We defend ourselves not against castration anxiety but against death, a far more absolute castration.
Ernest Becker, The Denial of Death
THE UNIVERSITY LIBRARY at my medical school was shared with students of Veterinary Medicine. Sometimes I’d find myself at a desk opposite one of the vet students; we’d glance at one another’s textbooks with curiosity, occasionally open at the same subjects – haematology, say, or orthopaedic surgery. It was reassuring to see how much common ground there was between medicine for humans and medicine for animals.
One day I was revising prostate cancer: the appearance of its malignant cells under a microscope, the stages of its spread, the radiotherapy, brachytherapy (embedding of radioactive pellets into the tumour), and standard chemotherapies used to treat it. In health, the prostate gland stores semen and mature sperm; it has strong muscular walls that squeeze during ejaculation. Exposure to a lifetime of testosterone increases the growth of the gland as well as its susceptibility to cancers. Many treatments for prostate cancer work by blocking testosterone’s generation within the testicles – with no testosterone, the growth of the tumour slows.
‘All that for prostate cancer?’ asked one of the vet students, glancing over at my notes.
‘Sure,’ I said; ‘what do you guys do to treat it?’
‘One word,’ he laughed, ‘castration!’
As a boy I’d see farmers castrating spring lambs in the fields near my home. They’d take a tiny rubber ‘O’, the diameter of its hole almost as wide as the rubber was thick, and with a pair of special pliers spring it over the lamb’s scrotum. The rubber squeezed off the blood supply to the testes, and a few weeks later they’d drop off. The first time I saw farmers gelding lambs I asked one of them, ‘Doesn’t it hurt?’
He shrugged. ‘It’s better this than the old way,’ he replied. ‘A century ago, shepherds used their teeth.’ After an afternoon spent gelding, the men’s beards would be clotted with blood.
Gelding animals takes testosterone out of their development, making them less aggressive and more biddable, but also bigger (sex hormones accelerate the closure of the growth plates of bones, so without testosterone, animals’ bones grow longer before fusing). Low testosterone levels also encourage the accumulation of fat. You can leave castrated animals grazing alongside females without fear they’ll reproduce. Agricultural societies have used it since long before written records: castrated oxen take a yoke more easily, and will pull a plough with less whipping. Castrated dogs are simpler to train, and will more readily round up the castrated sheep put out to fatten in the fields. Early Assyrian and Chinese civilisations transposed this knowledge to humans: boys born in poverty would be castrated and sent to work under the yoke of the state in the imperial household. (In China, both penis and testicles were removed – these ‘three treasures’ were pickled in a jar, brought out for special occasions, and buried with the eunuch.) Eunuchs were often taller, sometimes stronger than average, and were frequently employed as the core of an imperial guard. They could work in the imperial harem without fear that they’d cuckold the emperor.
When Alexander the Great conquered Persia he was struck by the utility of such eunuch slaves, and adopted the custom – eunuchs were also considered sexually desirable. The Romans copied it from the Greeks: the emperor Nero had a eunuch called Sporus (whom he dressed as a woman, and married) and the emperor Domitian had a favourite eunuch called Earinus. There’s usually an element of voyeurism in the Roman accounts, a curiosity about ambiguous gender and genitalia that’s still visible in media coverage of the phenomenon today. Eunuchs were high-class slaves, the most expensive in the market; in losing testicles they were believed to have lost family loyalty and to have become faithful only to their masters and to the empire.
