Clinical And Theoretical Parallels Between Desire For Limb Amputation And Gender Identity Disorder

Reviewed by Christopher H. Rosik, Ph.D.

Overview
A recent article by Lawrence (2006) provided a fascinating glimpse into the world of non-psychotic persons who desire the amputation of a healthy limb. Although case reports of this phenomena were documented as early as 1785, Lawrence noted that apotemnophilia (also referred to as Amputee Identity Disorder or Body Integrity Identity Disorder) gained wider attention after a Scottish surgeon performed the operation on two individuals in the late 1990s (Dyer, 2000). Individuals with this condition appear to share several common features (p. 264):

They "... typically experience an intense desire or overwhelming compulsion to change their bodies to match their idealized images of themselves as amputees."
"They usually describe their feelings as developing early in life, often before puberty."
"... Most emphasize that they are primarily seeking a sense of wholeness or completeness or are offering to correct a mismatch between their bodies and their identities."
They report an "... attraction to amputees as romantic or sexual partners."
They "... experience sexual arousal or pleasure from pretending to be an amputee."

Lawrence then proceeds to category two types of male-to-female (MtF) transsexualism/GID. One category "... includes persons who were overtly feminine as children, who are very feminine as adults, and who are exclusively sexually attracted to men; these individuals are usually referred to as homosexual MtF transsexuals" (p. 265). On the other hand, non-homoseuxal MtF transsexuals are not overtly feminine during childhood, are not remarkably feminine as adults, are not attracted to men but may be attracted to women, women and men, or neither sex. These individuals nearly always have a history of transvestic fetishism or sexual arousal with cross-dressing.

Lawrence subsequently contends that significant clinical and theoretical parallels exist between non-homosexual MtF transsexualism and the desire for limb amputation. Both varieties of transsexualism share the first two characteristics with apotemnophilia: 1) A profound discontent with embodiment and desire to surgically alter the body and 2) simulation of the desired embodiment or status using clothing, prostheses, etc. The remaining characteristics Lawrence viewed as shared solely by non-homosexual MtF transsexuals and individuals desiring limb amputation are:

The individual does not have a natural resemblance to the desired embodiment or status and this serves as a rational for surgery.
The presence of a closely related paraphilia from which the condition plausibly derives.
Sexual arousal is usually associated with simulation of the desired embodiment or status.
Sexual attractiveness to persons with the desired embodiment.
An elevated prevalence of other paraphilic interests.
The frequent belief that paraphilia-based explanations of the condition are inaccurate or incomplete. Persons from both conditions typically believe their desire is primarily related to expressing their true identity.

Lawrence seeks a unifying explanation of these parallels in the theory of erotic target location errors. She cited Freud and Blanchard's (1993) description of this concept:

For every class of sexual object, there will be small subgroups of men who develop fetishes for clothing associated with the desired object, who develop the erotic fantasy of being the desired object, and who develop the sustained wish to transform their own bodies into facsimiles of the desire object.

Thus, both non-homoseuxal MtF transsexuals and individuals desiring limb amputation share two distinct paraphilic aspects: 1) An uncommon erotic target preference and 2) An erotic target location error, where the person desires to turn his body into the desired erotic target rather than simply desiring that body status in another person.

In concluding sections of the article, Lawrence proposes several objections that might be offered to her theory and attempts to defend it by appealing to various aspect of the literature. Finally, the paper ends with a very brief section on treatment implications. Only two suggestions are offered for amputee seeking patients, both based on the treatment experiences of non-homosexual MtF transsexuals. Lawrence first noted that testosterone-lowering medications may prove useful in managing unwanted feelings of sexual arousal.

Second, and far more controversial, Lawrence observed that surgical removal of a limb may be an effective solution that could result in high levels of satisfaction, as the limited data to date seem to suggest.

Commentary
The existence of apotemnophilia raises some very intriguing questions for current discussion about human sexuality, particularly as pertains to transgenderism and the limits of pursuing civil rights for sexual minorities. Lawrence seems mostly concerned about understanding the reasons for finding such parallels between these conditions in order to enhance treatment. But when it comes to the surgical option, Lawrence's very tentative conclusion seems to beg the larger question: Should surgery ever be considered? However, in the current sociopolitical climate transgendered persons (including transsexuals) are riding the coattails of the gay rights movement with reasonable success. Therefore, given these extensive parallels it may be difficult for the mental health professions to make a rational argument against permitting amputation of a limb that would not also apply to the amputation of one's sexual organ.

Although Lawrence clearly treats the desire for amputation as a clinical disorder, the trajectory of contemporary sexual minority rights ideology would suggest that this appraisal may well be questionable. The American Psychological Association's recent FAQ about transgenderism (http://www.apa.org/topics/transgender.html) states:

A psychological condition is considered a mental disorder only if it causes distress or disability. Many transgender people do not experience their transgender feelings and traits to be distressing or disabling, which implies that being transgendered does not constitute a mental disorder per se.

Lawrence seems to indicate that many individuals desiring amputation do not experience their condition as particularly distress or disabling and one study cited indicated that 64% of participants reported they sought amputation so as to express their "true identity." Thus, by the APA's own criteria, it may be difficult to make the disorder label stick with apotemnophilia much longer. Once the psychological experience of patients is given precedence over their physical nature in determining the necessity and direction of treatment for an individual's gender identity issues, there is no logical reason why this standard should not also apply to other types of discrepancies between a persons' mental and constitutional make up.

Consequently, I suspect this has yet to happen primarily because of very low base rates of the disorder and the lack of an organized lobbying group to make the case for the normalization and empowerment of amputee identity. It's probably a long shot at present, but Lawrence's observations about individuals desiring amputation would seem to point them toward a strategy of playing up their sexual minority status and affiliating with other sexual minority groups. Then perhaps some day in the future we just might be hearing about the pursuit of GLBTIQA (i.e., gay, lesbian, bisexual, transgender, intersex, questioning and amputee) equality.

References:

Dyer, C. (2000). Surgeon amputated healthy legs. British Medical Journal, 320, 332.

Freud, K., & Blanchard, R. (1993). Erotic target location errors in male gender dysphorics, paedophiles, and fetishists. British Journal of Psychiatry, 162, 558-563.

Lawrence, A. A. (2006). Clinical and theoretical parallels between desire for limb amputation and gender identity disorder. Archives of Sexual Behavior, 35, 263-278.