title: Self-castration by a transsexual woman: financial and psychological costs: a case report.
abstract: BACKGROUND
  The out-of-pocket cost for an elective orchiectomy, which is often not covered by health insurance, is a significant barrier to male-to-female transsexuals ready to proceed with their physical transition. This and other barriers (lack of access to a surgeon willing to perform the operation, waiting times, and underlying psychological and psychiatric conditions) lead a subset of transsexual women to attempt self-castration. Little information has been published on the financial costs and implications of self-castration to both patients and health care systems.
  
  
  OBJECTIVE
  We compare the financial and psychological costs of elective surgical orchiectomy vs. self-castration in the case of a transsexual woman in her 40s.
  
  
  METHODS
  We interviewed the patient and her providers and obtained financial information from local reimbursement and billing specialists.
  
  
  RESULTS
  After experiencing minor hemorrhage following the self-castration, our patient presented to the emergency department and underwent a bilateral inguinal exploration, ligation and removal of bilateral spermatic cords, and complicated scrotal exploration, debridement, and closure. She was admitted to the psychiatric service for a hospital stay of three days. The total bill was U.S. $14,923, which would compare with U.S. $4,000 for an elective outpatient orchiectomy in the patient's geographical area.
  
  
  CONCLUSIONS
  From a financial standpoint, an elective orchiectomy could have cost the health care system significantly less than a hospital admission with its associated additional costs. From a patient safety standpoint, elective orchiectomy is preferable to self-castration which carries significant risks such as hemorrhage, disfigurement, infection, urinary fistulae, and nerve damage. Healthcare providers of transsexual women should carefully explore patient attitudes toward self-castration and work toward improving access to elective orchiectomy to reduce the number of self-castrations and costs to the overall health care system. Further research on the financial implications of self-castration from different health care systems and from a series of patients is needed.
authors.affiliation: School of Medicine, The George Washington University, Washington, DC 20037, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: St Peter
authors.forename: Anton
authors.initials: A
authors.lastname: Trinidad
authors.forename: Michael S
authors.initials: MS
authors.lastname: Irwig
mesh_terms: D000328:Adult; D017046:Cost Savings / Q000706:statistics & numerical data; D003646:Debridement / Q000191:economics; D004636:Emergency Service, Hospital / Q000191:economics; D005783:Gender Identity; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008484:Medicaid / Q000191:economics; D009919:Orchiectomy / Q000191:economics* / Q000523:psychology*; D010343:Patient Admission / Q000191:economics; D011183:Postoperative Complications / Q000191:economics / Q000601:surgery; D019106:Postoperative Hemorrhage / Q000191:economics / Q000601:surgery; D011567:Psychiatric Department, Hospital / Q000191:economics; D012648:Self Care / Q000191:economics* / Q000523:psychology*; D012652:Self Mutilation / Q000191:economics* / Q000523:psychology*; D057829:Gender-Affirming Procedures / Q000191:economics* / Q000523:psychology*; D014189:Transsexualism / Q000191:economics* / Q000523:psychology*; D014481:United States