- Email: [email protected]
More on Female Genital Self-Mutilation
Letters to the Editor
mate issues, such as competency and the right to refuse treatment, will be decided in the courts and by legal standards rather than by medical opinion. However, we feel that it is imperative that consultation-liaison psychiatrists be aware of legal concepts and statutory provisions so that medical opinion can enter into the courts' decisions appropriately. We also agree with Dr. Leong's observation that "competency" is not an "all or none" phenomenon. Revisions of some laws in recent years, fortunately, have recognized this fact, and this reasoning has been extended to areas such as mental disability. Nevertheless, competency decisions remain "all or none": the courts decide that the individual person either can or cannot decide about a specific issue. With regard to the value of efforts to develop instruments to assess competency, our position is that instruments exist to enhance the development of clinical opinion. In medical tradition the properly calibrated physician remains "the instrument." Laboratory tests and x-rays, without a physician's evaluation, do not lead to decisions. However, the MMPI in psychometrics, the Competency Assessment Instrument in evaluating competency to stand trial, and the Rogers Criminal Responsibility Assessment Scale for cases in which the insanity defense has been raised all stand as examples of instruments that have strengthened clinical opinion. Conclusions reached by the physician have to be based, as far as possible, on replicable findings before those conclusions can have their appropriate weight in the courtroom. This is as true of competency issues dealt with by consultation-liaison psychiatrists as for any other forensic issues. It is our view that an instrument to assess competency can clarify the legal and psychiatric concepts involved and can aid in training consultation-liaison psychiatrists. We further believe that such an instrument will strengthen medical opinion when expressed in forensic situations. Beverly G. Myers, M.D. Curtis L. Barrett. Ph.D. University of Louisville. Louisville, Kentucky
VOLUME 29. NUMBER 1 • WINTER 1988
More on Female Genital Self-Mutilation SIR: In his letter (Psychosomatics 28:344, 346, 1987), Dr. Coons somewhat overstates the scarcity of reports concerning female genital self-mutilation. Therapists may well be reluctant to report such distressing behavior; nonetheless, a number of other cases can be found in the literature. Goldfield and Glick l describe a patient who repeatedly gouged her internal genitalia with her fingernails. A patient reported by Gerstle et al. 2 malingered placenta praevia, mutilating her vagina with a knitting needle. The patients reported by French and Nelson) and Simpson4 both injured their genitals while suffering from eating disorders. These two cases led Goldney and Simpsons to postulate a discrete syndrome consisting of female genital self-mutilation, an eating disorder, and hysterical personality. Mutilation can also occur during attempts at self-induced abortion. In other cultures, ceremonial female genital self-mutilation has been recognized. I would also offer a reminder that self-mutilation of the breasts was well known among Amazon women; the word Amazon literally means "without breasts."6 Marc D. Feldman. M.D. Duke University Medical Center. Durham, North Carolina
Referem:es I. Goldfield MD. Glish IR: Self-mutilation of the female genitalia: a case report. Diseases of the Nervous System 31 :843-845. 1970 2. Gerstle ML. Guttmacher AF. Brown F: A case of recurrent malingered placenta praevia. Journal of the Mt. Sinai Hospital 24:641-646. 1957 3. French AP, Nelson HL: Genital self-mutilation in women. Arch Gen Psychiatry 27:618-620.1972 4. Simpson MA: Female genital self-mutilation. Arch Gen Psychiatry 29:808-810. 1973 5. Goldney RD. Simpson IG: Female genital self-mutilation. dysorexia. and the hysterical personality: the Caenis syndrome. Canadian Psychiatric Association Journal 20:435-441. 1975 6. Ross RR. McKay HB: Self-Mutila/ion. Lexington. Mass. D.C. Heath. 1979
141
mate issues, such as competency and the right to refuse treatment, will be decided in the courts and by legal standards rather than by medical opinion. However, we feel that it is imperative that consultation-liaison psychiatrists be aware of legal concepts and statutory provisions so that medical opinion can enter into the courts' decisions appropriately. We also agree with Dr. Leong's observation that "competency" is not an "all or none" phenomenon. Revisions of some laws in recent years, fortunately, have recognized this fact, and this reasoning has been extended to areas such as mental disability. Nevertheless, competency decisions remain "all or none": the courts decide that the individual person either can or cannot decide about a specific issue. With regard to the value of efforts to develop instruments to assess competency, our position is that instruments exist to enhance the development of clinical opinion. In medical tradition the properly calibrated physician remains "the instrument." Laboratory tests and x-rays, without a physician's evaluation, do not lead to decisions. However, the MMPI in psychometrics, the Competency Assessment Instrument in evaluating competency to stand trial, and the Rogers Criminal Responsibility Assessment Scale for cases in which the insanity defense has been raised all stand as examples of instruments that have strengthened clinical opinion. Conclusions reached by the physician have to be based, as far as possible, on replicable findings before those conclusions can have their appropriate weight in the courtroom. This is as true of competency issues dealt with by consultation-liaison psychiatrists as for any other forensic issues. It is our view that an instrument to assess competency can clarify the legal and psychiatric concepts involved and can aid in training consultation-liaison psychiatrists. We further believe that such an instrument will strengthen medical opinion when expressed in forensic situations. Beverly G. Myers, M.D. Curtis L. Barrett. Ph.D. University of Louisville. Louisville, Kentucky
VOLUME 29. NUMBER 1 • WINTER 1988
More on Female Genital Self-Mutilation SIR: In his letter (Psychosomatics 28:344, 346, 1987), Dr. Coons somewhat overstates the scarcity of reports concerning female genital self-mutilation. Therapists may well be reluctant to report such distressing behavior; nonetheless, a number of other cases can be found in the literature. Goldfield and Glick l describe a patient who repeatedly gouged her internal genitalia with her fingernails. A patient reported by Gerstle et al. 2 malingered placenta praevia, mutilating her vagina with a knitting needle. The patients reported by French and Nelson) and Simpson4 both injured their genitals while suffering from eating disorders. These two cases led Goldney and Simpsons to postulate a discrete syndrome consisting of female genital self-mutilation, an eating disorder, and hysterical personality. Mutilation can also occur during attempts at self-induced abortion. In other cultures, ceremonial female genital self-mutilation has been recognized. I would also offer a reminder that self-mutilation of the breasts was well known among Amazon women; the word Amazon literally means "without breasts."6 Marc D. Feldman. M.D. Duke University Medical Center. Durham, North Carolina
Referem:es I. Goldfield MD. Glish IR: Self-mutilation of the female genitalia: a case report. Diseases of the Nervous System 31 :843-845. 1970 2. Gerstle ML. Guttmacher AF. Brown F: A case of recurrent malingered placenta praevia. Journal of the Mt. Sinai Hospital 24:641-646. 1957 3. French AP, Nelson HL: Genital self-mutilation in women. Arch Gen Psychiatry 27:618-620.1972 4. Simpson MA: Female genital self-mutilation. Arch Gen Psychiatry 29:808-810. 1973 5. Goldney RD. Simpson IG: Female genital self-mutilation. dysorexia. and the hysterical personality: the Caenis syndrome. Canadian Psychiatric Association Journal 20:435-441. 1975 6. Ross RR. McKay HB: Self-Mutila/ion. Lexington. Mass. D.C. Heath. 1979
141