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Male genital self-mutilation: Combined surgical and psychiatric care
LAURENS D. YOUNG, M.D. DONALD L. FEINSILVER, M.D.
Male genital self-mutilation: Combined surgical and psychiatric care ABSTRACT: Advances in plastic surgery require that consultation
psychiatry respond with increasing sophistication. Self-mutilating patients may now undergo genital reimplantation, but few guidelines exist for their psychiatric management. We describe three contrasting cases of male genital self-mutilation, demonstrating the differential impact of psychiatric consultation, and offer guidelines for a consultative strategy to the surgical team, patient, and family. A general management plan for consulting psychiatrists is presented.
One of the most extreme kinds of cases linking psychiatry and plastic surgery is the self-mutilation of male genitals. Such patients are invariably psychotic or severely disturbed and so constitute a combined surgical and psychiatric emergency. The surgical literature, although surgically sophisticated, often deals incompletely with psychiatric issues.1.2 The psychiatric literature'-'O describes some demographic and psychodynamic characteristics of self-mutilators but provides few management guidelines.
Blacker and Wong' reported "remarkable similarities in the lives of autocastrates" with regard to impoverished childhood experiences; intense sexual confusion of long duration; submissive, masochistic relationships with women; depression relieved by genital mutilation; strong feminine identification; and repudiation ofthe penis. Kushner" found autocastration more frequent in rigid cultures such as Calvinistically-influenced Scotland. Our review of the literature found 53 cases of genital
From the 3/ st Annual Meeting ofthe Academy ofPsychosomatic Medicine. Philadelphia. November / / -14. /984. Drs. Young and Feinsilver are associate professors ofpsychiatry at the Medical College of Wisconsin. Reprint requests to Dr. Young. Director of Psychiatry. Milwaukee County Medical Complex. MCMC Box /75.8700 West Wisconsin Ave.. Milwaukee. W/53226.
JULY 1986· VOL 27 • N07
self-mutilation prior to 1981. The majority of these cases fit into three categories: (I) psychotic mutilations driven by command hallucinations, (2) impulsive amputations committed under the influence of alcohol or drugs, and (3) autocastration committed by dissatisfied transsexuals. >-, Although the psychiatric literature has described psychological profiles of individuals who seek surgical procedures such as rhinoplasty, breast enlargement, or face lift, far less has been written about patients requiring surgery related to self-mutilation. Microvascular plastic surgical techniques have so advanced that previously unthought-of results can now be obtained. It is now possible to reimplant genitals, and in many cases, using microsurgical techniques, full urethral and sexual function can be restored. 1.2 Immediate management of the psychiatric problem and rapid reduction of any associated agitation are necessary if the patient is not to undermine the surgical result. Yet there are few guidelines for the psychiatric management of such patients on surgical units. In the following three case pre513
Genital self-mutilation
sentations we will address this issue, and we will provide a management outline for consultation psychiatry in the perioperative period. Psychiatric consultation is necessary as soon as the self-mutilating patient arrives at the hospital. In the emergency department, these patients provoke feelings of fear and revulsion in the staff. Since staff members cannot easily identify and empathize with such patients, they may question the wisdom of surgical treatment of this self-inflicted injury. At other times they may view the patient as so psychiatrically disabled that they question the value of surgical treatment in relation to his ultimate quality of life. Case I illustrates such a response. Case 1 A 25-year-old man, without any psychiatric history, came to the emergency department accompanied by his mother. The patient stated that two months previously in another state, he had "cut (his) stuff off." After surgical closure, he had never returned for suture removal. Although his mother was one thousand miles away at the time of the mutilation, she described all the details as if giving a first-person account. At the time of the autocastration, no attempt had been made at reimplantation. Since the incident had occurred elsewhere, it is not clear if an operation would have been possible. Psychiatric consultation apparently had not been requested. At our emergency department the patient was regarded as a gruesome curiosity and was referred directly to psychiatry, without thorough physical examination and with the sutures still in place. Suture removal was finally effected at the psychiatrist's request. Noting loose associations, blunted affect, and marked religiosity with grandiose and persecutory components, in the absence of drug abuse or organic insult, the psychiatrist diagnosed paranoid schizophrenia.
