504821

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CCS13210.1177/1534650113504821Clinical Case StudiesKing

Article
Clinical Case Studies
2014, Vol. 13(2) 181­–189
Cognitive-Behavioral Intervention © The Author(s) 2013
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DOI: 10.1177/1534650113504821
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Paul R. King1

Abstract
Self-injurious behaviors are common among clinical populations, and have been associated with
mood disturbance, personality pathology, and trauma histories. Such behaviors often serve
to displace emotional pain, produce physical or emotional sensations, or call for attention
from others. Genital self-mutilation in particular is a statistically rare phenomenon that is
typically associated with psychosis, extreme religious practices, or unsophisticated attempts
at sexual reassignment. The present report describes a unique case of genital self-mutilation
in a nonpsychotic individual with history of chronic depression, hypersexuality, and sexual
masochism. Treatment consisted of a series of 10 individual therapy sessions that used
cognitive-behavioral and dialectical-behavioral techniques to reduce the frequency and severity
of self-injurious behaviors, to increase distress tolerance skills, and to implement and maintain
a healthy pleasurable activity schedule.

Keywords
cognitive-behavioral therapy, dialectical-behavioral therapy, genital self-mutilation, impulsive-
compulsive behavior, nonsuicidal self-injury

1 Theoretical and Research Basis for Treatment

As many as 4% of adults (Klonsky, Oltmanns, & Turkheimer, 2003) endorse nonsuicidal self-
injurious or self-mutilating behaviors. Self-injurious behaviors can pose a particular challenge
for clinicians given the complexity in managing the multidimensional nature of the problem. For
example, clinical management can transcend wound care, treating associated affective distur-
bances, and managing other short- and long-term biopsychosocial consequences of self-injury.
Such behaviors can exist within and outside the context of sexual activity. Common correlates of
nonsexual self-injurious behaviors include younger age, depression, low social support, Cluster
B personality features, sensation-seeking, and childhood sexual abuse (Heath, Schaub, Holly, &
Nixon, 2009; Joyce et al., 2006; Knorr, Jenkins, & Conner, 2013; Muehlenkamp, Brausch,
Quigley, & Whitlock, 2013). In contrast to paraphilic sexual masochism, literature suggests that
nonsexual self-injury typically happens impulsively and with minimal pain (Nock & Prinstein,
2005), serving purposes such as displacing emotional pain, producing physical sensation, induc-
ing an emotional “high,” managing stress, and attention-seeking action (Hicks & Hinck, 2009;
Nock & Prinstein, 2004; Starr, 2004). Some studies (e.g., Sacks, Flood, Dennis, Hertzberg, &

1VA Western New York Healthcare System, Buffalo, NY, USA

Corresponding Author:
Paul R. King, Center for Integrated Healthcare (116N), VA Western New York Healthcare System, 3495 Bailey Ave.,
Buffalo, NY 14215, USA.
Email: Paul.King2@va.gov
182 Clinical Case Studies 13(2)

