Open in a separate window Sexual Gratification Sexual gratification is commonly reported by patients and accepted by clinicians as the reason for autoerotic or consensual sexual acts involving the insertion of foreign objects into the erogenous zones of the urethra, 23 , 24 , 28 — 30 vagina, 31 or rectum. Psychoanalysts have long observed that psychosexual energy libido can become invested in actions that do not lead directly to orgasm, such that some behaviors may be primarily reinforced by a compelling emotional payoff that has become layered upon a secondary outcome of orgasm, or occurs in the absence of orgasm.
A deeper understanding of the patient's situation may also distinguish between nonpathologic sexual preferences and the paraphilic disorders. When a patient's sexual history reveals a pattern of recurrent behaviors, fantasies, or urges involving nonhuman objects that causes significant distress or functional impairment, a paraphilic disorder fetishism may be diagnosed.
Such behavior can take the form of foreign body insertion eg, 76 needles and hair pins self-inserted under the skin of a woman's arms, head, and neck, which required surgical excision, 36 or straightened paper clips inserted into the forearm Suicide Attempt Suicide attempts by foreign body insertion usually involve oral ingestion of toxic solids eg, batteries or sharp objects such as pins.
Psychosis With or Without Mood Disturbance Psychosis with or without mood disturbance can lead to foreign object insertion either directly in response to a delusional belief or command hallucination or indirectly via impaired judgment.
Recurrent depressive illness without psychosis has also been diagnosed in some insertions leading to hospital attention. One illustrative example of malingering and social contagion 51 involved 6 males 3 met criteria for antisocial personality disorder and 3 for BPD living in a maximum-security hospital who copied each other's urethral self-insertion technique in a deliberate attempt to control hospital staff.
All 6 inserters reported that their behavior released tension, while the initial inserter reported a sadistic fantasy during insertion in which he imagined the damage being inflicted to the urethras of other people. Cognitive Disorders Cognitive disorders may lead to foreign object insertion or influence its course.
In one case series of 17 men who presented with urethral insertion, substance intoxication was detected in 6 men. These include nonpathologic sexual preference; exploratory misadventures occurring in children as isolated acts driven by simple curiosity 54 — 57 ; insertions by other people during sexual assaults or pranks 58 — 61 eg, a man's friends inserted tennis wire into his urethra at a stag party and another man's roofing colleagues forced cylindrical rolls of tar into his urethra to have fun at his expense ; drug concealment or smuggling 62 , 63 ; and misguided attempts at contraception, abortion, or self-treatment of anal or urinary symptoms.
Although case reports of foreign body insertion are not uncommon, only a few large reviews on the subject exist; most were written before How people insert, embed, or ingest foreign bodies depends largely on the type of objects used, and the anatomic location of the object's placement.
Upper Gastrointestinal Tract Upper GI tract foreign body ingestions are more common in those who are either young, have comorbid drug or alcohol use histories, have psychiatric illness, or are prisoners. Intentionally ingested items were typically common household items eg, pens, plastic spoons, toothbrushes, or pencils , whereas accidentally ingested items were often food impactions, bones, or coins. Since then the incidence of colorectal foreign body insertion has been increasing; it is no longer considered an uncommon reason for ED care.
Vagina Many reports of foreign bodies placed into the vagina involve children and are usually associated with premenarchal vaginal discharge or sexual abuse. The actual prevalence of foreign object insertion in the general population or in specific psychiatric populations is unknown. However, many of those who seek medical attention on account of foreign object insertion report a history of the same behavior. A smaller but significant proportion have a history of medical complications from foreign object insertion, suggesting that developing medical complications and being hospitalized are insufficient to arrest insertion activity.
In one series of 17 men seeking management following urethral foreign object insertion, all reported a history of urethral insertions. As both Bibring and Groves have remarked, if an appropriate relationship cannot be established between the patient and the physician, it is not always because the physician does not understand the patient, but because the physician does not understand his or her own reaction to the patient.
Reactions by hospital staff to patients who insert foreign bodies are varied, ranging from genuine concern to revulsion and avoidance. As has been described in patients with self-mutilation, medical or surgical house staff who care for patients with foreign body insertion may experience dysfunctional behavior, clouded cognition, and labile affects, either due to disruptive patient behavior or due to the uniqueness of their medical or surgical presentation.
