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January 2024 Issue [Letter from Revelstoke]

If One Part Suffers

The enigma of body integrity dysphoria
Collage by Matthieu Bourel

Collage by Matthieu Bourel

[Letter from Revelstoke]

If One Part Suffers

The enigma of body integrity dysphoria

“It would be a grain hopper,” Robert said, our bodies twisted to take in the view out the driver’s-side window of his wife’s Toyota RAV4. I thought he might pull over there, on the stretch of beige gravel road where several of the train tracks that pass through Revelstoke, British Columbia, converge. I hoped for another of the smoke breaks that had punctuated our winding tour of the thumbprint town, pressed between the Selkirk and Monashee mountain ranges, where Robert lived.1 It was August 2022, and the heat, which I found mild, agitated him. He’d taken the day off to ferry me around; the tour had thus far included a view of an upscale ski resort that, since its opening in 2007, had helped to widen the town’s already sizable class divide, and the riverside burial site of KC, a chihuahua-terrier mix named for his way with kisses and cuddles. It was with KC by his side that Robert had first arrived in town, eighteen years ago, to begin his brief stint as a railway-conducting trainee.

Robert said things like “ginormous,” “friggin,” and “fuckwit,” habitually spoke in a question-and-answer format, and was free with his wheezy smoker’s laugh. Even more than his strong, octave-surfing Ontario accent, his willed congeniality—a mix of natural reserve and a morbid aversion to pretense—spoke to something in my bones. The temper he said had plagued his relationships with a neighbor and his teenage son (“Do I use expletives? Yes. Should I? No”) had thus far surfaced between us only as a rare and faint vibration.

Seeing the railway junction for myself had been my one request before arriving in Revelstoke. Robert had never quite replied, and in the weeks since we first spoke, I hadn’t mentioned it again. As plans often are, especially between strangers, ours had been mostly tacit, contingent, imbued with fantasy. Now my steady flow of questions stalled as Robert slow-rolled us past the spot in question, where what he called “Plan B,” a scenario for which he’d mapped out every detail, might unfold. I felt the intrusion of my presence, a sense of gross extraction, seeping forth. My fantasy, I suppose, having been that it would not.

“A grain hopper heading east,” Robert clarified, pointing out the curve in the tracks that would hide him from the train’s crew, many of whom he knew, and leave them no chance of stopping in time. His plan was designed to minimize the trauma inflicted on everyone involved, and to ensure his own survival. Calling 9-1-1 a minute or so before the train swung into sight would put ambulance arrival time, from the dispatch we’d passed on our way in, at about two minutes; a tourniquet he’d carry with him would limit the bleed.

I studied the site through the car window. It was littered with old train ties. A stand of aspens, white bark flashing, divided the tracks on the far side from Revelstoke’s main drag. Unable to make out whatever it was I imagined discovering there, I turned back to KC’s old collar, hanging from the rearview mirror, and said something useless about self-harm. “I see it as a beginning to an end,” Robert corrected me. “You’re forcing something to happen.”

The wish behind all of Robert’s planning was not to destroy his body but to alter it. I had come to meet him, this smiling, summer-dude vision in wraparound sunglasses, sweat-wicking shorts, and white Air Monarchs, because for at least forty of his fifty-two years, Robert has wanted nothing more than to shear away one of his two healthy, perfectly functioning legs. His physical form, tallish and solid-built, feels “overcomplete,” he’d told me repeatedly, possessed of an extra, deeply unwanted thing.

“I don’t know about your reaction to all that,” Robert said, as we turned off Track Street East and made our way back to Victoria Road. “You’re the first person I’ve opened up to about that specific thing.” We passed the grocery where, the night before, I had foraged a meal from indifferently stocked shelves. It stood on the site of the town’s first public hospital, which opened in 1902, at the peak of Revelstoke’s colonial invention. The town’s earliest hospital, a few minutes northwest, had taken as its first patient a Swedish-born miner who required, for reasons history has left unspecified, that part of his finger be removed. Recalling that Robert had in fact described Plan B to several medical professionals, I asked how it felt anyway. “Vulnerable,” he said quickly. “It makes me feel vulnerable. I’m not going into it willy-nilly. There is a plan. I’m just not looking forward to any of it.”

I noticed again the injured look, red and swollen, of Robert’s hands, now both gripping the wheel, where before one had tapped, or fiddled, or made the relaxed, curling gestures of an accompanist out the window as he spoke. I remembered the finishing touch of Plan B that he had described on the phone, surgical directives he would inscribe in waterproof Sharpie on his left upper thigh: “Four to five inches above knee center. Draw a fish mouth—do it right.” And then below this, underlined: “This is what ten years of therapy for BID looks like.”

