Sociology is not merely concerned with external social forces and relations but also with the mental life of its subject matter, which necessarily includes people. At least it should. I have always found sociological work that excludes or minimizes concrete individuals and human agency as incomplete at best.
Lately, I have been writing more about matters of psychiatry and social psychology. Although I have an undergraduate degree in psychology from a major state university, critics may claim I am unqualified to speak on this topic. In addition to several years conducting program evaluation for an alcohol and treatment facility, in which, despite not being qualified to evaluate clients, I was nonetheless exposed to psychiatric categories, cases, and industry-wide aggregate statistical patterns, I also have a masters degree and a PhD in sociology.
There is a robust social psychology in my chosen discipline. George Herbert Mead, a principal founder of the perspective Herbert Blumer tagged “symbolic interactionism,” describes his own views as “social behaviorism.” Erving Goffman writes powerfully on mental life, as you will see below, as does Peter Berger and Thomas Luckmann (social constructionism). Howard Becker and his cohort pioneered labeling theory. There is also a robust tradition in sociology of critical examination of the institution and practice of medicine. This essay is an instantiation of that tradition.
Body dysmorphic disorder (BDD) is a condition where persons obsess over perceived defects in their appearance. A woman with an emaciated body sees a fat person in the mirror. Another woman wishes to be an alien because the human form is ordinary. She want to become a “beautiful monster,” as the woman in the above video who appears to be wearing a mask describes herself. A man might see an arm that shouldn’t be there, so he removes it with a power tool. Another will crush his legs beneath concrete slabs so doctors will amputate them. The transabled person, if you will accept that construct for a moment, is a person who feels trapped or feels like an imposter in his own body. It’s the wrong body and he seeks to transform it into the right body, to become that which he feels is in him. His disability is by choice. Another man finds his genitals alien to him. I am describing actual cases.
The person suffering from BDD may desire to surgically alter her appearance in ways that are disfiguring to those who do not suffer from this disorder—and even to herself, if and when she realizes what she has done. In a bid to specify BDD in light of these cases, which are growing in frequency, a newer label has emerged, namely Body Integrity Identity Disorder (BIID). This named disorder appears around 2013. BIID is diagnosed when a person has a pathologically strong desire to remove an appendage or substantially alter his body. It is a species of BDD.
Some doctors believe persons who want to transform their bodies in disfiguring ways should be allow to do so. Such surgery is already occurring in the United States. Align Surgical Associates Inc., a medical firm based in San Francisco, endorsed by, among others, the American Society of Plastic Surgeons, the American Medical Association, and the Aesthetic Society, will perform a surgical procedure known as “nullification” on those who wish “to enjoy a relatively smooth genital area,” a “mostly unbroken transition from the abdomen down.” The firm offers this procedure for those who wish to “enjoy a body that looks closer on the outside to the way they feel on the inside.” Some people wish to have no genitals and Align Surgical Associates Inc. will make that happen. For a fee, of course. (The firm’s website has a gallery, if you are interested.)
I did not label the practice of complete removal of genitalia “nullification.” This is the term Align Surgical Associates Inc. use in marketing their services. It’s an industry term. In a world increasingly conveyed in Orwellian Newspeak, nullification is a straightforward way to describe a procedure that erases the genitals. To nullify is to make of no use or value, to cancel out, to invalidate. The difference between invalid and invalid is only a matter of pronunciation.
At this point, I want to emphasize two things. First, just as we have sympathy for those stricken with cancer or other serious physical afflictions, we must also have sympathy for those who suffer from mental afflictions, who feel trapped in the wrong body or find normal appendages alien or repulsive. The agony of such obsessive and self-destructive thoughts is nothing we would wish on others or should make light of. In the effort to destigmatize mental illness (without excusing the harm such illnesses may cause), we must treat such conditions seriously and in a manner that future generations won’t look back on in horror at the harm the doctor wrought. Psychosurgical interventions, such as the lobotomy, serve as poignant reminders of the excesses of surgical intervention in the treatment of psychiatric disorders.
Second, there are cases where a person has a defect, disfigurement, or a feature that does not conform with social expectations and wishes to change her or his appearance to experience greater inclusion in society. Sociologist Erving Goffman wrote about this in his landmark work Stigma, published in 1963. Goffman defines stigma as an “attribute that is deeply discrediting” (see this essay for a useful summary of his ideas and their elaboration in the literature). Plastic surgeons play an important role in helping persons suffering from physical stigma achieve a more socially inclusive appearance. The desire to erase or minimize physical stigma with surgical intervention is not BDD, but rather an effort to normalize a person.