514
In this case, there had been no collaboration between psychiatry and plastic surgery. Subsequent cases demonstrate the need for early psychiatric consultation. Establishing a psychiatric diagnosis and initiating appropriate psychiatric treatment prior to surgery is helpful, In the case of the psychotic patient, neuroleptic medication may be advised. The alcoholic patient may require detoxification. The acutely agitated psychotic patient may require sedation and physical restraints. Some information can be beneficially shared with the surgeons in an effort to reduce concerns about the "strangeness" of such patients or their behavior. Most of these patients, excluding transsexuals, generally do not try to repeat the autocastration. '-'.' The value of such early intervention and exchange of information is illustrated in the next case. Case 2 A 36-year-old intoxicated man was brought to the emergency department by the police, with deep self-inflicted knife wounds to his penis, scrotum, and groin. The patient explained that if he had not done it, somebody else would have. Later psychiatric findings revealed that he suffered from delusions that he was being shown on television, that the radio could speak to him personally, and that people were out to get him because he "did not know the password." The patient was taken directly to surgery without psychiatric consultation. After wound closure, he was moved to a general surgical floor where he was detoxified with heavy sedation. Two days later a psychiatric consultation was requested because the patient was "schizy and needed placement." The psychiatrist learned that the patient had a 15-year history of recurrent self-injurious behavior since shooting himself in the leg on duty in Vietnam in 1968. On another occasion, in 1974 he had slashed both wrists when he per-
ceived his family to be unsympathetic to his problems. He had a long history of emergency department visits for fractures, lacerations, and soft-tissue trauma. Ultimately it was discovered that the patient had been receiving psychiatric care and alcohol rehabilitation elsewhere. In general he had been chronically prone to self-injury and accidents. His treatment response had been minimal. The DSMIII Axis I diagnoses were paranoid schizophrenia and alcohol dependence. Since the patient required further care on the surgical ward, the psychiatric consultant advised that the psychiatric consultation team also monitor him on a regular basis. The consultant prescribed antipsychotic medication, and followed the patient daily. The value of intensive nursing observation and contact was emphasized. Since the patient was only occasionally agitated, restraints were used only at those times. In an attempt to stabilize his social situation, the psychiatric consultation team made contact with his sister. The sister denied any meaningful contact with the patient for months and expressed doubt that she could be helpful. Finally, the surgery team, uncomfortable with the patient on the ward for more than a few days, arranged transfer to another facility. The patient remained in psychiatric care, at a nearby hospital, long enough to develop a remission from the psychosis, participated in alcoholism rehabilitation, and no further self-injurious behavior was reported. After several months, hewas still on maintenance neuroleptics and compliant with his outpatient visits.
The next case illustrates the value of early intervention and continuity of care. Generally, the psychiatrist should follow the patient on as regular a basis as the surgeon. Beyond their value to the patient, such efforts provide a sense of collaborative effort, reduce exaggerated concern, and en-
PSYCHOSOMATICS
hance motivation among the surgical and nursing staff. Case 3 A 23-year-old graduate student was brought to the emergency department after completely amputating his penis with a pair of scissors. He had no psychiatric history. His parents reported that he was nearing graduation, had been looking for a job, and had lately seemed "pressured" and increasingly suspicious. He had previously been a friendly young man but recently had seemed aloof and unusually egocentric, making grandiloquent statements about his future prospects for success. A psychiatric consultation was obtained as soon as the patient arrived in the emergency department, because the surgeon feared the patient might attempt to reinjure himself or undo the proposed surgery. The patient demonstrated marked loosening of associations, clang associations, and delusions of persecution. On the basis of the above history and some subsequent information a diagnosis of schizophreniform disorder was made, and the patient's parents were informed of the purpose of the surgical and psychiatric interventions. The patient was given haloperidol and then taken to surgery where the penis was reimplanted without complications. As soon as he came out of anesthesia, psychiatric contact was reinstituted. Although on antipsychotic medication, the patient was guarded, explaining that he would not discuss "these very personal things" but that he had "man-woman problems," was "hard and soft," and "did not want to be a man." After several days, his loose associations diminished, and the psychiatrist requested a family conference. The family ventilated, and a plan was established to facilitate exchange of information between the psychiatric service, the surgical service, the family, and the patient. With the exception of when the patient wished to speak confidentially with the
JULY 1986· VOL 27· N07
physicians, all was done in an open, collaborative manner. The nursing staff was advised to care for and address the patient as they would any other patient. Medical students were discouraged from coming unnecessarily to "see the unusual case." When the patient's ambivalence subsided to the point that he wanted to keep his penis and to cooperate with his care, restraints were no longer necessary. Surgery and nursing staffs expressed reluctance about eliminating restraints but acquiesced with the psychiatrist's recommendations. The patient was encouraged to be more responsible for his own care. The family was involved with the team in planning for the future. Eventually the patient was transferred to a psychiatric hospital, and then discharged to outpatient psychotherapy and medication followup. He made a good surgical recovery and attempted no further self-mutilation. However, he remained sufficiently impaired psychiatrically that he did not return to school that year.
