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.

An eye for an I! A beginner’s guide to auto-enucleation

I have to say that I have no idea what it must be like to lose an eye (i.e., enucleation) but one thing I can’t possibly begin to imagine is what it must like is to remove my own eye (i.e., auto-enucleation). However, there are many clinical and medical reports of people that self-mutilate by stabbing or removing their eye(s). Arguably the most infamous auto-enucleator was Oedipus (in Sophocles’ play) who removed both his eyes after he realized he had unwittingly slept with his own mother and killed his own father.

The psychiatrist Dr. Armando Favazza defines self-mutilation as “the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue”. Dr. Niraj Ahuja and Dr. Adrian Lloyd writing in the Australian and New Zealand Journal of Psychiatry also add that self-mutilation relates to bodily self-damage without wishing to die. Dr. Favazza also believes there are three fundamentally different types of self-mutilation. Enucleation is included in the first type (major self-mutilation) and is the least common. Other forms of self-mutilation in this category include self-castration, penectomy (cutting off one’s own penis) and self-limb amputation.

The second type includes “monotonously repetitive and sometimes rhythmic acts such as head-banging, hitting, and self-biting” (which according to Dr Favazza occur mostly in “moderate to severely mentally retarded persons as well as in cases of autism and Tourette’s syndrome”). The final and most common forms of bodily self-mutilation are moderately superficial and include a compulsive sub-type (e.g., hair-pulling, skin scratching and nail-biting), as well as an episodic/repetitive sub-type (e.g., skin-cutting, skin carving, burning, needle sticking, bone breaking, and wound picking). Many of these self-harming behaviours are a symptom and/or an associated feature in a number of mental personality disorders (e.g., anti-social, borderline, and histrionic personality disorders).

Reports of auto-enucleation in the medical literature were first described in the 1840s. By the early 1900s, the act of removing one’s own eye was actually termed ‘Oedipism’ by Blonel. Auto-enucleation is (of course) exceedingly rare although a couple of studies in the American Journal of Ophthalmology (in 1984) and an analysis of 1,146 enucleations between 1980 and 1990 in the British Journal of Ophthalmology (in 1994) estimated there were 2.8 to 4.3 per 100,000 in the population. However, some papers (such as those by Dr. Favazza) on major self-mutilation have put the incidence as low as one in 4 million.

Enucleators are also known to be at increased risk of further self-harming, and (predictably) are more likely to be living in psychiatric institutions when the auto-enucleation event occurs. They are also at increased risk of removing the second eye at a later date if they didn’t pull out both eyes to start with. A review by Dr. H.R. Krauss and colleagues in a 1984 issue of the Survey of Opthalmology examined 50 cases of self-enucleation and reported that 19 of them had bilateral auto-enucleation (i.e., had removed both of their eyes). A 2007 paper by Dr. Alireza Ghaffari-Nejad and colleagues in the Archives of Iranian Medicine examined the many theories behind self-harming behaviour. They briefly overviewed theories ranging from Fruedian psychoanalytic theory to biologically-based theories. They wrote:

Psychoanalytically self-injurious behaviour has been linked to castration and explained as a process of failure to resolve oedipal complex, repressed impulses, self punishment, focal suicide and aggression turned inwards especially in cases of depression. [Other authors] have postulated interpersonal loss preceding self-injurious behaviour and linked it to rejection sensitivity…Biologically serotonergic depletion preceding self-mutilation has been linked to aggression and depression…Some authors have claimed strong moral, religious and delusional component”

A recent literature review by Dr. Alexander Fan in the journal Psychiatry reported that the vast majority of auto-enucleation cases suffer from psychotic illness (particularly schizophrenia) although other medical and/or psychiatric conditions associated with auto-enucleation include obsessive-compulsive neuroses, severe depression, post-traumatic stress disorders, drug-induced psychoses, bipolar mania. There are also case studies where auto-enucleation has been linked with structural brain lesions, Down Syndrome, epilepsy, neurosyphilis, and Lesch-Nyhan syndrome (juvenile gout). These are similar to other forms of extreme self-mutilation. For instance, self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome (in reference to the painter’s self-excision of his own left ear)

Other reviews of the psychiatric literature have reported that those who remove their own eyes commonly have delusions (typically sexual and/or religious) and that when asked about motivations for self-harming include reasons such as guilt, atonement, sin, evil, etc. Although some authors have noted that enucleators with religious beliefs are often Christian, other case studies have made reference to other religious faiths (e.g., Muslims). Finally, another paper by Favazza in Hospital and Community Psychiatry concluded that:

“Males in a first episode of a schizophrenic illness that is characterized by delusions associated with a body part or religious delusions are at the greatest risk for MSM [major self-mutilation]. However, MSM of this severity is so rare that it cannot be predicted accurately unless there has been a previous attempt at self-injury or the patient has spoken about wanting to remove or injure an organ. Threatened ocular mutilation deserves special mention because it may occur in a hospital setting, and the case histories suggest that one-to-one nursing is not always be sufficient to prevent enucleation”.

