No abstract

He talked of his previous incarnation in eighteenth century Russia when he had led a large religious movement, was persecuted, and had castrated himself with a red-hot poker. There was no psychiatric history, but his father had died three days previously. A consultant psychiatrist diagnosed an acute reactive psychosis, detained the patient formally, and sedated him. He was then transfused, and his wounds were explored under general anaesthetic. There was a 10 cm scrotal laceration, and he had successfully excised the left testis and the lower pole of the right. Haemostasis was achieved and the wound debrided and sutured. He made a satisfactory recovery and was reviewed by the consultant psychiatrist, who found him to be lucid and rational. He was discharged on sedation with psychiatric and surgical follow up arranged but subsequently committed suicide by swallowing weedkiller. Comment In a recent review of 53 reported cases of deliberate male genital self mutilation only seven patients were considered not to be psychotic at the time of self mutilation.3 Ten had made previous attempts at genital self mutilation, and at least half had received previous psychiatric treatment, many being long term inpatients. The two patients described here are unusual in that genital mutilation was the first indication of a psychiatric disorder. They are the first cases to be recorded after the recent death of a father, though in one previous case the patient had just lost his pet dog and a tame bird.3 Genital injuries varied from those without lasting harm to complete amputation of the genitals with other bodily injury, but no difference has been observed in the severity of injuries between the psychotic and non-psychotic groups.3 Genital self mutilation after paternal death might be expected on theoretical grounds in individuals with an unresolved oedipal complex. The son may have regarded his father as a potential rival and have felt guilty about his continuing sexual attachment to his mother. Thus the guilt that is part of any bereavement reaction4 might occasionally be greatly exaggerated. The son might then punish himself by genital injury or castration, thereby carrying out what he considered was his father's wish in an attempt at restitution. Further cases may be prevented by increased awareness. Sons at risk would probably have an undue attachment to mother, an intense ambivalent relationship to their deceased fathers, and a very intense or otherwise abnormal grief reaction. The subsequent suicide risk has been estimated at 50`50`by one group,5 but Greilsheimer and Groves thought that only five of their 53 reviewed cases were acutely suicidal.3 The second case reported here emphasises the risk in these patients. We thank Mr G H Jantet for his help and encouragement and Dr Averil Stedeford for her helpful advice and contribution to the paper.

No abstract