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
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
If I was playing a word association game and said the words ‘self-inflicted ear mutilation’, I would hazard an educated guess that the first thing that popped into most people’s minds would be the Dutch artist Vincent Van Gogh. On the evening of December 23, 1888, in Aries (France) Van Gogh (in a state of deep depression) cut off the lower part his own right ear with a razor (and later immortalized in his famous painting Self Portrait With Bandaged Ear). Earlier in the day he had threatened his long-time friend and artist Paul Gaugin with a razor and was not in a good state of mind (both that day and in life more generally). Van Gogh had become a heavy smoker and heavy drinker and had taken a liking to the alcoholic drink absinthe. After cutting off his ear, he took it over to a local brothel and gave it to a prostitute called Rachel (telling her to take good care of it). He would have died of blood loss but the local police took him to the hospital.
This incident has given rise to what has been called the Van Gogh Syndrome which has now become a catch-all term for self-mutilation, particularly in relation to amputation of a bodily extremity (such as the cutting off of one’s own penis, or the removal of one’s own eye). Such actions may be due to a wide range of conditions including psychoses, mood disorders (e.g., clinical depression), body dysmorphic disorder, or as a component of Lesch-Nyhan syndrome (a genetic disorder that affects how the human body builds and breaks down purines).
Van Gogh would have been classed as a ‘psychotic self-mutilator’ in psychiatrist Karl Menninger’s self-mutilation typology developed in the 1930s. He proposed that self-mutilators fall into one of six categories:
- Neurotic self-mutilators: These individuals comprise nail biters and pickers, extreme hair removal and those seeking unnecessary cosmetic surgery.
- Religious self-mutilators: These individuals comprise self-flagellators and/or genital self-mutilators.
- Puberty rite self-mutilators: These individuals comprise those who engage in hymen removal, circumcision or clitoral alteration.
- Psychotic self-mutilators: These individuals engage in eye or ear removal, genital self-mutilation and extreme amputation.
- Organic disease self-mutilators: These individuals comprise those who engage in repetitive head banging or hand biting, intentionally fracturing fingers and eye removal, due to diseases such as encephalitis or disorders such as severe mental retardation.
- Conventional self-mutilators: These individuals comprise normal people that engage in customary or conventional forms of self-mutilation (that most would argue is not self-mutilation at all, e.g., nail clipping, hair trimming, and beard shaving).
More recent typologies tend to talk about self-harm rather than self-mutilation and class such behaviour into one of three types (i.e., psychotic, organic or typical). Again, Van Gogh would be classed as a psychotic self-harmer:
- Psychotic self-harmers: These individuals comprise those who remove or amputate body parts (e.g., eyes, limbs, ears, genitals, digits). In these cases, body part removal is carried out in response to hallucinations bought on by psychosis. Unsurprisingly, this is the most severe type of self-harming.
- Organic self-harmers: These individuals comprise those who self-harm in the form of behaviours such as head-banging and lip-biting because of conditions such as Autistic Spectrum Disorders, developmental disabilities, and other similar disorders. Here the self-harm is a consequence of physical or chemical issues in the body.
- Typical self-harmers: These individuals comprise those who self-harm in the form of self-cutting, burning, hair-pulling (trichotillomania), skin-picking (dermotillomania), biting, hitting, interference with wound healing, scratching or bone-breaking. Here, the self-harm is initiated by emotional or psychological trauma that is unrelated to psychotic or organic conditions. This is the most common type of self-harming.
In a 2006 issue of the Journal of Deaf Studies and Deaf Education, Dr. David Veale reported that major self-injurious behaviours tend to “be very isolated events and consists of severe or life-threatening tissue damage, such as self-castration, eye nucleation, or less commonly self-amputation of a limb or ear. They mainly occur in young psychotic men or older males with psychotic depression usually in the context of command auditory hallucinations or delusions of guilt”.
Despite the fact that self-inflicted ear mutilation is well documented, there are surprisingly few published case studies. In 1989, Dr. J. Silver and colleagues published a case study of self-inflicted ear mutilation (as part of wider self-mutilation) in the journal Psychosomatics. Their case was a 35-year old male paranoid schizophrenic who presented for treatment following dermatological self-mutilation following severe lacerations (including the ear, arms, and face). They concluded that the self-mutilation behaviour appeared to be associated with his psychotic symptoms, and that the self-mutilation was exacerbated by failure to take his neuroleptic medication.
Dr. Christopher Alroe and Dr. Venkat Gunda reported some cases of self-inflicted ear mutilations in a 1995 issue of the Australian and New Zealand Journal of Psychiatry. They presented three cases of self-amputation of the ear by three white right-handed men. All three men had psychiatric problems (one having schizophrenia and two having personality disorders. They compared their cases with that of van Gogh. The authors also surveyed all Australian and New Zealand prisons to determine the frequency of self-mutilation of the ears within the last five years. They found only one other case. Based on the cases, they argued that connections exist between the self-amputees and supports the notion that self-mutilation is “contagious”.
It is also worth noting that there are cases of people who have cut off their ears but would not be classed as psychotic because they have done it for a very specific reason. The most recent case was that of British prisoner Michael O’Donnell who (on May 2, 2010) cut off his ear so that he could escape from an ambulance while he was being transported to hospital for treatment. In the end, it was all in vain as he was caught and re-arrested three weeks later.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Alroe, C.J., & Gunda, V. (1995). Self-Amputation of the Ear: Three Men Amputate Four Ears within Five Months. Australian and New Zealand Journal of Psychiatry, 29, 508-512.
Edwards, G. (1998). A brief history of ear mutilation. Deluxe. Located at: http://rulefortytwo.com/articles-essays/gallimaufry/ear-mutilation/
Menninger, K. (1935). A psychoanalytic study of the significance of self-mutilation. Psychoanalytic Quarterly, 4, 408-466.
Menninger, K. (1938). Man Against Himself. New York: Jovanovich.
Silva, J.A., Leong, G.B. & Weinstock, R. (1989). A case of skin and ear self-mutilation. Psychosomatics, 30, 228-230.
Press Association (2010). Prisoner who cut off ear to escape is recaptured. The Guardian, May 28. Located at: http://www.guardian.co.uk/uk/2010/may/28/prisoner-cut-off-ear-recaptured
Veale, D. (2006). A compelling desire for deafness. Journal of Deaf Studies and Deaf Education, 11, 369-372.