BID, body integrity dysphoria, is rare. Though experts are reluctant to estimate its prevalence, it is believed that at least a thousand people globally have the disorder. Medical recognition of the condition is growing, and its addition to the World Health Organization’s International Classification of Diseases (ICD) took effect last year. The ICD defines BID as “an intense and persistent desire to become physically disabled in a significant way”—to become, for example, a major-limb amputee, paraplegic, or blind—“with onset by early adolescence accompanied by persistent discomfort, or intense feelings of inappropriateness” regarding one’s body.

I learned of the ailment in 2011, the year that I met Dr. Michael First, a professor of clinical psychiatry at Columbia and an editor of the current Diagnostic and Statistical Manual of Mental Disorders (DSM), who had inaugurated an earlier term for the condition, body integrity identity disorder, in a 2005 study. First was then campaigning for BIID to be added to the DSM-5—what remains the most recent edition—which was in its deliberative stage. I was writing about those deliberations, specifically about the various political and institutional follies involved in defining normalcy. I was preoccupied, as well, with our culture’s competing blights of self-focus and self-alienation, and a possible synergy between them; how easily our efforts toward perfection can turn destructive. At the time, BIID seemed the ne plus ultra of this danger, a useful metaphor for an age on the verge, one might say, of dismantling itself.

Glancingly over the years, and recently, the political right wing has identified the disorder as a more specific beacon: a representation of the risks supposedly opened up by the freedom to express different gender identities and to modify one’s body accordingly, citing the affliction as evidence that trans rights and gender-affirming care are the first stops along a slippery slope. This assertion seems to have been supported by the fact that certain researchers, most prominently Michael First, have described the condition as analogous to gender dysphoria—associating it with a long-accepted diagnosis (what was at the time called gender identity disorder) as a means of clearing a path for medical recognition. The field has left First’s early terminology behind, turning to “body integrity dysphoria” in an effort to hew to more symptom-descriptive nomenclature, and, as First told me, to reflect more humility regarding the disorder’s root causes. But First’s public advocacy has been widely influential—he appeared on Dr. Phil in 2015—and many news articles still reference BIID, his original name. Some with the condition, including Robert, use language associated with issues of gender and sexuality, speaking of “true selves” and “coming out.”

This association has haunted the process of telling Robert’s story, threatening to make of his suffering a narrow allegory, grist for political milling. (Several BID sufferers I spoke with cited this as an ongoing problem.) Yet Robert’s distress seemed to have much broader parallels, beginning with the experiences of the millions of people who modify their healthy bodies through surgery in myriad ways every day: the woman who enlarges her breasts; the man lengthening his legs, millimeter by excruciating millimeter. Or the person who strives obsessively, through disordered behavior, to disappear parts of their physical self. I am regrettably familiar with this work—with the wish not just to alter but to vanquish parts of one’s body deemed alien, untrue, imparted by mistake. My endeavors remained within the realm of social acceptability—or, at least, what was socially tolerated—while Robert sought something readily understood as crazy.

What separated us, really? Was it merely a question of norms? Of scale? To learn, often, is simply to linger; in this case at the edge of a chasm. I wondered if I could reach across.

Attempts to name and define BID over the past five decades offer a fun-house reflection of a culture in flux, the career ambitions of a handful of clinicians, and at least one accident of history, the last coming at the start. The first medically documented modern sufferers of the disorder were two men who each contacted the Johns Hopkins Psychohormonal Research Unit in the early 1970s, believing that the unit might connect them with doctors who performed radical surgeries. As a result, both men were assessed by a sexologist, the later disgraced founder of the research unit, John Money. (Money would go on to face allegations of sexually abusing two child research subjects, among other scandals.) Money concluded that the two men, who each sought the amputation of one leg, were experiencing what was in essence a psychosexual disorder, what he called apotemnophilia, characterized by an “eroticization of the stump.”

Twenty years later, in 1997, a New Jersey doctor named Richard Bruno advanced the term “factitious disability disorder,” in which the psychosexual component asserted by Money became a subset of the condition. The same year, the Scottish surgeon Robert Smith performed the first known elective amputation of a healthy limb at a hospital; he carried out the second in 1999. Both amputees, who had each given up a leg, reported satisfaction, but when their stories went public, in 2000, Smith’s hospital put an end to the operations. A 2000 BBC documentary, Complete Obsession, follows the New Zealand–born psychiatrist Russell Reid as he interviews potential candidates for surgery with Smith. The documentary presents the ailment as a form of body dysmorphic disorder, a condition which experts believe affects one in one hundred people. (Later, Smith would develop a distinct classification called amputee identity disorder.) Reid, projecting a mild, professorial excitement, is shown approving one candidate—a man who in fact co-authored Money’s original study—for amputation of his right leg. The next patient, however, a soft-spoken woman seeking double amputation, leaves Reid “flabbergasted.” “To be rid of one leg is, you know, okay,” he reasons. “To be rid of two is a disaster.” Later in the film, Smith also declines to perform a double amputation, saying, “From a surgeon’s point of view, it’s really asking a bit much.” A third doctor, a psychiatrist, disagrees.

