Autocastration by a Male Transsexual

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Abstract
In recent years psychiatrists increasingly have been asked to evaluate patients who demand medical and surgical sex alteration procedures. Most psychiatrists do not welcome this challenge for which they are not properly trained, and conclusions in the recent literature are contradictory and confusing. An unusual case is reported which illustrates many of the difficulties in the diagnosis and the management of transsexuals. A schizoid, thirty-five year-old man with long standing gender identity problems performed successful autocastration after he repeatedly failed to obtain adequate psychiatric and medical treatment. Like most transsexuals described in the recent literature, he demonstrated an apparently unalterable conviction that he was a feminine being trapped in a male body from which he felt alienated and which he repudiated. Dressing in feminine clothes reduced his anxiety and made him feel ‘right’ but was not associated with sexual excitement. His background reveals a chaotic childhood, characterized by a close attachment to an overly permissive, possibly disturbed mother and the absence of a stable father-figure with whom he could identify. Unlike most transsexuals this patient also shows many features which support a diagnosis of schizophrenia. Diagnostic and therapeutic considerations are discussed with reference to the relevant literature. Management is complicated by the fact that the patient is persistent and insistent in his demand for sex change while the physician struggles with ethical and practical problems. A cautious but open-minded approach is advocated which involves an initial trial of supportive psychosocial rehabilitation and then a readiness to consider medical and even surgical sex change procedures if there is good evidence that the patient cannot otherwise be helped.

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