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International Journal of Research in Humanities and Social Studies
Volume 5, Issue 5, 2018, PP 33-53
ISSN 2394-6288 (Print) & ISSN 2394-6296 (Online)
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 33
The Beauty and the BIID
Lisa-Lucie Aner, Frederike Schmitt, Erich Kasten
Medical School Hamburg, University of Applied Sciences, Medical University, Am Kaiserkai 1, D-
20457 Hamburg, Germany
*Corresponding Author: Erich Kasten, Medical School Hamburg, University of Applied Sciences,
Medical University, Am Kaiserkai 1, D-20457 Hamburg, Germany
INTRODUCTION
BODY INTEGRITY IDENTITY DISORDER
BIID (“Body Integrity Identity Disorder”, also
known as “Amputee Identity Disorder”, “Body
incongruence Disorder” or “Xenomelia”), is an
intense feeling of a discrepancy between a real
intact body and the mental image of a disabled
body (e.g. amputation). BIID is associated with
a strong desire for a severe disability [1, 2]. The
afflicted person believes that they will only be
“complete” after the amputation of a limb. The
interest in disabled people and a curiosity to
play the role of an amputee has often existed
since early childhood. Obernolte et al. [20]
expected significant differences in experiences
with disabled people in childhood and young
adulthood between BIID sufferers and control
subjects. As a primary reason for the wish for
amputation, a feeling of perfection and internal
satisfaction was reported [2, 12]. Most persons
who successfully achieved the desired operation
showed healing from all BIID-symptoms [19].
As a possible cause of BIID, Stirn et al. [23]
defined a genetic based pre-pubertal imprinting
connected with the identification of an admired
disability on one's own body scheme. Often, a
feeling that some parts of the body are alien
occurs. In many cases, the affected people
ABSTRACT
Body Integrity Identity Disorder is an intense feeling of a discrepancy between a real intact body and the
mental image of a disabled body (e.g. amputation). Current models left several essential questions
unanswered: Why do the affected individuals feel “complete” only after amputation? Why can the wish for
an amputation change from one side of the body to the other? Why does the wish not follow the anatomical
dermatomes, but rather the everyday picture of a typical amputee? Why do many of the affected persons
have an erotic preference for an amputated partner? Why does the disturbance exist from early childhood?
The authors developed a model to determine whether the cause of BIID may be a disorder of the brain areas
which judge the beauty of the human body. From an evolutionary point of view, bi-legged/two-armed people
must be judged to be more attractive, as this increases the chance for survival in a hostile environment. Due
to genetic changes or ZNS-lesions, damage can occur in this beauty-ideal centre, which may result in the
case of BIID, where the brain estimates one-legged or one-armed bodies as an ideal form of attractiveness.
Pictures of amputees would then be judged extremely positively. In two pilot studies, the perception of
attractiveness and beauty in BIID-affected individuals who have a desire for amputation was examined,
concerning (1) their own body in its current physical state as well as after an imagined amputation, and also
(2) regarding the body of others (by drawings) in an unimpaired status or with an amputation. The
judgments of attractiveness were compared to the ratings of a control group and a group of BIID-affected
individuals who have a desire for palsy and those BIID sufferers who had already received an amputation
(3). Results: The data of the first pilot-study show that images of disabled people were judged to be
significantly more beautiful than a neutral photo. Another comparison showed that photos of amputees were
judged as more beautiful, positive, sexually arousing and fascinating than photos of non-amputated photos
with erotic content. The photos of amputees were estimated as slightly more positive than other usually
positive estimated pictures. The second pilot study showed that BIID sufferers judged drawings of amputees
more positively with regard to beauty and attractiveness compared to non-BIID sufferers and those BIID
sufferers with the desire to be paralysed. Additionally, the group of BIID-affected individuals who wish to be
an amputee assessed their own body in its actual status as less beautiful and attractive than their imagined
body with the favoured amputation. Conclusion: The results underline the theoretical consideration that
Body Integrity Identity Disorder might be associated with an altered ideal of beauty.
Keywords: BIID, Body Integrity Identity Disorder, Body Incongruence Disorder, Apoteimnophilia,
Acrotomphilia, Amelotism, Xenomelia, Amputee Identity Disorder, Mental Body Image
The Beauty and the BIID
34 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
perceive a very precisely defined line where the
amputation stump should be. However, this line
corresponds more to the naive concept of a one-
legged person, rather than to the sensory regions
of the spinal nerves [13]. Neither MRT nor
fMRI-examinations detected extensive
neurological lesions in the brain. Due to
similarities with neurological disorders such as
alien limb syndrome, hemineglect, or
asomatognosia, a dysfunction in the upper right
parietal lobe is discussed as a possible cause of
BIID [1, 3]. McGeoch et al. [16] proposed
minimal deficits in the right parietal lobe. In
contrast to this neurological explanation, the
choice in several patients for amputation of a
specific leg changed from one side to the other
based on rational reasons, such as the need to
drive a car [8, 13, 14], which supports a more
psychological based explanation.
In 2005, Michael First [8] pointed to the notable
similarities between Body Integrity Identity
Disorder and Gender Identity Disorder (GID,
transgender). Both groups suffer from feelings
of being in the wrong body. In BIID as well
GID, the disturbance emerges in childhood and
partially involves erotic feelings with regard to
the desired body.
In the area of fetishism, a group exists with a
preference for people with missing limbs
(named “Acrotomophilia”, “Mancophilia”,
“Amelotism”, “Deformation Fetishism” or
“Devotees”). Some BIID individuals feel
sexually aroused by the sight of leg- or arm-
stumps, too [21]. In a study by Blom et al. [2],
46% of BIID individuals felt sexual excitement
if they saw a person with an amputation similar
to the wished disability of the interviewee.
These first results led to a preliminary approach
for a model in 2009; Kasten & Spithaler [11]
suggested a multi-causal influence of (1) a
psychological, (2) a neurological and (3) a
sexual component.
WHAT IS “BEAUTY”?
According to the textbook of Renz [22] the
assessment of the “beauty” of a person is based
on firm principles, which have outlasted
millennia and are also very similar between
cultures. Eibl-Eibesfeldt [6], Liessman 15], and
Etcoff [7] gave the opinion that the human sense
of beauty has its origins in a genetically-
imprinted biological nature, formed by
evolution. However, it is also reinforced by the
norms of society and culture, and is modelled by
individual experiences [5, 10, 22].
One of the most important criteria for the choice
of a partner is physical attractiveness. The
majority of scientific research is concerned with
the beauty of the face of women, while the face
of men has been much less frequently
investigated [22]. Symmetrical facial features
suggest that no genetic defects are present.
However, a secondary but significant role is
played by the body shape. Here, developed from
ages earlier than the Stone Age, specific
proportions exist which signalled a higher
survival advantage in times when people
wandered in small hordes through the steppe
and were exposed to a variety of hazards. Thus,
women react positively to the muscular V-figure
of a man with broad shoulders, well-trained legs
and a well-shaped bottom, because in the dawn
of humanity this pointed to the fact that the man
was a good hunter and could bring sufficient
Mammoth-meat for his family. Slimness and
long hair in women are seen as signs of
virginity, which was important in ancient times
for the man to transmit his own genes and not to
have to feed the brood of another [6, 18]. In
addition, men react to stimuli like big breasts,
which point symbolically to the fact that the
woman can nourish her babies, because children
were the pension for aged people in these earlier
days of human history. Even smooth clear skin
symbolises youth, which underlines the fact that
a woman can still bear a lot of children. That,
which we judge as “attractive”, therefore,
depends on principles which were developed in
the evolution of humanity and were genetically
anchored in the brain, because they supported
the preservation of the human species.
