When Stephanie West Allen sent me the link, I was as appalled at the idea of “tranableism” as could be.
Smith’s patients are just two examples of people who have body integrity identity dysphoria, also known as being transabled: They feel they are disabled people trapped in abled bodies.
The gut reaction, that this was either good old psychosis or some nouvelle scam to get a handicapped parking permit came swiftly. But the next sentence took it to a very different place.
Some people feel that they are meant to be amputees and will even injure themselves in order to create the desired amputation or make it medically necessary for a surgeon to perform it. Other people feel that they were meant to be blind or deaf.
The isn’t about an otherwise “abled” person pretending to be disabled, although they exist and are known as “pretenders.” This is about people who, for reasons that are hard to fathom, make two nearly inconceivable choices. The first is to excise a healthy body part, often a leg, from their body. The second is to live the rest of their life as a person without that body part.
Then came the next wave of assumptions, that this was some extension of fashionable delusion by those suffering from a panoply of mental illnesses, from depression to anxiety to whatever else can be found in the DSM-V, as a “solution” to other problems. Hate yourself? Maybe you’ll like yourself better as a unidexter. Off with your leg!
But then someone told me about an article in The Atlantic from 20 years ago taking a deep dive into what was then called “apotemnophilia,” as the “trans” prefix had yet to become trendy. The phenomenon wasn’t new.
Although it took him eighteen months to work up the courage to do the first amputation, Smith eventually decided that there was no humane alternative. Psychotherapy “doesn’t make a scrap of difference in these people,” the psychiatrist Russell Reid, of Hillingdon Hospital, in London, said in a BBC documentary on the subject, called Complete Obsession, that was broadcast in Britain last winter. “You can talk till the cows come home; it doesn’t make any difference. They’re still going to want their amputation, and I know that for a fact.” Both Smith and Reid pointed out that these people may do themselves unintended harm or even kill themselves trying to amputate their own limbs. As the retired psychiatrist Richard Fox observed in the BBC program, “Let’s face it, this is a potentially fatal condition.”
There are two critical points in there, both of which remove the discussion for those called “wannabes” within the community of people who share this need to remove a limb. First, psychotherapy didn’t help. The obvious reaction upon learning of transableism is that these are seriously ill people who need help. Even psychologists figured this one out. But when help was given, it didn’t help.
It could be that the psychotherapeutic treatment just wasn’t right, or sufficient, and its failure wasn’t a reflection of there not being a mental illness, but not having the right cure.
The second point was that if surgeons weren’t willing to provide the medical assistance sought, people would do it themselves.
“It was kind of messy,” he says. “I did it with a log splitter.” He then explains, in a thoughtful, dispassionate manner, the details of his “accident” ten years ago—the research he had done on anesthesia and wound control, how he had driven himself to the emergency room after partially amputating his limb, the efforts of the hospital surgeons to reattach it. He lived with the reattached leg for six months, he said, until medical complications finally helped him persuade another surgeon to amputate it.
The Atlantic articles delves into the psychological reasons why someone would do this to themselves, but the point is that they do, and did long before anyone could call it a product of fashion.
There is a natural inclination to analogize “body integrity identity dysphoria” with “body dysmorphia,” the latter being a recognized condition in the DSM-V and a manifestation being reflected in transgender people. Both share a common aspect, the removal of healthy body parts in order to conform the physical body to the body image of its possessor. And before anyone leaps to facile connections, consider that there are many other examples, far more common and less controversial, such as breast reduction surgery or even rhinoplasty, a “nose job.”
But the analogy seems flawed in that the end result of the physical body alteration serves to create a new, intact, more positive body. Both give the person the body they want, or need, or desire, according to how one interprets the psychological motivations, but to give up a limb leaves a person with limitations they didn’t have before, and don’t need to have. Their body may be what they always felt it was meant to be, but they have caused themselves challenges that make their life more difficult.
This isn’t the case for transgender people, or people whose new noses give them the appearance they desired. They may have chosen to alter a healthy body, but the outcome is a healthy body as well.
But what of the surgeons who have agreed to remove a healthy limb from a healthy body? If this is a psychological problem, even if psychology has yet to achieve a means of addressing it, then isn’t their acquiescence in excising a leg doing harm?
And to be honest, haven’t surgeons made the human body fair game? You can pay a surgeon to suck fat from your thighs, lengthen your penis, augment your breasts, redesign your labia, even (if you are a performance artist) implant silicone horns in your forehead or split your tongue like a lizard’s. Why not amputate a limb? At least Robert Smith’s motivation was to relieve his patients’ suffering.
Is this a “complicated” question of medical ethics, or a means of relieving a patient’s suffering when nothing else works? Twenty years ago, there was no clear answer. We’re no closer to answering the question today.
Even if we set aside the interests of family, other patients and those who must bear the financial costs of providing for the patient’s lifelong disability, those who have a disorder that causes them to desire to maim and disable their bodies cannot meet this standard of voluntarily accepting the burden of choice that makes the practice of respecting autonomy acceptable.”