Cases That Test Your Skills

Self-mutilation after recent-onset psychosis

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Mr. K, age 23, is found bleeding after genital self-mutilation, and says voices told him to ‘cut it off.’ He has a history of psychosis and Cannabis use. How would you approach his treatment?



CASE Bleeding, bewildered

Mr. K, age 23, a South Asian male, is discovered in the bathroom bleeding profusely. Mr. K’s parents inform emergency medical services (EMS) personnel that Mr. K is “not in his right mind” and speculate that he is depressed. EMS personnel find Mr. K sitting in a pool of blood in the bathtub, holding a cloth over his pubic area and complaining of significant pain. They estimate that Mr. K has lost approximately 1 L of blood. Cursory evaluation reveals that his penis is severed; no other injuries or lacerations are notable. Mr. K states, “I did not want it anymore.” A kitchen knife that he used to self-amputate is found nearby. He is awake, alert, and able to follow simple directives.

In the emergency room, Mr. K is in mild-to-moderate distress. He has no history of medical illness, but his parents report that he previously required psychiatric treatment. Mr. K is not able to elaborate. He reluctantly discloses an intermittent history of Cannabis use. Physical examination reveals tachycardia (heart rate: 115 to 120 beats per minute), and despite blood loss, systolic hypertension (blood pressure: 142/70 to 167/70 mm Hg). His pulse oximetry is 97% to 99%; he is afebrile. Laboratory tests are notable for anemia (hemoglobin, 7.2 g/dL [reference range, 14.0 to 17.5 g/dL]; hematocrit, 21.2% [reference range, 41% to 50%]) and serum toxicology screen is positive for benzodiazepines, which had been administered en route to allay his distress.

Mr. K continues to hold pressure on his pubic area. When pressure is released, active arterial spurting of bright red blood is notable. Genital examination reveals a cleanly amputated phallus. Emergent surgical intervention is required to stop the hemorrhage and reattach the penis. Initially, Mr. K is opposed to reattachment, but after a brief discussion with his parents, he consents to surgery. Urology and plastic surgery consultations are elicited to perform the microvascular portion of the procedure.

The authors’ observations

Self-injurious behaviors occur in approximately 1% to 4% of adults in the United States, with chronic and severe self-injury occurring among approximately 1% of the U.S. population.1,2 Intentional GSM is a relatively rare catastrophic event that is often, but not solely, associated with severe mental illness. Because many cases go unreported, the prevalence of GSM is difficult to estimate.3,4 Although GSM has been described in both men and women, the literature has predominantly focused on GSM among men.5 Genital self-injury has been described in several (ie, ethnic/racial and religious) contexts and has been legally sanctioned.6-8

Psychiatric disorders associated with, and precipitating factors underlying, GSM have long remained elusive.8 GSM has been described in case reports and small case series in both psychiatric and urologic literature. These reports provide incomplete descriptions of the diagnostic conditions and psychosocial factors underlying male GSM.

A recent systematic review of 173 cases of men who engaged in GSM published in the past 115 years (since the first case of GSM was published in the psychiatric literature9) revealed that having some form of psychopathology elevates the probability of GSM10,11; rarely the individual did not have a psychiatric condition.11-17 Nearly one-half of the men had psychosis; most had a schizophrenia spectrum disorder diagnosis. Other psychiatric conditions associated with GSM include personality disorders, substance use disorder, and gender dysphoria. GSM is rarely associated with anxiety or mood disorders.

GSM is a heterogeneous form of self-injury that ranges from superficial genital lacerations, amputation, or castration to combinations of these injuries. Compared with individuals with other psychiatric disorders, a significantly greater proportion of individuals with schizophrenia spectrum disorders engage in self-amputation (auto-penectomy). By contrast, persons with gender dysphoria tend to engage in self-castration at significantly higher rates than those with other psychiatric conditions.11 Despite these trends, clinicians should not infer a specific psychiatric diagnosis based on the severity or type of self-inflicted injury.

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