One of the rarest behaviours 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 twentieth century. The first recorded case is thought to be a letter in the Journal of the American Medical Association by Dr D. Stroch in 1901.
GSM has been recorded in a variety of forms (e.g., simple lacerations, scrotal cutting, testicle removal, penile amputations, self-castration, and a combination of the above, so called ‘lock, stock and barrel mutilation’) across a variety of countries (USA, Middle East, India, Kenya, and Nigeria). There appears to be an increased incidence of GSM over the last decade although this may be due to increased reporting rather than increasing number of cases. GSM usually occurs in Caucasian men in the 20s and 30s (although there is a minority of cases from African and Indian descent and some case reports of individuals over the age of 70 years).
The range of instruments used to enable GSM include kitchen knifes, Stanley knives, scissors, blades, chain saw, and axe. In many cases, the genitals are disposed of immediately such as a recent case reported in the Saudi Medical Journal where a 37-year old male schizophrenic cut off both his penis and testicles and flushed them down the toilet.
A 1988 study by Tobias and colleagues 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). A 1991 study in the journal Psychopathology also reported that GSM may also be triggered by a feeling of guilt for sexual offences. Similarly, Dr A.C. Waugh writing in the British Journal of Psychiatry concluded that GSM most commonly occurred in men with chronic paranoid schizophrenia and a history of delusions where only castration absolves them of guilt for sexual wrongdoing
A 2003 case report in the journal Urology, reported an attempt by an Indian man to become a ‘hijra’ (i.e., eunuch of the Indian subcontinent) due to his dissatisfaction with the wait for gender reassignment surgery. Reports indicate that transsexuals often resort to genital self-mutilation especially if they are unaware of the availability of professional (medical) help. Dr. D.B. Russell and colleagues in a 2005 issue of Sexual Health reported that genital mutilation that has a more ‘rational’ basis usually involves removal of the testicles (i.e., auto-castration) whereas those in a psychotic state are more likely to engage in penile amputation. An early study in 1993 by Aboseif and colleagues in the Journal of Urology reported that among a group of 14 genital self-mutilators, 61% of episodes involved the mutilation of one or both testicles. They also reported that among repeat mutilators, around one-third (31%) had a history of alcohol abuse and over a half (55%) had a history of drug abuse. The degree of injury didn’t differ between the psychotic and non-psychotic self-mutilators. Reporting on 52 cases in the Archives of General Psychiatry, Greilsheimer and Groves found 87% of genital self-mutilators to be psychotic and 13% to be non-psychotic. The psychotic individuals ranged from those with functional psychosis through to those with brain damage.
Those who engage in GSM as part of a religious belief are typically diagnosed as having Klingsor Syndrome. This 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. According to Samir Shirodkar and colleagues in the Saudi Medical Journal, group genital mutilation is a custom of a sect of Australian Aborigines where the blood is drunk by the infirm (who believe it restores their health).
In a fairly recent issue of the journal Mental Health and Substance Use, Dr Thomas Dunn and colleagues reported an unusual case of GSM. A 55-year-old non-psychotic homeless male turned up at hospital with penis and scrotal maggot infestation that was secondary to GSM. The man had gender identity issues and had performed GSM while he was drunk. However, he only sought medical help when he was barred from travelling on public transport because of the smell emanating from his maggot infection.
In a 2007 issue of the Jefferson Journal of Psychiatry, Dr. Craig Franke and Dr James 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 behaviour, (iv) depression, (v) severe childhood deprivation, and (vi) pre-morbid personality disorders. However, the condition is complex and as Dr Nagaraja Rao and colleagues highlighted in the Indian Journal of Psychiatry, “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”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
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