One response to the desire to alter one’s body to align with social expectation is to demand that society reform its expectations—as if these expectations are arbitrary or chosen. Fat shaming is to be met with body positivity or children should be presumed genderless, to take two examples. The lethality of obesity in the context of the COVID-19 pandemic illustrates the wrongheadedness of the fat acceptance movement. However, social expectations roots, at least in part, in natural history and serve necessary functions for, among other things, the successful propagation of the species. Gender cannot be entirely disentangled from sex for this reason: humans don’t always get the sex of their desire right, but, if gender aligns, they get it right enough to produce offspring. We are startled by the woman’s appearance in the video because we have brains that evolved to detect faces that are within a normal range of appearance. Fetishes aside, faces lying outside that range create anxiety because they signal danger, deformity, or disease. Our brains tells us that she is a monster.
We can see that the woman in the video has disfigured herself. One is lying to himself if he says he believes she hasn’t. Or, again, maybe that person has a fetish for beautiful monsters. Perhaps, at first, she could not see what she and her doctors had done. In her mind, she was becoming what she feels on the inside. She thought she had cheeks like a hamster, she tells us in the video; she wanted bigger cheek bones. The process unfolded for her in much the same way it did for Michael Jackson. Was it Jackson’s goal to resemble a white-faced version of the Red Skull from Marvel Comics? At some point, people who do this to themselves must realize they have altered their face beyond the normal. The woman in the video certainly does. She realized this because of the societal reaction she provokes, especially from children who have not yet learned the practice of civil inattention. Rationalizing perhaps, she now describes herself as a monster, but a beautiful one. In the few short minutes we see her, it appears that a cluster B personality disorder accompanies her BDD.
I need to say more about stigma to get to the heart of the problem I see with surgical intervention to treat the various forms of body and identity dysmorphia. I will get at this by telling you story.
One day, I was picking up my son from school. All the parents were waiting outside, as they always do. There was a man on crutches who was missing a leg. He was unfamiliar to those assembled. At least I had never seen him before. Maybe a visiting uncle? A war veteran ready to face the world? Those who knew the man could see them engaged in civil inattention, i.e., the habitual disregard for abnormality. The adults behind the man, when they thought nobody could see them, stared at the empty space where a leg should be.
Of course, the man knew he had a leg missing. He also knew those engaged in civil inattention were acknowledging that fact by not acknowledging it. The thing with civil inattention is that its occurrence is quite conspicuous to those who are its subject. They shoulder the burden of knowing they are different, that everybody knows they are different, but that people are ignoring the difference because they believe regarding the difference would cause the person embarrassment or pain. It’s an act of reflexive empathy. Mature civil inattention can be so complete that the person doing the disregarding is not even aware that he is doing it. It is automatic.
My mind was working in that particular sociological way as I stood there observing the scene. I knew I was about to experience a Goffmanian moment. I wondered how many other parents knew what was about to happen. Soon, the bell would ring, the kids would burst from the school doors, and they would all see the man with the missing leg. Soon enough, the bell rang and the children burst from the doors, chockfull of the energy tedium accumulates. The limb difference immediately disrupted the expected social flow. The children’s gait quickly reduced to a slow walk. Mesmerized, they all looked at the empty space their parents had pretended not to notice. It was all the children could focus on. Of course it was. It was if time had slowed down.
I watched, one by one, as parents scolded their children, in that silent way, with a firm squeeze of the arm, and sometimes a hush when the child asked what they did wrong. I imagined the talk on the way home. Not hard to imagine. The children were made to feel bad over something they had no control over. Their animality worked as it should. But it is precisely our animality that requires suppression in human society. They were punished for being what nature made them, disciplined with an eye towards reflexively burying that nature beneath on overbearing ego.
How far should we take denial of abnormality? Perhaps you remember a recent controversy concerning Warner Bros’ remake of Roald Dahl’s The Witches. Anne Hathaway’s character’s hands depict an abnormality or deformity (or difference, to be politically correct) called ectrodactyly, commonly known as “split hand.” Advocates from the disability community, self-appointed spokespersons the social problems literature sometimes refers to as “moral entrepreneurs,” complained that the depiction is insensitive and even harmful, as it associates disability with disgust, evil, fear, loathing, monstrosity, etc. Warner Bros apologized for any offense caused.
The complaint is problematic for a couple of reasons. I have already at least implied much of this. It is not the portrayal of limb difference that causes anxiety or instills fear in children, reactions that may take extreme forms, for example apotemnophobia or dysmorphophobia (pathological fear or loathing of missing limbs or deformities respectively). Even a slight deviation from the normal can produce anxiety in many children. At least it will draw their attention. As people with strabismus (crossed eyes) or ptosis (drooping eyelid) will tell you, slight misalignment of an eye or a squinty eye will almost invariable cause children to ask, “What’s wrong with your eye?” Especially if their parents aren’t around. As a child, I suffered from apotemnophobia, a malady that my parents quickly corrected in a series of dinners with a lovely young friend of theirs missing her arm at the elbow. At first, I didn’t want to come out of my bedroom. Soon she once driving me to the movies in her VW. I marveled at her ability to shift gears.
