Stitches brew: A brief look at self-harm lip sewing

In previous blogs I have examined both self-harming behaviour (such as cutting off one’s own genitals, removing one’s own eye, removing one’s own ear, self-asphyxial risk taking in adolescence, and religious self-flagellation) and extreme body modification. One area where these two areas intersect is lip sewing. According to the Wikipedia entry on lip sewing:

“Lip sewing or mouth sewing, the operation of stitching together human lips, is a form of body modification. It may be carried out for aesthetic or religious reasons; as a play piercing practice; or as a form of protest. Sutures are often used to stitch the lips together, though sometimes piercings are made with needle blades or cannulas and monofilament is threaded through the holes. There is usually a fair amount of swelling, but permanent scarring is rare. Lip sewing may be done for aesthetic reasons, or to aid meditation by helping the mind to focus by removing the temptation to speak. BMEzine, an online magazine for body modification culture, published an article about a 23-year-old film student Inza, whose quest for body modifications was very varied. She spoke about her experiences with lip sewing as a form of play piercing”.

My reason for writing this blog was prompted by a case study published by Dr. Safak Taktak and his colleagues in the journal Health Care Current Reviews. (I ought to add that I have read a number of papers by Taktak and his colleagues as they have reported some interesting other interesting case studies including those on shoe fetishism, semen fetishism, and fetishes more generally – see ‘Further reading’ below). In this particular paper, they reported the case of a male prisoner who had continually sewed his lips together. Although they were aware of cases of sewing lips together as a form of protest, they claimed that there had never been any case reported in the medical literature.

The case report involved a male 37-year old Turkish (imprisoned) farmer, father of two children, with only basic education. After sewing his lips together, the man was brought into the hospital by the police, along with a handwritten note that read: “My jinns imposed speech ban to me and they made me sew my lips unwillingly. Otherwise, they threaten me with my children. I want to meet a psychiatrist urgently”. (Jinns I later learned are – in Arabian and Muslim mythology – intelligent spirits of lower rank than the angels, able to appear in human and animal forms and are able to possess humans). Not only were his lips sown together with black thread but he had also sewn both of his ears to the side of his head (these are also photographed in the paper and you can download the report free from here). This was actually the fourth time the man had sewed his lips together (but the first that he had sewn his ears). Each time, the doctors took out the stitches and dressed the wounds. The authors examined previous documentation about the man and reported that the man had been in prison for four years after injuring someone (no details were provided) and had been diagnosed with both anxiety disorder and anti-social personality disorder. On a prison ward comprising ten other prisoners, he had attempted suicide when trying to hang himself (in fact, you can clearly see the marks on his neck in the paper’s photographs). The authors reported that:

[The man] had blunted affect. He wasn’t able to stay in the [prison] ward because of the directive voices in his head. He declared he needed to stay in the ward alone. He heard all the words as swearing and he was punished by some people as well as some entities. He also said that some jinns in the form of animals threatened him not to speak and listen to anyone; otherwise they were going to kill his kids. He wanted to protect his children [and] he stitched his lips not to speak anyone and stitched his ears not to hear anyone. In his family history, he stated that his uncle committed suicide by hanging himself and saying ‘the birds are calling me’; his father was schizophrenia-diagnosed”.

The authors then reported:

“The patient stated that he sewed his lips with any colour of thread he could find. He had approximately fifteen pinholes on his upper and lower lips. He tended to suicide with directive auditory and visual hallucination (sic) and reference paranoid delirium. As he was imprisoned, he wasn’t able to use drugs. The patient who was thought to have a psychotic disorder was injected [with] 10 mg haloperidol intramuscularly and he was sent to a safe psychiatry hospital”.