Symmetry, Asymmetry, BIID and Attractiveness
The symmetry of the body plays a major role in
the estimation of health, abilities, and, in a
broader view, the genetic quality of a person
[22]. In contrast, in BIID-affected individuals,
the absence of a limb seems to belong to their
ideal image of a perfect body. In personal
discussions, almost all BIID-affected individuals
reported that they generally estimate people
with amputated extremities as “nicer”, “more
attractive”, “better looking” or “more
handsome” than individuals without any
handicap; they admire “the beauty of a stump”
[12] . The desire for a perfect body is often
given as the main motive for the strong demand
for an amputation [11, 23]. Blom et al. [2]
pointed out that BIID individuals feel sexual
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 35
excitement, even by mentally imagining their
own amputation. Thus, it seems that BIID-
affected individuals feel more comfortable in an
amputated body and accordingly feel an
additional erotic excitement.
Unsolved Problems and A New Model
Until now there is no comprehensive model
which really can explain the cause of BIID. The
above-mentioned theories do not explain some
essential questions:
Why do the affected persons regard
themselves as “complete” only after an
amputation?
Why can the wish for an amputation change
from one side of the body to the other, but
practically never from a specific body part to
another?
Why does the wish for an amputation not
follow the neuro-anatomical dermatomes, but
rather the everyday picture of a typical
amputee?
Why do many of the affected persons have
an erotic preference for a partner with a
similar impediment?
Why does the disturbance exist from early
childhood?
To solve these problems, we would like to
suggest the following theory:
People have an innate beauty ideal which
implies not only the attractiveness of the face,
but, for reasons of evolutionary survival, also a
well-built, intact body (i.e. with two legs, two
arms etc.). This beauty ideal must be anchored
somewhere in the brain, because it has not only
been extremely stable since ancient times, but is
also cross-cultural. This brain area (or more
likely a system of several parts of the brain) can
undergo changes and damage. Thus, there are,
e.g., men with preferences for women with
extremely small breasts or with a predilection
for very thick women. Other people estimate an
extremely athletic body as an ideal, which leads
to excessive bodybuilding. Anorexic patients
have the ideal of an extremely slender body.
People with trans-identity find themselves more
attractive if their appearance resembles the
desired gender. Most men prefer younger
women, but for some men, older women have a
greater attraction. These examples show that the
ideal of an attractive body is modifiable by
genetic defects as well as result of
environmental events or, possibly, also by small
pre-, peri- or postnatal brain damage of this
beauty area in the brain.
It is conceivable that a BIID-affected person
suffers from a micro-change in one of the brain
areas in which the main physical features of
human beauty are established. The result can be
that the affected person no longer considers the
usual two legged body as attractive, but the
cerebral area instead gives a one-legged body as
an ideal.
The next stage in this chain would be that the
BIID affected person cannot classify her or his
own body as attractive, because the beauty-ideal
gives the scheme of a one-legged body. To
compare it with a well-known example: If
individuals have the beauty ideal of slimness,
they will not feel good when they put on huge
amounts of weight. Today, most people have the
ideal of a slender, athletic body. Corpulence
makes us unhappy, because the external body
does not correspond to the mental ideal. Also,
BIID-affected persons seem to suffer from the
fact that their external two-legged body does not
correspond to this ideal of a beautiful one-
leggedness.
BIID-affected individuals pretend to have the
desired impediment e.g. by fixing the lower leg
at the thighs and then walking with a pair of
crutches. In this state they find mental concord,
feel happy, and, because attractiveness always
has the biological aim of sexuality, this state
also arouses erotic feelings. These pleasant
feelings lead to positive reinforcement, i.e. this
pretending-behaviour is performed increasingly
more often and is used as relief after frustrating
life events. In the long-term, it comes to an
operant conditioning with a solidification of the
wish to be handicapped. At this stage, auto-
suggestive thinking could also play a role: The
more often a person thinks about being disabled,
the more real the desire to fulfil this wish
becomes. Nevertheless, seen on a continuing
basis, these positive effects of pretending-
behaviour vanish gradually. The condition of the
person changes from positive strengthening to a
more negative reinforcement, i.e. the affected
individual needs the pretending-behaviour to
escape from the pressure of getting an
impediment. At this stage, the mental pressure
to carry out the operation grows.
This model could explain several of the above-
mentioned problems. Only after an amputation
does the person feel in harmony with their
subjective beauty ideal; comparable e.g. with
bodybuilding or liposuction. The beauty ideal
The Beauty and the BIID
36 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
gives only the general scheme of having one leg
less, but does not exactly state on which side of
the body. Here, which leg is concerned seems
relatively unimportant. Therefore, the model
explains that the wish for amputation can
change from one side to the other in some BIID-
sufferers. In addition, the mental beauty ideal
seems to be independent of the course of the
dermatomes on the skin, so that this model
could explain why BIID-affected amputations
correspond to the usual picture of amputees.
One of the most hotly discussed ambiguities of
BIID refers to the sexual aspect and the
overlapping with Mancophilia. Here, the model
offers an explanation, because people mostly
search a partner who corresponds to the ideal of
their own body. The judgment of attraction is
genetic anchored in the brain, this would
explain, why the symptom emerges in early
childhood.
Normal
BIID
Normal,
genetically in
the brain-
anchored
beauty ideal
Genetic or
pre-, peri- or
post-natal
occurring
CNS-lesion
with change
of the
neurobiologic
ally-anchored
ideal of
beauty in
BIID sufferers
First
confrontation
with a
disabled
person in
childhood
triggers in a
key-lock
principle
fascination
rather than
fear
After initially
unspecific
interest in
handicaps,
there is
increasing
focus on a
specific
disability after
puberty
Due to
pretending
(simulation of
the desired
state), a
positive
reinforcement
takes place as
a result of
positive and
erotic feelings
Increasing
suffering from
the age of ca.
30 y., because
the real body
does not
coincide with
the desired
body.
Pretending as
a negative
reinforcement
only
moderately
reduces the
pressure. The
desire for
amputation
increases.
Figure1.Development of the desire for amputation on the base of a lesion of the cerebrally-anchored beauty
ideal.
AIMS AND METHODS
From personal conversations, the authors learnt
that BIID-affected people value impediments
more positively than control subjects. They
often feel a fascination of and admiration for
people with handicaps. These subjctive
statements were checked with the help of a
standardised questionnaire for investigation of
the judgment of different pictures. In a first pilot
study, the estimation of BIID-affected
individuals of neutral photos was compared with
the assessment of photos showing people with
handicaps. In a second pilot trial, the judgments
of drawings of handicapped men or women with
different kinds of amputation were compared
between BIID-affected individuals and control
subjects. The main question was: Do BIID-
affected individuals judge pictures of disabled
persons as more positive, attractive, and
sexually arousing than photos of non-
handicapped people? In both studies, the
interviewees should judge different polarities on
a multistage rating scale with regard to the
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 37
attractiveness of the person shown in the picture.
Table 1.Judgments (average S.E.) of 28 BIID-affected persons of 12 photos on a scale from -3 to +3,
partially differentiated for hetero- and homosexual participants.
Methods of the First Pilot Study
A total of n = 31 BIID sufferers participated in
this first pilot study. The study included 3
women (9.1%) and 28 men (84.9%); since the
group of women was so small, female
participants were excluded from further data
analysis. In total, 18 (57.6%) of the participants
were heterosexual and 7 (28.8%) were
homosexual, with 3 (10.8%) stating that they
were bisexual; the latter group was excluded
from further data analysis, because it was
unclear how they generally assess the
attractiveness of men/women. Age final 25
participants was: 20-30 years: n=4 (16.0%), 31-
40 years: n=7 (28.0%), 41-50 years: n=6
(24.0%), 51-60 years: n=5 (20.0%), and 61-70
years: n=3 (12.0%). BIID desires were:
amputation of the left leg: n=11 (44.0 %);
amputation of the right leg: n=3 (12.0%),
amputation of both legs: n=4 (16.0%),
amputation of the left foot: n=1 (4.0%),
amputation of left arm/hand: n=2 (8.0%),
paraplegia: n=2 (8.0%), palsy of the right leg:
n=1 (4.0%), and palsy of both legs: n=1 (4.0%).
For the judgment of beauty, 12 photos were
used: 1. Right hand, 2. Empty wheelchair, 3.
