A New Way to Be Mad

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?
The Gender-Identity Parallel

Even wannabes who describe their wish for amputations as a wish for completeness will often admit that there is a sexual undertone to the desire. "For me having one leg improves my own sexual image," one of my correspondents wrote. "It feels 'right,' the way I should always have been and for some reason in line with what I think my body ought to have been like." When I asked one prominent wannabe who also happens to be a psychologist if he experiences the wish to lose a limb as a matter of sex or a matter of identity, he disputed the very premise of the question. "You live sexuality," he told me. "I am a sexual being twenty-four hours a day." Even ordinary sexual desire is bound up with identity, as I was reminded by Michael First, a psychiatrist at Columbia University, who was the editor of the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual. First is undertaking a study that will help determine whether apotemnophilia should be included in the fifth edition of the DSM. "Think of the fact that, in general, people tend to be more sexually attracted to members of their own racial group," he pointed out. What you are attracted to (or not attracted to) is part of who you are.

It is clear that for many wannabes, the sexual aspect of the desire is much less ambiguous than many wannabes and clinicians have publicly admitted. A man described seventeen years ago in the American Journal of Psychotherapy said that he first became aware of his attraction to amputees when he was eight years old. That was in the 1920s, when the fashion was for children to wear short pants. He remembered several boys who had wooden legs. "I became extremely aroused by it," he said. "Because such boys were not troubled by their mutilation and cheerfully, and with a certain ease, took part in all the street games, including football, I never felt any pity towards them." At first he nourished his desire by seeking out people with wooden legs, but as he grew older, the desire became self-sustaining. "It has been precisely in these last years that the desire has gotten stronger, so strong that I can no longer control it but am completely controlled by it." By the time he finally saw a psychotherapist, he was consumed by the desire. Isolated and lonely, he spent some of his time hobbling around his house on crutches, pretending to be an amputee, fantasizing about photographs of war victims. He was convinced that his happiness depended on getting an amputation. He desperately wanted his body to match his self-image: "Just as a transsexual is not happy with his own body but longs to have the body of another sex, in the same way I am not happy with my present body, but long for a peg-leg."

The comparison of limb amputation to sex-reassignment surgery comes up repeatedly in discussions of apotemnophilia, among patients and among clinicians. "Transsexuals want healthy parts of their body removed in order to adjust to their idealized body image, and so I think that was the connection for me," the psychiatrist Russell Reid stated in the BBC documentary Complete Obsession. "I saw that people wanted to have their limbs off with equally as much degree of obsession and need and urgency." The comparison is not hard to grasp. When I spoke with Michael First, he told me that his group was considering calling it "amputee identity disorder," a name with obvious parallels to the gender-identity disorder that is the diagnosis given to prospective transsexuals. The parallel extends to amputee pretenders, who, like cross-dressers, act out their fantasies by impersonating what they imagine themselves to be.

But gender-identity disorder is far more complicated than the "trapped in the wrong body" summary would suggest. For some patients seeking sex-reassignment surgery, the wish to live as a member of the opposite sex is itself a sexual desire. Ray Blanchard, a psychologist at the University of Toronto's Clarke Institute of Psychiatry, studied more than 200 men who were evaluated for sex-reassignment surgery. He found an intriguing difference between two groups: men who were homosexual and men who were heterosexual, bisexual, or asexual. The "woman trapped in a man's body" tag fit the homosexual group relatively well. As a rule, these men had no sexual fantasies about being a woman; only 15 percent said they were sexually excited by cross-dressing, for example. Their main sexual attraction was to other men.

Not so for the men in the other group: almost all were excited by fantasies of being a woman. Three quarters of them were sexually excited by cross-dressing. Blanchard coined the term "autogynephilia"—"the propensity to be sexually aroused by the thought or image of oneself as a woman"—as a way of designating this group. Note the suffix -philia. Blanchard thought that a man might be sexually excited by the fantasy of being a woman in more or less the same way that people with paraphilias are sexually excited by fantasies of wigs, shoes, handkerchiefs, or amputees. But here sexual desire is all about sexual identity—the sexual fantasy is not about someone or something else but about yourself. Anne Lawrence, a transsexual physician and a champion of Blanchard's work, calls this group "men trapped in men's bodies."

If sexual desire, even paraphilic sexual desire, can be directed toward one's own identity, then perhaps it is a mistake to try to distinguish pure apotemnophilia from the kind that is contaminated with sexual desire. Reading Blanchard's work, I was reminded of a story that Peter Kramer tells in his introduction to Listening to Prozac (1993). Kramer describes a middle-aged architect named Sam who came to him with a prolonged depression set off by business troubles and the deaths of his parents. Sam was charming, unconventional, and a sexual nonconformist. He was having marital trouble. One of the conflicts in his marriage was his insistence that his wife watch hard-core pornographic videos with him, although she had little taste for them. Kramer prescribed Prozac for Sam's depression, and it worked. But one of the unexpected side-effects was that Sam lost his desire for hard-core porn. Not the desire for sex: his libido was undiminished. Only the desire for pornography went away.

Antidepressants like Prozac are good treatments for compulsive desires, and clinicians also use them for patients with paraphilias and sexual compulsions. What is interesting about Kramer's story, though, is the way in which Sam came to view his desire. Before treatment he had thought of it simply as part of who he was—an independent, sexually liberated guy. Once it was gone, however, it seemed as if it had been a biologically driven obsession. "The style he had nurtured and defended for years now seemed not a part of him but an illness," Kramer writes. "What he had touted as independence of spirit was a biological tic." Does this suggest that sexual desire is simply a matter of biology? No. What it suggests is that an identity can be built around a desire. The person you have become may be a consequence of the things you desire. And this may be as true for apotemnophiles as it was for Sam, especially if their desires have been with them for as long as they can remember.

Presented by

Carl Elliott teaches at the Center for Bioethics at the University of Minnesota. He is the author of A Philosophical Disease (1998) and a co-editor of The Last Physician: Walker Percy and the Moral Life of Medicine (1999).

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