Female Genital Self-Mutilation

To the Editor: Psychotic and nonpsychotic genital self-mutilation is well recognized in males but not in females (1), even though the incidence of self-mutilation has been estimated to be higher in females (2). A possible explanation is that castration is more dramatic than cutting and therefore tends to be more frequently reported. We present the case of a female patient with genital self-mutilation.

The patient, a 23-year-old woman with borderline personality disorder, posttraumatic stress disorder, and polysubstance dependency, mutilated herself by inserting a razor blade into her vagina. She sought treatment in the emergency room for vaginal bleeding from the mutilation. She mutilated herself in clear consciousness and denied having any psychotic symptoms.

The patient described a chaotic early upbringing that included physical and sexual abuse by her stepfather and uncle when she was between ages seven and ten, and later by her foster parents between ages 11 and 15. Her first marriage at the age of 17 was chaotic and lasted for three months; her second marriage lasted for seven months. She started the self-mutilation after her second marriage ended. During the same period she also entered prostitution.

In the emergency room she was diagnosed as having major depressive disorder and borderline personality disorder, and she was admitted to the psychiatric inpatient unit. After two weeks of hospitalization, she inserted another razor blade, which was removed in the operating room. She was treated with sertraline 100 mg daily as well as with psychotherapy that explored her early childhood experience and its relationship to her current symptoms.

Patients with genital mutilation tend to fall into four distinct subtypes: psychotic patients with delusions regarding their genitalia, patients with severe personality disorder, transsexuals with self-sexual reassignment, and people whose mutilation reflects religious or cultural beliefs (for example, female circumcision among Moslems and in certain Australian and African tribes) (2). Although most reported cases of female genital mutilation involve self-induced abortions or insertion of a foreign body, one report describes a female who masturbated with a pair of scissors (3). It has also been suggested that female habitual self-mutilators may have a higher incidence of genital self-mutilation (4).

The name Caenis syndrome has been suggested for the triad of genital self-mutilation, hysterical personality disorder, and eating disorder (5). Neptune, the god of the sea, raped Caenis, a lovely girl in Thessaly. Neptune subsequently granted her a wish that her genitalia be ablated so that she might never again be sexually violated. Our patient repeatedly inserted a razor blade into her vagina but denied sexual gratification or psychotic symptoms.

Female genital self-mutilation may present as unexplained vaginal bleeding. Although self-mutilation is reported to be common in personality disorders, the use of sharp objects inserted into the vagina may suggest a more severe psychopathology, and clinicians should be aware of the existence of this behavior.