Half-naked woman on a beach, 4. Man with an
amputated arm, 5. Sleeping baby, 6. Beach with
a palm, 7. Double amputee runner with
prostheses, 8. One-legged woman in fishnet
stockings, 9. Face of Albert Einstein, 10. Sitting
female and male with leg-amputations and
prostheses, 11. Double leg-amputated man in a
wheelchair, and 12. Upper muscular torso of an
Ugly-beautiful
Negative-positive
Sexually neutral
- arousing
Boring-
fascinating
1. Hand (all participants)
0.30±0.23
0.37±0.23
-1.13±0.26
-0.50±0.23
2. Empty wheelchair (all)
0.80±0.32
1.00±0.33
-0.53±0.32
0.80±0.29
3. Woman on beach
(only heterosexual men)
2.11±0.26
2.21±0.24
2.11±0.19
1.42±0.22
3. Woman on beach
(only homosexual men)
0.29±0.18
0.57±0.30
-1.29±0.61
-0.29±0.18
4. Arm amputated man (all)
1.71±0.27
1.83±0.26
0.17±0.44
1.50±0.34
4. Arm amputated Man (homo-
men)
2.20±0.37
2.00±0.63
1.60±0.51
2.40±0.40
5. Baby (all)
1.31±0.33
1.52±0.32
-2.24±0.24
1.00±0.31
6. Beach with palm(all)
2.24±0.15
2.17±0.18
-1.69±0.31
0.89±0.31
7. Leg amputated runner with
prosthesis (all)
1.45±0.21
1.72±0.24
-0.03±0.40
1.90±0.23
7. Leg amputated runner with
prosthesis (hetero-men)
1.17±0.25
1.33±0.31
-0.83±0.47
1.61±0.30
7. Leg amputated runner with
prosthesis (homo-men)
2.00±0.44
2.28±0.42
0.71±0.7
2.29±0.47
8. Amputee. woman legs in
fishnet stockings (hetero-men)
2.22±0.22
2.06±0.26
1.67±0.35
2.11±0.27
8. Amput. woman legs in fishnet
stockings(homo-men)
1.00±0.44
0.86±0.63
-1.29±0.89
1.29±0.57
9. Face of Einstein (all)
0.18±0.33
1.31±0.31
-1.79±0.27
0.90±0.32
10. Two sitting amputees (all)
2.03±0.18
2.03±0.19
0.00±0.35
1.79±0.23
11. Amputated wheelchair
driver (all)
1.38±0.27
1.48±0.30
-0.21±0.44
1.76±0.27
11. Amputated wheelchair
driver (hetero-men)
0.89±0.35
0.83±0.38
-1.28±0.49
1.33±0.36
11. Amputated wheelchair
driver (homo-men)
2.29±0.42
2.29±0.42
1.00±0.79
2.14±0.46
12. Male torso with muscles
(hetero-men)
0.83±0.34
0.67±0.36
-0.94±0.39
0.11±0.39
12. Male torso with muscles
(homo-men)
2.43±0.37
2.43±0.29
2.00±0.31
1.71±0.29
The Beauty and the BIID
38 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
unclothed man. For the judgments, a 7-stepped
scale (from -3 to +3) was used with the bipolar
adjectives: ugly – beautiful, negative – positive,
sexually neutral – sexually arousing, boring –
fascinating. Averages and standard errors are
shown in Tab. 1.
In this first study, there was no comparison
group of non-affected participants; here, how
BIID-affected persons judge photos was studied
exclusively. The following hypotheses were
tested:
H1: BIID sufferers judge photos of people with
disabilities significantly more positively than
neutral pictures.
H2: BIID sufferers judge erotic photos of
disabled persons significantly more positively
than erotic photos of people without disabilities.
H3: BIID sufferers judge photos of people with
disabilities more positive than photos which are
commonly considered positively.
Table2. Wilcoxon differences between the photo of a hand (as a neutral body part) and the handicap-images. As
the level of significance was fixed at p <0.05, due to the repeated Wilcoxon tests, a Bonferroni correction was
carried out; i.e. significant values apply only under p <0.002 (marked with a star).
Empty
wheelchair
Arm
amputated
Man
Leg
amputated
runner with
prosthesis
Amput.
woman legs
in fishnet
stockings
Two
sitting
amputees
Amputate
d
wheelchair
driver
Ugly : beautiful
p=0.1920
Z=-1.29
p=0.0005*
Z=-3,49
p=0.0005*
Z=-3,46
p=0.0002*
Z=-3.68
p=0.0000*
Z=-4.13
p=0.0086
Z=-2.63
Negative:positive
p=0.1004
Z=-1.64
p=0.0004*
Z=-3.51
p=0.0003*
Z=-3.65
p=0.0018*
Z=-3.12
p=0.0004*
Z=-3.54
p=0.0111
Z=-2.54
Sexually arousing
p=0.0420
Z=-2.03
p=0.0395
Z=-2.06
p=0.0150
Z=-2.43
p=0.0010*
Z=-3.30
p=0.020
Z=-2.33
p=0.0418
Z=-2.04
Boring:fascinating
p=0.0007*
Z=-3.39
p=0.0004*
Z=-3.56
p=0.0000*
Z=-4.46
p=0.0000*
Z=-4.29
p=0.0000*
Z=-4.46
p=0.0000*
Z=-4.29
RESULTS OF THE FIRST PILOT STUDY
Table 2 shows the results of the non-parametric
Wilcoxon-test of differences between the photo
of a hand (as a neutral body part) and the
handicap-images. Even after a Bonferroni
correction of the level of significance, nearly all
comparisons show significant differences, i.e. in
contrast to the neutral photo of a “hand”, all
images of amputees were estimated as more
beautiful, more positive, more sexually arousing
and more fascinating.
Table3.Wilcoxon differences between the photos of usually sexually arousing pictures and the handicap-images.
As the level of significance was fixed at p <0.05, due to the repeated Wilcoxon tests, a Bonferroni correction
was carried out (M = average, p = significance, Z = result of Wilcoxon).
1. Woman on beach / 2. amput.
woman legs in fishnet stockings
(only heterosex. men)
1. Male torso with muscles / 2. arm
amputated man
(only homosex. men)
Ugly:beautiful
M1=2.11 : M2=2.22
p=0.7896
Z=-0.27
M1=2.43 : M2=2.20
p=0.4226
Z=-0.80
Negative:positive
M1=2.21 : M2=2.06
p=0.6566
Z=-0.45
M1=2.43 : M2=2.00
p=0.4226
Z=-0.80
Sex.arousing
M1=2.11 : M2=1.67
p=0.3505
Z=-0.93
M1=2.00 : M2=1.60
p=0.4652
Z=-0.73
Boring:fascinating
M1=1.42 : M2=2.11
p=0.050
Z=-1.96
M1=1.71 : M2=2.40
p=0.1775
Z=-1.35
The results of the Wilcoxon-test for the
differences between the photos of usually sexual
arousing pictures and the handicap-images are
shown in Table 3. Here, after Bonferroni
correction, no significant differences were
found. This shows that photos of amputees were
judged as positively as erotic images of non-
amputated persons (see Fig. 2).
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 39
Another Wilcoxon-test was carried out between
the judgments of photos which are commonly
positively estimated (sleeping baby, beach with
palm, Albert Einstein), and all photos showing
amputees. On average, the amputated pictures
(M=1.760.22) were judged slightly more
positively than the usually positively-estimated
photos (M=1.670.16). A Wilcoxon-test
revealed no significant difference (Z=-0.68;
p=0.495).
Figure2.Means and standard-error on a -3 to +3 scale for all four bi-polar items of the estimation of the
neutral picture (hand, all participants), and 1. comparison between the half-naked woman on a beach with the
amputated woman with fishnet stockings (only heterosexual BIID-men) and 2. comparison between the male
torso with the photo of an arm-amputated athlete (only homosexual BIID-men). On average, the amputated
persons were judged slightly more positively than the non-amputated erotic photos.
Figure3.Means and standard-error on a -3 to +3 scale about the bipolar item negative--positive of the
estimation of usually positively estimated photos (baby, beach, Einstein M=1.67
0.16), and all photos of
amputees (M=1.76
0.22). On average, the amputated persons were judged slightly more positively than the
usually positively-estimated photos.
