Body Modification, Autophagy

Source: American Journal of Forensic Medicine and Pathology, Vol. 20 (1999), pages 281-285

First report of non-psychotic self-cannibalism (autophagy), tongue splicing and scar patterns (scarification) as an extreme form of cultural body modification in a Western civilization

Original Version published in: American Journal of Forensic Medicine and Pathology (Am J Forensic Med Pathol), Vol 20(3):281-285. This is a raw version that cannot be used for purposes of scientic citation.

Scientists and medical doctors: Please go get the original text incl. pictures (click) or contact me.

Abstract
As part of her current lifestyle, a 28 year old Caucasian woman routinely injures and allows subsequent healing of her skin and other tissues.  Her body modifications include a “split tongue” (a tongue split to the base), which does not interfere with speaking and eating. Other modifications include large scarification patterns produced by branding and cutting.  This woman has been known to eat parts of her skin, which were previously cut out of her body.  She also performs “needle play” by allowing medical syringe needles to be lodged temporarily under her skin.  The patient had a normal childhood, is currently employed full-time as an office manager, and is psychologically stable.  Although one other case of self-induced penoscrotal hypospadias is known, this is the only report of extensive, non-psychotic, and autodestructive behavior.  However, this may not be the case in the future as an increasing number of young individuals have become interested in body modifications.

Introduction
During an ongoing interview series related to the medico-legal aspects of behavioral patterns in socio-cultural subgroups of people less than 30 years of age (1), we documented the life history and current status of a 28 year old Caucasian woman named S.E.  As part of her lifestyle, she commonly practices “body modification” by injuring and allowing subsequent healing of her skin and other tissues. These body modifications are easily concealed by her clothing and hair.   During our research, we discovered that S.E.’s behavioral patttern is similar to other people in the same age group and those even younger.  Therefore, it seems necessary to strengthen the awareness of such observed injuries in order to address a possible future trend in body modification. To our knowledge, the case reported in this paper is the only one of severe, non-psychotic body modification in the Western culture that is documented in the medical or psychological literature, with the exception of a case involving self-induced penoscrotal hypospadias (12).

Research Method
Human beings are the focus of interest in forensic and legal medicine. However, systematic monitoring of the daily life of humans, and especially pre-designed changes of experimental parameters concerning their lifestyle, is practically impossible.  Therefore, it is frequently substituted by case observations.  Depending on the number of observations, case studies can later be compiled by using mathematical re-analysis of raw data obtained from each case (e.g., 2).  In the context of professional criminalistic research, the author focuses on the socio-cultural behavior of persons under the age of 35.  This age group is largely underrepresented in forensic studies but displays many lifestyle related behavioral patterns that may puzzle even experienced forensic pathologists, criminalists, and law enforcement officials.  Therefore, we use a semi-quantitative approach that documents not only the behavior but also the zeitgeist.  This research method is based on extensive interviews, partially as pioneered in early sex research (5).  A modification of this method without a rigid structure and compilation of questions but includes verification of sources, is currently being used in scientific sociology (7). All of our interviews were conducted in a comfortable and reasonable environment.  Over a nine month period, we recorded over 24 hours of interviews.  This was complemented by actual, on-site visits of relevant locations in New York City and by viewing video recordings of the body modification procedures performed on S.E.

