Did you know that in the late 1990s, Dr. Robert Smith, a surgeon at Falkirk and District Royal Infirmary in Scotland, performed leg amputations on two perfectly healthy men? Horrifying, no? Unthinkable, right? It happened.
Both men suffered from a form of body dysmorphic disorder (BDD) known as apotemnophilia. This condition causes patients to believe that they will only be normal if they have a limb removed. In each case, the men had their leg amputated above the knee.
Smith performed the surgeries after the men had been turned away by other doctors. Before the surgeries, both patients underwent counseling by psychiatrists and a psychologist, and they were assessed by medical professionals. The procedures were discussed with Smith’s defense body and the ethics committee of the General Medical Council. The hospital charged £3,000 ($4,800) per leg amputation.
The chairman and board members of Forth Valley Acute Hospitals NHS Trust, which manages the hospital, were unaware of the surgeries at the time. They only became aware of them in the summer of 1999, when Mr Smith informed the trust’s new chief executive, Jim Currie, that he was evaluating a third patient, an American. The trust announced a ban on further amputations after a report from its ethics subcommittee.
Smith said that there were two groups of patients who wished to have limbs amputated. The larger group found the idea sexually arousing, while both of his patients were part of a small subgroup that sought amputation because they felt incomplete with four limbs but would feel complete with three. (It was later revealed that one of the two men did in fact have a fetish for amputees.)
According to Smith, people with this condition frequently harm themselves, such as shooting their leg off or lying on train tracks. One of the men was close to suicide, according to Smith. This necessitated affirming the identities as amputees. He stated that the patients’ lives had been greatly improved by the surgeries, and they were pleased with their new state. They received artificial limbs, but did not always wear them. Lucky for them they have no regrets, since their transition to the status of amputee is irreversible.
Smith told a press conference at the hospital, “At the end of the day, I have no doubt that what I was doing was the correct thing for those patients.” The trust’s chairman, Ian Mullen, stated at the time that such surgeries were not excluded in the future, but a strict protocol would have to be followed. Since then, the practice has been banned.
However, the problem of apotemnophilia hasn’t gone away. In 2017, Mirror covered the story of Nick, from Edinburgh. Nick says “I want it to be amputated. I perceive that to be my end goal. It is really the only way that I can see a future where I am happy and comfortable with myself.”
Mirror journalists explain that “Nick suffers from a rare, debilitating condition known as body integrity identity disorder, which stops sufferers from recognizing body parts as their own.”
Body integrity identity disorder (BIID), which includes apotemnophilia, is related to BDD, a condition where people have a distorted view of their physical appearance, leading them to obsess about perceived flaws in their body, which can include their limbs. (For more on the phenomenon, see Disordering Bodies for Disordered Minds.)
There is a condition called xenomelia, for example, in which individuals experience a strong feeling of discomfort or mismatch with one or more of their limbs, feeling that they do not belong to their body.
There is also a condition called blindness identity disorder (BID), also known as Body Integrity Identity Disorder, blindness subtype. Individuals with this condition have a strong desire to become blind. Some may even attempt to harm themselves in order to cause visual impairment.
As for Nick, binding his leg and imagining he has a stump relieves his dysphoria. But he can only maintain the strap for a few hours at a time. “I have no association with my right leg. It feels like it shouldn’t be there,” he says. “It’s similar to if you had a weird growth on your arm. It would revolt you and you’d want to get it taken off as quickly as possible. That’s how I feel about my leg but, obviously, I can’t get it removed.” Of course, Nick’s leg is not a weird growth on his arm. It is a limb he was born with.
Not all people with body dysmorphia have a desire to amputate a limb or be blinded. Should those who do be able to find a doctor who will surgically remove an arm or a leg—and charge them an arm and a leg to do it? I’m sorry for the sarcasm, but this is a money making operation. That the fees charged in the Smith case was returned to the National Health Service (NHS) is a function of state-run health care. The amputations occurred privately. The United States healthcare is largely private and for-profit. Should eyes be surgically removed for those who wish to be sighted? Is this desire be attributed to a new type of Oedipal complex? (See Making Patients for the Medical-Industrial Complex.)
The Atlantic covered the phenomenon in 2000 in the article “A New Way to Be Mad.” Carl Elliott writes, “The phenomenon is not as rare as one might think: healthy people deliberately setting out to rid themselves of one or more of their limbs, with or without a surgeon’s help. Why do pathologies sometimes arise as if from nowhere? Can the mere description of a condition make it contagious?”
