In Reply: Dr. Waugaman's point is well taken that dissociative symptoms and dissociative identity disorder frequently coexist with borderline personality disorder, posttraumatic stress disorder (PTSD), and other psychiatric diagnoses. Dissociative identity disorder is often associated with a high risk of self-mutilative behavior (1,2). It is therefore surprising that not much has been written about genital self-mutilation in women with dissociative disorders.
As we indicated in our letter, vaginal cutting tends to be less dramatic than castration and thus may be less frequently reported. It is also possible that clinicians are less inclined to report female genital mutilation for reasons of confidentiality. In addition, dissociative identity disorder is frequently overlooked and may be misdiagnosed as another psychiatric condition, such as schizophrenia (3) or PTSD. Patients with schizophrenia have also been found to have a tendency to dissociate (4).
It is unclear from the existing literature how often dissociative disorders are found in cases of genital self-mutilation like those described by us and Dr. Waugaman. One suspects that genital self-injury may be linked to a history of early sexual trauma that frequently precedes the development of both severe borderline pathology and dissociative disorders. As yet, the data are insufficient to confirm this association. Careful assessment for dissociative symptoms is warranted in patients who present with genital self-mutilation. Confirmation of such a diagnosis has implications for treatment.