To the Editor: In the July 1999 issue, Dr. Alao and associates (1) presented a case of genital self-mutilation by a woman with borderline personality disorder, posttraumatic stress disorder (PTSD), and substance dependency. They suggest that genital self-mutilation tends to occur in patients with psychosis or severe personality disorder, in transsexuals, and in persons with certain religious or cultural beliefs.
I was surprised by the authors' omission of patients with dissociative disorders. The diagnosis of a dissociative disorder is often overlooked. It often occurs in conjunction with borderline personality disorder, PTSD, and substance abuse. Their patient had a history of prostitution, and a substantial proportion of prostitutes may have dissociative disorders.
Recently a 26-year-old woman who was later diagnosed as having dissociative identity disorder entered a partial hospitalization program for treatment of depression and recurrent suicidality. She had made two prior suicide attempts that were almost fatal. She had a history of childhood sexual abuse and had been raped as an adolescent. She had repeatedly made incisions in her vagina with razor blades or surgical scalpels and had then sewn up the introitus in the hope that she could thus permanently close her vagina and protect herself from future sexual abuse.
The patient's dissociative identity disorder remained undiagnosed for the first five years of psychiatric treatment. She had never before disclosed her childhood sexual abuse or her severe symptoms of amnesia, including total loss of memory for ten months during her adolescence. However, she readily reported this information in response to direct questions when she was first admitted to our facility.
The differential diagnosis of genital self-mutilation should always include dissociative disorders.
Dr. Waugaman is clinical professor of psychiatry at Georgetown University School of Medicine in Washington, D.C.