Children only learn civil disobedience—the ability to disregard deviation or disturbance—over time. Moreover, extreme reactions towards difference are not always marked by fear and loathing. In some children and adults, limb difference may generate attraction, for example, in apotemnophilia, a fetish for amputees. And, of course, in a properly ordered personality, empathy is the common response, which reflect one’s horror at the thought of this being their own circumstance. The point is that it’s not the reaction that is social, but rather the non-reaction. The initial reaction is natural. The animal brain, an evolved organ, assumes normality. We inherited facial recognition wetware from our ancestors. It’s primordial. If a face is not quite right, it will produce anxiety or fascination. Phobias and fetishes are rooted in recognition of physical or behavioral deviation from the norm. Differences may produce anxiety or empathy, but they are inevitably experienced.
Second, monsters of all sorts, vampires, witches, etc., are the sublimations of behavioral and physical abnormalities in people. The real world is the concrete substance of folktales and myths, horror stories. It is the source of Zemeckis’ vision of the Grand Witch. This has been a feature of human society since the dawn of civilization—and likely long before then. Fear management and negotiation of difference may be functional. If a witch in the Warner Bros movies should not be so depicted because that is offensive to some in the disability community (and we cannot assume the moral entrepreneurs speak for the community—or that there even is a community), then there are great many movies that should not have been made or should not be made in the future. But if there are useful functions associated with literature and art made around difference, should we avoid it for the sake of those who are offended?
Which brings us to the heart of the problem: things have flipped. What we see in the cases of surgical treatments of BDD and BIID is changing the appearance of a person not to erase or minimize an objective appearance others find startling or revolting, but changing appearances others regard as normal into something they will find startling or revolting. The person seeking surgery in this case falsely perceives a defect or deformity, and in changing that feature, produces one.
In the video, the interviewers refer to what doctors did to this woman (will they do more?) as “treatments.” The doctors are making money by disfiguring her. The more people doctors can convince to accept as treatment for psychiatric disorders the surgical altering of the body to align with delusion, the more money these doctors can make cutting on people. The woman reports that none of the medical staff who have treated her have ever told her that she has gone too far. Look at her. Those who are supposed to care for her enabled her transformation into “beautiful monster.” The interviewers rationalize the situation saying that appearance is “subjective” and that the surgeon who believes she has been “over-treated” (even he can’t get away from the Newspeak) is expressing an opinion that apparently has no greater weight than the opinion of the victim of the medical-industrial complex.
This is a psychiatric disorder. As Thomas Szasz taught us, the mind is not something that can be defective or diseased. The notion of mental illness is a metaphor. But that doesn’t change much practically. The mind lives in the brain and the brain can be damaged, defective, or diseased, and such conditions can result in disordered thoughts and distorted perceptions. In BDD, there is a disruption in the normal process of transduction of environmental stimuli. The brain has difficulty accurately mapping the body and processing visual information. Those suffering from BDD have difficulty processing other faces, which confirms their perception that there is something wrong with their bodies. They see neutral faces as angry and judgmental faces. This suggests that something is going on in the regions of brain that process body language and facial expression, chief semiotic indicators of attitude and intent.
There is still a great deal we do not know about the pathophysiology of BDD, but “clues to its possible neurobiological substrates and abnormalities in information processing are starting to emerge,” writes Jamie Feusner and associates in “The Pathophysiology of Body Dysmorphic Disorder,” published in Body Image (2008). Here’s part of the abstract:
“This article reviews findings from genetic, brain lesion, neuroimaging, neuropsychological, and psychopharmacological studies that have allowed us to develop a tentative model of the functional neuroanatomy of BDD. There is likely a complex interplay of dysfunctions in several brain networks underlying the pathophysiology of BDD. A combination of dysfunctions in frontal-subcortical circuits, temporal, parietal, and limbic structures, and possibly involving hemispheric imbalances in information processing, may produce both the characteristic symptoms and neurocognitive deficits seen in BDD. An improved understanding of the pathophysiology of BDD will be crucial to guide the development of better treatments.”
When the medical industry develops those better treatments, how will society rationalize the legacy of the beautiful monsters who paid for the palatial estates of ambitious and enterprising plastic surgeons? Will we be allowed to tell the truth about it? Will we be allowed to use that truth to prevent the creation of future monsters?