As I have noted in my previous blogs on self-harming behaviour (and as noted in this particular paper), there are many different definitions of what constitutes self-destructive behaviour. This particular case was said to be suited to the psychotic behaviours characterised by Dr. Armando Favazza’s three self-destructive behaviours (i.e., compulsive, typical, and psychotic) outlined in his 1992 paper ‘Repetitive self-mutilation’ (published in the journal Psychiatry Annals). In their discussion of the case, the authors noted:

“The cases like sewing one’s own lips which we observe as a different type of destructing oneself in our case are mostly regarded as intercultural expression of feelings. The ones, who sew their lips in order to protest something, show their reactions by blocking the nutrition intake organ to the ones who want to continue their superiority. It can be expected in psychotic cases that the patients or his beloved ones might be harmed, damaged or affected emotionally. Thus, the patient who is furious and anxious might react by [attempting] violence as a reaction to these repetitive threats. Auditory hallucinations giving orders can cause the aggressive behaviours to start…In our psychotic case, this kind of behaviour is a way to prevent the voices coming from his inner world, not to answer them and hence making passive defending to world which he does not want to interact. By this means, he may harmonise with the secret natural powers which affect him and he may protect himself his children…[also] there can be a relief through sewing lips and ears or strangulation against the oppression created by the person not being able to adapt the prison…It should not be forgotten that the prison is a stressful environment and stressful living [increases] the disposition to psychopathologic behaviour that the living difficulties in prisons can affect the way of thinking and the capacity of coping and it may cause different psychiatric incidences”.

As noted at the start of this article, lip sewing is typically attributed to religious reasons, reasons of protest or aesthetic reasons. In this particular case, none of these reasons was apparent (and therefore notable – in the medical and psychiatric literature at the very least). The addition of sewing his ears appears to be even more rare, and thus warrants further research.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Favazza, A.R. (1992). Repetitive self-mutilation. Psychiatric Annals, 22(2), 60-63.

Taktak, S., Ersoy, S., Ünsal, A., & Yetkiner, M. (2014). The man who sewed his mouth and ears: A case report. Health Care Current Reviews, 2(121), 2.

Taktak, S., Karakus, M., & Eke, S. M. (2015). The man whose fetish object is ejaculate: A case report. Journal of Psychiatry, 18(276), 2.

Taktak, S., Karakuş, M., Kaplan, A., & Eke, S. M. (2015). Shoe fetishism and kleptomania comorbidity: A case report. European Journal of Pharmaceutical and Medical Research, 2, 14-19.

Taktak, S., Yılmaz, E., Karamustafalıoglu, O., & Ünsal, A. (2016). Characteristics of paraphilics in Turkey: A retrospective study – 20years. International Journal of Law and Psychiatry, in press.

Wikipedia (2016). Lip sewing. Located at: https://en.wikipedia.org/wiki/Lip_sewing

Making the cut: A beginner’s guide to Klingsor Syndrome

In one of my previous blogs, I looked at one of the world’s rarest behaviours – male genital self-mutilation (GSM). As I noted in that article, there have only been about 125 cases ever recorded in the clinical and/or medical literature. (Having said that, it may be that this number of cases relates to those published in the English language as I did come across a Japanese case study of male GSM by M. Tomita and colleagues published in 2002 in the Japanese journal Hinyokika Kiyo, that noted that their case study was the 24th case of male GSM in the Japanese scientific literature). A 1988 study by Dr. C. Tobias and colleagues published 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, religious preoccupation, substance abuse, and/or social isolation.

Today’s blog specifically looks at genital self-mutilators who engage in the behaviour because of a religious belief, and are typically diagnosed as having Klingsor Syndrome. The name of the syndrome was derived from the character Klingsor in Parsifol (a Wagner opera) who engaged in an act of self-castration to gain entry into the Brotherhood of the Knights of the Holy Grail.

In a 1990 issue of the Australian and New Zealand Journal of Psychiatry, Dr. I. Schweitzer wrote a paper called ‘Genital self-amputation and the Klingsor syndrome’. In his paper, he described two psychotic individuals, who had carried out GSM on themselves (one of which had done it in an attempt to kill himself). He noted that those most at risk from committing GSM were similar to self-mutilators more generally and comprised:

“Psychotic patients with delusions (often religious), sexual conflict associated with guilt, past suicide attempts or other self-destructive behaviour and depression, severe childhood deprivation, and major premorbid personality disorder”.