Around the time that Christianity began to spread into the Roman Empire there was already a cult of a eunuch god called Attis, who was celebrated in springtime and believed to have died then been resurrected after three days. His priests committed self-castration in honour of a fertility goddess, and they did it on the hill in Rome where Vatican City sits now. The practice survived the Christianisation of the Roman Empire: one of the early church fathers, Origen, is famous for committing self-castration. Castration continued in Byzantium (where gelded boys were trained as choristers) and into the twentieth-century Russian Orthodox church, where the skoptsy sect encouraged self-castration as late as the 1920s. St Paul’s advice that women should keep quiet in church was taken to its logical conclusion during the Italian Renaissance: God’s glory was sung in soprano by castrated men from the mid-1500s. The Jesuit Tommaso Tamburini, active in the early seventeenth century, sanctioned castration only ‘provided there is no mortal danger to life and that it is not done without the boy’s consent’. How much choice they had in the matter is hard to assess, though reports throughout the seventeenth and eighteenth centuries describe boys ‘pleading’ for the honour of being castrated, to bring both prestige and financial security to their families. The complex, high-pitched melodies for which castrati were most in demand by the Vatican were those sung around Easter week – the same time of year that the priests of Attis celebrated castration.
The Vatican didn’t ban the castration of boys for its choirs until the late nineteenth century, and the last castrato of the Sistine Chapel, Alessandro Moreschi, died in 1922. But twenty years before he died, with his voice already fading in quality, he made a series of recordings for the ‘Gramophone and Typewriter Company’ that would become ‘His Master’s Voice’ or HMV. You can find the recordings online, Moreschi’s voice a wavering, ghostly soprano that makes every song an elegy.
THE COMEDIAN BILLY CONNOLLY once joked that he’d reached an age when doctors had become uninterested in his balls, and had begun showing greater interest in his rectum. The median age for testicular cancer is around thirty-four, for prostate cancer it’s nearer seventy-two. To have your prostate gland checked manually you have to lie on one side, knees pulled up to your chest, while a doctor puts a gloved finger in through your anus – the size and consistency of the prostate can be assessed through the thin bowel wall.
Prostate cancer is common: among my local patient population of almost four thousand, there are several new diagnoses a year. Alex Sinclair was one of them: a sixty-two-year-old builder, muscular and stoical, bald, with a beard so dense and black it was as if the lower half of his face was eclipsed. He told me he was divorced, and hinted at a dynamic sex life; his children had long ago grown up and moved away. He came to clinic wearing his overalls. ‘I used to get up once or twice a night to pee,’ he told me, ‘but now it can be five or six times. I wake up exhausted.’ There were times he found himself standing at the toilet for a full minute before urine began to trickle out. ‘I prefer not to see doctors,’ he said. ‘But I couldn’t put it off any more.’
We worked through a questionnaire called the ‘International Prostate Symptom Score’ which asks for a rating of one to five across a series of questions, from how often you have had the sense that you haven’t emptied your bladder, to how often you have to strain to initiate urine flow: Alex scored an impressive twenty-two. I took a blood sample from his arm, to examine levels of a substance specific to the prostate – this ‘PSA test’ varies broadly with prostate size, and can on occasion flag up cancer. I asked if I could do a rectal examination up on the couch. ‘I’ve heard about these,’ he said with resignation, standing up to unzip his overalls; ‘if you must.’
Alex’s prostate was huge, jutting back from its position under the bladder and indenting his rectum. On one side of the crease down the middle of the gland I felt a firmer, discrete lump, like a pebble lodged in tarmac.
‘Well, that’s why you’ve been struggling,’ I told him; ‘your prostate is so large, urine can hardly squeeze through it.’ Alex stood up and started pulling up his overalls. ‘I’d like you to see one of the specialists,’ I added, then caught and held his eye. ‘They’ll want to check tiny pieces of the gland under a microscope.’
His actions slowed as he took in this information. Then he asked carefully: ‘How do they get the pieces out?’
‘They’ll pass a very fine needle in through your anus, and through the bowel wall.’ I was hoping to reassure, but wondered if perhaps I was making his anxiety worse. ‘Your prostate gets bigger the longer it’s been exposed to the testosterone in your body – so the longer you’ve lived, the bigger your prostate grows. You’re not alone – it’s quite common to start getting problems around your age.’
‘Is it the same thing as cancer?’ he asked, pulling up his zip and reaching for his hat.
