BEST OF PSN: Extreme body modification culture pushes surgical, ethical boundaries
Editor's note: The following article was originally published in May 2006 and remains one of PSN's most talked-about cover stories. The article received a Gold Award in Feature Writing from the Society of National Association Publications and a Silver Award in Feature Writing from the Magnum Opus Awards.
Dennis Avner first walked into a plastic surgeon's office in 1980 seeking to have some work done on his upper lip - specifically, he wanted it clefted to resemble the mouth of a cat. Avner, a descendant of Native Americans, had already begun the process of tattooing his body with tiger stripes as part of an ancient Huron Indian tradition to transform himself into his totem - a tiger - and the surgery would be part of the process. Before the physician would consider operating, however, he requested that Avner first seek clearance from a psychiatrist.
Frustrated and offended, Avner, now 47, never again set foot in a plastic surgeon's office despite undergoing a dozen surgical procedures over the years - including the creation of a cleft, three operations to elongate and point his ears, transdermal eyebrow implants for mounting whiskers, flattening of his septum to change the shape of his nose, an implant in the bridge of his nose and silicone injections in his cheeks, upper lip and chin (received in Mexico) - in his ongoing spiritual quest. Labeled as having body dysmorphic disorder by various plastic surgeons he's confronted in the media, the electronics technician from Freedland, Wash., is quick to lash out against the implication, insisting that while his ideas may be well beyond the status quo, he has the right to look how he wants.
"They've come out and said that they wouldn't do what I'm doing, that what I'm doing is wrong, yet we have Michael Jackson," he says pointing out the notorious pop singer who is as famous for his drastic plastic surgery as he is for his music. "If you have enough money to be eccentric, you can get anything you want done. The real issue here is that I don't make enough money to be eccentric, I guess."
Performance artist Erik "Lizardman" Sprague, 33, Austin, Texas, has also undergone some radical procedures in his ongoing quest to achieve a reptilian look. In addition to tattoos resembling scales from head to toe, he also has Teflon eyebrow implants (five above each eye), teeth filed into points and, in 1997, is believed to have become one of the first to have his tongue surgically forked. Unlike Avner, however, Sprague would welcome the safety and professionalism of a plastic surgeon to continue his transformation, which he hopes will include the surgical erasure of his nipples and navel.
"I would vastly prefer to have all my modification work done by qualified surgeons for their greater overall expertise and safeguards in the event of complication," he says. "I also believe that with their resources, surgeons would be in a position to offer even more technically advanced and difficult procedures to people - along with increased comfort and shortened healing times. However, social and professional prejudice along with prohibitive costs often remove plastic surgeons from the list of viable options for people seeking procedures outside the mainstream."
Body modification culture
Avner and Sprague are among the most highly visible members of the extreme body modification community - people who go beyond tattoos and piercings to surgically alter their bodies beyond society's cultural norms. Such extreme modifications include forked tongues and ear reshaping, branding and scarification, and a wide range of subdermal and transdermal implants such as devil horns, forehead ridges and small rings, balls and heart-shaped jewelry rising from beneath the skin of the shoulder, wrist or chest.
And while the media often views such modifications as a fringe element of plastic surgery, the vast majority of such work is performed by practitioners without medical degrees.
"The goal of plastic surgery is to bring people toward the cultural norm of beauty, whereas the goal of this stuff is to bring people to their personal beauty goal - the two do not always line up," says Shannon Larratt, 33, the Toronto-based founder and editor of BMEzine.com, a website that hosts more than 700,000 photos of body modifications submitted by roughly 500,000 subscribers since 1994. Larratt estimates that one in 10 of the body modification community qualifies as "extreme."
Who does this work?
The majority of people offering these surgical services are body piercers and tattoo artists who vary greatly in terms of training and skill.
"A few have had some good medical training, some are just very good autodidacts, and there are a few people out there who just see pictures on the Internet and figure they can do it," says Quinn Norton, a freelance journalist in northern California who spent several months getting to know the notoriously publicity-shy body modification community for an article in Wired.com. "That's the magic of being an unregulated field - there are people out there using butter knives as dermal elevators."
And though performing extreme body modification procedures is probably not the sort of work most medical professionals would advertise, there are some trained surgeons who would - and do - perform it. For instance, several tongue bifurcations (including Sprague's) have been credited to an oral surgeon in upstate New York.
