Acrotomophilia, Sex and Disability:
New Concepts and Case Report

John Money
Kent W. Sirncoe

From the Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, The John Hopkins University and Hospital, Baltimore, Maryland 21205, USA.

ABSTRACT:
Sexual disability is commonly thought of as being secondary to another condition or disease. It may also be a primary disability of the peripheral genitalia, or of their mental governance in the brain/mind. Paraphilias are an example of the latter. Acrotomophilia is a paraphilia that pertains to amputation and amputees. Apotemnophilia pertains to self-amputation. Each of these little known syndromes offers a challenge to diagnosis and to sex therapy.

     Sex and disability is a subspecialty in the-practice of sexual medicine with a brief history. Its growth has been haphazard rather than systematic, and it lacks a cohesive theory of what constitutes either ability or disability in sex. Theoretically, it is biased more or less toward attributing sexual disability to sources that are extrinsic rather than intrinsic to the sexual system itself. One consequence has been the neglect of sexual disability as related to birth defects of the sex organs. Similar neglect has been accorded to the primarily mental sexual disabilities, the paraphilias, one of which, acrotomophilia, is the subject of this paper.
     A paraphilia is a condition occurring in men and women of being compulsively responsive to and obligatively dependent Upon an unusual and personally or socially unacceptable stimulus, perceived or in the imagery and ideation of fantasy, for optimal initiation and maintenance of erotosexual arousal and the facilitation or attainment of orgasm ^1 [from (Greek, para, beyond, amiss, or altered + -philia, love]. Paraphilic imagery may be replayed in fantasy during solo masturbation or intercourse with a partner. In legal terminology, a paraphilia is a perversion or deviancy; and in the vernacular it is kinky or bizarre sex. Antonyrn, normophilia.
     Among the forty-odd clinically identified paraphilias, acrotomophilia and its reciprocal or antipode, apotemnophilia, are both only recently named.^1,2,3 Acrotomophilia [from Greek, akron, extremity + tome, a cutting + philial is the one of the paraphilias in which the eligibility of the partner is contingent upon specific bodily features or stigmata. In acrotomophilia, the specificity is that the partner must be an amputee. An acrotomophile is erotically excited by the stump or stumps of the amputee partner, and is dependent on them for erotosexual arousal and the facilitation or attainment of orgasm. In apoterpnophilia the amputation is an obsession that applies usually to the self. It may apply also to the intact partner. In the absence of self-demand surgery, an amputation may be self-induced, as in an apparent hunting accident. The amputation is then completed professionally, usually in a hospital emergency room.

CASE REPORT
     The following self-report was received, unsolicited, from a member of a self-help network of amputation paraphiliacs, known among themselves as devotees. It was addressed to John Money.

