Apotemnophilia: Two Cases of Self-Demand Amputation as a Paraphilia

Author(s): John Money, Russell Jobaris and Gregg Furth

Source: The Journal of Sex Research, Vol. 13, No. 2 (May, 1977), pp. 115-125
Published by: Taylor & Francis, Ltd.
Stable URL: http://www.jstor.org/stable/3811894
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The Journal of Sex Research Vol. 13, No. 2, pp. 115-125 May, 1977

Apotemnophilia: Two Cases of Self-

Demand Amputation as a Paraphilia
JOHN MONEY, RUSSELL JOBARIS AND GREGG FURTH*

The findings in two cases show that self-demand amputation (apotemno-

philia) is related to erotization of the stump and to overachievement despite
a handicap. The apotemnophiliac obsession represents an idee fixe rather
than a paranoid delusion. It may be conceptually related to, though it is not
identical with transsexualism, bisexuality, Miinchausen syndrome, and
masochism. As with most paraphilias it undoubtedly occurs more fre-
quently, if not exclusively, in men. The two patients related apotemnophilia
to recalled experiences of childhood which were necessary but not sufficient
for a causal explanation. The precise etiology of the condition is not known,
and there is no agreed-upon method of treatment.

Introduction

The relationship between sexual attraction and amputated limbs is a

little known phenomenon. The phenomenon was brought to public
attention in 1972 with a series of letters published in the forum section of
the September and October issues of the magazine Penthouse. At first
glance, it may have seemed that these letters were pranks. However, a
student, himself a paraphiliac for self-amputeeism, found that the let-
ters were indisputably bona fide. The writers, like himself, proved to be
erotically obsessed with getting themselves amputated, and some had
succeeded.
There is, in the nomenclature of the paraphilias, no nosological term
for the syndrome of erotic obsession or fetishism for amputated limbs or
digits. In accordance with the tradition whereby a philia is assigned its
appropriate Greek prefix, the name for this syndrome is apotemnophi-
lia, literally meaning "amputation love."

Supported by USPHS Grant #HD-00325 and by funds from the Grant Foundation,
New York.
Leo Wollman, M.D., kindly made available the records of his examination of one of
the patients.
* John Money, Ph.D., Professor of Medical Psychology and Associate Professor of
Pediatrics at Johns Hopkins University and Hospital, Baltimore, Maryland 21205.
Russell Jobaris, B.A. Research Assistant, Psychohormonal Research Unit, Johns
Hopkins University School of Medicine and Hospital, Baltimore, Maryland 21205.
Gregg Furth, Lecturer in the Department of Human Development, California State
University - Hayward.
115

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116 JOHN MONEY, RUSSELL JOBARIS, AND GREGG FURTH

In the history of the psychohormonal research unit (PHRU) of Johns

Hopkins Hospital, there have been two cases of men voluntarily apply-
ing for amputation of a limb. Apotemnophilia in both cases was mani-
fested as an obsessive desire to have one leg surgically amputated above
the knee.
This paper deals with the phenomenology of the syndrome in the two
cases. Summarized case histories were made of the psychohormonal
records. For Case 1 these records consist of notes taken during patient-
initiated telephone calls and written correspondence. Medical notes
made available by a physician in the home town confirmed the patient's
general good health and gave evidence of his active attempts to pur-
posely injure his left leg so as to necessitate its amputation.
For Case 2, psychohormonal records consist of patient-initiated mail
correspondence, transcripts of taped interviews with the patient on
visits to the PHRU, and follow-up written correspondence. The man's
general state of health was good and noncontributory to the findings of
the case with the exceptions of his right foot being two sizes smaller
than his left, and his right calf muscles appearing somewhat atrophied
and hence thinner than the left.

Case 1

Referral Data: The patient began his correspondence with the PHRU
by way of a telephone call. He stated that he was a "cryptic transsex-
ual," with the clarification that his problem did not involve his genitals
but rather his leg. He was aware of the program in the PHRU of
counseling qualified transsexual candidates. Considering himself to be
qualified, his purpose for calling was to obtain a referral to any surgeon
who would amputate his left leg. He was informed that this would not be
possible, and having been assured of a confidential and nonjudgemental
consultation, he continued correspondence by way of telephone calls and
mail over a period of four years.
In the course of identifying himself, he gave the impression that he
had been referred by a well-known psychotherapist and a physician who
was active in the care of presurgical transsexuals. In contacting these
professionals it was found that, although they were acquainted with the
patient, they had not actually referred him. It was confirmed that for
three years prior to his communications with the PHRU he had engaged
in group and private sessions with the psychotherapist. The physician's

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 APOTEMNOPHILIA: A PARAPHILIA 117

notes confirmed the patient's various problems, especially in reg

his active attempts to self-inflict injury to the left leg.

