Understanding Infantilism (.org)
Chapter 2 of The Clinical Mental Health Experience of Persons with Paraphilic Infantilism and Autonepiophilia. A phenomenological research study, a doctoral dissertation Dr. Rhoda J. Lipscomb, PhD, LPC, DAACS, BCPC. It is also available in PDF.
“People seem forever intrigued by what peculiar sexual activities others might perform. Given the apparently high human interest, it might seem plausible that a large army of researchers would be working to further the collective understanding of sexual deviance. It might be surprising then, to learn the reality. Relatively little empirical work has been done regarding unusual sexual activities and preferences, and precious little is known for sure in this area. Perhaps part of the reason for the comparative lack of research attention is the common assumption that sexuality researchers investigate topics of personal relevance, and presumably few researchers want to be thought of as sexual deviants” (Wiederman, 2003, p. 315). In the twenty first century, those who study clinical sexology continue to be viewed differently in the academic world (Wiederman, 2003). Another problem is that sexuality research has had difficulty attracting public funds. According to researchers, from 1972 to 1996 in the USA less than 1% of the research funding from the National Institutes of Health went to sex research (Ng, 2000, p. 275). So it is understandable that sexuality and especially the areas of legal, consenting paraphilias are given even less attention in the multiple peer-reviewed journals, textbooks, and grant-funded studies than those involving such areas as pedophilia, exhibition or voyeurism that have real legal consequences. However this does not make the studies any less important in the scope of the field of sexology and psychotherapy. This chapter will present information from some of the major contributors to the world of psychology throughout recent history, looking at how the psychological world view has changed when it comes to the area of atypical sexual behavior. The research will also look at some recent studies conducted from within the infantilism community, who have performed their own surveys, to increase understanding of this phenomenon. From terminology, to attitudes and treatment approaches, examination of how beliefs about sexual behavior, the need to control, limit or change it, and hopefully in more recent times, a desire to understand and accept it have emerged.
“Whilst it is almost certainly the case that all human societies through history have imposed limits on the types of sexual behavior regarded as acceptable, a degree of variation across cultures has occurred, whilst, within cultural traditions, change in sexual mores may occur over time. Throughout history, it is evident that societies require a concept of sexual deviancy, but that it is subject to changes in social perspective” (Gordon, 2008, p. 79).
“The concept that unconventional sexual interests are mental illnesses or crimes (religious or societal) predates both the DSM and modern psychiatry” (Moser & Kleinplatz, 2006, p. 94). It has not been unusual for many of those in the seats of power to attempt to control the masses by expounding upon the sins against nature for engaging in sexual activity other than for procreation. When religion was not enough to control people the legal system was used. “At first, it was considered a sin to be governed by penitentials and religious courts. Over time, civil laws were used to “control” the unacceptable behavior. In the 19th century the medical model was applied to transform these “sins” or “crimes” into “pathology” (Moser & Kleinplatz, 2006, p. 94). An illustration of how easily discussion of sexuality was suppressed is the case of Dr. Denslow Lewis, a Chicago physician, who wanted to discuss and present a paper for publication with his colleagues at the 1899 meeting of the American Medical Association. Based on the objections of Dr. Howard Kelly, a famous Johns Hopkins University gynecologist on the grounds that the “discussion of the subject is attended with filth and we besmirch ourselves by discussing it in public” the AMA refused to authorize the publication of Dr. Lewis’s paper (Bullough & Bullough, 1977, p. 2). Homosexuality was often cited in the legal system as a crime worthy of punishment and in some Islamic and African countries around the world it remains so today (Reynolds, 2013).
Throughout Europe, the history books are full of criminal codes outlawing homosexuality including King Henry the VIII of England in 1553 declaring that all acts of sodomy were against nature and punishable by death (Heath & White, 2002, p. 22) and the infamous case of Queen Victoria’s Criminal Law Amendment Act 1885 in which oral sexual contact between men was outlawed and although lesbian behavior was generally condemned, it was not explicitly recognized in the legislation (Heath & White, 2002, p. 22). Apparently, Her Majesty did not believe that women would ever engage in such behaviors. Yet these conflicting attitudes regarding sexuality in Victorian England were reflected in the growth of pornographic materials as well as a large number of brothels, some with specialties in flagellation and homosexual prostitutes (Bhugra, Popelyuk, & McMullen, 2010, p. 246). In early colonial American times, the court of public opinion was often used, such as Nathaniel Hawthorne’s story of the Scarlet Letter, where the heroine was forced to wear a large red A on her chest to show she had been sexual out of wedlock, even though the sex was non-consensual (Hawthorne, 1994).
“Two figures of noble European origin are associated enduringly with the public image of sexual deviance – the Marquis de Sade (1740-1814) and the Baron Leopold von Sacher-Masoch (1835-1895), who have given their names to ‘sadism’ and ‘masochism’. De Sade was confined in a lunatic asylum more than once, and in fact died there, possibly suggesting a contemporaneous association between deviance and mental abnormality” (Gordon, 2008, p. 79).
In the United States during the late nineteenth and early twentieth century the name often cited as a powerful force in the area of sexual repression was Anthony Comstock (1844-1915). During the post-Civil War period the country began to transition from a predominately rural country to an urban one as many from the younger generation flocked to the larger cities for opportunities. Many from the older generation were shocked by what they considered to be the evils of city life. Comstock became a leader in an effort to return America to its pure, pristine innocence. Due to his campaign he was able to be appointed a special agent by the United States Post Office. Here he was able to confiscate all kinds of materials he deemed pornographic such as birth control information written by physicians (Bullough & Bullough, 1977, p. 2) as well as publications for women encouraging sexual pleasure (Arnold, 2006). During his time in power, Comstock imprisoned over 3,600 people for distributing sexual information. One of which was Ida Craddick, a woman arrested in 1902 who wrote The wedding night in order to inform women about their right to sexual pleasure within marriage. She was found guilty and committed suicide before she was imprisoned. Comstock also charged Margaret Sanger, in 1914 for her publication of the Woman Rebel which advocated birth control and sexuality education for women. Sanger was charged yet never convicted because she fled to Europe until such time as the charges were dropped. Margaret Sanger eventually went on to found Planned Parenthood and was instrumental in the development of oral contraceptives in 1960 (Arnold, 2006).
In addition to Comstock, in 1906, John Harvey Kellogg invented the bland breakfast cereal, Corn Flakes, to keep the stomach full, suppressing the stomach and the loins, in order to reduce sexual urges, especially masturbation among young men and women. When this was not enough, he would have the cereal administered by enema, and in the most severe cases blisters applied to the genitals or removal of the clitoris was performed (Arnold, 2006).
