Two cases of male genital self-mutilation.

Male genital self-mutilation (GSM) is a rare but serious phenomenon. Some of the risk factors for this act are the presence of religious delusions, command hallucinations, low self-esteem, and feelings of guilt associated with sexual offences. Other risk factors include failures in the male role, problems in the early developmental period, such as experiencing difficulties in male identification and persistence of incestuous desires, depression, and having a history of GSM. The eponym Klingsor Syndrome, which involves the presence of religious delusions, is proposed for GSM. Psychiatric case reports of male GSM in the literature are rare and mostly anecdotal.

Behaviors that involve damaging the body tissues without intending suicide are defined as self-mutilation. The most common types of self-mutilation are damaging the skin, the eyes, or the genitals.[1] It is proposed as a fast self-aid action, providing temporary relief from inner tension and confusion, depersonalization, feelings of guilt, negative feelings of being rejected, hallucinations, and preoccupation with sexual matters. One of the rarest behaviors in the world is the act of genital self-mutilation (GSM) in males. To date, approximately 125 cases have been recorded in the clinical literature dating back to the turn of the 20th century.[2] The first recorded case is thought to be a letter in the Journal of the American Medical Association by Stroch in 1901.[3]

Men who intentionally mutilate or remove their own genitals are likely to be psychotic at the time of the act, to have a number of goals and aims relating to conflicts about the male role and to be vulnerable to sociocultural and psychological forces in a causal network as yet unknown. However, from a review of the cases of 53 male self-mutilators, it appears that a significant number of individuals involved were not psychotic at the time of the act but rather having character disorders and rageful feelings toward themselves or women and transsexual males who premeditate their own gender conversion surgery. Greilsheimer and Groves found 87% of genital self-mutilators to be psychotic and 13% to be nonpsychotic. The psychotic individuals ranged from those with functional psychosis to those with brain damage.[4] Blacker and Wong identified six risk factors for male GSM: Absence of a competent male figure for identification during the early developmental period, overcontrolling mothers who encouraged their sons' masochistic behaviors, pathological feminine behaviors of the male child, repudiation of body image (especially the penis), unresolved sexual conflicts, and anxiety and feelings of guilt often relieved by GSM.[5]

CASE REPORTS

Case 1

A 38-year-old male with family history of depression in mother, no past history of psychiatric illness, chronic medical illness, or psychoactive substance use, manifested with insidious onset and gradually progressive belief that people around are making innocuous gestures toward him, referring him as “half man” and monitoring him/poisoning his food of about 3 months duration. Later, he would hear voices of many people discussing/warning him to cut his penis to save him and his family from his alleged persecutors. He believed that there is a big plan to harm him and his family members. He went to the bathroom, latched the door, and sliced off his penis from the base with a shaving blade and threw the shaft into the toilet. He did not perceive any pain or expressed any shock and did not get perturbed after seeing blood. Instead felt relieved that his family members will be saved. He was managed by urologist and subsequently referred for psychiatric evaluation. Physical examination revealed amputated penis wound with catheter in situ. Mental status examination revealed him to be perplexed with delusions of persecution, reference and third person auditory hallucinations, impaired judgment and insight, and deranged biodrives in a clear sensorium. Relevant investigations revealed no organicity for his psychiatric symptomatology. Psychological testing including Rorschach confirmed his diagnosis of psychosis. He was managed as a case of paranoid schizophrenia with antipsychotics (tablet olanzapine 20 mg/day), insight-oriented therapy, and other supportive measures. He gradually responded to therapy and gained insight into his illness. Urologist advised no further intervention for his amputation of penis as he was voiding urine normally [Figure 1].

Figure 1

Post operative image showing healed wound

Case 2

A 42-year-old male was consuming around 180–240 ml of alcohol (rum) almost daily for past 4 years on a dependence pattern (craving, tolerance, loss of control, withdrawal features on delay, or abstinence and salience) with socio-occupational dysfunction. His CAGE (Cut down; Annoyed; Guilty: Eye opener) score was ¾ suggestive of harmful drinking (cut off 2 or more) and AUDIT (Alcohol Use Disease Identification Test) score was 26 (13 or more indicate Alcohol dependence). He manifested on abrupt cessation of above pattern of alcohol use with confusion, autonomic hyperactivity, disorientation, hearing voices of his alleged persecutors threatening to cut his genitalia, and altered sleep-wake cycle. He, on above background, thought that he would not allow his persecutors to succeed and himself brutally mutilated his genitalia (scrotum, testes, and penis) with a blade. There was no past or family history of psychiatric illness. Physical examination revealed mutilated genitalia. Detailed evaluation revealed features of alcohol withdrawl delirium and Clinical Institute Withdrawl Assessment (CIWA) score was 37 (>20 is suggestive of severe alcohol withdrawl). He was diagnosed as a case of mental and behavioral disorders due to alcohol withdrawal state, complicated with delirium and was managed with tapering doses of benzodiazepines, individual and group psychotherapy, anticraving medications, and other supportive measures. He is presently on self-catheterization and reconstructive surgery is planned [Figure 2].

