Phallicide: A case of auto penile amputation as a mode of suicide

To the Editor

Genital self-mutilation (GSM) has been frequently reported in association with psychiatric disorders (Stunnell et al., 2006). However, GSM in the form of auto penile amputation has been infrequently described and the few reports are of patients who had psychotic symptoms (Schweitzer, 1990). We describe a case of a non-psychotic individual who performed auto penile amputation as an attempt at suicide.

K.S. was a 33 year old single male from Southern India presented with low mood, decreased self-esteem, easy fatigability and disturbed sleep persisting for four years with intervening periods of partial remission. Assessment revealed a pre-morbidly well-adjusted individual with adequate occupational functioning and a past history of an untreated and partially remitted episode of severe depression without psychotic symptoms which had lasted for six to eight months, four years previously, precipitated by the suicide of his brother who was diagnosed with Bipolar Disorder. Following this, a Complicated Grief Reaction (CGR) ensued, and eight months later, he suddenly one day performed penile amputation using a razor blade. He subsequently reported committing the act with intent to end his life. During the process, he had amputated about two-thirds of the shaft of his penis and left his scrotum and testes untouched. He was rushed to the hospital and, after controlling the blood loss and as per surgical advice, he underwent penile reconstruction carried out over seven stages and two years. He was co-operative during the whole course of surgery and expressed regret over his action. The reconstructed penis was without any anatomical/physiological deficits.

Detailed evaluation at our hospital revealed an absence of previous suicide attempts, substance use, body image disturbance or disturbance of sexual identity. There were no past/present psychotic or schizophrenia symptoms. A diagnosis of Recurrent Depressive Disorder with Moderate Depressive Episode and CGR was made. Psychological assessment with projective tests revealed multiple conflicts regarding heterosexual relationships, poor self-concept and low ego strength.

As he had come prepared for only a brief admission, Behaviour Therapy was initiated with a focus on grief resolution. He was initiated on Tab.Mirtazapine 15–30mg per day. Individual therapy to work on conflict areas was planned. At discharge, he reported improvement in low mood and sleep. He was scheduled for follow-up in a month’s time.

There are probable antecedent factors such as his brother’s suicide leading to a chronic CGR and a poorly remitting depressive illness which could have contributed towards risk of GSM in this case. Literature reveals that more than 10% of self-mutilations are performed with the intention of suicide (Romilly and Isaac, 1996), and it is widely believed that amputation of the phallus is fatal and male GSM be considered a suicide attempt (Conancher et al., 1991). The fact that this patient had sexual conflicts and had a belief that phallic amputation is fatal could have led to the circumstances surrounding his act; based on this the authors have decided to coin this as a case of attempted ‘phallicide’.

This case of attempted phallicide is unique as the patient did not have psychosis and there were factors such as sexual conflicts playing a major role, perhaps vindicating a need for a more psychodynamically oriented approach towards assessment and intervention in such cases.