Male genital self-mutilation due to tomophobia – case report and review of literature

Introduction

Scrotal traumas are included in genital self-mutilation with lesions varying from simple lacerations to the ablation of the whole external genitalia. Self-inflicted orchidectomy and auto-castration (also known as Eshmun complex) is a type of major self-mutilation that are usually common among younger individuals with psychiatric illness. ¹ Throughout history there have been numerous reports of self-mutilation which usually involves mutilation of eyes, ears and genitals. ² It is estimated that the incidence of genital self-mutilation between the ages of 18–35 is 1800 individuals per 100,000. ³ The first such case of genital self-mutilation was reported by Strock in 1901. ⁴ Several factors are attributed to self-mutilation including homosexual or transsexual tendencies, religious beliefs, feeling of guilt after committing a sexual offence, and self-harm. As only a small number of cases get reported, there is no data available on the incidence of genital self-mutilation, which is probably high. ⁵

Phobia derived from the Greek word phobos, defined as an “irrational, intense and persistent sensation of fear in relation to specific situations, activities, objects or individuals”. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), exposure to a phobic stimulus almost invariably leads to an anxiety response. The anxious anticipation or distress in response to a feared situation interferes significantly with an individual’s normal routine, social activities or relationships. ⁶ Preoperative fear or anxiety, which is known as tomophobia, is medically defined as an irrational fear of surgery. Individuals who are booked for surgery experience a feeling of dread, shortness of breath and palpitations which may lead to them avoiding or postponing the surgery. In a study done by Chekwubechukwu et al., it was stated that the fear of surgery is common amongst individuals booked for surgery despite differences in culture, education, profession, age and gender. ⁷

Case report

A 45-year-old male, who was living alone in Mangalore, was found deceased at his residence. His genitals were mutilated, and a knife and a pair of scissors were found lying next to his body. He had recently visited a hospital for his complaint of testicular swelling which was diagnosed as hydrocoele and he was advised to undergo a surgery. His family and colleagues had mentioned that he was very anxious about the surgical treatment and that he was afraid to undergo the procedure. In addition to this, his colleagues poked fun at his predicament. The situation he was facing could have upset him and he took matters into his own hands by trying to get rid of the swelling with the use of a pair of scissors and knife. He made an incision measuring 5 × 4 cm in the left inguinoscrotal region in an attempt to alleviate the hydrocoele. Due to the increased abdominal pressure, his intestines partially came out through the incision and the patient pulled out his intestines thinking that this was the cause of his condition. This led to his demise as a result of massive blood loss which resulted in a haemorrhagic shock.

Autopsy findings externally revealed the body of a 45-year-old male lying in left lateral position with slightly flexed knee and elbow, measuring 160 cm in length and weighing 55 kgs (Figure 1 and Figure 2). Rigor mortis was present all over the body. Postmortem lividity was present on right lateral aspect of the body and was fixed. There was an incised cut wound in the left inguinoscrotal region, measuring 5 × 4 cm. Two cut pieces of the small intestine, measuring 16 cm and 8 cm respectively, were found outside the body (Figure 1 and Figure 2). No other external injuries were found. Upon internal examination, the brain and spinal cord showed congestion and oedema. Both lungs were pale and oedematous on cut section. Trachea showed no haemorrhage or effusion, large vessels were patent and heart unremarkable. Mucosa of mouth, pharynx and oesophagus was pale. Stomach revealed 100 gm of semi-digested food particles with unusual odour. Intestinal mucosa along with cut sections of liver, spleen and kidneys was pale.

OPEN IN VIEWER

Figure 1.

Dead body lying in a pool of blood with mutilated external genitalia next to cut pieces of small intestine, a blood-stained knife and a razor blade.

OPEN IN VIEWER

Figure 2.

Dead body lying in a pool of blood with mutilated external genitalia next to cut pieces of small intestine, a blood-stained knife and a razor blade.

Discussion

According to our literature search, there is no published report of a self-mutilation of external genitalia as a result of tomophobia. A PubMed search using the terms “self-inflicted injury”, “genital self-mutilation” and “tomophobia” did not yield any reports. Genital self-mutilation is a rare form of non-suicidal self-harm with varying severity. There are mainly three groups of genital self-mutilators typically involving men: psychotics, transvestites, and individuals with complex religious beliefs. ⁸ Certain studies have reported that after 110 cases were reviewed for literature, the feelings of guilt after committing a sexual offence or related to religious experiences were found to be some of the important factors or motives for this particular act. ⁹

In a study done by Grielsheimer et al., it was reported that out of 52 cases of self-mutilation of genitals, a total of 87% were found to be psychotic while only 13% were non-psychotic. ¹⁰ It was believed that the psychotic cases occurred as a result of functional psychosis or due to brain damage while the non-psychotic cases occurred as a result of character disorder, religious or cultural beliefs. ¹⁰ In another study done by Aboseif et al., out of a series of 14 cases, 64% were found to be psychotic while only 36% were non-psychotic. ¹¹

A few studies have also reported that genital self-mutilation in non-psychotics occurred as a result of bizarre auto-erotic acts ¹² or due to attempts of crude sex change operations by transsexuals. ¹³ Some of the identified risk factors for genital self-mutilation in males are absence of a competent male figure during developmental years, repudiation of genitals, unresolved sexual conflicts, anxiety and sociocultural vulnerability. ¹⁴

The majority of the reported cases have been in patients with psychiatric disorders or in patients with functional or organic brain disease. ¹⁵ Men who mutilate their genitals are most likely to suffer from psychosis during the act. However, a review of cases showed a significant number of men were not psychotic while they were performing the act but rather had a character disorder. ⁵ The eponym “Klingsor syndrome” describes the “act of genital self-mutilation which is associated with religious delusions”. ¹⁶

Tomophobia is usually accompanied by a feeling of impending death due to the surgical intervention. ¹⁷ The deceased in our case did complain of intense fears related to the impending operation. It is believed that the number of undiagnosed cases might be much higher than that number of cases reported because avoidance of feared situations is the leading behaviour in phobic patients. In a study done by the American Psychiatric Association, it was reported that only 12–30% of the patients suffering from a specific phobia seek professional psychiatric help. ¹⁷ With the development of invasive treatment and the establishment of interventional procedures, the cases of diagnosed tomophobia might increase in the future. The deceased in our case became symptomatic when he was informed about the operation. The patient’s refusal of the surgical treatment can be comprehended as a typical avoidance behaviour due to his phobic disorder.

Conclusion

The act of genital self-mutilation with the intention of suicide is commonly witnessed in individuals with a psychiatric disorder. In this case, the phobia of surgical treatment and sociocultural factors could have played a role in this particular act leading to the demise of the individual. With the rapid progress of modern medicine, tomophobia will likely be an increasingly common clinically impairing anxiety disorder.