AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2001, Volume 3, Number 9.

Did You Know?

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The Difficult Appendage

Medical trivia about the ethical issues surrounding patient-requested amputations.

Did you know that...
  • Robert Smith, a surgeon at Falkirk and District Royal Infirmary in Scotland, amputated the legs of two patients. Stories about amputations are generally not newsworthy, but in this case there was no medical reason for the amputations except that the patients' requested the body-altering operations. Dr. Smith and the psychiatric consultants who reviewed these difficult cases concluded that the amputations were justified because other options were ineffectual and self-induced amputations could have proved fatal for these patients. There were plans to carry out a third amputation when the a new hospital oversight committee rejected further patient-requested amputations [1].
  • Individuals who request elective amputation of otherwise healthy and non-deformed limbs are believed to suffer from apotemnophilia. In 1977, the Johns Hopkins psychologist John Money published the first modern case history of apotemnophilia—an attraction to the idea of being an amputee. It is considered to be part of a group of psychosexual disorders called paraphilias, often referred to as perversions by the lay public. However, very few articles have been published [2,3] on this disorder, and not much is known about its pathophysiology and treatment. Some consider these patient requests to be no different than that which motivates inappropriate cosmetic surgery based on a pathology in body image, while others view these amputations as invasive psychiatric treatment.
  • Michael First, a psychiatrist at Columbia University, who was the editor of the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) of Mental Disorders, is undertaking a study that will help determine whether apotemnophilia should be included in the 5th edition of the DSM. If apotemnophilia is included, assessing whether amputations are an appropriate treatment for this mental disorder will pose some unusual dilemmas for potential investigators and members of institutional review boards.
  • The 2 patients who requested and received amputations performed by Dr. Smith have voiced great satisfaction and relief that now they feel complete without 4 limbs.


  1. Background information for this column came from Elliott C. A New Way to be Mad. The Atlantic. December 2000. The article was accessed here
  2. Wise TN, Kalyanam RC. Amputee fetishism and genital mutilation: case report and literature review. J Sex Marital Ther. 2000;26:339-344.
  3. Everaerd W. A case of apotemnophilia: a handicap as sexual preference. Am J Psychother. 1983;37:285-293

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