Leandro Loriga

This book confronts the fragmentation of meaning and the exhaustion of reason in the aftermath of postmodernity. Instinct, Reason and the Self in the Aftermath of Postmodernity: Beyond Reason argues that meaningful orientation cannot be restored through propositional reasoning alone. What must be recovered is instinct: embodied attunement to the world prior to deliberative thought. Following the collapse of grand narratives, we navigate a liquid terrain with conceptual tools designed for solid ground, one increasingly shaped by digital infrastructures and AI-driven systems of engineered salience, which together form the Sensorial Nexus: a state in which algorithmic mediation pre-organises perception, narrowing the space for reflective judgement and originality. Drawing on Arnold van Gennep's tripartite ritual schema, the book proposes the reawakening of instinct and introduces the DIEM Method, a practical framework for disengaging from the Sensorial Nexus and restoring interior coherence.

This chapter introduces the moral and ethical dilemmas associated with on-demand amputations for Body Integrity Dysphoria (BID), mainly focusing on whether BID-related surgeries can be ethically aligned with gender-affirming surgeries. Through an examination of the four-principle approach to bioethics—beneficence, non-maleficence, autonomy and justice—the chapter analyses the fairness and accessibility of care for individuals seeking BID-related amputation. The chapter poses a voluntarily provocative question: should BID-related amputations be considered on par with Sex Reassignment Surgeries (SRS)? If not, what are the morally relevant factors that set them apart? The idea proposed is that, as of today, no morally relevant criteria exist to accept SRS and reject BID’s wish for amputation. Rather than advocating for BID surgeries, however, the chapter highlights the moral and practical challenges that medical practitioners face, along with the knowledge gaps in distinguishing ethically and morally relevant differences between these two types of procedures.

Body Integrity Dysphoria (BID) is a rare condition now included in the ICD-11. The individuals affected experience a mismatch between their sense of Self and their body perception. Such a mismatch, recognised today as dysphoria, emerges during early adolescence and accompanies the individual throughout their life. This leads to a drop in the overall Quality of Life of those affected. The sense of dysphoria is often focalised towards a specific body part recognised as alien by the individual who often wishes to have it removed through amputation. However, amputation currently is not a feasible option as it is rarely recognised as a viable therapeutic approach for BID. Chapter 1 establishes a foundation for examining BID by analysing the relevance of concepts such as autonomy, identity and gender to today’s medical discourse. Such concepts are gaining renewed attention, especially considering postmodern critiques of traditional medical and ethical standards. By highlighting the constructed nature of identities and how medical categories impact these, the chapter discusses how historically shifting perspectives on sex and gender add complexity to contemporary understanding of the body, which brings an added value when debating the BID desire.

This chapter provides a state-of-the-art review of the current knowledge on Body Integrity Dysphoria (BID). The chapter presents three putative approaches for the emergence of dysphoria: a neurological account, a psychological one and a social one. By moving from merely neurological factors towards psychological and sociological ones, the chapter argues for the need to understand BID holistically. Its insurgence might be the result of multifactorial elements that do not fall exclusively within any of these domains. The chapter also introduces the concept of the malleability of long-term bodily representations. By addressing notions such as body image and body schema, the focus is moved towards the idea of how the long-term bodily representations internalised by the individual during life development phases are not fixed but instead malleable and influenced by a variety of factors. Such malleability is accentuated by an image-centric culture typical of Postmodernity, in which the Self becomes an individualised endeavour disconnected from societal standards, leading to an increased state of fluidity and fragmentation.

This chapter concludes the work by retrieving the opening aims, objectives and research questions that drove the present research project, contextualising them, and providing answers. A key focus is on autonomy, which emphasises informed, voluntary decisions free from external and internal control. Body Integrity Dysphoria (BID)’s classification in an officially recognised medical taxonomy, such as the International Classification of Diseases 11th Revision (ICD-11), clearly challenges conventional boundaries of medical intervention and autonomy. BID is an oddity. Its classification in the ICD-11 highlights a peculiar gap in medical practice: BID’s recognition without an accepted treatment approach is an anomaly that prompts deeper reflection on the criteria used to assess patient autonomy and decision-making capacity. The very existence of BID as a recognised condition forces a reassessment of other conditions not rooted in physiological dysfunction, raising questions about concepts such as harm, beneficence and non-maleficence. This reflection reveals the significant impact of social norms on both lay and professional perspectives regarding bodily autonomy and the medical options available to individuals who wish to go against such established medical and normative standards.

