Psychiatric Evaluation of a “Monk” Requesting Castration: A Patient's Fable, With Morals

History of the Presenting Problem

An Anglo man who introduced himself as “Brother David,” a “monk” from “Ascension Monastery,” was referred by a urologist in private practice for a psychiatric evaluation at the University of New Mexico Health Sciences Center during the summer of 1995. The consultation was prompted by concern about the patient's request for an elective bilateral orchiectomy. The patient could not explain the urgency behind the request, and he denied a recent or specific precipitant for it. He was willing to comply with the psychiatric evaluation simply because he thought that the urologist would “help” him if the psychiatrist said it was “OK.”

Over the course of five evaluative sessions with one of us (M.H.), the patient stated that he wished to undergo an orchiectomy because he felt that his sexual impulses interfered with his spirituality. He described his sexuality as a stumbling block and a barrier between himself and “the Creator.” He had worked hard for many years to minimize and master his sexual feelings and felt that he had achieved good success. Nonetheless, he felt that castration was the final and best option to ablate his sexuality. His body, he said, was merely a tool of the mind and spirit. He described his testicles as obsolete, useless, and harmful to his purpose in life. He likened his genitalia to “a pest.a fly you swat away that keeps coming back.” He also described guilt, shame, and conflict surrounding his sexual impulses. However, this was not the case for his nocturnal erections (“when the vehicle wants to stimulate itself”), which he saw as normal physiology. He reported that a past trial of finasteride had not been helpful. He stated that he had been considering the orchiectomy procedure for 10 years and thinking seriously about it for the preceding 2 years.

In describing the beliefs behind his castration request, Brother David talked about other “monks” he knew who felt that castration had been helpful to them in diminishing or eliminating their sexual impulses. In this context, he lamented his male hormones as “a lot of chemistry that I don't need.stimulating areas I have been trying to ignore, or move on from.” He felt that his refractory sexual nature was a feature of “lower existence.” He repeatedly suggested that his hormones might, in fact, be partially responsible for his rebelliousness with respect to following rules in the monastery. In explaining his wishes, Brother David referred to two scripture passages: “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. He that is able to receive it, let him receive it.” When asked whether it might, in some way, be a spiritual failure to need an orchiectomy to deal with his sexuality, he replied, “[God] cares about overcoming, not how you overcomeIs it a failure for a cripple to be given crutches?” He expressed chagrin over the difficulties he had experienced in complying with the restrictions of his religious life, but he felt that overall he had gained much more than he had lost by joining the monastery.

Psychiatric Evaluation

Brief background. Brother David was the second of three children. He described his family upbringing as “laid back” but punctuated by occasional chaotic emotional responses from his homemaker mother. While this was difficult and resulted in distance between family members, the patient said that he always felt cared for. During childhood he felt closest emotionally to his grandfather. He discussed his early life as otherwise uneventful, and he denied physical and sexual abuse. He was raised as a Catholic. He related that during his young adulthood he became disillusioned with the Church (“it talked the talk, but didn't walk the walk”), and he abandoned his early thoughts of becoming a priest.

The patient's first sexual interaction occurred at age 8 and involved another boy of similar age. He stated that this “homosexual” experience was pleasurable. From early adolescence he recognized that he was aroused by males and not by females. He became openly gay during college, and he briefly underwent supportive psychotherapy, which he described as very helpful overall. Brother David described his behavior over the next few years as promiscuous; he reported numerous homosexual partners, daily masturbation, and brief experimentation with transvestitism and sadomasochistic sexual practices, which he did not like. He received frequent treatment for sexually transmitted infections (“that was before AIDS”). In retrospect, the patient described feeling never satisfied, experiencing life and sex as if he were “marking time.”

In his mid-20s, Brother David “realized that there's more to life than sex.than reproducing,” although he had not had heterosexual experiences and had not fathered children. He felt that he wanted to change in order to “learn the truth” and returned to reading the Bible. Around that time he found out about a monastery from two “monks” whom he met one evening at an advertised public gathering. He joined the religious community shortly thereafter.

Brother David stated that he had been celibate over the ensuing years, had frequently moved with the others at the monastery, and had little contact with his family. Nevertheless, he reported that his commitment to “rising to a higher level” was not as strong as he would have liked it to be. He engaged in frequent masturbation and felt considerable remorse. He had left the monastery for a time as recently as 3 years before the psychiatric evaluation. At that time he had obtained an outside job. This foray was short-lived, though, as he quickly “realized that there was nothing in the outside world” for him. He felt that his religious dedication had been intermittently undermined by his rebellious nature but that he belonged within the monastery's spiritual community.

Brother David gave the impression that the monastery was a branch of the Catholic Church, but not so “rote” in its teachings. He did not give further information about the monastery, except to refer to his “bishop” and the other “monks” and to indicate that he could not be reached by telephone or mail.

Brother David agreed to ask one of the other “monks” if he would come in to discuss his positive personal experience with castration. At the fifth meeting, Brother David was accompanied by Brother Thomas, a middle-aged heterosexual man who had also been involved with the monastery for more than two decades. Brother Thomas had undergone bilateral orchiectomy in 1994 elsewhere in the United States. Since that time he noted a “75% decrease” in sexual interest and attention toward women. He reported that this change pleased him and that the procedure had helped him with his spirituality.

