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ďż˝ s o m e w ha t v i s u a l d i c o u r s e o n t h e a lt e r e d h u m a n b o d y i n 3 c ha p t e r s.

State of the Part the mInd-body Problem

the hand provides a basic introduction for the following contents.


Plastic People PlaStIC SurGery: a brIef hIStory

the Sun indicates texts relating to actual plastic surgery and related devotees.

the CoSt of averaGe PerfeCtIon aSIan eyeS

10 16 18

Bionic Beings a matter of PerSPeCtIve

the orbItal corresponds to texts stressing developments in prosthetics.

SIx bIllIon dollar SoldIerS

24 28

wIthIn the blInk of an eye


ChaSInG the GhoSt: Phantom PaInS

36 Strange Souls

addICtIon to PlaStIC SurGery

the moon marks texts focussing on the psychological relating to the body.

Paul’S love lIfe a CuttInG deSIre StronGer than…

42 46 48


theSe StarS provide additional insights, supplementing the actual texts.

�ood for the body is the work of the body, good for the soul the work of the soul, and good for either the work of the other. � Henry David Thoreau



BODY PROBLEM Essay written by Tim Crane Published by University College London

The mind-body problem is the problem of explaining how our mental states, events and processes — like beliefs, actions and thinking — are related to the physical states, events and processes in our bodies. A question of the form, ‘how is A related to B?’ does not by itself pose a philosophical problem. To pose such a problem, there has to be something about A and B which makes the relation between them seem problematic. Many features of mind and body have been cited as responsible for our sense of the problem. Here I will concentrate on two: the fact that mind and body seem to interact causally, and the distinctive features of consciousness. A long tradition in philosophy has held, with René Descartes, that the mind must be a non-bodily entity: a soul or mental substance. This thesis is called ‘substance dualism’ (or ‘Cartesian dualism’) because it says that there are two kinds of substance in the world, mental and physical or material. One reason for believing this is the belief that the soul, unlike the body, is immortal. Another reason for believing it is that we have free will, and this seems to require that the mind is a non-physical thing, since all physical things are subject to the laws of nature. To say that the mind (or soul) is a mental substance is not to say that the mind is made up of some non-physical kind of stuff or material. The use of the term ‘substance’ is rather the traditional philosophical use: a substance is an entity which has properties and persists through change in its properties. A tiger, for instance, is a substance, whereas a hurricane is not. To say that there are mental substances — individual minds or souls — is to say that there are objects which are non-material or non-physical, and these objects can exist independently of physical objects, like a person’s body. These objects, if they exist, are not made of non-physical ‘stuff ’: they are not made of ‘stuff ’ at all. But if there are such objects, then how do they interact with physical objects? Our thoughts and other mental states often seem to be caused by events in the world external to our minds, and our thoughts and intentions seem to make our bodies move. A perception of a glass of wine can be caused by the presence of a glass of wine in front of me, and my desire for some wine plus the belief that



THE CENTRAL CLAIM of what is often called Carte-

sian dualism, in honour of Descartes, is that the immaterial mind and the material body, while being ontologically distinct substances, causally interact. This is an idea which continues to feature prominently in many non-European philosophies. Mental events cause physical events, and vice-versa. But this leads to a substantial problem for Cartesian dualism: How can an immaterial mind cause anything in a material body, and vice-versa? This has often been called the ‘problem of interactionism.’

there is a glass of wine in front of me can cause me to reach towards the glass. But many think that all physical effects are brought about by purely physical causes: physical states of my brain are enough to cause the physical event of my reaching towards the glass. So how can my mental states play any causal role in bringing about my actions? Some dualists react to this by denying that such psychophysical causation really exists (this view is called ‘epiphenomenalism’). Some philosophers have thought that mental states are causally related only to other mental states, and physical states are causally related only to other physical states: the mental and physical realms operate independently. This ‘parallelist’ view has been unpopular in the 20th century, as have most dualist views. For if we find dualism unsatisfactory, there is another way to answer the question of psychophysical causation: we can say that mental states have effects in the physical world precisely because they are, contrary to appearances, physical states. This is a monist view, since it holds that there is one kind of substance, physical or material subtance. Therefore it is known as ‘physicalism’ or ‘materialism’. Physicalism comes in many forms. The strongest form is the form just mentioned, which holds that mental states or properties are identical with physical states or properties. This view, sometimes called the ‘type-identity theory’, is considered an empirical hypothesis, awaiting confirmation by science. The model for such an identity theory is the identification of properties such as the heat of a gas with the mean kinetic energy of its constituent molecules. Since such an identification is often described as part of the reduction of thermodynamics to statistical mechanics, the parallel claim about the mental is often called a ‘reductive’ theory of mind, or ‘reductive physicalism’.


Many philosophers find reductive physicalism an excessively bold empirical speculation. For it seems committed to the implausible claim that all creatures who believe that grass is green have one physical property in common — the property which is identical to the belief that grass is green. For this reason (and others) some physicalists adopt a weaker version of physicalism which does not have this consequence. This version of physicalism holds that all particular objects and events are physical, but allows that there are mental properties which are not identical to physical properties. (‘Mental events.’ by L. Foster and J. Swanson. is one inspiration for such views.) This kind of view, ‘non-reductive physicalism’, is a kind of dualism, since it holds there are two kinds of property, mental and physical. But it is not substance dualism, since it holds that all substances are physical substances. Non-reductive physicalism is also sometimes called a ‘token-identity theory’ since it identifies mental and physical particulars or tokens, and it is invariably supplemented by the claim that mental properties supervene on physical properties. Though the notion can be refined in many ways, supervenience is essentially a claim about the dependence of the mental on the physical: there can be no difference in mental facts without a difference in some physical facts. If the problem of psychophysical causation was the whole of the mind-body problem, then it might seem that physicalism is a straightforward solution to that problem. If the only question is, ‘how do mental states have effects in the physical world?’, then it seems that the physicalist can answer this by saying that mental states are identical with physical states. But there is a complication here. For it seems that physicalists can only propose this solution to the problem of psychophysical causation if mental causes are identical with physical causes. Yet if properties or states are causes, as many reductive physicalists assume, then non-reductive physicalists are not entitled to this solution, since they do not identify mental and physical properties. This is the problem of mental causation for non-reductive physicalists.



cribed with a logical line of argumentation: 1 .  According to physicalism all that exists in our world (also consciousness) is physical.  2.  Thus, if physicalism is true, a logically possible world in which all physical facts are the same as those of the actual world must contain everything that exists in our actual world. In particular conscious experience must exist in such a possible world.  3.  In fact we can conceive of a world physically indistinguishable from our world but in which there is no consciousness and we can not see why it is not logically possible.  4.  Therefore, physicalism is false.



S AINT THOMAS AQUINAS held that ‘soul of St. Peter

pray for us’ would be more appropriate than ‘St. Peter pray for us’, because all things connected with his person, including memories, ended with his corporeal life. Interestingly, Aquinas does not hold that the human person is able to remain integrated at death. The separated intellectual soul is neither a man nor a human person.

However, even if the physicalist can solve this problem of mental causation, there is a deeper reason why there is more to the mind-body problem than the problem of psychophysical interaction. The reason is that, according to many philosophers, physicalism is not the solution to the mind-body problem, but something which gives rise to a version of that problem. They reason as follows: we know enough to know that the world is completely physical. So if the mind exists, it too must be physical. However, it seems hard to understand how certain aspects of mind — notably consciousness — could just be physical features of the brain. How can the complex subjectivity of a conscious experience be produced by the grey matter of the brain? As McGinn (1989) puts it, neurones and synapses seem ‘the wrong kind’ of material to produce consciousness. The problem here is one of intelligibility: we know that the mental is physical, so consciousness must have its origins in the brain; but how can we make sense of this mysterious fact? Thomas Nagel dramatised this in a famous paper. Nagel says that when a creature is conscious, there is something it is like to be that creature: there is something it is like to be a bat, but there is nothing it is like to be a stone. The heart of the mind-body problem for Nagel is the apparent fact that we cannot understand how consciousness can just be a physical property of the brain, even though we know that in some sense physicalism is true. Some physicalists respond by saying that this problem is illusory: if physicalism is true, then consciousness is just a physical property, and it simply begs the question against physicalism to wonder whether this can be true. But Nagel’s criticism can be sharpened, as it has been by what Frank Jackson calls the ‘knowledge argument’. Jackson argues that even if we knew all the physical facts about, say, pain, we would not ipso facto know what it is like to be in pain. Someone omniscient about the physical facts about pain would learn something new when they learn what it is like to be in pain. Therefore there is some knowledge — knowledge of what it is like — which is not knowledge of any physical fact. So not all facts are physical facts. In late twentieth century philosophy of mind, discussions of the mind-body problem revolve around the twin poles of the problem of psychophysical causation and the problem of consciousness. And while it is possible to see these as independent problems, there is nonetheless a link between them, which can be expressed as a dilemma: if the mental is not physical, then how we make sense of its causal interaction with the physical? But if it is physical, how can we make sense of the phenomena of consciousness? These two questions, in effect, define the contemporary debate on the mind-body problem.   ·

I definitely believe in plastic surgery. I don’t want to be an old hag. �ere’s no fun in that. � Scarlett Johansson

Plastic People




Plastic surgery, the practice of reshaping body tissues for reconstructive or aesthetic purposes dates back to antiquity. Derived from the Greek ‘plastikos’, meaning ‘to mold’, plastic surgery holds a critical place in cultures all over the world. For centuries, tribes would disc their lips, stretch their earlobes, bind their feet, file their teeth, and tattoo and scar their skin. If contemporary popular series such as »Extreme Makeover« and »Nip/Tuck« are any indication, plastic surgery has not lost any of its cultural power. While filed teeth may not appeal to everyone, men and women of today still have a wide range of surgical procedures from which to choose, including liposuction, nose jobs, eyelid surgery, tummy tucks, and breast augmentation and reduction. The term ‘plastic surgery’ also includes nonsurgical options such as Botox, microdermabrasion, collagen injections, laser hair removal, and chemical peels. Plastic surgery, however, was not always so readily available or varied and was even shrouded in mystery, magic, and eroticism. Ancient Egypt: Plastic Surgery to Recognize the Dead While the Egyptians did not practice extreme forms of plastic surgery on the living, they would often prepare their dead using principles of plastic surgery. For example, Ramses II's mummy was surgically altered by having a small bone and a handful of seeds inserted into his nose to ensure that his most prominent feature would be recognizable in the afterlife. The mummy of Queen Nunjmet also had bandages stuffed in her cheeks and belly in the same sense that modern plastic surgeons implant silicone into a body. While the Edwin Smith Papyrus shows that the Egyptians had skills to perform similar surgical procedures on the living, there is no solid documentation that is was actually done. Scholars suggest this reluctance to perform plastic surgery on the living was due to the Egyptian belief that one’s face remained the same in the afterlife and, therefore, should remain recognizable even after death. Ancient India: The Birthplace of Plastic Surgery Most historians agree that the first recorded account of reconstructive plastic surgery on the living is found in ancient Indian Sanskrit texts. These texts describe procedures to repair noses and ears that were lost either as punishment for crimes (such as adultery) or in battle. Hindu surgeon Sushruta, working near the modern-day city of Varanasi described the »attached flap« method of plastic surgery in his 600 B.C. text Sushruta Samhita. The procedure involves reconstructing the nose by cutting skin from either the cheek or forehead, twisting the skin skin-side-out over a leaf of the appropriate size, and sewing the skin into place. To keep the air passages open during healing, two polished wooden tubes would be inserted into the nostrils. This method became known as the ‘Indian Method of Rhinoplasty’ and was kept secret for centuries in India.


