Psychosomatics 50:178-a-180, March-April 2009
doi: 10.1176/appi.psy.50.2.178-a
© 2009 Academy of Psychosomatic Medicine
Self-Amputation of the Nipples and Penis in a Nonpsychotic, Non–Gender-Dysphoric Man
Carol I. Ping Tsao, M.D.,
Gina Negrette, M.D., and
Aaron Riley, M.D., Dept. of Psychiatry and Behavioral HealthMedical College of WisconsinMilwaukee, WI
TO THE EDITOR: Genital self-mutilation in men is relatively rare and usually manifests in either psychosis or gender-identity disorder (GID).1,2 Breast/nipple self-mutilation among men occurs with even greater rarity, usually involving the use of bondage equipment in sexual activity.3 We report a case of breast/nipple and penis self-mutilation in a nonpsychotic, non-GID male with borderline personality disorder.
Case Report
"Mr. H" is a 49-year-old white man who was referred to psychiatry by urology after he used a pair of scissors to cut off the right side of his glans penis. His physical examination was significant for localized erythema, induration, and some tenderness, which responded to wound care and antibiotics.
Although he denied any previous history of psychosis, compulsive behaviors, or gender-dysphoria, Mr. H’s psychiatric history is significant for alcohol and benzodiazepine abuse and self-mutilation to breasts and genitalia. His first experiences with self-mutilation began at age 17, when he begun inserting sharp needles into the shaft of his penis. At age 18, he used a pair of scissors to cut off both nipples because "they stuck out too much." At age 45, the patient had sought and received bilateral breast-reduction surgery.
After his parents’ divorce, Mr. H, at age 9, was placed with his biological father. He reports emotional and physical abuse by his stepmother for bed-wetting that continued through his 13th year. He remembers his stepmother threatening, "I’ll cut that thing off."
At age 29, Mr. H married an older, twice-divorced woman. Although the marriage produced no children, he described their relationship as amicable and sexually gratifying. After 10 years, his wife left him for another man. Although exclusively heterosexual in his practices, the patient confided sexual fantasies that included homosexual and sado-masochistic acts.
There was an increase in mutilating behaviors in the decade after his divorce. Genital self-mutilation relieved feelings of "loneliness" and "emptiness," elevating his mood for "several hours," and occasionally resulting in sexual arousal culminating in orgasm.
Mr. H’s mental status examination was significant for his masculine appearance, gregariousness, and lack of distress. He was interpersonally engaging and eager to please. There were no signs of thought-process disorganization, internal preoccupation, or delusional focus in his presentation material (for example, some past real or imagined misdeed for which retribution was being exacted). He was cognitively intact and exhibited a normal range of emotions. He credibly denied suicidal inclination. His review of symptoms was absent for gender-identity disorder features.
After transfer to the inpatient psychiatry service from urology, Mr. H. was observed for 1 week, during which time he exhibited no further self-mutilation. While in the hospital, Mr. H was treated with daily individual supportive psychotherapy and started on a full-dose SSRI and low-dose atypical antipsychotic that he tolerated without difficulty.
About 1 month after discharge, he again presented to the urology service, after the self-amputation of half of his penis. Mr. H reported that he was home watching Monday Night Football when he went to the kitchen, put his penis on a cutting-board, and took a butcher knife and cut through the entire shaft of his penis. He called 911 for help immediately. After evaluation, the urology department determined that penile replantation was not possible. He was stabilized, from a surgical standpoint, and again transferred to the psychiatry unit.
Mr. H’s interval history and subsequent mental status were essentially unaltered from his initial presentation. Psychological testing during this hospitalization corroborated the absence of psychosis and the likelihood of a primary severe personality disorder.
Mr. H expressed regret with regard to his actions, but his remorse seemed superficial. Only after some persistent inquiry did the patient reluctantly admit to thoughts of further amputation. At the time of his last hospital discharge, the patient’s prognosis was considered quite poor, given that he evinced a trend toward increasingly more severe genital self-mutilation, failed to engage in outpatient psychiatric treatment, and appeared emotionally disconnected from his troubling behaviors. The event of complete penile amputation and other forms of severe self-mutilation in the future was viewed as a distinct possibility.
Discussion
Although breast/nipple self-mutilation and genital self-mutilation have each been previously reported, progression from one to the next in a single patient over the course of half-a-lifetime has not been described before. This suggests that in patients with severe personality disorder, marked self-mutilation (such as bilateral nipple amputation) in early life can progress to even more severe forms of self-mutilation, such as serial penile amputation attempts.
REFERENCES
- Greilsheimer H, Groves JE: Male genital self-mutilation. Arch Gen Psychiatry 1979; 36:441–446[Abstract/Free Full Text]
- Nakaya M: On background factors of male genital self-mutilation. Psychopathology 1996; 29:242–248[Medline]
- Rao VJ, Penneys NS: Symmetrical hypopigmentation of the nipples secondary to trauma. J Forens Sci 1984; 29:938–940[Medline]
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