8 search results for "apotemnophilia"

The Complicated Issue of Transableism

The complicated issue of transableism 1050x700I’ve written here a few times about a condition to which I referred as apotemnophilia, a craving to have a body part amputated. I had never considered the parallels, as this article does, to gender dysphoria and gender transition. Being transabled, or having body integrity identity dysphoria, refers to the feeling that one is a disabled person trapped in an able body, that one is meant to be an amputee. The anthropologist Jenny Davis has written about the variety of ways transabled people express what she has called their “impairment needs”:

The term wannabe refers to those who want/need to have a physical impairment. Pretenders act out their impairment-needs by, for example, folding an appendage, inserting ear plugs, wearing opaque contacts, walking on crutches, wheeling themselves in a chair, or wearing neck/leg/back braces. Devotees experience fetishistic attractions toward the physically impaired bodies of others…

The natural reaction to transablism (which I admit I felt when I wrote about apotemnophilia) is one of incredulity or abhorrence. Exploring that reaction, it seems to be based on the assumption that amputation is a choice, or a learned preference, for the affected person. And the choice of such a “socially devalued bodily state” as disability is stigmatized. But Davis’ investigation suggests that it might rather be thought of as essential. Again, this is in many ways parallel to the experiences of transgendered people as I understand them. Until gender dysphoria was understood and accepted, it seemed to many that the choice to transition was the problem, or the disorder, rather than the solution for the affected person. In both the transgender and the transable situations, wanting to transition is a route toward being one’s true self rather than departing from it. Transable people, observes Davis, often initially resisted a notion of wanting to stable themselves which they found abhorrent, but lost the battle. In the subset of “wannabes” who had sought psychotherapy for their amputation urges, therapy was never successful in changing the desires or relieving the distress. In contrast, it appears that those who have obtained a desired amputation find relief in ways they have been unable to get by other means.

So accepting the concept of body integrity identity dysphoria challenges us to consider the assertion that transabled people seeking amputation ought to be able to get them from reputable surgeons. If denied, many may either patronize disreputable back alley surgeons, injure a limb to compel medical amputation, or attempt to do it to themselves. Other elective surgical procedures are used to make the body conform better to social ideals; why shouldn’t people be allowed to change in ways with which society is less comfortable?

Of course, the parallel to gender transition may break down in at least one way. Satisfying the desire to maim or disable the body may entail enormous financial costs to care for the resultant lifelong disability. Thus, it may not merely be a matter of respecting the right to autonomy.


Via JSTOR Daily

Psychological disorder causes you to hallucinate your doppelgänger

Via Boing Boing: ‘In the book The Man Who Wasn’t There, Anil Ananthaswamy explores mysteries of self, including the weirdness of autoscopic phenomena, a kind of hallucination in which you are convinced that you are having an out-of-body experience or face to face with your non-existent twin. From a BBC feature based on one of the book chapters…’

Of the lectures I have given, one of those that most fascinated my audience, and which I have therefore rolled out over and over to entertain, has been a roundup of odd and offbeat psychiatric disorders. These include autoscopic phenomena, as noted above, as well as Fregoli, Cotard’s, apotemnophilia, Alice in Wonderland syndrome, Munchausen’s (of course) and my personal favorite, Capgras, about some of which I have written here in the past and all of which challenge fundamental aspects of our perception of reality. Do a Google search on “odd unusual psychiatric|psychological syndromes” to explore these topics further.

Exploring the Ethics of Contested Surgeries

Metapsychology review: Cutting to the Core, edited by David Benatar, deals with ethical issues surrounding some of the most controversial surgeries in practice. Discussed are male circumcision and female genital cutting, sex assignment and reassignment, conjoined twin separation, limb and face transplantation, cosmetic surgery, and placebo surgery. The book is organized into six parts, each corresponding to one of these topics. As the editor mentions in his introduction, the aim of this collection was not to present an article for each side of the subjects (i.e., one ‘for’ and one ‘against’). Rather, the goal was to highlight the ethical issues involved with these surgeries by offering the reader various views of and approaches to these issues. Even when the authors’ conclusions agree, their approaches might not… ” It sounds like an interesting book, but I am surprised that it does not appear to include anything about surgical amputation for patients with apotemnophilia, about which I have written several times in FmH.