Middle Ages: Decline of Plastic Surgery During the time of Galen (A.D. 129-216), plastic surgery gained momentum and sophistication due to increased obsession with the human body. Galen attempted to cure eyes that squinted and drooped,and performed aesthetic rhinoplasty on both women and men of wealth who simply wanted a new nose. After the fall of Rome, however, many of Galen’s medical texts were lost; of his 600 books, only 20 survive. Though there were discussion of proper dental care during the Middle Ages, surgery in general was deemed to be pagan and sinful because the spilling of blood by a surgeon and the power he held over the body were akin to magic. The Renaissance: A Brief Rise in Plastic Surgery Heinrich von Pfalzpaint, a knight from the Teutonic order, held secret the procedure of a nose job that was taught to him by a foreigner and made him »very much money.« Many surgeons took skin grafts from donors, such as a neighbor’s pig, but were confused when the new nose would shrivel up and fall off. They concluded that the flesh was »sympathetic,« meaning that the graft died when its owner died. Most plastic surgeons today recognize Italian Gasparo Tagliacozzi (1546-1599) as the »father of modern plastic surgery« and as the first author of a plastic surgery textbook, ‘De curtorum chirugiau’ (1597). Noting the need for plastic surgery due to »frequent duels, street brawls, and other clashes of armed men« as well as a pervasive outbreak of syphilis which destroyed the nose, Taglioacozzi experimented with the use of pedicles which involves relocating a section of skin, subcutaneous tissues, and vasculature to another area to cover a wound. Specifically, Tagliacozzi would take skin grafts from the upper arm and, after several painful procedures, attach the flap onto the nose. Motivated by radical claims of autonomy present in the High Renaissance (e.g., Tagliacozzi is significant because in contrast to prevailing views that interpreted illness as a punishment, he used the vocabulary of High Renaissance humanists such as Giovanni Francesco Pico della Mirandola (1463-94), who advocated autonomous self-remaking individual as justification for his surgical innovations. For Taglioacozzi, plastic surgery was one way humankind seeks improvement of self, both physically and emotionally. Still, his reconstructed nose was still a ‘virtual’ nose that could fall off if the user blew too hard, and young women with reconstructed noses were hardly objects of desire. Young women who lost their noses could be disowned by their fiancés because it suggested either a venereal or moral disease. However, Tagliacozzi mused whether a reconstructed nose was still grounds for terminating a marriage arrangement. For a time in Renaissance Europe, Tagliacozzi’s surgical innovations promised at least partial restoration of the nose but, due to the religious zeal of the Counterreformation and the concomitant emphasis on the syphilitic nose as a justifiable punishment from God, Tagliacozzi’s work disappeared.


The Enlightened Nose Plastic surgery would reappear in Europe in 1794 when British surgeons witnessed an Indian bricklayer repaired the nose of a British cattle driver who had had his nose and hand cut off while a prisoner of Tiu Sultan. British surgeons then imported the procedure to northern Europe, where interest rapidly grew. In 1818, Karl Ferdinand Graefe (1787-1840) coined the term ‘plastic surgery’ and described connected grafts in his 1818 text titled Rhinoplastik. Graefe, like Tagliacozzi, believed that the world needed to see the nose-less patient in medical terms rather than as a morally branded sinner. Graefe further attempted to remove the moral stigma associated with nose reconstruction by giving the procedure a classical name (rhinoplasty) similar to other surgical procedures. The move to a medical model for understanding the lost nose began to spread. However, the first notable plastic surgeon in the United States, John Peter Mettauer of Virginia (who primarily operated on cleft palates and hypospadias using tools he designed himself), still struggled with American surgeons who lived by Dryden’s admonition that »God did not make his Works for man to mend«. In addition, as the nineteenth century wore on and the European culture began its colonizing efforts in earnest, the nose became inextricably associated with race, an association that lasted until the current era, as seen in what is now called the ‘Michael Jackson Factor.’ Two World Wars and Innovations in Plastic Surgery War has played a significant role in the history of plastic surgery. For example, WWI trench warfare meant heads and necks were more vulnerable, and pilots and passengers in the new and dangerous airplanes often suffered serious facial injuries that were unprecedented any time in history. Injuries such as shattered jaws, blown-off noses, and gaping skull wounds accelerated the techniques and experimentation of plastic surgery and prompted Harold Delf Gilles (1882-1860) to establish the first hospital devoted to reconstructive plastic surgery (Backstein and Hinek 2005). In addition, these drastic surgeries enabled surgeons to imagine that even transgender surgery could be performed. WWII ushered in such plastic surgery techniques as rebuilding entire limbs, extensive skin grafts, microsurgery, antibodies, as well as increased knowledge about tissue health. Several factors contributed to the postwar plastic surgery boon and the breaking down of traditional reluctance to undergo plastic surgery. First, continued activity of professional organizations and publications helped further legitimize the industry. In addition, after there was no war to generate patients, surgeons consequently began a widespread trend toward marketing surgical techniques toward particularly groups — particularly middle-aged, middle-class women who were affluent and largely finished with raising families.


Post-War Developments Furthermore, this demographic felt increasing pressure to remain young in a postwar culture often dubbed the »cult of the body beautiful«. Indeed, plastic surgeons would often use the vocabulary of postwar domesticity — such as sewing, housecleaning, and cooking — to refer to their procedures. Some critics even accused surgeons of inventing new names, such as ‘bat wing deformity’ (the flabby skin on the upper arms) or ‘spare tire deformity’ (protrusion of the lower abdomen) to create a need for plastic surgery that might not otherwise exist. By the 1960s, plastic surgery was fully integrated into the medical establishment. Silicone breast implants also grew in popularity during the 1960s. Showgirls would inject their breasts with liquid silicon, a substance initially used in Japan in WWI to plump out legs withered by polio. Injecting liquid silicone, however, often had dangerous side effects, such as amputation of the breasts due to infection and guaranteed ‘pendulous’ breasts by the time women were 40. Yet advances in silicone breast augmentation (which later was made available in sac), gave hope to women who had undergone a mastectomy. 1990s: Continued Popularity Though silicone breast implants would remain available for breast cancer patients throughout the 1990s, the FDA removed them from the open market in 1992 due to reports of leaking implants. Even with this setback, plastic surgery continued to grow in the 1990s, with more than 5,000 board-certified surgeons active in the U.S. alone. In an important move for both plastic surgeons and their patients, President Bill Clinton signed a bill which required insurance companies to cover the cost of plastic surgery for women who had undergone a mastectomy. Groups are still working to ensure that reconstructive surgery for children’s deformities will also be covered by insurance plans. The Future of Plastic Surgery Throughout its history, plastic surgery has been shaped by cultural priorities and pressures that illuminate the complex interplay between the cosmetic and reconstructive. The fact that many Western societies today have become more comfortable with plastic surgery suggests that they view it as another method of self-improvement — not just for women, but men as well. Big Tent Books even published a new picture book that explains to kids why mom is getting a flatter tummy. While critics warn that plastic surgery is creating a world where beauty standards are brutally conformist, plastic surgeons today implement an exciting array of technological advances that continue to push the boundaries of their industry. For example, surgeons are researching new fillers that last longer and new lasers that inject ‘energy’ into the skin. They are also exploring the potential of cloning technology as a method of body rejuvenation and are looking to the secrets of growth within the womb where scarless healing takes place. Without such imagination of plastic surgeons and their patients over the ages, plastic surgery would not be the phenomena it is today.


arm lift

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Cheek implant


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Collagen injeCtion

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permanent lipliner

nose surgery

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eyelid tuCk

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permanent eyeliner

forehead lift

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Cheek implant


eyelid tuCk

· the ever-inCreasing numer of plastiC surgeries undertaken for non-mediCal reasons has been doCumented to a wide extent. but how Costly Can a possible fixation on ‘body-improvement’ be?

the Cost of average perfeCtion

arm lift

$ 5000 - 6500


$ 400 - 1000

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fulfilling every need through surgery, providing surgeons would perform almost 30 operations on one patient, Could Cost in between $77,500 and $100,100. 路

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hair removal $ 2500 - 4000

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tummy tuCk

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spider vein rx

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When most women get ready in the morning, they reach for lipstick, mascara and concealer. For Caroline (not her real name), 29, the makeup routine also includes glue, a brush and a mini fork. It’s not an emergency fondue kit. She’s a Chinese-American hellbent on forcing a crease, or a fold, onto her eyelids and these are her tools. First she sweeps the glue above her eyes, then uses the fork to hike up her eyelid, and presses it into place. The skin stays folded for most of the day. She says it makes her eyes look bigger, prettier, and as some might argue, more Caucasian. Sound unusual? Hardly. In Japan and Taiwan, stores sell tubes of eyelid glue and pre-cut tape that women use to create a fold. Other girls, says Caroline, »hold their eyelids back with toothpicks to ‘train’ them into place.« But for those who balk at sticking toothpicks and forks in their eyes (visions of ‘A Clockwork Orange’) there is a third option — plastic surgery — where a permanent crease is stitched into place and excess fat is sucked out of the eye socket. While the procedure, formerly called blepharoplasty (from the Greek ‘blepharo’ for eyelid, and ‘plasty’ which means to shape) has been around since the ’70s, more and more women — and increasingly, men — are having it done. According to the American Academy of Facial, Plastic and Reconstructive Surgery (AAFPRS), 167,000 blepharoplasty procedures were performed in 1998. Asian-Americans represented 7.5 percent of all patients undergoing facial cosmetic surgery in 1998. Plastic surgeons say it is the most common procedure elected by Asian-Americans (and Asians in the Orient), followed by rhinoplasties and breast augmentation. Although the surgery is casually known as ‘the Asian eyelid surgery’ it is not undergone solely by Asians. It’s basically a good old-fashioned ‘eye lift’, which gives the eye a fresher, younger appearance by pulling the skin up and back. The surgery isn’t always done for cosmetic reasons. Normal aging can cause eyelids to droop and obscure vision; in some cases a blepharoplasty can be a necessity. Naturally, the Asian eyelid surgery is a sticky issue and questions posed about it are often met with silence, a blast of anger or both (some critics call it ‘barfoplasty’ because it makes them so sick.)




I N A STUDY Asian-Americans have by far the highest rate of eyelid surgery performed compared to any other ethnic group. With 39% of all facial surgery, it surpasses nose surgery 16%, with chin augmentation and face-lifts trailing below 5%. In comparison, African-Americans have only 5% on average of eyelid surgery conducted, Caucasians about 24% and Hispanics approximately 15% of overall performed surgeries.

Carrie Chang, a 29-year-old Stanford graduate, is so horrified by the surgery that it inspired her to launch Monolid magazine in December. »Asians are becoming pro-assimilation and monolid is a buzzword for yellow power and not being ashamed of it. It says ‘I don’t want the surgery,’« says Chang. Monolid’s premiere issue featured a profile of the band ‘Superchink’ and a poem called ‘Recipe for Round Eyes’ by Janice Mirikitani. And while no one interviewed said they had the surgery to look more Caucasian, discussing it inevitably dissolves into a game of semantics. »People say, ‘I want to look prettier, I want to look more awake.’ But what does pretty mean? How does it come to mean a Western eye? As a historian, we have to look at how words come to mean what they mean,« says Elizabeth Haiken, assistant professor at the University of British Columbia and author of ‘Venus Envy: The History of Plastic Surgery.’ The word used by most of the women interviewed for this article was ‘makeup.’ They cited a problem with eye makeup as their primary incentive for having the surgery. Others said they simply wanted to look more ‘awake’ or have a larger eye because it’s universally prettier. »I’ve never had a patient come in and specifically say, ‘I want to look Caucasian,’« says Dr. Marc Yune, a Korean-American plastic surgeon and spokesman for the AAFPRS. »In fact, they specifically say, ‘I don’t want an American eye, I don’t want a round eye.’« Dr. James Penoff says the number one factor that drives women to his Honululu office is complaints they can’t wear false eyelashes. »It's evidence of internalized racism,« says Mura. »It really indicates something about the way in which Asians in America are indoctrinated by white standards of beauty. They feel less beautiful than those who fit the Caucasian standard of beauty.« The main reason for that, Mura says, is the low representation of Asians in the media. »People grow up watching the media, which is where people are beautiful and powerful. You see very few Asian faces. The message is: the way you look is not beautiful, or doesn't count, or doesn't even exist,« he says. He believes the American media also account for much of the surgery's popularity in Asia. »The power of the American media and American culture stretches all over the globe, and can cause people to devalue their own culture,« says Mura.