Eroticism: The patient succinctly expressed his presenting com

in the following written statement:

Since my 13th year, my conscious life has been absorbed, with varying i
in a bizarre and prepotent obsessive wish, need, desire to have my leg
tated above the knee; the image of myself as an amputee has as an eroti
(each one different) accompanied EVERY sexual experience of my life:
homo-, and heterosexual, since, and beginning with, puberty.

He reported a secondary symptom of overachievement, to whi

ascribed an erotic component, related to seeing amputees perfor
despite their handicap. He would fantasize on the achievement a
a leg amputee walking with crutches more than on the possibili
having that person as a sexual partner. Photographs of seminude or
fully dressed amputees served as a visual aid during masturbation.
There had been two separate occasions when the patient was able to
have homo- and heterosexual experiences with amputees. The first
entailed homosexual relations with an older male amputee. Although
he would have preferred an adolescent male amputee, he expressed
satisfaction with this experience. One specific reason he cited that
contributed to his pleasurable experience was the asymmetry of the
man's body. Coitus with a female amputee was not as pleasurable, and
he proved unable to ejaculate with her.
He considered his heterosexual experiences as being generally unsat-
isfactory. His first marriage, when he was in his midtwenties, ended in
annulment after two years. He married again in his early thirties. The
marriage lasted twelve years, during which time he had his first and
only child, a daughter. The marriage ended in a legal separation. He
retrospectively described this marriage as "turbulent."
Between marriages, he actively engaged in what he termed "promis-
cuous homosexual activity." His partner preference was for adolescent
males. He verbalized his homosexuality in saying "I'm not turned off to
girls, but boys turn me on more strongly." He recalled first having been
sexually attracted to boys younger than himself when he was 14, but he
had maintained nothing more than a platonic relationship with them.
At this age his self-demand amputation desires were firmly established.
The patient himself perceived a relationship between his gender

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118 JOHN MONEY, RUSSELL JOBARIS, AND GREGG FURTH

identity and apotemnophilia:

There are scattered occasions when I "feel like a woman," viscerally, in terms of
body image, and in these situations I loathe myself- it makes me very appre-
hensive. Somehow this seems linked with the amputation fantasy. I would
rather this [amputation] than lose the penis which would mean that I would be
like a woman . .. My entire erotic activity now consists of trying to make "real"
the fantasy that I am an amputated homosexual adolescent, for in possessing my
stump I can, concurrently, possess my penis.

Self-Amputation: The patient was serious in his quest to "make real

the fantasy." Having received negative response from the medical
profession for a proper surgical amputation, he began contemplating
various accidents which could injure his leg enough to require an
amputation. He finally settled on inserting a tapered stainless steel
stylus into his left tibia; using a hammer to drive it into the porous
structure of the bone. Upon removal of the stylus he attempted to infect
"the fistula" with facial acne pus mixed with nasal and anal mucous,
thereby hoping to produce osteomyelitis. When his leg showed signs of
serious infection, he reported to a hospital. During his stay nobody
challenged his pat story of an occupational accident. Much to his dis-
may, however, the infection was cleared up and he was released.
He continued the attempt to get rid of his leg by placing a tourniquet
around his left thigh and numbing the area with ice and injections of an
anesthetic. The pain eventually became unbearable and he stopped.
There were other attempts with the stylus, and he ritualized the pro-
ceedings into daily insertions of it into a new fistula proximal to the first
one.

He informed a physician of his action. The physician responded by

providing remedial care to the infected area of his leg and provisions
antibiotics. The physician, aware of the patient's psychological status,
was reported to be unable to help further.
Reflecting on the seemingly masochistic aspect of his actions, he said:

The most disturbing aspects of these acts is that I am inflicting injury on

myself-I do not like this. Pain is related to one's appetite for non-pain. The
pain involved is trivial, and it is the result of these actions, not the anguish of
the process, which is my goal.

The patient also disclosed his fear of social disapproval and loss of
insurance benefits if it was discovered that his amputation was self-
induced.

