Auto-orchiectomy is the deliberate act of self-removal of one or more testicles. The act of self-castration historically has been associated with severe psychiatric disorders.
However, such an act has been linked with several underlying factors including psychosis, substance use, gender dysphoria, and complex religious or cultural principles. We report two cases of auto-orchiectomy in unrelated heterosexual males as a result of psychotropic substance use with psychiatric history and religious conviction, respectively.
Introduction
We reviewed 2 unrelated cases of bilateral auto-orchiectomy resulting from psychosis related to substance use and religious conviction. Both cases involved patients who encountered complications, notably hemorrhagic shock, requiring immediate attention in the operating room.
Throughout history, auto-orchiectomy has been documented in relation to psychiatric disorder, religious conviction, prevention of secondary sexual characteristic development, and medical issues. However, we now recognize other contemporary contributing factors, such as substance-induced psychosis and gender dysphoria.
Auto-orchiectomy can be carried out using different methods, the most common of which is amputation with a sharp object. Other methods may include manual prolonged torsion, external crushing, and the injection of corrosive chemicals into the testes. The extent of scrotal removal varies amongst individuals spanning from full resection to minimal scrotal involvement, and in some cases may encompass the penis. While our cases demonstrate bilateral auto-orchiectomy, unilateral resection has also been observed.
We report on 2 consecutive cases of auto-orchiectomy, exploring the potential underlying causes that could influence an individual to attempt auto-orchiectomy.
Methods
Within a single month, 2 cases of auto-orchiectomy presented to a suburban Level I trauma center in Saint Louis, Missouri.
The first patient, a 38-year-old unmarried heterosexual cisgender male, arrived at the trauma center in a state of hemorrhagic shock. He had a history of manic depression, suicide attempts, and was under the influence of psychotropic substances on arrival. The injuries included stab wounds to the right neck, bilateral upper extremities, and scrotum, which were reported to have been self-inflicted using a knife. The patient received 2 units of packed red blood cells and underwent multiple wound explorations and repairs in the operating room. The neck and upper extremity lacerations were found to be superficial. During scrotal exploration, the absence of bilateral testes was confirmed. Hemostasis was achieved through cord structure ligation and repair of the scrotal laceration. The patient had an uneventful recovery. After psychiatric evaluation, the patient was deemed as no longer at risk for self-harm or suicide, and he was discharged home. Subsequent postoperative follow-up visits indicated no further issues.
The second patient, a 29-year-old unmarried heterosexual cisgender male, arrived at the trauma center a month later in a state of hemorrhagic shock, approximately 2 hours after a presumed bilateral auto-orchiectomy. In response to the critical nature of the situation, massive transfusion protocol was activated, resulting in the administration of 6 units of red blood cells to stabilize the patient's condition. In the operating room, it was confirmed that both testicles were absent and approximately 80% of the scrotum had been excised. Achieving hemostasis proved challenging due to the partial retraction of vessels. The remaining scrotum was sufficient for primary closure, and scrotal repair was performed. Unfortunately, the testicles were not recovered, and prehospital records indicated they had likely been consumed by the patient’s dog. The patient recovered without encountering any complications. Following recovery, the patient revealed the auto-orchiectomy was driven by religious conviction, as he believed removing his testicles would make him a "better Christian." The patient was evaluated by psychiatry, but no definitive psychiatric illness was identified. The patient had no history of known psychiatric disorders, prior suicide threats, or attempts. He denied the incident was a suicide attempt. After further recovery, the patient was discharged home for ongoing recuperation. Subsequent postoperative follow-up visits proceeded uneventfully.
Discussion
Auto-orchiectomy, also referred to as self-castration, is a rare form of self-mutilation characterized by the voluntary removal of one's own testicles. Historically, auto-orchiectomy has been primarily linked to profound mental health and psychiatric disorders. However, emerging literature indicates that several factors, such as psychosis, substance use, gender dysphoria, and intricate religious or cultural beliefs may contribute to the occurrences.1
In this report, we presented 2 instances of auto-orchiectomy in 2 unrelated unmarried heterosexual cisgender males. One case involves a psychiatric history with the presence of psychotropic substance use as a contributing factor, while the other revolves around religious conviction. These cases highlight the complexity of the underlying motivations and the potential outcomes associated with auto-orchiectomy.
The utilization of psychotropic substances has been recognized as a risk factor for self-harm and impulsive behaviors. It is well-documented that substances such as alcohol, amphetamines, and hallucinogens can induce changes in mood, perception, and judgment, thereby leading individuals to engage in self-destructive actions.
In the first case, it is likely that the patient's impaired judgment resulting from substance use played a significant role in the self-inflicted injuries, including the auto-orchiectomy.2
In the second case, religious conviction played a significant role as the patient held a strong belief that the removal of his testicles would enhance his Christian faith. Historical text documents castration as a form of purification and offering as early as 300 BC, and it has been recorded that ancient Christian scholars performed auto-orchiectomy as a way to maintain chastity.3,4 The impact of religious and cultural beliefs on self-inflicted testicular mutilation has been observed across different settings, emphasizing the importance of comprehensively grasping the intricate interplay between personal convictions, psychological well-being, and extreme behaviors.5
In both cases, prompt surgical intervention was imperative to address the critical hemorrhagic shock and repair the scrotal lacerations, thereby ensuring the patients' survival. Attention was placed on attaining hemostasis and restoring anatomical integrity. Nevertheless, it is important to acknowledge the potential long-term psychological aspects in both cases. Comprehensive psychiatric assessments and continuous mental health support play a critical role in managing the care and subsequent monitoring of individuals who have performed self-inflicted genital mutilation.6
Additionally, we must acknowledge that some patients may perform auto-orchiectomy as a means of gender confirmation out of desperation after being failed by the health care system. This is especially true of patients who have been forced to wait significant periods of time for their surgery to be approved, or for patients whose surgery is denied by insurance.
Management
Given the rare occurrence of auto-orchiectomy, formulating standardized protocols for managing such cases poses a challenge. Instead, tailored strategies are necessary, involving a collaborative effort from a diverse team of emergency medical specialists, surgeons, urologists, chaplains, psychiatrists, and other health care professionals. This multidisciplinary approach is crucial in addressing the intricate physical, psychological, and social implications linked to these self-inflicted injuries.
References
- Cleveland S. Three cases of self-castration. J Ner Men Dis. 1956;123(4):386-391.
- Skegg K. Self-harm. Lancet. 2005;366(9495):1471-1483.
- Chadwick H. Origen. Encyclopedia Britannica. 2023.
- Pachis P. The rites of the day of blood (dies sanguinis) in the Graeco-Roman cult of Cybele and Attis: A cognitive historiographical approach. J Cog Historiography. 2019; 5(1-2).
- Schwerkoske JP, Caplan JP, Benford DM. Self-mutilation and biblical delusions: a review. Psychosomatics. 2012;53(4):327-333.
- Veeder TA, Leo RJ. Male genital self-mutilation: a systematic review of psychiatric disorders and psychosocial factors. Gen Hos Psychiatry. 2007;44:43-50.