Apotemnophilia is a neurological disorder characterized by the intense and long-standing desire for amputation of a specific limb.  It can be associated with body integrity identity disorder (BIID) in which otherwise sane and rational individuals express a strong and specific desire for the amputation of a healthy limb or limbs. Apotemnophilia has features in common with somatoparaphrenia. Some apotemnophiles seek surgeons to perform an amputation or purposefully injure a limb in order to force emergency medical amputation.
A separate definition of apotemnophilia is erotic interest in being or looking like an amputee. This separate definition should not be confused with acrotomophilia, which is the erotic interest in people who are amputees.
Apotemnophilia was first described in a 1977 article by psychologists Gregg Furth and John Money: "Apotemnophilia: two cases of self-demand amputation as paraphilia." More recently (2008), V.S. Ramachandran, David Brang and Paul D. McGeoch have proposed that it is a neurological disorder caused by an incomplete body image map in the right parietal lobe. However, the notion of a body image map localized to one area of the brain is not supported by contemporary neuroscience.
The parietal cortex has widely distributed functional neuronal networks, and the prospect that the body image in the brain could be localized to some specific cerebral location has not stood the test of time, with our changing views of neural activity and integration. From the neuroanatomical point of view, there can be no strict localization of the perceived body.
The study carried out David Brang, Paul McGeoch and V.S. Ramachandran in 2008 was only able to work with two subjects. In 2011 Paul McGeoch et al. published the results of an experiment in which they were able to obtain MEG images of the parietal lobes for four research subjects, three of whom desired amputation. McGeoch and his co-researchers concluded that the images suggest "that inadequate activation of the right superior parietal lobe (SPL) leads to the unnatural situation in which the sufferers can feel the limb in question being touched without it actually incorporating into their body image, with a resulting desire for amputation."
Michael First, a psychiatrist at Columbia University, has pointed out that the theory advanced by Ramachandran and his colleagues fails to account for the fact that people who desire amputation of a limb sometimes change their preference as to which limb they would like to have amputated.
In 2011 a group of researchers at the University of Southern California (Brain and Creativity Institute) proposed an alternative hypothesis. These researchers proposed that "individuals with BIID may have a discrepancy between the commands from the motor cortex to the parietal lobe and from the sensory feedback to the same regions in the parietal lobe." This theory was based on the discovery that individuals who desire amputation sometimes experience phantom limbs after amputation.
- 1 Definition
- 2 Classifications
- 3 Signs and symptoms
- 4 Sexual motivation
- 5 Management
- 6 Ethics
- 7 Research directions
- 8 See also
- 9 References
- 10 External links
A paraphilia of the stigmatic/eligibilic type in which sexuerotic arousal and facilitation or attainment of orgasm are dependent upon oneself being an amputee. In this disorder, otherwise sane and rational individuals express a strong and specific desire for the amputation of a healthy limb or limbs. Most date this desire to their childhood, and not uncommonly the sufferer will attempt to obtain amputation of the specific limb. As few surgeons are willing to amputate healthy limbs, this often means that the patient themselves will attempt to irrevocably damage the limb in question, thus necessitating formal amputation. After amputation most report to being happy with their decision and often state, paradoxically, that they are ‘complete’ at last.
Patients diagnosed with apotemnophilia are sometimes classified as being patients of body integrity identity disorder (BIID). Apotemnophilia is usually classified under BIID because patients feel discontented with their bodies and want to remove an otherwise healthy limb. An apotemnophile becomes fixated on carrying out a self-contrived amputation, or obtaining one in a hospital. Until recently,[when?] any desire for amputation was classified as this "disorder", but recently, the psychiatric community has begun to differentiate between this condition and Body Integrity Identity Disorder, in which an individual desires an amputation without an accompanying sexual component to this desire.
An individual with true apotemnophilia may be chronically unsatisfied with their sexual relationships, or even completely sexually dysfunctional until their desire for amputation is realized. Apotemnophilia condition is similar to acrotomophilia but is differentiated by the desire for oneself to be an amputee as opposed to one's partner having an amputation.