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 APOTEMNOPHILIA: A PARAPHILIA 119

Etiology: The patient expressed the notion that possible etiolo

determinants for his apotemnophilia extended back into his early
hood and familial interpersonal relationships. Prominent in his rec
tions was a domestic accident which occurred when he was two yea
old. His left leg and foot had been severly burned when he capsized
of boiling oatmeal, rendering him unable to walk for almost a year
He supplied a large amount of biographical information concer
his early family life, which can be characterized as showing co
psychopathology. He considered his mother to have been highly over
tective of him throughout his childhood, and he closely identified
her. She, too, had been severely burned by fire in another domestic
accident when he was five years old. Regarding the father-son relation-
ship, he recalled that his father was overbearing, sex repressing, remote
and above all hypercritical of his close association with the mother. He
incorporated the traumatic effect of the father in a self-justification for
his behavior by writing:

Most of my emotional unrest accrues from the fact that I am acting out an
overwhelmingly forbidden wish-like to be a girl-savagely forbidden. It is
almost as if I will be establishing my male identity by means of the amputation.
I could get trapped in a kind of surgical masochism . . . in trying to acquire
characteristics more apt to secure my father's love or at least sympathy. Homo-
sexuality at present is my retreat from overt masculine functioning. One of the
anticipated "pleasures" (for me) of being an amputee is the possibility of a
genuine experience of identification....

In addition to apotemnophilia, he had a rubber fetish and had a homo-

sexual interest in adolescent youth. He disclosed that not only had he
been affected by a psychopathological family but that he also had an
adult older brother who was a chronic nocturnal enuretic and a divorced
younger sister who was a lesbian.

Rehabilitation: The patient was discharged from the armed forces in

his early twenties as "undesirable," because he requested a release from
service to enter psychotherapy. He claimed to have received no benefit
from this.
He graduated from college and had been employed as a design engi-
neer in a technical institute for several years. He became dissatisfied
with his job as he felt he could perform the same work as an amputee,
despite the concomitant handicap. His ambition focused on a new career
of helping amputees-and himself as a voluntary amputee-to achieve

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120 JOHN MONEY, RUSSELL JOBARIS, AND GREGG FURTH

and possibly exceed the capabilities and performance of normal persons.

He began taking introductory courses at a university which he would
need in order to take up prosthetics as an dccupation. Financial obliga-
tions prohibited him from quitting his former job altogether. He ex-
pressed satisfaction in having embarked on a new career which would
allow him to express his obsession in a more personally and socially
acceptable manner.
He said that the non-judgmental approach taken in counseling served
to lessen his anxieties regarding his identity and his guilt for self-
inflicting injuries to his leg.
His follow-up correspondence mentioned some attempts to contact
other well-known sexologists and psychiatrists for application of,
amongst other programs, LSD therapy. It is unknown if he ever entered
any such special therapy programs. In the final follow-up report, he still
had his leg and was working. He expressed more of a feeling of depres-
sion regarding apotemnophilia as he could neither resolve it by self-
amputation nor by psychotherapy.

Case 2

Referral Data: The patient wrote to the PHRU and identified himself
as a graduate of a major state university. He stated a personal interest
in the areas of homosexuality and fetishism. In the course of his re-
search he had come across, and initiated a correspondence with, a group
of people who voluntarily desired amputation of their limbs. He asked
for any available references on the phenomenon of self-demand amputa-
tion. He did not disclose in this introductory letter that his interest in
self-amputeeism was personal as well as investigational.
In his first visit to the PHRU the patient expressed that his purpose in
coming to a noted gender identity clinic was to discuss possible ways in
which his own obsession for surgical amputation of his right leg could be
dealt with. He did not actually preclude the possibility of some form of
therapy which could relieve him of his obsession, but he made it clear
that he wanted a referral for a surgical amputation.
There was no self-induced injury to his leg requiring a medical work
up. Follow-up was maintained for three years.

Eroticism: The patient stated that while he was engaged in homosex-

ual or heterosexual intercourse, or masturbation, he would fantasize

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 APOTEMNOPHILIA: A PARAPHILIA 121

either an actual amputee that he had seen, or a picture of an am

or himself as one. These fantasies were not an absolute prerequ
his sexual arousal. At times he had sexual intercourse without intrud-
ing thoughts of amputeeism.
His amputee fantasies did not invariably entail erotic imagery.
Rather, there was a strong nonerotic imagery of overachievement which
provided the erotic turn-on, namely, in visualizing an amputee engaged
in some activity which required a considerable effort to surmount a
physical handicap. In the patient's own words:

Basically, it's the event or occurrence of compensating or overcompensating,

achieving, going out and doing things that one would say is unexpectable [as an
amputee]. Like water skiing or snow skiing and doing these different activities.
I think the achievement is then very stimulating....
There is sexual satisfaction from the amputation and doing things and partici-
pating in different events. There would be orgasm in going to bed with someone
else and masturbating. But, that is not why one would want to have an
amputation, because he wants to have a higher or greater orgasm. You can
fantasize on that but I think I have fairly good sex and orgasm. When one is
having an orgasm, he's fantasizing doing these other events. And these other
events are the ones you want to get into and participate as you fantasize the ones
which brought about the orgasm.

