castration. Motivations for castration vary greatly between individuals. Clinicians need to understand men's diverse perceptions on castration in order to provide appropriate care for individuals with strong castration desire.

Castration for Pleasure: Exploring Extreme Castration Ideations in Fiction.

The Eunuch Archive (EA) is an online community which includes individuals who read and write sexual fantasies with themes related to castration and eunuchs. Here we analyzed the 100 stories rated highest by EA readers among the >8800 currently posted. Our goal was to gain insights into commonalities within, and specifics of, castration sexual fantasies. Simply stated, we want to know what the authors (and readers) fantasize about and why. The most popular EA stories link sexual gratification and romantic partnership with genital abuse. They are characterized by the absence of consent for genital ablations and multiple SM-related paraphilias. Many stories feature attraction to, and ablation of, the genitals of pubescent or adolescent males. Some EA members have acted on their interests and been voluntarily castrated. Others wish to be. The most popular stories in the EA collection typically link the sacrifice via SM abuse to securing a permanent sexual partnership. The idea of sacrificing one's genitals to build dyadic adhesion has been noted before in individuals with extreme castration ideations. Here we identify the common features of sexualized fantasies that are popular among individuals with exceptional interest in castration.

Paraphilic Sexual Attraction to Males Without Genitals Is Associated with Traumatic Childhood Experience, Body Image, and Thoughts/Behaviors Related to Genital Ablation.

In rare cases, some male individuals are sexually attracted to men who have their genitals removed. We investigate here if paraphilic attraction to men without genitals was associated with childhood experience, body image, and thoughts/behaviors related to body modification. An online survey, consisting of both validated questionnaires and questions developed by our team, was launched on the Eunuch Archive and MTurk websites. Out of 875 participants, 48.5 and 32.2% reported being attracted to males without testicles or without a penis, respectively; 49.7 and 31.0% felt they would themselves be attractive without testicles and without a penis, respectively. In terms of body modification, many reported having tattoos (19.0%) and piercings (26.1%). About half (48.3%) had played as children with male action figures without genitals, i.e., GI Joe, and Ken dolls. Additionally, some participants reported having: (1) witnessed animal castration (23.7%); (2) having been threatened with castration during their childhood (11.9%); (3) receiving genital injuries inflicted by others (11.0%); (4) pretending to be castrated (60.2%); (5) thinking of self-castration (54.2%); or (6) injuring their own penis (23.4%). Having received genital injuries inflicted by others was associated with attraction to males without testicles (OR = 1.997, p < .05), but not for attraction to males without a penis. Paraphilic attraction to males without genitals (i.e., castrated or penectomized) was associated with feeling attractive without genitals, having pretended to be castrated, considering self-castration, and having injured one's own penis. In conclusion, paraphilic attraction to males without genitals may be associated with traumatic early life events, body image, and desire for one's own genital ablation.

A 2-year prospective analysis of insomnia as a mediator of the relationship between androgen deprivation therapy and perceived cognitive function in men with prostate cancer.

BACKGROUND: Androgen deprivation therapy (ADT) may affect cognitive function in men with prostate cancer (PCa). This study examined whether insomnia symptoms mediate the relationship between ADT and perceived cognitive function and whether depressive symptoms, fatigue severity, and physical activity moderate the strength of this relationship. METHODS: This was a prospective study of ADT recipients (n = 83) who were matched with control patients with PCa who were not on ADT (n = 92) and with controls with no history of cancer (n = 112) over a 2-year follow-up period. Perceived cognitive function and satisfaction were assessed with the Everyday Cognition Scale. Insomnia was assessed with the Insomnia Severity Index. Multilevel mediation analyses were conducted to estimate the indirect effect of ADT on perceived cognitive function through insomnia symptoms. Exploratory moderated mediation analyses assessed whether the indirect effect of ADT on perceived cognitive function through insomnia symptoms was dependent on levels of fatigue, depression, or physical activity. RESULTS: Insomnia symptoms significantly mediated the relationship between receipt of ADT and perceived cognitive function (P < .001) and satisfaction with cognition (P < .001) after controlling for comorbidities. Men with greater fatigue had a more pronounced association of ADT with insomnia severity. Men with greater depressive symptoms had a stronger association between insomnia severity and worse perceived cognitive function. Physical activity was not a significant moderator of the relationship between ADT and perceived cognitive function. CONCLUSIONS: Insomnia influenced the relationship between ADT and perceived cognitive abilities. Interventions to address insomnia, fatigue, and depression may improve perceived cognitive function.

Hormones and visual attention to sexual stimuli in older men: an exploratory investigation.