Within the literature, a more modern notion of sexuality began to shape in the last two decades of the nineteenth century, especially in the works of psychiatrist Richard von Kraft-Ebing (1840-1902) and neurologist Albert Moll (1862-1939). This modernization of sexuality was closely linked to the recognition of sexual diversity, as it was articulated in the medical-psychiatric understanding of what, at that time, was labeled as perversion (Oosterhuis, 2012, p. 133). By todays beliefs about typical human sexual expression it can be difficult to read their works and see them as advancing the cause of normalizing sexual behavior since their use of the term ‘perversion’ and thoughts about masturbation and homosexuality, would be considered highly judgmental. However compared with other voices of their era theirs are closer to modern beliefs about sexuality. As an example of the era, in 1872, ovariotomy, the removal of normal ovaries was the fashionable treatment for many female maladies, some of which were nymphomania and masturbation as well as ‘all cases of insanity’ (Studd, 2006, p. 411). It becomes clear reading the works of Kraft-Ebing, Moll, as well as Freud, Hirschfeld, Stekel, and Ellis that their personal views on normality is based on religion, law and the upper-class level of society in which they interacted affect their opinions yet they are considered by many today to be brilliant thinkers who were far ahead of their time. Not everyone agrees. “Edward Brecher has gone so far as to write that Kraft-Ebing made sex a loathsome disease” (Bullough & Bullough, 1977, p. 207).
In the late nineteenth century, physicians believed that mental and nervous disorders were the result of ‘unnatural’ behaviors, while psychiatrists began to take a different view, suggesting that such disturbances were actually the cause of sexual deviance. Their assertions were that irregular sexual behavior should not be regarded as sin or crime but rather as symptoms of pathology to be treated rather than punished (Oosterhuis, 2012, p. 134).
The transition of sexual deviancy, being regarded as a medical phenomenon from a social nuisance or crime may well has been with the publication of Psychopathia Sexualis (Kraft-Ebing, 1886) (Gordon, 2008, p. 79). Kraft-Ebing does advocate for the understanding of sexual acts that are other than for procreation. In his words (translated into English in 1965 by Dr. Harry E. Wedeck) “In order to differentiate between disease (perversion) and vice (perversity), one must investigate the whole personality of the individual and the original motive leading to the perverse act. Therein will be found the key to the diagnosis” (Kraft-Ebing, 1965, p. 108). Freud saw the roots of perversion as interplay between physical and social factors (Gordon, 2008, p. 80). While Ellis and Hirschfeld were known for their beliefs on the normalizing of homosexual behavior, with both Kraft-Ebing and Moll having conflicting views about the subject, Kraft-Ebing becoming more lenient as he aged while Moll become more conservative, yet both signed onto Hirschfeld’s petition to abolish Section 175 of the German legal code, which made so-called ‘unnatural vice’ punishable (Oosterhuis, 2012, p. 137). The terms homosexual and heterosexual were introduced in 1869 by Karl Maria Kertbeny, yet did not gain much use until Kraft-Ebing reintroduced them, along with Moll around 1890 (Oosterhuis, 2012, p. 144).
Kraft-Ebing is believed to have coined some of the terms for various paraphilias, such as sadism, masochism and pedophilia, (Oosterhuis, 2012, p. 144) while Stekel is believed to have coined the term paraphilia to replace the more judgmental term perversion which was a standard term in the literature of the time. The exact date of when Stekel coined the term appears to vary in the literature with dates of 1905 (Seligman & Hardenburg, 2000, p. 107), 1908 (Downing, 2010, p. 276), 1912 (Money & Lamacz, 1989, p. 17), 1922 (Granzig, 2002, p. 3), 1924 (Wiederman, 2003, p. 315), and 1925 (Fankhanel, 2006, p. 16). The term was not widely adopted in the professional lexicon until its assimilation into the DSM-III in 1980 and promotion by Money in the 1980’s with his extensive research and naming of many of the various paraphilias (Money, 1986).
The meaning of the word deriving from the Greek words para defined as other or outside of, and philia defined as love or loving (Wiederman, 2003, p. 315). It has also been defined by Dr. Charles Moser, who is less fond of the term, as “interest in perversion or love of the perverse”. Moser believes the term should have been coined as paralagnia with the root lagnia, meaning lust rather than love (Moser, 2001, p. 94). While Stekel may have believed he was improving the lives of those referred to as “perverts” with the creation of a less pejorative term, it appears the medical and psychological community just switched one term for another leaving the basic meaning one of a mental diagnosis needing to be treated or cured.
“The word fetish derives from the Portuguese feitico. It was apparently first used by 15th Century Portuguese explores to describe West African sacred carvings. In its original (and current anthropological) meaning, fetish refers to a sacred artifact invested with spiritual or talismanic power. The erotic fetish is not merely a symbol of the divine but is itself divine. It possesses a discrete power: It can arouse and, sometimes, induce ecstasy in its devotee. For fetishists, a shoe may be sexier than the foot it adorns; lingerie more enticing than the erotic anatomy it screens; a rubber coat more stimulating than the person it contains” (Brame, Brame, & Jacobs, 1993, p. 358).
“The APA first published a predecessor of the DSM in 1844, as a statistical classification of institutionalized mental patients. It was designed to improve communication about the types of patients cared for in these hospitals. This forerunner to DSM also was used as a component of the full U.S. census. After World War II, DSM evolved through four major editions into a diagnostic classification system for psychiatrists, other physicians, and other mental health professionals that described the essential features of the full range of mental disorders” (APA, 2013, p. 6).
In 1952, the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published by the American Psychiatric Association as a means of giving psychiatrists a guide to better understand and treat mental disorders. In that edition, the term sexual deviation, as part of the classification for Personality Disorders, was under Sociopathic Personality Disturbances and included in its definition “the type of pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation) (Diagnostic and Statistical Manual of Mental Disorders (1st; American Psychiatric Association, 1952, p. 38-39). This was not surprising, since at the time homosexuality was aggressively treated by psychiatrists with various forms of olfactory and electro-shock aversion therapy (Smith, Bartlett, & King, 2004) and nymphomania in women was treated with similar practices and even incarceration in an insane asylum (Angel, 2010). Even though it has been over 60 years and we now have the DSM 5 published, there remain those in the psychological community who are quick to pathologize sexual behavior such as Patrick Carnes and the “sex addiction” movement creating a whole industry from support groups such as SAA (Sexoholics Anonymous) (Lipscomb, 2007) to treatment facilities specializing in repressing sexual behavior. To be clear, yes there are those whose sexual lives can become problematic, however the term “sexual addiction” can be and often is used to describe a very broad range of sexual expression that falls outside of what a few individuals deem appropriate (Taverner, 2008, p. 11).
In DSM I, (1952) while the description of 000-x63 Sexual deviation is short, the tone created by language such as “deviant sexuality” and “pathologic behavior” (American Psychiatric Association, 1952, p. 38-39) gives a strong impression that the listed behaviors, homosexuality, transvestism, pedophilia, fetishism and sexual sadism are clearly not to be tolerated and in need of change.
The publication of DSM II in 1968 attempted to expand upon the previous edition and gave clinicians a little more definition of what the intention behind the committee for the American Psychiatric Association had in mind regarding sexual deviation. The new addition re-coded Sexual deviations from 000-x63 to 302 with an additional numeral for the list of deviations of clinical significance. In DSM II, the diagnosis was made when “individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances” (American Psychiatric Association [APA], 1968, p. 44). The description states that many who engage in these practices find them “distasteful” yet are unable to substitute normal sexual behavior for their deviant ones (APA, 1968, p. 44). The list of the deviations is similar to DSM I with the addition of exhibitionism, voyeurism, masochism, other sexual deviation, and unspecified sexual deviation (APA, 1968, p. 44). There is no definition of either “other sexual deviation” or “unspecified sexual deviation.” It is unclear whether sexual acts such as oral or anal sex and mutual masturbation by opposite sex partners would qualify them for a diagnosis of sexual deviation either with the “other sexual deviation” or “unspecified sexual deviation.” It appears to be an individual clinical judgment whether such acts could be considered as not usually associated with coitus or “bizarre.” Other researchers have criticized the descriptions of disorders in the various versions of the DSM since even the accusation of interest in specific sexual practices and especially the diagnosis of a sexual deviation could result in death, imprisonment, and/or loss of civil rights (Moser & Kleinplatz, 2006, p. 92).
