(276) Self-Performed Bilateral Testicle Amputation for Gender Affirmation

Abstract

Abstract Introduction Genital gender-affirming care is an essential aspect of care for individuals with gender dysphoria. Bilateral orchiectomy is performed for both hormonal control and for gender identity physical transition. The time and financial costs required to access such procedures can be prohibitive, leading to pursuit of morbid gender affirmation outside of healthcare systems. While genital self-mutilation is rare, up to 32% of cases have been found to involve self-castration. Management of this varies but in severe cases prompt surgical repair is imperative. We present a case report of a non-binary patient who underwent self-amputation of both testicles, with subsequent primary closure of the perineum. Objective A 34-year-old non-binary individual with autism spectrum disorder and gender dysphoria presented with uncontrolled bleeding after self-amputating both testicles (Photo 1). This was done with use of a zip tie around the scrotal base, application of lidocaine cream to the scrotum, and a sterilized kitchen knife. The patient performed this to eliminate the physical and psychological effects of testosterone, and cited lack of access to care as a motivating factor. Methods Psychiatry consultation confirmed decision-making capacity without acute severe mental illness, and no substance abuse was involved. Sperm cryopreservation was discussed with the patient but was declined. While awaiting capacity assessment, measurements of the testicular arteries and vas deferens were obtained to assess the possibility of reanastomosis, which was deemed technically feasible. Results After the patient was deemed decisional they were taken to the operating room for vascular control and planned primary closure and possible skin grafting. Cystoscopy confirmed no concomitant urethral injury. Intraoperatively the bilateral spermatic cords were tied off to achieve hemostasis. Skin closure was able to be performed primarily with a favorable result (Photo 2). Conclusions We present a unique case of a non-binary individual with gender dysphoria who underwent successful self-amputation of both testicles. This case highlights the significant barriers faced by individuals seeking gender affirmation procedures and the lengths to which patients may go to conform with their gender identity. Our case also highlights important management steps, including sperm cryopreservation, decisional capacity evaluation, and reattachment versus primary closure with or without skin grafting. The patient's decision to pursue self-amputation underscores the urgent need for improved access to gender-affirming procedures and mental health support for individuals with gender dysphoria. Disclosure No.