Despite having been described for more a century, there is no understanding of the origin of the attractions, desires and behaviors of devotees, pretenders and wannabes (DPW's). Devotees are non-disabled people who are sexually attracted to people with disabilities, pretenders are non-disabled people who act as if they have a disability by using assistive devices and wannabes actually want to become disabled, sometimes going to extraordinary lengths to have a limb amputated. Two cases are presented in an effort to understand the psychology of DPW's and to suggest one psychologic concept - that of Factitious Disability Disorders - that may explain not only the obsession to be with disabled persons, but also the desire to pretend to be disabled and even the compulsion to become disabled. Also presented is a combined cognitive-behavioral approach to modify DPW's obsessions and compulsive, intrusive, illegal and sometimes self-injurious behaviors.
Amputees; paraphilias; sexual deviations; factitious disorders; Munchausen's syndrome
Devotees, pretenders and wannabes: Two cases of Factitious Disability Disorder.
Richard L. Bruno, Ph.D.
The advent of the Internet has brought to the attention of people with disabilities individuals who had heretofore largely remained hidden: Devotees, pretenders and wannabes (DPW's). Devotees are nondisabled people who are sexually attracted to people with disabilities, typically those with mobility impairments and especially amputees; Pretenders are nondisabled people who act as if they have a disability by using assistive devices [e.g., braces, crutches, and wheelchairs] in private and sometimes in public, so that they 'feel' disabled or are perceived by others as having a disability; Wannabes actually want to become disabled, sometimes going to extraordinary lengths to have a limb amputated. (1)
While the most common Internet bulletin boards, chat rooms and web sites are for male devotees of female amputees, others are for male and female, heterosexual and homosexual, plaster cast, crutch, leg, back and neck brace and even orthodonture DPW's. (1,2) An America Online bulletin board posting entitled "Bunion Love" requested "photos, videos, or correspondence dealing with gals [having] deformed/crippled feet, or toe/toes amputated . . . or who have severe bunions on their feet. The more severe, the better."
However, the Internet is by no means providing the first information on DPW's. Since the late 1800's the medical literature has described men and women who are sexually attracted to amputees, those who limp, or use crutches, braces and wheelchairs, as well as individuals who pretend to be or who actually want to become disabled. (3-13).
DPW's interest in amputation has been the most frequently documented. Cases of men and women who are attracted to amputees, who themselves want to have amputations and who have successfully become amputees have been described since 1882. (3,10,11,14-17) Money (14), who has focused on the interest in amputation, coined the terms apotemnophilia (achieving sexual fulfillment by fantasizing about being an amputee) and acrotomophilia (requiring amputee partners, real or in fantasy, to achieve sexual satisfaction).
In 1983, Dixon (18) published results of the first survey of male acrotomophiles, individuals who were customers of AMPIX, a company providing stories about and pictures of amputees. The 195 acrotomophiles were college educated, professional, white males, 75% of whom had been aware of their interest in amputees by age 15. Although 55% of respondents had dated amputees and 40% had had sex with an amputee, only 5% had married an amputee. Fifty-three percent of the respondents had pretended to be an amputee (11% having done so publicly) and 71% had fantasized about being an amputee, indicating that the majority of devotees were also pretenders and wannabes.
Consistent with these data is a recent study of 50 acrotomophiles by Nattress. (3) Again, subjects were college educated, professional, white males, 96% of whom had been aware of their interest in amputees by their teens. In this sample, 41% had been married to or lived with an amputee, more than 43% had pretended to be amputees and 22% desired to become amputees.