Asian Americans who disagree with Mura's interpretation often point out that a large percentage of Koreans, Japanese, and Chinese are born with creased eyelids, although they certainly tend to be shaped differently than those of, say, Caucasians. In fact, in some regions, such as in southern China, as many as 70 percent are born with them. In addition, double-eyelid surgery is enormously popular in Asia, and has been considered attractive since well before the infiltration of Western media. Therefore, many argue, Asians seeking double eyelids are simply trying to look like the more attractive members of their own race. »The desire for double eyelids has taken on a strange idea in the U.S. that Asian women want to look like Caucasians and that they desire [moon-shaped] eyes,« says Shi Kagy, editor of AsiaMs, an online Asian beauty magazine (www. »In truth, Asian women want double eyelid folds that look like natural Asian type folds, and dislike the Caucasian type,« she says. For ten years, Dr. Jeffrey Ahn, Director of Facial Plastic Surgery at Columbia University Medical Center, has performed about 200 Asian blepharoplasties a year. He dispels the idea that his patients have tried to obscure their racial identity. The surgery creates the indention of the eyelid right on top of the eyeball that makes it stand out — where women normally put eye shadow. As Penoff, a spokesman for the American Society of Plastic and Reconstructive Surgery explains, roughly 50 percent of Asians do not have the crease because they lack the levator muscle that holds the crease up, kind of like a window shade. As a result, the Asian eye has a smooth, solid look. But there’s more to the surgery than appearance. There is also the functionality issue, says Yune, because the smooth lid can cause entropion, when the eyelashes point down and poke in. And without a crease, you’re more apt to have sagging skin that can hang down and obscure vision. The surgery is quick but expensive — about $3,500 — and the recovery, as with most plastic surgeries, can be painful. Hie Shun, a recovery room nurse in her 30s who had it done last year, says she had to sleep in a semi-standing position and »when you lay down, it feels like the swelling is burying you.« While some people truly require eye surgery for drooping eyelids that can obscure vision,


TESTIMONIALS FROM a Los Angeles based surgeon have patients speak of »an amazing difference in my life! I feel much more attractive and confident now.« Ironically, another patients’ statement that »everything was perfect! There’s no need for any changes.«



why go through all this? Mary Andres, a clinical psychologist and professor at the University of Southern California, offers two explanations. Altering the eyelids is one way for Asians to distinguish themselves from their peers. »If you’re Asian and work in an allAsian office and you dye your hair blond, it’s going to make you look different from everyone else. So you’re not necessarily trying to make yourself look Caucasian.« Another theory, says Andres, is that the surgery is an indicator of internalized racism. »This surgery is the antithesis of self-esteem, when you don’t like who you are and how you look.« She pauses for a moment. »You know, I really don’t see why people are doing this. It’s not like they have a goiter they have to hide from the world.« But some may feel they do. The eye is the Asian feature most often reduced to a caricature in popular culture. »Think of Charlie Chan movies or the Mickey Rooney character in ‘Breakfast at Tiffany’s,’« says Haiken, the author of ‘Venus Envy.’ »Those were awful, so it’s not surprising that eyes are the one feature that Asians want to change. Most people probably don’t have a conscious desire to look white, but there’s such a history of racism and prejudice against Asians in this country.« And on the playground. »The first thing kids do in school is make fun of your eyes,« says Chang of Monolid. »They’ll stick their fingers under their eyes and pull them until they’re slanted. In books, heroines always have big eyes and the villains always have small, piggy eyes. These little things do affect you.« All of which can consciously — or subconsciously — inspire someone to get plastic surgery. As Heather, 21, explains in halting English: »Sometimes Asian eyes look cold or hard. I look warmer after surgery. My family likes it. I look smooth. My friends have done it and they really like it. We don’t want to be American. We just want to have bigger eyes.« In many Asian communities, the surgery is seen almost as a rite of passage for teens and young adults. Or as Haiken puts it, it’s the Asian equivalent of Jews getting nose jobs for their 16th birthday. Many choose to go abroad to Taiwan or Korea to have it done. Yune says 90 percent of his blepharoplasty clients are female, with the majority of high school or college age. Likewise, the number of blepharoplasties he performs jumps during winter break and the summer. And more often than not, it’s accompanied by subtle — or not so subtle — pressure from parents.   ·

�e perfectly designed machine is one in which all its working parts wear out simultaneously. I am that machine.  � Frederick Alexander Lindemann

Bionic Beings



Section 1: Your Prosthesis a.

In the last four weeks, rate how happy you are with your current prosthesis:

Extremely unhappy

Extremely happy {…}


Over the last four weeks, rate your comfort felt when sitting:


Excellent {…}


Over the past four weeks, rate the feel (such as the temperature and texture) of the prosthesis (sock, liner, socket) on your residual limb (stump):

Worst possible

Best possible {…}


Over the past four weeks, rate how often your prosthesis made squeaking, rattling or belching sounds:






Over the past four weeks, rate the damage done to your clothing while putting on (donning) the prosthesis:


None {…}


Over the past four weeks, rate any blisters or rashes you developed on your residual limb:

Very bothersome

None {…}

Section 2: Phantom Limb This Section refers to the limb that is missing. People have reported feeling sensations and/or pain in the part of the limb that has been amputated, that is, in their phantom limb.


Over the past four weeks, rate how often you have been aware of nonpainful sensations in your phantom limb: � � � � � � �

Never Only once or twice A few times (about once/week) Fairly often (2-3 times/week) Very often (4-6 times/week) Several times every day All the time or almost all the time {…}


If you had any pain in your phantom limb this past month, rate how intense it was on average:

Extremely intense

Extremely mild


Section 3: Social and Emotional Aspects a.

Over the past four weeks, rate how often the desire to avoid strangers' reactions to your prosthesis made you avoid doing something you otherwise would have done:

All the time



Over the past four weeks, rate how frequently you were frustrated with your prosthesis:

All the time



If you were frustrated with your prosthesis at any time over the past month, think of the most frustrating event and rate how you felt at that time:

Very frustrated Or check  ďż˝


Not at all I have not been frustrated with my prosthesis.

Over the past four weeks, rate how your partner has responded to your prosthesis:

Very poorly

Very well {‌}


Over the past four weeks, rate how much a burden your prosthesis has been on your partner or family members:

Very burdensome


Not at all

Over the past four weeks, rate how much having your prosthesis has hindered you socially:

A great deal

Not at all



Section 5: Particular Situations a.

Over the past four weeks, rate how satisfied you have been with your prosthesis:


Satisfied {…}


Over the past four weeks, how would you rate your quality of life:

Worst possible life

Best possible life {…}

Final Notes a.

If any of the following have happened in the past four weeks, please check off and give a brief description: � � � �

A serious medical problem A noticeable change in pain A serious problem in the family Some other big change has occurred in your life

If you checked any of the five previous items, please give a brief description:


Please share with us anything else about you or your prosthesis that you think would be helpful for us to know:

Thank you very much!



The seaside setting of Bournemouth University might seem a world away from Afghanistan and the improvised explosive devices (IEDs) that the Taliban are using there to injure British troops. But a group of Bournemouth academics hope that the work they are carrying out at the university’s Design Simulation Research Centre might one day transform the lives of the rising number of amputee soldiers injured in Iraq and Afghanistan, and potentially return them to active service. It’s not war theory that Professor Siamak Noroozi, 54, and his team are working on, but practical design and engineering work. Using artificial intelligence and new technology, they are developing a ‘smart’ prosthetic socket that is able to measure the individual interactions between the socket and the stump of a limb and, they hope, will transform the lives of amputees. »We came across this project because we know that a lot of people are very dissatisfied with current prosthetic sockets,« Noroozi, a mechanical engineer, explains. »Currently, prosthetic limbs are made of two components: the leg — the mechanical part, which connects the person to the ground — and the socket, which connects the mechanical part to the body. But that interface can be very comfortable or very painful and can definitely generate pain if not designed properly. »You cannot create the perfect prosthetic socket that has the same feeling as your normal leg, but you should be able to get a socket with a profile that can be modified to create an optimum comfort level, and then maintain that whether the person is walking, sitting and so on.« Noroozi learned that prosthetists rely on their own experience to fit a patient with a prosthetic limb. But there was no tool available to quantify that fit by giving data or feedback. As a result, he and his team decided to try to create one. »For many years, research has been carried out to try to improve the fitting process for prosthetic limbs, but from what we know, none of this research resulted in a clinical tool that can inform processes about the quality of the fit, or the changes made during the fitting process, or what happens as a result of those changes,« Noroozi explains. »So, if you modify the socket — making it better or worse — there’s no qualitative tool that can tell you the variation of the resultant pressure after the changes you make to it.«



L EROY ARTHUR PETRY is a Sergeant First Class in

the United States Army. He has obtained the Medal Of Honor, the highest military medal in the US, for risking his life by protecting five fellow soldiers from an enemy grenade, losing his lower right arm when trying to throw it away.



S FC PETRY NOW USES a state-of-the-art prosthetic

called an iLimb Pulse, in place of his right hand, allowing him to still remain in active duty, and has since had a deployment to north-western Afghanistan, serving as an advisor to injured soldiers and their families.


In a bid to create that tool, Noroozi and his team at the Design Simulation Research Centre are using their knowledge of engineering and artificial intelligence to create a »virtual« socket, which can record data to see how it reacts to different loads, and react to the incoming information to ensure the socket maintains a state of comfort for the user at all times. »The socket can be used to monitor the progress of the person, telling us what is happening when they are static, or walking, or running, or going up stairs, to create a load profile and then judge whether those load profiles result in a comfortable or painful socket,« says Noroozi. »That would mean we could transform every individual socket so it suits the person specifically and any required adjustments can be done very quickly. This should reduce the time it takes to fit each individual socket and possibly extend the life of sockets from six to nine months, as at the moment, to several years.« As a result, the academics expect the socket to save the NHS significant amounts of money. »One of the reasons that the cost of fitting is so high at the moment its that you are paying for the experience of the prosthetist,« says Noroozi. »With our new tool, that experience can be encapsulated, which means we'll be able to better visualise the effect of any corrections to the socket and, we hope, get things right the first time.« The engineers on the project, which has received funding from the Engineering and Physical Sciences Research Council and the medical charity Remedi, are now working with Blatchford, a private company that works with the Ministry of Defence Medical Rehabilitation Centre at Headley Court, Surrey, where soldiers are sent following injury in the Afghanistan and Iraq conflicts. »When we started work on this project, we had all of the population in mind,« says Noroozi. »But more recently there are, sadly, larger numbers of younger people with amputations who want to be more active once they’ve had their limb amputated. Many of these are soldiers returning from conflicts like Afghanistan whom Blatchford are working with to improve the quality of their lives.« Noroozi and his team hope that better-fitting limbs could help thousands of amputees around the world to enjoy a fuller life. »It is our hope that we will be able to help many people — including soldiers — with our smart socket to give them as much of a return to normal life as possible,« he says. »Comfortable sockets allow amputees to return to an active life, and, in the case of soldiers, to return to active duties. One of our colleagues is specifically working on research related to prosthetic limbs for people who wish to be more engaged in Paralympic activities.« For now, the academics are focusing on ‘miniaturising’ their work, as well as making it wireless and optimising the number of points for collecting data. Blatchford is currently manufacturing a socket that integrates the smart technology, which will then be tested by amputees. That hope — that the new socket could make a difference to the lives of soldiers and other amputees — inspires his work, says Noroozi. He adds: »If I can improve the quality of life for one person with an outcome that is beneficial and sustainable, that is where the passion for my job comes from.«   ·




