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Clinical and Theoretical Parallels Between Desire for Limb Amputation and Gender Identity Disorder

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Desire for amputation of a healthy limb has usually been regarded as a paraphilia (apotemnophilia), but some researchers propose that it may be a disorder of identity, similar to Gender Identity Disorder (GID) or transsexualism. Similarities between the desire for limb amputation and nonhomosexual male-to-female (MtF) transsexualism include profound dissatisfaction with embodiment, related paraphilias from which the conditions plausibly derive (apotemnophilia and autogynephilia), sexual arousal from simulation of the sought-after status (pretending to be an amputee and transvestism), attraction to persons with the same body type one wants to acquire, and an elevated prevalence of other paraphilic interests. K. Freund and R. Blanchard (1993) proposed that nonhomosexual MtF transsexualism represents an erotic target location error, in which men whose preferred erotic targets are women also eroticize their own feminized bodies. Desire for limb amputation may also reflect an erotic target location error, occurring in combination with an unusual erotic target preference for amputees. This model predicts that persons who desire limb amputation would almost always be attracted to amputees and would display an increased prevalence of gender identity problems, both of which have been observed. Persons who desire limb amputation and nonhomosexual MtF transsexuals often assert that their motives for wanting to change their bodies reflect issues of identity rather than sexuality, but because erotic/romantic orientations contribute significantly to identity, such distinctions may not be meaningful. Experience with nonhomosexual MtF transsexualism suggests possible directions for research and treatment for persons who desire limb amputation.

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Notes

  1. Most authorities believe that the sine qua non of adult transsexualism/GID is the desire to live as a member of the other sex, not the desire to surgically alter the body. For example, the International Statistical Classification of Diseases and Related Health Problems (World Health Organization, 1992) describes transsexualism as

    A desire to live and be accepted as a member of the opposite sex, usually [italics added] accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex. (p. 365)

    Similarly, the Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) states that

    Adults with Gender Identity Disorder are preoccupied with their wish to live as a member of the other sex. This preoccupation may be manifested as an intense desire to adopt the social role of the other sex or [italics added] to acquire the physical appearance of the other sex through hormonal or surgical manipulation. (p. 577)

  2. A few studies have reported prevalence rates of sexual arousal with cross-dressing ranging from 10 to 36% in ostensibly homosexual MtF transsexuals and gender-dysphoric males (Bentler, 1976; Blanchard, 1985; Blanchard, Clemmensen, & Steiner, 1987; Freund et al., 1982; Leavitt & Berger, 1990). It seems probable, however, that most of the ostensibly homosexual persons who reported sexual arousal with cross-dressing were not genuinely homosexual but were, instead, heterosexual or bisexual persons who either deliberately misrepresented their sexual orientation in order to appear more “typically” transsexual (Blanchard, 1985; Walworth, 1997) or who were pseudohomosexual, i.e., aroused by the autogynephilic fantasy of sex with a male partner but lacking a genuine erotic preference for the male somatotype (for a discussion, see Freund, 1985). Leavitt and Berger (1990), for example, reported that 36% of a group of MtF transsexuals who reported an erotic interest in male partners gave a history of sexual arousal with cross-dressing. However, 30% of participants had been married to women and 38% gave a history of sexual attraction to women, suggesting that many were bisexual, not homosexual. Similarly, Lawrence (2005), in a large survey of MtF transsexuals, found that most persons who reported sexual arousal to cross-dressing or cross-gender fantasy before SRS and who were characterized as homosexual based on their reported patterns of sexual partnering or attraction before SRS were arguably either bisexual (having been married to women or having had multiple female sexual partners before SRS) or asexual (having had no sexual partners before SRS).

  3. I will argue that the desire for limb amputation can be understood as a direct outgrowth of paraphilic sexual arousal/attraction to the idea of being an amputee and, consequently, that all or nearly all participants in the study by First (2005) can be understood as being apotemnophiles, whether or not they identified as such. However, even if one assumes that only a subset of First's participants were apotemnophiles, these data still confirm the predictions of the erotic-target-location-error model.

  4. I would prefer to use the term sexual orientation in reference to paraphilic sexual interests, but that term typically is used only to denote a tendency to choose sexual and romantic partners of the other sex, the same sex, or both sexes. Consequently, I will use the term erotic-romantic orientation to denote the tendency to be erotically attracted to, and to fall in love with, any of a broader range of erotic targets.

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I would like to thank Paul L. Vasey for reviewing an earlier version of the manuscript.

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Portions of this article were presented at the 3rd Annual International Body Integrity Identity Disorder Conference, New York, New York, June 2003, and at the 30th Annual Meeting of the International Academy of Sex Research, Helsinki, Finland, June 2004.

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Lawrence, A.A. Clinical and Theoretical Parallels Between Desire for Limb Amputation and Gender Identity Disorder. Arch Sex Behav 35, 263–278 (2006). https://doi.org/10.1007/s10508-006-9026-6

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