Patients with body integrity identity disorder (BIID) typically desire to have one or more limbs amputated from their bodies. Today, there are no specific causes of BIID. There have been multiple theories behind the cause of BIID and why some people suffer from this illness. One theory states that a child adopts this body image of being an amputee which results in the development of wanting the body from a young age – this has been seen in the majority of apotemnophiles. Another theory suggests that a child who feels unloved may believe that becoming an amputee will bring attention, love and sympathy. BIID is a neuro-psychological condition where there is a difference in the cerebral cortex relating to the connection between the brain and the limbs. If the condition was neurological, it is conceptualized as a form of somatoparaphrenia, a condition that often follows a stroke afflicting the parietal lobe. It has been seen through recent studies that most patients with BIID are male. This may be because the right side of the inferior-parietal lobule is significantly smaller in men than women. It has also been seen that requests for amputations are most often on the left-side of the body than the right side. The right side of the brain is known for controlling the left side and the left side of the brain is known for controlling the right side. Damage to the right side of the inferior-parietal lobule contributes to the desire of patients wanting to amputate the left side of the body.
Acrotomophilia (from the Greek akron "limb", temnein "to cut" and philein "to love"), is a paraphilia in which an individual expresses strong sexual interest in amputees. It is a counterpart to apotemnophilia, the sexual interest in being an amputee.
Signs and symptoms
Apotemnophiles will become prone to extreme levels of depression caused by isolation, confusion and the inability to determine what they're supposed to be like physically and emotionally. Patients with apotemnophilia will feel that they are apart from the norm and will isolate themselves from socializing.
Injuries are caused by desperate attempts to get the unwanted limbs to be amputated. People with apotemnophilia have an ideal image of their bodies as an amputee with missing limbs. Originally developed at a young age, apotemnophiles will go through drastic measures to ensure that their ideal image of being an amputee is fulfilled. Mentioned below, apotemnophiles will purposely induce infections onto limbs or even harm themselves by going as far as partially sawing off limbs so medical professionals do not have a choice other than to remove the limb.
Apotemnophilia has frequently been connected to sexual desires. Apotemnophilia has been connected to sexual desire for a number of years, but it is important not to confuse apotemnophilia with acrotomophilia. One excerpt from a case study from the American Journal of Psychotherapy entitled A case of apotemnophilia: a handicap as sexual preference by Dr. Walter Everaerd, PhD. from Utrecht, The Netherlands interviews an apotemnophile who describes his development of sexual preference:
"He became attracted to amputation in his 10th year. An amputated boy is according to him happier than he himself... When he was about 11 year old, he thought that he would be happier with an amputated leg. He therefore tried to infect sores on his leg. No infections developed at the time. After that he did not make any more attempts. He feels that he would not be able to bear the pain resulting from it... In addition he has photos and drawings of amputated boys and men, war victims, at his disposal. He fantasizes a lot about these photos. The image of amputation takes on erotic importance. When masturbating, amputated boys and men play at the role of partner in his fantasies. He is often occupied with self-amputation or the amputation of possible partners. He fantasizes for example, that a group of young boys who were playing together erected a guillotine. They chopped off each others legs. He does not find his desire for amputated partners and his fantasies about amputation sadistic. He often reacts astonished when I ask him that. It is not the amputation itself that is important but rather the result of it. In the development of this preference alloapotemnophilia and autoapotemnophilia were established. Now amputation of his own leg has no longer a sexual meaning. He says now that he only could feel complete once his leg has been amputated. Wanting to be amputated plays an important role in his sense of identity." Sexual desires from a life experience at a young age can be connected to one of the causes of apotemnophilia.