I waited a couple of moments, until again his gaze swung back towards me. ‘Just as every man’s prostate grows the longer he’s lived, they say every man gets prostate cancer if he lives long enough. But in most men it grows slowly, and never causes bother.’
‘How will I know if it’s going to cause bother with me?’
THROUGH THE 1980S, an editor at The New York Times called Anatole Broyard wrote a series of short, brilliant essays about being diagnosed and treated for prostate cancer. The essays were collected and published by his widow following his death from the illness. Broyard had for many years been a literary critic, and he brought to the essays an immense breadth of reference, humour, a ferocious intellect, and prose as luminous as an arc light. ‘What goes through your mind when you’re lying, full of nuclear dye, under a huge machine that scans all your bones for evidence of treason?’, he wrote of one scan, undertaken to see if cancer had infiltrated his skeleton; ‘There’s a horror-movie appeal to this machine: Beneath it you become the Frankenstein monster exposed to the electric storm.’
Broyard experienced his own diagnosis as a storm of anxiety and fear, but also, paradoxically, a liberation – life became as colourful as a ‘paisley shawl draped over a grand piano’. As a critic he turned to books to help him come to terms with his cancer, but complained that too many memoirs were humourless, over-respectful, and soaked in Romanticism, ‘so pious they sound as if they were written on tip-toe’. He admitted that a part of him felt exalted by the diagnosis, as if in hearing some of the worst news anyone can hear – a diagnosis of terminal illness – he’d been granted a great blessing by the universe. There was an element of gratitude for some aspects of his illness: it had given him a deeper and more intimate appreciation of the glory of being alive, as well as licence to give in to a long-suppressed desire to be more impulsive.
In an essay called ‘The Patient Examines the Doctor’, he spells out the kind of physician he’d prefer – someone with a ‘furious desire to oppose himself to fate … intense enough or wilful enough to prevail over something powerful and demonic like illness’. Broyard often felt that he had to put on a stoical front for his friends, who’d congratulate him on his bravery, but knew that a good doctor should see through the bravado and recognise his loneliness, even act as a guide through the inferno of cancer therapy. He didn’t want a doctor that relied on bluster, or phoney confidence tricks. His ideal doctor would be schooled in poetry, or be at least familiar with the possibilities of metaphor:
I would like a doctor who is not only a talented physician, but a bit of a metaphysician, too. Someone who can treat body and soul …. To get to my body, my doctor has to get to my character. He has to go through my soul. He doesn’t only have to go through my anus.
Broyard refused the physical castration his first surgeon offered (‘My urologist, who is quite famous, wanted to cut off my testicles, but I felt that this would be losing the battle right at the beginning’); but he accepted that most treatments for his prostate cancer might make him impotent, or affect his libido. He advised against thinking of sex as physical, rather than an intimate extension of the imagination, and accepted the diminution of his sex life as a reasonable bargain in the hope of gaining more years of life. ‘In my own case,’ he wrote, ‘after a brush with death, I feel that just to be alive is a permanent orgasm.’
THE UROLOGISTS CONFIRMED IT: Alex had prostate cancer. What’s more it had spread, and so removing his prostate gland to eliminate the tumour wasn’t an option. The first step to improving his quality of life was to widen the urinary passage through the prostate, or ‘bore it out’ as Alex put it (builders have a useful store of analogies when thinking about the body and its failings). I had assisted in these operations as a junior doctor: a patient was laid anaesthetised on their back, legs in stirrups, while a narrow instrument with a camera inside it was advanced down through the penis and into the bladder. It was always an amazement to watch the procedure, the camera exploring an unseen, barely credible world of pink tunnels and embankments, delicately veined and whorled with contours. Once into the prostate a wire loop emerged from the instrument, which, when heated up by an electric current, could simultaneously peel away and cauterise the tissue that had been blocking the urine’s flow. It took a few days for the bleeding to settle down – days in which Alex had to stay in hospital with a wide-bore catheter draining the bladder. Following the procedure Alex’s urine was flowing, but his cancer was too far advanced to be eliminated. I started him on injections to shut down the production of testosterone in the testes, as well as hormone blockers. Plans were made for radiotherapy at the local hospital.
