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Forensic Psychiatrist
Graduate School of Medicine University of Wollongong

Leg lopping for beginners – not

December 17, 2015

Leg lopping for beginners – not

Article submission by Robert M. Kaplan in The Medical Republic.
Publishing date: 16/12/2015.

The following article is a reader contribution by Dr Robert M Kaplan, a forensic psychiatrist at the Graduate School of Medicine, University of Wollongong.

In 2000 Scottish surgeon Robert Smith was charged with an unusual form of medical misconduct: amputating the healthy limbs of two men.

The patients had long desired to be rid of their offending limb, and either attempted to damage it, or threatened to do so until they were successful if they could not get a surgical amputation. After protracted deliberation, the tribunal ruled that Smith was forbidden to amputate any more healthy limbs.

Publicity surrounding the case brought attention to a phenomenon known as apotemnophilia, the word meaning “love of amputation” (from ancient Greek, those lads knew it all). In his prophetic 1973 novel Crash, JG Ballard (who else?) added apotemnophiliac sex to car crash fetishism.

Some people suffer from the desire to become paralysed or to use orthopaedic appliances such as leg-braces, etc. Others pretend they are an amputee by using crutches and wheelchairs. People sexually attracted to other people who are already missing limbs have acrotomophilia. It emerged that there were websites where people who sought to have sex with amputees could share information, pictures and make contact.

Apotemnophilia passed into the cultural cyberwildnerness, occasionally surfacing as a Trivial Pursuit question (in the sort of parlour games sold by Hustler Magazine and only played at home with companions over 18 years).

The condition then emerged in a completely unexpected paradigm. The prime motive of patients seeking amputation, studies showed, was to relieve intense discomfort, usually existing from early childhood, at the presence of the offending limb – in some cases, even both legs or hands. They would go to extraordinary lengths to self-amputate or damage the limbs so that surgery was then inevitable. Tactics including shooting, dropping heavy stones, placing the limb on a railway track before an approaching train, freezing with snow or ice, or applying constrictive tourniquets to cause gangrene. Clearly, they were not going to stop until the limb was removed, one way or the other.

Doctors dealing with these cases had to exclude psychosis, where the desire for mutilation arose in response to delusions. Were these Munchausen’s Syndrome patients, seeking a ticket of entry to hospital treatment where they could have attention, surgery and drugs? If this was the case, as soon as the limb was removed, they would develop further complaints. This was not the case. After surgery, patients reported feeling comfortable with their new body shape and cooperated with recovery and rehabilitation.

But why go to such lengths to attain extreme mutilation? While many – but not the majority – of patients associated amputation with sexual arousal and pleasure, the discomfort (dysphoria in psychiatric jargon) was a modified version of the reactions experienced by transsexuals towards their body. Transsexualism (gender dysphoria, if you like) is a complex phenomenon involving sexual, hormonal, social, anatomical and probably genetic factors. Apotemnophilia, by contrast, seems to arise from a single problem, namely body image. To date, body image problems have been extraordinarily difficult to treat, so surgery has been the only realistic option. This is now being challenged by new developments in neuroscience.

Pioneering pain researcher Ronald Melzack showed how chronic pain (such as reflex sympathetic dystrophy) was related to changes in the neuromatrix, the representation of the body in the cortical brain. If the condition was neurological, it could be conceptualized as a malfunction of the right inferior-parietal lobule, which is smaller in men, explaining not only why men are much more likely to have apotemnophilia, but also why amputations are most often of left-side limbs. This is akin to a rare condition, somatophrenia, which is treated by the simple measure of running ice cold water in the ear of the affected side.

Taking this approach even further, neurologist VS Ramachandran has shown how visual representations of phantom limbs can be changed by the use of a simple piece of technology, the mirror box, to fool the visual cortex into changing its distorted image. Ramachandran, a man to watch as a future Nobel laureate, is optimistic that mirror visualisation will save the need for the drastic step of amputation, but it’s a case of watch this space for now.

Psychiatrist Michael First reviewed 51 apotemnophilia cases, the largest study on record, showing good results from surgery and opening the way for amputation to be the accepted means of treating highly selected and screened cases. The recommendation for amputation has provided much work for those philosophers-in-sheltered-employment, namely medical ethicists. Surprisingly, the consensus has been largely in favour of surgery.

Is apotemnophilia a new phenomenon? Most unlikely; unrecognised cases have been sneaking through the system ever since surgery was invented. A good historical review awaits, but until then we have to content ourselves with the biblical aphorism – those desert wanderers, it seems, didn’t miss a thing:

And if your right hand causes you to sin, cut it off and throw it away. It is better for you to lose one part of your body than for your whole body to go into hell.

Being in full possession of all four limbs, Robert M Kaplan intends to hang on to them for as long as humanly possible. His Brother Grimm has helpfully offered to remove any offending body parts with a small chainsaw, but the offer has been politely refused.

Robert M Kaplan is a forensic psychiatrist at the Graduate School of Medicine, University of Wollongong. His book Prophet of Psychiatry: In Search of Reg Ellery was released in January 2015.

View the published article.

About the Author
Robert Kaplan is a Clinical Associate Professor, Graduate School Of Medicine, University of Wollongong. A forensic psychiatrist, writer and speaker, his books are Medical Murder: Disturbing Tales Of Doctors Who Kill (Allen & Unwin 2009) and The Exceptional Brain and How It Changed The World (Allen & Unwin 2011). He has written on a range of medical, psychiatric, historic and forensic topics and is looking for something else to take up his time so he can yet again avoid finishing his autobiography Memoirs of a Marginal Medical Student.