This patient also reported having used pictures of naked and dressed,
male and female amputees as a visual aid during masturbation. He
enjoyed the visual turn-on of males more than of females: "I have sex
with men and women. I enjoy sex with men more, so I am homosexual."
He recalled having had satisfactory heterosexual intercourse until the
age of nineteen, at which time he engaged in his first homosexual
experience with an older man.
The patient had had no sexual experience with amputees. He ex-
pressed a considerable interest in doing so, saying that the most direct
sexual turn-on would be rubbing and fondling the partner's stump and
seeing the asymmetry of the body. This would be a realization of his
recurrent fantasy during masturbation and when having heterosexual
intercourse. His fantasies while having sex leading to orgasm with a
nonamputee male, often were of amputees functioning in walking and
moving activities using crutches and not wearing a prosthesis. While
discussing his feelings about having sex with an amputee, he referred
only to having sex with male amputees.
In response to the questioning of his own sexual behavior if he were to

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122 JOHN MONEY, RUSSELL JOBARIS, AND GREGG FURTH

obtain an amputation, he said:

Sex would be more satisfying with a woman if I was an amp'. I think I would enjoy sex as
much and probably more. Maybe the people I'm having sex with would be turned off by
an amp', but there are others who would like it. When I'm in bed with a woman, I
fantasize. If I was an amp', I wouldn't need to - so I would enjoy sex with women more.

Self-Amputation: The patient's numerous attempts to get a referral

for surgical amputation of his right leg had failed. He expressed his
frustration in writing "I still believe it is interesting to note that
transsexuals can obtain sex change (operations), people obtain cosmetic
surgery to meet the norms of society, and I cannot obtain my fulfillment
legitimately. ... I believe legitimate avenues should be available for
this 'living' process."
As a matter of researching alternate ways to cut of his leg, he made
contact with several people who had been successful in getting an
amputation. He contacted them by way of their 'underground' ads in the
personal columns of community newspapers. He found their methods of
achieving amputation, by way of contrived injuries, to be too brutal for
his liking. He wanted only a stump, and not the pain to produce it.
Contact with other apotemnophiliacs did not lessen his own amputa-
tion obsession, for they expressed great satisfaction with their amputa-
tion stumps. Many wished that they had been amputated at a younger
age.

Etiology: The patient cited particular childhood episodes to which he

attributed a possible psychogenic basis for his apotemnophilia. He was
born with a minor talipes (clubbing) of the right foot, causing a faulty
gait, for which his father severely criticized him. When this condition
was surgically corrected prepubertally, he received no positive rein-
forcement for his perfected walking ability. His first thoughts of having
a leg amputation began when he was eleven years old. He recalled
having amputation fantasies by the time he was fifteen, and being
involved with amputees, because there was an amputee who worked
with him.
When he was in his late teens, the patient suffered a fracture of his
right leg while he was at work. "I enjoyed that," he said. "But the pain
was so bad that all I could do was laugh. I didn't mind the pain at all. I
didn't mind the cast. In fact, I rather enjoyed this experience of cast,
crutches, and means of mobility."
The patient perceived a possible relationship between the trauma

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 APOTEMNOPHILIA: A PARAPHILIA 123

focused on his right leg and apotemnophilia in stating:

I guess the relationship of everything happening to my right leg is the

that pulled me toward it. . . . I'm thinking also of my life, about my rel
with my father, etc., how that went. I think a lot of it was, and this mig
way off, you were born and you were not the one wanted in the family
that has something to do with it too .... And maybe, the element of my
rejection of me through the leg, is just his open action of regret and hatre
for even coming.

The patient was a young man at the time of his father's death, w
had no effect on his obsession for amputation.
He considered two additional factors which could possibly have
tributed to the onset of apotemnophilia. The first factor was reli
literal sense of offering his leg as a sacrifice of atonement, based
early childhood rearing as a devout church member. The second f
was a need to be self-restricted, especially in sexual partner pre

Maybe what I'm doing is searching for an avenue out of homosexuality

realizing that most amputees, one way or the other, do get married. Ma
I'm doing is searching for an avenue to run away from homosexuality . . .
through amputation.

The patient's siblings, male and female, were described as being very
tight about religion and sex, and nonaccepting of him. But none was
described as having any major psychopathology.