In DSM I both rape and pedophilia were listed as ‘sexual deviations’ and classified as disorders, yet in DSM II rape was eliminated and pedophilia remained. It is unclear what caused pedophilia to remain a psychopathology and rape was not. The commonalities between rape and pedophilia are quite similar. Both are crimes that involve sex, power, and victimization and adversely affect the survivors subsequent functioning. The inclusion of one criminal behavior and not the other is inconsistent (Moser, 2001, p. 104).
“The publication of the DSM III in 1980 marked a revolution in the history of the DSM. One of the most visible changes was the increase in the number of mental disorders: from 182 disorders in the DSM II of 1968, to 265 disorders in the DSM III” (Singy, 2012, p. 141). The sketchy psychoanalytic models of some disorders described in DSM I and DSM II were abandoned and replaced with more detailed criteria and the atheoretical approach predominated the new DSM III (Zucker, 2010, p. 217). The sexual deviations section within both DSM I and II was contained within a single paragraph. It appears the APA attempted to address some of the perceived weakness of the previous editions with the edition of DSM III (American Psychiatric Association [APA], 1980) which went from a single paragraph to a chapter with 22 pages. “With the publication of DSM III, the focus of the DSM changed from a theoretically based, psychoanalytic model of illness to an evidence-based and descriptive model” (Moser & Kleinplatz, 2006, p. 93). DSM III renamed the sexual section from Sexual Deviations to Psychosexual Disorders (APA, 1980, p. 261) and divided the chapter into four groups; gender identity disorders, paraphilias, psychosexual disorders and other psychosexual disorders (APA, 1980, p. 261). Despite the APA’s decision to remove homosexuality from its list of mental disorders in 1973, the “other psychosexual disorders” group continued to list “Ego-dystonic Homosexuality” as a diagnosis (APA, 1980, p. 281).
In DSM III, the use of the term paraphilia is seen for the first time replacing the more pejorative term, sexual deviation. The advisory committee explains their rationale for the change by stating it was “preferable because it correctly emphasizes that the deviation (para) is in that to which the individual is attracted (philia) (APA, 1980, p. 267). The influence of John Money, who is listed as part of the psychosexual disorders advisory committee at the beginning of DSM III, is likely the reason for the change in terminology. His journal article about paraphilia and his book, Lovemaps, which helped to popularize the term paraphilia, were both published shortly after DSM III’s release (Money, 1984) (Money, 1986).
Paraphilia’s in DSM III were characterized as “arousal in response to sexual objects or situations that are not part of normative arousal-activity patterns and that in varying degrees may interfere with the capacity for reciprocal affectionate sexual activity” (APA, 1980, p. 261). DSM III continued with some of the judgmental language of the previous versions when discussing paraphilia. It states that an essential feature was “unusual or bizarre imagery or acts necessary for sexual excitement” (APA, 1980, p. 266). The three areas used to diagnose a paraphilia included 1) preference for use of a nonhuman object for sexual arousal, 2) real or simulated suffering or humiliation, or 3) sexual activity with non-consenting partners. It goes on to further explain that associated features of paraphilia have individuals admitting to “guilt, shame, and depression at having to engage in an unusual sexual activity that is socially unacceptable” (APA, 1980, p. 266-267).
The paraphilia listed in the DSM III are 302.81 Fetishism, 302.30 Transvestism, 302.10 Zoophilia, 302.20 Pedophilia, 302.40 Exhibitionism, 302.82 Voyeurism, 302.83 Sexual masochism, 302.84 Sexual sadism, and 302.90 Atypical paraphilia for individuals with paraphilias that cannot be classified in any other categories (APA, 1980, p. 268-275). For the first time the DSM further expanded upon the definitions of the various paraphilia as well as listed categories such as age at onset, differential diagnosis, course, and in some cases, predisposing factors (APA, 1980, p. 268-275).
The diagnostic criteria for fetishism involved A) “use of nonliving objects (fetishes) is a repeatedly preferred or exclusive method of achieving sexual excitement” and B) “fetishes are not limited to articles of female clothing used in cross-dressing (transvestism) or to objects designed to be used for the purpose of sexual stimulation (e.g., vibrator)” (APA, 1980, p. 269).
The essential feature was the use of nonliving objects as a preferred or exclusive means of achieving sexual excitement. It was not considered a fetish if the nonliving objects were limited to female clothing used for cross-dressing as that was considered transvestism, a separate category. The differential diagnosis was allowed for “nonpathological sexual experimentation” when the use of the object for stimulation was neither preferred nor required (APA, 1980, p. 268).
In 1987, the DSM was revised with the publication of DSM III-R (American Psychiatric Association [APA], 1987) and in this revision the category name changed once again from Psychosexual Disorders to simply Sexual Disorders and dropped from four to two main groups; Paraphilias and Sexual Dysfunctions, as well as a residual class referred to as Other Sexual Disorders (APA, 1987, p. 279). The revision kept the basic essential features of the disorder the same with the addition to children to non-consenting partners in number three.
DSM III-R did for the first time begin to allude to the possibility that Paraphilic behavior was not always diagnosable. When discussing the imagery in a paraphilia it gave the example that “being humiliated by one’s partner may be relatively harmless and acted out with a consenting partner” and also stated that many men are sexually excited by female undergarments, however this did not mean they would quality for a diagnosis of transvestism (APA, 1987, p. 279). DSM III-R was the first edition to finally drop the judgmental and non-clinical language of “unusual and bizarre images or acts” when describing paraphilias and fetishes specifically. These shifts began to show an appreciation for a broader range of sexual expression without being pathological or diagnosable. DSM III-R also finally dropped all mention of homosexuality as any type of mental disorder. While officially the DSM would drop homosexuality from its editions as a mental disorder, the controversy surrounding the issue would fail to so easily be extinguished. Well into the twenty first century, while same-sex marriage would become legal in 25% of the states, organizations such as NARTH (National Association for Research and Therapy of Homosexuality) would continue to advocate for therapies such as Reparative Therapy designed to change a person’s sexual orientation (The NARTH Perspective, n.d.).
The specific paraphilia described in DSM III-R was similar to DSM III with the exclusion of zoophilia, the addition of frotteurism, and the revision of “Atypical Paraphilia” to “Paraphilia Not Otherwise Specified” (APA, 1987, p. 280). There was also the additional criterion for severity of manifestation of a paraphilia ranging from mild, (distressed about urges, yet has not acted upon them), moderate, (has occasionally acted upon the paraphilic urge), to severe (has repeatedly acted upon the paraphilic urge) (APA, 1987, p. 281).