     A member of our group has passed along copies of several of your articles pertaining to paraphilias, particularly with regard to amputees. I would like to offer my view of the development of my own amputee fascination, offer some comments about the theses which you are presenting, and give additional observations. I am forty-seven years old, born in January, 1935.
     I am a customer support engineer with an electronics manufacturing company. My education includes masters degrees in electrical engineering and business and a half-completed masters degree in counseling psychology. 1 have been married for twenty-five years to a non-amputee. We have four children ranging from thirteen to twenty years old.
     I am the eldest of two sons. My father was a railway mail clerk and my mother was a secretary. Dad was an easy-going extrovert, mother an uptight introvert. My sense of my upbringing was one of caring but with little affection. Early IQ tests put me at the genius level. I am definitely an achiever, but I can not reca11 being pushed to achieve. It was more a matter of striving far an elusive approval to which i have sometimes come close but have never achieved.
     Some of my earliest memories (preschool) are of girl friends and of being a helpful person. I consider myself thoroughly heterosexual. I have six close acquaintances who are openly homosexual and have no difficulty in working and interacting with them. Friends and acquaintances consider me to be a secure and kind individual.
     At about age six I experienced my first Orgasm. I became aware that if I would hang on a street sign or a rope or pole in the school gymnasium, I could stimulate a pleasant, throbbing sensation in my groin. Bending my legs up at the knees would facilitate the production of the sensation and I sometimes fantasized that I was hanging without legs. The orgasms did not include any ejaculate, and I do not recall that an erection was involved
     My desire to be a helpful person drifted into wanting to help the handicapped 1 sensed that society in general thought that there was some wrong with handicapped people, and I fantasized being able to be a friend and helper. The girl in the wheelchair in the movie Heidi particularly impressed me and I imagined her as one of my girl friends.
     A thoughtless and unfeeling first grade teacher discovered me to be colorblind and punished me on that account. A situation that had become unknown to me, but had suddenly become a handicap. I identified more strongly with the handicapped and wanted more interaction. My desire for interaction and my images of handicaps were very broad and general through grade school. I had Saturday afternoon dates to go to the movies with many of my female classmates. In seventh grade I had a deaf girl friend.
     Also during seven, grade I had a circumcision. Only today as I real1y consider my life and upbringing do I realize how important this event was. My father was never circumcised. It was my mother’s idea that I should be. As I came out from under the ether, I had to urinate. I had nothing to do it with! My penis was gone! For several anxious days I really feared that I had no penis, because I was bandaged so tightly. When I was finally unbandaged, I had a penis, but the head was deformed and remains so to this day. I have a great excess of tissue on the under side at the base of the glands.
     Seventh grade had been in the grade school. Eighth grade was part of the high school. I quit dating. I was a fat kid; slow and clumsy. In addition I was late developing and really hated to appear nude in the shower room. Gym class became hell. I once faked a sprained ankle to escape running the low hurdles. When I was "wel1," I got a special session with the coach which was even worse. I thought that if I was an amputee, I would not have to run the hurdles. I began to practice being an amputee with my leg tucked up in my pants. Sometimes I made a "peg" from a board and would walk around the basement as an amputee. I decided that I could live as an amputee. Losing a leg would beat losing my penis.
     Once when practicing to be an amputee, I leaned against the workbench and the magic feeling appeared in my groin. I could facilitate an orgasm by pretending to be an amputee! This became my sole method of masturbating.
     After eighth grade I escaped from gym class by taking R.O.T.C. One day during my freshman year in high school, I was working with the sound system on the stage. I was forty-two feet above the stage sitting on a metal grate which provided adequate support but left me with the feeling that I was levitating. Purely from the fright and tension and without an erection, or any thought of masturbating, I had my first wet orgasm. I messed up my R.O.T.C. trousers. Then I realized what the sensation in my groin had been all these years.
     My self-confidence was increasing and I began dating again toward the end of my freshman year. Slowly I was transfering the fantasy of being an amputee to having an amputee partner. I would make paper dolls of magazine pictures of Marilyn Monroe and other celebrities, and bit by bit amputate them until they were limbless torsos. By my senior year I had done quite a bit of dating and had a steady girl friend. Never had I encountered a real amputee of my own age.
     In college I manually masturbated while fantasizing amputations of some form or another upon a female acquaintance. Even through four years no female amputee appeared. immediately after graduation in 1960, I married the girl that I had been dating for two years.
      In many regards, my wife is the perfect mate. We share much in the way of education, interests, and activities. Our sex life, though not exuberant, seemed adequate. After four years of marriage, I confessed my arousal at the thought or the sight of an amputee. She took it very hard and it was not discussed for another six years.
      Limerent pairbonding has not fully occurred for us. I enjoy cuddling with her and we have shared the same bed for twenty-five years, but copulation is seldom. This is of course a great burden. At times she has agreed to pretend to be an amputee, but it has been done with such reluctance and hesitation that there is no fun in it for me. At my insistence the attempts to pretend stopped. Without something to feel "guilty" about now, she seems to have difficulty becoming aroused. It seems that for her, "love below the belt" must be attended by some feelings of guilt.
      It was not until 1970 that I discovered that I was not alone in my preoccupation and fantasy. Some pictures had been crudely torn out of some prosthetics manuals at a local university. Realizing that the fascination was primarily sexual, I scouted the porno bookstores trying to get a clue. Nothing to be found. The only "respectable" girlie magazine that I even saw was Playboy. I missed the entire "Monoped Mania" in Penthouse when it first appeared. It troubled me greatly that 1 felt no lust and some disgust for the centerfolds that the magazines presented when I knew that I could fall in lust instantly with a woman missing even the smallest fraction of a digit.
      You write of two amputee related paraphilias, self and partner. I would suggest that there is a third form. Certainly for myself and for some of my devotee acquaintances, the desire to possess an amputee has led us to fantasize that we are Pygmalion or Professor Higgins sculpting our own Fair Lady. The act, rather than the result becomes the imagery at the moment of ejaculation. My personal imagery can go any of the three ways, though it is predominently of the latter form due to a usual lack of an amputee partner.