I Won’t Be Happy Until I Lose My Legs

I have written before, here (“A New Way to be Mad”; scroll down or use your browser’s search function to find ‘apotemnophilia’) (2000) and here (“Costing an Arm and a Leg”; ditto) (2003), about apotemnophilia. It is back in the news because of this Guardian article, but it seems it has a less tongue-tying name now — BIID or body identity integrity disorder. Here are a spate of recent references (Google) under the new name. [“Squick!” — acm]

Annals of Depravity (obviously):

‘If Armin Meiwes gets off on the insanity degree, I’ll eat my…’ On trial in Germany, cannibal says victim was willing. Meiwes says that being an only child yearning for a younger brother transmuted itself into an obsession with wishing to consume someone to incorporate them into him and bind them to him forever, according to his testimony. He says he got over four hundred responses to an ad he placed seeking someone for “slaughter and consumption.” When he met his victim, they apparently dined on his penis after Meiwes amputated it. Later, his victim was killed and dismembered, and Meiwes consumed various body parts over ensuing months. He was arrested after authorities were alerted to a subsequent ad he placed; buried human remains were found at his home. The case is legally complex, since cannibalism per se is not a crime, and since the victim was seemingly a willing accomplice in his own death.

A reader was reminded loosely of my two essays on apotemnophilia here and here. I share the sense of being challenged about how to conceptualize situations in which people collaborate in their own gruesome mutilation, disfigurement or death for inexplicable reasons. I am in a way more stupified by the four hundred people who responded to Meiwes’ ad than by his depravity.

Related? Victoria Van Dyke is the pseudonym of an artist who describes her work in this way:

My drawings and paintings of the past have been deeply personal and often of a sexual nature. It is only natural that my photography is deeply personal, sexual and sometimes confusing, even to me. I work with models in my photography because I am uncomfortable showing my own body…

I now identify myself as a cannibal, although I have never attacked or eaten anyone, nor do I feel the urge to do so at this time. I simply am a cannibal who due to social restrictions decides not to eat. Much like a vegetarian who decides not to eat meat. This overlap of my eating beliefs with my art is an intriguing one, because I feel it grabs people’s attention, and I like the attention that I get.

Perhaps I am only interested in being a cannibal because of the attention it gives me, but psychologically speaking, if I was ever given the opportunity to eat someone, and get away with it, I would.

Costing an Arm and a Leg —

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On the occasion of a new documentary about the subject, philosopher of medicine Carl Elliott writes in Slate about apotemnophilia. “The victims of a growing mental disorder are obsessed with amputation.” Apotemnophilics at times succeed in obtaining a medically unjustified amputation of a healthy limb either from a sympathetic surgeon or after intentionally damaging a limb so badly that it must be amputated. I reflected here on Elliott’s earlier thoughtful overview of the phenomenon, A New Way to be Mad, published in The Atlantic Monthly in December 2000, which he says inspired the documentary film.

The phenomenon is of course of interest for its — shall we say — titillating gruesomeness, but for Elliott and myself another concern revolves around the significance of the attempt to make it, or the presumption that it is, a psychiatric disorder. Should it be considered so? And if so, is it its own category of disorder or should it be considered a manifestation of another, already recognized, class of disorder? Elliott notes that it is usually treated as if it is a paraphilia or displaced sexual disorder, because “many wannabes are attracted to the idea of themselves as amputees, and some are attracted to other amputees.” But, in the absence of a body of clinical experience with apotemnophilics, it is not clear to me that those who would like to see themselves with amputees are the same as those who would like to see themselves as amputees. Perhaps it is heterogeneous? If a disorder, is it closer to a body image disorder? In body dysmorphic disorder, the individual insists that one of their bodily features is misshapen or grotesque (although others do not perceive it in that way) and may seek surgical correction. Some BDD is psychotic (delusional) in degree and improves with treatments such as antipsychotic medication. And some psychotics under the influence of other kinds of delusions mutilate or injure themselves as well, sometimes grotesquely — I have seen enucleations, castrations and, yes, amputations of a hand, an arm or a leg.