Psychiatric review of symptoms. Brother David stated that other than the counseling he had received in college, he had not previously received psychiatric treatment or psychotropic medications. He reported having symptoms of mood disturbance in the past, such as anhedonia, sleep disturbance, appetite changes, mild suicidal ideation, and dysphoria connected to the feeling that at times he “didn't belong.” Once during college he had taken a handful of aspirin when feeling confused, depressed, and impulsive, but he could not identify a specific precipitant. He had not attempted suicide again. He currently felt that suicide was not an option, stating that one “cannot gain anything from it.” His most recent period of significant depressive symptoms had occurred 3 or 4 months before the evaluation and was short-lived. He reported that since he had entered the monastery his dysphoria had been less pronounced, his sense of sexual conflict had diminished, and his depressive episodes had become less frequent. He denied mania, panic attacks, auditory, visual, and olfactory hallucinations, paranoia, self-mutilation, obsessions, and compulsions. He denied having physical health problems, including head injuries or seizures. He had not used alcohol, tobacco, or drugs in 20 years. He further denied a family history of psychiatric illnesses.

Mental status examination. Brother David presented as a healthy man of medium build, wearing dark, casual clothing. He was punctual, polite, pleasant, and engaging, and his manner was consistent over the course of the five interviews. His speech had regular tone and rhythm but was often slow, as he appeared to be very deliberate in his choice of words. He used humor sparsely. He had difficulty describing his mood; he said it was in general “OK.” His affect was somewhat restricted, with a normal range; it varied in accordance with the content of the dialogue. His thought process was linear and clear. He revealed no extreme or unusual beliefs (outside of his desire for an orchiectomy), and there was no evidence of psychotic symptoms. The patient did not appear impulsive. He acknowledged past suicidal tendencies but denied suicidal or homicidal ideation at the time of the evaluation. He denied the desire to hurt or mutilate himself. His capacity for self-reflection, his insight, and his judgment were adequate and appropriate to the context of the consultation. In general, his thinking about a number of topics appeared to be flexible throughout the interviews, yet he was concrete and fixed—even to the point of lacking language—regarding his options for spiritual growth.

Clinical impression and recommendations. The consulting psychiatrist concluded that Brother David's wish for castration was authentic, long-standing, and nonpsychotic in nature. Although the request was thought to be unrelated to delusional beliefs, his overvalued ideas regarding the relationship between sexuality and spirituality seemed unusual, rigid, and intractable. No symptoms of a current, full psychiatric syndrome were observed. However, it was noted that his past history was suggestive of a recurrent depressive disorder and of ego dystonia surrounding sexual desire and purposeful sexual behaviors. Thus, it was concluded that no strictly psychiatric contraindications to an orchiectomy were evident in this patient. Still, the consultant recommended that other approaches to his suffering (e.g., pharmacological therapy) be considered, as the effectiveness and the long-term medical and psychological implications of the surgical procedure were unknown.

The private practice urologist chose not to perform the surgery. The patient was then seen by a second urologist at the university hospital who conducted his own evaluation. Subsequently, an ethics committee meeting was requested jointly by the consulting psychiatrist and the urologist at the university hospital. The committee's discussion focused on the ethical aspects of such an elective procedure; no formal clinical recommendation was sought or offered. The urologist also spoke with officials of the Archdiocese in Santa Fe; it was unambiguously stated that Catholic doctrine fundamentally opposes the performance of castration for spiritual purity.

Ultimately, the second urologist also chose not to perform the bilateral orchiectomy. He did, however, prescribe a gonadotropin-releasing hormone analogue, leuprolide, for 6 months. The patient complied with treatment and was pleased by the results of this intervention. He also agreed to follow-up with psychiatric care but stated that the monks were going to travel for a while so that he could not commit to another appointment.

Consent

After the psychiatric assessment was completed and clinical recommendations were reviewed fully with Brother David, he was approached regarding possible publication of his case history in the medical literature. He was receptive to this idea, suggesting that it might help clinicians to understand better the sexual issues faced by their patients. It was explicitly and accurately discussed that his decision would in no way influence his clinical care at the University of New Mexico Health Sciences Center. The patient gave his permission; his consent was informed and voluntary.

Epilogue

Brother David and Brother Thomas were two of 39 members of the Heaven's Gate cult who, apparently believing that they would evolve into a supernatural life form, committed suicide in Rancho Santa Fe, Calif., in March 1997. Eight of the men who died were reportedly found to have been castrated (1); we do not know whether Brother David was one of them.

We were distressed to learn of the tragic and unanticipated end to this patient's life. It is only after careful study, thought, and consultation that we have chosen to publish this case report because of the many morals to its story. To protect confidentiality, we have disguised critical features of this patient's history and clinical presentation, in keeping with the literature on ethical case reporting (2–5).

Cultism

Ethical Issues in the Physician-Patient Relationship