Self-reported childhood maltreatment and erotic target identity inversions among men with paraphilic infantilism

Johannes Fuss, M.D., Laura Jais¹, M.Sc., B. Terrance Grey², Sascha R. Guczka³, M.Sc., Peer Briken¹, M.D., Sarah V. Biedermann^1,4, M.D.

¹ Human Behavior Laboratory, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Germany

² http://understanding.infantilism.org

³ Psychological Methods and Statistics, Institute for Psychology, University of Hamburg, Germany

⁴ Department of Psychiatry and Psychotherapy, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Germany

* Corresponding author:

Institute for Sex Research, Sexual Medicine and Forensic Psychiatry

Center of Psychosocial Medicine

University Medical Center Hamburg-Eppendorf

Martinistraße 52

20246 Hamburg

Germany

Phone: +49-40-7410-52225

Fax: +49-40-7410- 56406

E-Mail: jo.fuss@uke.de

Abstract

Adults with paraphilic infantilism may desire to wear diapers or engage in infant-like role-play. Erotic target identity inversions (ETII) and childhood maltreatment have been hypothesized to cause regressive interests. To evaluate these two etiological hypotheses, we surveyed the online Adult Baby/Diaper Lover community. Data from 1904 cisgender men revealed a prevalence of pedophilic interests comparable to the general male population, arguing against ETIIs as common in paraphilic infantilism. In contrast, self-reported childhood neglect and abuse were highly prevalent, suggesting that infantilism might be correlated with childhood maltreatment. Additionally, some participants described repetition and/or sexualization of negative childhood experiences.

Keywords: adult baby syndrome, pedophilia, erotic target identity inversion, childhood trauma, erotic target location error, sexual abuse

Introduction

The terms paraphilic infantilism or adult baby syndrome (Pate & Gabbard, 2003) describe adult individuals showing a variety of infant-related interests and behaviors, such as wearing diapers or engaging in infant-like role-play. People sharing these or similar interests, along with those with diaper fetishes, are collectively called Adult Baby / Diaper Lovers (AB/DLs) by their online community. These phenomena are poorly understood and the few case reports suggest a broad heterogeneity concerning symptom descriptions, interests and behaviors (Caldwell, 2008; Croarkin, Nam & Waldrep, 2004; Dinello, 1967; Evcimen & Gratz, 2006; Kise and Nguyen, 2011; Malitz, 1966; Pate & Gabbard, 2003; Tuchman & Lachman, 1964).

In a prior exploratory study of the online AB/DL community, Hawkinson and Zamboni (2014) found evidence for two distinct subgroups within the AB/DL community, which they termed “the Adult Baby”, with a primary interest in role play, and “the Diaper Lover” without an interest in role play. So far, it is unclear how paraphilic infantilism develops but affected people often struggle with shame and fear of disclosing their desires because it has repeatedly been associated with pedophilia.

Money (1986) coined the terms nepiophilia (i.e. a sexual interest in infants) and autonepiophilia (i.e. a sexual interest in dressing as an infant). He wrote that they were obverse syndromes, both relating to infancy. Later, Freund and Blanchard (1993) proposed that a small subgroup of people with a certain external erotic target would become sexually aroused by the idea or fantasy of being their erotic target themselves. They termed this transformation an Erotic Target Identity Inversion (ETII), resulting in an Erotic Target Location Error (ETLE). The most frequent application of this hypothesis is autogynephilia, where gynephilic (i.e. women are the preferred erotic target) men develop gender dysphoria and want to become women. Freund and Blanchard (1993) also applied the ETII hypothesis to pedophilia (i.e. a sexual interest in prepubescent children), asserting that some of those who want to have sex with children might also tend to want to be children themselves. Recently, Hsu and Bailey (2017) reported data that apparently support ETII as an etiology for paraphilic infantilism. They identified the co-occurrence of pedophilia and sexual arousal associated with the idea of being a child in an online sample of pedophilic men. They showed a tendency for heterosexual pedophilic men to want to become girls, as expected from ETIIs. They also stressed that the external erotic targets and internal identities are similar in men with ETIIs. Given that the ETII hypothesis thus assumes that the erotic targets of people with paraphilic infantilism are infants or children, we were interested in exploring the prevalence of pedophilic and nepiophilic sexual fantasies in people with paraphilic infantilism.