Furthermore — how akin to gender identity disorder is it, and how deep may the analogy go to sufferers’ seeking sex reassignment surgery in that condition? Is it a type of obsessive compulsive disorder? Broadly speaking, compulsions are of two sorts, those which are experienced as distressing by the affected individual, who attempts to resist complying with them; and those which are not resisted and mostly cause distress only to those surrounding the individual. What relationship might it bear even to Munchausen’s Disease, in which an individual simulates or creates a medical condition in themselves presumably for the sympathy and support they aspire to?

Or is apotemnophilia on a continuum with other body modifications or mutilations — scarification, piercing, tattooing — we do not usually consider evidence of psychiatric disorders? If you come away from the film about apotemnophilics experiencing them sympathetically no matter how difficult you find it to understand their desires, will your sympathy be for them as mentally disordered and distressed or as oppressed by a society that does not allow them the gratification of desires which are not understood and sometimes abhorred but which do no harm to anyone else?

Elliott is interested in, as he puts it, “why so many people have begun to use the tools of medicine for purposes other than curing illness, such as self-improvement and self-transformation”, and I share that interest especially as it applies to the appropriation of growing dimensions of distress by psychiatry and the expanding notion of the indications for psychopharmaceutical treatment.

Obviously, if the boundary between curing illness and self-improvement is a murky and shifting one, then so will be the definition of illness. Elliott observes that it is well-known to historians of medicine that illnesses come and go, and he lists a number of conditions once seen as rare or nonexistent but then ballooning in popularity:

“social anxiety disorder, post-traumatic stress disorder, attention deficit-hyperactivity disorder, gender identity disorder, multiple personality disorder, anorexia, and chronic fatigue syndrome.”

He attempts to generalize about these conditions that:

“…(t)his is not simply because people decided to “come out” rather than suffer alone. It is because all mental disorders, even those with biological roots, have a social component. While these new conditions are very different from one another, they share several important features.

  • First, the conditions are usually backed by a group of medical or psychological defenders whose careers or reputations depend on the existence of the disorder and who insist that the condition is real.
  • Second, there is usually no hard data about the causes or the mechanism of the condition.
  • Third, no independent lab tests or imaging devices are available to provide objective confirmation of the diagnosis, which is usually made solely on the basis of the narratives and behavior of their patients.
  • Finally, there is often (but not always) a treatment for the condition even in the absence of knowledge about its causes and mechanism.”

The phenomenon of faddish diagnoses in psychiatry has been one of my pet interests, about which I have written, taught and lectured since soon after my training. I would quibble with the list of conditions Elliott includes but more significantly with his attempt to generalize about the phenomenon. Elliott may be, to paraphrase his first point above and turn it back on him, staking his credibility on the existence of shared generalities among a group of phenomena he insists is homogeneous but may not be.

First, a contribution of equal importance to the medical/psychological practitioners’ insistence on the reality of these diagnoses is often the incredible appeal they have to classes of patients who are deeply motivated to have them. There may be a core of ‘legitimate’ sufferers the class of whom becomes broadened by others’ insistence on joining that class. This in turn may obscure the ability, when the supposed class of sufferers are studied, to find the hard data, the lab or imaging abnormalities that could definitively define the condition. In a sense, the core findings are diluted beyond statistical significance by the influx of wannabes to the class.

Often, in particular, the controversial syndromes are on the borderline between psychiatry and other medical areas (consider attention deficit [neurology], fibromyalgia [rheumatology], TMJ [orthopedics or dentistry], hypoglycemia [endocrinology], spastic colon [gastroenterology], chronic fatigue [originally considered to be chronic Epstein-Barr virus infection]) and relate to shifting conceptions on the part of both medical science and the lay public about the mind-body boundary. Certain classes of patients have long been interested in having their distress defined “medically” instead of “mentally”, to whatever extent the zeitgeist draws a distinction. This, of course, bears on Elliott’s third point, that the diagnosis “is usually made solely on the basis of the narratives and behavior of … patients.” This is no less true of the vast majority of ‘legitimate’ psychiatric disorders; the CNS is still a black box. No definitive tests or imaging studies exist for any psychiatric disorder. The more important thing about the faddish or dubious diagnoses may be, in a way, how similar they are to, rather than how different from, the universe of the rest of psychiatric diagnoses.