Beckham, 2008) have found that a primary motivator for self-injurious behaviors is the percep-
tion that it leads to increased positive affect, even if only temporarily, and a review by Bresin and
Gordon (2013) suggested that self-injury may regulate affect by prompting the release of endog-
enous opioids. Yet others (e.g., Brown & Kimball, 2013; Buser & Buser, 2013) posit that nonsui-
cidal self-injury may constitute a process addiction. The recent edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) has
identified nonsuicidal self-injury as a condition for further study.
Like nonsuicidal self-injury, there has not been a clear consensus as to whether problematic
sexual behaviors fall along an impulsive-compulsive spectrum (Mick & Hollander, 2006),
within a behavioral or process addictions model (Garcia & Thibaut, 2010; Schneider & Irons,
2001), or among a separate sexual disorder taxonomy (Bradford, 2001; Cantor et al., 2013;
Finlayson, Sealy, & Martin, 2001; Kafka, 2001; Kingston & Firestone, 2008; Marshall &
Briken, 2010). Although the pathological taxonomy and nomenclature of aberrant sexual behav-
ior are controversial (Karim & Chaudri, 2012; Samenow, 2010), it is clear that problematic
sexual behaviors do exist. For example, nonparaphilic hypersexuality can be associated with
medical and psychosocial risks such as infectious disease, mood disturbance, and relationship
conflict, particularly in cases where unprotected and multiple-partnered sex are routinely
involved. Some paraphilic behaviors, for example sexual masochism (which entails nonsimu-
lated injury by self or other), can be associated with increased risk of medical complications,
serious physical injury, and even death (consider hypoxyphilia, for example) depending on the
severity of the injury sustained. Some paraphilia-related behaviors (e.g., repetitive and exces-
sive use of pornography; Kafka, 2001; Kafka & Hennen, 1999) can also be associated with
isolation and psychosocial disruption.
Despite the prevalence of other self-injuring behaviors, genital self-mutilation is an especially
rare phenomenon (Catalano, Morejon, Alberts, & Catalono, 1996), and one that is typically asso-
ciated with psychosis (Chand, Kumar, & Murthy, 2010; Feldman, 1988; Nakaya, 1996). Some
literature suggests that nonpsychotic individuals engage in genital self-mutilating acts for reli-
gious or cultural purposes (e.g., self-circumcision), to deal with sexual guilt, or as independent
attempts at sexual reassignment surgery (Cole, O’Boyle, Emory, & Meyer, 1997; Feldman,
1988). Presumably due to the low base rate of the phenomenon, there is a corresponding paucity
of research specific to clinical interventions for nonpsychotic genital self-mutilation. However,
cognitive-behavioral interventions such as replacement skill training, behavior modification,
stimulus control, relapse prevention, cognitive restructuring, and dialectical behavior therapy
have shown promise in reducing the frequency of impulsive-compulsive behaviors, paraphilic
and hypersexual acts, and other forms of self-injurious behavior (see Andover, Pepper, & Gibb,
2007; Bradford, 2001; Dracobly & Smith, 2012; Feldman, 1988; Franklin, Zagrabbe, &
Benavides, 2011; Healey, Ahearn, Graff, & Libby, 2001; Kreuger & Kaplan, 2002; Linehan et al.,
1999). Recent literature (e.g., Muehlenkamp et al., 2013) suggests that interventions that target
improving social support, coupled with emotion regulation skills, also may be of therapeutic
benefit.

2 Case Introduction
The present report describes a case of genital self-mutilation in M, an individual with a history of
hypersexuality, excessive pornography use, and sexual masochism. M was a 56-year-old,
Caucasian, male Vietnam-era veteran referred to a Department of Veterans Affairs (VA) outpa-
tient mental health clinic by his psychiatrist for treatment for dysthymia and nonsuicidal self-
injurious behavior. He lived alone and was unemployed at the time of intake. The therapist was
a predoctoral psychology intern who was supervised by a licensed clinical psychologist.
King 183

3 Presenting Complaints
M described his chief complaints as depression and self-injury in the form of genital mutilation.
He reported a long history of depression and anxiety, with boredom, lack of concentration, and
rapid loss of interest in things as notable features of his mood disturbance. He also endorsed what
he referred to as a 30-or-more year history of autoerotic genital “manipulation,” which ultimately
escalated to cutting behavior and other forms of self-mutilation.

4 History
M was born in a large metropolitan area to an intact family. He described a childhood wrought
with familial conflict and physical and emotional abuse. Multiple family members abused alco-
hol, and his paternal grandfather and great grandfather died by suicide. His mother died when he
was a teenager, and he eventually was estranged from all biological family members with the
exception of one sister. He enlisted in the military within 2 years of completing high school, and
married shortly thereafter. By his report, he was honorably discharged from the military after
approximately 1 year of service after revealing that he was bisexual. Though he divorced after 2
years of marriage, he stated that he remained on amicable terms with his former wife. He admit-
ted to drinking and experimenting with illicit drugs during his 20s and 30s.
M described a history of hypersexuality from the time of his divorce through his mid 40s. By
his report, he engaged in solo and/or partnered sexual activity up to six times a day, at times
anonymously or with multiple partners. He stated that frequent sexual activity helped him man-
age stress, and that perception of his own sexual prowess improved his chronically low self-
esteem. He also became increasingly preoccupied with his genitalia during this time frame, and
began to frequently engage in what he termed genital “manipulation” as a habitual autoerotic,
masochistic act.
M was diagnosed with HIV/AIDS in his early 30s. Shortly thereafter, a long-term partner of
his died from AIDS-related complications. M previously trialed antiretroviral therapy, but dis-
continued due to financial limitations, the perception that it would not help him, and belief that it
worsened a preexisting irritable bowel condition. His last partnered sexual activity was at approx-
imately age 45. Previous medical and mental health records suggested that he had injured his
penis in the past, though it is unknown whether this was intentional as with his current behaviors,
or unintentional side effects of the masochistic “manipulation” he described. One episode of
genital manipulation circa age 46 led to excessive penile bleeding, though he avoided emergency
medical treatment due to embarrassment. He hypothesized that this episode may have ultimately
contributed to the onset of erectile dysfunction, though there was no current medical evidence
that this was the case. He estimated that his last erection was at age 47, and he admitted to sub-
stantial rumination over his impotence since that time. Even considering his inability to attain an
erection, he began to view pornography in excess, which he described as “out of character.” He
also reported that the types of pornography he sought access to had become increasingly “bizarre”
in hopes that it would stimulate him, though he did not provide explicit details on the content.
M reported that depressive symptoms had been present for most of his life, and that he also
suffered from a historically low frustration tolerance. He cited a single inpatient psychiatric hos-
pitalization for suicidal ideation, but framed it in the context of a consequence of sleep depriva-
tion over several days. This hospitalization coincided temporally with the onset of erectile
dysfunction. He endorsed a long history of suicidal ideation and fantasies of public suicide, but
denied history of attempts, intentions, and plans to end his life. Though he had credentials as a
home inspector, he was prevented from working due to disability, and his only current income
was derived from disability benefits. He accrued over $20,000 worth of debt due to longstanding
financial limitations, and his home was in foreclosure. He occasionally attended religious
184 Clinical Case Studies 13(2)