Methods of the Second Pilot Study
In this second pilot study, the data of a BIID-
group were compared with the results of an
unaffected control group. The following
hypotheses were tested:
H1a: BIID-affected individuals with a wish for
amputation perceive their own body as
moreattractive by having an (imagined)
desired amputation than in an unimpaired
condition.
H1b: BIID-affected individuals with a wish for
amputation perceive their own body in its
actual state as less beautiful and attractive
than non-affected subjects perceive their
own bodies.
H2: BIID-affected individuals with a wish for
amputation perceive drawings of amputees
as more beautiful and more attractive than
drawings of intact persons.
-3
-1
1
3
Hand
Woman on
beach
Amput.
woman
fishnet
stocking
Male
muscle-
Torso
Arm-
amputated
Man
Mean
0
1
2
3
Usually positive photos
Photos of amputees
Mean
The Beauty and the BIID
40 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
H3a:BIID-affected individuals rate drawings
featuring their own desired amputation as
the most positive.
H3b: Corresponding to their sexual orientation
BIID-affected individuals regard the
drawing showing the desired amputation as
more positive than the same drawing
without amputation.
H4a: BIID-affected individuals with a desire for
amputation rate drawings featuring
amputations more positively than non-
affected subjects.
H4b: BIID-affected individuals with a desire for
paralysis rate drawings with amputations as
beautiful as BIID-affected individuals with
a desire for amputation.
Besides these hypotheses, one finding, quoted
multiple times in the literature, shall be
replicated. Among others, Kasten [11] and Stirn
et al. [23] reported that BIID sufferers do not
perceive the part of their own body affected by
their wish for an amputation to be hideous.
To answer the hypotheses, a questionnaire was
developed. The main items consisted of an
evaluation of depicted drawings showing bodies
of human beings and allowed a response along a
7 point Likert-scale from -3 (“I strongly
disagree”) to 0 (“neutral”) to +3 (“I strongly
agree”). The participants had to judge the
drawings in respect of some body-related
attributes (“hideous” – “beautiful”;
“unattractive” – “good-looking”; “imperfect” –
“unflawed”; “unerotic” – “erotic”; “repulsive” –
“attractive”). Even though the terms “Beauty”
and “Attractiveness” are often used
synonymously in the literature, in this survey,
the evaluation regarding the adjectives “hideous
– beautiful” and “unattractive – good-looking”
was requested separately because the
terminologies seem to have a slightly different
meaning. Altogether, 23 drawings of human
bodies were presented. Among these, 8 male
and 8 female drawings displayed amputations of
a limb. Those individual drawings differentiated
regarding the respective body‟s side and
location of the limb‟s amputation. Because it is
shown in the literature that most BIID sufferers
wish for the amputation of only one limb [8, 11,
14, 17], no drawings with bilateral amputations
were displayed. In addition to the drawings of
amputees, 4 male and 3 female drawings with a
different body shape (from average
proportioned, rather mesomorphic, less
mesomorphic and thick respectively thin) were
shown. Those drawings also had to be judged
concerning their beauty and attractiveness.
Influence of the beauty of the face on the
evaluation were ruled out by always using the
same face. Some drawings are shown in figure
4. Demographic data (i.e. age, gender, sexual
orientation) were recorded at the beginning of
the questionnaire. To identify whether the
participants in fact suffered from BIID, the
“Inventory for the assessment of severity” by
Fischer et al. (2015) was used.
Because the BIID-participants of this study are
spread over the whole world, an internet-based
questionnaire was used, generated with the
survey software “Questback EFS Survey”. To
recruit BIID sufferers, the link to the
questionnaire was provided to potential
participants by e-mail. Furthermore, the link to
the questionnaire was placed on the website
www.formum.biid.ch, which contains a
member‟s area for BIID sufferers with 615
registered members at that corresponding
period.
Figure 4. Selection of male and female line drawings.
(Based on line drawings of source: Carl Sagan;
https://upload.wikimedia.org/wikipedia/commo
ns/9/93/Human.svg)
The control group, including non-BIID
sufferers, corresponded with the BIID-group by
gender, age and sexual orientation as closely as
possible. Likewise, participants for the control
group of this study were recruited via e-mail as
well as from social networks.
Due to the small sample size of each group, the
statistical analysis was implemented using non-
parametric-tests. Hypotheses 1a, 2, 3a and 3b
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 41
were verified using the Wilcoxon-test for paired
samples. The Mann-Whitney-U-test for
independent samples was used for the statistical
analysis of hypotheses 1b, 4a and 4b.
First, respective mean scores of the five items
measuring beauty, attractiveness and the
perception of eroticism, attractiveness and
perfection of one‟s own body and figures of
other persons were created. Each of the items
was rated on a seven-level Likert-scale and
ranged from “very hideous, hideous, rather
hideous” to “neutral” to “rather beautiful,
beautiful, very beautiful“, using the example of
“Beauty”. The other items assessed the appraisal
regarding the line drawings and one‟s own body
from “very unerotic” to “very erotic”, “very
unattractive” to “very good-looking”,
“imperfect” to “unflawed” and “very repulsive”
to “very attractive”. Thus, a mean score for all
five items could be established which is labelled
as “Overall attractiveness score” hereafter.
Cronbach‟s Alpha was calculated to examine
the scale‟s individual items. Possible values for
the scales range from 1 to 7, with a neutral pole
of 4. Accordingly, values from 1 to 3 include the
respective adjective‟s negative form, while
values from 5 to 7 cover the positive
manifestation of the particular attribute. Cohen’s
d was calculated for those hypotheses requiring
a Wilcoxon-Test for dependent samples. Below,
the effect size d according to Cohen is always
denoted in its absolute amount.
Results of the Second Pilot Study
Forty-one BIID sufferers took part in the
investigation, with 22 subjects used as controls
(non-BIID sufferers). The group of 41 BIID
sufferers was divided into 22 subjects who
reported the need to amputate a healthy limb
and 19 subjects who stated having a desire for
being paralysed; furthermore, there was a small
sample of 6 subjects who had already undergone
an amputation. The parts of the body reported
by the group feeling the need for an amputation
were: right leg above the knee n=10 males; left
leg above the knee n = 6 males + 2 females;
both legs above the knee n = 2 males; and others
(e.g. one arm, one leg + one arm) n = 2 males.
The entire sample age ranged from 23 to 64
years. The subgroups‟ mean age was: control
group M=47.68 (±9.05); BIID – desire for
amputation M=50.14 (±8.55); BIID – desire for
paralysis M=41.11 (±12.46); and BIID – already
an amputee M=50.50 (±8.07). The Kruskal-
Wallis-Test shows a tendentious significant
difference (p=0.065) concerning the age
between all groups. The gender distribution
within the samples was heterogeneous: 90.9%
(n=20) of the BIID sufferers wanting an
amputation and the parallel control group were
male and 9.1% (n=2) were female. The group of
BIID sufferers with a desire for palsy contained
68.4% (n=13) male and 31.6% (n=6) female
participants, while the group of BIID-affected
individuals who already received an amputation
amounted to 66.7% (n=4) male and 33.3% (n=2)
female subjects. Due to the sexual orientation
among the BIID sufferers with a desire for
amputation, there were 15 (68.2%)
heterosexuals, 6 (27.3%) homosexuals and 1
(4.5%) participant who stated another sexual
orientation. Within the controls there were 16
(72.7%) heterosexuals and 6 (27.3%)
homosexual participants. Fourteen (73.7%) of
the BIID-affected individuals with a desire for
palsy stated that they were heterosexual, 1
(5.3%) was homosexual, 2 (10.5%) were
bisexual and 2 (10.5%) participants stated
another sexual orientation. Within the third
BIID-group, those BIID sufferers who had
already undergone an amputation, there were 4
(66.7%) heterosexuals, 1 (16.7%) homosexual
and 1 (16.7%) participant who stated that they
were bisexual.
