Male Genital Self-Mutilation

Genital self-mutilation (GSM) is a form of self-mutilation in which an individual purposely inflicts injury to the genital region. Self-mutilation is frequently classified by the degree of injury, with major self-mutilation referring to behavior that results in severe tissue trauma. Likewise, GSM exists on a spectrum ranging from superficial cuts to castration or penile amputation. Given the potential for permanent physical and psychological damage associated with GSM, it is important for providers to understand this behavior. In addition to the risk of infection and anatomical alterations, GSM may be associated with an increased risk of suicide, repeated self-injury, and greater severity of psychopathology (1, 2).

Since the first published case report in 1901 (3), multiple reports describing GSM have appeared in the psychiatric and urological literature. However, given the lack of dedicated epidemiological studies, the true incidence and prevalence of GSM remain unknown. It is possible that this behavior remains underreported because patients may not seek care due to associated shame and stigma. In a recent systematic review, the investigators identified only 173 cases of GSM published between 1900 and 2017 (1). Of note, 88% of these cases involved penile amputation, castration, or both, and only about 12% involved less severe mutilation (such as superficial cuts) (1). However, it is likely that less severe cases are underreported. There have been reports of incidental discoveries of GSM, supporting the notion that patients may avoid seeking care in situations that do not demand immediate medical attention (2).

Compared with other forms of self-injury, such as those involving the arms, legs, or thoracoabdominal regions, self-injury to more sensitive regions, such as the genitalia, appears to be less common (4, 5). In comparison with reported rates of other forms of major self-mutilation, such as enucleation or limb amputation, GSM seems to occur at an equivalent or slightly higher frequency; in a review article of 189 cases of major self-mutilation, the investigators noted that penile amputation occurred in 44% of cases and castration in 33%, compared with enucleation in 40% of cases and limb amputation in 9% (6). Limited data suggest that GSM may be more common among men, and the average age is estimated to be approximately 36 years old (1). There is no clear association between GSM and sexual orientation, relationship status, or intellectual development, and there are insufficient data to determine the significance of factors such as social support and access to health care (1, 2, 7).

Possible explanations for GSM may be categorized as psychiatric disorders and nonpsychiatric etiologies. In a systematic review of GSM, psychiatric illness was reported in ~91% of patients, with schizophrenia spectrum disorders implicated in 49% of these patients; substance use disorders, 19%; personality disorders, 16%; gender dysphoria, 15%; depression, 9%; and bipolar disorder, 1% (GSM may have been attributable to more than one psychiatric disorder for a particular patient) (1). Among patients diagnosed with schizophrenia spectrum disorders, schizophrenia is by far the most common (comprising about 85% of such cases), followed by schizoaffective disorder, schizophreniform disorder, and brief psychotic disorder. It is estimated that more severe forms of GSM, such as amputation, are correlated with more severe psychopathological symptom burden (1). Among reported cases with individuals diagnosed with personality disorders, 58% involved cluster B subtypes, and 42% involved cluster A subtypes (1). Among cases with individuals diagnosed with substance use disorders, the most commonly implicated substances include cannabis, cocaine, and amphetamines (2, 8). Finally, in a small portion of the patient sample (an estimated 9%–13%), psychiatric disorders are either not reported or not present. Among these patients, possible etiologies include sexual conflicts, guilt regarding sexual desires, religious beliefs, unconventional forms of sexual arousal, and genetic conditions associated with self-injury, such as Lesch-Nyhan syndrome (1, 2, 9). Here, we present a case of GSM and discuss issues related to the epidemiology, etiology, management, and prevention of GSM to contribute to an improved understanding among psychiatric providers.