Joel’s Story

A freak accident while surfing took young Joel Cooke on an extraordinary journey. In Joel’s words - »I Caught A Wave That Changed My Life«. Well I was up at Lancelin, an hour and a half north of Perth, surfing with a couple of mates. Just a normal day really… when I caught a wave that changed my life. I fell off backwards and the surfboard came up over the wave and hit me straight in the mince pie (my eye). The pointy end went right into the eye. At the time I came up and went to one of my mates and said, »I think I’ve hurt myself«. I didn’t realise what had happened. He said, »You better paddle in.« It was a fairly long paddle, about 500 metres. Half way in I put my hand up and felt blood. I was trying to feel if my eye was still there by pushing on my eyelid not knowing that in fact the eye had burst. I cried out to my mate, »Find my eye before the fish eat it!!« By the time I got to the beach another friend had waved down a four-wheel drive. That guy gave me a towel and rushed me to the medical centre. From the medical centre I got an ambulance to Charles Gairdner Hospital. All this time I was thinking will I ever see again, asking everyone that looked at me »Is it bad?« I had surgery for three hours trying to save my eye. The doctors had to make my eye back into a ball but they still couldn’t tell me if I was going to see out of the eye again. Then all I could do was wait and see (pardon the pun). The whole area was so swollen. During those couple of days I was bracing myself for the worst, and that was living the rest of my life with one eye. Once the swelling went down the doctors shone a torch into the eye but I couldn’t see anything. Not even any light. I’d damaged the optic nerve too severely. They advised me that removing the eye was probably the best option due to the extent of the damage. I saw Professor Constable, a leading eye doctor around the world. He was my only hope that maybe I could see again. It took him less that ten minutes to tell me that there was no hope. I was devastated, I remember sitting in a wheelchair in the waiting room waiting to go back to my ward, crying to myself. I just couldn’t stop. Professor Constable was concerned the other eye might go in sympathy. It was a very slim chance but trying to deal with having lost sight out of one eye was bad enough but now the other could die as well. I didn’t know what to do. He said surgery should happen within twelve days to avoid this. The next day I had the surgery and the eye was removed and the grieving process began. My parents flew over from Melbourne. My girlfriend and my mates didn’t leave my side but it was like I’d lost a good friend. I didn’t really know how I was going to look after the operation, everyone kept telling my how good artificial eyes look these days. I kept thinking it’s easy to say when it’s not you. I’d had to wear an eye patch for four weeks. Once the bandages did come off and the swelling went down from my fractured cheekbone I looked exactly the same but with a red eye I couldn’t see out of. I was relieved that my face looked the same and wasn’t all smashed up. The doctors did a won-


derful job but the little conformer shell kept falling out. They had to stitch my eyelid together for four weeks to keep the conformer in while it did its job. This was the most painful time, putting the needle into the eyelid so the doctors could stitch it up. That night the conformer fell out again, so I had to go and get that same needle all over again. Was it ever going to end? About eight weeks later and after my conformer did stay in I met Paul and Jenny. They started making my prosthesis and helping me come to terms with my loss. Reading and hearing stories about other people’s eye loss helped. I started to understand that your life could be exactly the same as what it was only now you’ve got one eye. Getting the new eye was exciting. When Paul put it in for the first time I closed both my eyes and looked in the mirror. When I opened them, it was like the past couple of months were a dream because I looked no different. I was still coming to terms with not seeing out of it and having to look at myself with an eye instead of a red dot. I was happy again. I felt like the whole accident was over and my luck was changing. I knew life would go on but I was nervous about driving, using power tools and if I could stay in my trade. It has been almost a year now and I still get angry and ask why it happened to me. What did I do to deserve this? I think this to myself but I know you can’t live like that because there is no answer. Every night I turn on the news and hear about someone else’s horrible day and think that life with one eye isn’t so bad. One thing that I’m still dealing with is the fact that my eye will never be the same. Having had my eye removed, I know I’ll never be able to look through that eye again. Sometimes when you are walking around people might notice. You do wonder what they think of you or what you really do look like and I feel like I have to explain what happened. Sometimes though when I am telling my story to strangers I feel I’m just sooking but I think it does help. It helps by just the reaction of everyone. The more people you meet, the more comfortable you become with yourself. I’ve been surfing again, not on the same board. I tried to once but there were just too many bad memories. I’ve been snorkelling and swimming nearly everyday and have no problems with my eye. I was with my girlfriend at the time and we are still together. I still go to the pub and out to meet other people. To other blokes going through this I want them to know that girls still come up to you and want to talk to you. It doesn’t make you unattractive. It is coming up to about a year since my accident. Looking back on the last ten months and I can see how much I have moved on and got back into my normal life. I know that life will keep getting better with each day. Even when I do get angry and upset about the accident I know over time things will get better.


Maureen Muskett’ tells how two people within the same family can respond very differently to eye loss.

Maureen’s Story

I lost my eye as a child in the bombing of London in 1940. I woke up in a cot with my hands tied to the rails. As a result of this experience I had an incredible fear of the bomb sirens and feeling restricted in any way. I did play up as a child. I didn’t wear the eye to school so I could be sent home. The teachers wouldn’t teach me to read until Year Two, as they were worried about eyestrain. It was only when my younger sister started to read that I protested and insisted on being taught. My younger sister was very protective of me during those school years and still is. I didn’t meet anyone else with an artificial eye until I was an adult. I was very honest with people when I met them. If I noticed that people were studying the eye I just told them. »That is my war wound«. It was never an issue after that. I didn’t need glasses until I was forty-something. I had to strain to read the bus numbers. My husband had to pick me up from some obscure places a couple of times. I ended up at Takapuna on the north shore of Auckland three times. Finally he suggested I should have an eye test.


I was very upset when I found out I needed glasses. My father was diagnosed with cancer behind the eye when he was 57. He was very upset when he found out he was going to lose his eye. He went through a bad depression for one year. My advice to him was, don’t worry! He used to hide behind dark glasses. It took him about three years until he would leave the dark glasses off. It was pretty funny — someone wearing dark glasses in the winter in England. We were very different in this respect — I was more upset about having to wear glasses than having to wear a glass eye. Toward the end of his life, when he had six weeks to live, I went home to see my father. By then he was used to the glass eye and he found it hilarious that we both had artificial eyes. We could laugh about it then. I told him, »See, I told you it was alright!«


Marx’s Story

After being shot, Marx Melencio lost his eye when he was 23 years old, and turned his adversity into an advantage. I was buying fried rice at a neighborhood food stall in the Phillipines when I was gunned down. It was November 2003. I went from a man to a cowering little boy. The first bullet went through my chest. After a blink of a second, a bullet went through my head from a gun poked straight at my left temple. Left totally blind and without possibility of treatment, I was broken. I badly wanted to regain what I had lost. A month after checking out of the hospital, I did nothing but wait for a miracle. There will be changes, but this doesn’t mean everything just took a turn for the worst. A good friend introduced me to JAWS, a screen reader. Being quite savvy with computer hardware and software myself, I was browsing the Internet and creating a Friendster account in no time. I needed to continue with my studies at UP. Learning about UP’s virtual learning system, I enrolled. Taking up all the units I was lacking from my science degree in mathematics, I graduated based on credited units at UP with a liberal arts degree in Political Science last Oct, 2005. Having a wife and a 3-year old daughter, I needed a job. Hearing about a medical transcription course being offered by a computer school for the blind, I went to ATRIEV last Oct, 2005. Before going to every customer support company, I explicitly told them over the phone that I was totally blind. Their exams were to be taken on a computer. I told them I had a software application that can allow me to access the exams on the computer, and they told me they couldn’t install it. I told them the installation CD was in my bag, and I could install it with my eyes closed — of course, pun was intended by all means. They told me they didn’t have the hardware to support my software, and I told them I had a headset in my bag, and that was all I needed to make a mid-end computer accessible to me. When they finally told me that they’d just call me up as soon as they have everything sorted out, I stepped back. My wife was fuming mad. I told her it was better that way since they all knew they had to think of blind people in the near future. After a couple of months, I went into seclusion. By the way, the phone calls never came. I turned my adversity into an opportunity. Grayscale started out without any capital investment other than time, a couple of computers, an Internet connection, and a place that also acted as our home. It started out last Sept. 2006 with manpower resources worth 4 people — me, my wife, a young UP professor based in Bicol, and a college student in India. Today, Grayscale has 7 production departments collectively worth 75 people, 3 websites, a virtual office with a document management system developed by a Liverpool-based company, 7 long-term contracts in which 2 are with prominent software security companies, and substantial plans to expand with services for a few specialized niches in the IT industry. Looking back, I was given a lemon in life, and I turned it into lemonade, so let’s all have a drink!



Heath Elkington, father of Saskia, talks about coming to terms with his one year old daughter’s eye loss.

Heath’s Story

Saskia was diagnosed a couple of weeks after her first birthday. She went to hospital and had lots of tests. The advice was that they needed to enucleate the eye. It came out pretty quick. When she was diagnosed I took a couple of months off work. I was lucky that my work could accommodate that. Because of the nature of the cancer it all happened very fast. It is very difficult at first to come to terms with her losing the eye. These days the eyes are so good. People can’t really notice. You worry about people teasing her but that doesn’t happen. When she got her new eye, her »magic« eye, people would say, »which is the real one?« As a parent your job is to protect the child. In these circumstances to help them involves watching them suffer. You have to watch them go through surgery, needles and being poked and prodded. It’s very stressful. It certainly puts other things in perspective. We made contact with every other family we could find with bilateral retinoblastoma. They were all happy to talk to us and it really helped. We’d be pleased to talk to other people who ring with the same condition.


Kendall’s Story

This young women stresses that after eye loss even at an early age, this never prevented her from acting out or get married. I had my eye removed when I was eighteen months old because of chronic fibrosis staphyloma. Mum still feels guilty,  like it is something she did. I have never felt that way. It was just one of those things. I remember as a kid when it was time for a new eye I could tell because it would fall out at school. I actually lost it one day at Ascot Water Playground. I swam around and found it again. Most kids at school didn’t know I had an artificial eye. If they did find out they’d say, »what does it look like behind the eye?« A couple of times I showed close friends after school. Once there was a boy I didn’t like. I pretended to take my eye out and drop it in his drink. I actually dropped a ten-cent piece in instead but he was really freaked out. He went all white, it was great. Turning 18, I discovered a useful advantage in having an artificial eye. I wasn’t allowed to drive at night. This meant that when my friends and I headed off to the pub I didn’t have to take a turn at skipper. Driving is still a bit interesting with the depth perception thing. Parking can be fun especially because I drive a big four-wheel drive Patrol. My husband didn’t see my eye socket for about five years. This was mainly because I don’t take the eye out all that often. When he finally did see it he said, »Is that all?« Like, big deal. I wear a large scleral lens over my good eye and people often mistake it for the artificial one. I recently met a two year old who had just lost an eye. I told her parents, »Don’t stress. The new eye will just be part of her. She won’t know any different.«   ·



We have been raised to believe in a concrete reality defined by matter, which is something that occupies space, and is either perceived by our sensory organs, or measured by other tools. As beings with a physical dimension, we humans tend to think of our ‘selves’ as unified ‘wholes’. Of course, our everyday lives and activities pose little threat to this perception: the reality of the different parts of this ‘whole’ is proven to us every day through our sensory experiences. We are constantly seeing, hearing, and feeling the world through our sensory organs. It is then only natural that any sensation in these organs, including pain, should be considered ‘normal’, if not always welcome, for we have learned that our body parts, which compose our physical substance, are entitled to sensations. The question that comes up, however, is whether the opposite is necessarily untrue. The phantom limb phenomenon has intrigued mankind for centuries. The medical description of the condition dates back to the 1530s, when the French military surgeon Ambroise Paré described pain in the non-existent amputated limbs of soldiers. The term ‘phantom limb’ was coined by Silas Weir Mitchell, another military surgeon, in 1872. Like many others, Mitchell was intrigued by soldiers’ accounts of the vivid sensation of pain in these ‘ghost organs’, i.e. the limbs that were no longer present. Naturally, the questions that came to mind were: what is causing this sensation of pain? And is this pain real or illusory? The initial speculations regarding pain in a non-existent body part attributed it to some form of hallucination, for how could an organ that does not exist claim to sense anything? This may reflect the huge variability in the reports of the prevalence of phantom limb pain, which is said to affect anywhere between 2% - 80% of all amputees. Older reports tend to indicate a much lower rate in comparison with more recent studies, possibly because amputees may not have been willing to report their phantom pain for concerns over a label of insanity. Even today, the view that phantom limb pain is ‘all in the patient’s head’ is still prevalent, and there are those investigators who place it in the same category as ‘other mental disturbances’. However, for those suffering from this phenomenon, the feeling of pain in an organ that no longer exists is a living reality. This pain has been described with various qualities, such as shooting, stabbing, boring, squeezing, throbbing, and burning. The pain is usually experienced intermittently and is primarily localized to those parts of the missing limb which are farthest from the site of amputation (for example in the fingers of an arm amputee). Various factors may trigger the sensation of phantom pain, including certain movements, pressure, and psychological factors. The onset of pain is often early after the amputation, and although some studies report that the pain diminishes over time, others report no such reduction. The pain could often be excruciating, and can involve experiences of voluntary movement, paralysis, or strong involuntary spasms in the absent limb.


