The testis, eunuchs, and testosterone: a historical review over the ages and around the world.

INTRODUCTION: Testosterone therapy for men with testosterone deficiency is widely used, yet remains controversial. The rich and fascinating history of the testicles, including human castration, provides a valuable perspective on this important topic. OBJECTIVES: This study reviewed the history of testosterone from antiquity to the modern day. METHODS: Primary sources consisted of books and relevant articles, augmented by a MEDLINE search using the key words "testis," "testicles," "castration," "eunuchs," "testosterone," and "testicular function." RESULTS: An early scientific observation was that castration reduced sexual development and activity, originating with domestication of animals approximately 10 000 years ago. Human castration appears in ancient Egyptian mythology more than 4000 years ago, in Greek mythology from 8th century BCE, and in the Bible. The history of eunuchs in China spanned 2000 years, beginning with the Hsia dynasty (2205-1766 BCE). The concept that the testicles produced some factor responsible for male sexual development and behavior was thus known throughout the world since the beginning of recorded history. Testosterone was isolated and synthesized in 1935 and was soon available as a treatment. Multiple benefits of testosterone therapy were apparent by 1940. Recent large, controlled testosterone studies have conclusively demonstrated sexual and general health benefits, with a strong safety profile. CONCLUSION: Testosterone has been a known substance for <1% of the historical timeline, yet knowledge that the testes were responsible for male sexual development and behavior has been known since the beginning of recorded history. Today, modern evidence has demonstrated the importance of normal levels of testosterone for general health as well as sexual function and desire. Yet, testosterone therapy remains controversial. We believe this historical review provides a helpful perspective on this age-old issue.

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

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Essential trace and toxic elemental concentrations in biological samples of male adult referent and Eunuch subjects.

BACKGROUND: The influence of essential nutrients such as calcium (Ca), copper (Cu), iron (Fe), magnesium (Mg), selenium (Se), and zinc (Zn) on male fertility has been extensively studied. For reproductive health, adequate spermatogenesis, sperm maturation and motility, as well as optimal sperm function, these essential elements are required. Several pathologic and male infertility disorders have been linked to an imbalance of these elements. METHODS: The purpose of this study was to determine the relationship between essential and toxic elements, such as Ca, Cu, Fe, Mg Se, and Zn, as well as cadmium (Cd), lead (Pb), and mercury (Hg) in human biological samples, such as blood, serum, and seminal plasma, from 96 referent male adults aged 21 to 49 years, who were further divided into three age groups. The biological samples of Eunuch people (n = 37), ranging in age from 21 to 42 years, were also analysed for comparison. The method of acid digestion was controlled by a microwave oven. The essential and toxic elements in the oxidised biological samples were determined using atomic absorption spectrometry. Certified reference material of blood and serum was being used to validate the methodology's accuracy. RESULT: The Ca, Cu, Fe, Mg, Se, and Zn concentrations in blood and serum samples of Eunuch people were found to be lower, whereas Cd, Pb, and Hg levels were significantly higher than those found in data from normal adult male subjects (p 0.001). The results reveal that the concentrations of Ca, Cu, Fe, Mg, Se, and Zn in the seminal plasma of adult male participants in the younger age group (21-29) were higher than those in the older age groups (30-39) and (40-49). Although essential trace element levels in Eunuch people's biological samples were significantly lower than those observed in adult male subjects. CONCLUSION: Essential elemental deficiency and elevated levels of toxic heavy metals in all biological fluid samples may have significant negative effects on human reproductive health (sperm quality and function), leading to male infertility.

"My son was castrated as a result of a medical error. Is it OK to raise him as a eunuch?"

A 12-year-old boy lost both testes after testicular torsion. He is now 14, and his father wants to know if the boy should immediately start supplemental testosterone or if he might reasonably choose to live as a eunuch. The boy does not yet express any strong opinion except that he is embarrassed about his weight gain. We advised the father that there is no need to rush the decision as the boy could at least delay testosterone therapy until his teens or early 20s and still go through male puberty with little risk of adverse health effects. We seek to know if others endorse our endocrinological advice. The boy's father wants to be honest with his son about the social challenges the boy may face if he elects to delay or avoid puberty altogether and chooses to openly identify as a eunuch.

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.

A Rare Case of Male-to-Eunuch Gender Dysphoria.

The aim of this case report is to improve the awareness of this gender dysphoria both for the single patient interest as well as for the community. This is a single-patient case report. Literature search and Internet browsing for forum concerning this subject were performed. Healthcare professionals must be aware of this group of patients as they have a greater risk of self-harm in order to self-castrate, which could be acute and life threatening if not performed in the right way. Hermann M and Thorstenson A. A rare case of male-to-eunuch gender dysphoria. Sex Med 2015;3:331-333.

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.

Fertile eunuch syndrome in association with biventricular noncompaction, bicuspid aortic valve, severe aortic stenosis, and talipes equinovarus.

Noncompaction of the ventricular myocardium is a congenital cardiomyopathy characterized by prominent ventricular trabeculations and deep intertrabecular recesses. In most cases, noncompaction is an isolated disease confined to the left ventricular myocardium. Fertile eunuch syndrome is a hypogonadotropic hormonal disorder in which the levels of testosterone and follicle-stimulating hormone are low. We report a case of biventricular noncompaction in association with bicuspid aortic valve and severe aortic stenosis in a 42-year-old man who was diagnosed with talipes equinovarus and fertile eunuch syndrome during childhood.