Michael First’s study establishing the term body integrity identity disorder arrived just a few years later. First’s efforts to add BIID as a diagnostic category to the DSM-5 were ultimately unsuccessful, and in 2016 he joined researchers in Switzerland to propose that the condition be included in the WHO’s ICD under the name body integrity dysphoria.

Leading researchers now see BID as multifactorial—with psychological, social, cultural, and neurological components. Recent studies also affirm a long-standing view that people with BID are neither psychotic nor suffering from delusions. Dr. Gianluca Saetta, a cognitive neuroscientist at the university ETH Zurich and a clinical psychologist, whom I spoke with last summer, is investigating the relationship between BID and atypical mechanisms in the brain. In a 2020 imaging study of sixteen men who sought amputation of their healthy left leg, Saetta and co-authors found atrophy in the right parietal superior lobule, a region of the brain associated with the conscious representation of the size and shape of one’s body. There was additional atrophy in the left premotor cortex, believed to be involved in integrating sensory information regarding one’s limbs. While the causation is unclear, both the degree of desire for amputation and the frequency with which subjects engaged in “pretending behaviors” (using crutches or a wheelchair, for example) were shown to correlate to an increase in these atrophies. Saetta is also researching methods to help those with BID cope, including the use of virtual reality technology to provide them with an experience of their body as they would like it to be.

According to Saetta, as yet unpublished research suggests that psychotherapy may relieve dysphoria in some cases. And though data remains scarce overall, at least two studies and some anecdotal evidence suggest that amputation could lead to remission of symptoms in cases like Robert’s. All of the researchers I spoke with agreed that BID requires further study.

Nonetheless, Michael First believes that some patients should have access to healthy-limb amputation and says that many physicians, if acquainted with all the relevant information, would agree. First, among others, has cited the concern that patients may injure themselves if they aren’t able to alter their bodies through the medical system. Richard B. Gibson, a U.K. scholar of bioethics and medical jurisprudence, has become a minor hero of the online BID community by making a case for “therapeutic amputation” in his doctoral dissertation, published in 2021. Gibson interrogates basic medical precepts, rejecting the Aristotelian teleology that prioritizes “health” over the autonomy of the individual. When I spoke with Gibson, he pointed out that medicine already makes allowances for operations that do not have a “nice, clear benefit” to the patient, such as kidney donation. “Surgery’s complicated; medical interventions are complicated,” he said. “The justifications we use aren’t always ‘It will make that person better.’”

Robert and I were headed to another lookout when the xylophonic chirps of Ed Sheeran’s “Shape of You” sounded from his phone: his new boss was calling, from the more populous town a few hours south to which Robert, his wife Brit, and their teenage son would move in a little over a month.2 Revelstoke had changed too much, grown too posh; their trailer park home could now pay for a much bigger place elsewhere.

Robert had held many jobs before and after his short time in the train-conducting program: baggage handler, sanitation worker, cable guy. But driving a service van for locals with mobility issues, some of whom were amputees, had stuck. He would have the same job with benefits down south, plus union protection and a retirement plan. (In his imagined future as an amputee, Robert would continue working—driving in some capacity.) Though hopeful about the move, he dreaded leaving the doctors with whom he felt familiar, even as they frustrated him; ones he returned to knowing they would let him down.

Robert described his condition as a “medical issue” that is “majority mental,” but stopped short of calling it an illness or a disorder. In conversation he often mirrored my wonder, and sometimes my confusion, reverting always to the certain knowledge of what he felt.

His first memory of experiencing BID was of sitting in a sandbox with one foot folded under his butt, at age five or six, and of the feeling of relief that bloomed as he noticed the empty space where the rest of his left leg had been. He baffled his parents with drawings of himself as an amputee, and at around eight bound his left leg up to the thigh with a roll of tensor bandage. By age fourteen, he was certain that everything below the four-inch mark above his left knee absolutely did not belong there. When he fractured that same leg playing football in ninth grade in his hometown of Ottawa, a confused doctor believed he was heeding Robert’s wails to “just take it off!” when he cut away the cast he had just finished setting.