Another possible risk factor for the development of paraphilic infantilism may be past traumatic events.

In a number of case studies, patients with paraphilic infantilism also reported sexual and physical abuse (Evcimen & Gratz, 2006; Kise & Nguyen, 2011) and it was hypothesized that childhood maltreatment may contribute to the development of paraphilic infantilism (Evcimen & Gratz, 2006). However, case studies might over-report childhood maltreatment out of confirmation bias. Moreover, the case studies were based on histories of psychiatric patients with psychotic symptoms, where increased rates of childhood maltreatment are common (Varese et al., 2012). Hawkinson & Zamboni (2014) reported correlations that suggest that specific AB/DL behaviors may compensate for a poor relationship with mothers or fathers in some male participants, yet also warned against assuming that AB/DL behaviors exclusively develop to cope with negative feelings. We were thus aiming to systematically explore the supposed connection between paraphilic infantilism and childhood maltreatment.

We conducted an online survey within the AB/DL online community to understand more about the development of paraphilic infantilism. We were interested in exploring the two hypotheses about the origins of paraphilic infantilism that have appeared in the literature, namely that paraphilic infantilism is (i) an ETII and related to pedophilia or nepiophilia and (ii) associated with childhood maltreatment.

Moreover, we also collected qualitative data on participants’ own opinions about the etiology of their paraphilic infantilism and further quantitative items to understand more about the nature of paraphilic infantilism.

Methods

Participants

In total, 2686 participants started the survey and gave informed consent. From these, 80 were deleted because they were younger than 18 years old. To be included in the current analysis, participants had to be cisgender men and answer every question except for the open questions in the end (N = 1904). Male participants had a mean age of 30.91 years (SD 11.36) and a range from 18 to 90 years. Demographic characteristics of the sample are displayed in Table 1.

Procedure

Ethical approval was received by the local ethics committee (Psychotherapeutenkammer, Hamburg) and the study was conducted in accordance with the good clinical practice guidelines as defined in the Declaration of Helsinki. Inclusion criteria were self-reported affiliation to the AB/DL community and being aged 18 years or older. The questionnaire was distributed online on different AB/DL-related websites, forums and Facebook groups (e.g. reddit.com/r/ABDL, adisc.org, AB/DL groups on fetlife.com). With approval of the group or website administrators, a link to the survey was posted, alongside a short description of the study regarding what kind of questions would be asked and how much time it would take to answer the survey. Participants were informed that we intended to better understand the fantasies and behaviors of people with AB/DL-related interests. Before they consented to take part in the study, participants were informed that the survey was strictly anonymous, that their participation was completely voluntary and could be stopped at any time throughout the answering process. The survey took approximately 20 to 30 minutes to complete.

Instruments

The questionnaire consisted of 69 items. First, we asked for basic demographic data like age, gender (male, female, transgender: female to male, transgender: male to female, intersex and gender nonconforming), highest formal education (less than 9^th grade to graduate degree) and annual income (less than 25.000$ to 100.000$ or more).

These were followed by questions about AB/DL-related interests and behaviors. Next, we asked on how many days (0 – 31) they wear a diaper in a typical month, in which situations they wear diapers (all the time, never, while working, during daytime when I am alone, during day time when I am with others, while sleeping, during sexual activities) and for the reasons they are wearing diapers. For each reason (relaxing, sexual stimulation, because I am a baby, role play, because I have a medical condition (for example incontinence)) they could chose the frequency on a 5-point Likert scale from 1 always to 5 never.

We also asked for the age at which participants became interested in AB/DL practices. In addition, participants were asked about their AB/DL age. They could type in the lower and upper limit of the age range they regress to (0–99 years). Participants who reported regressing to a prepubescent age (age 012) were subsequently labeled childhood regressers and participants who did not report regression under the age of 13 were labeled childhood non-regressers. These groups were roughly analogous to the “adult baby” and “diaper lover” in a prior study (Hawkinson & Zamboni, 2014), where those with an interest in regression were termed “adult babies”.

