There are probably 8-10 different medical drama tv shows on the air now, and I must confess that I watch at least 5 of them fairly regularly (mostly to poke fun at all of the inaccuracies). I do believe that one particular show, "The Good Doctor" is really good at talking about ethical issues in medicine.
If you watch this show, then ***Spoiler alert***
On a recent episode, a patient came into the ER with stroke-like symptoms from several clots. This particular patient was a man that was taking high doses of anti-androgen hormones. At first, the patient did not reveal that he was taking these, but the doctors noticed low androgen levels in his blood work and assumed he was going through a sex change. After some discussion with the apprehensive patient, he told the doctors that he takes the anti-androgens to curb sexual urges and that he cannot discontinue them even if they increased his risk for stroke.
Long story short, the doctors discovered that these sexual urges were those of a pedophile, but the patient never acted on his urges and wanted to be castrated (the patient actually ends up ~very dramatically~ mutilating his scrotum himself too).
The ethical dilemma falls in the decision: Do we castrate this patient to prevent a potential pedophile from acting on his urges? (Taking away his testicles would also pose a huge risk of lowering his levels of testosterone and potentially causing death) OR do we discontinue the anti-androgens and treat him psychiatrically in the hopes that he can work through these urges in a less invasive manner?
Knowing the major side effects that castration can imposed on a male, I think it would be ethically responsible to not further the patient’s wishes in this case. The patient should be enrolled in a mental health hospital or program to further understand his want of castration and how to properly control his sexual urges. Reading a study by Wassersug et al. (2003), they reported from a survey-based study, directed toward men with a fascination in castration, 40% of participants desired castration to free themselves from sexual desire and establish what they called a “eunuch calm” state. Their results showed men who desired to be castrated (or were castrated) were motivated by having the desire to obtain that eunuch calm state, possess control over one’s sexual urge, developed excitement in the idea of castration itself, wanted it performed for cosmetic reasons, and had a desire to be submissive to their partner (Wassersug, 2003). Of those individuals who took part in the study, ~40% said they are too embarrassed to discuss their interest in castration with their healthcare physician. I think that knowing there are males out in the world with this type of yearning, we as future physicians need to be prepared to approach these difficult topics and need to able to have an open conversation with our patients in cases like this.
ReplyDeleteWassersug, R. J., Zelenietz, S. A., & Squire, G. F. (2004). New age eunuchs: Motivation and rationale for voluntary castration. Archives of Sexual Behavior, 33(5), 433-442. Retrieved from http://dml.regis.edu/login?url=https://searchproquestcom.dml.regis.edu/docview/66793707?accountid=28590
As Auna mentioned, there can be major negative side effects associated with castration in men. Therefore, all other options should be considered before resorting to a procedure/"treatment" that realistically is quite extreme. This is especially true considering that certain forms of psychotherapy have proved effective in down regulating abnormal sexual thoughts and behavior, as determined by the DSM-IV. More specifically, not so recent research has demonstrated that monthly injections of 3.75 mg of triptorelin (a long-acting agonist analogue of gonadotropin-releasing hormone) in conjunction with supportive psychotherapy for 8 - 42 months can lead to significantly decreased abnormal sexual behavior. This effect was so significant that these researchers actually witnessed the number of incidents regarding abnormal sexual behavior decline from 5 +/- 2 per month to zero and also witnessed the number of deviant sexual fantasies and desires decrease from a mean of 48 per week to zero. However, there were negative side effects associated with the drug administration as well. The major side effects included erectile failure, hot flashes, and a decrease in bone mineral density.
ReplyDeleteRosler, A., Witztum, E. (1998). Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone. New England Journal of Medicine, (338), 416-422.
https://www.nejm.org/doi/full/10.1056/NEJM199802123380702