Robert’s parents had divorced when he was a toddler, and he lived with his mother, who was bipolar and whose alcohol and drug problems made her an unstable and often abusive presence. With little supervision and few friends, Robert found it easy to investigate his longings. In the aftermath of the football incident, he found his way to an Ontario Medical Supply store, looking to experiment with plasterwork. Starting with a basic thumb spica splint—from the forearm to the tip of that digit—he worked his way up to a full-leg cast, fashioning joints from dismantled knee braces. More than crutching, bandaging, or tethering his left foot to his backside to create a pseudo-stump, casts and prosthetic overlays approximated the desired sensation of constraint. When he lacked the resources for a full-leg plaster—fiberglass rolls got pricey—he would settle for casting his left arm: the sense of immobility was at least a faint proxy of what he sought. Though he only broke one more bone, he sported casts with the regularity of a stuntman in the wrong line of work. After high school, drifting between odd jobs, rec leagues, and drug circles, Robert discovered how easily people accepted whatever story he told about his foot, his wrist, his arm; how remaining on the periphery meant telling fewer and less elaborate lies. He began working as a long-haul mover around age twenty, and some dabbling in cocaine led to eighteen months strung out on crack. He quit abruptly, resulting in two brutal weeks of withdrawal. Living with BID, he told me, was worse.

Shortly after we left the train tracks, I ventured to share a growing impression: that Plan B was more like a place Robert went in his head than a thing he might actually do. “A way out when it’s really bad.”

He heaved, and went silent. Another of the puffballs seeding the thin, golden air drifted through my window, and we turned onto one of the arterial roads that flowed upward from the center of town and into the surrounding Columbia Mountains. “It’s the pain, it’s the what-ifs,” he said finally. “That’s where I think I’m chickenshit. That’s where some of the depression comes in, you know? This is what I need so badly, but I can’t make myself do it. Does that make me crazy or does that mean I keep coming to my senses?” A sob caught in his throat, not for the first time that day. “That’s where the suicidal tendencies come in,” he said. “Like maybe it would just be easier to swallow a bunch of pills and not wake up.”

He told me he had made two suicide attempts in his twenties, before he knew his feeling of overcompleteness to be anything more than a private agony. The second was in 1999, when he was twenty-eight. A planned move to British Columbia had unraveled, and Robert was suffering from what those in BID circles refer to as a wave—an acute surge of intrusive thoughts. He downed a bottle of Tylenol in the back of his 1975 van. Waking up the next day, KC at his side, he decided to head back west, try again at a new life.

After marrying Brit in 2004, Robert vowed to stop casting and threw out most of his prosthetics. A West Coast native who rotated through HR and office admin positions, Brit was Robert’s first serious girlfriend and his devoted protector. But despite his horror of discovery and his hatred of lying to Brit, Robert soon resumed making the casts and prosthetics that he would use to hobble around the house in private, hiding them in the joists above the basement ceiling of their first place in Revelstoke.

Around 2007, Robert found his way to web page after web page on what was then known as BIID. Eventually, he worked up the nerve to call Michael First, who during an hour stuck in Manhattan traffic gave Robert an informal diagnosis. According to Robert, First also passed along details of a Yahoo discussion group and connected him with someone known as the Gatekeeper, an anonymous figure—possibly one of multiple such figures—who brokers amputation surgeries in foreign countries for a fee of what was then ten thousand dollars. (First denies connecting any patient with the Gatekeeper, and also denies sharing details of any web forum.) Robert said that in a brief interaction, the Gatekeeper warned him against the transfemoral, above-knee amputation he was set on, urging him instead to consider a knee disarticulation, which leaves the femor and patella untouched and makes the use of weight-bearing prosthetics easier. But that wasn’t what Robert was after. And the process struck him as too shady, even if he’d had that kind of money. The amputation he sought would be secured through “proper medical channels,” as he would describe it to me later; the freedom he imagined as its result would release him from a lifetime of secrecy, shame, and lies.

At thirty-eight, depressed and in and out of work, Robert filed for bankruptcy; shortly after, his father died of pancreatic cancer. By the afternoon in 2012 when he called Brit to tell her he’d taken a fall climbing into his Chevy Tahoe—a fiction—the couple’s relationship was suffering. For the first time since they’d married, Robert worked quickly in the back of his truck with fiberglass rolls, cast padding, and stockinette bandages, covering his left leg from foot to hip before making the drive back home.