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

Further reading

Berguaa, A., Sperling, W. & Kuchlea M. (2002). Self-enucleation in drug-related psychosis. Ophthalmologica, 216, 269-271.

Eric, J.C., Nevitt, M.P., Hodge, D. &  Ballard, D.J. (1984). Incidence of enucleation in a defined population. American Journal of Ophthalmology, 113, 138-44.

Fan, A.H. (2007). Autoenucleation: A case report and literature review. Psychiatry, October, 60-62.

Favazza, Armando (1998) ‘Introduction’, in Marilee Strong A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Viking.

Favazza, A. & Rosenthal R. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.

Field, H. & Waldfogel, S. (1995). Severe ocular self-injury. General Hospital Psychiatry, 17, 224-227.

Gamulescu, M.A., Serguhn, S., Aigner, J.M., Lohmann, C.P., & Roider J. (2001). Enucleation as a form of self-aggression, two case reports and review of the literature. Klin Monatsbl Augenheilkd, 218, 451-454.

Ghaffari-Nejad, A., Kerdegari, M., & Reihani-Kermani, H. (2007) Self-mutilation of the nose in a schizophrenic patient with Cotard Syndrome. Archives of Iranian Medicine, 10, 540-542.

Gottrau, P., Holbach, L.M. & Nauman, G.O. (1994). Clinicopathological review of 1,146 enucleations (1980-90). British Journal of Ophthalmology, 78, 260-5.

Jeffreys, S. (2000). ‘Body art’ and social status: Cutting, tattooing and piercing from a feminist perspective Feminism and Psychology, 10, 409-429.

Krauss, H., Yee, R. & Foos, R. (1994). Autoenucleation. Survey of Ophthalmology, 29, 179-87.

MacLean, C. & Robertson, B.M. (1976). Self enucleation and psychosis. Archives of General Psychiatry, 33, 242-249.

Patil, B. & James, N. (2004). Bilateral self-enucleation of eyes. Eye, 18, 431-432.

Patton N. (2004). Self-inflicted eye injuries: A review. Eye, 18, 867-872.

Rao, K.N. & Begum, S. (1996) Self enucleation in depression; A case report. Indian Journal of Psychiatry, 38, 267-70

Witherspoon, D., Feist, F., Morris, R. & Feist, R. (1989). Ocular self-mutilation. Annals of Ophthalmology, 21, 255-259.

Private practices: A brief overview of male genital self-mutilation

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

Further reading

Aboseif, S., Gomez, R. & McAninch, J.W. (1993). Genital self-mutilation. Journal of Urology, 150, 1143-1146.

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.

Dunn, T.M., Collins, V., House, R.M. & Dunn, P.W. (2009). Male genital self-mutilation with maggot infestation in an intoxicated individual. Mental Health and Substance Use, 2, 235-238.

Eke N. (2000). Genital self-mutilation: there is no method in this madness. BJU International, 85, 295-298.

Franke, C.B. & Rush, J.A. (2007). Autocastration and autoamputation of the penis in a patient with delusions of sexual guilt. Jefferson Journal of Psychiatry, 21, Located at: jdc.jefferson.edu/jeffjpsychiatry

Greilsheimer, H. & Groves, J.E. (1979). Male genital self-mutilation. Archives of General Psychiatry, 36, 441.

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

Master, V. & Santucci, R. (2003). An American hijra: A report of a case of genital self-mutilation to become India’s ‘‘third sex’’. Urology, 62, 1121.

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

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.

Shirodkar, S.S., Hammad, F.T. & Qureshi, N.A. (2007). Male genital self-amputation in the Middle East: A simple repair by anterior urethrostomy. Saudi Medical Journal, 28, 791-793.

Stroch, D. (1901). Self castration (Letter to the Editor). Journal of the American Medical Association, 36, 270.

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.

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