Why virtual reality exposure isn’t necessarily an ethical, harm-free alternative to BID surgery.  

Body Integrity Dysphoria (BID) is defined by the ICD-11 as ‘an intense and persistent desire to become physically disabled in a significant way’. For example, a BID patient may experience an incongruence with their otherwise healthy leg and develop a desire to amputate it. This distress is sometimes so severe it causes sufferers to undergo make-shift, non-medical BID surgeries. Clearly, BID warrants medical intervention. 

However, there is no medical consensus regarding an effective or ethical treatment. Psychotherapy and psychopharmacological methods are currently largely impotent in relieving the distress. BID surgery: satisfying the BID desire, has often been alleged to alleviate BID completely. However, there are no long-term, methodologically sound studies regarding BID surgeries efficacy. Furthermore, BID surgery remains very controversial. Some question the autonomy of those with BID to give consent to BID surgery and others argue that it leaves the patient in a disabled state and thus violates the Hippocratic Oath. Clinicians are therefore left with no easy option. Either they perform untrialled and seemingly ethically dubious BID surgeries or persist with “less-invasive” but ineffective treatment strategies.  

The potential of a new and innovative treatment strategy, therefore, will be welcomed by those tasked with tackling BID. Rather than looking at orthodox strategies such as medication and psychotherapy, neuroscientists, psychologists and social scientists from Switzerland and Ireland teamed to study the capacity of virtual reality in providing BID sufferers relief without the need to impose disability. They experimented with exposing 18 BID sufferers to their desired body (in these cases a leg stump) via VR and tasked them with performing games involving their virtual stump. The researchers observed that BID patients experienced a higher increase in body ownership against the control group and conclude that VR simulation may be used as a therapeutic technique for BID management. This study builds Turbyne and colleagues’ 2021 study which observed psychological relief of 2 BID patients who underwent a similar augmented reality exposure.  

As AR/VR simulation seems to provide relief without causing disability, this begs the question, does it provide an ethical, harm-free route for clinicians to mitigate BID suffering? Whilst I believe this technique has potential and can conceivably be used by BID sufferers and clinicians as a BID coping strategy, I think there are reasons to be cautious.   

There is a concern that AR/VR techniques may be too therapeutic. I think there are two issues here. Firstly, consider that similar simulation (or “pretending”) techniques often provide short-term relief but intensify disownership in the long-term. Given that non-AR/VR simulation involves similar visual and functional dismissal of the affected limb, it would be unsurprising if this technique also provides short-term relief but intensifies the disorder in the long-term.  

Secondly, if this short-term relief is great, BID patients will likely seek it as much as possible. The patient’s capacity to relent from it may be diminished all the while its effectiveness may continually lessen. Although Saetta and colleagues suggest this study demonstrated that VR normalized altered patterns in the reward systems, suggesting it might be less addictive than pretending’, I’m not convinced this solves the issue. Given many suffer greatly from BID and some have suggested obsessionally so; if the only means patients can relieve this suffering is by AR/VR it would be unsurprising if BID patients do everything in their power to achieve this relief. Whilst many disabled people, including those who have undergone BID surgery, have fulfilling and holistic social lives, it is hard to imagine the possibility that BID patients could experience AR/VR therapy in social settings. If a sufferer’s BID was severe, it would be unsurprising, and perhaps even rational, for BID sufferers to sacrifice a holistic and healthy lifestyle for a reclusive and synthetic life mitigating their dysphoria. This is unlike BID surgery, where the dysphoria seems to relent without the need for social retreat.  

Many perceive BID surgery as morally repugnant. Although repugnance can accurately detect moral transgressions, we ought to be careful to guard against it creeping into our method. Whilst it is a fair to contest the evidence of successful BID surgeries as anecdotal or methodologically flawed, we cannot commit a double standard here, namely scrutinising the evidence of BID surgery’s efficacy whilst giving evidence for the efficacy of “less-invasive” therapies a free pass. I see three possible methodological issues. Firstly, although we have limited empirical data on the long-term efficacy of BID surgery, we have even less evidence on the long-term effect of AR/VR simulation. Given the potential issues I have raised, this is a concern. Secondly, there is a concern that the seemingly universal evidence in favour of BID surgery is a result of study cross-pollination. However, as Saetta and colleagues’ note, both of Turbyne and colleagues’ participants also participated in the most recent study. Therefore, any concern of a false consensus in favour of BID surgery can also currently be levelled at AR/VR simulation. Thirdly, Saetta and colleagues note that ‘mood and anxiety symptoms are known to occur in individuals with BID, these were not clinically significant in our sample and did not meet the threshold for exclusion’. Although we do not know the threshold for exclusion, this may suggest that Saetta and colleagues’ study only researched the short-term effect of AR/VR simulation on those who only suffer somewhat from BID and not those who suffer from it severely. If so, this warrants a reasonable conclusion. Namely, that if an individual suffers somewhat from BID this may be a reason to prefer AR/VR simulation over BID surgery. Yet this leaves us no further in deciphering how to manage severe BID cases.  

Finally, this type of therapy can only be used in limb-affected BID variants. AR/VR simulation provides relief via visual stimuli and thus it seems only potent for somewhat satisfying amputation BID variants. It is difficult to imagine how well AR and VR can harken a desire for paraplegia, blindness or deathless for example. It was reported that in 2024 a Canadian BID sufferer experienced immediate and lasting relief from a medical BID surgery, a finger amputation. It would be difficult to conceive how AR/VR could be used to harken this, and, considering the resulting disability is mild, that the burden of having to set-time aside to utilise AR/VR technology is less-invasive than the disability imposed by BID surgery.  

I do not wish to condemn VR/AR techniques here. They may very well be useful and therapeutic for many with BID. However, my concern is that as it has shown some potential in helping manage BID clinicians and commentators may view it as preferential to BID surgery by default. Whilst we ought to welcome and explore its capacity in providing relief and better comprehending BID, we shouldn’t lose sight of the fact that many with BID feel as though they are being gatekept from an effective treatment by illusion to some less-invasive future innovative cure which may never arrive.