The applied questionnaire of Fischer et al. [9],
to determine the severity of BIID, showed a
mild form of BIID for 2 (9.1%), a medium form
of BIID for 9 (40.9%) and a severe BIID for 11
(50.0%) of the BIID sufferers with a desire for
amputation. The group of BIID-affected
individuals with a desire for palsy included one
sufferer (5.3%) with a very mild form and also
one (5.3%) with a mild form of BIID;
furthermore, 12 sufferers (63.2%) had a medium
and 5 (26.3%) a severe form of BIID.
Additional sociodemographic data of the sample
are shown in Table 4. First of all, all scales were
examined separately concerning their internal
consistency. Attractiveness-scales for every
drawing displayed and relevant for the analysis
were examined, as well as ratings with regard to
one‟s own body. High Cronbach‟s Alpha values
The Beauty and the BIID
42 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
were found for all attractiveness-scales across
all investigation groups; the values are within a
range from 0.76 to 0.99. Merely the scale
“Overall score attractiveness” showed a weak
Cronbach‟s Alpha of 0.57 within the group of
BIID-affected individuals who had already
undergone an amputation.
Table 4. Socio demographic characteristics.
Control group n = 22
BIID_amp. n = 22
BIID_palsy n = 19
BIID_already-amp.n = 6
P1,2
n
%
n
%
n
%
n
%
Age
0.065
(M, SD; Range)
47.68 (9.05; 23-61)
50.14 (8.55;30 64)
41.11(12.46;18-61)
50.50 (8.07;39-63)
Gender
0.101
male
20
90.9
20
90.9
13
68.4
4
66.7
female
2
9.1
2
9.1
6
31.6
2
33.3
Nationality
0.256
German
22
100
19
86.4
17
89.5
5
83.3
other
0
0.0
3
13.6
2
10.5
1
16.7
BMI
0.715
(M, SD; Range)
26.63(5.4;20.8-40.8)
26.82(3.9;19.6-33.6)
27.08(6.8;19.6-45.0)
27.78(4.6;22.6-27.8)
Sexual orientation
0.155
heterosexual
16
72.7
15
68.2
14
73.7
4
66.7
homosexual
6
27.3
6
27.3
1
5.3
1
16.7
bisexual
0
0.0
0
0.0
2
10.5
1
16.7
other orientation
0
0.0
1
4.5
2
10.5
0
0.0
Martial status
0.060
unmarried
8
36.4
9
40.9
13
68.4
0
0.0
married
11
50.0
9
40.9
5
26.3
4
66.7
divorced
2
9.1
4
18.2
1
5.3
1
16.7
widowed
1
4.5
0
0.0
0
0.0
1
16.7
Partnership
0.218
yes
15
68.2
19
86.4
11
57.9
4
66.7
no
7
31.8
3
13.6
8
42.1
2
33.3
partner with
amputation
1
6.7
1
5.3
0
0.0
0
0.0
Graduation
0.012
lower secondary
education
1
4.5
0
0.0
3
15.8
0
0.0
middle school
4
18.2
7
31.8
1
5.3
0
0.0
Advanced school
7
31.8
2
9.1
9
47.4
1
16.7
university degree
8
36.4
13
59.1
5
26.3
5
83.3
another
0
0.0
0
0.0
1
5.3
0
0.0
Vocational
education
0.096
none
0
0.0
0
0.0
3
15.8
0
0.0
apprenticeship
9
40.9
7
31.8
5
26.3
0
0.0
professional school
4
18.2
2
9.1
1
5.3
0
0.0
college
1
4.5
1
4.5
2
10.5
1
16.7
university
8
36.4
12
54.5
5
26.3
5
83.3
other
0
0.0
0
0.0
3
15.8
0
0.0
Occupation
0.003
not employed
0
0.0
5
22.7
8
42.1
3
50.0
part-time employed
2
9.1
1
4.5
3
15.8
0
0.0
full-time employed
20
90.9
16
72.7
8
42.1
3
50.0
1 Kruskal-Wallis-test.
2 Fisher’s exact test.
Hypothesis H1a:
BIID-affected individuals with a wish for
amputation perceive their own body as more
attractive by having an (imagined) desired
amputation than in an unimpaired condition. As
appears from figure 5, BIID-affected individuals
with a desire for amputation rated all items
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 43
concerning the attractiveness of their own body
having an imagined amputation higher than their
own body in its current, unimpaired condition.
The Wilcoxon-test for dependent samples
proved significant differences (all p<0.001) and
high effects between all items. The strongest
effect was found for the item “imperfect to
unflawed” (d=2.32), the smallest effect was
recorded for the item “very repulsive to very
attractive” (d=0.88); however, according to
Cohen (1988), even this effect is large.
Figure 5. Perception of attractiveness of one’s body in its current physical state compared to the own body after
an imagined amputation for the group of BIID-affected individuals with a desire for amputation (mean and
standard deviation). 4 is the neutral value, 1 to 3 are in the direction of the first adjective (e.g. “hideous”) and 5
to 7 are in the direction of the second adjective (e.g. “beautiful”).
Looking at the Item “Rating from very hideous
to very beautiful”, the average comparison
showed a significant difference (p<0.001)
between the rating of one‟s current beauty
(M=3.73, SD=1.20) and the rating of the body‟s
beauty featuring the imagined desired
amputation (M=5.64, SD=1.14) with a large
effect of d=1.05.
Likewise, the analysis of the scale “overall score
attractiveness”, which summarized the
previously quoted items, showed a significant
difference (p<0.001) for the ratings of the body
in its “current state” (M=3.55, SD=1.01)
compared to “having an imagined amputation”
(M=5.79, SD=0.87) with a large effect of
d=1.44 for the group with the need for
amputation.
Hypothesis H1b:
BIID-affected individuals with a wish for
amputation perceive their own body in its actual
state as less beautiful and attractive than non-
affected subjects perceive their own bodies.
As shown in Figure 6, BIID-affected individuals
with a desire for amputation rated their own
body in its current (unimpaired) condition on
average as less beautiful than the group of
controls. The Mann-Whitney-U-test for
independent samples showed considerably
significant differences (p<0.001). Furthermore,
large effects were found (d=1.37 for the scale
“Overall score attractiveness” and d=0.97 for
the item “Beauty”).
At this point, examining the assessment
regarding the attractiveness of one‟s own body
in its current condition between the group “BIID
wish for amputation” and the other groups of
BIID-affected individuals seemed to be of
interest. Comparing the ratings regarding the
own body in its current state, the Mann-
Whitney-U-test showed no significant
differences (p>0.05) with small effects (d=0.06
respectively d=0.36) for the BIID-affected
individuals with a need for amputation and the
BIID-affected individuals with a desire for
paralysis. Significant differences and large
effects (d=1.61) were found for the scale
“Overall score attractiveness” (p<0.001) and the
3.73
3.77
3.77
2.45
4.05
3.55
5.64
5.59
5.73
6.36
5.64
5.79
1
2
3
4
5
6
7
hideous -
beautiful
unerotic -
erotic
unattractive -
good-looking
imperfect -
unflawed
repulsive -
attracting
overall
attractiveness
mean values
current
after imagined amputation
The Beauty and the BIID
44 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
item “Beauty” by comparing the ratings of the
group who wished an amputation and the group
who already had achieved the one-leggedness.
The group of BIID-affected participants who
already had an amputation estimated the
“Overall score attractiveness” of their own body
in its current condition (M=5.50, SD=0.94) as
more positive than the BIID-affected individuals
with a desire for amputation regarding their own
body in its current (unimpaired) state (M=3.55,
SD=1.00).
Figure6. Perception of attractiveness of one’s body in its current physical state. Comparison of all groups. 4 is
the neutral value, 1 to 3 are in the direction of less beautiful and 5 to 7 are in the direction beautiful (Error bar
= standard deviation; Controls = group of non-BIID-affected individuals; BIID_amp. = group of BIID-affected
individuals with a desire for amputation; BIID_palsy = group of BIID-affected individuals with a desire for
paralysis; BIID_already-amp. = group of BIID-affected individuals who had already undergone an
amputation).
Hypothesis 2:
BIID-affected individuals with a wish for
amputation perceive drawings of amputees as
more beautiful and more attractive than
drawings of intact individuals.