So what is the nature of this well-characterized, ‘real’, and often debilitating pain? How can one be made to feel a vivid sensation in a body part which no longer exists? And how can this unwelcome sensation be treated when the afflicted site has no physical reality? These are some of the questions that drove researchers to deciphering the mechanisms of phantom limb pain. In this attempt, the earlier studies turned their eyes to peripheral nerve factors. For example, it was found that the amputated nerve endings at the stump cluster together to form structures called ‘neuromas’. It was then postulated that neuromas (which are quite sensitive and also capable of spontaneous neural activity) generate impulses that go to the brain and are perceived as pain. Support for this hypothesis came from the finding that in many patients, a surgical removal of the neuromas leads to pain relief. However, not all patients benefit from this treatment. Furthermore, the peripheral theory does not explain why some amputees suffer from phantom limb pain and some don’t. Therefore, although the peripheral nerve mechanism may play a role in generating phantom limb pain, it cannot be the entire story behind this ghostly sensation. One remarkable facet of the phantom limb pain is that it seems to be related to the pre-amputation pain. It has been reported that if the individual has had chronic pain in the limb prior to amputation, phantom limb pain has a higher incidence. It has a lower incidence if the amputation is performed when the individual is very young. Furthermore, the phantom pain seems to be qualitatively similar to the pre-amputation pain. For example, if a patient suffers a painful ulcer on her leg prior to amputation, s/he may later report phantom pain with the same characteristics and in the same location as the ulcer pain. These findings have led some researchers to suggest a role for ‘pain memory’ in the formation of phantom limb pain. It is however quite remarkable that phantom limb pain can also be observed in people born without a limb. And even though this congenital phantom limb pain is reported to be rare, it may bring the importance of pain memory into question. Another attempt at understanding phantom limb pain was made by studying the brain and the spinal cord. It has been postulated that after an amputation, the loss of sensory input to the spinal cord will cause changes in spinal structures called dorsal root ganglia (which previously received input from the presently missing limb). These changes include increased excitability and increased activity in NMDA-receptors, which may lead to the perception of pain. Another theory is that there is a genetically determined ‘matrix’ of interconnected neurons in the brain, and phantom limb pain is caused when the matrix is deprived of normal sensory input from the limbs. The deprivation causes the neurons to fire abnormally, giving rise to the perception of pain. Although this theory provides a framework that is consistent with peripheral, spinal, and central mechanisms and explains some previously puzzling data, it is difficult to test and thus its accuracy remains unknown.


Some interesting insight into the phantom pain phenomenon has come from studies of the somatosensory cortex of the brain. It has long been known that the various parts of the body relay their somatosensory (i.e. touch) messages to different parts in the somatosensory cortex. When amputation leads to an abolition of sensory input from a specific body part, the area of the somatosensory cortex corresponding to that body part is often ‘invaded’ by the adjacent parts. For example, it has been observed that when the face of someone with a hand amputation is touched, the person feels a sensation of touch in his/her phantom hand. This may be due to an ‘invasion’ or ‘cortical reorganization’, because the face and hand areas are adjacent in the map of the somatosensory cortex. Remarkably, it has been found that phantom pain intensity increases with an increased degree of cortical reorganization. Cortical remapping can sometimes be reversed by eliminating input from the amputation stump by inducing anaesthesia, and in one study, peripheral anaesthesia completely eliminated cortical reorganisation and phantom pain in three of six patients. Yet cortical reorganization does not explain all phantom limb-related phenomena. For instance, little reorganization is observed in non-painful phantom limb sensations and the extent to which this mechanism plays a role in pain sensation is still not clear. Even though these neurological studies have contributed significantly to our understanding of phantom limb pain, the role of psychological explanations should not be neglected either. Strangely enough, the view that the phantom limb pain is only in the patient’s head, and is a somatic manifestation of an underlying anxiety or personality disorder is still accepted, even though empirical evidence has shown that people who suffer from phantom limb pain have normal psychological profiles. It is however important to note that phantom limb pain can be elicited and exacerbated by a variety of psychological factors, in particular stress. Cognitive factors may also play a role, for example those patients with a better pain appraisal and better coping strategies may be able to reduce the amount of phantom pain experienced.


Despite the above findings, the phantom limb pain phenomenon remains poorly understood and although various treatment approaches have been experimented with, the results have been of limited use. Medication (particularly the use of antidepressants, sodium channel blockers, NMDA-receptor antagonists, and calcitonin) remains the most ‘successful’ form of treatment. Various anaesthetic blocks have been claimed to be effective, but none have proven to be effective in well-controlled trials. Other forms of treatment have also been implemented, including electrical stimulation of the spinal cord and deep brain structures (with some benefit in alleviating chronic pain), and neurosurgical techniques (which may be effective at providing temporary pain relief). More recently, alternative approaches have been suggested, such as acupuncture and use of ‘virtual reality’. Preliminary studies have indicated some benefit for these methods, but larger samples and more careful controls are needed to establish any definitive results. For example, several studies have shown that when patients with an upper arm amputation placed their intact hand inside a box with a mirror inside (so that they could see the reflection of their hand in the mirror) and asked to place their phantom hand behind the mirror (where the image of the intact hand is reflected), they can eventually project the movements of the intact hand onto the phantom limb, and in this way control the involuntary movements of the phantom. However, there have been mixed reports about the effects of this procedure on phantom pain. The difficulty with studying phantom limb pain stems from several factors. Most studies have small sample sizes and short follow up periods. Furthermore, all descriptions of pain are reported by patients, usually after the amputation, and patients’ description of pain may be imprecise, and their memories of previous pain may not always be accurate. In addition amputees are quite a diverse population and may differ in a variety of characteristics. These factors also create difficulties in comparing the studies on phantom limb pain and reaching a consensus about its causes and mechanisms. Thus, the mysteries of phantom limb pain live on to this day. However, studying this phenomenon has led to profound insights into the organization of the normal human brain. For instance, it was previously thought that brain remapping can only take place early in development, whereas it is now known that even the adult human brain can undergo functional reorganization. Another example is how the brain integrates visual and tactile stimuli in the mirror box experiment to ‘feel’ the non-existent limb. This shows how these ‘fragments of information’ coming from different senses are combined to form a unified body image and an enduring sense of self. Many people are fascinated by questions relating to the nature of the self and how our brain comes to construct a body image. And although these questions are not directly addressed by most neuroscience experiments, extraordinary puzzles such as the phantom limb pain, though difficult to understand, may shed some light upon the mysteries of the human mind.   ·

�e body is a big sagacity, a plurality with one sense, a war and a peace, a flock and a shepherd.  � Friedrich Nietzsche

Strange Souls



Body Dismorphic Disorder affects about two percent of the people in the United States and strikes males and females equally, usually before age eighteen (70% of the time). However, there aresome studies that indicate that ��� is more prevalent in men than in women. The reasonfor this difference is not known. Some people with ��� use plastic surgery as an answerto their never ending dissatisfaction with their physical appearance. One of the manifestations of Body Dimorphic Disorder is seeking professional medical help, in particular, going to plastic surgeons to correct aspects of ones appearance. As many as half of the people with ��� turn to cosmetic surgery and dermatological treatments for help. In study by Phillips and Dufresne, out of 268 patients presenting for dermatological treatment 11.9% screened positive for ���. In another study done on 289 people (250 adults and 39 kids) who have meat diagnostic criteria for ��� according to ����� demonstrated that 76.4% of them were looking for non-psychiatric treatment and 66% of adults received it. Phillips and Dufresne, A guide for dermatologist and cosmetic surgeons, out of patients presenting for cosmetic surgery 7% were women and 33% were men. Another study said that men are as likely as women to seek non-psychiatric treatment such as dermatologic, surgical, and dental. However, they are less likely to receive it than women. Nevertheless, men with ��� are as likely as women to receive plastic surgery. But women receive it much more often than men do.


B B B B � * B B B * 

B ODY DYSMORPHIC DISORDER is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of their physical features. The person complains of a defect in either one feature or several features of their body; or vaguely complains about their general appearance, which causes psychological distress that impairs either occupational or social functioning, or both. Occasionally, BDD occurs to the degree of causing severe emotional depression and anxiety, and the possible development of other anxiety disorders, social withdrawal, or social isolation.

In contrast to females, male patients seem to lack a clear body concept and an in-depth awareness of their physical appearance. As a result, they often have difficulty articulation their objective for cosmetic surgery. Men are also more likely to have muscle dysmorphia. This is form of ��� in which men think that they are too small and wimpy looking. They take anabolic steroids and work out obsessively. Furthermore, men are usually obsessed with their hair, skin, facial features, and size of their penis. In fact, penis enlargement is one of the many cosmetic surgeries thought out by men. Those patients who are turned down by cosmetic surgeons perform ‘D.I.Y.’. In study in Psychiatric Bulletin (2000), 25 patients with ��� had a total of 46 procedures. 9 out of 25 performed their own D.I.Y. surgery in which they attempted by their own hand to alter their appearance dramatically.. However, plastic surgery proves no benefit because it is never good enough, and the obsession is still present. In many cases symptoms get worse after the cosmetic procedure or a person becomes obsessed with another part of their body. The results demonstrated that surgeries and dermatological treatments rarely improved ��� symptoms. The study demonstrates that majority of ��� sufferers get non-psychiatric treatments, but respond poorly to it. About 63 percent of patients get treatment in both surgery and dermatology. In the survey of cosmetic surgeons, 7% replied that patients with ��� stop requesting surgery after one procedure, 13% stop sometimes, and 63% continue asking for repeated surgeries. Patients who are dissatisfied with their operations feel guilty and angry with themselves or the surgeon for having made their appearance worse. After getting plastic surgeries men with ��� tend to direct their anger at the surgeons. Nevertheless, they continue with getting repeating plastic surgeries in pursuit of correcting their imagined ugliness. It seems as though people with ��� get addicted to plastic surgeries.


