Now jumping to the other end: Tattoos. Piercings. Cosmetic surgery, more pleasantly euphemised as plastic or aesthetic (Mendelson and Steggall, 2013; Gilman, 1999) surgery. The co-called “boob jobs” of actors, major or minor celebrities and porn stars. I will not say much about the series of circumcisions for reasons of Muslim or Jewish faith, or American cultural reasons. Or female genital mutilation for a mix of cultural and perhaps religious reasons. This is where a split originates. Many psychotherapists draw the line here, and whether or not they go to formal diagnoses, or think about particularly pointed terms for what is wrong, they will, in one way or another, be influenced by the thought that there is something wrong – doubtful – and questionable about these practices. 

I think it behoves us as psychoanalysts and psychotherapists to consider our countertransference very carefully, before wading in and “exploring” our clients’ feelings about such “doubtful” kinds of body modification, before we do so and find that unconscious to unconscious, body to body, our client hears loud and clear that we are convinced that what they do or intend to do is wrong, very wrong, pathological, and that the only successful outcome of psychotherapy is that our client sees the light, understands the pathological background to their misguided wishes, and gets access to a strong dosage of spontaneous motivation to make the “right” decision for themselves – which inevitably would be, not to make the body modification. This was of course also how it worked in the days when, 50 years ago, many psychotherapists and analysts reacted like this to clients who would share with them their “homosexual” inclinations or behaviour. 

A third class forms a series of even more clearly proscribed and proscribable categories: 

  • “non-suicidal self-injury” as named by Favazza (2011), with more durable self-mutilation as a subcategory; 
  • suicide attempts; 
  • consciously risking self-harm such as in boxing, climbing Mt Everest, possibly rugby and pro-football, and certain other sports and martial arts; 
  • more or less superficial injury risked or actually caused by BDSM/kinky activities, including erotic auto- or allo-asphyxiation 

How can we look at different variations on the theme of bodily change for reasons of gender self-perception, expression or identity, and compare them with these other acts of influencing, changing, or modifying the body?