The bioethical principle of autonomy is of paramount importance within medical practice. The extent to which a patient’s autonomy overlaps or conflicts with the physician’s duty of beneficence and non-maleficence, however, is not so clear cut, especially for those cases in which the patient’s request for medical intervention goes against the physician’s advice, either because of personal belief or because there is uncertainty regarding the therapeutic approach. Body integrity dysphoria (BID) is a condition that has been included recently in the International Classification of Diseases, 11th edition (ICD-11). It may lead an affected individual to develop an intense desire to remove a specific body part in order to restore congruity between their body and their mind. Thus, its occurrence creates challenging moral and ethical dilemmas for the medical world (Loriga, 2023). The aim of this study was to investigate how Czech physicians understood, assessed and supported patient autonomy regarding requests for invasive body modifications. The objective was to produce a blueprint regarding how much a patient could influence the medical treatment they could gain within the Czech medical system and to develop a comparison with the ethical challenges of BID. A five-section survey was designed and submitted to Czech physicians on topics relevant to the BID debate. On the surface, the results showed an apparent predisposition toward collaboration between doctors and patients. However, further investigation showed that this supposed collaboration crumbled as the physiological risk-reward ratio moved further toward risk, which caused physicians progressively to rely less on the patient’s opinion and psychological needs. Moreover, a strongly authoritarian approach was evident, which became overwhelming in cases of amputation requests and removed, a priori, any collaboration. The results indicate that the Czech medical system does not accept or comprehend fully patients’ psychological needs, and therefore the BID phenomenon is a long way from being understood, which requires a fundamental paradigm shift.

This paper presents the foundation upon which the contemporary knowledge of body integrity dysphoria (BID) is built. According to the World Health Organisation’s International Classification of Diseases, 11th edition (ICD-11), the main feature of BID is an intense and persistent desire to become physically disabled in a significant way. Three putative aetiologies that are considered to explain the insurgence of the condition are discussed: neurological, psychological and postmodern theories. The concept of bodily representation within the medical context is highlighted, with the concept of dysphoria, which was brought to the fore with the introduction of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and the ICD-11. Contemporary issues of “justice” are addressed to identify ethically relevant distinctions between BID and sex reassignment surgery. It is argued that there is no ethically relevant difference between the BID actor’s desire for invasive surgical intervention and the wish of gender dysphoric individuals to undergo sex reassignment surgery procedures. Some BID actors self-mutilate, and this presents medical professionals with difficult choices regarding whether or not to intervene in order to satisfy the BID patient’s desire. Both abstention and intervention may lead to severe ethical complications for doctors and patients despite the positive outcomes in terms of quality of life for BID individuals who manage to undergo such procedures.

This chapter addresses the practicalities of assessing an individual’s medical decision-making capacity, specifically during the pre-operative risk phase and the post-operative behaviour assessment in surgical contexts. By utilising fieldwork data, Body Integrity Dysphoria (BID) is compared to other types of invasive medical procedures, such as gastric banding and sleeve gastrectomy. Such a daring comparison emerged unexpectedly during the interview phase, and it is used to assess the psychological criteria that current medical professionals use to differentiate between those eligible to undergo such procedures and those who are not. By leveraging on gastric banding and sleeve gastrectomy, the chapter aims at addressing one of the most frequent oppositions moved against amputation as a potential therapeutic approach to BID: the patient’s regret post-surgery. It is argued that there cannot be medical certainty on the outcome of any surgical procedure, particularly those done to address psychological state. The opposition to BID regret post-amputation, therefore, seems to be beyond what is currently considered an acceptable standard for similarly invasive medical practice.

In this chapter introduces well-being as a central concept to understanding Body Integrity Dysphoria (BID). By drawing on three of the most prominent theories of well-being—Hedonism, Desire-Fulfilment and Objective-list theories—the chapter aims to address what are the conditions which would grant BID on-demand amputation the status of morally viable action. The chapter challenges the assumption that the desire to amputate necessarily negates the moral responsibility of the individual. Instead, it argues that such a decision, under the right conditions, can be to every extent rational, so much so to be praised as the best viable option for those affected by BID. Amputation, in fact, might be seen as a means for individuals with BID to pursue a hypothetical state of well-being, one that requires them to overcome their natural self-preservation instinct. Nevertheless, again, the chapter does not advocate for amputation, but it highlights how the reasoning used to reject the amputation request can be similarly used to defend its legitimacy.