BACKGROUND: Testosterone is associated with sexual desire and performance in men, but little is known about cognitive mechanisms underlying this relationship. Even less is known about the influence of estradiol, despite its production from testosterone, and high receptor density in brain regions related to male sexual behavior. METHOD: We used eye-tracking to compare men's visual attention to images of fully clothed (i.e. neutral) and minimally clothed (i.e. sexy) models in three groups: androgen-deprived (n = 6) and not androgen-deprived with prostate cancer (n = 11), and healthy controls (n = 7). We also assessed effects of serum testosterone, estradiol, and sex hormone-binding globulin levels. RESULTS: We found no group effect for fixations to sexy compared to neutral images, and no influence of testosterone on either total fixations, or proportion of fixations to sexy images. In contrast, we found that sex hormone binding globulin positively predicted total fixations, and estradiol positively predicted proportion of total fixations on sexy images--regardless of androgen treatment status. CONCLUSION: Our results suggest that visual attention to sexual stimuli in men may be significantly affected by hormones. This has potential implications for clinical populations that experience sexual side effects, such as prostate cancer patients on androgen deprivation therapy.

Sexual Function After Voluntary Castration.

Some genetic males undergo voluntary castration, with and without hormonal supplementation. Here, we investigate the sexual function of 163 such individuals (average age = 52 ± 16-years-old). Specifically, we explored how hormonal, social, and psychological factors play a role in their sexual function. In this study, 47% identified their gender as "eunuch", and 36% identified their gender as "man." Furthermore, 64% were in a relationship (80% with a woman), and 28% had a strong attraction for both sexes (Kinsey 2-4). We found that castrated individuals with androgen supplementation have higher sexual function than those without any hormone supplementation. Individuals with anxiety symptoms reported better sexual parameters (better orgasm satisfaction, easier to achieve an erection and an orgasm) than those without anxiety symptoms. Among those low in anxiety, individuals without hormone supplementation had a weaker sex drive and more difficulty in getting sexually aroused than those on supplemental estrogen or androgen. Hierarchical multiple regressions indicated that control variables (i.e., age, depressive symptoms, time since castration, type of hormone supplementation) accounted for 13-30% of the variances in sexual parameters. Including sexual guilt in the models predicted 4-8% additional variances in all sexual parameters except for ease in getting and maintaining an erection. Adding in participants' sexual trauma scores accounted for an additional 3.7% in the strength of their reported sex drive. In conclusion, various factors-hormone therapy, anxiety, sexual guilt, and childhood trauma-may influence the sexual outcomes for castrated individuals.

Differences in the Psychological, Sexual, and Childhood Experiences Among Men with Extreme Interests in Voluntary Castration.

Some genetic males seek voluntary castration. We designed a survey to compare the psychological, sexual, and childhood experiences for subgroups of men with extreme interest in castration. The survey was posted on the Eunuch Archive, an online platform for individuals interested in the topic. Data from 822 individuals were included in the analyses. Respondents were divided into four groups: Interested (claiming only an interest in castration topics), Fantasy (fantasize about castration sexually, but not desiring castration), Wannabe (considering being castrated in the future), and Castrated (already castrated). More individuals desiring castration (Wannabe and Castrated groups) claimed equal attraction to both sexes than individuals in the Interested group. The Interested group was more religious than the other groups, and the Fantasy group had lower sexual guilt than those with castration desire. All groups had similar psychological well-being and body image acceptance, despite the Castrated group having lower sexual functioning than the others. Childhood trauma was more common in those with castration desire than those without. The Interested group had a lower desire for castration, lower erotic attraction to castration, and pretended to be castrated at a younger age than the others. Childhood trauma and sexual guilt are common, but not limited, predictors for castration desire and erotic attraction to castration, respectively. In conclusion, childhood experiences, as well as psychological and sexual parameters, may vary in different subgroups of males with interests in castration.

Characteristics of Males Who Obtained a Voluntary Penectomy.

We report here on survey data from 11 genetic males, who had voluntary penectomies without any explicit medical need, yet did not desire testicular ablation. This group was compared to a control group of men who completed the same survey but had no genital ablation. The penectomy group was less likely to identify as male than the control group. They were also more likely to have attempted self-injury to their penis (at a median age of 41.5 years), been attracted to males without penises, and felt that they were more physically attractive without a penis than the controls. Motivations for voluntary penectomy were aesthetics (i.e., a feeling that the penile removal made them more physically attractive) or eroticism (i.e., at least two individuals thought that a penectomy would make them a better submissive sexual partner). In terms of sexual function, the penectomized and control groups reported comparable sexual function, with six penectomized individuals claiming to still be able to get and keep an erection, suggesting possible incomplete penile ablation. In their childhood, penectomized individuals were more likely than the controls to have pretended to be castrated and to have involved the absence of genitals of their toys in their childhood play. We discuss characteristics and sexual outcomes for individuals who have had a voluntary penectomy. A future study with a larger sample size on men who desire penectomies is warranted.