The major concern is that ��� is not recognized by plastic surgeons and general practitioners. In the survey of cosmetic surgeons 13 percent of the surgeons replied that they treat patients with ���, 51 percent do not, and 36 percent do it sometimes. People with ��� see dramatic problem in their appearance. They get repeated unnecessary plastic surgeries to correct the problem with their appearance – addictive behavior. However, even after getting the surgery which is supposed to fix the problem, they do not stay satisfied for a long time. People with ��� either find something else wrong with the ‘problem area’ that they had a plastic surgery for or their concern/preoccupation moves to another area of the body. . Another study assessed the nonpsychiatric treatment sought and received by 289 individuals with ���. The treatment was sought by 76.4% and received by 66%, followed by surgery by 23.2%. the symptoms rarely improved ��� symptoms. Results were similar in children and adolescents. These findings indicate that a majority of patients with ��� receive non-psychiatric treatment but tend to respond poorly. Cosmetic surgery in men has been cited as sometimes generating aggression toward the surgeon, even triggering murder. Among adults and adolescents combined, the most common areas of concern were the skin, hair, and nose. Over the course of their illness, subjects were concerned with 3 to 4 body areas. In this study 76.4% of patients sought non-psychiatric treatment for their perceived appearance flaws. 38.2% of these individuals requested treatment for more than one treatment category, most often both surgery and dermatological treatment. Of the entire sample of adults, 66% received non-psych treatment. Of these adults who sought such treatment 86.4% received it. 63% received more than one treatment.  

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Katherine Philips involving more than 500 patients:  Skin 73% Hair 56% Weight 55% Nose 37% Toes 36% Abdomen 22% Breasts/chest/nipples 21% Face size/shape 20% Eyes 20% Thighs 20% Teeth 20% Legs 18%


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A S A CASE STUDY I will present a case of the suc-

About 27% received treatment from more than one category. There was no significant association between the number of non-psychiatric treatments sought or received and current ��� severity. Although there was a trend for subjects with more severe ��� symptoms to seek more non-psychiatric treatment. Approximately one third of all requested treatments were not received. Females and males were equally likely to seek treatment. Women and men were also equally likely to receive treatments, however, women received a greater number of treatments than men (2.4+-3.4 versus 1.5 +- 1.8). The most common treatment outcome was no change in overall ��� severity. Patients are instructed to look into the crooked mirrors. Therefore, they are actually seeing distorted reflection of themselves. In one of them the patient had two plastic surgeries and like most of the other people with ��� was dissatisfied with the results. Another patient did not have any plastic surgeries. However, she had a number of surgeries to reconstruct and fix body parts that were destroyed and distorted due to her OCD (e.g., obsessively working out to the point that the knee caps break). And yet another patient did not have any plastic surgeries at all. In all those cases the technique with using crooked mirrors for exposure exercises was successful.   ·

cessful treatment of the patient BJ who has had 17 plastic surgeries prior to the treatment. In the past five years she has not had any plastic surgeries done at all. BJ is a 45 year old Caucasian female, American born. Prior to coming to UCLA she has undergone several treatments for her OCD and BDD conditions. When I met her she appeared to be demoralized by living with the disorder for many years. At the time BJ met criteria for severe BDD & OCD. She has undergone 17 plastic surgeries. She grew up in supportive and loving environment. Rituals were done to be safe and also to protect herself from aging and getting to be ugly. Her rituals of perfections and facial rubs would take more than 8 hours a day. BJ developed a magical thinking which resulted in separating positive and negative spaces. The applied treatment consisted of doing things only once, refrain completely from looking into the mirror, wearing different earrings, exposing her to negative spaces and doing all activities incompletely. At the end of the program symptoms were not ameliorated completely because we were not able to reverse sleep/wake cycle so she was referred to sleep clinic. She also still had trouble transitioning from one activity to another without compulsive behaviors, although her perfectionalistic concerns were reduced.



How did you lose part of your leg? It was amputated when I was nine years old due to a congenital bone defect. I was unable to walk normally even before the amputation. Have you ever used your stump during sex? Yes, with both women and men. The first time was with a man in his 50s, and I used my stump to masturbate his cock. It was strange to start with, but I quickly got into the swing of things. After a couple minutes of this, he ejaculated onto my stump, and then licked off the cum with his tongue. I ejaculated quickly after seeing this: it was such a turn on! I’ve also done similar to a woman’s pussy. She loved it. I’ve realised that my stump is an opportunity for enjoyable sexual fun, and therefore I’m happy to use it in any way I can to satisfy both my partners and myself. That’s hot. Since you use a prosthetic leg in daily life, do the people you meet not initially realise you are disabled? When you are dating someone, how long do you wait to bring it up? I do wear my prosthetic leg all day, but I sometimes take it off at home and use crutches or crawl about. (I also find crawling a turn on, and would love to be forced to crawl about naked by a sexual partner.) I have always told people in the past about my leg before I met them — if it was a blind date, or someone from the internet, etc. — because I’ve found that some people just don’t want to get into a deep relationship with a disabled person. I lost a few girlfriends due to the leg — they said even though I’m a nice guy, they didn’t want to have a physical relationship with someone with one leg. That knocked my confidence pretty badly. Were you ever married? No, but I came close once. It was in the early 70s, but the girl I was dating (and never had sex with) broke it off because she had more feelings for another women. They are still together today. Are you dating anyone now? No. Sadly I have not had sex in over three years, but even at my age I live in hope. There aren’t many people local to where I live that I could develop a friendship and/or relationship with. ‘Normal’ dating sites never seem to get me anywhere — not sure if it’s me or what.


So you have more success on sites that are geared specifically for disabled people? I have certainly had more online chats with people on disabled sites than on normal sites, and have met some in person, most of whom turned out to be guys. I’ve been on DisabledDating4u, AmputeeDate, Caffmos (a gay site) and some others. There are also sites specifically for amputee devotees, as you know. What are most of the people on the amputee-devotee forums into? Have you had any weird requests from people? Most people want me to use my stump to jerk them off, or to be penetrated. The weirdest was probably this guy who asked me to stand using my crutches, with my stump just hanging down, and then he would crawl over and suck the base of the stump, then lick it all the way up to my penis while his friend watched. That was kinky. What's the most extreme sexual situation you’ve ever experienced? I haven’t really been in one... maybe the time that I was in a group of five men, and we all were jerking each other off and peeing on each other. That sounds kind of extreme. Yeah, it just sort of happened. We were all hanging out and watching a porn video, and then eventually we started either masturbating ourselves or each other. Then in the video a guy started peeing on a girl — and wow it was hot! — and then one of the guys suggested that we all pee on him. As you know, at that stage of horniness anything goes, so we all stood over him and began urinating. It was a wonderful feeling, I think he loved it! How did you lose your virginity? It was in my mid twenties, to someone I met on a dating site (a normal one). But it was a one-off with her. She didn’t say anything, but I had a feeling she wasn’t into my disability. I lost my male-to-male virginity in my 30s to a guy in his 50s. I’d been chatting to him on an amputee-devotee site. We did oral. I’m not too keen on having a cock in my ass, although toys or a strap-on would be nice to try.  Agreed. I like your glamour shots, by the way. Thanks. They were taken by a photographer for The Outsiders, a group that was set up for disabled people to help with discrimination, especially on the sexual side. I loved posing nude and hope to again. Do you have an ultimate sexual fantasy? I would love to have a Master. I’ve never actually been a slave, but I live in hope that I will be one day. The idea of being someone’s slave, and of being punished if I don’t perform a task well, really turns me on. I have a very submissive nature. For example, before I retired I worked in marketing as a supervisor, and had staff working for me, but I did not like it, and was always happier being told what to do, both at work and in my private life. Even at 52 I have hope for a newfound, kinky sexual future!   ·




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? In January of this year British newspapers began running articles about Robert Smith, a surgeon at Falkirk and District Royal Infirmary, in Scotland. Smith had amputated the legs of two patients at their request, and he was planning to carry out a third amputation when the trust that runs his hospital stopped him. These patients were not physically sick. Their legs did not need to be amputated for any medical reason. Nor were they incompetent, according to the psychiatrists who examined them. They simply wanted to have their legs cut off. In fact, both the men whose limbs Smith amputated have declared in public interviews how much happier they are, now that they have finally had their legs removed. Healthy people seeking amputations are nowhere near as rare as one might think. In May of 1998 a seventy-nine-year-old man from New York traveled to Mexico and paid $10,000 for a black-market leg amputation; he died of gangrene in a motel. In October of 1999 a mentally competent man in Milwaukee severed his arm with a homemade guillotine, and then threatened to sever it again if surgeons reattached it. That same month a legal investigator for the California state bar, after being refused a hospital amputation, tied off her legs with tourniquets and began to pack them in ice, hoping that gangrene would set in, necessitating an amputation. She passed out and ultimately gave up. Now she says she will probably have to lie under a train, or shoot her legs off with a shotgun. For the first time that I am aware of, we are seeing clusters of people seeking voluntary amputations of healthy limbs and performing amputations on themselves. The cases I have identified are merely those that have made the newspapers. On the Internet there are enough people interested in becoming amputees to support a minor industry. One discussion listserv has 1,400 subscribers. »It was the most satisfying operation I have ever performed,« Smith



told a news conference in February. »I have no doubt that what I was doing was the correct thing for those patients.« 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.« Yet the psychiatrists and the surgeon were all baffled by the desire for amputation. Why would anyone want an arm or a leg cut off ? Where does this sort of desire come from? Smith has said that the request initially struck him as »absolutely, utterly weird.« »It seemed very strange, »Reid told the BBC interviewer. »To be honest, I couldn’t quite understand it.« The True Self In 1977 the Johns Hopkins psychologist John Money published the first modern case history of what he termed »apotemnophilia« — an attraction to the idea of being an amputee. He distinguished apotemnophilia from »acrotomophilia« — a sexual attraction to amputees. The suffix -philia is important here. It places these conditions in the group of psychosexual disorders called paraphilias, often referred to outside medicine as perversions. Fetishes are a fairly common sort of paraphilia. In the same way that some people are turned on by, say, shoes or animals, others are turned on by amputees. Not by blood or mutilation — pain is not usually what they are looking for. The apotemnophile’s desire is to be an amputee, whereas the acrotomophile’s desire is turned toward those who happen to be amputees.

GER I found John Money’s papers on amputee attraction at the University of Otago, in Dunedin, New Zealand, shortly after the Falkirk story made the news. Money is an expatriate New Zealander, and he has deposited his collected manuscripts in the Otago medical library. I had come to Dunedin to write a book at the university’s Bioethics Centre, where I’d worked in the early 1990s. I have a medical degree, teach university courses in philosophy, and write a fair bit about the philosophy of psychiatry, and I was interested in the way that previously little-known psychiatric disorders spread, sometimes even reaching epidemic proportions, for reasons that nobody seems fully to understand. But I had never heard of apotemnophilia or acrotomophilia before the Falkirk story broke. I wondered: Was this a legitimate psychiatric disorder? Was there any chance that it might spread? Like Josephine Johnston, a lawyer in Dunedin who is writing a graduate thesis on the legality of these amputations (and who first brought the Falkirk case to my attention), I also wondered about the ethical and legal status of surgery as a solution. Should amputation be treated like cosmetic surgery, or like invasive psychiatric treatment, or like a risky research procedure?