These are questions that need answering. The second more so than the first. Maybe we will never explain why a person with no deformities feels his body is in some way deformed. In genuine cases, it seems mostly likely a defect in the brain’s capacity to properly map the body. But how could one tell an authentic case from a delusion? And why would it matter? Would that justify mutilating a person’s body?
As for the second question, we know from our experience with anorexia nervosa, cutting, and Tourette syndrome that among the risk factors there is the problem of social contagion. (See Why Aren’t We Talking More About Social Contagion?)
Anorexia nervosa is a serious psychiatric disorder characterized by a distorted body image and an intense fear of gaining weight. Individuals with anorexia often restrict their food intake, leading to significant weight loss and, in severe cases, malnutrition. The disorder typically begins in adolescence or early adulthood and is more common in women than in men.
Anorexia nervosa can have serious physical and psychological consequences. The physical consequences may include amenorrhea (absence of menstruation), cardiovascular complications, gastrointestinal problems, and osteoporosis. The psychological consequences may include depression, anxiety, social withdrawal, and suicidal thoughts or behaviors.
The exact causes of anorexia nervosa are not fully understood, but it is thought to be a complex interplay of environmental and psychological factors. Some of the risk factors for anorexia include a family history of eating disorders, certain personality traits such as perfectionism or neuroticism, and cultural pressures to be thin.
Cutting behavior, also known as self-harm or non-suicidal self-injury, is a psychiatric disorder that involves deliberately harming oneself without the intention of causing death. Cutting behavior can take many forms, including cutting, burning, scratching, hitting oneself, or other types of self-injury.
Cutting behavior is often associated with underlying mental health conditions, such as anxiety, depression, post-traumatic stress disorder (PTSD), and borderline personality disorder (BPD), which is a cluster B type personality disorder I have discuss before on Freedom and Reason. Cutting may be a way for individuals to cope with intense emotions, feelings of worthlessness, or a sense of alienation from self and others.
As with anorexia, cutting is more common among adolescents and young adults, particularly those who have experienced trauma or abuse. And like anorexia, cutting behavior can have serious physical consequences, including infection, scarring, and nerve damage.
With regard to anorexia, research has found that individuals who have friends or family members with an eating disorder are more likely to develop an eating disorder themselves. Exposure to media images of thin models and celebrities has been shown to contribute to the development of body dissatisfaction and disordered eating behaviors in some individuals.
Perhaps you have heard about the phenomenon of “Anna,” is a personified way of being used to convey a pro-anorexia, or “pro-ana,” subculture that has over the last several years emerged online. For the “pro-ana” community, anorexia is viewed as a lifestyle choice rather than a serious mental health disorder. Within this community, individuals who struggle with anorexia are often referred to as “Anna,” and the disorder is often romanticized and portrayed in a positive light.
Some individuals who participate in the “Anna” community view anorexia as a way to achieve a certain aesthetic or idealized body type, while others view it as a means of gaining control over their lives or coping with emotional distress. The community often promotes extreme weight loss methods and encourages individuals to engage in disordered eating behaviors.
With regard to cutting behavior, the practice can spread among groups of adolescents and young adults, particularly in peer group and social settings. As with the pro-anorexia community, this is in part due to the behavior being viewed as a way to cope with emotional distress or to gain attention or social acceptance. There is also evidence to suggest that exposure to media coverage of self-harm may contribute to the normalization and spread of the behavior.
So the second question has a well-known answer. Social contagion is a very real phenomenon. If limb removal were ever normalized and enjoyed in back of it an opportunity for individuals to be part of something bigger than oneself, an opportunity to belong to a community, an explanation for why one feels uneasy with the world, then we might have a rash of cases of people wanting to remove body parts. The “new way to be mad” would become, at least among some circles, a new identity. It might be identified as an ideology, something like “Transableism.” (See Sanewashing—It’s More Widespread Than You Might Think. Also, this 2014 article in Psychology Today, “Out on a Limb.”)
In the Scottish case, Smith continued practicing “medicine.” The government never investigated him. Should Smith have been allowed to continue his work? How about prison? To be sure, voluntary amputation was banned in the end (was it criminalized?), and as a general rule ex post facto consequences are problematic. But what sociopath thinks it’s okay to remove the healthy body parts of individuals suffering from psychiatric disorders?
The Smith case is reminiscent of the Nazi medical experiments. Should there be a Nuremberg 2.0? What other analogous medical experiments are being performed today? Medicalizing atrocities doesn’t make them any less atrocious.
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Source for the historical case: “Surgeon Amputated Healthy Legs.” British Medical Journal. February 5, 2000: 320(7231): 332.