Androgen deprivation therapy's impact on the mood of prostate cancer patients as perceived by patients and the partners of patients.

OBJECTIVE: To assess the relationship between of androgen deprivation therapy (ADT) and the mood of prostate cancer (PCa) patients and partners of PCa patients. METHODS: PCa patients (n = 295) and partners of patients (n = 84) completed an online survey assessing the patients' current mood and mood prior to treatment, relationship adjustment, and sexual function. We compared men on ADT to men who received non-hormonal treatments for their PCa. RESULTS: Patients currently treated with ADT (n = 82) reported worsened mood as measured by the Profile of Mood States compared to those not on ADT (n = 213). The negative impact of ADT on mood, however, was reduced in older patients. Partners of patients on ADT (n = 42) reported similar declines in the patient's mood that patients reported, but to a greater degree than patient-reported levels. CONCLUSIONS: Our data support ADT's impact on PCa patients' mood and verify that partners concurrently see the effects. The psychological changes related to ADT can impact relationships and affect the quality of life of both PCa patients and partners. Patients and their partners are likely to benefit from being well informed about the psychological effects of androgen deprivation on men beginning ADT. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

The perspective of prostate cancer patients and patients' partners on the psychological burden of androgen deprivation and the dyadic adjustment of prostate cancer couples.

OBJECTIVE: Prostate cancer and its treatments, particularly androgen deprivation therapy (ADT), affect both patients and partners. This study assessed how prostate cancer treatment type, patient mood, and sexual function related to dyadic adjustment from patient and partner perspectives. METHODS: Men with prostate cancer (n = 206) and partners of men with prostate cancer (n = 66) completed an online survey assessing the patients' mood (profile of mood states short form), their dyadic adjustment (dyadic adjustment scale), and sexual function (expanded prostate cancer index composite). RESULTS: Analyses of covariance found that men on ADT reported better dyadic adjustment compared with men not on ADT. Erectile dysfunction was high for all patients, but a multivariate analysis of variance found that those on ADT experienced greater bother at loss of sexual function than patients not on ADT, suggesting that loss of libido when on ADT does not mitigate the psychological distress associated with loss of erections. In a multiple linear regression, patients' mood predicted their dyadic adjustment, such that worse mood was related to worse dyadic adjustment. However, more bother with patients' overall sexual function predicted lower relationship scores for the patients, while the patients' lack of sexual desire predicted lower dyadic adjustment for partners. CONCLUSIONS: Both patients and partners are impacted by the prostate cancer treatment effects on patients' psychological and sexual function. Our data help clarify the way that prostate cancer treatments can affect relationships and that loss of libido on ADT does not attenuate distress about erectile dysfunction. Understanding these changes may help patients and partners maintain a co-supportive relationship. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners.

The clinical benefits of androgen-deprivation therapy (ADT) for men with prostate cancer (PC) have been well documented and include living free from the symptoms of metastases for longer periods and improved quality of life. However, ADT comes with a host of its own serious side effects. There is considerable evidence of the adverse cardiovascular, metabolic, and musculoskeletal effects of ADT. Far less has been written about the psychological effects of ADT. This review highlights several adverse psychological effects of ADT. The authors provide evidence for the effect of ADT on men's sexual function, their partner, and their sexual relationship. Evidence of increased emotional lability and depressed mood in men who receive ADT is also presented, and the risk of depression in the patient's partner is discussed. The evidence for adverse cognitive effects with ADT is still emerging but suggests that ADT is associated with impairment in multiple cognitive domains. Finally, the available literature is reviewed on interventions to mitigate the psychological effects of ADT. Across the array of adverse effects, physical exercise appears to have the greatest potential to address the psychological effects of ADT both in men who are receiving ADT and in their partners.

What do Canadian uro-oncologists believe patients should know about androgen deprivation therapy?