Dr. Schweitzer tried to argue that ‘Klingsor syndrome’ should be applied to anyone that carries out GSM as a result of psychotic illness and not just those with religious delusions. However, this does not appear to have been taken up that widely in more recent published case studies. A couple of (seemingly) genuine cases of the ‘archetypal’ Klingsor Syndrome, were reported in the Indian Journal of Psychiatry. The first one was by Malay Dave and colleagues in 1997, and described the case of a 22-year old unmarried schizophrenic Muslim male:

“[He] was admitted in the urology department with self-inflicted traumatic amputation of the penis At that time some Muslim men accosted him and told him not to be seen in that locality again. After this incident the patient became fearful, started hearing voices belonging to the devil and Allah which would tell him that he was not… At the initial interview the patient was uncommunicative and rapport was difficult to establish. He had a perplexed affect…As the patient gradually became more controlled delusions of persecution, reference and control were elicited along with thought insertion and broadcast. His concept formation was average and auditory hallucinations (2 voices belonging to the God and the devil talking amongst themselves and to him, saying derogatory things) were elicitable. These voices had initially commanded the patient to cut off his penis”.

The second one was published in 2001 by Dr. Subhash Bhargava and colleagues. They wrote that:

“A 25-year old unmarried male presented to the emergency services as he had severed off his penis with a knife. Patient reported of feeling no pain at that time and explained this act as carrying out the orders given to him by the goddess. The voice had assured him that by doing so his sins would be expiated and that he would attain sainthood. His family reported that he had disturbed sleep, a decline in work performance, increased talking, mainly religious in content and disinhibited behaviour off and on for the past seven months…Mental status examination revealed bizarre sexual and religious delusions and auditory hallucinations. The latter were accusatory as well as commanding in nature and mainly religious in content. A diagnosis of schizophrenia was made”.

A 2010 paper in the Israel Journal of Psychiatry and Related Sciences by Turkish clinicians led by Dr. Erol Ozan outlined four cases of GSM (three schizophrenics, and one with psychotic bipolar depression) forwarded some other symptoms that appear to put men at risk of GSM including (i) failures in the male role, (ii) problems in the early developmental period, (iii) such as experiencing difficulties in male identification and persistence of incestuous desires, (iv) depression, and (v) having a history of GSM. They also proposed a new concept in formulating religiously themed psychotic male GSM – atonement.

Another more recent (2012) paper in the Israel Journal of Psychiatry and Related Sciences by Indian researchers Dr. Ranjan Bhattacharyya and colleagues described a case of male GSM who was a paranoid schizophrenic who castrated himself at a time when no psychotic symptoms were present (but were enacted during a period of what the authors described as “post-psychotic depression”). Following a review of the psychological literature on male GSM, they considered that their case “best [fitted] the description for Klingsor Syndrome” probably because their case study was of a man “recovering from a psychotic episode with possible sexual guilt, religiosity and intense hatred towards women”. The religiosity in this case didn’t seem to be as pronounced as the two cases published in the Indian Journal of Psychiatry (outlined above). Given the rarity of any kind of GSM, it would appear that Klingsor Syndrome is arguably one of the world’s rarest syndromes. Every new case study appears to add to our knowledge of this strange (and potentially life threatening) behaviour.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ajape, A.A., Issa, B.A., Buhari, O.I.N., Adeoye, P.O., Babata, A.L. & Abiola, O.O. (2010). Genital self-mutilation. Annals of African Medicine, 9, 31-34.

Bhargava, S.C., Sethi, S., & Vohra, A.K. (2001). Klingsor syndrome: a case report. Indian Journal of Psychiatry, 43, 349-350

Bhattacharyya, R., Sanyal, D. & Roy, K. (2011). A case of Klingsor Syndrome: when there is no longer psychosis. Israel Journal of Psychiatry and Related Sciences, 48, 30-33.

Dave, M., Apte, J., Dhavale, H.S. & Pinto, C. (1997). The Klingsor Syndrome. Indian Journal of Psychiatry, 39, 341-342.