"He had done about 15 tongue splits," says Larratt. "He did a great job in a medical office with a full support staff, so it was probably one of the safest ways you could do this procedure. From his point of view, it wasn't a problem. It's reversible and he said he did very similar biopsies for people with tongue cancers, so he didn't really see an ethical problem doing it."
Larratt says that as the oral surgeon's peers began to get wind of his unique subspecialty, however, he abruptly stopped the practice and disavowed any knowledge of it.
"So then all of a sudden these people have to go back to basement people, you know?" Larratt says.
Surgical theater of the absurd
When Larratt refers to basement people, he isn't being colorful. While some body modification work is performed in tattoo parlors and body piercing shops, Norton says the majority is performed in people's homes - especially the extreme modifications.
"A room will be set aside at someone's home; it'll have an autoclave and the correct set-up - at least the more reputable ones," she says. Noting the potential irony in her statement, she adds: "There's ‘reputation' within the community as well."
"Many of them are very talented, but they don't have full training," says Larratt. "Where they're really lacking is when things go wrong. They can't write a prescription, for example, and little things like that make a big difference. Complications are quite common, especially for some types of procedures like transdermals."
Larratt, who has undergone a number of body modifications himself, says he recently experienced a complication with magnetic implants in his fingertips that he says were inserted to allow him to "feel" electromagnetic fields. Unfortunately, the implants also resulted in what he describes as "really grotesque cysts."
Rather than go to an E.R., however, like many in the body modification culture, Larratt sought help from within the community - a local body piercer. "We basically cut a flap all the way around the front of my finger, excised some tissue and pulled (the magnet) out."
The reason Larratt says those with body modifications avoid seeking treatment in hospitals when there is an infection or other problem is for fear of having the implants removed.
Matthew Concannon, MD, Columbia, Mo., director of Hand & Microsurgery division of the University of Missouri School of Medicine, says that while removing the implant is likely the safest thing to do, physicians will not force treatment.
"If someone came to me in that situation, I would offer to remove the foreign body and try to fight the infection," Dr. Concannon says. "But this is America and they can decide if they don't want that to happen - but there's no way we can eradicate the infection without removing the foreign body."
Despite the complication, Larratt doesn't blame the person who inserted the implant. "I went into it knowing there was a chance that this was going to happen, and I was willing to deal with those consequences."
In fact, Larratt's philosophy of personal accountability is a mantra of the body modification community, though he wonders if many of them truly recognize the risks. "I've been into this for a long time and I understand what I'm getting myself into," he says. "But I worry that sometimes the artists don't even know the risks, yet they promote this stuff as safe."
Tools of the trade
Each body modification artist has his or her own signature techniques. Many use scalpels and pick at scabs to form the desired keloid. Others will use whatever they can find to get the job done. The most sophisticated, however, use surgical-grade dermal elevators for implants and cautery tools for procedures like tongue-splitting and elaborate scarification.
"It's equipment you should be trained on before you use it on a human being," Norton says. "Again you're in a situation where you have a wide range of skills from people who understand everything about them to people who've managed to get (a piece of surgical equipment) off the Internet."
"Depending on what state they're in, if they don't have access to supplies, they're probably buying them illegally," adds Larratt.
One of the most prominent figures in the community is Phoenix-based body modification artist Steve Haworth, who has a background in designing dermal elevators and other tools for plastic surgeons as part of his family's manufacturing business. Though Haworth declined to comment for this article, he is considered a pioneer of subdermal implants and his website states that he began exploring the idea of three-dimensional body art "due to his extensive knowledge of anatomy that was necessary for producing medical equipment."
Though he emphasizes his experience designing and manufacturing medical equipment for plastic surgery, however, he also points out that he is an artist, not a surgeon - and flesh is his medium.
"Steve Haworth very strictly doesn't call it surgery, he calls it art," says Norton. "That dictates how state boards react to the practice. There's a very compelling reason why they don't use the ‘S' word - that's when they get into legal trouble. As long as it's ‘art' and not ‘surgery,' they're allowed to practice what they want."
Avner, who has gone to Haworth for several of his procedures, says he's never had a complication and plans to visit him again soon to have magnets implanted beneath his scalp that would allow him to attach and remove tiger-like ears.