State of Interviewee’s Body Modifications
At the age of 16, S.E. started to continuously scrape the interior of her hands until a small bleeding wound appeared in which a scar approximately 2mm in length is still visible.  Three years later, she began to cut her wrists to produce triangle-shaped scar patterns (~7x5cm).  During these procedures, S.E. clearly avoided damaging her blood vessels, which she could see and feel while cutting.  The scar patterns on her wrists are still clearly visible (Fig. 1). S.E. relocated to New York City at the age of 26 and with help from her male friends, who were professional piercers, she became interested in having up to 150 medical syringe needles (gauge size 16-27.5) temporarily stuck under the skin of her back and front torso.  This would include her nipples and clitoral hood.  She also became transfixed (permanently pierced) with removable jewelry, such as rings and short sticks at the labia majora, clitoral hood, nipples, and tongue (~2cm from the tip).
At the age of 27, S.E. had surgery to split her tongue.
She had prior knowledge of tongue splicing performed in an extremely painful procedure using fish line, which was pulled through a pierced hole in the center of the tongue and slowly tightened over a period of three weeks (9).  Attracted to this type of body modification, S.E. approached a maxillo-facial surgeon who was known to perform tongue splicing.  Using a laser beam, the surgeon split her tongue 4cm from the tip.  After a few weeks, the tongue healed together from the base.  The surgeon then performed maintenance operations in June, 1998 and again in September, 1998 (Fig. 2, 3) in order to keep the tongue split apart.  The actual wounds continued to heal within a few days without complications.  In addition, having a split tongue does not interfere with eating, speaking, etc. and S.E. quickly adapted to this oral modification.
Another body modification procedure performed by S.E. was to remove strips of skin in order to produce large scar patterns, the largest of which stretches in a zigzag and diamond shape from left to right across her entire back.  Also, she has another scar pattern that stretches over the front abdominal region (Fig. 4).  The width of the scars are ~7mm.  During one of the cutting sessions, which are always performed without anesthetic (including alcohol), S.E. consumed some of the tissue, with the largest piece measuring ~10cm x 7mm.  After chewing on the skin, which she could not bite through, she swallowed the piece of tissue.
Other body modifications performed on S.E. include tattoos and brandings (i.e., scarification patterns caused by induction of heated metal forms).  During all of the aforementioned body modification procedures, S.E. showed extreme control and immunity to pain.

Personal Background
S.E. grew up in an immigrant, middle-class family from a town with approximately one million inhabitants in the western region of the United States.  In addition to her regular school education, S.E. also attended Sunday school until the age of 15.  Later, she relocated to another State and finished college with a Bachelor of Arts (B.A.) degree in Sociology.  S.E. then moved to New York City where she currently works as a full-time office manager. Her current friendships are focused on people involved in body modification (tattoos, piercing, branding, needle play, etc.).  In order to maintain a relationship, S.E. has performed sado-masochistic acts but has no personal interest such activities. Although she is psychologically balanced, S.E. may be classified into the schemes of attention seeking and self-caring behavior (4,11).  Also, peer pressure may play a role in her ongoing body modifications. 
S.E. has constant and stable contact with her family.  She has two older brothers, one is a physician, and the other is an engineer.  Her parents were never divorced and the family did not move during S.E.’s childhood or adolescence.  The entire family disapproves of her body modifications and to try and comprehend such behavior, they have openly discussed the possibility of psychological disturbances (and even sexual abuse) in S.E.’s early childhood or adolescence.  However, there is no evidence pointing to such influences.  She never performed pre-suicidal parallel cuttings on her skin or any other related modifications and she is not involved in any religious or pseudo-religious activity.

Current Status
S.E. lives in New York City’s East Village, which is a highly multicultural area of town and the primary focus of tourism for many young visitors between the ages of 15 and 30 years. A large number of tattoo and piercing studios along with comic book, leather, fantasy, and role-playing game shops are concentrated here (Fig. 5).  This area is the successor of Greenwich Village and Chelsea, which are historically known to have been the avant garde parts of the city.

Historical Note
Body modification behavior is widely documented in many native populations including those in Australia, North and South America, and Southeast Asia (3,8,12,13).  Ancient rituals, like the Indian sundance, involve the insertion of flesh hooks under the skin and slowly removing them.  Also, the Mayas performed penis perforations, as documented on their engravings (12).  Among some Australian natives, penoscrotal hypospadias was known and used, and in Africa, huge wooden inserts and cuttings into the facial tissue are still common practice.  Also, clitorectomy is practiced in some small African populations but now is becoming less prevalent. In modern Western cultures, tattoos have become the best known type of body modification.  The interest in tattoos grew steadily since the time when sailors and prisoners were the primary group displaying them.  It was not until the 1970s that the first tattoo conventions were held and since the 1980s, tattoos and piercing have been recognized as a possible art form.  Consequently, in some large cities in Europe and the United States, the number of piercing studios exceeds the number of possible customers (8, 12).  Today, displaying body art and body modifications are often considered to be part of a person’s lifestyle.
An extensive overview of body modifications, such as tattooing, piercing, spiritual use of flesh hooks, subcutaneous penis beads, stretching of ear lobes, etc. is given in Vale and Juno (12).  Currently, the cultural context of body modifications extends from urban lifestyle (as reported here) over S/M-related/sexual topics, or identification purposes in the Japanese yakuza Mafia, to the spiritual/meditationaluse of permanent and non-permanent body modification techniques.