The 1987 revision changed the essential feature of fetishism describing it as “recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months’ duration, involving the use of nonliving objects” (APA, 1987, p. 282). The diagnostic criteria were expanded from two to three criteria. Criteria A, added the measure of time with “over a period of at least six months” as well as “recurrent intense sexual urges and sexually arousing fantasies” (APA, 1987, p. 283). A ‘Note’ was also added to A. criteria stating that at times the nonliving object may be used with a sexual partner (APA, 1987, p. 283). Criteria B from DSM III became Criteria C in DSM III-R and the new criteria B became “the person has acted on these urges, or is markedly distressed by them” (APA, 1987, p. 283).
This new diagnostic criteria has brought questions from critics of the Paraphilias in the DSM. The questions of “why 6 months?, what does recurrent mean?, what does intense mean?, and is it meaningful to discuss sexual urges independent of sexual fantasies?” abound in the literature (Fedoroff, 2008, p. 638).
In DSM III-R was the first mention of the term “infantilism” as part of the Sexual Masochism disorder. There is one sentence about the issue which states “The term infantilism is sometimes used to describe a desire to be treated as a helpless infant and clothed in diapers” (APA, 1987, p. 286). The implication is that infantilism is part of the aspect of humiliation discussed within the diagnosis for sexual masochism and gives no indication of how to work with a patient for whom this is a desired, self-inflicted activity rather than one where they were forced and is done for humiliation. “If the infantile role playing does not involve feelings of humiliation and suffering, then the diagnosis of sexual masochism would not be appropriate and a diagnosis as paraphilia NOS is warranted” (Milner, Dopke, & Crouch, 2008, p. 407).
In 1994 the DSM IV was published and again the name of the chapter relating to sexual issues changed from Sexual Disorders to Sexual and Gender Identity Disorders and lists four major categories, Sexual Dysfunctions, Paraphilias, Gender Identity Disorders, and Sexual Disorder Not Otherwise Specified (American Psychiatric Association [APA], 1994, p. 493). Much of the description and tone of the Paraphilia section of DSM IV is similar to DSM III-R with a few notable exceptions. Under the heading of Associated Features there was the addition of Specific Culture and Gender Features which mentions the issue of the difficulty diagnosing paraphilia across cultures and religions since what is considered deviant in one cultural setting may be acceptable in another (APA, 1994, p. 524). The Course section expounded upon what had been briefly mentioned in previous editions regarding age of onset, childhood to adolescence, and that the disorders tend to be chronic. However here it expanded upon the chronic and lifelong to add that the fantasies and behaviors often diminish as adults advance in age (APA, 1994, p. 524-525).
In DSM IV the diagnostic criteria was altered slightly. Criteria A remained the same, with the removal of the Note relating to the use of the fetish object with a sexual partner. Criteria B were expanded to “the fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 1994, p. 526). Here the DSM changes its approach by describing the issue of “clinically” significant distress or impairment in areas of a patient’s life functioning leaving behind terminology that could not be empirically measured such as “unusual or bizarre” and aiming for a more scientific approach to understanding human sexual behavior.
In another shift from previous editions, DSM IV added a ‘Differential Diagnosis’ section which stated that “a Paraphilia must be distinguished from the nonpathological use of sexual fantasies, behaviors, or objects as stimulus for sexual excitement in individuals without a Paraphilia” (APA, 1994, p. 525). Paraphilias are only diagnosed when fantasies, behaviors, or objects lead to clinically significant distress or impairment (APA, 1994, p. 525). Some found this to be a significant step forward in the DSM’s position on atypical sexual behavior. Moser stated that this section of the DSM IV was becoming more liberal and less pathological (Moser, 1999, p. 83).
In 2000, the DSM IV-TR was published with a few minor revisions from the previous edition. For the first time in several editions, the section name, Sexual and Gender Identity Disorders, remained the same as well as the essential features of paraphilia and the diagnostic criteria for fetishism. Under the heading of Associated Features and Disorders, the subsection of ‘Associated general medical conditions’ was added specifically mentioning that “frequent, unprotected sex may result in infection with, or transmission of, a sexually transmitted disease” (APA, 2000, p. 567). This disclaimer warning clinicians to look for unprotected sex among those with paraphilias was missing from the same ‘Associated general medical conditions’ section under the Sexual Dysfunctions and the Gender Identity Disorders sections (APA, 2000, p. 560, 579). Apparently the belief by the committee was that those engaging in paraphilias were more sexually active and careless about their sexual encounters than the remaining populations despite evidence to the contrary.
Before the publication of DSM 5 in 2013, as with many previous editions of the DSM, there was much controversy about potential changes to be made within the chapter on sexual diagnoses. Voices both within and outside of the psychological community were vocal regarding their thoughts about the previous editions, as well as potential changes for the upcoming edition. In 2006, Charles Moser, PhD, MD, and Peggy Kleinplatz, PhD published an article in the Journal of Psychology and Human Sexuality advocating the removal of paraphilias from the DSM. According to their research findings, the concept of paraphilia as psychopathology does not meet the DSM’s own definition of a mental disorder and therefore the category should be removed (Moser & Kleinplatz, 2006, p. 91). They argue that “empirically based, scientific definitions of healthy and pathological sexual behavior continue to elude us” and that the paraphilia section is severely flawed (Moser & Kleinplatz, 2006, p. 92). DSM IV-TR states it is to be neutral with respect to theories of etiology (APA, 2000, p. xxvi) and based on objective observation, and able to support its statements with empirical research (Moser & Kleinplatz, 2006, p. 93). Since little empirical research is conducted on many of the paraphilias and there is little opportunity for objective observation, the argument that Moser and Kleinplatz made is a sound one.
Moser and Kleinplatz are not the only ones advocating for the removal of the paraphilias from the DSM. Baumeister and Butler in 1997, and Hucker in 2008, stated that many of the paraphilias were not pathological and addressed a call to remove the paraphilias from the DSM (Krueger, 2010, p. 349). Many in the field of psychology feel that the DSM when evaluated according to the empirical scientific criteria of validity and reliability is found to be fundamentally flawed, unable to account for the complexity of human subjectivity and on both clinical and ethical grounds fails as a valid diagnostic instrument (Bradford, 2010, p. 335, 348).
Prior to the publication of DSM 5, Hinderliter proposed the committee consider making a distinction between paraphilias and paraphilic disorders. He stated that the use of the term paraphilia had been used to label certain sexual interests as mental disorders and that creating a non-pathologizing term for non-normative sexual interests would be a better choice (Hinderliter, 2011). He went on further to state “the DSM does not seem to be an appropriate place for classifying what are acknowledged to be nonpathological variations in human sexuality” (Hinderliter, 2011, p. 20).
DSM 5 divided the sexual disorders into three separate chapters under Section II, Diagnostic Criteria and Codes. Those chapters were Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders. Included under Paraphilic Disorders were voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, and transvestic disorder. The various disorders were divided into two groups. The first group of disorders were based on anomalous activity preferences and then subdivided into courtship disorders, which relate to distorted components of human courtship behavior (voyeuristic disorder, exhibitionistic disorder and frotteuristic disorder) and algolagnic disorders which involve pain and suffering (sexual masochistic disorder and sexual sadism disorder). The second group of disorders was based on anomalous target preferences which include one directed at other humans (pedophilic disorder) and two directed elsewhere (fetishistic disorder and transvestic disorder) (American Psychiatric Association [APA], 2013, p. 685).