Martin, T. & Gattaz, W.F. (1991). Psychiatric aspects of male genital mutilations. Psychopathology, 24, 170.

Murota-Kawano, A, Tosaka, A. & Ando, M. (2001). Autohemicastration in a man without schizophrenia. International Journal of Urology, 8, 257-259.

Ozan, E., Deveci, E., Oral, M., Yazici, E., & Kirpinar, I. (2010). Male genital self-mutilation as a psychotic solution. Israel Journal of Psychiatry and Related Sciences, 47, 297-303.

Rao, K.N., Bharathi, G., & Chate S. (2002). Genital self-mutilation in depression: A case report. Indian Journal of Psychiatry. 44, 297-300.

Russell, D.B., McGovern, G. & Harte, F.B. (2005). Genital self-mutilation by radio frequency in a male-to-female transsexual. Sexual Health, 2, 203-204.

Schweitzer, I. (1990). Genital self-amputation and the Klingsor syndrome. Australian and New Zealand Journal of Psychiatry, 24, 566-569.

Stunnell, H., Power, R.E., Floyd, M., & Quinlan, D.M. (2006). Genital self-mutilation. International Journal of Urology, 13, 1358-1360.

Tobias, C.R., Turns, D.M., Lippmann., S., Pary, R. & Oropilla, T.B. (1988) Evaluation and management of self-mutilation. South Medical Journal, 81(10), 1261-1263.

Tomita, M., Maeda, S., Kimura, T., Ikemoto, I. & Oishi, Y. (2002). [A case of complete self-mutilation of penis]. Hinyokika Kiyo, 48, 247-249.

Waugh, A.C. (1986). Autocastration and biblical delusions in schizophrenia. British Journal of Psychiatry, 149, 656-658.

Cutting womb flaw: A brief overview of female genital self-mutilation

In a previous blog I examined the rare act of genital self-mutilation (GSM) in males. More rare are cases of female genital self-mutilation. Back in 1970, Goldfield and Glick first described a syndrome of dysorexia (i.e.. disordered and/or unnatural appetite) and GSM in the Journal of Nervous Diseases. Of the cases reported since 1970, the majority of cases reported have had personality disorders (typically borderline personality disorder) and a history of childhood sexual abuse. In the Journal of Sex and Marital Therapy, Wise and colleagues categorized female GSM into three groups: (i) patients with personality disorders, (ii) self-induced aborters and (iii) psychotic patients. This slightly differs from male GSM where the cases have been categorized into: 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.

Excluding injuries secondary to self-induced abortion or the insertions of foreign bodies in children, to date, only a handful of female genital self-mutilation have been reported in the literature. Some papers have discussed the differences between self-induced abortion and GSM. However, the differential diagnosis has become increasingly rare because abortion laws have become liberal in many countries.

An early 1957 case in the Journal of Mount Sinai Hospital described a patient who mutilated her vagina on four occasions with a hatpin and knitting needle in late pregnancy that eventually led to a Caesarean section. The 1970 case in the Journal of Nervous Diseases (above) involved a 19-year old female who scratched and gorged her internal genitalia with her fingernails and led to a lot of vaginal bleeding that needed medical attention. A 1972 case in the Archives of General Psychiatry reported the case of a woman who lacerated her vulva with a razor blade.

Following one instance of sexual intercourse with her boyfriend, she feared pregnancy and subsequently penetrated her vagina with a knitting needle. This particular act was not her first episode of self-mutilation. For instance, she had previously swallowed dangerous metal objects, cut her wrists, and had inflicted a deep laceration on her left breast. She also began inserting objects into her vagina including (on one occasion) a twig that had to be medically removed. She later lacerated her vulva and vagina with a knitting needle and a kitchen knife. While in hospital she smashed a window on the gynaecology ward and slashed her arm. Several months later, she again ended up in casualty having cut her vagina with scissors on the previous day, sustaining multiple superficial lacerations of the vagina and cervix.