services, sang in a choir, and had lunch with two acquaintances. Prior to initiating this episode of
treatment, he had been linked intermittently with multiple other therapists and psychiatrists for
management of depression over two decades, with his last use of psychotherapeutic services 4
months prior. He reported that he had discarded many of the tools with which he injured himself
at the urging of his medical and psychiatric providers, but admitted to retaining a wire brush,
paint scraper, and box cutter.

5 Assessment
M completed two neuropsychological assessments prior to commencing therapy for his current
concerns. The first evaluation found mild deficits in verbal learning and recall associated with
severe depression. The second evaluation (2.5 years later) found similarly severe depressive
symptoms. Personality assessment indicated that he was prone to obsessive and negative rumina-
tions, and suggested that therapeutic interventions avoid introspective self-analysis in favor of
concrete problem-solving interventions. Though previous medical records documented history
of stroke with mild memory loss, neither neuropsychological evaluation suggested substantial
cognitive impairments typically associated with history of stroke or immunodeficiency. During
the course of the current treatment episode, M was assessed with the Beck Depression Inventory-II
(Beck, Steer, & Brown, 1996), which suggested severe symptoms of depression; the Beck
Anxiety Inventory (Beck & Steer, 1993), which suggested mild to moderate anxiety; and the
Alcohol Use Disorders Identification Test–Consumption questions screening tool (AUDIT-C;
Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), which did not suggest current alcohol
abuse. Self-report ratings of mood pathology were consistent with history documented over
many years. As such, the primary assessments during the current treatment episode pertained to
tracking the frequency and severity of self-injurious behavior as well as the frequency and nature
of pleasurable activities.

6 Case Conceptualization
M reported a long history of hypersexuality and masochistic activity. He recently began to utilize
an excessive amount of pornography despite that he felt it was “out of character” for him. He
admitted to using sexual activity as a coping skill, and indeed linked his sexual performance to
his self-worth. Impotence was a notable point of rumination for him, and he went to great lengths
to seek stimulation via use of masochism and viewing pornography, which intensified in terms of
frequency, duration, and content over the years. The frequency and manner in which he viewed
pornography resembled the concept of behavioral addiction. Genital manipulation escalated to
mutilation in an attempt to experience penile sensation; evidence of a sensation-seeking motiva-
tion was found in his description of what motivated his self-injurious behavior: “When I see
blood, it’s like a climax; I feel that there’s life down there.”
Cognitive-behavioral and dialectical behavioral techniques, to include behavior chain analy-
sis, have been implemented in cases of nonsuicidal self-injury (e.g., Andover, 2012). The primary
behavioral antecedent to M’s self-injury appeared to be his use of internet pornography, though
isolation and close proximity to tools with which he typically would injure himself were also
important contextual factors. Specific target behaviors included cutting, squeezing, and piercing
his penis and scrotum, and inserting foreign objects into his urethra. Consequences of his self-
injurious behavior included the primary reward of sensation (perhaps as a substitute for sexual
release), but also necessitated wound care and may have contributed to ongoing issues with
incontinence.
Beyond the hypothesis that M’s self-injurious behaviors were attributable to a sensation-
seeking hypothesis, other explanations for M’s behaviors may be viable as well. For example, it
King 185