Reviewing the medical literature, one might conclude that apotemnophilia and acrotomophilia are extremely rare. Fewer than half a dozen articles have been published on apotemnophilia, most of them in arcane journals. Most psychiatrists and psychologists I have spoken with — even those who specialize in paraphilias  — have never heard of apotemnophilia. On the Internet, however, it is an entirely different story. Acrotomophiles are known on the Web as »devotees,« and apotemnophiles are known as »wannabes.« »Pretenders« are people who are not disabled but use crutches, wheelchairs, or braces, often in public, in order to feel disabled. Various Web sites sell photographs and videos of amputees; display stories and memoirs; recommend books and movies; and provide chat rooms, meeting points, and electronic bulletin boards. Much of this material caters to devotees, who seem to be far greater in number than wannabes. It is unclear just how many people out there actually want to become amputees, but there exist numerous wannabe and devotee listservs and Web sites. Like Robert Smith, I have been struck by the way wannabes use the language of identity and selfhood in describing their desire to lose a limb. »I have always felt I should be an amputee.« »I felt, this is who I was.« »It is a desire to see myself, be myself, as I ‘know’ or ‘feel’ myself to be.« This kind of language has persuaded many clinicians that apotemnophilia has been misnamed — that it is not a problem of sexual desire, as the -philia suggests, but a problem of body image. What true apotemnophiles share, Smith said in the



BBC documentary, is the feeling »that their body is incomplete with their normal complement of four limbs.« Smith has elsewhere speculated that apotemnophilia is not a psychiatric disorder but a neuropsychological one, with biological roots. Perhaps it has less to do with desire than with being stuck in the wrong body. Yet what exactly does it mean to be stuck in the wrong body? For the past several years I have been working with a research group interested in problems surrounding the use of medical interventions for personal enhancement. One of the issues we have struggled with is how to understand people who use the language of self and identity to explain why they want these interventions: a man who says he is »not himself« unless he is on Prozac; a woman who gets breast-reduction surgery because she is »not the large-breasted type«; a bodybuilder who says he took anabolic steroids because he wants to look on the outside the way he feels on the inside; and — perhaps most common — transsexuals whose experience is described as »being trapped in the wrong body.« The image is striking, and more than a little odd. In each case the true self is the one produced by medical science. At first I was inclined to think of this language as a literal description. Maybe some people really did feel as if they had found their true selves on Prozac. Maybe they really did feel incomplete without cosmetic surgery. Later on, however, I came to think of the descriptions less as literal than as expressions of an ambivalent moral ideal — a struggle between the impulse toward self-improvement and the impulse to be true to oneself. Not that I can see no difference between a middle-aged man rubbing Rogaine on his head every morning and a man whose discomfort in his own body is so


all-consuming that he begins to think of suicide. But we shouldn’t be surprised when any of these people, healthy or sick, use phrases like »becoming myself« and »I was incomplete« and »the way I really am« to describe what they feel, because the language of identity and selfhood surrounds us. It is built into our morality, our literature, our political philosophy, our therapeutic sensibility, even our popular culture. This is the way we talk now. This is the way we think. This is even the way we sell cars and tennis shoes. We talk of self-discovery, self-realization, self-expression, self-actualization, self-invention, self-knowledge, self-betrayal, and self-absorption. It should be no great revelation that the vocabulary of the self feels like a natural way to describe our longings, our obsessions, and our psychopathologies. This leads to larger questions about the nature of identity. What prompts people to conceptualize themselves as amputees? And at a time when identity seems so malleable, when so many people profess uncertainty about who they really are, is it possible that the desire for this particular identity might spread? »I Knew I Didn’t Want My Leg« The question to be answered is not only why people who want to be amputees use the language of identity to describe what they feel but also what exactly they are using it to describe. One point of contention among clinicians is whether apotemnophilia is, as John Money thought, really a paraphilia. »I think that John Money confused the apotemnophiles and the acrotomophiles,« Robert Smith wrote to me from Scotland. »The devotees I think are paraphilic, but not the apotemnophiles.« The point here is whether we should view apotemnophilia as a problem of sexual desire — a variety of the same condition that includes pedophilia, voyeurism, and exhibitionism. Smith, in agreement with many of the wannabes I have spoken with, believes that apotemnophilia is closer to genderidentity disorder, the diagnosis given to people who wish to live as the opposite sex. Like these people, who are uncomfortable with their identities and want to change sex, apotemnophiles are uncomfortable with their identities and want to be amputees. But just what counts as apotemnophilia is part of the problem in explaining it. Some wannabes are also devotees. Others who identify themselves as wannabes are drawn to extreme body modification. There seems to be some overlap between people who want finger and toe amputations and those who seek piercing, scarring, branding, genital mutilation, and such. Some wannabes, Robert Smith suggests, want amputation as a way to gain sympathy from others. And finally, there are »true« apotemnophiles, whose desire for amputation is less about sex than about identity. »My left foot was not part of me,« says one amputee, who had wished for amputation since the age of eight. »I didn’t understand why, but I knew I didn’t want my leg.« A woman in her early forties wrote to me, »I will never feel truly whole with legs.« Her view of herself has always been as a double amputee, with stumps of five or six inches.


W HAT IS Body Integrity Identity Disorder, or BIID, is a condition characterised by an overwhelming need to align one’s physical body with one’s body image. This body image includes an impairment (some say disability), most often an amputation of one or more limbs, or paralysis, deafness, blindness, or other conditions. In other words, people suffering from BIID don’t feel complete unless they become amputees, paraplegic, deaf, blind or have other ‘disabling’ conditions.



C OMMOM SYMPTOMS ARE a feeling of ‘incomplete-

ness and disability’ as an able bodied individual but a certainty of a feeling of ‘completeness and enablement’ after acquiring the required impairment. A fixed idea about the impairment required. It appears that the most common required impairment is a unilateral above knee amputation but different impairments may be needed by different people, such as paralysis, blindness, deafness, and others yet. A feeling of intense jealousy at the sight of someone who has the impairment required.

Many devotees and wannabes describe what Lee Nattress, an adjunct professor of social work at Loma Linda University, in California, calls a »life-changing« experience with an amputee as a child. »When I was three years old, I met a young man who was completely missing all four of his fingers on his right hand,« writes a twenty-one-year-old woman who says she is planning to have both her arms amputated. »Ever since that time, I have been fascinated by all amputees, especially women amputees who were missing parts of their arms and wore hook prostheses.« Hers is not an unusual story. Most wannabes trace their desire to become amputees back to before the age of six or seven, and some will say that they cannot remember a time when they didn’t have the desire. Nattress, who surveyed fifty people with acrotomophilia (he prefers the term »amelotasis») for a 1996 doctoral dissertation, says that much the same is true for devotees. Three quarters of the devotees he surveyed were aware of their attraction by the age of fifteen, and about a quarter wanted to become amputees themselves. Many of the news reports about the case at the Falkirk and District Royal Infirmary identified Smith’s patients as having extreme cases of body dysmorphic disorder. Like people with anorexia nervosa, who believe themselves to be overweight even as they become emaciated, people with body dysmorphic disorder are preoccupied with what they see as a physical defect: thinning hair, nose shape, facial asymmetry, the size of their breasts or buttocks. They are often anxious and obsessive, constantly checking themselves in mirrors and shop windows, or trying to disguise or hide the defect. They are often convinced that others find them ugly. Sometimes they seek out cosmetic surgery, but frequently they are unhappy with the results and ask for more surgery. Sometimes they redirect their obsession to another part of the body. But none of this really describes most of the people who are looking for amputations—who, typically, are not convinced they are ugly, do not imagine that other people see them as defective, and are usually focused exclusively on amputation (rather than on, say, a receding hairline or bad skin). Amputee wannabes more often see their limbs as normal, but as a kind of surplus. Their desires frequently come with chillingly precise specifications: for instance, an above-the-knee amputation of the right leg. By calling apotemnophilia a paraphilia, John Money placed it in a long and distinguished lineage of psychosexual disorders. The grand old man of psychosexual pathology, Richard von Krafft-Ebing, catalogued an astonishing range of paraphilias in his Psychopathia Sexualis (1886), from necrophilia and bestiality to fetishes for aprons, handkerchiefs, and kid gloves. Some of his cases involve an attraction to what he called »bodily defects.« One was a twenty-eight-yearold engineer who had been excited by the sight of women’s disfigured feet since the age of seventeen. Another had pretended to be lame since early childhood, limping around on two brooms instead of crutches. The philosopher Renè Descartes, Krafft-Ebing noted, was partial to cross-eyed women. Yet the term »sexual fetish« could be a misleading way to describe the fantasies of wannabes and devotees, if what is on the Web is any indication (and, of course, it might well not be). Many of these fantasies seem almost presexual. I don’t want to be misunderstood: there is plenty of amputee pornography on the Internet. Penthouse has published in its letters section many of what it terms »monopede mania» letters, purportedly from devotees, and Hustler has published an article on amputee fetishism. But many other amputee Web sites have an air of thoroughly wholesome middle-Amer-



ican hero worship, and perhaps for precisely that reason they are especially disconcerting, like a funeral parlor in a shopping mall. Some show disabled men and women attempting nearly impossible feats — running marathons, climbing mountains, creating art with prostheses. It is as if the fantasy of being an amputee is inseparable from the idea of achievement — or, as one of my correspondents put it, from an »attraction to amputees as role models.« »I’ve summed it up this way,« John Money said, a little cruelly, in a 1975 interview. »Look, Ma, no hands, no feet, and I still can do it.« One woman, then a forty-two-year-old student and housewife whose history Money presented in a 1990 research paper, said one of the appeals of being an amputee was »coping heroically.« A man told Money that his fantasy was that of »compensating or overcompensating, achieving, going out and doing things that one would say is unexpectable.« One of my amputee correspondents wrote that what attracted him to being an amputee was not heroic achievement so much as »finding new ways of doing old tasks, finding new challenges in working things out and perhaps a bit of being able to do things that are not always expected of amputees.« I am on the phone with Max Price, a graphic designer in Santa Fe, who has offered to talk to me about apotemnophilia. (He has asked me to change his name and the details of his life and history if I write about him, and I have.) Price is a charming man, articulate and well-read, and despite my initial uneasiness about calling him, I am enjoying our conversation. I had corresponded by e-mail with a number of wannabes, but had not managed to talk to any of them until now. The conversation has taken on an easy intellectual tone, more like a discussion between colleagues than an interview. Price is telling me about his efforts to get doctors to adopt some guidelines for deciding when a person with apotemnophilia should have surgery. I am tossing out ideas, trying out some of my thoughts, and I wonder aloud about a relationship between apotemnophilia and obsessive-compulsive disorder. I ask Price whether he feels that his desire is more like an obsession, a fantasy, or a wish. He says, »Well, it was definitely like an obsession. Until I cut my leg off, of course.«That brings me up short. I had been unaware that he had actually gone ahead with an amputation. »Ah,« I say. I pause. Should I ask? I decide I should. »May I ask how you did it?« Price laughs. »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

FULand 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. I met Price through an Internet discussion listserv called »amputee-by-choice,« one of the larger lists. At first I had simply prowled through the archives and listened to the ongoing conversation. I found many of the archived messages very creepy. Here were people exchanging photographs of hands with missing fingers; speculating about black-market amputations in Russia; debating the merits of industrial accidents, gunshot wounds, self-inflicted gangrene, chain-saw slips, dry ice, and cigar cutters as means of getting rid of their limbs and digits. When I introduced myself to the active electronic group, however, the discussion abruptly stopped, like the conversation in a village pub when a stranger walks in. For several days only a handful of new messages were posted.



I had invited wannabes to get in touch with me individually, telling them that I was a university professor working on apotemnophilia, and over the next few days a dozen or so people responded. Some, like Price, were insightful and articulate. Some had become mental-health professionals, in part as a way of trying to understand their desires. The few who had managed an amputation seemed (somewhat to my surprise) to have made peace with their desires. But others obviously needed help: they were obsessive, driven, consumed. Many seemed to have other psychiatric problems: clinical depression, obsessive-compulsive disorder, eating disorders, transvestism of a type that sounded anything but playful or transgressive. They did not trust psychiatrists. They did not want medication. They wanted to know if I could find them a surgeon. I felt like an ethnographer in a remote country, unfamiliar with the local customs, who the natives believe can help them. I began to understand how Robert Smith must have felt. I also began to wonder at the strength of a desire that would take people to such lengths. By all accounts, the Internet has been revolutionary for wannabes. I can see why. It took me months to track down even a handful of scientific articles on the desire for amputation. It took about ten seconds to find dozens of Web sites devoted to the topic. Every one of the wannabes and devotees I have talked with about the Internet says that it has changed everything for them. »My palms were actually sweating the first time I typed ’amputee’ into a search engine,« one wannabe wrote to me. But the results were gratifying. »It was an epiphany,« she wrote. When Krafft-Ebing was writing Psychopathia Sexualis, people with unusual desires could live their entire lives without knowing that there was anyone else in the world like them. Today all it takes is a computer terminal. On the Internet you can find a community to which you can listen or reveal yourself, and instant validation for your condition, whatever it may be. This same wannabe told me that she has never spoken about her desire for amputation with a friend, a family member, or a mental-health professional, and that she never will. Yet she is a frequent anonymous participant on the wannabe discussion listserv.