To assess pedophilia, we asked participants about the age ranges of people they have felt sexually attracted to or had fantasized about having sex with within the past 12 months, based on Santtila et al. (2015). We modified the age ranges (0–1 years: baby, 1–3 years: toddler, 4–12 years: child, 13–19 years: adolescent, 20–40 years: adult, 40–60 years: middle-aged, above 60 years: senior) to also get information about sexual attraction to infants (nepiophilia). We also asked about the role-played age ranges participants have felt sexually attracted to using the same age ranges. Participants were asked if they were sexually aroused by the thought of being a baby, and the thought of being a baby/child who is sexually abused (5-point Likert scale from 1 always to 5 never).

Moreover, we assessed childhood adversity with the 28-item version of the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 2003). The retrospective questionnaire assesses five types of childhood adversity on a self-reporting basis; emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. It consists of 25 clinical and 3 minimizing/denial items (e.g., I had the perfect childhood), which are scored on a 1 (never true) to 5 (very often true) Likert scale according to the extent in which subjects agree with the statement (e.g. When I was growing up, someone tried to make me do sexual things or watch sexual things (childhood sexual abuse: CSA); people in my family looked out for each other (reverse item; childhood emotional neglect: CEN); my parents were too drunk or high to take care of the family (childhood physical neglect: CPN); people in my family said hurtful or insulting things to me (childhood emotional abuse: CEA); I got hit so hard by someone in my family that I had to see a doctor or go to the hospital (childhood physical abuse: CPA)). Scores range from 5 to 25 for each type of abuse. The CTQ has shown excellent reliability (Bernstein et al., 1994; Bernstein & Fink, 1998) as well as validity compared to a clinician rated interview of childhood abuse and a therapists’ rating of abuse (Bernstein et al., 1997; Bernstein & Fink, 1998; Fink et al., 1995). Additional to the dimensional ratings we calculated threshold scores for each type of abuse or neglect to determine the severity of childhood maltreatment (none to minimal (1), mild (2), moderate (3) or severe (4)) in analogy to the manual by Bernstein and Fink (1998). For example, a score over 16 indicates severe CEA; while a score over 13 indicates severe CPA, CSA, and CPN. For CEN a score over 18 is required to indicate severe neglect. Moreover, dichotomized variables were created for each dimension (absent (none to minimal) vs. present).

The last questions were open questions with a textbox. For the present study, we focused on the question “What do you think are reasons for your AB/DL interests? Why have these interests developed and what is their purpose?” Further qualitative and quantitative data regarding sexuality were collected and will be reported elsewhere. The questionnaire was developed with input from one member of the AB/DL online community.

Qualitative data

We analyzed the qualitative (open-ended) responses to the question “What do you think are reasons for your AB/DL interests? Why have these interests developed and what is their purpose? ” Qualitative content analysis (Mayring, 2010) was used to analyze the responses. Data were first rated by a coder in order to determine categories. The codes were discussed with another coder, who had also read the responses, and were subsequently modified. Fourteen categories were formed. Responses of the first 500 participants were subsequently coded by two independent raters to compare the inter-rater reliability and calculate Cohen’s kappa. The kappa value can be interpreted according to Altman (1991) and was very good for 8 categories (0.81–1) and good for 6 categories (0.61–0.80). The remaining data were coded by one rater.

Statistical analyses

Statistical analyses were carried out using IBM SPSS Statistics 22.0 (IBM Corp., Armonk, NY). Data are reported as percentages or means ± SD. For statistical analysis we formed subgroups of participants who reported “regressing to a prepubescent age” during AB/DL role play (childhood regressers) and those who did not (childhood non-regressers). Prevalence rates between groups were compared using 2 x 2 Chi-square tests of independence. To compare age between groups we used a two-tailed t-test. To compare the means of the CTQ subscores we used a MANOVA with CTQ scores as dependent, subgroups (regresser vs non-regresser) as independent variable and age as covariate. According to the central limit theorem we assumed normal distribution due to the large sample size when calculating the MANOVAs. Because we found relatively high levels of childhood sexual (CSA) and physical abuse (CPA) in our sample, we tested possible relationships between CSA and CPA with core demographic variables using parametric and non-parametric tests, as appropriate. Statistical significance was set at p<0.01 due to the large sample size.