After two months on crutches, Robert sat Brit down in their kitchen to tell her about his BID. He remembers mutual tears, bewilderment. At some point, their six-year-old son emerged from his bedroom and joined in the sobbing, though he wasn’t told the cause. The months that followed were dark; the more Robert shared, the darker they got. That first night, Brit had promised to support him even if she didn’t understand, but hearing Robert talk more openly about seeking amputation made her fierce. To avoid fighting they came to avoid the subject.

Robert told his family physician the truth around the same time. According to Robert, his doctor limited his help to shrink referrals and cast-removal services. He started seeing a psychiatrist an hour away, in Salmon Arm, but in the winter the drive was unmanageable. Their sessions lasted twenty-five minutes and generally ended with a new scrip to treat his depression. Over the years, Robert tried Trintellix, which made him puke, then Abilify, which helped but gave him a hand tremor. He hated taking pills and resented the prescriptions, seeing even in their upsides a misapprehension of what ailed him, and a barrier to its cure. Having imagined finding allies—or at least one clinician, God willing one surgeon—with the nerve to help forge a new path, Robert sometimes regretted telling anyone at all. The humiliation so often outweighed whatever good it had done.

About five months before we met, Robert put himself in a cast for the first time in the ten years since opening up to Brit. What was supposed to be a private outlet, lasting only a few days while his wife and son were visiting family in Vancouver, became a six-week affair, complete with a tall tale about breaking his arm. The relief wasn’t what he’d hoped, and the sense of deceit greater than he’d anticipated. He was grateful, though, for the bout of compartment syndrome that followed the cast’s removal, giving his story a ring of truth: for weeks Robert’s left arm and hand remained painfully swollen, a phase of supposed healing that didn’t look healthy at all.

Now the ongoing failure of Robert’s Plan A seemed well summarized by his tagline on the web forum where I first found him: “Searching for a legitimate solution through proper medical channels for over a decade.” Robert knows of people who have forced their own impairments—via acids, ethanol shots, and most often by a method involving prolonged immersion of the unwanted limb in dry ice until necrosis sets in and a surgeon is forced to amputate. But something about these methods, as with the Gatekeeper route, deters him. Before we visited the tracks, Robert had taken me past Queen Victoria Hospital, the dough-colored Seventies facility where he had long imagined waking up after a safe, medically sanctioned amputation, rising from his bed, and crutching over to the window. There he would “look out at my mountains,” he’d told me during our first conversation, “the way I’m supposed to be.”

Late in the afternoon, we parked by an elbow bend in the river that splits Revelstoke in two. In the distance we could see the three bridges that led into town: first the Big Eddy, then the railroad, and finally the suspension bridge, the one Robert drove across when he first arrived, overwhelmed by a sense of belonging, of being home.

Robert had just declared himself to be “pro-choice,” in response to the question of whether people should be allowed to do whatever they want with their bodies. I asked what that meant, how he drew the limits around personal autonomy. With Robert, I’d noticed, there were tough ones, tricky ones, funky ones, and sticky ones. Abortion? “That’s a sticky one,” he said. He supported the right to terminate pregnancies in cases of rape and for the health of the fetus or mother, but he felt that simply not wanting a baby was not reason enough. He mentioned a miscarriage Brit had suffered, then asked to step out for a smoke.

“This is actually a nasty little section of river,” he said. We looked from the mountain-cut horizon, the sun poaching in the sky, to the currents twisted in a scrum at our feet. “You go swimming in it, it will take you away.” Robert began to describe the bitterness that had taken hold of him after a 2017 accident on his garbage route led to a hernia operation and a nerve condition called inguinodynia. Since then he’d experienced near-constant pain in his groin and right leg—the one he wants to keep, onto which he habitually shifts his weight. “If I’d had help within the first five years of coming out this wouldn’t have happened,” he said. He wouldn’t have been hurling trash cans as an amputee. “I’d be much more able-bodied—I’d be sit-skiing, I’d be into adaptive sports. Now I can’t even throw a ball with my boy.” The injury had temporarily made amputation seem less urgent. “But very shortly after, it was: Yeah, I can still do this. I still need to be the way I need to be.” He mentioned the death of a friend earlier that year. Time ran shorter each day: “I want to enjoy my life. I gotta be on the other side of this.”

I was reminded of my conversation, some weeks before, with a man—whom I’ll call T—who posts on the forum Robert frequents. A fifty-year-old foreign national who lives in the Pacific Northwest, T returned in 2005 to his home country, which has a public health care system, to incite the amputation of his lower left leg via dry-ice immersion. T recalled the admitting nurse’s disgust at his apparent self-mutilation, the disappointment of the surgeon who wanted to save his leg. After two months’ recovery, he returned home with a fabricated story about a car accident, received a prosthetic leg, and resumed work at his white-collar job. Only his wife knew what he had done. The thoughts that had tormented him from early childhood—“a continual need, a continual feeling that things were not right”—were gone. “BIID”—T used the condition’s former name—“is a weighing of mental harm versus physical harm,” he told me. “I have been physically harmed, but it’s minuscule in comparison to the mental harm. It was worth ticking that box.” Worth it with the exception, perhaps, of having alienated his only child, now in his late teens, who eventually learned the truth. “He went from having the dad with the cool robot leg,” T said, “to the dad who mutilated himself.”