INTRODUCTION: Patients prescribed luteinizing hormone-releasing hormone agonists for androgen deprivation therapy (ADT) have significant misconceptions about treatment side effects and how to manage them. We surveyed a subset of Canadian physicians about what they think is important information to tell patients starting on ADT to determine the degree to which there is consensus of opinion. METHOD: A questionnaire about ADT side effects and management strategies was distributed to physicians-urologists, radiation oncologists, and medical oncologists - actively practicing within cancer and urology centers in the Canadian provinces of British Columbia, Alberta, Ontario, and the Maritime Provinces. RESULT: A total of 75 physicians filled out the survey. Physicians agreed that osteoporosis, erectile dysfunction, hot flashes, loss of libido, and loss of muscle mass were drug responses that were essential or important to warn patients about. However, for six commonly reported side effects (i.e. depression, diabetes, elevated cholesterol, anemia, delayed or absent orgasm, and genital shrinkage), physicians showed great variance, with less than 60% agreeing on whether to discuss these topics or not. CONCLUSION: There is little consensus among physicians regarding what to tell patients when prescribing this treatment. The lack of agreement among physicians may partially explain the lack of awareness of ADT side effects by patients and partners. The current findings may help guide strategies for the design, evaluation, and implementation of educational interventions for both physicians and patients that will better prepare patients to recognize, adapt to, and overcome ADT side effects.

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.

Enhancing care: evaluating the impact of True North Sexual Health and Rehabilitation eTraining for healthcare providers working with prostate cancer patients and partners.

Background: Educational programs that enhance healthcare providers' competence in managing the care of patients with sexual dysfunction following prostate cancer treatments are needed to facilitate comprehensive sexual health treatments for patients and their partners. Aim: In this study we evaluated the impact of a real-world online sexual health educational intervention called the True North Sexual Health and Rehabilitation eTraining Program. This program is designed to increase healthcare providers' knowledge and self-efficacy in providing sexual healthcare to prostate cancer patients and their partners. Methods: Healthcare providers were invited to join a 12-week virtual training program. Participants completed precourse surveys (n = 89), retrospective prepost surveys (n = 58), and a 3-month follow-up survey (subset n = 18) to assess retention of relevant outcomes. Additionally, a course satisfaction survey was administered to participants (n = 57) at the end of the course. Outcomes: The main outcomes focused on participants' perceived knowledge and self-efficacy in conducting assessments and providing interventions for various relevant physical, functional, psychological, and relational domains of sexual dysfunction in prostate cancer patients and their partners. Results: According to the retrospective analysis of post-then-pre-survey results, graduates perceived that their knowledge of and self-efficacy in providing sexual health counseling improved after completing the course. The 3-month follow-up survey indicated that the course graduate self-efficacy remained high 3 months after the course. Furthermore, the satisfaction survey indicated that a vast majority (98.2%) of participants were satisfied with the educational intervention. Clinical Implications: This real-world sexual health educational intervention can increase self-efficacy and knowledge in healthcare providers who are supporting prostate cancer patients dealing with sexual dysfunction. Strengths and Limitations: The use of a retrospective post-then-pre-survey helped to mitigate response shift bias while minimizing data gaps. However, it is important to note that this investigation was not a traditional research study and lacked a control group, thus limiting causal attributions. Conclusion: The True North Sexual Health and Rehabilitation eTraining program acts as an accessible and effective resource for healthcare providers seeking specialized training in providing sexual healthcare for prostate cancer patients and their partners.

A Proposal for the Comprehensive Care of Men on Androgen Deprivation Therapy: Recommendations From the Multidisciplinary Prostate Cancer 360 Working Group.

INTRODUCTION: To promote comprehensive care of patients throughout the androgen deprivation therapy (ADT) prescribing process, the Prostate Cancer 360 (PC360) Working Group developed monitoring and management recommendations intended to mitigate or prevent ADT-associated adverse events. METHODS: The PC360 Working Group included 14 interdisciplinary experts with a dedicated clinical interest in prostate cancer and ADT management. The working group defined challenges associated with ADT adverse event management and then collaboratively developed comprehensive care recommendations intended to be practical for ADT prescribers. RESULTS: The PC360 Working Group developed both overarching recommendations for ADT adverse event management and specific recommendations across 5 domains (cardiometabolic, bone, sexual, psychological, and lifestyle). The working group recommends an interdisciplinary, team-based approach wherein the ADT prescriber retains an oversight role for ADT management while empowering patients and their primary and specialty care providers to manage risk factors. The PC360 recommendations also emphasize the importance of proactive patient education that involves partners or other support providers. Recommended monitoring and assessment tools, risk factor management, and patient counseling points are also included for the 5 identified domains, with an emphasis on lifestyle and behavioral interventions that can improve quality of life and reduce the risk for ADT-associated complications. CONCLUSIONS: Comprehensive care of patients receiving ADT requires early and ongoing coordinated management of a variety of health domains, including cardiometabolic, bone, sexual, psychological health. Patient education and primary care provider involvement should begin prior to ADT initiation and continue throughout treatment to improve patient and partner quality of life.