A detailed case study was reported in 1974 by Simpson and Anstee in the Postgraduate Medical Journal. The authors reported that her self-mutilating behaviour shared several features with the typical wrist cutters (e.g., planning the incident carefully, enjoying the anticipation of the event). She felt no pain when cutting and felt relief and fascination when watching blood flow from her vagina.

There have been a few reports of female GSM associated with psychosis and one 1989 report in the Journal of Sex and Marital Therapy reported an association between, an isolated delusional system, and body dysmorphic disorder. In fact, the feelings of a distorted body image have been noted in a couple of cases where the women view their genitals as abnormal, and as a consequence tried to remove them.

In a 2005 issue of the German Journal of Psychiatry, Dr. Silke Marckmann and colleagues reported the case of a female with paranoid psychosis who had injured her external genitals in an attempt to stop coenaesthetic dysaesthesias (i.e., feelings of abnormal sensations which in this case was described as “feeling like an electric current” running through her genitals). They also noted that in this particular case, secondary erotomania was a feature associated with female GSM. (Erotomania is a type of delusion where the affected person believes that another person is in love with them). The authors also reported that:

“In the last months before hospital admission she felt that the dysaesthesias did not allow her to concentrate on anything else which included eating. She lost 10 kg weight in the 2 months before she agreed to hospital admission. She then reported, that she had been hitting herself repeatedly in the genital area in the attempt to stop the dysaesthesias”

However, the condition is complex and as Dr Nagaraja Rao and colleagues highlighted in the Indian Journal of Psychiatry, that “genital self mutilation like any other serious self injury is not a single clinical entity and it occurs in any psychiatric condition with corresponding psychopathology”.

Marckmann and colleagues believe that compared to male GSM, female GSM might be underreported. This is because they speculate there may be a bias towards those individuals with GSM needing acute medical attention (e.g., men cutting of their penis and/or testicles). Female self-mutilators may find it easier to hide their chronic self-inflicted genital injuries and not seek immediate medical help. Such GSM injuries may be more likely to be spotted by gynaecologists (and as Marckmann and colleagues note, there have been increased reporting of female GSM case studies in gynaecological journals such as the Journal of Obstetrics and Gynaecology and European Journal of Obstetric, Gynecological and Reproductive Biology).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ajibona, O.O. & Hartwell, R. (2002). Feigned miscarriage by genital self-mutilation in a hysterectomised patient. Journal of Obstetrics and Gynaecology, 22, 451.

Alao, A.O., Yolles, J.C & Huslander, W. (1999). Female genital self- mutilation. Psychiatric Services, 50, 971.

French, A.P.& Nelson, H.L. (1972). Genital self-mutilation in women. Archives of General Psychiatry, 27, 618.

Gersble, M.L., Guttmacher, A.F. & Brown, F. (1957). A case of recurrent malingered placenta praevia. Journal of Mount Sinai Hospital, 24, 641.

Goldfield, M.D. & Glick, I.R. (1970). Self-mutilation of the female genitalia: a case report. Diseases of the Nervous System, 31, 843.

Habek, D., Barbir, A., Galovic, J., Habek, J.C. et al. (2002). Autosection of the prolapsed uterus and vagina. European Journal of Obstetric, Gynecological and Reproductive Biology, 103, 99-100.

Krasucki, C, Kemp, R., & David A. (1995). A case study of female genital self-mutilation in schizophrenia. British Journal of Medical Psychology, 68, 179-186

Marckmann, S., Garlipp, P., Krampfl, K., & Haltenhof. H. (2005). Genital self-mutilation and erotomania. German Journal of Psychiatry. Located at: http://www.gjpsy.uni-goettingen.de

Simpson, M.A. & Anstee, B.H. (1974). Female genital self-mutilation as a cause of vaginal bleeding. Postgraduate Medical Journal, 50, 308-309.

Standage, K.F., Moore, J.A,. & Cole, M.G. (1974). Self-mutilation of the genitalia by a female schizophrenic. Canadian Psychiatric Association Journal, 19, 17-20.

Wise, T.N., Dietrich, A.M. & Segall, E. (1989). Female genital self- mutilation: Case reports and literature review. Journal of Sex and Marital Therapy, 15, 269-274