First, finding possible differences caused by
gender or sexual orientation regarding the rating
of the drawings within the group of BIID-
affected individuals with a desire for amputation
was of interest.
Results of the Mann-Whitney-U-tests displayed
in Table 5 with regard to the ratings of
attractiveness revealed no significant differences
between the genders (p>0.05). Therefore, the
responses of BIID-affected males with a desire
for amputation cannot be differentiated from
female affected participants in view of their
perception of attractiveness concerning
drawings with and without amputations. In
addition to the item "Beauty" and the scale
"Overall score attractiveness", the item "Ideal
image" is relevant for this hypothesis as well,
indicating to what extent the presented drawing
is equivalent to the ideal image of a beautiful
body for the respective subject. A mean score
over all participant's ratings, separated by
amputated and not amputated drawings, was
also calculated. For this item, the results
indicated no significant difference (p>0.05) in
the drawing's rating for male and female
subjects.
Based on these results, the collective group of
BIID-affected individuals with a desire for
amputation was included (n=22) for the
following calculations regarding hypothesis 2.
As displayed in Table 6, the group of BIID
sufferers with a desire for amputation rated
drawings of amputees (M=4.85, SD=0.93) as
more attractive (p<0.05) than drawings without
an amputation (M=4.33, SD=0.81). However,
regarding only the item "Beauty", no significant
difference (p>0.05) between the drawing's rating
of attractiveness with and without amputation
was found, even though a slightly higher
response behaviour was detected for the ratings
of drawings with an amputation when
comparing mean values. Only a small effect was
found here (Cohen's d=0.27). The item "Ideal
Image", however, directly asked to what extent
the respective drawing is equivalent to one's
ideal image of a beautiful body; there was a
significant difference (p<0.05) in the drawing's
rating to that effect that line drawings with
amputation. On average, these were more
consistent with the ideal image of a beautiful
4.96
3.55
3.62
5.50
4.91
3.73
4.16
5.67
1
2
3
4
5
6
7
controls
BIID_amp
BIID_palsy
BIID_already-amp
mean values
overall score current attractiveness
current beauty
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 45
body (M=4.48, SD=1.05) than those drawings
without amputation (M=3.80, SD=0.97) with a mean effect of d=0.53.
Table 5. Perception of attractiveness of line drawings with and without amputation by male and female BIID-
affected individuals who have a desire for amputation (n=22).
Table6. Perception of attractiveness of drawings with and without amputation by all BIID-affected individuals
who have a desire for amputation (n=22).
Hypothesis 3a: H3a: BIID-affected individuals
rate drawings featuring their own desired
amputation as most positive.
In Table 7, each subject of the group "BIID need
for amputation" was initially grouped by the
body part affected by their amputation's wish as
well as their gender. Mean scores of the ratings
regarding attractiveness ("overall score
attractiveness") and the value of the item
"Beauty" concerning the drawings of the desired
body were displayed and confronted with the
summarised mean scores of the ratings
concerning all line drawings featuring other
amputations (“Overall score attractiveness all
other line drawings with amputation”andbeauty
of all other line drawings with amputation”).
Those four individuals who reported a bilateral
wish for amputation or desiring the amputation
of multiple limbs could not be included in
further analysis regarding hypothesis 3, since no
line drawings showing multiple amputations
were presented for the purpose of this study,
which would represent exactly those
participant's desired bodies.
Looking at the mean scores of the scale "overall
score attractiveness" for the ratings of
attractiveness regarding line drawings with the
desired amputations, higher scores than for the
overall score of attractiveness of all other
group
n
M±SD
z
Mann-Whitney-U-test
Overall score attractiveness of all line
drawings with an amputation
male
20
4.89 ± 0.96
-0.69
p = 0.554
female
2
4.48 ± 0.65
Overall score attractiveness of all line
drawings without an amputation
male
20
4.33 ± 0.84
-0.11
p = 0.952
female
2
4.35 ± 0.64
Beauty of all line drawings with an
amputation
male
20
4.93 ± 0.91
-0.80
p = 0.485
female
2
4.44 ± 0.62
Beauty of all line drawings without an
amputation
male
20
4.60 ± 1.34
-0.87
p = 0.424
female
2
4.44 ± 0.62
Ideal image of all line drawings with an
amputation
male
20
4.48 ± 1.11
-0.23
p = 0.866
female
2
4.50 ± 0.27
Ideal image of all line drawings without
an amputation
male
20
3.83 ± 0.96
-0.29
p = 0.779
female
2
3.50 ± 1.41
Group BIID-desire for amputation
M±SD
z
Wilcoxon-test
d
Overall score attractiveness of all
line drawings with an amputation
4.85 ± 0.93
-1.96
p = 0.049
0.47
Overall score attractiveness of all
line drawings without an
amputation
4.33 ± 0.81
Ideal image of all line drawings
with an amputation
4.48 ± 1.05
-2.26
p = 0.024
0.53
Ideal image of all line drawings
without an amputation
3.80 ± 0.97
Beauty of all line drawings with an
amputation
4.88 ± 0.89
-1.07
p = 0.283
0.27
Beauty of all line drawings without
an amputation
4.57 ± 0.98
The Beauty and the BIID
46 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
drawings with amputations were found for 17 of
the remaining 18 subjects. Only one male BIID-
affected individual rated drawings featuring
other amputations as slightly more positive
(M=4.74) than those showing his desired body
(M=3.60). Looking exclusively at the item
"Beauty", BIID-affected individuals regarded
those drawings corresponding to their own
desired amputation as more beautiful on average
than those featuring other amputations. A
statement made by one of the female individuals
with a desire for amputation of the left leg above
the knee was an exception here.
Table7. Exposition of the mean values regarding the perception of attractiveness of the drawings featuring the
individual desired amputation compared to all other drawings with an amputation. Group of BIID-desire for
amputation (n=18).
Case
Overall score
attractiveness of
line drawings with
the desired
amputation
Overall score
attractiveness of all
other line drawings
with an amputation
Beauty of line
drawings with the
desired
amputation
Beauty of all other
line drawings with
an amputation
M
M
M
M
Right leg, above the knee (n=10, male)
1
6.20
3.43
7.00
3.43
2
4.60
4.43
7.00
4.00
3
7.00
6.09
6.00
6.14
4
7.00
4.66
7.00
5.00
5
6.20
2.71
4.00
2.71
6
7.00
5.14
7.00
5.14
7
5.20
4.09
7.00
4.00
8
7.00
4.54
7.00
4.57
9
3.60
4.74
7.00
5.00
10
7.00
5.46
5.00
5.43
Mean ±SD
6.08 ± 1.22
4.53 ± .97
6.40 ± 1.08
4.54 ± 1.02
Left leg, above
the knee (n=6,
male)
1
6.60
5.49
6.60
5.57
2
6.00
4.31
6.00
4.43
3
7.00
5.63
7.00
5.29
4
7.00
5.06
7.00
4.86
5
7.00
4.43
7.00
4.43
6
7.00
5.03
7.00
5.00
Mean ±SD
6.77 ± .41
4.99 ± .54
6.83 ± .41
4.93 ± .70
Left leg, above
the knee (n=2,
female)
1
4.40
4.23
4.00
4.00
2
7.00
4.57
7.00
4.57
Mean ±SD
5.70 ± 1.84
4.40 ± .24
5.50 ± 2.12
4.29 ± .40
For her, no difference was found regarding her
beauty's rating of the compared drawings (each
M=4.00). Additionally, two male individuals
with a desire for amputation regarding the right
leg above the knee perceived the drawings
showing amputations of other than their own
desired body parts as slightly more beautiful
(M1=6.14; M2=5.43) than those displaying their
own wished amputation (M1=6.00; M2=5.00).
With regard to the male subjects desiring
amputation of their "right leg, above the knee"
(n=10) as well as "left leg, above the knee"
(n=6), tests for significance regarding the
difference of their desired body's rating
compared to all other same-gender bodies with
amputations were conducted, since those
subjects could be seen as two separate samples.
All of the other subjects were not integrated into
the following analysis of hypothesis 3.