Comparative feeding kinematics of tropical hylid tadpoles.

Anuran larvae, which are otherwise simple in shape, typically have complex keratinized mouthparts (i.e. labial teeth and jaw sheaths) that allow them to graze upon surfaces. The diversity in these structures among species presumably reflects specializations that allow for maximal feeding efficiency on different types of food. However, we lack a general understanding of how these oral structures function during feeding. We used high-speed digital imaging (500 Hz) to observe tadpoles of six species from the anuran family Hylidae grazing on a standardized food-covered substrate. Tadpoles of these species vary in the number of labial tooth rows, belong to two different feeding guilds (benthic and nektonic), and inhabit ponds and streams. We confirmed that the labial teeth in these species serve two functions: anchoring the mouth to the substrate and raking material off of the substrate. In general, tadpoles with a larger maximum gape or those with fewer labial tooth rows opened and closed their mouths slower than tadpoles with smaller gape or more tooth rows. Nektonic feeding tadpoles released each of their tooth rows proportionally earlier in the gape cycle compared with benthic feeding tadpoles. Lastly, we found some support for the idea that deformation of the jaw sheaths during a feeding cycle is predictable based on tadpole feeding guild. Collectively, our data show that anatomical (e.g. number of labial teeth) and ecological features (e.g. feeding guild) of tadpoles significantly influence how tadpoles open and close their mouths during feeding.

Gender Differences among Healthcare Providers in the Promotion of Patient-, Person- and Family-Centered Care-And Its Implications for Providing Quality Healthcare.

The concept of "patient-centered care" (PCC) emphasizes patients' autonomy and is commonly promoted as a good healthcare practice that all of medicine should strive for. Here, we assessed how six medical specialties-pediatrics, OBGYN, orthopedics, radiology, dermatology, and neurosurgery-have engaged with PCC and its derivative concepts of "person-centered care" (PeCC) and "family-centered care" (FCC) as a function of the number of female physicians in each field. To achieve this, we conducted a scoping review of three databases-PubMed, CINAHL, and PsycInfo-to assess the extent that PCC, PeCC, FCC, and RCC were referenced by different specialties in the medical literature. Reference to PCC and PeCC in the literature correlates significantly with the number of female physicians in each field (all p < 0.00001) except for neurosurgery (p > 0.5). Pediatrics shows the most extensive reference to PCC, followed by OBGYN, with a significant difference between all disciplines (p < 0.001). FCC remains exclusively embraced by pediatrics. Our results align with documented cognitive differences between men and women that recognize gender differences in empathizing (E) versus systemizing (S) with females demonstrating E > S, which supports PCC/PeCC/FCC approaches to healthcare.

Exposures to information about castration and emotional trauma before puberty are associated with men's risk of seeking genital ablation as adults.

Background: Little is known about childhood experiences, outcomes, and self-recollections of those men who were voluntarily castrated as adults. Aim: The study sought to determine how learning about castration before and after 13 years of age is associated with differential childhood experiences, outcomes, and self-recollections of those who were voluntarily castrated as adults. Methods: We designed a survey of voluntarily castrated individuals, who learned about castration before and after 13 years of age. Our survey consisted of both validated questionnaires and questions. Data were from 208 individuals. Both descriptive and quantitative statistics were performed. Outcomes: Learning about castration before 13 years of age is associated with more adverse childhood experiences (ACEs) such as being threatened with castration and other forms of emotional, physical, and sexual trauma. Results: As compared with those who learned about castration after 13 years of age, those who knew about castration earlier were more likely to have self-injured their penis (χ2 1 = 5.342, P < 0.05), had thoughts of performing self-castration (χ2 1 = 10.389, P < 0.01), witnessed animal castration (χ2 1 = 10.023, P < 0.01), been threatened with castration as a child (χ2 1 = 21.749, P < 0.001), had childhood physical trauma (χ2 1 = 4.318, P < 0.05), had childhood emotional trauma (χ2 1 = 3.939, P < 0.05), and had childhood sexual trauma (χ2 1 = 5.862, P < 0.05). Clinical Implications: Mental health screening and support should be offered to any men seeking emasculating procedures in line with the World Professional Association of Transgender Health's Standards of Care Version 8. Strengths and Limitations: This study had a large sample size and used a validated questionnaire to evaluate for ACEs. The average age of respondents was above 50 years of age, which may increase recall bias. Conclusion: Understanding how ACEs influence the age when some eunuchs first desire, pretend, and become castrated can help clinicians develop better assessments and treatment protocols for individuals with male-to-eunuch gender dysphoria, and other conditions in which emasculating medical procedures are requested.