In this chapter moves the focus towards the idea of Moral Responsibility. By dwelling on the concept of autonomy and medical decision-making capacity, the chapter poses the question of whether the existence of the amputation desire affects the autonomous status of the individual, and if so, to what extent. The chapters lay down the foundation to develop a better understanding of the implication of distinguishing Body Integrity Dysphoria (BID) amputation as elective in nature versus classifying it as non-elective. Such a distinction is crucial, as depending on its categorisation, the legitimacy of the request shifts. The chapter also sets the stage for a better understanding of moral responsibility, including the moral significance of actions and what it means to have moral agency. Building on this framework, the chapter questions whether the desire for amputation in BID cases could be a form of coercion, which would impact the person’s autonomy and exclude amputation from being considered as a possible therapeutic approach. If such coercive influence is excluded, the reason for refusing to perform amputation must necessarily be nested somewhere else.

This chapter breaks down the instinctual rejection of amputation requests displayed by surgeons during the fieldwork phase. The physician demonstrates an evident scepticism on the legitimacy of such demands, which presupposes assumptions of potential patients’ inner coercion due to the amputation desire or even hidden intent from the patient’s side to deceive the physician. A central issue is whether pursuing amputation through official medical channels reflects genuine medical needs or stems from other motivations. Through interviews and fieldwork, the chapter reveals that many physicians see BID patients as potentially seeking amputation for personal satisfaction rather than true medical relief, which raises ethical concerns. However, another perspective is also considered: some BID patients might lack knowledge about alternative treatments due to limited access to information or social stigma. This dual view—where blame could stem from either questionable intentions or simple unawareness—adds complexity to the moral discussion. The chapter closes with a thought-provoking suggestion: in situations where options are limited, self-amputation might be the commendable moral choice for the BID individual.

This chapter draws on fieldwork data by analysing cosmetic and reconstructive surgery standards with the aim of identifying and analysing the criteria used today to grant or deny certain types of surgical interventions which do not emerge from the medical necessity to address physiological dysfunctionalities. The ethical complexities of bodily modification interventions are intertwined with the medical decision-making capacity of the individual, and the evidence-based approach to surgery is contrasted with those instances in which the surgery aims at addressing psychological states rather than physiological ones. The chapter takes on the topic of how societal norms influence perceptions of physical appearance and how normative standards are often used as a main access point for the surgeon to evaluate the legitimacy of bodily modification requests. A key area is the surgeon’s assessment of whether patients are mentally and emotionally prepared, ensuring they have realistic expectations and are making informed decisions.

This book, explores the complex moral and ethical dilemmas surrounding Body Integrity Dysphoria (BID) and its recent classification in the ICD-11. The examination offers a pioneering view into a condition that remains deeply controversial within medical and public discourse. BID is characterised by a persistent desire to acquire a physical impairment, often through amputation. Such a situation forces the medical world to take a stance by either granting the amputation request or rejecting it with the risk of pushing individuals toward self-made solutions. Through a review of the contemporary understanding of BID as well as original data obtained during extensive fieldwork with medical professionals, this book addresses the ethical and moral aspects of the condition. Fundamental questions are posed about the relationship between bodily autonomy and embodiment, identity and gender, well-being and moral responsibility, and how these elements intertwine, shape and are shaped by sociocultural understanding of illness and body. The book aims to move beyond traditional understandings of body functionality to consider the implications of autonomy and the extent to which an individual considered mentally and physically sound can dispose of one's own body within the contemporary medical paradigm. This is done to question long-standing assumptions about bodily integrity and traditional views on the wholeness and naturalness of the human form. As postmodern theories challenge established frameworks, a paradigm shift emerges in medical and societal approaches to identity, embodiment, and impairment, and this needs to be addressed. Drawing on insights from medicine, psychology, sociology, and ethics, this book situates BID within a broader cultural and philosophical context. It raises essential questions about where individuals' rights intersect with medical responsibility and societal perceptions of normalcy and health. By doing so, the book provokes readers to reconsider the boundaries between health, pathology, and self-determination.