Discussion As is summarized in the Table, the phases of consultation change as hospitalization progresses, A previous models has comprised early, middle, and late phases of intervention. We follow this outline in a modified form. Early (admission) phase. A brief preoperative psychiatric evaluation is valuable. Although not extensive, this sets the tone of the hospitalization. Initially, a diagnosis should be offered, recommendations for medication and continued psychiatric intervention made, and contact with the family established. The decision to operate is primarily a surgical decision. Psychiatric diagnosis per se is not a contraindication. I." If suitable tissue is available, reimplantation should be attempted. Patients at this stage are usually delirious or in shock, in addition to being quite ambivalent, and usually cannot partic-
ipate meaningfully in decision-making. Psychotic patients are often ambivalent about their actions, but the presence of suitable tissue is considered a favorable sign. 10 If the patient is thought to be a dissatisfied transsexual, specifically refusing surgery, the psychodynamic factors leading to this decision can be addressed." The surgical and nursing staffs frequently have strong negative reactions. A common attitude voiced is, "Patients like this will just do it again." This statement should be interpreted as an indication of anxiety and is unsupported in the literature. u.s Since genital self-mutilation is rare, it is unlikely that the staff has really seen "patients like this." Expressions of therapeutic nihilism such as, "He's so sick. What's the use?" may also be heard. The psychiatrist can confront these issues by pointing out that revulsion, fear, or disgust would be natural reactions to such behavior, but that many patients can enjoy a satisfactory surgical outcome. Despite the violence of the self-mutilative act, the majority of patients do not reattempt self-mutilation, and if properly managed, may not be repetitively self-injurious. u.s The family can also be offered an explanation and guarded reassurance. Middle (post-surgical) phase. Although much emphasis is still directed by the psychiatrist toward staff members, an increasing amount of time will be spent with the patient, who will need considerable emotional support, if not supportive care to the point of protection. An early decision should be made with the surgeon as to who will write orders for psychoactive medications and restraints. The psychotropic dosage must be carefully titrated. Frequent assessments of the patient's mental status are necessary in order to provide sufficiently rapid and accurate changes in plans and 515
Genital self-mutilation
Tabl~Time
Phase
Type of Intervention
Focus
Issues
Early (admission)
Diagnostic evaluation, specific recommendations
Patient and team
Establish diagnosis. reduce symptoms, facilitate compliance with surgical procedures
Middle (post-surgical)
Frequent visits, ventilation, and explanations
Patient, family, and staff
Reduce anxiety, guilt, and psychopathology
Late (approaching discharge)
Infrequent visits, psychotherapy
Patient and family
Future planning, psychodynamic issues
timely recommendations for care. Staff members are encouraged to administer care and dressing changes just as they would for any other patient. The psychiatrist should listen for hidden meanings in the reactions of persons caring for the patient. Reluctance to touch a patient who would "do something like this" may uncover a fear that the patient could be dangerous to staff members. On the other hand, unnecessary occurrences, such as hospital personnel or medical students not directly connected with the patient's care coming to see the wound or to meet an unusual patient, should be actively discouraged. If the operation has been successful, the surgical team may express fear of the patient's "ruining the work." There may be a reluctance to let the patient out of restraints or an expressed desire to move him, in restraints, precipitately to a psychiatric ward or another hospital. The psychiatrist may find it necessary in this case to advocate for the patient in order to deliver comprehensive biopsychosocial care postoperatively.' As soon as possible, the issue of transfer to a psychiatric unit should be addressed, and when the patient's surgical needs are acceptable to a psychiatric unit, those patients with acute psychosis or other