      This is a great problem for a devotee if an amputation should be necessary for a close friend, or if someone has lost one or more limbs to mayhem. For me the mutilation of a teenager by a drunken merchant seaman was the breaking point. He cut off her arms with an ax and left her for dead. She was found and recovered. I found the mutilation to be both horrifying and exceedingly exciting. My wife refused to talk with me about it and I had nowhere to turn. Previous visits to counselors had been most unsatisfactory. My ultimate response to this episode has been to learn all that I can about amputee-oriented paraphilias for my own relief and possibly so as to make it easier for others to live with theirs.
      With a substantial effort I have made the acquaintance of and developed a friendship with several amputee women. Several of the relationships are platonic for a variety of reasons, but a couple of them are carnal. I have had the pleasure of being friend, confidant, mentor, and benefactor to a number of people whom I find physically delightful. I have been a lover to two especially exciting amputees.
      In intercourse with my wife, my imagery is most usually of a fresh amputation of her. Sometimes the imagery is of one of the real amputees. When masturbating, my imagery can be either of being an amputee myself, or of visiting a new amputation, either "real" or "pretend," upon any female acquaintance. In intercourse with real amputees, they themselves are sufficient with no other imagery.
      I presently correspond with fifty-five devotees. Some are married to amputees. Some have never encountered one. All but two are of northern European extraction (one is Latin, one is negro). Some have had relationships with amputees that have not provided whatever they desired, and they now self-direct their fantasy and become "wannabees." Some of my "wannabee" acquaintances have already caused the loss of some fingers and toes. One man, fairly well known within the fraternity, has shot off his right leg with a shotgun. His only regret now is that he did not do it years sooner. Not only is he now the amputee that he always wanted to be; he is also a transvestite and practices being the woman he always wanted to possess.
      About a fourth of my devotee acquaintances are sharply focused upon the stump. They have fairly tight specifications about what it should look and feel like. Two of my contacts are strongly attracted to scars; the more severe, the better. Approximately a fourth of the crew really turns on to asymmetry that a single amputation brings. This bunch does not turn on to bilateral amputees. Three of these acquaintances judge the desirability of the amputee by the aesthetics of the remaining limb, tending to ignore the stump beside it, or in fact preferring hip disarticulates, hemipelvectomies, or shoulder disarticulates. The remainder of us seem to be catholic in our appreciation of the abbreviated body. For my own part, I find that my excitement is keyed mainly to the quality of the presentation that an amputee makes. Crippled and broken is a turn-off. Vital and alive drives me wild.
      I have encountered only one person who has latched onto the handicapped condition of his amputee wife. He is a borderline personality type and I do not consider him to be a devotee in the sense that is understood within the fraternity. He does what he can to keep her away from the world. He does not interact with other amputees or devotees. His sense of power comes from her seeming helplessness. All the rest of the devotees that I know who have established significant amputee contacts have worked to improve the independence and quality of life of their special friends and lovers.
      If I could go back to a particular point in my life with the knowledge and wisdom that I have so far gained, I would be thirteen again. I would stick my left knee under a passing freight train and become the amputee that 1 was practicing at that age. Being the amputee, I would not have transferred my desire to the opposite sex and would have avoided many years of pain, frustration, and exhaustion. Now for the amputee interactions that I desire, I spend a great effort sublimating primal urges into beneficial acts. It is pleasing, but exceedingly tiring. If I were the amputee myself, I would still be a helpful, giving person, but I would not be wearing myself out with sublimation.
      Now it is too late for any significant amputation to be of any relief for me. I do have the desire for amputee partners, and being an amputee myself would not change that now. Thus I am not a "wanna-bee." However, I would allow others to become amputees upon demand. At least two of my correspondents, one man and one woman, seriously desire to have a leg amputated. They are both very firmly focused on the loss of a single limb, and do not seem to turn on to the process. If I could, I would allow them to realize their respective long-term dreams.
      On the other hand, there are some in the "wannabee" ranks who are into the process instead of the result. No single amputation could satisfy them for long. One correspondent has already amputated more than eight fingers or toes. Eventually he would be limbless if he could be. I would not be a party to any amputations for him.
      Amputee fascination has been viewed from a number of seemingly negative viewpoints. Typically, the devotee or hobbyist is described as someone lacking in social development or underlying psychology. Certainly there have been some among the ranks whom we freely recognize as weirdos. They are a small, but unfortunately too obvious, minority. Conversely, the devotees whom I have met interact easily with life and others. Most of us consider that we have something extra rather than something less to offer. To berate us for our ability to feel genuine lust for another who is in some manner abbreviated, is a real waste of a great interpersonal energy. I want better understanding of amputee fascination to make it easier for devotees and amputees to get together and to feel pleased about the totality of each other without any unnecessary overlookings. Some amputee/devotee pairings have fared quite well in this regard.
      An additional feature of the amputee/amputation paraphilias is that they have strong social as well as sexual components. I would guess that none of the other paraphilias can come close in terms of being twenty-four hour fantasies. Most of my devotee contacts report fantasizing all forms of activities with amputees on an around-the-clock basis. Wining and dining may rightly be termed extended foreplay; but sailing, skiing, and backpacking? Most amputee fantasy seems to be of very complete social relationships as well as genital sexual contact. This can make reality difficult to deal with when a devotee finally encounters an amputee and discovers that only the outer surface matches the fantasy partner.
      All my "devotee" friends are focused in "limb loss," 100 per cent. Only a quarter of my contacts are sharply focused upon a specific form of stump. Most assume that stumps remain after amputations, but I think that some of the "stump focused" characteristics of acrotomophilia have been over-stressed. Personally, I find fondling stumps to be as exciting as fondling breasts, but I am neither particular about the form of the stump nor even that it be present. Some of the brotherhood prefers no stump or stumps at all. Those sharply focused in apotemnophilia are quite specific about the stump they wish to own, however. I assume that this last group is the most often seen by the helping professions and I would offer that they have probably skewed the perceptions of the practices of amputee fascination, particularly with regard to the role which stumps play in the fantasy and real love-making.
      Amputee fascination in whatever form it takes is a great burden to the bearer. It is a real relief to find that one is not alone. It is an even greater relief to find that you are looking at the phenomenon as a scholar seeking understanding rather than as a practitioner attempting to "fix" something. We appreciate the work that you are doing. Please keep it up. If I may be of service, please let me know.