A Word on Ethics
The ethical implications of operations carried out by medical surgeons who perform tongue splittings are open to discussion.  All physicians who are asked to perform an operation like this have to confront the classic dilemma of performing such an unusual procedure (for pragmatic reasons) or allowing the patient to deal with his/her own desire for their own ethical reasons.
The author has learned from direct observation that most members of the “mutilation scene” are not willing to discuss their own desires to perform body modifications with those individuals outside of the scene.  In fact, many of them will perform the operation on themselves if no professional help is offered.  As previously mentioned, the first tongue splitting was performed by an adolescent female who used a fish line (9).  This procedure is likely to result in severe damage and infection to the tissue.  However, a professional operation performed by a highly qualified surgeon would significantly reduce the chance of these unwanted side effects.
The decision between pragmatics and ethics also has to be addressed from a psychological point of view.  Based on comments made directly to the author by those people involved in body modification, the underlying psychodynamics of their behavior may include feelings of disconnection from their body or certain emotions.  Some members of this youth subgroup further stated that this connection may be re-established by infliction of pain, or by control over their emotions.  In reality, it may be difficult to decide whether body modification can be understood as self-therapy or as an “unwanted behavior”.

References
1. Benecke M. Techno. Phenomenology of a prevailing trend. Kriminalistik 1997;51:475-9
1(a) Benecke M, Body Modification: Freiwillige massive Selbstbeschädigungim Kontext einer modernen westlichen Jugendsubkultur. Jahrestagung der Dt. Ges. f. Rechtsmedizin, Frankfurt 1999
2. Berghaus G. (1978) Mathematisch-statistische Differenzierungsmöglichkeiten zwischen Selbstmord und Unfall bei Sturz aus dem Fenster. Z Rechtsmed 80:273-286
3. Brown DE, Edwards JW, Moore RP. The penis inserts of Southeast Asia. Occasional Paper Series (#15), University of Berkeley at California, 1988
4. Eckert WG. Self-inflicted injuries. In Tedeschi CG, Eckert WG, Tedeschi LG, Forensic Medicine. A study in trauma and environmental hazards, Vol. 1. Saunders, Philadelphia, 1997:496
5. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human male. Saunders, Philadelphia, 1948
6. Laratt S. Tongue Splitting. The Oral Overview. Tatoo Savage (Escondido, CA) 1998;24:34-5
7. Lautmann R (1994) Die Lust am Kind. Klein, Hamburg, 1994:12-13;91-92
8. Miller J. The body art book. A complete, illustrated guide to tattoos, piercings, and other body modifications. Berkeley Books, New York, 1997
9. Musafar F. Dustin’s Split Tongue. Body Play (Menlo Park, CA) 1997;4(4):14-20
10. Rothschild MA, Ehrlich E, Klevno WA, Schneider V. Self-implanted subcutaneous penile balls - a new phenomenon in Western Europe. Int J Legal Med 1997;110:88-91
11. Sachse U. Selbstbeschädigung als Selbstfürsorge. Zur intrapersonalen und interpersonellen Psychodynamik schwerer Selbstbeschädigungen. Forum Psychoanalyse 1987;3:51-70
12. Vale V, Juno A. Research: Modern Primitives. An investigation of contemporary adornment & ritual. V/Search, San Francisco, 1989
13. Wan SP, Soderdahl DW, Blight EM. Non-psychotic genital self-mutilation. Urology 1995;26:286-7

Figures
Fig. 1. Non-suicidal triangle-shaped scar pattern produced by the patient at the age of 19.
Fig. 2. Healed tongue splitting. Both tongue parts can be moved separately and do not interfere with eating or speaking. 
Fig. 3.  State of tongue one day after third operation (1998): swollen but fully functional.
Fig. 4. From top to bottom: Piercing, zig-zag scar patterns, flame-like tatoo surrounding a scar produced by a "cutting" (removal of tissue).

Remark
This study was performed while the author was employed at the New York City Office of Chief Medical Examiner (OCME).  However, all of the research, including the preparation of this manuscript, was done independently by the author during the time he was not obligated to the OCME.  This study was not performed in connection, cooperation, or on behalf of any United States federal, state or local government agency.  This was part of an ongoing study on prevailing trends among subculture youth communities.

Acknowledgements
I wish to thank my colleague Dean Wideman, M.Sc., NYC, who did the final corrections on the manuscript, and S.E., Chris, and Keith Alexander, who openly discussed matters of body modification with the author.