On psychometric testing, the 50 acrotomophiles were found on average to have high scores on self-esteem and intuitive thinking, but low scores on social interest, emotional stability and personal relations. The low scores were referred to by Nattress as "problematic behavior tendencies." Such tendencies have become a concern of people with disabilities since devotees do demonstrate problematic behaviors, ranging from collecting names, addresses and phone numbers of disabled persons, to obsessive and intrusive phone calls, letters and e-mail to persons with disabilities, attending and sometimes organizing disability-related events, lurking in public places to watch, take covert pictures of, talk to and touch disabled persons, and even engaging in predatory stalking. (1,3,19) For example, over 85% of Nattress' sample agreed with the statement, "If I see a female amputee at a shopping mall I will follow her," and over 57% agreed that, "If I see a female amputee in a store I will try to talk to her."
In spite of more than a century of description, the origin of DPW's attractions, desires, and behaviors has yet to be determined. The following cases are presented in an effort to understand the psychology of DPW's and to suggest a single psychologic model - that of Factitious Disability Disorder - that may explain not only the obsession to be with disabled persons but also the desire to pretend to be disabled and even the compulsion to become disabled.
Case 1: Devotee/Pretender
Ms. D. is a 48 year old white female who presented when her husband was evaluated for Post-Polio Sequelae (PPS). (20) (N.B.: Some demographic information and circumstances in the cases have been changed to protect the patients' anonymity.) She had been married for ten years to her husband, a 55 year old polio paraplegic who walked with forearm crutches and two knee-ankle-foot orthoses. She presented crying and agitated after reading an article in New Mobility magazine entitled "Devotees of Disability." (1) "I am all of this," she said tearfully, "I can't live with this inside of me any longer."
Ms. D. described herself as a devotee and pretender. She had been interested in men who had mobility impairments since she was a teenager. The first evidence of her interest was in high school when she dated a boy who had a severe limp, "He was very self-centered, not very likable, but I dated him anyway. I wanted to hold him, to feel his limp as we danced, to touch his hip and leg." Although they kissed, she reports not being very sexually aroused by him and was interested, not in having intercourse, but in being with him and potentially seeing his affected leg.
When Ms. D. went to college she would occasionally sketch men who were naked except for leg braces and crutches. She dated a number of non-disabled men in college and had her first sexual experience with someone who was not disabled, which she described as "very satisfying and orgasmic." However, she was constantly looking for disabled men. While visiting a museum she saw a man her own age walking with long leg braces and crutches, "I became flushed and flustered. I followed that poor man throughout the museum." She became despondent when she could not figure out a way to meet the man.
In graduate school she dated a teaching assistant who limped as a result of an amputation, "He would walk around in summer with loafers and no socks. I could not take my eyes off the cream-colored artificial foot I could see above his shoe." She reported not being attracted to this man but dated him anyway, saying, ""I wanted to hold him, to feel him limp and his artificial limb. I so very much wanted to sleep with him so I could see his artificial leg." Ms. D. suggested that they have sex but the man said he had never had intercourse and that he would not sleep with the patient because of he was an amputee.
Shortly thereafter, a singles magazine was mailed to her post office box. In it was a personal ad from a man using a wheelchair. Ms. D. answered the ad and arranged for a date. She met the man at his home and they had dinner at a restaurant, "He was obese and I think mildly retarded. But I was so excited to be seen in public with him." They went back to the man's home and began kissing. "Incredibly aroused" at first, her ardor quickly cooled. She excused herself, retired to the bathroom and masturbated to orgasm by imagining herself having sex with the man, "At the time I thought it was so strange. He was in the other room, but he did not excite me. Yet the thought of being with him, and especially seeing his wheelchair in my mind, is what brought me to orgasm." They did not continue to have sex nor did they meet again.
After finishing her graduate degree she began working for a large corporation. She continued to occasionally date non-disabled men and had sex that included orgasms. However, she continued to search, obsessively at times, for disabled men. Two or three times a year her interest would surface for up to a week, triggered by accidentally seeing a man with a limp, on crutches or using a wheelchair, "I would follow the man down the street or through a store, never able to figure out how to strike up a conversation." Occasionally, she would see a disabled man in the company of a non-disabled woman and feel, "sad and lonely. I would think to myself, 'I would love you more than she does. I could take better care of you than she can'."