At our last stop of the day, in Centennial Park, Robert and I watched the odd hiker hump by and disappear into a thatch of woods. He spoke of the web forum where I’d found both him and T; in Robert’s opinion, it had become too chaotic. “That whole site is scary,” he said, “I feel they’re my people, but it’s uncontrolled.” He worried especially about someone who online went by the name of Lexie, a twenty-eight-year-old trans woman who had co-founded the site, and who in recent months had forced the amputation of her left foot, also by the dry-ice method. Neither of us had cracked a window when Robert cut the engine, and we sat strangely bound by that decision as heat piled up inside the car. Robert had interpreted Lexie’s relative silence following her amputation as a sign of remorse.

In fact, I’d talked with Lexie when she was four weeks post-op, a month before my arrival in Revelstoke, and she’d told me that she was overjoyed with the result, saying specifically that she had “not a single regret.” But a complex frustration seized Robert as he spoke. “I don’t think she did it for the right reasons,” he blurted out. “And I’m so guarded about that opinion.” He said he wasn’t sure Lexie’s condition should rightly be called BID—she’d longed to be disabled since childhood, but only recently determined precisely how. Robert would revise his thinking in the months that followed, but he maintained vehement disagreement with Lexie’s decision to not tell her doctors and loved ones about her BID. “There has to be a right way,” he said, growing heated. “My dignity, my integrity—pardon the pun—my morals, my values … ,” he trailed off. “If you’re going to do something, talk about it, do it in a controlled way, in a controlled environment, seek the proper professional help.” I noted that doing all of those things had not necessarily helped him. After a beat, he replied in the form of a tangent, a retreat into some more private debate.

The following day, Brit and I spent her lunch break—she was working for a local non-profit—sipping fruity Starbucks drinks in the shadow of Mount Revelstoke. We stood facing each other under a thick carpet of cloud, near a trailhead overlooking Mounts Begbie and Macpherson. In answer to a question about what had first attracted her to Robert, Brit called him forthright and down-to-earth. “I’m not fancy. I’m not glamorous by any means,” she said. “I respect honesty.”

Small and round in stature, with butter-blond hair cut to her chin and a friendly, direct affect, Brit told me that the roles she was raised to play—“the mother figure, the nurturer, the protector, the caregiver”—had always suited her well enough. She had agreed to speak to me because Robert believed it might help people. Brit mentioned accompanying him to a recent appointment for his nerve condition, with a new pain specialist whom they both found haughty and dismissive. When the doctor said that Robert needed to treat his depression before undergoing radiofrequency ablation for the pain in his groin, Robert, who had disclosed his BID during the intake, went stony. Brit became irate: “I just looked at him and I said, ‘Everybody has some form of depression and anxiety. Nobody’s perfect.’ And he’s like—he just looks at me. And I said, ‘His pain is not because he’s depressed.’ Basically I was about to tell him to fuck off, but I bit my tongue.”

The act of looking featured heavily in Brit’s recollections. The suggestion was that of various encounters turning on the power of her gaze to reveal, to indict, to protect. In our conversations, that gaze and its certainties were missing only from the night Robert told her about his BID. “We were at home, a different place down on Front Street,” she said. “I just remember him saying, ‘There’s something I gotta talk to you about, it’s kind of way out there.’ I said, ‘Okay, well, tell me. I’ll listen, I won’t react.’” A moment passed. “I just remember sitting there, just taking it in. Like, am I dreaming? Is this real?”

Her memory of Robert raising the possibility of an underground amputation sometime in the months that followed was more clear: “I looked at him and I said, ‘And how would you get all that money? We can barely pay our rent.’ I was just like, ‘There’s nothing wrong with your limbs, any one of them. Why would you, in God’s name, think to have one of them removed? And then you’re going to try to live life like that? How are you going to explain that to your son?’” A ghost rain was passing around, behind us, speckling our limbs, the back of our necks. “We got into an argument. I couldn’t understand. And I don’t think I wanted to, to be honest.” I asked her if that had changed. “I guess I don’t even think about it? Sometimes I feel scared to even ask. Because I don’t want him to do anything. It would make his life go backwards. He would fall backwards.” I noted that Robert seemed to see it the opposite way.