is possible that his actions were an extension of his masochistic tendencies and sexual fantasies.
It is plausible that he became desensitized to severe masochistic activities over time. Self-injury
also could have served to manage stress in the absence of his ability to attain an erection. As
sexual activity had certainly been a significant component of his identity, he may have at times
acted to punish himself out of depression or self-loathing, and a body of literature does exist to
support that some individuals self-injure to alleviate feelings of guilt (Inbar, Pizzaro, Gilovich, &
Ariely, 2013). Aside from his difficulties with impulse control, a number of other Cluster B per-
sonality features and risk factors were evident as well. For example, persistent mood disturbance,
chronic suicidal ideation, and disruption of identity were important historical trends. Other clini-
cal factors, such as personal abuse history, inadequate social support, and suboptimal engage-
ment in medical treatment for wound care and HIV/AIDS management were also noteworthy.

7 Course of Treatment and Assessment of Progress

M presented for 10 sessions of individual therapy, scheduled weekly for 50 min each. The first
session was dedicated to a comprehensive intake, consisting of mental status examination, per-
sonal medical and social history, lethality assessment, and behavior chain analysis, which detailed
self-injurious behaviors as recent as approximately 2 weeks prior to intake. Session 2 centered
around joint treatment planning and introducing basic cognitive-behavioral principles and tech-
niques such as identifying core beliefs, belief testing, and behavior modification. At this meeting,
M commented that psychotherapy had recently been his only positive interpersonal exchange,
and he was hopeful that it would facilitate his ability to lead a healthier life. Consistent with ini-
tial aims of dialectical behavioral therapy, a general goal was to reduce behavioral dyscontrol.
Specific treatment goals included reducing the frequency and severity of self-injurious behav-
iors; implementing and maintaining a healthy pleasurable activity schedule; and enhancing M’s
overall quality of life.
At Session 3, M reported that he had resumed self-injury by striking his penis with a wire
brush and “jamming” his finger into his urethra, which resulted in excessive penile bleeding. He
recounted that this and other episodes of self-injury began after using pornography, and described
regular feelings of self-loathing. Medical records suggested that he refused wound examination
at an earlier clinic visit. Additional coping strategies were introduced, including distress toler-
ance skills (e.g., distraction and self-soothing skills) and activity scheduling. We also discussed
the possibility of pharmacological therapy as a way to continue moving toward M’s goal of a
better quality of life. M agreed to follow up with his medical care provider for wound care and to
discuss the merits of starting a medication, and was ultimately started on alprazolam .25mg as
needed. By the time of our fourth session, M reported one additional instance of nonpenetrative
self-injury and increases in suicidal ideation. This meeting was dedicated to crisis management
and safety planning. Sessions 3 and 4 endured for 60 and 75 min, respectively.
M reported improvements in mood in Sessions 5 and 6. He limited his use of pornography and
did not engage in self-injurious behavior. He also had been implementing a behavior activation
plan which included watching comedy and going to see movies. Over the course of these meet-
ings, he discarded some other items that he used to injure himself and was able to successfully
use response-prevention skills to avoid pornography on some occasions, and to avoid what he
described as the “temptation” to self-injure. He agreed to trialing an antidepressant after Session
6, and also began to discuss the possibility of resuming antiretroviral medications with his medi-
cal provider at his regularly scheduled follow-ups.
M reported one episode of genital cutting at Session 7. He did not take alprazolam one day,
relapsed with pornography use, and subsequently cut his penis. In contrast, he was notably bright
at Sessions 8 through 10, consistently indicating that he felt more hopeful and “in control” of his
186 Clinical Case Studies 13(2)

destiny, increased his social activity, and denied using pornography or engaging in self-injurious
behavior.
Session 10 was a planned transition session. By this meeting, M had not injured himself in
over a month, had regularly attended church and other social activities, and concluded that he
would resume antiretroviral medications because it was consistent with goals for his future
health. He transferred to another psychologist at the completion of the therapist’s doctoral intern-
ship. Records confirmed that he resumed antiretroviral therapy at a future medical visit.

