Sigmund Freud developed the notion of “castration anxiety” in the early 20th century as a part-literal and part-metaphorical fear. By all accounts, a poor choice of words. After all, any of us — man or woman, of whatever sexuality — can have fears of becoming swallowed up in a relationship, of losing our identity.
Now a new form of castration anxiety, truly relevant only to men, has sprung up. Indeed, a sizable number of men face castration anxiety — more accurately, castration terror — related to treatment for aggressive metastatic prostate cancer. More than 220,000 cases are diagnosed annually, and 30,000 men die of the disease every year. Most of those who die are probably on hormonal treatment before their death. I have been facing this terror off and on for the past 25 years.
Castration fears in a literal form took hold in the 19th century when young boys were threatened with having their penises cut off for misbehavior. Freud claimed that these anxieties developed by age 3 to 5. But in an era when corporal punishment was rampant, children no doubt also had head-severing anxiety induced by parents’ sometimes threatening to decapitate them for misbehavior. The penis and testicles were beside the point.
In 1941, Charles Huggins and Clarence V. Hodges discovered that prostate cancer growth can be slowed or in some cases eliminated by the removal of testosterone, just as some breast cancers can be slowed by the removal of estrogen. Male hormones, otherwise known as androgens, are a crucial growth factor for prostate cancer. Androgen deprivation, Huggins and Hodges discovered, could stop prostate cancer in its tracks, at least temporarily.
Huggins and Hodges won a Nobel Prize in 1966 for their discovery.
Androgen deprivation via a surgical castration — removal of both testicles — is quite a mixed blessing. The good news: You will live longer with castration than without treatment. The bad news: You are no longer a sexual being.
Back in 1989, five years after the diagnosis of my prostate cancer and after the surgical removal of my prostate, a new test — for prostate specific antigen, or PSA — indicated that I had signs of metastatic disease. As a physician, I knew all too well what this meant: castration as soon as possible. Terror and more terror.
In fact, the surgeon who performed my radical prostatectomy at New York-Presbyterian Medical Center called me upon seeing the elevated PSA finding and urged me to come up from Washington so that he could perform an immediate surgical castration.
Articles in the New England Journal of Medicine and in respected urologic and oncologic journals at that time fed the belief that the sooner a man with early signs of metastatic disease got a full-scale surgical castration, the longer one would be likely to live.
Although reversible chemical castrations were available, a number of researchers and physicians were convinced that permanent surgical castration was the best treatment, the most effective way to remove all testosterone from the system.
Yes, but . . . . In any other context, this recommendation might sound like playground bluster or trash-talking or even a threat from a Mafia hit man: “Come up to New York and we’ll cut off your testicles. Hey, you want to keep living, you want to not die a quick death? Then I gotta cut off your testicles.”
Not so fast, man. It turned out that I could wait a while before going through a neutering. While my PSA readings were rising, they still were low, an indication that the disease was not an immediate threat to my life.
I also discovered that less is often more with respect to androgen deprivation. A cancer endocrinologist in Vancouver, B.C., had discovered that intermittent androgen blockades — a fancy term for intermittent reversible chemical castrations — could work just as well as if not better than permanent castration for most men with metastatic prostate cancer.
For me, now surviving and often thriving 30 years after the original diagnosis and 25 years after the emergence of signs of metastatic disease, the intermittent treatment has clearly worked. We tease and fool the cancer cells: We feed them testosterone for a while, and they grow and temporarily take over. Then we abruptly remove all androgens. The cancer cells shrivel, and many of them die. But we do this androgen blockade for only a short time so that the cancer cells do not go looking for another hormone or internal chemical to serve as their fuel. They have a sterling survival mechanism, not unlike their hosts.
A game, a potentially deadly one, a real battle between two first-rate battlers. Six to eight months of androgen blockade, then back to normal levels of testosterone for about a year and a half.
I have faced chemical castration 10 times over the past 25 years. It never gets any easier. A kind of Groundhog Day: I experience a loss of sexual desire, a genuine prepuberty, not unlike the experience of the first 12 years of one’s life. Then a reflowering, a renewed puberty and adolescence. You would expect I might get it right by now, but it never happens.
Castratos from the 16th century — castrated before puberty to maintain their soprano voices — may never have known what they were missing, but I clearly do know. And I also know keenly what my partner is missing, what a profound loss it is for both of us.
The poet W.H. Auden once pointed out, “Lust is less a physical need than a way of forgetting time and death.” Not entirely true: Lust as a physical need is a wonder, a gift from the gods. Its loss is unfathomable, ineffable. And recognizing and acknowledging time and death are overrated, not necessarily good for one’s emotional health.
Yet with the intermittent blockade, good times do come again. Castration anxiety will not last forever. We can dream of getting lucky some night or some day, and dreams can become reality. We can get back in touch with our inner skirt chaser. With the right mate we can combine a sharing of passions with a genuine sense of grounding. We may periodically face true castration dread, but we can finally rid ourselves of Freud’s notion of castration anxiety, a tired construct that has lost its meaning and value.
Steinberg, a Washington psychiatrist, is the author of “A Salamander’s Tale: My Story of Regeneration — Surviving 30 Years with Prostate Cancer.”