Figure 2

Post operative image showing healed wound with foley's catheter in situ

DISCUSSION

A 1988 study by Tobias et al. in the South Medical Journal reported that self-mutilators (including all types of self-mutilation, not just GSM) were most likely to suffer from schizophrenia (particularly command hallucinations), religious preoccupation, substance abuse, and/or social isolation. Genital self-mutilators are similar and tend to fall into one of four types – schizophrenics, transsexuals (i.e., those with a gender identity crisis), those with complex cultural and religious beliefs, and a small number of severely depressed people who engage in GSM as part of a suicide attempt (around one-tenth of cases).[6] A review of 110 male GSM cases revealed that guilt feelings associated with sexual conflicts were the most significant factor leading to self-mutilation in a state of psychosis. The GSM acts of these cases were also related to psychotic religious experiences that were often the direct motives. Self-mutilators with sexual conflicts and guilt feelings were more likely to injure themselves more severely than those without.[7] The term Klingsor Syndrome has been suggested for GSM associated with religious delusions. The name Klingsor was based on a fictitious character in Wagner's opera, Parsifal. Klingsor was a magician who wanted to be accepted as a Knight of the Grail, a religious brotherhood. He castrated himself because of his inability to remain chaste to be accepted into this brotherhood.[8] In a 2007 issue of the Jefferson Journal of Psychiatry, Franke and Rush provided some risk factors that help in the identification of people at risk for GSM. These included: (i) Psychotic patients with delusions of sexual guilt, (ii) psychotic patients with sexual conflict issues, (iii) prior self-destructive behavior, (iv) depression, (v) severe childhood deprivation, and (vi) premorbid personality disorders.[9] However, the condition is complex, and as Sudarshan et al. highlighted in the Indian Journal of Psychiatry, “GSM like any other serious self-injury is not a single clinical entity and it occurs in any psychiatric condition with corresponding psychopathology.”[10] Bhatia and Arora published a case report of a 24-year-old male, whose explanation for penile self-mutilation was that he did not want to succumb to any sexual temptation which could obstruct his way to salvation.[11]

Zislin et al. also discussed GSM in the context of religious belief: The Jerusalem Syndrome. This syndrome is a well-defined example, named for a group of mental phenomena involving the presence of religiously themed obsessive ideas, delusions, or other psychosis-like experiences triggered by, or leading to, a visit to the city of Jerusalem. It is not endemic to one single religion or denomination but has affected Jews and Christians of many different backgrounds. The psychosis is characterized by an intense religious theme and typically resolves to full recovery after a few weeks or after being removed from the area. GSM in the cases mentioned above was performed for “atonement” for perceived sins. Although physical suffering and mutilation do not seem to be the primary means of atonement in Islam, in a state of active psychosis, the perception of atonement seems to exceed cultural boundaries.[12]

In Case 1, the patient initially had delusions referring to his sexuality and later had threatening command hallucinations to shed his “penis” to save his family members. The patient sacrificed his penis for the above cause. We can assume that as a psychotic solution, patients sacrificed their genitals or donated their belongings to atone for their sins and to feel purified. Auto castration may be a psychotic solution as in the above case. Patients having problems with the early developmental period and with a self-mutilation history as well as experiencing religious delusions, command hallucinations to self-mutilate, and who are noncompliant with treatment are at greater risk for GSM. Therefore, they need special attention and may need to be hospitalized.[13]

In Case 2, the patient had auditory hallucinations of alleged persecutors in the alcohol withdrawal delirious state threatening to mutilate his genitalia. In the confusional state, he butchered his scrotum, penis, and both testes. Some of the unusual features of the present case are severe self-injuries that have been reported mostly in schizophrenia and other psychotic episodes but not in Delirium. This case has no apparent sexual or religious connotation. Charan and Reddy reported a similar case in the Indian Journal of Psychological Medicine in 2011; however, the penis was spared in the mutilation.[14] Another published case report is from urology, where patient sliced the penis in alcohol withdrawal state.[15]

It is suggested that the examining psychiatrist needs to be aware of the cultural background of the patient. Investigating probable plans for sacrifice related to atonement might be helpful in predicting and preventing self-mutilation acts, especially GSM. Psychotropic medication must be the first-line intervention in both treating the active psychotic episode and in preventing recurrences. An important contributing and motivating factor for male GSM appears to be sexual dysfunction; hence, clinicians may prefer medications causing fewer sexual side effects. Furthermore, during the remission period, cognitive and behavioral techniques may be helpful for replacing thoughts of sacrifice with harmless alternatives for atonement. The psychiatric consultant's role in the management of such an individual in the general hospital setting includes not only care of a patient with a psychotic or impulse disorder but also involves support of the house staff, who are distressed by the fear, guilt, hopelessness, anger, and revulsion that are caused by the patient's act of GSM.[13]

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