The Wilcoxon-test indicated significant results
(p<0.05) for the respective groups of male BIID
sufferers with a desire for amputation of their
"right leg, above the knee" and "left leg, above
the knee" with the effect that drawings with the
desired amputation were rated as more attractive
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 47
and beautiful than those drawings featuring a
different amputation. Concerning the item "Ideal
image", a significant difference at the
significance level of p<0.01 was shown for the
group of male affected subjects with a desire for
amputation of their right leg above the knee.
Overall, large effects were found for all scales
and items (from d=1.14 to d=4.52) (see Table 8)
Table8. Comparison between the perceptions of attractiveness of the drawings featuring the individual desired
amputation and all other drawings with an amputation corresponding to their own gender. Calculated by groups.
Hypothesis 3b: Corresponding to their sexual
orientation, BIID-affected individuals regard the
drawing showing the desired amputation as
more positive than the same drawing without an
amputation.
Table 9 shows significant differences for the
group of male BIID-affected individuals with
the amputation desire "right leg, above the knee"
(n=10) regarding their estimation of the drawing
showing the desired amputation compared to the
rating of the male drawing without amputation
for the item "Beauty" and the scale "Overall
score attractiveness" (p<0.05), as well as for the
item "Ideal image" (p<0.01). Also, the
Wilcoxon-test indicates significant differences
(p<0.05) for the group of male BIID-affected
individuals with the desire for an amputation of
the left leg above the knee (n=6) regarding
beauty, the ideal image and the overall score for
attractiveness. On average, those individuals
perceived the drawings showing their desired
amputations as more beautiful and more
attractive than the same-gender drawing without
an amputation. Here, large effects from d=1.01
to d=2.33 were found for all scales and items.
Hypothesis 4a: BIID-affected individuals with
a desire for amputation rate drawings featuring
amputations more positively than non-affected
subjects.
As shown in Table 10, significant differences
regarding the response behaviour (p<0.001)
were found for all scales and items between the
groups of BIID sufferers and the control group.
On average, BIID-affected individuals with a
desire for amputation rated drawings featuring
amputations as more attractive, more beautiful
and more consistent with their ideal image of a
beautiful body than the control group. Large
effects (from d=1.23 to d=1.94) were found for
all scales and items. Also, the scale "Difference
between the drawing's attractiveness with and
without amputation" showed that the control
group rated line drawings without an amputation
as more attractive on average than drawings
Group BIID-desire for amputation
Right leg, above the knee (n=10, male)
M±SD
z
Wilcoxon-test
d
Overall score of attractiveness of line drawings
with the desired amputation
6.08 ± 1.22
-2.40
p = 0.017
1.14
Overall score of attractiveness of all other line
drawings with an amputation
4.53 ± 0.97
Beauty of drawing with the desired amputation
6.40 ± 1.08
-2.20
p = 0.028
1.43
Beauty of all other line drawings with an
amputation
4.54 ± 1.02
Ideal image – line drawings with the desired
amputation
6.60 ± 0.70
-2.81
p = 0.005
3.00
Ideal image – all other line drawings with an
amputation
3.77 ± 1.16
Left leg, above the knee (n=6, male)
M±SD
z
Wilcoxon-test
d
Overall score of attractiveness of line drawings
with the desired amputation
6.77 ± 0.41
-2.20
p = 0.028
3.48
Overall score of attractiveness of all other line
drawings with an amputation
4.99 ± 0.54
Beauty of line drawings with the desired
amputation
6.83 ± 0.41
-2.20
p = 0.028
4.52
Beauty of all other line drawings with an
amputation
4.93 ± 0.70
Ideal image – line drawings with the desired
amputation
7.00 ± 0.00
-2.20
p = 0.028
2.72
Ideal image – all other line drawings with an
amputation
4.57 ± 0.89
The Beauty and the BIID
48 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
with an amputation. For subjects affected by BIID, the opposing applies.
Table9. Comparison between the perception of attractiveness of the line drawings featuring the individual
desired amputation and all same-gender line drawings without an amputation. Calculated by groups.
Table10. Perception of attractiveness of line drawings by BIID-affected individuals who have a desire for
amputation and the control group of non-BIID-affected individuals.
Hypothesis 4b: BIID-affected individuals with
a desire for paralysis rate drawings with amputations as beautiful as BIID-affected
individuals with a desire for an amputation.
Group BIID-desire for amputation
Right leg, above the knee (n=10, male)
M±SD
z
Wilcoxon-test
d
Overall score for attractiveness of line drawings
with the desired amputation
6.08 ± 1.22
-2.30
p = 0.021
1.01
Overall score for attractiveness of male line
drawings without an amputation
4.54 ± 1.14
Beauty of line drawings with the desired
amputation
6.40 ± 1.08
-2.56
p = 0.011
1.06
Beauty of male line drawings without an
amputation
4.80 ± 1.40
Ideal image – line drawings with the desired
amputation
6.60 ± 0.70
-2.92
p = 0.007
1.46
Ideal image – male line drawings without an
amputation
4.00 ± 1.56
Left leg, above the knee (n=6, male)
M±SD
z
Wilcoxon-test
d
Overall score for attractiveness of line drawings
with the desired amputation
6.77 ± 0.41
-2.21
p = 0.027
1.63
Overall score for attractiveness of male line
drawings without an amputation
3.47 ± 1.88
Beauty of line drawings with the desired
amputation
6.83 ± 0.41
-2.23
p = 0.026
1.42
Beauty of male line drawings without an
amputation
3.67 ± 2.16
Ideal image – line drawing with the desired
amputation
7.00 ± 0.00
-2.23
p = 0.026
2.33
Ideal image – male line drawings without an
amputation
2.67 ± 1.86
Group BIID-desire for amputation
vs. control group
BIID_amp.
(n = 22)M±SD
KG
(n = 22)M±SD
z
Mann-Whitney-U-test
D
Overall score for
attractiveness of all line
drawings with an amputation
4.85 ± 0.93
3.30 ± 1.08
-4.25
p < 0.001
1.54
Difference between the
attractiveness of line
drawings with and without an
amputation
0.53 ± 1.13
-1.57 ± 1.03
-4.92
p < 0.001
1.94
Beauty of all line drawings
with an amputation
4.88 ± 0.89
3.70 ± 1.03
-3.62
p < 0.001
1.23
Ideal image - all line
drawings with an amputation
4.48 ± 1.05
2.74 ± 1.42
-3.98
p < 0.001
1.39
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 49
The Mann-Whitney-U-test revealed significant
differences for all scales (p<0.05) with medium
to large (from d=0.73 to d=0.81) effect sizes
regarding the responses of BIID-affected
individuals with a desire for paralysis in
comparison to BIID-affected individuals with a
desire for amputation. On average, BIID-
affected individuals with a wish for paralysis
regarded the drawings with amputations as less
good-looking, beautiful, unflawed, attractive
and erotic than BIID-affected individuals with a
wish for amputation. Also, the item "Difference
between attractiveness of the line drawings with
and without amputations" indicated that BIID-
affected individuals with a desire for paralysis
found the drawings without amputations to be
more attractive on average than the drawings
with an amputation (M= -0.40, SD=1.17) (see
Table 11).
Table11. Perception of attractiveness of line drawings by BIID-affected individuals who have a desire for
amputation and BIID-affected individuals who have a desire for palsy.
Additional question: Do BIID-affected
individuals perceive the body part affected by
their desire for amputation as hideous,
unattractive, imperfect and repulsive while it's
still intact?
The descriptive analysis regarding the rating of
the body part affected by the desire for
amputation shown in Table 12 indicates mean
scores close to the mean of the possible rank of
the used Likert-scale from 1 to 7 for individual
items, as well as the scale "Overall score
attractiveness". Midpoints are at 3.27 (SD=1.42)
for the item "very unerotic to very erotic" up to
3.50 (SD=1.37) for the item "very repulsive to
very attractive". Altogether, the item as well as
the scale midpoints are very close to each other
and display standard deviations of similar sizes.
Table12. Perception of beauty regarding to the own body part affected by the desire of amputation evaluated by
BIID-affected individuals with a desire for amputation (n=22).
