To the Editor,
Self-mutilation involving the genitals is a rare and severe form of deliberate self-harm, often arising from profound psychiatric disturbances. Klingsor syndrome—a term derived from Wagner’s opera Parsifal—describes genital self-amputation (autopeotomy) in the context of psychotic or delusional beliefs.[1] While fewer than 200 cases of genital self-mutilation (GSM) have been reported worldwide, fewer than 25 explicitly meet the criteria for Klingsor syndrome.[2] Co-occurrence with culture-bound syndromes, such as Koro, is exceedingly rare. We report a unique case illustrating the intersection of Klingsor and Koro syndromes, presenting a significant diagnostic, and therapeutic challenge.
A 35-year-old married male driver with a 10th-grade education was brought to the emergency department after genital self-amputation and attempted suicide by drowning. He underwent emergency urological stump closure and was medically stabilized. A psychiatric evaluation revealed a 6-month history of progressive paranoid ideations (infidelity, persecution) and intense guilt over perceived past sexual misdeeds. He reported a firm, delusional belief of penile shrinkage, fearing retraction into his abdomen would cause his death (a Koro-like symptom), leading to severe socio-occupational dysfunction. Overwhelmed by delusional guilt, he enacted the self-amputation.
Mental status examination revealed a poorly groomed man with active persecutory and infidelity-related delusions, reduced psychomotor activity, and blunted affect. A comprehensive evaluation, including normal laboratory investigations and neurological exam, ruled out organic causes. A provisional diagnosis of a primary psychotic disorder (ICD-11: 6A20-6A25) was established, given the clear delusions and functional decline. A family history of psychiatric illness was noted in his father.
The patient was managed in an inpatient unit under high-risk suicide protocol. Pharmacological management included risperidone (titrated to 6 mg/day) and lorazepam for agitation, supplemented with daily supportive psychotherapy. The consultation-liaison team reviewed him daily. His psychotic symptoms improved significantly. He was discharged with a plan for depot medication and close outpatient follow-up, but was subsequently lost to follow-up despite multiple attempts to contact him.
This case is unique in its demonstration of Koro-like symptoms arising within a primary psychotic disorder. A review of the literature finds that while Koro-like symptoms secondary to schizophrenia are reported,[3] progression to actual self-amputation (Klingsor syndrome) is exceptionally rare. In most Koro cases, patients use physical maneuvers to prevent retraction.[4] In our patient, overriding delusional guilt, and psychosis reframed the organ as the source of suffering, leading to its removal. This convergence of a culture-bound fear with a psychotic drive represents a unique and dangerous psychopathological mechanism.
The primary implication is that clinicians must assess for underlying psychotic disorders when Koro-like symptoms present, especially with functional decline, or bizarre delusions. Management requires an integrated, multidisciplinary approach. While immediate surgical stabilization is vital, psychiatric intervention with antipsychotics (e.g., risperidone) to target the core psychosis is paramount. A robust, long-term follow-up plan, involving community health workers and family psychoeducation, is critical to ensure medication adherence, prevent relapse, and avoid further harm. This case underscores the need for culturally-sensitive, timely psychiatric intervention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Schweitzer I. Genital self-amputation and the Klingsor syndrome. Aust N Z J Psychiatry. 1990;24:566–9. doi: 10.3109/00048679009062914. [DOI] [PubMed] [Google Scholar]
- 2.Veeder TA, Leo RJ. Male genital self-mutilation: A systematic review of psychiatric disorders and psychosocial factors. Gen Hosp Psychiatry. 2016;38:130–4. doi: 10.1016/j.genhosppsych.2016.09.003. [DOI] [PubMed] [Google Scholar]
- 3.Strong YN, Cao DY, Zhou J, Guenther MA, Anderson DJ, Kaye AD, et al. Koro syndrome: Epidemiology, psychiatric and physical risk factors, clinical presentation, diagnosis, and treatment options. Health Psychol Res. 2023;11:70165. doi: 10.52965/001c.70165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.American Psychiatric Association . Arlington (VA): American Psychiatric Publishing; 2013. Cultural Concepts in DSM-5. [Google Scholar]