8 Complicating Factors
Perhaps the most notable complication in working with M was the elevated risk of infection
given his diagnosis of HIV/AIDS. Nonsuicidal self-injury is not typically life-threatening, but M
had injured himself on multiple occasions with a variety of nonsterile foreign objects, any of
which could have posed very serious complications in an individual with a compromised immune
system. M also endorsed a personal history of stroke. Although neuropsychological testing did
not detect any substantial deficits, minor cognitive problems that were likely associated with
mood pathology were evident. With regard to use of antiretroviral therapies, M had a long history
of complaints related to incontinence, anal dysplasia, and irritable bowel syndrome, some of
which he believed were complicated by immunotherapy agents. The multitude of relevant clini-
cal factors made a concise conceptualization challenging. In terms of his psychiatric history, M
suffered from a long history of depression and impulsivity, experienced chronic suicidal ideation
and fantasy, and evidenced enduring Cluster B personality traits. Sexuality had served as a long-
term coping skill and substantially influenced his perception of self-worth. Replacing that coping
skill with novel skills unrelated to sexuality posed a challenge, as did the prospect of beginning
to restructure a series of well-established personal schema and core beliefs. Despite the fre-
quency of nonsuicidal self-injury, genital self-mutilation is an especially rare occurrence, and
little empirical support is available to guide clinical intervention for this unique presenting
concern.

9 Access and Barriers to Care

M was a veteran entitled to VA services. As such, there were relatively few barriers to care.
Co-pays and financial limitations posed a minor but surmountable challenge. After concluding
treatment, he planned to relocate to another metropolitan area which also had a VA facility nearby.

10 Follow-Up
As planned, M transferred to another therapist after completing 10 sessions of individual therapy.
He attended two outpatient follow-up sessions with a psychologist, and one outpatient follow-up
with his psychiatrist prior to relocating. Follow-up at 2-months post-therapy suggested that M
had continued to avoid self-mutilating practices at that time and did in fact continue with therapy,
psychopharmacological intervention, and antiretroviral therapy.

11 Treatment Implications of the Case

M’s case illustrates the application of cognitive-behavioral and dialectical-behavioral techniques
for the rare phenomenon of genital self-mutilation. Prior to therapy, M had engaged in multiple
instances of self-injurious behavior, many of which led to substantial bleeding, and all of which
posed inherent health risk in a person with a compromised immune system. After learning a
series of individual coping skills and engaging in behavior activation, M appeared to reduce his
King 187

use of pornography, discontinue self-injurious behavior, increase social contact, and maintain a
pleasurable-activities schedule. A significant strength of this treatment setting was that it allowed
for regular, direct communication and consultation with medical providers, and facilitated multi-
disciplinary care management for this individual. Despite the relative success of this therapeutic
endeavor, M did relapse with self-injury three times over the course of therapy. However, with
ongoing medical, psychiatric, and therapeutic support, M appeared to maintain therapeutic gains
at approximately 2 months post-intervention.

12 Recommendations to Clinicians and Students

The nature of presenting concerns, client preferences, and limitations of clinical settings do not
always allow for the full implementation of manualized treatment protocols. However, M’s case
highlights that the use of cognitive-behavioral and dialectical-behavioral techniques is flexible
and indeed can afford the opportunity for clients to learn a set of skills that are highly transfer-
rable to their daily lives. Despite the effectiveness of these approaches, the importance of the
therapeutic alliance and clinical supervision and technical consultation cannot be understated.
Given the delicacy and multimorbidity of M’s presenting concerns, a strong therapeutic alliance
served to promote the notion that the therapist and client would work together to develop treat-
ment and safety plans, and to establish short- and long-term goals. Treatment planning and goal-
setting were facilitated by open and ongoing communication among M’s therapist, psychiatrist,
and medical provider. Although neither supervisor nor supervisee had clinically managed genital
self-mutilating behaviors in the past, each had experience in the delivery of cognitive-behavioral
and dialectical behavioral interventions, and biweekly supervision was used to plan interventions
and to review progress.

Author’s Note
The views expressed in this article are those of the author and do not necessarily reflect the position or
policy of the Department of Veterans Affairs or the United States government.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.

Funding
The author disclosed the receipt of the following financial support for the research, authorship, and/or pub-
lication of this article: Writing of this article was supported in part by the Department of Veterans Affairs
Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment;
the Department of Veterans Affairs Center for Integrated Healthcare; and the VA Western New York
Healthcare System at Buffalo.

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Author Biography
Paul R. King is a postdoctoral fellow in the VA Advanced Fellowship Program in Mental Illness Research
and Treatment. He earned his MA and PhD from the University at Buffalo, State University of New York.