Grey Matter Episode 5: Body Modification

“Body Modification”
by Kaitlin Puccio

The question of when body modifications become harmful is particularly salient when discussing issues such as gender reassignment surgery. From a plastic surgery perspective, there are some procedures that doctors will not perform on certain patients because the doctor sees them as harmful. Some other doctors may proceed with those procedures on the same patients that were denied the surgery. There is no clear point at which certain body modifications transition from being harmless to harmful, and surgeons must make a determination based on where they place a procedure on the harm spectrum.

The Sorites paradox is an ancient puzzle that deals with vague predicates. It asks: If a heap of sand were reduced by a single grain at a time, at what precise point does it cease to be a heap? The answer is unclear, or vague. In practice, there is a heap spectrum, where “heap” is the vague predicate. On one end of the spectrum is “not a heap,” and on the other end of the spectrum is “heap.” The end points of the spectrum are undisputed—all observers would agree on them. Say a single grain of sand is the end point of “not a heap,” and one million grains is a “heap.” Are two grains of sand considered a heap? Twenty? Twenty-thousand? Where at the far ends of the spectrum all observers would agree on what to consider a heap, as we move toward the middle of the spectrum, the answers to the question of what is a heap would start to become mixed. These are the borderline cases. There must be some point at which “not a heap” changes to “heap,” because they are on the same spectrum. But what is that point? The paradox shows that no number of grains can constitute a heap, because where there are no clear boundaries, if one grain of sand is not a heap, then neither is two grains of sand, and if two grains is not a heap, then neither is three, and so on until we reach the impossible conclusion that one million grains is not a heap.

Philosophical paradoxes may not provide solutions to practical plastic surgery issues, but they can guide our analysis. If “harm” is a vague predicate like “heap” that gives rise to borderline cases (i.e., different doctors may perceive the same procedure as harmful and not harmful), then those are the cases that must be scrutinized.

Body modifications may range from ear piercings to limb amputations. A plastic surgeon asked to perform a standard, single-lobe piercing with no complicating factors on a consenting adult in the U.S.—where culture has accepted such piercings as “normal”—will likely not foresee any harm in doing so. The same surgeon asked to amputate a healthy leg will likely consider the procedure harmful and look further into the patient’s psychological well-being before proceeding to perform any body modification operation—harmful or not—on the patient.

Where on the spectrum does gender reassignment surgery fall? Is it considered in the same way as any other body modification? An individual might get rhinoplasty to remove a certain bump that is indicative of biological heritage; is this the same as removing breasts that are indicative of biological gender? How is removing a leg for the same purpose of living authentically as X—X being “male” or X being “disabled”—any different? We might view amputating a healthy limb as maiming but view performing an orchiectomy on a healthy patient as beneficial. What is the distinction, if any?

Psychologically, is someone that is trapped in a body that has what he perceives to be an extra appendage—say, a leg—any less fit to decide to have it removed than someone that is trapped in a woman’s body that decides to have a subcutaneous mastectomy? One wants to become “differently abled” to live more authentically as a crippled individual, and the other wants to become a different gender to live more authentically as a man (though some would argue that the former are fetishists and want to become something they are not: disabled—which is not living authentically as disabled. This is an open question.) Some individuals who suffer from body integrity identity disorder (BIID) and desire the amputation of a healthy limb refer to themselves as “transabled,”[1] with the term mirroring the component parts of the term “transgender.” On the same spectrum is gender dysphoria, however, we treat gender dysphoria differently from BIID. In a move to distance transgenderism from mental illness, the medical community and society at large have begun to refer to gender reassignment surgery as gender affirmation surgery. The DSM (the Diagnostic and Statistical Manual of Mental Disorders) has also updated the language used to discuss transgender individuals in an effort to separate the association between gender identity issues and mental health issues.

But much like a “transabled” individual suffers from BIID and is subjected to psychological evaluations upon his or her request to amputate a healthy limb, we must not be afraid to provide psychological support to transgender-identifying individuals who suffer from a different but similar type of body dysmorphia. Regardless of how the DSM—which is man-made and not infallible, but is a guide to the human mind based on currently available knowledge—refers to transgender individuals, we still need to consider what is harm when performing gender reassignment surgery. While a small percentage of the population may benefit from such a procedure, removing the discussion of a potential psychological disorder may mean that more individuals are getting the surgery than are actually transgender, with “actually transgender” here referring to those who would remain satisfied with their decision to surgically transition long-term. (Note that this does not necessarily mean that to be transgender one must receive surgery or take hormones, etc.). That is, if we are afraid to overtly provide psychological support for individuals who believe they are transgender because we are afraid of stigmatizing the transgender community, we are failing and harming those who wind up getting the surgery that are not “actually transgender,” but rather are suffering from one or more psychological disorders—whether related to the body or not—that apparently manifests as fleeting transgenderism.

A disorder is defined as an abnormal physical or mental condition. Abnormal means deviating from the average. A biological male that identifies as a female would likely agree that his biological body is an abnormal physical condition for a woman to have, and a gender reassignment surgery could effectively be seen as a correction of a physical defect or deformity. But society views his being transgender from the opposite perspective, such that his mind is the piece that is abnormal due to his perception that his body is not reflective of his authentic female self. In the former sense, the body is what is “wrong,” and in the latter sense, the mind is what is “wrong.” (Note here that the question of when to change pronouns from “his” to her” is unsettled. There is no consensus on what event triggers the change of pronouns—is it simply the pronouncement that one is transgender? Is it determined by a timeline personal to that individual? Is it upon “official” transition, or “Day 1 of being a woman?” Or “Day 1 of living authentically as a woman” (rather than “being”), if the argument is that the individual is and always was a woman? For linguistic clarity, biologically accurate pronouns are used here.)

Altering the language in the DSM does not change the real-world facts. Depression is a disorder—it is a mood disorder. Many more Americans are depressed than are transgender, but we are seemingly less concerned about the stigma of labeling depression as a mental illness than we are about the stigma of labeling transgenderism as a psychological disorder. There should be no stigma surrounding depression, gender dysphoria, or otherwise. Whether we refer to someone as being “transgender” or having “gender dysphoria” or use another term to describe it, the fact is that some individuals—particularly those that would end up regretting their decision to surgically transition—would benefit from putting a name to what they are feeling and seeking psychological help, instead of being told by society that what they are feeling is normal. The borderline cases—the individuals in the middle of the Sorites spectrum that are not obviously “not transgender” on one end and not obviously “transgender” on the other end (some indeed argue that this too requires psychological intervention, however, this argument is not addressed here)—are the ones being harmed by a refusal to discuss potential mental health issues in the same breath as gender identity issues.

[1] Sabine Müller (2009) Body Integrity Identity Disorder (BIID)—Is the Amputation of Healthy Limbs Ethically Justified?, The American Journal of Bioethics, 9:1, 36-43, DOI: 10.1080/15265160802588194

A related article entitled “Understanding the Transgender Spectrum” may be found on my Psychology Today column, From Obscurity.

Copyright © 2023 Kaitlin Puccio