»The Internet was, for me, a validation experience,« writes a wannabe who is also a transsexual. She says she found herself thinking less about amputation after logging on, because her desire was no longer such a dark secret. »When one is afraid of discovery, I think one thinks rather more about the secret in order to guard against accidental revelation.« She also points out that the Internet helped her get information on how to lose her legs. Another wannabe, a therapist, says that discovering the Internet was a mixed blessing. »There was a huge hole to be filled,« she told me, and the Internet began to fill it. To discover that she was not alone was wonderful — but it also meant that a desire she had managed to push to the back of her mind now shoved its way to the front again. It occupied her conscious thoughts in a way that was uncomfortable. She says she knows wannabes who subscribe to as many as a dozen wannabe and devotee online mailing lists and spend hours every day wading through electronic messages. Contagious Desire I am simplifying a very complex and subtle argument, but the basic idea should be clear. By regarding a phenomenon as a psychiatric diagnosis — treating it, reifying it in psychiatric diagnostic manuals, developing instruments to measure it, inventing scales to rate its severity, establishing ways to reimburse the costs of its treatment, encouraging pharmaceutical companies to search for ef-



OTHER SYMPTOMS INCLUDE feelings of shame and

unworthiness about the feelings. These individuals feel completely alone and do not believe anyone else can suffer from such bizarre ideas. They may have been in psychiatric treatment without ever informing the therapists of their underlying desire. Repeated episodes of depression and sometimes suicidal thoughts. An apparent failure of the currently available psychiatric treatments to resolve their problem. A feeling that they are alone in the world with their desire.

fective drugs, directing patients to support groups, writing about possible causes in journals — psychiatrists may be unwittingly colluding with broader cultural forces to contribute to the spread of a mental disorder. Suppose doctors started amputating the limbs of apotemnophiles. Would that contribute to the spread of the desire? Could we be faced with an epidemic of people wanting their limbs cut off ? Most people would say, clearly not. Most people do not want their limbs cut off. It is a horrible thought. The fact that others are getting their limbs cut off is no more likely to make these people want to lose their own than state executions are to make people want to be executed. And if by some strange chance more people did ask to have their limbs amputated, that would be simply because more people with the desire were encouraged to »come out« rather than suffer in silence. I’m not so sure. Clinicians and patients alike often suggest that apotemnophilia is like gender-identity disorder, and that amputation is like sex-reassignment surgery. Let us suppose they are right. Fifty years ago the suggestion that tens of thousands of people would someday want their genitals surgically altered so that they could change their sex would have been ludicrous. But it has happened. The question is why. One answer would have it that this is an ancient condition, that there have always been people who fall outside the traditional sex classifications, but that only during the past forty years or so have we developed the surgical and endocrinological tools to fix the problem. But it is possible to imagine another story: that our cultural and historical conditions have not just revealed transsexuals but created them. That is, once ‘transsexual’ and ‘gender-identity disorder’ and ‘sex-reassignment surgery’ became common linguistic currency, more people began conceptualizing and interpreting their experience in these terms. They began to make sense of their lives in a way that hadn’t been available to them before, and to some degree they actually became the kinds of people described by these terms. I don’t want to take a stand on whether either of these accounts is right. It may be that neither is. It may be that there are elements of truth in both. But let us suppose that there is some truth to the idea that sex-reassignment surgery and diagnoses of gender-identity disorder have helped to create the growing number of cases we are seeing. Would this mean that there is no biological basis for gender-identity disorder? No. Would it mean that the term is a sham? Again, no. Would it mean that these people are faking their dissatisfaction with their sex? No. What it would mean is that certain social and structural conditions — diagnostic categories, medical clinics, reimbursement schedules, a common language to describe the experience, and, recently, a large body of academic work and transgender activism — have made this way of interpreting an experience not only possible but more likely. Whether apotemnophilia (or, for that matter, genderidentity disorder) might be subject to the same kind of molding and shaping that Hacking describes is not clear. One therapist I spoke with, an amputee wannabe, believes that the desire for amputation, like multiple-personality disorder, is often related to childhood trauma. This is only one person’s hypothesis, of course, and it may be wrong. But it is clear that sexual desire is malleable. It doesn’t seem far-fetched to imagine that amputated limbs could come to be more widely seen as erotic, or that given the right set of social conditions, the desire for amputation could spread. For a thousand years Chinese mothers broke the bones in their daughters’ feet and wrapped them in bandages, making the feet grow twisted and disfigured. To a modern Western eye, these feet look grotesquely deformed. But for centuries Chinese men found them erotic.



TREATMENT SEEMS UNLIKEY at the moment, as there is no officially accepted treatment protocol for transabled individuals. The majority of transabled individuals who have used psychotherapy to treat BIID report that it doesn’t help. Medication also seems unable to control the feelings. Anecdotal evidence suggests that the only way to alleviate the emotional suffering is to acquire the desired impairment.

Ian Hacking uses the term »semantic contagion« to describe the way in which publicly identifying and describing a condition creates the means by which that condition spreads. He says it is always possible for people to reinterpret their past in light of a new conceptual category. And it is also possible for them to contemplate actions that they may not have contemplated before. When I was living in New Zealand, ten years ago, I had a conversation with Paul Mullen, who was then the chair of psychological medicine at the University of Otago, and who had told me that he was a member of a government committee whose job it was to decide whether pornographic materials should be allowed into the country. I bristled at the idea of censorship, and asked him how he could justify being a part of something like that. He just laughed and said that if I could see what his committee was banning, I would change my mind. His position was that some sexual acts would never even occur to a person in an entire lifetime of thinking about sex if not for seeing them pictured in these books. He went on to describe to me various alarming acts that, it was true, had never occurred to me. Mullen was of the opinion that people were better off never having conceptualized such acts, and in retrospect, I think he may have been right. This is part of what Hacking is getting at, I think, when he talks about semantic contagion. The idea of having one’s legs amputated might never even enter the minds of some people until it is suggested to them. Yet once it is suggested, and not just suggested but paired with imagery that a person’s past may have primed him or her to appreciate, that act becomes possible. Give the wish for it a name and a treatment, link it to a set of related disorders, give it a medical explanation rooted in childhood memory, and you are on the way to setting up just the kind of conceptual category that makes it a treatable psychiatric disorder. An act has been redescribed to make it thinkable in a way it was not thinkable before. Elective amputation was once self-mutilation; now it is a treatment for a mental disorder. Toss this mixture into the vast fan of the Internet and it will be dispersed at speeds unimagined even a decade ago. The borders between pretenders, wannabes, and devotees do not look very solid. Many wannabes are also devotees or pretenders. A study published in 1983, which surveyed 195 customers of an agency selling pictures and stories about amputees, found that more than half had pretended to be amputees and more than 70 percent had fantasized about being amputees. Nor do the lines look very clear between ‘true’ apotemnophiles (say, those for whom the desire is a fixed, long-term part of their identities) and those whose desire has other roots, such as an interest in extreme body modification. We also need to remember that even if a core group of people with true apotemnophilia could be identified, their diagnosis could come only from what they report to their psychiatrists. There is no objective test for apotemnophilia. People seeking amputation for other reasons — sexual gratification, for example, or a desire for extreme body modification — could easily learn what they need to say to doctors in order to get the surgery they want. Specialists working in gender-identity clinics were complaining of something similar with their patients as early as the mid-1970s. Intelligent, highly motivated patients were learning the symptoms of gender dysphoria and repeating them to clinicians in order to become candidates for sex-reassignment surgery.



The Elusiveness Of ‘Help’ I will confess that my opinions about amputation as a treatment have shifted since I began writing this piece. My initial thoughts were not unlike those of a magazine editor I approached about writing it, who replied, »Thanks. This is definitely the most revolting query I've seen for quite some time.« Yet there is a simple, relentless logic to these people's requests for amputation. »I am suffering,« they tell me. »I have nowhere else to turn.« They realize that life as an amputee will not be easy. They understand the problems they will have with mobility, with work, with their social lives; they realize they will have to make countless adjustments just to get through the day. They are willing to pay their own way. Their bodies belong to them, they tell me. The choice should be theirs. What is worse: to live without a leg or to live with an obsession that controls your life? For at least some of them, the choice is clear — which is why they are talking about chain saws and shotguns and railroad tracks. 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. It is exactly this history, however, that makes me worry about a surgical ‘cure’ for apotemnophilia. Psychiatry and surgery have had an extraordinary and very often destructive collaboration over the past seventy-five years or so: clitoridectomy for excessive masturbation, cosmetic surgery as a treatment for an ‘inferiority complex,’ intersex surgery for infants born with ambiguous genitalia, and —most notorious — the frontal lobotomy. It is a collaboration with few unequivocal successes. Yet surgery continues to avoid the

OUT AN kind of ethical and regulatory oversight that has become routine for most areas of medicine. If the proposed cure for apotemnophilia were a new drug, it would have to go through a rigorous process of regulatory oversight. Investigators would be required to design controlled clinical trials, develop strict eligibility criteria, recruit subjects, get the trials approved by the Institutional Review Board, collect vast amounts of data showing that the drug was safe and effective, and then submit their findings to the U.S. Food and Drug Administration. But this kind of oversight is not required for new, unorthodox surgical procedures. (Nor, for that matter, is it required for new psychotherapies.) New surgical procedures are treated not like experimental procedures but like »innovative therapies,« for which ethical oversight is much less uniform. The fact is that nobody really understands apotemnophilia. Nobody understands the pathophysiology; nobody knows whether there is an alternative to surgery; and nobody has any reliable data on how well surgery might work. Many people seeking amputations are desperate and vulnerable to exploitation. »I am in a constant state of inner rage,« one wannabe wrote to me. »I am willing to take that risk of death to achieve the needed amputation. My life inside is just too hard to continue as is.« These people need help, but when the therapy in question is irreversible and disabling, it is not at all clear what that help should be. Many wannabes are convinced that amputation is the only possible solution to their problems, yet they have never seen a psychiatrist or a psychologist, have never tried medication, have never read a scientific paper about their problems. More than a few of them have never even spoken face to face with another human being about their desires. All they have is the Internet, and their own troubled lives, and the place where those two things intersect. »I used to pretend as a child that my body was 'normal' which, to me, meant short, rounded thighs,« one wannabe wrote to me in an e-mail. »As a Psychology major, I have analyzed and reanalyzed, and re-reanalyzed just why I want this. I have no clear idea.«   ·


�e body never lies.  � Martha Graham

State of the Part ImPrInt

the artICleS, eSSayS and StudIeS in this volume were used courtesy of Christina Valhouli, Azadeh Arjmandi, Carl Elliot, Eda Gorbis, Paul & Jenny Geelen, Karley Scortino, Lucy Thobin, Loftus Plastic Surgery Center and

their respective institutes, publishers and copyright holders. the layout of thIS volume including all typography and design elements was done by Jesse Benjamin. the fontS uSed In thIS volume are Berthold Akzidenz Grotesk Family and Hoefler Text Family.

moSt SInCere thankS towardS all inspiring, correcting and thought-provoking people, especially Julia Fuchs, Marcel Franke, Thomas Schindler, Ben Tauber and Deutsche Bahn Druck- und Reprozentrum.

� �u r g i c a l p r o c e d u r e s ha v e b e e n o n t h e r i s e i n w e s t e r n s o c i e t y, w h e t h e r t o a u g m e n t o r r e p l a c e . �is v o l u m e d e a l s w i t h P l a S t I C S u r G e r y, b I o n I C P r o S t h e S I S a n d S o C I e ta l I m Pa Ct S . �ith texts by Azadeh Arjmandi, Carl Elliot, Eda Gorbis, Tim Crane and many more.

State Of The Part  

A three-part volume dealing with the altered human body. ________ Note: This is a student work, completely uncommercial in nature.

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