The definition in DSM 5 changed for paraphilias to “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” (APA, 2013, p. 685). It was also said to be defined as “any sexual interest greater than or equal to normaphilic sexual interests” (APA, 2013, p. 685).
In a shift from previous DSM editions, the DSM 5 states that while having a paraphilia is necessary to diagnose a paraphilic disorder, a paraphilia alone does not necessarily justify or require clinical intervention. The diagnostic criteria for a paraphilic disorder consists of Criteria A) the qualitative nature of the paraphilia and Criteria B) the negative consequences of the paraphilia. In order to diagnose a paraphilic disorder, both Criteria A and B must be met. In the case where one criterion is met, yet the other is not, then the individual may have a paraphilia and not a paraphilic disorder (APA, 2013, p. 686).
The DSM 5 goes on to add that assessing the strength of a paraphilia should be evaluated in relation to their normaphilic sexual interests and behaviors. This can be done with clinical interviews and or self-administered questionnaires examining whether their paraphilic sexual fantasies, urges, or behaviors are weaker than, equal to, or stronger than their normaphilic sexual interests and behaviors (APA, 2013, p. 686).
The Diagnostic Criteria for Fetishistic Disorder remained relatively the same as DSM IV-TR with the addition of some specifiers. After the A) B) and C) criteria there is the addition to specify: body part(s), nonliving object(s), or other, as well as specify if: in a controlled environment (such as institutional settings) or in full remission (no distress or impairment in social, occupational, or other areas of functioning for at least 5 years) (APA, 2013, p. 700).
Under Diagnostic Features it states that since it is not uncommon for fetishes to include both inanimate objects and human body parts that the definition of fetishistic disorder would re-incorporate partialism (which was defined as an exclusive focus on a living body part) into the boundaries (APA, 2013, p. 701).
News of this shift after publication of the DSM 5 spread quickly through channels of the fetish communities. NCSF, the National Coalition for Sexual Freedom, a national organization designed to protect the rights of alternative sexual expression, released a press release the month following DSM 5’s publication. The title of their release was “The DSM-5 Says Kink is OK!” (NCSF, personal communication, June 22, 2013). It goes on to say, “The APA has made it clear that being kinky is not a mental disorder, says Susan Wright, Spokesperson for NCSF. That means people no longer have to fear being diagnosed as mentally ill just because they belong to a BDSM group. We’ve already seen the impact- NCSF immediately saw a sharp rise in the success rate of child custody cases for kinky parents after the proposed DSM-5 criteria was released three years ago” (NCSF, personal communication, June 22, 2013).
One area where the DSM 5 appears to be behind the empirical evidence in the area of Fetishistic Disorder was the category of Gender-Related Diagnostic Issues. The DSM 5 states “fetishistic disorder has not been systematically reported to occur in females. In clinical samples, fetishistic disorder is nearly exclusively reported in males” (APA, 2013, p. 701). However this contradicts the data discovered by B. Terrance Grey in 2008. He found that approximately 8% of his survey populations were female and that women are actually more common in Paraphilic infantilism and diaper fetishes than other paraphilias (Grey, 2008).
Other researchers have also found higher numbers of women with fetish interests. In the book, Different Loving: The world of sexual dominance & submission, the authors state they have interviewed a larger number of women than expected who volunteered that they were fetishists. They state that there are extensive case studies of female fetishists in the early psychological literature, however do not list it (Brame, Brame, & Jacobs, 1993, p. 360).
Darcangelo also questioned the belief that the number of female fetishists are as low as the DSM 5 committee would want therapists to believe. According to them fetishism is considered to be more common in males than females yet due to the lack of sound epidemiological evidence the extent of this difference is actually unknown (Darcangelo, 2008, p. 110). She quoted an article by Wilson investigating the sexual fantasies of 1,862 male and 2,905 female readers of a national newspaper. The analysis revealed that 18% of the men reported fetishistic elements to their fantasies while 7% of women included fetishistic elements (Darcangelo, 2008, p. 110).
In 2012, Bent wrote that up until recently it was considered that almost all Adult Babies were male. We now know this is fundamentally inaccurate. While men appear to be in the majority, it is approximately a 60/40 split favoring men. One of the big changes in the AB/DL world over the past decade has been the discovery that women can be just as regressive as men (Bent, 2012, p. 24).
In the previous three editions, (DSM III-R, DSM IV, and DSM IV-TR) infantilism was listed briefly as part of Sexual Masochism. In DSM 5 this was eliminated, however under the area of ‘Comorbidity’ it states that disorders are possible to comorbidly occur with sexual masochism disorder and typically include Paraphilic disorders (APA, 2013, p. 695). Infantilism is not specifically mentioned, however, it does imply that infantilism could comorbidly occur with sexual masochism disorder.
Throughout the seven editions of the DSM, sexuality in general and the paraphilias specifically, indicate that the normative definitions of health have reflected a theoretical and perhaps biased construct of mental illness on the dominant values and biases of western culture. It has been argued that the DSM reflect the interests and assumptions of the elite psychologists who are involved in its development and shifts the power to determine normality from the individual to the mental health professional whose sexist and heterosexist assumptions dominate their diagnoses (Cermele, Daniels, & Anderson, 2001). In the DSM’s defense, over the last several editions, the section on sexual disorders has become more liberal. In the words of Dr. Charles Moser, “it is not the last word on the subject” (Moser, 1999, p. 83).
Much of this review of the psychological literature has focused broadly on the historical view of human sexuality and behaviors, the terminology for atypical sexual behaviors, as well as a look at psychology’s ultimate definition of disorders and dysfunction, the DSM. The remainder of the review of the literature will focus specifically on what has been written about the phenomenon of paraphilic infantilism and autonepiophilia within the past sixty years. “In the clinical literature the description of the psychosexual infantilist portrays a severely dysfunctional individual. He is likely to have come to the attention of law enforcement or other authorities and been required to receive treatment” (Speaker, 1986, Chapter 1). Three journal articles, published by the American Journal of Psychiatry in the mid 1960’s exemplify this portrait.
The first article written in 1964, described a man who was arrested and charged with sexually molesting his daughters and after his arrest, admitted to authorities that his wife had urged him to seek psychiatric treatment when she learned he was wearing diapers and rubber pants (Tuchman & Lachman, 1964, p. 1198). The next case, published two years later, involved a twenty year old college student who had been caught stealing diapers from people’s homes and leaving his soiled ones behind for them to find (Malitz, 1966). The following year another article was published in the same journal about a seventeen year old male, brought to psychiatric treatment by his family when they learned he was wearing diapers under his clothing, drinking from a baby bottle and eating baby food (Dinello, 1967). Each of these cases involved a psychoanalytic therapeutic approach that was designed to change their sexual behaviors to typical, heterosexual sexual functioning. It was unclear from these articles whether there was continued use of diapers by these patients once they were in consenting sexual relationships with a partner or if this was only a temporary behavior. Since most of the literature defines these fetishes as life-long and chronic, it is unlikely that the behaviors were extinguished by the therapies described as the articles would have us believe.