I reviewed him a couple of weeks after the first injection. His interest in sex had collapsed, his skin felt hot and dry, his urine heavy and stinging. ‘I’ve never been much of a worrier,’ he told me, ‘but I’m getting uptight about everything these days. And I can’t watch a film without blubbing like a baby.’ He wanted to continue working, but found his muscles ached after even minimal exercise, and he was losing much of his strength. These were all symptoms that could be put down to the loss of testosterone, rather than to the cancer. ‘I used to lift four sheets of plasterboard no problem,’ he told me, ‘but I think I’ll be lucky if I can manage two.’ Over subsequent weeks his testicles shrank, and though he didn’t lose the density of his beard his skin took on a pink, delicate sheen, as if it were becoming more fragile.
‘Have you had enough?’ I asked him one day, after he’d detailed all the side effects that were troubling him. ‘Do you want to stop the treatment?’
‘Not if it’s doing me good,’ he replied. ‘If it’s keeping down the cancer, for me at least – it’s worth it.’
ALEX STILL ATTENDS my clinic every twelve weeks for the injections which wither his testicles but slow the growth of his tumour. A pragmatist by nature, he sees the exchange as a reasonable compromise: ‘I’m lucky to be here,’ he says, as he loosens his belt for the injections which, for their size, have to be given into the largest muscle in the body – the buttock.
After the initial shock of the treatment his libido returned, slowly, and one day he told me he had a new girlfriend. ‘Her eyes are wide open,’ he said, ‘she knows I might not be around for ever.’ I told him just to let me know if he wanted to try medication for impotence, but he just winked: ‘no need,’ he said, ‘I’ve just got to use a bit more imagination than I used to.’
SOME MEN PERCEIVE the loss of testosterone as a punishing humiliation. Castration has long been exploited as punitive: the Oracle Bones of the Shang Dynasty in China, carved around 1500–1400 BCE, list castration as a sentence for prisoners of war, and an Egyptian Pharaoh who lived a couple of centuries later boasted of having castrated more than six thousand soldiers of an invading Libyan army. More recently, the Janjaweed militia in Sudan perpetrated the same on their prisoners. Some western jurisdictions today order chemical castration as a combined punishment and ‘treatment’ for convicted sex offenders, with controversial results.
Given the cultural hinterland of castration as punishment, it’s a mystery as to why, historically, many young men and boys volunteered for such an ordeal. In The Castrato, a comprehensive examination of the phenomenon, the historian Martha Feldman explores some of the reasons why they did so. She proposes that we think of the exchange as much more than a bargain, but rather as a sacrifice – the transformation being in some sense sanctifying or sacralising. The castrato was offering something precious as a gift to celebrate the greater glory of God, but also in the hope of receiving something precious in return. Castrati, says Feldman, were ‘sacralized creatures’, in a way comparable to kings. In Confucian China that sacrifice was made to the state, and in Renaissance Italy, the church. It was seen as a kind of rebirth, much as Broyard felt that his life was given back to him when he received his terminal diagnosis.
Sir Thomas Browne noticed that after undergoing castration, males seemed to increase their chances of a long life – in part because diseases of the prostate had been neutralised. The Roman poet Lucretius, in The Nature of Things, describes sufferers of the plague sacrificing their testicles in the hope that they’d avoid the disease. Matthew’s Gospel reads:
There are some eunuchs, which were so born from their mother’s womb: and there are some eunuchs, which were made eunuchs of men: and there be eunuchs, which have made themselves eunuchs for the kingdom of heaven’s sake.
And there are some who choose castration in the hope of prolonging their lives.