And Elliott’s fourth generalization too is true of most psychiatric diagnosis as well — that there is often “a treatment for the condition even in the absence of knowledge about its causes and mechanism.” For example, the universe of psychiatric patients began to be ‘carved up’ differently between those with schizophrenia and manic depression (bipolar disorder) after the arrival in the early ’50’s of lithium carbonate on the scene as a treatment for the latter, and again after the entrée of chlorpromazine (Thorazine), the first of the so-called antipsychotic medications. More recently, I have written here in the past about the much-observed (and ongoing) redefinition of the scope of antidepressant-responsive conditions after the introduction of Prozac in the early ’80’s ushered in the SSRI era and made antidepressant prescribing so much easier. One may argue that the most important influence of new drug developments on diagnosis is exerted via the pharmaceutical companies’ inexorable marketing pressures, or it may be the prescribers’ pull to the novelty of new agents. In any case, in deriving principles that apply generally to psychiatric diagnosis, Elliott has failed to identify what may be distinctive about or explanatory of the controversial diagnoses.

Furthermore, one must not focus on the social factors in the rise of a diagnosis to the exclusion of the medical-scientific ones. Disparate diagnoses may balloon through their own unique balance between being better recognized (it was there, but we didn’t see it before), being reclassified (it was there but we referred to it as or lumped it in with something different before) or being created (it wasn’t there until people began to shape their behaviors to the newly-promulgated definition). It’s like the old joke about the umpires and the strike — “I calls ’em as they are”; “I calls ’em as I sees ’em”; and “They ain’t strikes ’til I call ’em.”

To return to apotemnophilia, it is not clear where it will fit with these other faddish diagnoses, but we will probably get an opportunity to see, as interest in it appears to be burgeoning, both among the wannabes and among clinicians.

Here is a site to which Elliott points from “a group of medical, psychological and psychiatric professionals committed to increasing the knowledge about this disorder, particularly within the medical and psychological communities”; they propose renaming it Body Integrity Identity Disorder. Elliott is troubled by his observation that mental health practitioners have so far proposed no treatment other than surgery. He seems to consider this a failing in the face of an obvious mental disturbance. I would suggest an alternate explanation. Psychiatrists and other therapists are more accustomed than the lay public to nonjudgmental toleration of a wide variety of unconventional and disturbing thoughts , beliefs and feelings in their patients. As bizarre and gruesome as the apotemnophilic’s desires are, while they are not easily understood they may be more tolerable to the mental health practitioner sitting with the patient than to others. (I have never sat with a patient with this preoccupation myself; I don’t know.) These patients, not believing they have a psychiatric disturbance, will probably present only rarely if ever for a mental health consultation. They may not be treatable when they do present, since psychiatric treatment cannot be compelled against one’s will unless a person is so disturbed that they represent an imminent danger to themselves or others, no matter how bizarre we find their symptoms. Most psychiatric practitioners are respectful of that constraint. But if a sufferer presents acknowledging their distress and its psychiatric nature and voluntarily seeking treatment, I would wager that few psychiatrists would be at a loss to treat them in any one of a variety of ways depending on how they formulated the individual case, perhaps along one of several hypotheses I suggested above about where BIID/apotemnophilia may fit; or others.The number of psychiatrists who would send such a patient for surgical intervention would, I would venture to say, be vanishingly small. Perhaps, if the condition does burgeon in popularity to an extent that mainstream surgeons (rather than the apparently marginal characters who seem to be performing the bulk of the amputations these days) have to pay attention to it, psychiatric evaluation and clearance will become as de rigeur before surgery as it has become for gender transition surgery.