For several days after seeing a disabled man she would drive to shopping centers on the way home from work and pass the handicapped parking spaces, try to catch a glimpse of another disabled man. After several days of unsuccessful searching she would become dejected and despondent, angry at herself for "giving in" to her compulsion.
Pretending. Ms. D. rose to a position of responsibility in her company and traveled for at least one week each month. On one trip she noticed a wheelchair behind the front desk of the hotel, "It struck me that I could get a wheelchair while I was in a city where no one knew me and roll around as if I were disabled. Flushed with excitement, my heart pounding in my ears, I went to a surgical supply store and rented a wheelchair."
She drove to a mall, parked and pulled the wheelchair out from behind the front seat, "I slowly and laboriously pulled myself into the wheelchair, letting my legs drag. I was eager for people to watch me, to see that my legs couldn't move. I pushed myself into the mall, again looking to see if people were watching me. I was full of emotion. I felt whole for the first time in my life."
As she pushed herself through the mall, she realized that what she wanted was to encounter a disabled person, preferably a man. Not finding a disabled person, she returned to the car and reversed the same laborious process, dragging herself and then the wheelchair into the car, hoping that she would be watched. She returned to the hotel and researched the locations of other malls. Every night after her business meetings she drove to a mall "and became the disabled person I wanted to be. I was obsessed with being out in my wheelchair, to find someone who had a disability 'just like me'."
After several days she parked next to a handicapped parking spot where a man was getting out of his car, "He had a brace on one leg and a severe limp. I loved his watching me drag myself into the wheelchair, lifting my limp legs with both hands onto the foot rests. I felt an overwhelming arousal. I was flushed, my whole body was burning. I wanted to be with this disabled man...not sexually, although I would have. I just wanted to be with him, be seen with him, to be disabled with him." She did not pursue a conversation with the man and they parted.
Ms. D. flew home, stimulated by her "adventure." For her next trip she decided to bring a rented wheelchair to the hotel and "arrive as a disabled person." She found a surgical supply store in advance of her trip, booked a wheelchair accessible room at the hotel and picked up the rented wheelchair on the way from the airport, "I was again flushed and aroused. I loved the hotel staff looking at me wheeling through the lobby. The man behind the desk and the bellmen were so kind and thoughtful to me."
While at the hotel she went to the indoor pool, "I loved people looking at my paralyzed legs, wondering why I couldn't move them." She again traveled to local malls in search of "other disabled people." She would return to her room after these adventures and masturbate to orgasm while sitting in the wheelchair, "The fantasies that aroused me were not even sexual. I would imagine my legs being paralyzed or a man's paralyzed legs, or picture my being in a wheelchair, his walking on crutches, or his braces, and have an orgasm." She admitted that she could not remember having a masturbatory fantasy that did not involve disability since she had been a teenager.
Her ultimate fantasy was to meet a disabled man while she was pretending to be disabled and have sex, "I wanted to be accepted by a disabled person as being disabled myself." However, she denied strongly that she herself wanted to have a disability, "I wanted to be accepted as a disabled person, not become one. I remember sitting at a stop light and seeing a beautiful woman about my age in the car next to mine with a wheelchair behind the front seat. Without thinking I said to myself, 'Poor thing. I bet she never gets dates. I wouldn't really want to be disabled for anything'." Ms. D. admitted thinking at the time that this statement was bizarre given her desire to be seen as disabled in public and accepted by people with disabilities as "one of them."
Ms. D. did not rent a wheelchair on future trips, saying, "Pretending was exciting and even sexually arousing but frustrating, exhausting and not fulfilling."