There was a gap in the academic literature until 1980 with the publication of a little known master’s thesis by Thomas Speaker called Sexual infantilism in adults: Causes and treatment. In his case study he had self-proclaimed infantilists complete his survey after he discovered his first subject in a personal ad in The Fetish Times, a monthly publication for fetishes of various varieties. From these personal ads, he compiled his research from the surveys of twelve individuals, eleven men and one woman, ranging in age from 24 to 50 years, who completed his self-administered questionnaire for the case study (Speaker, 1980). He used an ecological model to relate a number of causal factors: biology, stress (psychoanalytic view), faulty learning (behavioral view), blocked or distorted personal growth (humanistic or existential view), unsatisfactory interpersonal relationships and/or pathological social conditions (Speaker, 1980, p. 64). He concluded that, “infantilism is just as much a coping mechanism as it is a fetish. They are not fixated at a certain level, but rather behave as ‘time-travelers’, alternating between functioning at an adult level (managing careers, families, relationships, etc.) and functioning at an infantile level (wearing diapers, wetting, drinking from a baby bottle, etc.). Sexual infantilism behavior is compartmentalized, being a behavior that is engaged in only in certain times and situations when it seems “appropriate”. There is a conscious decision as to whether to have an infantile experience or not, whether the motivation is for sexual pleasure or as a coping behavior. They use regression as a defense mechanism in times of stress to gather strength for coping or as a method of using illusion to maintain momentum in the face of a difficult reality” (Speaker, 1980, p. 72). He found that none of the models (behavioral, psychoanalytic, humanistic, etc.) fully supported the primary causal relationship yet stated the behavioral model justified the strongest support (Speaker, 1980, p. 73).
When he addressed the area of therapy, he strongly recommended that “assessment and therapy should be individually tailored to the needs of the client.” If not severely maladaptive or socially disruptive there appears to be little to no desire for extinction in the subjects. So long as the behavior is self-managed through discretion and does not involve criminal behavior, uninvited intervention could be argued to be an unethical violation of individual rights (Speaker, 1980, p. 74).
Six years later, Speaker completed his doctoral dissertation continuing his earlier research on the subject of infantilism. In, Psychosexual Infantilism in Adults: The eroticization of regression, he was able to expand his case studies, using 7 of the original 12 cases and examining their infantilistic behavior during the 5 year period since his previous study. He added an additional 20 respondents to his new study for a total of 27; 26 male and 1 female. The one female participant had been in his original study. He created an infantilism survey as well as a fantasy questionnaire that he used with his participants to then eventually create an ‘average’ profile from his survey group. Unlike Stekel and other previous researchers who found most infantilists involve a “retreat from reality” (Speaker, 1986, p. 2) be rather pathetic individuals and lead a completely dysfunctional lifestyle, (Stekel, 1952) Speaker’s participants portrayed a different vision. Speaker found the average infantilist to be male, mid-30s, college educated in a professional career. Most were in committed relationships and were not sexually exclusive with their fetish. He did report that most of his participants reported a later than average age of achieving bladder control and voluntarily returned to diapers in adolescence as part of their sexual practices (Speaker, 1986).
While he found that few participants had sought out psychotherapy he stated that “psychotherapy can be helpful in minimizing the possible harmful ‘side-effects’ of engaging in infantilism” (Speaker, 1986, Chapter 6). In both studies he found the goal of psychotherapy was to open options for patients from which to choose, remove blocks from conventional scripts, increase control over sexual behaviors that may have become out of control and heal emotional side-effects such as guilt, anxiety, and depression. Additional goals were to help patients improve communication skills within romantic relationships so that participation with a partner was not from a place of coercion but rather understanding and negotiation (Speaker, 1986).
Speaker’s research was some of the first within the academic community that looked at paraphilic infantilism and diaper fetishism through a far less judgmental lens than others before him. His research showed that many people who engaged in these unique sexual behaviors were also able to function successfully within the world and were not completely disabled by their fetishes.
In 2003, Pate and Gabbard published an article in the American Journal of Psychiatry titled Adult Baby Syndrome. It described a case of a 35 year old male who presented for treatment stating he wanted to “be a baby.” The patient presented for treatment dressed in baby clothes and wearing diapers, talking in a child-like manner and often lying on the couch drinking from a baby bottle. He reported that there was a sexual nature to his condition and that he only masturbated while in diapers. He stated his fetish greatly affected his ability to engage in interpersonal and especially romantic relationships yet he was able to maintain a career in law enforcement where he said he “did not feel like a baby” (Pate & Gabbard, 2003). Despite his social isolation, he appeared to terminate therapy when the clinician theorized that he could not establish a perfect parent/child relationship in which no demands would be placed on him for adult behavior (Pate & Gabbard, 2003).
Three additional articles were published regarding adult baby syndrome in the Archives of Sexual Behavior in 2006, 2007, and 2011. Two referred to the Pate and Gabbard article and all three referred to the term ‘Adult baby syndrome’ despite the term not yet becoming part of any official psychiatric classification system (Evcimen & Gratz, 2006, p. 115). It appears the term ‘adult baby syndrome’ has begun to take on acceptance in the academic literature despite the lack of official classification.
Two cases involved male patients in psychiatric care for additional more serious psychiatric diagnoses such as hallucinations and delusions, and neither case reported any sexual gratification from their diaper wearing related to thoughts or behaviors. One case did have the additional component of gender identity disorder as the patient presented as a female baby, and when in his baby persona preferred to be referred to using female pronouns (Kise & Nguyen, 2011, p. 857). The authors appeared uncertain whether these particular cases were related to true infantilism or some form of obsessive-compulsive disorder, a paraphilia or an additional psychiatric disorder (Evcimen & Gratz, 2006) (Kise & Nguyen, 2011).
In 2007, Dickey described a case of a 25 year old male who presented for treatment stating a desire to be a 10 year old girl. This patient reported he achieved sexual arousal associated with the fantasy of having the physical characteristics and social role or a prepubescent girl yet denied any actual interest in prepubescent girls. He categorized the patient as “autohebepedophilic dysphoria” (Dickey, 2007, p. 131).
Most journal articles relate cases of individuals who either self-present for treatment or are part of in-patient psychiatric care. In a rare case in 2008, Caldwell presented a case of a couple where a 48 year old male and his wife of 26 years presented for couples therapy. She had been in psychiatric hospitalization on several occasions and on one occasion expressed relationship difficulty due to her husband’s voluntary use of diapers. He had struggled with his use of the diapers since he was a teenager and found the diapers to be part of not only his sexual fantasies, but also as a means to reduce stress as various points in his life (Caldwell, 2008, p. 158). Caldwell did acknowledge that despite the ‘maladaptive coping strategy’ related to diaper wearing and the effects on the relationship, there was no evidence of cognitive impairment, psychosis, or affective disorder (Caldwell, 2008).
The most recent academic survey as of the publication of this study, was an internet-based study conducted by Hawkinson and Zamboni published online in the Archives of Sexual Behavior (Hawkinson & Zamboni, 2014). The study had 1,795 male and 139 female subjects who were members of an online AB/DL web site and participated in an anonymous survey. The research focused on discerning two possible subgroups, those who focused on role play behavior and those who were primarily interested in sexual arousal in their AB/DL behavior (Hawkinson & Zamboni, 2014). The purpose of the study was to provide descriptive information on individuals who engage in AB/DL behaviors as well as focus on whether AB/DL behaviors were associated with negative mood states (Hawkinson & Zamboni, 2014).