A New Way to Be Mad (Caution: the referenced article has graphic details not for the squeamish) Carl Elliott, a philosopher of psychiatry, with a medical degree, writes a long reflection on the growing epidemic of apotemnophilia, a psychological malady in which people seek the amputation of one or more of their limbs without medical cause. This is done with or without the assistance of a surgeon, some of whom feel there are no humane alternatives to relieve their patients’ distress. (“It was the most satisfying operation I have ever
performed. I have no doubt that what I was doing
was the correct thing for those patients”, said one.)

was interested in the way that previously
little-known psychiatric disorders spread, sometimes
even reaching epidemic proportions, for reasons
that nobody seems fully to understand. But I had
never heard of apotemnophilia or acrotomophilia
before the Falkirk story broke. I wondered: Was this
a legitimate psychiatric disorder? Was there any
chance that it might spread? …I also wondered about the ethical and
legal status of surgery as a solution. Should
amputation be treated like cosmetic surgery, or like
invasive psychiatric treatment, or like a risky
research procedure?

Other interesting questions — is this a problem of sexual desire (there are certainly large numbers of “devotees” who are sexually aroused by people missing limbs, but it does not appear that the “wannabes”, those who seek amputation, are sexually motivated) or a disorder of body image or sense of self? What does it say about the nature of our self-identity? What relationship does it bear to other, less extreme, body modification techniques in our own and other cultures? What is the balance between its psychological, possible neurobiological, and sociological determinants? How deep do the homologies between amputation-by-choice and sex-reassignment surgery go? Is it adequately explained as a subset of some other existing category of psychopathology — e.g. body dysmorphic disorder, obsessive compulsive disorder, the paraphilias — or is it something distinct from all of them? More radically, is it a disorder at all? If it is, what is to be considered acceptable treatment, in light of the “extraordinary and often very destructive collaboration” between psychiatry and surgery over the past seventy-five years?

clitoridectomy for
excessive masturbation, cosmetic surgery as a
treatment for an “inferiority complex,” intersex
surgery for infants born with ambiguous genitalia,
and — most notorious — the frontal lobotomy. It is a
collaboration with few unequivocal successes. Yet
surgery continues to avoid the kind of ethical and
regulatory oversight that has become routine for
most areas of medicine.

I’ve long had professional concern about the role that popularizing faddish new diagnoses may have in spreading them. Consider for example multiple personality disorder, which I’m convinced barely exists if at all but has hordes of adherents (“wannabe” sufferers, and “devotee” clinicians). Dr. Elliott has a fine summary of the arguments of a historian of medicine, Ian Hacking, whose thoughtful work about how “transient mental illnesses” arise and take hold I’ve followed closely.

Crucial to the way this worked is what Hacking calls
the “looping effect,” by which he means how a
classification affects the thing being classified.
Unlike objects, people are conscious of the way
they are classified, and they alter their behavior
and self-conceptions in response to their
classification…In the 1970s, he
argues, therapists started asking patients they
thought might be multiples if they had been abused
as children, and patients in therapy began
remembering episodes of abuse (some of which may
not have actually occurred). These memories
reinforced the diagnosis of multiple-personality
disorder, and once they were categorized as
multiples, some patients began behaving as multiples
are expected to behave. Not intentionally, of
course, but the category “multiple-personality
disorder” gave them a new way to be mad.

Is apotemnophilia going to be a particularly malignant example of such contagion? What is the balance between the extent to which cultural and historical conditions reveal, as opposed to create, new disorders? How far do we want to go in regarding it as a psychiatric diagnosis, including it in DSM-V, the next edition of the “Bible” of officially acceptable diagnoses (and, by the way, the basis for insurance reimbursements). In essence, is this going to spread like a new meme, to which Hacking refers as “semantic contagion”? Its severity may be enhanced by the potential for connectivity among “devotees” and wannabes”. As Dr. Elliott points out, part of the motivation of apotemnophiles may be an aspiration to heroism, and of their devotees to hero worship, which the web facilitates tremendously. One discussion group on the topic has over 1400 participants. Atlantic Monthly