516
Course of Interventions
indication for inpatient psychiatric care should be transferred. In many cases, however, this will not be possible for several days or weeks because of the patient's need for acute postoperative care. If the initial interventions with the surgical team and nursing staff have been successful, consultant time can be productively turned to other issues. Increased attention should be paid to the patient's famil y at this phase of recovery. The psychiatrist can help the family reduce guilt by ventilation and also can act as a liaison between the family and the treatment team. At this time, the family, in tum, can provide additional useful history. Since the patient may still be reluctant to discuss the intimate details leading up to the self-mutilation, this history may help elucidate relevant psychodynamics. Lale (predischarge) phase. This phase begins when the patient's psychiatric condition has stabilized and discharge is anticipated by the surgical team. Staff issues should largely have been resolved by this phase. Increasing time will be spent with the patient who by this time may be ready to begin psychotherapy. Plans for the continuation of psychiatric treatment after discharge should be made. The patient may express guilt or shame
over his act through regressive or antitherapeutic behavior. The relevance of psychiatric care to his quality of life in the future should be addressed. New family issues may also arise. Both patient and family members may worry about what they will tell their friends. Parents will be concerned as to whether they were responsible for the patient's actions. Plans for continued family follow-up and support should also be discussed and put into definite form prior to discharge. Those patients with persistent psychosis or other behavioral indicators for continued psychiatric inpatient care should be transferred to an inpatient psychiatry unit. In these cases, although outcome oftreatment studies are not extensive, the treatment issue would be analogous to those in other self-injurious patients, and the psychiatry staff would be expected to better manage the anxiety induced by these patients. "" Our experience has been that patients, when adequately treated postoperatively, begin to suppress their symptoms rapidly, so they do not present unique treatment problems to inpatient psychiatric units.
Summary From the moment of arrival at the hospital, the genital-mutilating patient re-
PSYCHOSOMATICS
quires continuous surgical and psychiatric care. With the possibility of full restoration of function through microsurgery, early contact is increasingly important. Although the presenting psychopathology might usually serve as an indication for psychiatric hospitalization, the necessary surgical man-
agement mandates that the patient initially remain on a surgical unit. The psychiatrist must render consultation and treatment there. The course of treatment can be conceptualized as consisting of three phases, with the emphasis of the psychiatric consultations shifting as the patient pro-
gresses. The consultation psychiatrist's time can be used most efficiently by shifting the major emphasis from surgical team to family and to patient as the clinical course permits. Surgical and psychiatric collaboration so rendered can optimize outcome and decrease management difficulties. 0
hallucinations and self·amputation of the pe· nis and hand during a first psychotic break. J Clin Psychology 42:322-324. 1981. Mora W, Drach GW: Self·emasculation and self·castration: Immediate surgical management and ultimate psychological adjustment. JUro/124:208-210.1980. Pabis R. Mirza MA. Tozman S: A case study of autocastration. Am J Psychiatry 137:626627. 1980 Clark RA: Self·mutilation accompanying religious delusions: A case report and review. J Clin Psychiatry 42:243·244.1981. Strain J, Demuth G: Case of the psychotic
self-amputee undergoing reimplantation. Ann Surg 197:210-214.1982. Beresford TP: The dynamics of aggression in an amputee: A case report. Gen Hosp Psychiatry 3:219-225. 1980. Greilsheimer H. Groves JE: Male genital selfmutilation. Arch Gen Psychiatry 36:441-446. 1979 Schneider SF, Harrison SI. Biegel BL: Self castration by a man with cyclic changes in sexuality. Psychosom Med27:53-70. 1974. Lowy FH. Kolivakis TL: Autocastration by a male transsexual. Can Psychiatr Assoc J 16:399-405.1971.