One of the opinions asked by the researchers related to participants opinion about where their AB/DL interests originated. Using a 7 point Likert-type scale, they were asked whether they believed A. one is born with AB/DL sexual interests, B. one learns AB/DL sexual interests, C. AB/DL interests are related to something in childhood, or D. AB/DL interests are related to toilet training (Hawkinson & Zamboni, 2014). The results showed that in most participants believed their AB/DL interests related to something in childhood, followed by they learned their sexual interests in AB/DL, then they were born with the sexual interests with the least believing their AB/DL interests were related to their toilet training (Hawkinson & Zamboni, 2014).
The results also showed little support for the idea that AB/DL behavior functions to reduce negative mood states and most participants reported few problems in their lives due to their AB/DL behavior (Hawkinson & Zamboni, 2014). The researchers concluded that due to the diversity of the AB/DL community it is difficult to make any clear assumptions about persons involved in AB/DL behaviors. It appears the behaviors are not designed to cope with negative mood states; most participants in online communities have become comfortable with their sexual behaviors and have managed to make it work in their relationships (Hawkinson & Zamboni, 2014).
Several of the articles in the twenty first century referred to the growing Internet-based community of adult babies and diaper lovers and their frustration over the lack of scientifically based resources related to treatment of individuals when they present with such conditions. For that reason the review will now turn to some of the more credible sources of information as well as surveys done by members of the AB/DL community.
An Internet search for information on adult babies or diaper lovers will produce a large number of books, articles and magazines regarding the subject from more of an erotic, story-telling type of perspective rather than books or websites designed to educate and inform people about the phenomenon. Two of the books that differ from the rest are written by two women who come from the AB/DL community with the desire to inform more than titillate. In 2011, Penny Barber, (a pseudonym) published The age play and diaper fetish handbook: The ultimate guide to the world of AB/DL (Barber, 2011) to better inform the public about this phenomenon as well as tell her own story as a diaper fetishist. In 2012, Rosalie Bent published There’s a baby in my bed! Learning to live happily with the Adult Baby in your relationship (Bent, 2012). The focus of her book was for romantic partners and family of those who identify as an adult baby. Neither book was written with the standards of academic texts, yet each has valuable information to be gained towards a better understanding of this unique fetish.
In her introduction, Barber explains that she began her interest in diapers at the age of eighteen when she began dating a closeted diaper fetishist. She states that “I like to think that my interest comes from a healthy, bright place, my history correlating with my sexuality, but not causing it” (Barber, 2011, p. 3). Barber goes on to define both age play and diaper fetishes, explaining the various terms used in the community as well as how for many it can be a part of the larger fetish and BDSM (bondage and discipline, dominance and submission, sado/masochism) community.
Barber discusses the difficulty and the distrust that many within the AB/DL community have with the mental health community. She states that the mental health field view paraphilic infantilism as a mental disorder, yet claims the average age play or diaper fetishist is no more maladjusted than any average person with completely commonplace sexual interests. She states the term “paraphilia” is derogatory, especially when considering the other socially unacceptable sexual practices (sadism, masochism, and pedophilia) are all grouped under a single heading (Barber, 2011, p. 9).
Bent, who like Barber is part of the AB/DL world, comes at the subject from a different perspective. She describes herself as a post-graduate level trainer and communicator who has been happily married to a regressive Adult Baby for almost 40 years. With tertiary training in mathematics and psychology she has learned to understand the inner workings of the Adult Baby’s mind and wrote the book to help spouses and families who are dealing with these unique issues (Bent, 2012, p. 203).
Early in the book she makes a point to discuss the concept of difference between a coercive and non-coercive paraphilia. She states that paraphilic infantilism at its core is a non-coercive paraphilia. A coercive paraphilia is one in which the individual needs to involve an unwilling participant to become aroused. Examples of coercive paraphilias would be pedophilia, necrophilia, exhibitionism, zoophilia, voyeurism and frotteurism. However, paraphilic infantilism can become coercive when the Adult Baby wears baby clothes, engages in loud baby talk or crawls in public, thereby bringing others into their orbit without their permission or consent. If a biological child is involved it is considered ‘highly coercive’ (Bent, 2012, p. 19-20).
The main focus of her book is about regressive age play and the “Parent/Child Relationship”. “There is a very special kind of relationship that can exist between a loving couple, where one of them is a regressive Adult Baby, or what I call Little One. Rather than something to be feared, it is in fact an aspect that can greatly enhance and build the relationship” (Bent, 2012, p. 5). She mentions the difference between regression and role play stating that the common aspect of regression is that the individual thinks as a child. This is the defining difference between regression and role-play. She states that even during the deepest regression, the individual is essentially still an adult with access to all the adult abilities and emotions if needed. Choosing to sideline the adult side does not mean the adult disappears, just that the adult is in the background while the child is in the foreground (Bent, 2012, p. 26). Bent explains that Adult Babies have regressive needs and if these needs are not met, it leads to frustration, anger and other negative experiences (Bent, 2012, p. 27). She does discuss how this is different from Dissociative Identity Disorder and that the person who needs this regressive experience does not have a separate inner personality (Bent, 2012).
One of the unique aspects of her book is where she created a Regression Scale, going from Level Zero to Level Five, where she describes the levels of regression, the pros and cons of each with the exception of Level Five which she states is entirely negative and dysfunctional. The levels she describes are as follows:
Bent gives an in-depth account regarding her thoughts about the identification, communication, interaction and modification of the Parent/Child relationship with an Adult Baby. For the spouse/partner dealing with these types of issues, her book is a wealth of information despite much of it being based on her personal experiences rather than empirical evidence based information
Understanding.infantilism.org is an Internet web site started in 1995 by B. Terrance Grey to provide information resources to the AB/DL community. Between 2006 and 2013 the site began The Survey Project, to get a better idea of how alike the AB/DL community was as well as how it fits into the larger fetish and BDSM communities ("AB/DL surveys," 2011). The surveys have led to a much more detailed picture of the AB/DL community overall. While some would state that some archetypes are typical of all or most AB/DL’s, this would be an oversimplification. The surveys ask those in the AB/DL community who they are and while they show a number of trends, there are exceptions to the rule. The surveys cover a number of areas of interest including ‘The Range between AB and DL’, ‘The changing AB/DL community’, ‘Mapping Paraphilic Infantilism and Diaper Fetishes’, ‘Girls, Boys, and Diapers’, ‘Trauma and Exposure among AB/DL’s’, ‘Diaper Preference’, ‘Other Conditions prevalent among AB/DL’s’, as well as an in-depth exploration into AB/DL practices ("ABDL surveys," 2011, p. 1-2).