Consultation psychiatrists may assist in averting these potentially harmful outcomes by providing education and awareness of common countertransference reactions. Rationale for Psychiatric Consultation At present there is no consensus about when psychiatric consultation should be sought or what it should involve for the management of patients admitted for foreign object insertion.
Some have suggested that consultation should be ordered on a case-by-case basis, appropriate only for patients with a history of psychiatric problems 30 , 58 or for cases involving unusual foreign objects or a history of foreign object insertion.
By doing so, psychiatric problems that may have contributed to the insertion behavior can be identified and treated. Even in the absence of psychiatric illness, harm-reduction strategies may be taught to psychologically normal individuals who embrace the insertion behavior as a lifestyle preference. Goals of Psychiatric Consultation for Foreign Object Insertion Diagnosis Minimize harm to the patient during the hospital course Evaluate the risk of imminent insertion in the inpatient setting Identify any underlying syndromal psychiatric illness Identify and contain countertransference reactions of staff Treatment Minimize harm to the patient after discharge Minimize anxiety and shame associated with the experience of being exposed Counsel patients about harm-reduction strategies and less dangerous means of insertion Consider referral to outpatient psychiatric treatment including psychotherapy Open in a separate window In addition, psychiatric consultation may minimize harms associated with traumatic affective states caused by interactions with the hospital and its staff.
Numerous reports attest that anxiety and shame are commonly experienced by inserters particularly those who do so for sexual gratification on initial presentation to the hospital. Mr A initially declined opportunities to explain his insertion behavior to the primary team, leading them to seek psychiatric consultation.
He waved off the psychiatric consultant when he initially arrived. He began to dread daily rounds by the primary team and nurse encounters. He reported feeling more anxious and ashamed—even when no external audience was present—and he became less receptive to conversations with anyone.
Countertransference reactions by caretakers may intensify unpleasant affective experiences of inserters during the hospital course. Staff reactions of perplexity, disgust, and titillation in regard to Mr A appeared to stem from the discovery that he practiced a sexual behavior considered perverse. In a large-scale repetition of earlier shame-inducing discoveries of Mr A's behavior, x-rays showcasing the flower vase circulated around the hospital to and possibly by staff not directly caring for him.
The consultant should do the following. Titrate the duration, frequency, intensity, and setting of consultation visits to the patient's level of anxiety and shame. Drawing a curtain around Mr A's bed blocked visual exposure to the gaze of passersby, but his speech remained audible to his roommate. Arranging for a private office down the corridor from his room enabled Mr A to speak with less discomfort.
Review initial and all subsequent iterations of the insertion behavior. What were the psychological circumstances fears, wishes, feelings surrounding the initial insertion? What have been the intended effects of the behavior, as compared with its actual effects? Has the behavior progressed in frequency, size, and type of objects used or its effect on the patient? What does the patient think has shaped or reinforced the behavior over time?
How does the patient feel about the behavior now? Review prior presentations to medical care. Have there been medical complications of the behavior in the past? Has the patient previously delayed or avoided presentation for medical attention? Elicit a psychosexual history as part of the general social and developmental history. What are the patient's preferred sexual practices and masturbatory fantasies? Is there a history of sexual abuse or trauma?
What level of sexual education has the patient received? These matters may be particularly important in regard to urethral and rectal insertions, as there is anecdotal evidence that insertion by these routes may be correlated with telltale psychosexual themes including sadistic fantasies, isolation, and a perception of having had an overbearing parent. Consider staff's countertransference reactions, including one's own. Mr A was raised primarily by his mother, while his father maintained an active sexual life outside of the marriage.
Mr A reported conflicted feelings toward his mother, fancying himself as her protector and as her victim. He had no visitors during his hospitalization.
He lived alone in a boarding house and maintained few social contacts. He no longer felt close to his mother. Only rarely did he experience orgasm associated with the insertion. He was unaware of commercial products that were available for the purpose of anal stimulation.
Previous encounters with the health care system on account of his insertion behavior augmented his shame. He denied any similarity between his mother's initial discovery of his behavior decades ago and the recent discoveries by his doctors on each presentation to the hospital. He said that it was his anxiety about others discovering his behavior that had prevented him from entering sex shops to purchase safe insertion toys and from presenting promptly for medical attention on previous occasions when he realized he could not remove the inserted objects.