Apotemnophiles are usually normal in terms of psychology and have been proven to be emotionally healthy. However, due to its connections to being neurological, treatments are available to apotemnophiles. The major problem in providing treatment is that most apotemnophiles do not seek professional treatment for their condition. They are more likely to be found in the act of self amputation before actively seeking medical attention themselves. As mentioned in the article "I am in Depression", "One of the most prominent problems in the treatment of this disorder is that most apotemnophiles do not seek professional treatment for the condition, but rather receive it only when they have been caught in the act, referred by a surgeon they approached for getting an amputation or on the request of their sexual partner. Thus, their motivations for change may often stem from a desire to do it for someone else rather than from a genuine desire to change".
Cognitive and behavioral elements
Treatments for apotemnophiles have been studied; however, the two main forms of treatment seem to be a combination of cognitive and behavior elements that have been scientifically modified to change patterns of behavior and fetishes. These combinational therapy have significantly shown that there are reduced rates of recidivism than seen in untreated individuals.
Along with a combinational treatment of cognitive and behavioral focuses, another element that has been studied is something known as aversion therapy. The therapy provides aversive conditioning to deviant sexual fantasies. Therapies are provided by medical attention and have shown to reduce the effects of apotemnophiles. Along with therapy, apotemnophiles will be exposed to treatment that focuses on cognitive behavioral programs that include training in social skills that may help maintain the deviant sexual arousal and behavioral patterns.
Surgeons are placed in a difficult situation when apotemnophiles confront them about their situation. A surgeon or a medical professional will have to make the decision between amputating a perfectly normal limb or allowing his or her patients to remain unhappy. Whether the medical professional performs this surgery has not been defined as "allowed" or "disallowed". Although many professionals will agree that a patient's happiness is primarily important, amputating a limb may be out of the question because there is nothing medically wrong with the limb itself.
Apotemnophilia has been studied for a number of years to determine whether this disorder is actually neurological or psychological. However, in-depth research related to apotemnophilia and its correlation to the mind and body are still not clear. Recent research has shown small breakthroughs such that apotemnophiles are three times more likely to want removal of a left limb than right, in accordance with damage to the right parietal lobe, and also in concordance with sufferers of somatoparaphrenia; in addition, skin conductance response is significantly different above and below the line of desired amputation, and the line of desired amputation remains stable over time, with the desire often beginning in early childhood. Among a convenience sample of 52 apotemnophiles recruited from internet groups, the great majority wanted a single leg removed, cut above the knee. There are parallels between apotemnophilia as a motivation for body integrity identity disorder and autogynephilia as a motivation for some cases of male-to-female gender dysphoria.
One study by Brang and his team helped scientifically back his hypothesis that apotemnophilia is a neurological disorder. His findings provide psychophysiological evidence to support the hypothesis that apotemnophilia arises from a congenital dysfunction of the right parietal lobe and, in particular the right superior parietal lobule, which receives and integrates input from various sensory areas and the insula to form a coherent sense of body image.
Recently,[when?] Brang proposed that the failure of a congenitally dysfunctional right superior parietal lobule to form a unified body image leads to changes in skin conductance readings. When this dysfunction is acquired, as in somatoparaphrenia, the brain seems sometimes to rationalize the discrepancy by denying ownership of the limb. When the dysfunction is congenital it leads to a feeling that affected area should not be there to begin with and a desire for an amputation. Body integrity identity disorder is located under Body Dysmorphic Disorder in the current DSM V.
- Disability pretenders, those who behave as if they are disabled
- Attraction to disability
- Prefrontal cortex
- "Apotemnophilia" (PDF).
- Brang, D McGeoch, P & Ramachandran VS (2008). "Apotemnophilia: A Neurological Disorder" (PDF). Cognitive Neuroscience and Neuropsychology 19: 1305–1306. doi:10.1097/WNR.0b013e32830abc4d. PMID 18695512.
- Bensler, J. M.; Paauw, D. S. (2003). "Apotemnophilia masquerading as medical morbidity". Southern Medical Journal 96 (7): 674–676. doi:10.1097/01.SMJ.0000078367.94479.B9. PMID 12940318.
