I very much enjoyed your fascinating case report “Xenomelia: Profile of a man with intense desire to amputate a healthy limb” (Current Psychiatry, August 2018, p. 34-36, 41-43) and your hypotheses regarding neurodevelopmental correlates to xenomelia and related disorders such as apotemnophilia and body dysmorphia. However, you comment that because your patient’s desire to have a limb removed began in early childhood, before genital sexual maturation, the condition must be “…independent of sexuality.” This omits Sigmund Freud’s adumbration of infantile sexuality (oral, anal, phallic stages) with the phallic stage of infantile sexuality reaching a period of strong arousal between age 3 and 5, which is at the height of the Oedipus and Electra complexes.
Your patient traced the history of his desire to amputate his leg (as do other individuals with xenomelia) to age 4, when he saw a man with a missing limb, which made a vivid impression on him. As you discuss, this was probably a moment when he had an intensely psychosexual imprinting of this perception. However, the actual memory of the man with the amputation may well have been a screen memory for other more arousing and traumatic experiences that the patient experienced at this early age, such as castration anxiety with or without actual overstimulation of the physical body.
Nathan Szajnberg, MD, and I reported a case of a man who desired that his partner pretend to be an amputee in order to strengthen sexual arousal, an arousal that he recalled having as early as age 5 or 6.1 The report traced this fetish back to research films of his upbringing, which indicated heightened physical stimulation in very early life.2 As we wrote, “The case provides unusual information about the manner in which early childhood events interdigitate with intrapsychic processes and mental structuralisation.” This has led me to wonder if similar mental processes are at work in the current wave of young people who are convinced that they are a different gender than the one indicated by their anatomy.