Rehabilitation: When last heard from, the patient reported satisfac-

tion in his professional career, and had earned an excellent reputation
for the quality and success of his volunteer work with the handicapped.
He was still attempting to find a surgeon who would amputate his leg.
He stated that his desire was as strong as ever, and the only way he
could be at peace with himself was through the amputation. There was
no mention of any further attempts to seek psychotherapy.

Discussion

The apotemnophiliac patient finds no surgical tradition within wh

he can expect to obtain the service he requests. Therefore, if he arra
a self-mutilation or amputation and presents himself for follow-up c
he has little choice other than to be secretive about the origin of
injury. In this sense, the apotemnophiliac may, in the emergency r

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 124 JOHN MONEY, RUSSELL JOBARIS, AND GREGG FURTH

or clinic, share something in common with the patient with Miinchau-

sen's syndrome. The latter patient is obsessed with self-inducing symp-
toms repetitively for the sake of being a patient. By contrast, the
apotemnophiliac induces his symptom himself for the sake of being an
amputee, and for the sake of erotic arousal, and usually does not repeat
self-injury.
The idea of self-amputation meets so seldom with consensual accept-
ance by other people that it might readily be stigmatized as a paranoid
delusion. It is, in fact, an idee fixe rather than a delusion. Judging by
the two cases of this report, the apotemnophiliac, unlike the paranoic,
recognizes that other people do not accept his own idea concerning self-
amputation.
One may think that apotemnophilia is synonymous with masochism.
In the two cases reported, there was no history of the erotization of pain
itself, but only of the healed, amputated stump. Thus, apotemnophilia,
because it involves injury and pain, bears a peripheral relationship to
masochism, but is not identical with it.
Several of the paraphilias can be classified in pairs, the one being
reciprocal to the other, as in sadism/masochism, or exhibitionism/voy-
eurism. The same reciprocity occurs in apotemnophilia, in that it may
be both self-directed (autoapotemnophilia) and other-directed (alloapo-
temnophilia). Less frequently, a patient may be obsessed with persuad-
ing a partner to be amputated. More commonly, he searches for a
partner among men and women victims of involuntary amputation.
Pictures of amputees, revealing the amputated limb, with or without
covering, may become his pornography or visual erotica. To involuntary
amputees it comes as a surprise that there are some people for whom
their deformity makes them a primary erotic choice, instead of a reject.
Though neither wanted an alteration of his gender status, the two
patients reported perceived a relationship between amputation and
transsexualism in the sense that both involve self-demand surgical
alteration of the body. Transsexualism has been known to be associated
with self-mutilation and self-castration (Money and DePriest, 1975).
Transsexualism is one manifestation of a transposition of gender iden-
tity from masculine to feminine, or vice versa. A lesser degree of
transposition was evident in the two cases, in that bisexualism was a
feature of each; and the amputee impulsion could be interpreted as a
way of preserving the penis and masculinity. In nonerotic aspects of
gender identity/role, neither patient projected a public image of effemi-
nacy.

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 APOTEMNOPHILIA: A PARAPHILIA 125

The two patients reported happen to be males. All of the paraphi

occur either predominantly or exclusively in males. The correspond
on amputeeism in Penthouse (see Introduction) was male-initiated.
However, since Penthouse is a predominantly heterosexual male
oriented magazine, it is also possible that the occurrence of female
apotemnophilia has not yet been uncovered. If it does exist, then as in
the case of other paraphilias, it almost certainly occurs less frequently
than male apotemnophilia.
Both patients cited a nonerotic imagery of masculine overachieve-
ment as providing an erotic turn-on in their amputee fantasies. The
over-achievement imagery primarily consisted of amputees overcoming
the adversity of a handicap. This reversal of an aversive element would
fit apotemnophilia into the schema of other paraphilias, as it is the
quality of all paraphilias to transcend the aversive or forbidden, in the
manner of a counterphobia. In apotemnophilia therefore, the fear of los-
ing one's limb and struggling with a handicap is metamorphosed and
eroticised into an impulsion to be amputated and to emerge superior or
supernormal in achievement.
The present status of informed consent in medicine with respect to
investigative procedures and the threat of malpractice charges, makes it
unlikely that there will be an early answer to the question of whether
self-demand amputation is an effective form of therapy in apotemnophi-
lia or not. The answer will have to come from patients who have
engineered an amputation for themselves and then are generous enough
to volunteer themselves for post-surgical study.

Reference

MONEY, J., AND DEPRIEST, M. Genital self-surgery: Relationship to transsexualism in 3

cases. Journal of Sex Research 12: 4, Nov. 1975.

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