REFERENCES 1. Wei PC, McKee NH. Huena FJ. et al: Microsur· gical reimplantation of a completely amputat· ed penis. AnnPlast Surg 10:317-320,1982. 2. Henriksson TG. Hahne B. Hakelius L. et al: Mi· crosurgical reimplantation of an amputated penis. CanJ Urol Nephro/14:111-114. 1980. 3. Blacker KH. Wong N: Four cases of autocas· tration. Arch Gen Psychiatry 8:169-176. 1963 4. Kushner WA: Two cases of autocastration due to religious delusions Med Psychol 40:293-298.1967. 5. Hall DC. Lawson BZ. Wilson LG: Command
JULY 1986-VOL 27- N07
6.
7.
8.
9.
10,
11.
12.
13.
517
Male genital self-mutilation: Combined surgical and psychiatric care ABSTRACT: Advances in plastic surgery require that consultation
psychiatry respond with increasing sophistication. Self-mutilating patients may now undergo genital reimplantation, but few guidelines exist for their psychiatric management. We describe three contrasting cases of male genital self-mutilation, demonstrating the differential impact of psychiatric consultation, and offer guidelines for a consultative strategy to the surgical team, patient, and family. A general management plan for consulting psychiatrists is presented.
One of the most extreme kinds of cases linking psychiatry and plastic surgery is the self-mutilation of male genitals. Such patients are invariably psychotic or severely disturbed and so constitute a combined surgical and psychiatric emergency. The surgical literature, although surgically sophisticated, often deals incompletely with psychiatric issues.1.2 The psychiatric literature'-'O describes some demographic and psychodynamic characteristics of self-mutilators but provides few management guidelines.
Blacker and Wong' reported "remarkable similarities in the lives of autocastrates" with regard to impoverished childhood experiences; intense sexual confusion of long duration; submissive, masochistic relationships with women; depression relieved by genital mutilation; strong feminine identification; and repudiation ofthe penis. Kushner" found autocastration more frequent in rigid cultures such as Calvinistically-influenced Scotland. Our review of the literature found 53 cases of genital
From the 3/ st Annual Meeting ofthe Academy ofPsychosomatic Medicine. Philadelphia. November / / -14. /984. Drs. Young and Feinsilver are associate professors ofpsychiatry at the Medical College of Wisconsin. Reprint requests to Dr. Young. Director of Psychiatry. Milwaukee County Medical Complex. MCMC Box /75.8700 West Wisconsin Ave.. Milwaukee. W/53226.
JULY 1986· VOL 27 • N07
self-mutilation prior to 1981. The majority of these cases fit into three categories: (I) psychotic mutilations driven by command hallucinations, (2) impulsive amputations committed under the influence of alcohol or drugs, and (3) autocastration committed by dissatisfied transsexuals. >-, Although the psychiatric literature has described psychological profiles of individuals who seek surgical procedures such as rhinoplasty, breast enlargement, or face lift, far less has been written about patients requiring surgery related to self-mutilation. Microvascular plastic surgical techniques have so advanced that previously unthought-of results can now be obtained. It is now possible to reimplant genitals, and in many cases, using microsurgical techniques, full urethral and sexual function can be restored. 1.2 Immediate management of the psychiatric problem and rapid reduction of any associated agitation are necessary if the patient is not to undermine the surgical result. Yet there are few guidelines for the psychiatric management of such patients on surgical units. In the following three case pre513
Genital self-mutilation
sentations we will address this issue, and we will provide a management outline for consultation psychiatry in the perioperative period. Psychiatric consultation is necessary as soon as the self-mutilating patient arrives at the hospital. In the emergency department, these patients provoke feelings of fear and revulsion in the staff. Since staff members cannot easily identify and empathize with such patients, they may question the wisdom of surgical treatment of this self-inflicted injury. At other times they may view the patient as so psychiatrically disabled that they question the value of surgical treatment in relation to his ultimate quality of life. Case I illustrates such a response. Case 1 A 25-year-old man, without any psychiatric history, came to the emergency department accompanied by his mother. The patient stated that two months previously in another state, he had "cut (his) stuff off." After surgical closure, he had never returned for suture removal. Although his mother was one thousand miles away at the time of the mutilation, she described all the details as if giving a first-person account. At the time of the autocastration, no attempt had been made at reimplantation. Since the incident had occurred elsewhere, it is not clear if an operation would have been possible. Psychiatric consultation apparently had not been requested. At our emergency department the patient was regarded as a gruesome curiosity and was referred directly to psychiatry, without thorough physical examination and with the sutures still in place. Suture removal was finally effected at the psychiatrist's request. Noting loose associations, blunted affect, and marked religiosity with grandiose and persecutory components, in the absence of drug abuse or organic insult, the psychiatrist diagnosed paranoid schizophrenia.
