Brother David: An Ethical Tale, Part 1
By Polly Davis and Frank Steiner
Becoming a Eunuch for the Kingdom of Heaven
In the summer of 1995, a private practice urologist referred a 46-year-old man to the University of New Mexico Health Sciences Center for a psychiatric evaluation. The patient had made an urgent and unusual request that caused the urologist to question the patient’s sanity. He had asked to be castrated.
The patient willingly complied with the psychiatric referral because he believed that if a psychiatrist confirmed that he was mentally healthy, the urologist would perform the surgery. He introduced himself to the psychiatrist as Brother David, a monk at Ascension Monastery, and readily participated in five evaluation sessions. During these sessions, psychiatrist Michael Hollifield, M.D., carefully recorded the history of the presenting problem, gathered information about the patient’s background, performed a psychiatric review of his symptoms, conducted a mental status examination, and documented his clinical impressions and recommendations.
Brother David told Dr. Hollifield that he wanted to undergo a bilateral orchiectomy — the surgical removal of both testicles — because he felt his sexual impulses were an obstacle to his spirituality. He believed that castration was necessary to eliminate, or at least reduce, his sexual desires, which were a source of guilt, shame, and conflict to him. David thought that if he could master his sexual feelings, he would be able to improve his relationship with God and attain his spiritual goals. He believed that his male hormones were to blame for his sexual impulses, which he found unmanageable. He also felt that his sexual nature kept him from reaching the level of spirituality he wanted to achieve. He quoted two Bible verses: “If your right hand offends you, cut it off,” and “There be eunuchs which have made themselves eunuchs for the Kingdom of Heaven’s sake.”
David had tried taking finasteride to curb his sexual impulses, but it had not been helpful. Finasteride, a pharmaceutical marketed under the brand name Propecia, has been used to treat prostate enlargement and male-pattern baldness. It has an effect on testosterone that decreases prostate size and increases scalp hair. David, however, was likely taking the drug for its side effects: decreased interest in sex, erectile dysfunction, and loss of sexual ability or performance.
Prior to joining his spiritual community, David was openly gay. As a young man in his 20s, he had many sexual partners, masturbated daily, and experimented with transvestism and sado-masochistic sex. He reported to Dr. Hollifield that he had experienced depressive symptoms, mild thoughts of suicide, and feelings of dysphoria, such as feeling like he “didn’t belong”, while in college. Although he had once impulsively swallowed a handful of aspirin in a confused attempt at killing himself, he no longer felt suicidal.
Back in those days, David found his life unsatisfying. It was around that time that he decided to join his current religious community. After entering a secluded monastic life, David experienced less dysphoria and fewer depressive episodes. More importantly, he had diminished feelings of conflict surrounding his sexual impulses. Even though he gained some control over his sexual desires after joining the monastic community, David indicated that he had been thinking about castration for 10 years. During the last two years, he had become serious about seeking the procedure.
For his final evaluation session with Dr. Hollilfield, David brought another man from the monastery, Brother Thomas. Thomas was a middle-aged, heterosexual man who had undergone castration three years earlier. He estimated that his sexual desires had decreased by 75% since the operation, and he believed that his spirituality had benefited from it.
Based on the psychiatric evaluation, Dr. Hollifield concluded that Brother David had a nonpsychotic, longstanding, authentic desire to undergo the orchiectomy. He also concluded that David had overvalued and rigid ideas relating to sexuality and spirituality, but he did not have symptoms of a psychiatric syndrome. Although the evaluation revealed no condition that would make castration psychiatrically inappropriate, the doctor recommended non-surgical, pharmacological solutions for David’s problem. The psychiatrist could not recommend castration because of the uncertain effectiveness of the procedure and its unknown long-term medical and psychological effects.
Dr. Hollifield communicated his clinical impression and recommendations to the referring urologist, who subsequently decided not to perform the orchiectomy. After learning of this decision, David sought a second opinion from another urologist at the same hospital where Dr. Hollifield had his practice. The second urologist evaluated David’s request and together with Dr. Hollifield jointly asked the hospital ethics committee to meet to discuss the issue.
The committee weighed five ethical principles when evaluating David’s case, 1) respect (treating the patient respectfully and with due regard), 2) clinical competence (acting with proficiency, knowledge, and skill), 3) patient autonomy (allowing the patient to make informed decisions about his care), 4) beneficence (promoting what is good and prioritizing the patient’s best interests), and 5) nonmaleficence (avoiding and preventing harm). These principles often conflict with each other in patient cases when medical ethics are questioned. In this case, respecting David’s beliefs and choices conflicted with the urologist’s duties to promote what is good and to prevent harm.
In addition to discussing these five ethical principles, the ethics committee considered the results of David’s psychiatric evaluation. Dr. Hollifield’s report revealed no particular medical reasons why castration would be indicated for David nor any specific contraindications that would make it inadvisable. The committee also questioned the benefits of the procedure because, without testes, the adrenal glands continue to produce testosterone under the regulation of the hypothalamus and pituitary gland in the brain. In addition, the committee considered the results of a 1993 study, which indicated that sexual impulses, erections, and performance ability may continue in up to 25% of sex offenders who are required by law to be castrated. To supplement the committee’s information regarding David’s religious reasons for elective orchiectomy, the second urologist communicated with the Roman Catholic Archdiocese in Santa Fe. A representative of the Archdiocese made it clear that the Catholic Church does not support castration for spiritual purity.
The committee also discussed three other issues: 1) whether members of society have the right to refuse to pay for unnecessary or questionable surgery, 2) whether gender should be explored in cases like Brother David’s, given that doctors have been willing to recommend and perform elective oophorectomy (removal of the ovaries), and 3) whether doctors are more willing to recommend medical interventions that enhance natural sexuality, such as breast or penile implants, than interventions that reduce or distort it, like orchiectomy or vaginoplasty. Ultimately, after evaluating the five ethical principles, the three ethical questions, and other ethical issues, the ethics committee determined that orchiectomy was not medically necessary or appropriate for David.
Following the meeting of the ethics committee, the second urologist also chose not to perform the procedure. He treated David with appropriate care by taking the time to consult a psychiatrist, ethics committee members, and religious sources before making his final determination. As an alternative to castration, he prescribed leuprolide, a synthetic hormone that decreases testosterone production. David complied with the treatment for six months and was happy with the results, but because his religious community moved to a new location, he did not follow-up his treatment with the second urologist.
Brother David was a gay man with a history of depression, dysphoria, suicidal thoughts, and cross dressing. Today, someone would suggest he was trans. If he had been seeking castration in pursuit of gender transition, he would have been immediately affirmed and likely approved for gender affirming surgery, no pesky psychiatric evaluation or ethics committee needed. While transgender patients get the green light, Brother David’s doctors spent weeks questioning the appropriateness and ethics of the procedure he sought and ultimately put up a big red stop sign.
To learn more about the authors, Frank Steiner and Polly Davis, please visit their Substack @prankandfolly
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