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.

Case Presentation

A 63-year-old White male with a history of schizophrenia, methamphetamine use, alcohol use disorder, diabetes mellitus, and hypothyroidism presented with a chief complaint of GSM; he stated, “I tried to cut my penis.” The patient had used a blunt knife to inflict multiple superficial penile lacerations and described delusions of two women arguing over his penis. He was unable to provide further information about the women. However, he adamantly defended the assertion that the women were not hallucinations and that self-mutilation had been a reasonable means of resolving the conflict, dismissing the seriousness of this behavior. Collateral information was unavailable.

His past psychiatric history included three previous psychiatric hospitalizations for episodes of psychosis with or without substance intoxication and two previous instances of severe self-mutilation. The first instance of severe self-mutilation involved stab wounds to the chest and abdomen in the context of nonsubstance-induced auditory hallucinations, and the second involved stab wounds to the chest in the context of alcohol and methamphetamine intoxication.

His substance use history included current weekly smoking of amphetamines and cannabis (the patient was unable to quantify the amounts) and a history (3 years earlier) of consuming 15 alcoholic beverages per week. His social history included homelessness, unemployment, divorced status, limited social support, and multiple arrests for public intoxication.

A mental status examination revealed that the patient had poor hygiene, slurred speech, poor eye contact, a disorganized thought process, an evasive and withholding attitude, poor insight, and delusional thought content (as described in the history of present illness) and that he was without suicidal ideation or hallucinations. A urine drug screen was positive only for methamphetamine. Other clinical work-up, including plasma ethanol level, comprehensive metabolic panel, complete blood count, and computed tomography head scan, revealed no remarkable findings.

The patient’s wounds were repaired by the urology team, and he was admitted for psychiatric care and initiated on oral risperidone (1 mg, twice daily). Throughout his 5-day hospital stay, his thought process became more organized, and he became less evasive and more willing to engage in treatment and perform activities of daily living. He demonstrated improvement in judgement and insight, recognized the harm caused by his self-injury, and agreed to seek medical care for future urges to engage in self-harm.

Discussion

We presented a case of male GSM in the context of methamphetamine intoxication in an individual with a history of repeated severe self-mutilation, methamphetamine and cannabis use, and schizophrenia. This history is consistent with known risk factors for GSM. While GSM of any variety is likely rare, milder injury—such as that observed in this patient—represents an even more uncommon scenario because among reported cases, only about 12% were identified as being less severe, compared with cases involving castration or amputation (1).

Management of GSM requires collaborative care between medical and psychiatric providers. The patient described in this case report received acute psychiatric and urological care, and outpatient follow-up with both psychiatry and urology was arranged. Wound care education was collaboratively performed by nursing staff and an internal medicine–psychiatry resident physician. The patient was initiated on antipsychotic medication given his documented history of schizophrenia and his providers’ concern for symptoms of delusions and disorganized thought process. Risperidone was chosen due to its decreased propensity for metabolic side effects—given the patient’s concurrent diabetes mellitus—and potential for transition to a long-acting injectable, which would increase the feasibility of future treatment adherence.

In caring for patients presenting with GSM, it is imperative that all team members exhibit professionalism and respect to avoid exacerbating shame or embarrassment. Case reports in the urological literature emphasize the importance of psychiatric referral following surgical management of injuries to ensure a thorough assessment for psychiatric symptomatology (10, 11).

Unfortunately, data on the psychiatric management and prevention of GSM are severely limited. The available literature suggests that GSM is a manifestation of co-occurring psychiatric illnesses (namely, psychotic and substance use disorders) rather than a stand-alone disorder. As such, focusing on identification and management of such disorders is likely to be the most effective approach in preventing this behavior. Clinicians should collect a thorough history—aimed to identify recent substance use; history of psychiatric conditions; and symptoms of psychosis, gender dysphoria, or mood disorders—and inquire about nonpsychotic considerations, including sexual conflicts and guilt, sexual arousal, or religious motivations. In the context of a psychotic episode, such patients should be admitted, and antipsychotics should be initiated.

Following acute management, outpatient follow-up with both psychiatry and urology should be arranged to assess wound healing and stabilization of psychiatric symptoms. An episode of GSM likely serves as a prognostic indicator of suicide risk: an estimated 55%–85% of those who engage in self-mutilation attempt suicide at least once (2). Some reports describe a pattern of recurrent self-injurious behavior among individuals who engage in GSM (12, 13), which is consistent with the pattern of behavior noted in our patient. A study of major self-mutilation, including GSM, demonstrated that treatment of first-episode psychosis with antipsychotic medication was effective in decreasing future episodes of mutilation (6). For individuals with recurrent episodes of GSM or those with additional severe self-mutilation despite antipsychotic treatment, group or assisted living for individuals with severe mental illness may be a necessary consideration.

Our understanding of GSM is limited due to insufficient literature on this topic. There is a notable lack of epidemiological studies reporting incidence and prevalence rates. In line with other investigators who have studied this topic, we advocate for the establishment of an electronic database for reports of rare psychiatric cases, including those involving GSM, to facilitate improved epidemiological understanding of such behaviors (2, 6). Furthermore, additional research on this topic is needed, and future work should focus on identifying optimal psychiatric management of GSM and effective strategies for prevention.

Key Points/Clinical Pearls