“Yeah,” she said. “And I can see him going into a bigger depression.”

Brit gets regular massages for neck pain related to scoliosis and disk degeneration. She doesn’t tell anyone about the fights between Robert and their son, in which she intervenes and often comes away bruised, or about Robert’s BID. They still don’t really talk about it themselves. Each separately mentioned a close family friend with diabetes who recently underwent the double amputation of her feet. Robert had been forced to confront his envy when the friend became one of his service-van patrons. I asked Brit if he had shared those feelings with her. “No, but I was wondering,” she replied. “I thought in my head, I wonder if he knows she had no option, she was suffering, physically suffering. That’s a medical reason. For me, I don’t think his is a medical reason.”

“Medical meaning it involves physical pain in the body, not so much psychic pain?” I asked.

“There was infection. I saw her feet,” she said. “I see Robert as different … I know that it’s—I don’t know, psychological?” Hikers were trickling back into the lot, dazed and veiled with dew. “I see it as black and white, but I know there’s gray,” she went on. “It’s just hard to change your mind. I’m fifty. That it’s not happening to me doesn’t mean it not’s happening; it doesn’t mean it’s not the truth. But it’s hard to understand.”

I asked how she would feel if amputation were an option and Robert decided to go through with it. She paused. “I don’t know, probably shocked,” she said. “Probably angry. Supporting him doesn’t mean that I have to like it, or agree with it.” I asked if that meant that she would ultimately accept it. “Yeah,” she said. “But it would take, like, a while.”

On the drive back into town, I noted the tattoo on Brit’s right calf, a heart with her son’s name inside it—a fortieth birthday gift to herself. Robert’s aversion to tattoos had kept her from considering one on her arm, or anywhere more conspicuous. She laughed at the thought of it. “He’d divorce me!”

As we pulled out of the motel parking lot a few hours later, Robert seemed distracted and tense. He’d downgraded my dinner invitation to a quick home tour and visit. As Led Zeppelin’s “Black Dog” ground to a finish on the radio, he said that we’d need a cover story to explain my presence to his son. I said I couldn’t agree to a false pretense. “We’ll just say you’re a friend from back East,” he replied, turning brisk. “He probably won’t even come out of his room.”

Robert and Brit’s trailer was easily the nicest within view, trimmed by a lush stretch of lawn, built-out porches, potted petunias, and a raised garden bed where Brit planted carrots in the spring and Russian garlic in the fall. I was thinking about how much remained unsaid between husband and wife, about the silent partner in every close relationship. Brit had surprised me when I mentioned Robert’s casts, specifically the one he was wearing when he first told her about his BID. “Yeah, ’cause he broke his leg,” she’d replied quickly. “Right up to his hip.” She made a sound of wifely forbearance. “Yeah, that was silly.”

Before taking me into the house, Robert brought us to the eight-by-eleven cedar shed where he did all of his shop work, and where he hid the casts and prosthetics that had provided his only reliable source of relief. Boxes were piled up along each wall of the narrow space, leaving barely room for the two of us. Speaking in hushed tones and making quick, nervous movements, Robert pulled out some of his choice creations—including a knee joint made from a truck cap clamp and cantilever bicycle brakes—handled them briefly, and shut them away. I thought of Brit telling me, a few hours earlier, that the shed was Robert’s happy place, where he went to play music, tinker, “just move stuff around, do stuff, do something in his own element.” She had laughed her merry, knowing laugh. “And I’m like, Good, stay out of my hair!

“There’s not much to see in here now,” Robert said, looking around. “It’s all packed up for the move.” On our way out, he pulled back some coats hanging behind the door, revealing a set of plaster and fiberglass casts, shadow limbs strewn in a pile. After a moment he let the coats drop and threw the shed door open, his discomfort an invisible, ushering hand. Earlier he had described the nights he spent worrying about a snowfall so intense it would collapse the shed and lay his remaining secrets bare.

Inside their railroad-style home, many of the family photos and personal touches had already been removed. A small country kitchen sign hung by the kitchen sink; a vacuum cleaner stood inside an aproned-cow coverlet. Among the few books on a console shelf were titles by the comedians George Carlin and Steven Wright, and the televangelist Joel Osteen. Their son was sealed in his bedroom, playing video games with the curtains drawn, loud chortles and the odd cry—“You’re a fucking psycho!”—sounding through the door.