The spectrum between adult baby and diaper lover has not always been easy to define. The obstacle to understanding the AB/DL community is their diversity as well as how to define those who practice it. The surveys found that the trend from diaper lover to adult baby appears to be an increased emphasis on role-play, younger roles, and more elaborate collection of paraphernalia. One common differentiation is based on role-play: adult babies act like babies, while diaper lovers do not. If asked to define themselves 47% would state they are exclusively or mostly a diaper lover, 19% consider themselves equally adult baby and diaper lover, while 25% state they are mostly or exclusively an adult baby ("The Basics," 2013, p. 5). When the issue of regression was added in, the differences became even more apparent. 91% of adult babies admitted to regression sometimes or more, while 0% of diaper lovers regress. While diapers are often a sexualized component for diaper lovers and adult babies, the survey found a significant minority for whom AB/DL practices do not include sex. This is important in the debate regarding whether AB/DL can be summarized as a fetish. The majority of AB/DL’s (93%) find diapers to be sexually arousing yet most (57%) also found a human sexual partner more sexually arousing than diapers (Grey, 2006).
The issue of whether this phenomenon can be a fetish continues to be difficult to define. The results show that 85% of AB/DL’s consider the feel, sound, and smell of diapers either important or very important. For contrast, only 18% considered sexuality most important or one of a few most important aspects. This observation is especially interesting given that sexuality and paraphilia are often strongly associated in the clinical literature. While many in the AB/DL population practice sexually, many do not consider it an inherent part of their scenes, games or fantasies (Grey, 2007).
The surveys addressed the issue of gender and while they found that the majority of AB/DL participants were male (86%) they discovered that 8% were female with the final 6% falling somewhere on the transgender continuum (transvestites, MTF or FTM transsexuals, and intersexed). The research showed that the age of first interest was similar for males and females with peaks at five and twelve years of age. However, females were more likely to develop an interest after the age of 20 which therefore skewed the average age as 13.1 years for females compared with 9.8 years for males. Females are far more common in paraphilic infantilism than other paraphilias. The ratio was roughly ten-to-one male to female and actually higher than expected. By comparison, the APA places the sex ratio for masochism (which up until DSM 5 included paraphilic infantilism) at twenty to one (Grey, 2008).
It has been assumed that past childhood trauma could be a cause for paraphilias so a survey was done regarding this area. Depending on how trauma was defined, only 2-3% thought that their interest in AB/DL could have been caused by some form of trauma. 30% felt that their interest had always just been a part of them, while 52% thought it may have been caused by some event which could include stumbling across a reference to adult babies/diapers, being introduced to it by someone, wanting to try a new kink or an emotional incident where they sought out comfort. While some individuals may have believed their fetish was caused by their trauma the research would show that if this were possible, due to the large percentage of individuals who have experienced childhood trauma (physical, sexual and emotional) the percentages of those having paraphilic infantilism or diaper fetishes would be much higher. The observations do not support the conclusion that trauma generally causes infantilism or diaper fetishes (Grey, 2009).
In addition to the issue of trauma, there has been the belief that other psychiatric conditions may be associated with paraphilic infantilism and autonepiophilia. To explore the possibility, a survey of data was gathered on ten specific conditions. These conditions were Asperger’s Syndrome, Attention Deficit/Hyperactivity Disorder (ADHD), autism, Bipolar Disorder, Borderline Personality Disorder, Dissociative Identity Disorder, epilepsy, fecal incontinence, Obsessive-Compulsive Disorder and urinary incontinence. For most of these conditions the report of them was usually lower than expected. Autism, epilepsy, and Dissociative Identity Disorder were reported by only 2% of the respondents so not analyzed further. 11% of respondents were reported as being incontinent. For many of them, this was a desired aspect of their infantilism. Five percent of AB/DLs reported having been diagnosed with Asperger’s Syndrome, and eight percent reported a diagnosis of Obsessive-Compulsive Disorder. For both of these, the prevalence and sex ratios were significantly higher than expected due to coincidence. It is believed that the over-representation of Asperger’s Syndrome and Obsessive-Compulsive Disorder among AB/DLs is consistent with a relationship between these conditions and a desire for diapers and/or babyhood. Other possible explanations include a general over-diagnosis of these conditions among those who have AB/DL issues (Grey, 2010).
Regarding the mental health community the surveys found some conflicting views and opinions. When asked, many from the surveys had positive experiences with therapists, believed that it would be helpful for those of the younger generation to seek therapy to help them with self-acceptance, and that there needed to be more studies and additional training of psychotherapists in these specific areas. ("Odds and ends part 4," 2013) Yet it appears many from the survey do not take their own advice. When asked if they have talked to a therapist or counselor about their AB/DL interests 53% have never seen one, 21% have seen one yet never discussed their fetish interests, 13% mentioned it while being seen for another reason, 5% sought a therapist out because of their interest, and 7% went because family/spouse asked them to go. Of those 25% who went and mentioned it to a therapist, 16% found it very helpful, 28% somewhat helpful, 47% neutral with only 6% hurtful and 3% very hurtful ("Odds and ends part 3," 2013).
When it comes to the issue of diapers the majority of AB/DLs follow a typical profile. They were raised in diapers, and were taken out of them once toilet trained, most at a typically normal age. Then, years later, they desired to wear diapers again. Often without a clue as to why the desires occurred. In contrast a small number of AB/DLs remained in diapers late due to late toilet training, bed wetting, or incontinence. While some with later toilet training or bed wetting whose parents had them wear diapers shunned the experience and were happy to finally get out of diapers, others came to find the experience enjoyable and arousing for some unknown reason (Grey, 2009).
The Survey Project provided a number of insights into paraphilic infantilism and diaper fetishes. The report comparing the views of those in the community born at different times shows changes that are mirrored in the culture in which they grew up. Developments such as the sexual revolution and the broad growth of the Internet have greatly affected the AB/DL community. Along with a historical perspective this study also shed some light to the question: Are infantilism and diaper fetishes disorders, conditions, or merely interests?
Infantilism and diaper fetishes can be troubling issues for many. The survey shows that 52% have tried to quit at some time yet virtually no one reports any success. This could suggest that for many these are serious paraphilias as opposed to mere interests. However, those who have grown up in the Internet age were more than twice as likely to report positive views of their infantilism or diaper fetish compared to previous generations. By DSM Criterion B standards, Fetishism is a disorder if it causes clinically significant distress or impairment. It is believed that while the same number of individuals might develop infantilism or a diaper fetish, fewer in the younger generations will experience them as a disorder. Those born since 1950, who meet Criterion B has decreased by an average of 1.5% for each 5 year period. The negative impact may be partly cultural. With increased cultural awareness and access to information AB/DLs are viewing their interests more positively. The probability is that this trend will continue (Grey, 2011).
To conclude the review of the literature, it is clear that atypical sexual behaviors have a long history of being suspect, if not downright criminal in our society. It is no surprise that those who find they enjoy paraphilic infantilism and/or autonepiophilia are less than eager to share their interests with spouses, family or even their therapists. While the mental health community is believed to be a safe and understanding haven for those who need our help, reviewing the seven editions of the DSM as well as peer reviewed journal articles show that the beliefs within the community have a strong judgmental bias against those with what are considered to be different sexual behaviors. A look at information written by members of the AB/DL community clearly shows that they see the biases of the mental health community and fear the consequences if they are brave enough to seek us out for assistance. There is a lot of work to be done to improve both the publics and professionals knowledge of paraphilic infantilism and autonepiophilia before those in that community will seek the help they need to improve their self-acceptance, treatment of mood disorders, and navigating relationship challenges.
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This work is copyright Dr. Rhoda J. Lipscomb, PhD, LPC, DAACS, BCPC, posted by permission. Dr. Lipscomb can be reached at [email protected].