514
In this case, there had been no collaboration between psychiatry and plastic surgery. Subsequent cases demonstrate the need for early psychiatric consultation. Establishing a psychiatric diagnosis and initiating appropriate psychiatric treatment prior to surgery is helpful, In the case of the psychotic patient, neuroleptic medication may be advised. The alcoholic patient may require detoxification. The acutely agitated psychotic patient may require sedation and physical restraints. Some information can be beneficially shared with the surgeons in an effort to reduce concerns about the "strangeness" of such patients or their behavior. Most of these patients, excluding transsexuals, generally do not try to repeat the autocastration. '-'.' The value of such early intervention and exchange of information is illustrated in the next case. Case 2 A 36-year-old intoxicated man was brought to the emergency department by the police, with deep self-inflicted knife wounds to his penis, scrotum, and groin. The patient explained that if he had not done it, somebody else would have. Later psychiatric findings revealed that he suffered from delusions that he was being shown on television, that the radio could speak to him personally, and that people were out to get him because he "did not know the password." The patient was taken directly to surgery without psychiatric consultation. After wound closure, he was moved to a general surgical floor where he was detoxified with heavy sedation. Two days later a psychiatric consultation was requested because the patient was "schizy and needed placement." The psychiatrist learned that the patient had a 15-year history of recurrent self-injurious behavior since shooting himself in the leg on duty in Vietnam in 1968. On another occasion, in 1974 he had slashed both wrists when he per-
ceived his family to be unsympathetic to his problems. He had a long history of emergency department visits for fractures, lacerations, and soft-tissue trauma. Ultimately it was discovered that the patient had been receiving psychiatric care and alcohol rehabilitation elsewhere. In general he had been chronically prone to self-injury and accidents. His treatment response had been minimal. The DSMIII Axis I diagnoses were paranoid schizophrenia and alcohol dependence. Since the patient required further care on the surgical ward, the psychiatric consultant advised that the psychiatric consultation team also monitor him on a regular basis. The consultant prescribed antipsychotic medication, and followed the patient daily. The value of intensive nursing observation and contact was emphasized. Since the patient was only occasionally agitated, restraints were used only at those times. In an attempt to stabilize his social situation, the psychiatric consultation team made contact with his sister. The sister denied any meaningful contact with the patient for months and expressed doubt that she could be helpful. Finally, the surgery team, uncomfortable with the patient on the ward for more than a few days, arranged transfer to another facility. The patient remained in psychiatric care, at a nearby hospital, long enough to develop a remission from the psychosis, participated in alcoholism rehabilitation, and no further self-injurious behavior was reported. After several months, hewas still on maintenance neuroleptics and compliant with his outpatient visits.