Evaluate the risk of imminent recurrence of foreign object insertion in the inpatient setting. This means removing foreign bodies present in the hospital milieu that could be used in repeated injury, as well as treating any acute psychiatric illness that may predispose to such behavior.
One year-old woman with BPD who inserted 76 needles and hair pins into the skin of her head, neck, and lower arms continued to incorporate new foreign bodies following surgical excision, 36 suggesting that those for whom insertion is a means of regulating painful affects may be at particular risk of imminent repeated self-injury. A one-to-one sitter at the bedside may be needed to protect patients from repeated inpatient insertions. Counsel patients about harm-reduction strategies including less dangerous means of insertion.
Deaths have been reported from inherently unsafe autoerotic foreign body insertion practices eg, vaginal insertion of a carrot causing fatal air embolism, urethral insertion of a lead pencil causing bladder perforation and peritonitis, and rectal insertion of a shoe horn causing anal canal laceration and hemorrhage. Mr A eventually accepted a listing of local sexual novelty shops offering these products.
Treat underlying psychiatric factors that predispose to recurrent insertion. Specific pharmacologic approaches may be indicated for acute psychiatric problems such as psychosis, mania, and depression amenable to medication management.
Patients with recurrent self-injurious insertions serving an emotional regulatory function may be assisted in establishing initial contact with treatment teams that specialize in behavioral treatment of recurrent self-harm. However, many inserters decline referral to psychiatric follow-up at the time of discharge. Individuals incurring injury from foreign body insertion often delay their presentation to the hospital once injury has resulted, usually out of a wish to avoid embarrassment or guilt.
Common potential etiologies include sexual gratification, self-injury to inflict pain, embarrassment, punishment [possibly to alleviate mental anguish] , psychosis eg, to obey command hallucinations or to diminish some perceived bizarre threat through that bodily territory , reexperience of nostalgic memories with high affective valence, compulsivity eg, to relieve anxiety associated with not performing this activity , and factitious illness ie, to become a patient with a dramatic arrival to the health care system.
While sexual gratification seems to have been the primary motivation for Mr A's rectal insertion of a foreign body as he himself stated , other features of the case suggest that additional factors were in operation. Early conflict between these feelings may have led to difficulty in separating from her as this did not occur until his late 20s and to an unstable self-image prone to profound bursts of shame.
His earlier shame-ridden experience of being discovered by his mother while a teenager seems to have been repeated in a series of similarly shaming presentations to the attention of hospital staff, brought on by his own choices that posed unclear meaning to him. Thus, in addition to being sexually gratifying, Mr A's escalating foreign object insertion may have been a factitious, unconsciously motivated revisiting of a prior relationship with powerful, complex affective valence.
The consultant identified 2 potentially useful interventions: The 2 aims were related insofar as Mr A needed to tolerate thinking and talking about the insertions in order to become receptive to harm-reduction interventions and any indicated treatment recommendations.
Planned, brief, confidential visitations by the consultant gradually led to a more complete understanding of the function of the insertion behavior, as Mr A spoke about his mother, his loneliness, and his wish to feel less empty inside.
He was counseled on ways to equip himself with safer means of sexual gratification, but he identified shame as a substantial barrier to availing himself of these harm-reduction strategies. The consultant eventually referred him for psychotherapy due to the distressing impact of the insertion behavior and the hospitalization. Psychotherapy was explained as a setting in which he might be gradually exposed to, and eventually learn to tolerate, overwhelming thoughts and feelings related to his hospital experience, insertion behavior, and upbringing by his mother.
Unfortunately, such behavior exposes the affected individual to medical morbidity eg, complications of object insertion, surgical removal, and its aftermath. Unearthing the etiology for foreign body insertion can lead to management strategies that target the motivation for the behavior without the infliction of bodily harm.
Staff reactions fraught with fear, shame, anger, derision, scorn, and perplexity to such behaviors are often intense and can impinge upon compassionate care. Timely psychiatric assessment in addition to assessment and treatment of medical surgical complications is of paramount importance.
Failures to address the underlying cause will very likely lead to an individual's remaining at increased risk of repeated occurrences.
Pediatric foreign body ingestion. American Society for Gastrointestinal Endoscopy.