Brit and Robert chatted easily, talking up their dream house, worrying about the mortgage coming through. They took turns scooping a testy, salt-colored Havanese named Abby off her feet: Brit held her belly-up, like a baby; Robert perched her in the crook of his right arm. At one point Abby was made to perform her best party trick: “You tell him!” said Brit, plunking the dog on the ground and pointing at her husband. “Go on, tell him!” Assuming the position despite her advanced age, Abby sent a tear of opinionated barks in Robert’s direction.

On our final afternoon together, I rode in the back of the twenty-seat, wheelchair-accessible van Robert had driven three days a week for the past year, since his predecessor was fired for refusing a COVID shot. Robert had done his part there, he told me, but the third jab would be his last. “I don’t like shots,” he shouted over his shoulder. “I’m not one for needles.”

Robert was animated with his passengers, in his neon safety vest, black sneakers, and Ottawa Senators hat, securing and unsecuring scooters and riders, cheerfully reminding patrons to pay the man his two bucks. He gave no sign of the groin pain he said was always with him, a never-ending kick in the nuts.

Early in the afternoon, we stopped to kill some time beside an immaculately groomed baseball diamond. The sun was mellow, and Robert somewhat sobered. Upwind and slightly upslope from me, he made constant pivots to keep his cigarette smoke from blowing in my face. He spoke about an upcoming appointment with the psychiatrist in Salmon Arm, whom he hadn’t seen in three years. He hoped this time she would help him with “a plan of action,” a series of steps culminating in surgery.

I had been matching Robert’s edging steps away from me with a creeping advance, afraid of his voice becoming too quiet for my recorder, aware that the novelty of my presence and my interest was wearing thin. I asked if Brit knew about his suicide attempts. “Um, I don’t—I think she might be aware of one of them? I’m not sure. I really haven’t talked about that part of it.” He wasn’t sure, either, if she knew the extent of his depression. “I think she’s aware there is something big bothering me. I felt vulnerable yesterday when you two were talking!”

“I got the impression that she doesn’t know as much as I thought,” I said.

“I don’t discuss it with her all the time,” he replied. “It’s not a normal conversation to have with your spouse.”

I told him then what Brit had told me: that she believed that an amputation would only make things worse. Robert stilled, almost visibly withdrawing into himself. “That’s where the stigma around disability comes in,” he said quietly. “It’s definitely a complex scenario. Not just for me, for everybody involved.” We needed to go, he added, or we were going to be late.

Before leaving Revelstoke I returned alone to Track Street, where roach-colored boxcars sat in long rows along the rails, some open and piled high with rocks. There again were the aspens, and on the other side of the tracks, sprays of reed grass, of tansies, clover; blue chicory hinted at the forest behind me. The scene had an enclosed, forsaken quality, its stillness precluding not just forward-charging freight trains but movement of any kind. But I had heard the whirring rhythms and siren drone of the trains each night, just as the motel clerk warned I would; just as Robert did. Walking along a set of tracks, I thought of what Robert had said about a trespassing charge—one more barrier, as he saw it, to enacting Plan B.

During one of our conversations that week, I’d noted to Robert how often, in describing himself, he’d used the word “chicken.” “Chickenshit,” he’d corrected. “You asked the question yesterday: ‘Why haven’t you done it yet? Most people this desperate would have done it.’ I’m chickenshit, you know?” In my wondering if his planning was perhaps a form of release, Robert had heard an indictment, confirmation of a gnawing fear. The mind has its own habits of constraint, of inversion and foreclosure.

We would speak again in the days before Christmas, the family settled in their new home. Robert had convinced the Salmon Arm psychiatrist to read Richard B. Gibson’s dissertation, and took heart in her response. The bigger house? Perfect. His new shop? Complete with a woodstove. They had finally entered the middle class, found comfort in fitting in. Yet Robert was drinking more, crying more. He sat alone in his shop at night, wishing he could enjoy these clear improvements. He found toughest the days he transported a diabetic amputee to and from dialysis, a woman to whom he’d offered encouragement through the loss of her left leg. Envy and shame formed an old, stubborn taunt: not normal, not normal, not normal. He thinks of the trains, and the spot he’s picked out in this new place, where the tracks run straight and flat. He games out its distance from the nearest hospital, the ambulance station. He passes by it in moments of need, as he’d once returned to Track Street, where I stood for a dizzying twenty minutes, turning from the wildflowers to the train axles and back again, gripped above all by a sense of vacancy, and of trespass. If Robert’s torment was not as impenetrable as it had first seemed, the question of its redress still formed a vast and bare terrain, one I could only wander, noting the rough textures underfoot. I can picture Robert there, pacing between the tracks; pausing to rest, then rising on both feet. Drawing and redrawing the lines he will and won’t cross in the name of being free.

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August 2013

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