The next case illustrates the value of early intervention and continuity of care. Generally, the psychiatrist should follow the patient on as regular a basis as the surgeon. Beyond their value to the patient, such efforts provide a sense of collaborative effort, reduce exaggerated concern, and en-
PSYCHOSOMATICS
hance motivation among the surgical and nursing staff. Case 3 A 23-year-old graduate student was brought to the emergency department after completely amputating his penis with a pair of scissors. He had no psychiatric history. His parents reported that he was nearing graduation, had been looking for a job, and had lately seemed "pressured" and increasingly suspicious. He had previously been a friendly young man but recently had seemed aloof and unusually egocentric, making grandiloquent statements about his future prospects for success. A psychiatric consultation was obtained as soon as the patient arrived in the emergency department, because the surgeon feared the patient might attempt to reinjure himself or undo the proposed surgery. The patient demonstrated marked loosening of associations, clang associations, and delusions of persecution. On the basis of the above history and some subsequent information a diagnosis of schizophreniform disorder was made, and the patient's parents were informed of the purpose of the surgical and psychiatric interventions. The patient was given haloperidol and then taken to surgery where the penis was reimplanted without complications. As soon as he came out of anesthesia, psychiatric contact was reinstituted. Although on antipsychotic medication, the patient was guarded, explaining that he would not discuss "these very personal things" but that he had "man-woman problems," was "hard and soft," and "did not want to be a man." After several days, his loose associations diminished, and the psychiatrist requested a family conference. The family ventilated, and a plan was established to facilitate exchange of information between the psychiatric service, the surgical service, the family, and the patient. With the exception of when the patient wished to speak confidentially with the
JULY 1986· VOL 27· N07
physicians, all was done in an open, collaborative manner. The nursing staff was advised to care for and address the patient as they would any other patient. Medical students were discouraged from coming unnecessarily to "see the unusual case." When the patient's ambivalence subsided to the point that he wanted to keep his penis and to cooperate with his care, restraints were no longer necessary. Surgery and nursing staffs expressed reluctance about eliminating restraints but acquiesced with the psychiatrist's recommendations. The patient was encouraged to be more responsible for his own care. The family was involved with the team in planning for the future. Eventually the patient was transferred to a psychiatric hospital, and then discharged to outpatient psychotherapy and medication followup. He made a good surgical recovery and attempted no further self-mutilation. However, he remained sufficiently impaired psychiatrically that he did not return to school that year.
Discussion As is summarized in the Table, the phases of consultation change as hospitalization progresses, A previous models has comprised early, middle, and late phases of intervention. We follow this outline in a modified form. Early (admission) phase. A brief preoperative psychiatric evaluation is valuable. Although not extensive, this sets the tone of the hospitalization. Initially, a diagnosis should be offered, recommendations for medication and continued psychiatric intervention made, and contact with the family established. The decision to operate is primarily a surgical decision. Psychiatric diagnosis per se is not a contraindication. I." If suitable tissue is available, reimplantation should be attempted. Patients at this stage are usually delirious or in shock, in addition to being quite ambivalent, and usually cannot partic-
ipate meaningfully in decision-making. Psychotic patients are often ambivalent about their actions, but the presence of suitable tissue is considered a favorable sign. 10 If the patient is thought to be a dissatisfied transsexual, specifically refusing surgery, the psychodynamic factors leading to this decision can be addressed." The surgical and nursing staffs frequently have strong negative reactions. A common attitude voiced is, "Patients like this will just do it again." This statement should be interpreted as an indication of anxiety and is unsupported in the literature. u.s Since genital self-mutilation is rare, it is unlikely that the staff has really seen "patients like this." Expressions of therapeutic nihilism such as, "He's so sick. What's the use?" may also be heard. The psychiatrist can confront these issues by pointing out that revulsion, fear, or disgust would be natural reactions to such behavior, but that many patients can enjoy a satisfactory surgical outcome. Despite the violence of the self-mutilative act, the majority of patients do not reattempt self-mutilation, and if properly managed, may not be repetitively self-injurious. u.s The family can also be offered an explanation and guarded reassurance. Middle (post-surgical) phase. Although much emphasis is still directed by the psychiatrist toward staff members, an increasing amount of time will be spent with the patient, who will need considerable emotional support, if not supportive care to the point of protection. An early decision should be made with the surgeon as to who will write orders for psychoactive medications and restraints. The psychotropic dosage must be carefully titrated. Frequent assessments of the patient's mental status are necessary in order to provide sufficiently rapid and accurate changes in plans and 515