DISCUSSION
The aim of the study was to prove whether
BIID-sufferers judge pictures of amputees as
beautiful, attractive and sexually arousing. This
work should be a first investigation of the
model, and whether the cause of BIID may be a
disorder of the brain areas which assess the
beauty of the human body. From an
evolutionary point of view, bi-legged/two-armed
people must be judged to be more beautiful,
because this increases the chance of survival in
a hostile environment. Due to genetic changes
Group BIID-desire for amputation
vs. Group BIID-desire for paralysis
BIID_amp.(n = 22)
M±SD
BIID_palsy(n = 19)
M±SD
Z
Mann-Whitney-
U-test
D
Overall score for
attractiveness of all line
drawings with an amputation
4.85 ± .93
3.93 ± 1.28
-2.41
p = 0.016
0.81
Difference between
attractiveness of line
drawings with and without an
amputation
0.53 ± 1.13
-0.40 ± 1.17
-2.18
p = 0.029
0.75
Beauty of all line drawings
with an amputation
4.88 ± 0.89
4.09 ± 1.26
-2.14
p = 0.033
0.73
Ideal image - all line
drawings with an amputation
4.48 ± 1.05
3.46 ± 1.68
-2.05
p = 0.040
0.74
Group BIID-desire for amputation
Perception of attractiveness
Overall score attractivenessof the affected part
of the bodyM±SD
Rating fromvery hideous to very beautiful
3.45 ± 1.41
Rating fromvery unerotic to very erotic
3.45 ± 1.41
Rating fromvery unattractive to very good-looking
3.45 ± 1.34
Rating fromimperfect to unflawed
3.32 ± 1.56
Rating fromvery repulsive to very attractive
3.50 ± 1.37
Overall score attractiveness of the body part affected by
the desire for amputation
3.40 ± 1.33
The Beauty and the BIID
50 International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018
or ZNS-lesions, damage can occur in this
beauty-ideal, which may result in the case of
BIID, where the brain estimates a one-legged or
one-armed body as the ideal attractiveness.
Pictures of amputees would then be judged
extremely positively.
The data from the first pilot-study show that
images of disabled people were judged to be
significantly more beautiful, positive, and
fascinating than the neutral photo (hand). Of the
24 Wilcoxon tests, all were significant at the 5%
level; after Bonferroni correction, there were
only 15 significant differences. However, the
assumption that images of people with
disabilities from BIID sufferers are judged more
positively than a neutral photo is accepted. It is
interesting that the picture of an empty
wheelchair was already judged to be clearly
positive (it was still not judged as sexually
arousing).
The comparison of photos with erotic content
and photos of disabled people showed virtually
no differences at the 5% level; these differences
disappear completely after a Bonferroni
correction. The comparison of averages showed
that erotic photos of amputees were judged to be
as beautiful, positive, sexually arousing and
fascinating as photos with erotic content (half-
naked woman on the beach for heterosexual
men or muscular male torso for homosexual
men and heterosexual women).This confirms
that images of handicapped persons have an
erotic effect for BIID affected individuals.
A statistical test between the judgments of
commonly positive estimated photos (sleeping
baby, beach with palm, Albert Einstein), and all
photos showing amputees revealed no
significant difference. The photos of amputees
were estimated to be slightly more positive in
comparison with the photos of other emotional
positive things.
Within the second pilot study, BIID-affected
individuals with a desire for amputation were of
special interest. Concluding the second pilot
study, it can be said that there is a strong
difference between the perception of beauty of
BIID-affected individuals with a desire for
amputation compared to the subject group
without BIID, and even to those suffering from
BIID with a desire for paralysis. Subjects
affected by BIID perceived drawings displaying
amputations as more beautiful, more attractive
and more consistent with their ideal image than
those not suffering from BIID.
In addition, the findings indicate that BIID-
affected individuals with a desire for amputation
perceived the amputated drawings as more
attractive and more consistent with their ideal
image of a beautiful body; however, they did not
find them to be significantly more beautiful than
the drawings without amputations. This could be
related to the fact that the ideal of beauty is
always influenced by society, as well as by a
genetic component [10, 22]; hence, individuals
with intact extremities might not necessarily be
viewed as less attractive by people suffering
from BIID and having a desire for amputation.
However, when comparing only the one
drawing showing an image of the individual's
desired body, thus featuring the respective
desired amputation, to all of the other amputated
line drawings, significant differences regarding
the rating of the average attractiveness and
beauty as well as the assessment in regard to the
ideal image were found. Line drawings with the
desired amputation were consistently rated more
positively (see Hyp.3a). This was also evident in
the comparison between drawings with
amputated, desired bodies and those drawings
who are not amputated. The drawings of the
desired body were rated as more beautiful, more
attractive and more consistent with the ideal
image on average (see Hyp.3b). These findings
imply that BIID-affected individuals have
internalised a very accurate image of their
desired body and will display the most positive
reaction when perceiving it.
For some affected people, the literature suggests
a shift of the desired amputation from one limb
to another [14]. At this point, how the
perception of beauty is changing for BIID-
affected people along with the shift in the
desired amputation should be examined in
greater detail.
As already stated by Kasten [12] and Stirn et al.
[23], this study's participants also did not rate
the body part affected by their desire for
amputation as particularly hideous, unattractive
or repulsive. They rather seem to have a more
neutral attitude towards the concerned limb. As
a result, BIID-affected individuals are not
focused on one part of their body being
perceived as hideous, but rather on their whole
body, which is viewed by the affected as more
beautiful and attractive after being amputated
[14].
The Beauty and the BIID
International Journal of Research in Humanities and Social Studies V5 ●I5 ●2018 51
Results further indicate a more negative self-
rating regarding the beauty and attractiveness of
one's body for the group of BIID-affected
individuals with a desire for amputation
compared to the control group, and those
affected by BIID who have already undergone
an amputation. It should be noted that the rating
regarding the perception of beauty and
attractiveness concerning one's own body
resulted in much higher scores for BIID-
participants who already have an amputation
than for participants with a desire for
amputation. When asked how beautiful, good-
looking, erotic, attractive and unflawed they
perceive their own body to be after an imagined
amputation, the reports of BIID-affected
participants with a desire for amputation were
distinctly more positive compared to those
regarding their current physical state. These
findings are supported by evidence displayed in
the literature. According to the literature, BIID-
sufferers do not experience regret after a
successful amputation, but rather feel satisfied
in their striving towards the ideal image of their
own body [19].
CONCLUSION
The results of these two pilot studies indicate a
perception of beauty by BIID-affected
individuals with a desire for amputation that is
divergent from non-affected persons. In order to
be able to make differentiated statements
regarding the perception of beauty concerning
one's own body and those of others, further
research should undertake evaluations by using
modified (amputated and not amputated)
photographs of the respective participant as well
as of a different person. Assessing photographs
instead of line drawings would allow for a more
realistic estimation of the perception of beauty.
Because at this point no statement can be made
of to what extent an altered neuronal structure in
those brain areas involved in the rating of
beauty and attractiveness is responsible for the
differing evaluation of BIID-affected
individuals compared to control subjects without
BIID, and what causal conclusion should be
drawn, for the time being, the shifted ideal of
beauty can be seen as a symptom of BIID.
Conducting fMRT-studies in further research is
suggested in order to enable more precise
statements to be made about this perception of
beauty indeed being rooted in the neuronal
structure.
Because there are significant differences
concerning the ratings of beauty between the
results of BIID-sufferers with a desire for
amputation and those with a wish for paralysis,
further research focused on BIID-affected
individuals with a desire for paralysis makes
sense, as well as reviewing to what extent this
desire is connected with the person's ideal of
beauty. Thereby, generalised or more
differentiated statements regarding the group of
BIID-sufferers as a whole would be possible.
ACKNOWLEDGEMENT
The authors thank all of the participants of these
studies for their contribution and support. The
ambitious and confiding participation of the
BIID patients and controls contributed
fundamentally to the knowledge gained. We
thank Proof-Reading-Service.com LTD for their
corrections of English.
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