- Berger, B. D.; Lehrmann, J. A.; Larson, G.; Alverno, L.; Tsao, C. I. (2005). "Nonpsychotic, nonparaphilic self-amputation and the internet". Comprehensive Psychiatry 46 (5): 380–383. doi:10.1016/j.comppsych.2004.12.003. PMID 16122539.
- Money, J.; Jobaris, R.; Furth, G. (1977). "Apotemnophilia: Two cases of self demand amputation as a sexual preference". The Journal of Sex Research 13: 115–124. doi:10.1080/00224497709550967.
- Everaerd, W. (1983). "A case of apotemnophilia: A handicap as sexual preference". American Journal of Psychotherapy 37 (2): 285–293. PMID 6869634.
- Dixon, D. (1983). "An erotic attraction to amputees". Sexuality and Disability 6: 3–19. doi:10.1007/BF01119844.
- Brang,David, McGeoch, Paul, Vilayanur, Ramachandran, Apotemnophilia:a neurological disorder, Cognitive Neuroscience and Neuropsychology, Vol 19, No 13, 27 August 2008
- Trimble, M, "Body Image and Parietal Lobes", Primary Psychiatry, June 20, 2007, 
- McGeorch, Paul, Brang, David, Song, Tao, Lee, Roland, Huang, Mingxiong, Xenomelia: anew right parietal lobe syndrome, J Neurol Neurosurg Psychiatry, 22 May 2011
- Callaway Ewen, NewScientist, Life, March 24, 2009
- Demographics, Learning and Imitation, and Body Schema in Body Integrity Disorder, Johnson,A, Liew, S, Aziz-Zadeh, L., Indiana University Undergraduate Journal of Cognitive Science 6 (2011),
- First, M. (2005). "Desire for an amputation of a limb: paraphilia, psychosis, or a new type of identity disorder". Psychol Med 35 (6): 919–923. doi:10.1017/S0033291704003320. PMID 15997612.
- Bayne, T; Levy, N. (2005). "Amputees by choice: body integrity identity disorder and the ethics of amputation". J Appl Philos 22 (1): 75–86. doi:10.1111/j.1468-5930.2005.00293.x. PMID 15948330.
- Everaerd, W (1983). "A Case of Apotemnophilia: A Handicap as Sexual Preference". American Journal of Psychotherapy 37 (2): 285–293. PMID 6869634.
- "Apotemnophilia Treatment". I am in Depression.com. 2009. Archived from the original on 29 November 2010. Retrieved 2010-12-03.
- First, M. B. (2005). "Desire for amputation of a limb: Paraphilia, psychosis, or a new type of identity disorder". Psychological Medicine 35 (6): 919–928. doi:10.1017/S0033291704003320. PMID 15997612.
- Lawrence, A. A. (2006). "Clinical and theoretical parallels between desire for limb amputation and gender identity disorder". Archives of Sexual Behavior 35 (3): 263–278. doi:10.1007/s10508-006-9026-6. PMID 16799838.
- Lawrence, A. A. (2009). "Erotic target location errors: An underappreciated paraphilic dimension". Journal of Sex Research 46 (2-3): 194–215. doi:10.1080/00224490902747727. PMID 19308843.
- Critchley M. (1953). The parietal lobes. 225–255.
- Har R, Forss N (1999). "Magnetoencephalography in the study of human somatosensory cortical processing". Philosophical Transactions of the Royal Society B 354: 1145–1154. doi:10.1098/rstb.1999.0470.
- Felleman D, Van Essen DC (1991). "Van Essen DC. Distributed hierarchical processing in the primate cerebral cortex". Cereb Cortex 1 (1): 1–47. doi:10.1093/cercor/1.1.1-a. PMID 1822724.
- Critcheley H (2002). "Electrodermal responses: what happens in the brain". Neuroscientist 8 (2): 132–142. doi:10.1177/107385840200800209. PMID 11954558.
- The dictionary definition of apotemnophilia at Wiktionary