Marriage. When she was 38, Ms. D. met a new co-worker, "I was waiting to begin a meeting and in came a handsome man walking on forearm crutches and wearing two long leg braces. I couldn't talk, my whole body flushed and I almost passed out." She was introduced to this man and found him to be "pleasant and gentle, if quiet and shy." After taking several days "to recover my senses," she invited him to lunch and they dated frequently thereafter, "I was overwhelmed. All I could think about was being with him, being seen in public with him. I loved to have him next to me walking on his crutches. I loved to hear the metal 'clink' of his crutches and braces."
Over the next several months she went to great lengths to help him when he had significant difficulty dealing with company politics, "It was actually sexually arousing to me to be able to help him." Although they kissed and fondled each other on dates, they did not have intercourse for the first two months, "I enjoyed kissing. I would grab the top of his braces and pull him to me. Feeling the metal against my legs and was very arousing, but I was not eager for intercourse. I would go home and immediately masturbate, having orgasms remembering him on top of me and us walking together in public."
After two months they would take off their clothes while kissing but she arranged for him to keep his braces on. They finally had intercourse without his wearing braces and she was orgasmic, "The first time I was aroused by how thin his legs were, how they couldn't move. The second time I missed the feel of his braces. I had to look at the braces and crutches standing against the wall in order to have an orgasm. By the third time, I stopped having orgasms but would go into the bathroom afterward to masturbate, again imaging his braces or him walking with his crutches."
After six months he professed his love and asked her to marry him. By this time she was totally disinterested in sex but had come to care for him and enjoy his company, "I thought, 'You've found what you always wanted. Why shouldn't you marry him?'" They married three months later and moved into his accessible apartment.
Over the next years they lived companionably and she provided him with sex weekly although she stated, "I know it is ludicrous but I have to fantasize during intercourse that I am with some other disabled man just like him, with braces and crutches." Their frequency of intercourse decreased to about once a month as her company responsibilities grew and she began traveling about 15 days a month. She still masturbated several times per month, fantasizing about being with other disabled men, men with disabilities identical to her husband, "I know this is ridiculous. I have married my fantasy man. Why doesn't he arouse me?"
Over the last 5 years Ms. D.'s husband developed PPS, with bilateral shoulder pain from crutch walking, new arm muscle weakness and pain, back pain and increasing fatigue. He began to use a wheelchair for distance one year ago which disappointed Ms. D., "I had still been aroused by his walking on crutches. This is selfish and horrible, but I know you'll tell him to use the wheelchair all the time and I won't even have the pleasure of watching him walk anymore."
Insight: Childhood Dream of Disability. Ms. D. came to the fourth therapy session reporting that she had had a dream in which she was a young girl walking into her elementary school wearing long leg braces and using crutches, "I walked into the school and felt in the dream, 'Yes! This is the real me. This is who I want to be: a disabled child.'"
When asked about the relationship of her dream to her attraction to disabled men and her pretending to be disabled, she cried and began talking about her parents, saying, "I was an accident born 15 years after my brother. He left home when I was 2 and I was raised as an only child." She described her father as "unsatisfied and a demanding tyrant." Her father would nightly scold her mother for the mother's flaws, "My mother would just sit there silently, looking wounded." Ms. D. described herself as "a terribly lonely child," with neither parent displaying emotion or affection, "They basically ignored me. My father worked and my mother kept scrubbing the kitchen floor. They never hugged each other or me or uttered one kind word."
We discussed why the patient wanted to be a disabled child and she recounted an incident when a local child, who had had polio and walked with crutches and leg braces, walked past their home on the way to school, "My father saw the girl as he retrieved the morning paper and said to my mother, 'I saw poor Sally walking to school.' 'Yes,' said my mother, 'Poor Sally' and her eyes filled with tears. I had never seen either one of them show any tender emotion before!"
Ms. D. also remembered a class trip a few years later when she saw another girl who walked with crutches and leg braces, "I just stared at her from a distance, seeing how her classmates carried things for her, how the teacher walked with her behind the rest of the class." After that experience Ms. D. would play in the family garage using croquet mallets as crutches and tying sticks to her legs for braces. She also remembered finding her old baby carriage and pretending it was her wheelchair. The patient concluded, "I wanted to be a disabled child so I would be loved. Pretending to be disabled now that I am an adult - even if I actually became disabled - cannot make up for the love and attention my parents did not give me."