Genital self-mutilation
Tabl~Time
Phase
Type of Intervention
Focus
Issues
Early (admission)
Diagnostic evaluation, specific recommendations
Patient and team
Establish diagnosis. reduce symptoms, facilitate compliance with surgical procedures
Middle (post-surgical)
Frequent visits, ventilation, and explanations
Patient, family, and staff
Reduce anxiety, guilt, and psychopathology
Late (approaching discharge)
Infrequent visits, psychotherapy
Patient and family
Future planning, psychodynamic issues
timely recommendations for care. Staff members are encouraged to administer care and dressing changes just as they would for any other patient. The psychiatrist should listen for hidden meanings in the reactions of persons caring for the patient. Reluctance to touch a patient who would "do something like this" may uncover a fear that the patient could be dangerous to staff members. On the other hand, unnecessary occurrences, such as hospital personnel or medical students not directly connected with the patient's care coming to see the wound or to meet an unusual patient, should be actively discouraged. If the operation has been successful, the surgical team may express fear of the patient's "ruining the work." There may be a reluctance to let the patient out of restraints or an expressed desire to move him, in restraints, precipitately to a psychiatric ward or another hospital. The psychiatrist may find it necessary in this case to advocate for the patient in order to deliver comprehensive biopsychosocial care postoperatively.' As soon as possible, the issue of transfer to a psychiatric unit should be addressed, and when the patient's surgical needs are acceptable to a psychiatric unit, those patients with acute psychosis or other
516
Course of Interventions
indication for inpatient psychiatric care should be transferred. In many cases, however, this will not be possible for several days or weeks because of the patient's need for acute postoperative care. If the initial interventions with the surgical team and nursing staff have been successful, consultant time can be productively turned to other issues. Increased attention should be paid to the patient's famil y at this phase of recovery. The psychiatrist can help the family reduce guilt by ventilation and also can act as a liaison between the family and the treatment team. At this time, the family, in tum, can provide additional useful history. Since the patient may still be reluctant to discuss the intimate details leading up to the self-mutilation, this history may help elucidate relevant psychodynamics. Lale (predischarge) phase. This phase begins when the patient's psychiatric condition has stabilized and discharge is anticipated by the surgical team. Staff issues should largely have been resolved by this phase. Increasing time will be spent with the patient who by this time may be ready to begin psychotherapy. Plans for the continuation of psychiatric treatment after discharge should be made. The patient may express guilt or shame
over his act through regressive or antitherapeutic behavior. The relevance of psychiatric care to his quality of life in the future should be addressed. New family issues may also arise. Both patient and family members may worry about what they will tell their friends. Parents will be concerned as to whether they were responsible for the patient's actions. Plans for continued family follow-up and support should also be discussed and put into definite form prior to discharge. Those patients with persistent psychosis or other behavioral indicators for continued psychiatric inpatient care should be transferred to an inpatient psychiatry unit. In these cases, although outcome oftreatment studies are not extensive, the treatment issue would be analogous to those in other self-injurious patients, and the psychiatry staff would be expected to better manage the anxiety induced by these patients. "" Our experience has been that patients, when adequately treated postoperatively, begin to suppress their symptoms rapidly, so they do not present unique treatment problems to inpatient psychiatric units.
Summary From the moment of arrival at the hospital, the genital-mutilating patient re-
PSYCHOSOMATICS
quires continuous surgical and psychiatric care. With the possibility of full restoration of function through microsurgery, early contact is increasingly important. Although the presenting psychopathology might usually serve as an indication for psychiatric hospitalization, the necessary surgical man-
agement mandates that the patient initially remain on a surgical unit. The psychiatrist must render consultation and treatment there. The course of treatment can be conceptualized as consisting of three phases, with the emphasis of the psychiatric consultations shifting as the patient pro-
gresses. The consultation psychiatrist's time can be used most efficiently by shifting the major emphasis from surgical team to family and to patient as the clinical course permits. Surgical and psychiatric collaboration so rendered can optimize outcome and decrease management difficulties. 0
hallucinations and self·amputation of the pe· nis and hand during a first psychotic break. J Clin Psychology 42:322-324. 1981. Mora W, Drach GW: Self·emasculation and self·castration: Immediate surgical management and ultimate psychological adjustment. JUro/124:208-210.1980. Pabis R. Mirza MA. Tozman S: A case study of autocastration. Am J Psychiatry 137:626627. 1980 Clark RA: Self·mutilation accompanying religious delusions: A case report and review. J Clin Psychiatry 42:243·244.1981. Strain J, Demuth G: Case of the psychotic
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