"Steve's major limitation is that he's not a doctor," says Avner. "He cannot do medical procedures like breast augmentation that virtually anybody with any kind of medical degree is allowed to perform, even if they have no experience whatsoever. But anything that falls outside of what is considered an established medical procedure, there is not, as yet, any regulation."
"It's very gray right now," agrees Larratt. "Nobody quite knows if it's legal or not. But if I say I'm doing artistic surgery, that doesn't mean I can do surgery on anybody. Cosmetic surgery is art in the same way, but you can't perform cosmetic surgery without a medical license."
Of course, like any practitioner who dabbles in procedures beyond his or her scope of practice - medical or otherwise - body modification artists offer lower prices for their services than qualified physicians would likely charge. While having a pair of devil horns implanted in your forehead by a body modification artist would cost around $500, to have the same procedure performed by a plastic surgeon - if one could find a physician willing to do it - would cost much more.
"I don't think the market would support their rates," says Larratt. "A lot of these people who are doing it don't have a few grand to drop on it. Personally, I'd love to see doctors doing it, but they are being threatened with losing their livelihoods for doing it."
ASPS Ethics Committee member Jeffrey Rosenberg, MD, Los Angeles, points out, however, that the notion of professional intolerance isn't entirely accurate. Though he concedes many members of the society might find such practices distasteful, ASPS doesn't dictate what procedures its members can perform.
"Whatever procedures our members perform should be safe and in the best interests of the patient," he says. "And it would be incumbent upon the member to evaluate the patient carefully from both physical and psychological aspects. I think most surgeons might consider splitting a tongue to be a potentially harmful procedure, and we certainly wouldn't condone any harmful procedure. I don't know all the repercussions of tongue-splitting, but it seems like it would be a really bad idea."
While neither the American Medical Association nor ASPS has specific rules against performing such body modifications, Norton says she has heard from doctors who have wanted to serve the body modification community but feared losing support of the medical community.
"Everybody likes something different," says Larratt, who points to a cultural bias against body modification practices as a factor keeping qualified surgeons from offering their services. "Most people like the cultural average - that's why the cultural average exists - but there's a very wide bell curve of interests. You can even make the argument that it's bigoted to say you're only going to support the center of the bell curve and if you fall outside of the center, I'm sorry, but you're going to have to go to a hack."
"We turn people down all the time and we can't be responsible for where they go from there," counters Dr. Rosenberg. "For example, people come in requesting silicone breast implants and threatening to go to Mexico when we can't accommodate them. Likewise, we don't need to feel obligated because a patient may run off to a tattoo parlor where nonstandard, nonsterile or substandard techniques might be used."
"If I step back, I guess you could say that part of it is my own conceived notions and my own culture," says Dr. Concannon, who is also a member of the ASPS Ethics Committee. "Theoretically, there's a culture that says extreme body modification is pretty cool to do, but that's not our culture right now."
An ethical quandary on the horizon?
"The ASPS Code of Ethics is based largely on common sense - it's only about three pages and the guidelines are pretty general," says Dr. Concannon. "For instance, there's nothing in our code that specifically says you can't split someone's tongue, but the bottom line is that it's mutilation, and beyond our society's ethical rules - our most primal oath as physicians is "Do no harm." Occasionally in our society, issues arise that force us to codify our rules more specifically, but I don't think there's going to be a whole lot of problems with doctors doing these extreme body modifications because it's surgical mutilation."
"A lot of stuff we do could be considered unnecessary and decorative in a way," adds Dr. Rosenberg. "There are limits, however. We must be careful not to engage in what would be considered bizarre forms of ritualistic self-deformation."
As cultural norms continue to shift at an increasingly rapid pace, however, Norton suspects that, like tattoos and piercing before it, some body modification that may be considered extreme today might be considered mainstream tomorrow.
"I can see transdermal implants going mainstream easily," she says. "All it takes is one Britney Spears-like figure to decide she wants a little heart implant on her shoulder and plastic surgeons are going to be deluged with requests. As freakish as it is right now, the actual medical practice of inserting subdermal implants is considerably less complicated than other things people regularly have done. It takes almost no time, very little resources, and it's an area of use in the body that's well explored and understood - and the procedure is also completely reversible. I think it's only a matter of time until plastic surgeons are confronted with this."