After the dream and the discussion of her childhood, Ms. D.'s interest in pretending she was disabled and even looking for disabled men decreased markedly, "I will get somewhat excited if I see disabled men, but I am no longer compelled follow or go looking for them. Sometimes I have the urge to rent a wheelchair when I'm on a trip, but there's no point to it any longer?"
Ms. D. is no longer aroused by fantasies of disabled men and has stopped masturbating using such fantasies. She has for the first time begun fantasizing about and even achieves orgasm thinking about having sex or intercourse with non-disabled men. Ms. D. also has begun to enjoy sex with her husband, "My husband is a good man and I do love him. I am ashamed that I used him, that I married him under false pretenses. But I want our relationship to work."
Ms. D. discontinued psychotherapy just before her husband was about to begin treatment with the Post-Polio Service so that, "he will not discover my secret."
Psychology of DPW's
A variety of explanations have been offered for DPW's attractions, desires and behaviors. A preference for a disabled or disfigured, and therefore less threatening, more attainable or more easily dominated, 'love object' is a commonly-heard explanation for attraction to disabled persons (3,7) However, this explanation for preferring a disabled partner explains neither DPW's obsessive and compulsive attraction to disabled persons nor the powerful desire to appear or to become disabled. Ms. D. had had a number of relationships with non-disabled men and did not marry her husband out of a fear of abandonment, i.e., that a disabled husband would 'not be able to run away from her.'
Another explanation for devotees' attraction is the association in childhood of a disability-related stimulus, e.g., an amputee's stump or leg braces, with a powerful emotional state. Money suggested that one apotemnophile's childhood fear of amputation may have been replaced by the erotitization of the stump, transforming a terror into a joy. (21) A more intuitively appealing mechanism would be the pairing in childhood of a disability-related stimulus with sexual arousal. For example, one plaster cast devotee had his first sexual experience with a girl who was wearing a leg cast. (1). However, only 19% of respondents to the AMPIX survey related their interest in amputees to any kind of direct contact with a disabled person, and the overwhelming majority of devotees have reported their interest in disabled persons began long before puberty. (3,18) Ms. D.'s interest also predated puberty and she had had no childhood fear of amputation or disability.
Attraction to disabled persons has also been related to homosexuality, sadism and bondage. (10) An amputee's stump has been suggested to resemble a penis, therefore providing a less threatening sexual stimulus for male "latent homosexuals" and a counterphobic protection against the fear of castration. (10) A stump's similarity to a penis has also raised the possibility that a desire for amputation is a "counterphobic" antidote for male acrotomophiles' fear of castration, although such fears have not been documented. (7,10,16) However, recent surveys find no increased prevalence of homosexuality, sadism or interest in bondage among acrotomophiles. (3,18) Any similarity between a stump and one's own penis would have little personal meaning for Ms. D., not only because she is a woman but also because she was primarily attracted to men with braces and crutches and was herself interested in pretending to be a wheelchair user. Further, Ms. D. was exclusively heterosexual and had no interest in sadism or bondage.
Several case studies indicate that there may be a higher incidence of transvestites and transsexuals among DPW's. (3,10,13,14,22,23) However, the notion that an apotemnophile is a "disabled person trapped in a nondisabled body" is difficult to justify, there being no 'naturally-occurring' state of disability that would correspond to the the two naturally-occurring genders. Ms. D. was neither a transvestite nor uncomfortable with her gender.
Riddle (24) suggested that DPW's desires develop from a combination of a strict anti-sexual attitude in the child's household, deprivation of maternal love and parental rejection in early childhood that creates a fear for survival and a self-generated fantasy for security:
are we playing "poke fun at paraphilias"?