DISCUSSION
      The foregoing information is consistent with what one learns from individual patients in the clinic. Thus it may be accepted as phenomenologically authentic. Etiologically, there is still no completely adequate explanation of the genesis of acrotomophilia in particular, nor of paraphilias in general. The available evidence points to a developmental onset in late infancy or early childhood, long before the onset of puberty, probably as a response to the thwarting and warping of normophilic development. ^1 Current forensic and clinical evidence indicates a higher prevalence in males than females.
      The report illustrates well the longevity of acrotomophilia namely its persistence throughout adult life, as is the rule with all paraphilias. An adult may cope with acrotomophilia by learning to live with it and capitalizing on its virtues. This solution, as the writer of the report indicates, is feasible if the acrotomophile is able to establish a reciprocated, limerent relationship with an amputee partner. The relationship is then a consensual one, and the paraphilia functions in a benign and not a pathological fashion. The logic of consensualmatching does not, however, prevail in all cases. For example, the acrotomophile obsessed with the amputation of an intact partner typically finds that his paraphilic obsession is not reciprocated. The same applies also to an acrotomophile who is also an apotemnophile obsessed with self-amputation either alone, or with the amputation of the partner as well.
      Another option, in cases of reciprocal mismatching, is a program of treatment first used in the united States in 1966.^4 It combines hormonal (antiandrogenic) and counseling therapy, the latter preferably involving also the partner. The hormone used in the united States is medroxyprogesterone acetate (Depo-Provera, Upjohn). In Europe the corresponding hormone is cyproterone acetate (Androcur, Schering A.G.). Dosage and other details of treatment are published in Money.5

REFERENCES

1. Money, J. Lovemaps: Clinical Concepts of Sexual/Erotic Health & Pathology, Paraphilia, and Gender Transposition in Childhood, Adolescence, & Maturity. New York, Irvington, 1986.

2. Money, J., Jobaris, R. and Furth, G. Apotemnophiiia: Two cases of self-demand amputation as a paraphilia. Journal of Sex Research, 1977; 13:115-~25.

3. Money, J. Paraphilias. In Handbook of Sexology (J. Money and 1[(. Musaph, eds.). Amsterdam-London-New York, Excerpta Medica, 1977.

4. Money, J. Use of an androgen depleting hormone in the treatment of male sex offenders. Journal of Sex Research, 1970; 6:165-172.

5. Money, J. Love and Lovesickness: The Science of Sex, Gender Diffrrence, and Pair-bonding. Baltimore, Johns Hopkins University Press, 1980.