Results

Roughly half of the participants were in a relationship. Those in a relationship were significantly older than those without a relationship (M = 33.04 (SD 11.62) vs. M = 28.81 (SD 10.68); t(1886) = -8.23, p < 0.001). When asked about their role-play age, 78.4% (n = 1483) stated that they regress to under the age of 18, 76.4% (n = 1445) under the age of 13, 62.8% (n = 1188) under the age of 5 years and 19.8% (n = 374) to the age of a newborn or 1 year old child. Thirteen participants did not provide valid information about their role-play age.

Sexual arousal by the thought of being an infant was acknowledged by 62.0% at least rarely. Participants who reported regressing to a prepubescent age (age 0–12) (childhood regressers) significantly more often (73.7%) reported sexual arousal by the thought of being an infant compared to childhood non-regressers (24.2%; χ2 (1) = 354.37, p < 0.001). Moreover, 28.4% acknowledged that at least rarely imagining that they are a baby/child who is being sexually abused excites them sexually. Again, this was more often reported by childhood regressers (33.6%) than non-regressers (11.4%; χ2 (1) = 82.17, p < 0.001).

Pedophilia and nepiophilia

When asked about the age ranges of people they have felt sexually attracted to or fantasized about having sex with in the past 12 months, 17 participants (0.9%) reported a sexual attraction to babies (age 0–1), 40 participants (2.1%) to toddlers (age 1–3) and 70 participants (3.7%) to children (age 4–12).

Importantly, the overall 12-month incidence for any attraction to children (<13 years) was 5.0% (n = 95). Childhood regressers were significantly more often attracted to children below the age of 13 years (6.3%) compared to childhood non-regressers (0.4%; χ² (1) = 24.94, p < 0.001).

We moreover asked to which role-played age range participants feel sexually attracted to. Overall, 26.2 % (n = 498) of participants were attracted to people role-playing as a prepubescent child. Of these 83 (4.4%) felt sexually attracted to people role-playing as babies, 310 (16.3%) to people role-playing as toddlers, and 359 (18.9%) to people role-playing as children. Again childhood regressers were significantly more often attracted to people role-playing as children below the age of 13 years (31.7%) compared to childhood non-regressers (8.5%; χ² (1) = 94.6, p < 0.001).

Childhood maltreatment

Notably, 620 participants (32.6%) reported having experienced none to mild childhood maltreatment, 553 (29.0%) reported mild to moderate, 325 (17.1%) reported moderate to severe, and 406 (21.3%) reported severe to extreme childhood maltreatment.

Childhood regressers scored significantly higher in all five subscales of the CTQ (p < 0.001) compared to childhood non-regressers. In a MANOVA we found small but significant differences between both groups concerning child emotional abuse (CEA: 9.2 ± 4.8 vs. 7.8 ± 3.9 ; F_{1, 1888} = 33.91, p < 0.001, partial eta² = 0.018), child physical abuse (CPA; 7.1 ± 3.7 vs. 6.2 ± 2.3; F_{1, 1888} = 23.5, p <0 .001, partial eta² = 0.012), child emotional neglect (CEN: 11.2 ± 4.9 vs. 10.2 ± 4.7; F_{1, 1888} = 13.85, p < 0.001, partial eta² = 0.007), child physical neglect (CPN: 7.1 ± 2.9 vs. 6.6 ± 2.5; F_{1, 1888} = 14.37, p < 0.001, partial eta² = 0.008) and child sexual abuse (CSA: 6.5 ± 3.9 vs. 5.7 ± 2.5; F_{1, 1888} = 11.3, p = 0.001, partial eta² = 0.006), with higher maltreatment rates in childhood regressers. The prevalence was twice as high for severe CEA (12.9% vs. 5.4%) and severe CSA (6.5% vs. 3.6%) and almost three times as high (8.0% vs. 2.9%) for severe CPA in the childhood regresser group. Detailed information on group differences is displayed in Table 2.

Participants who indicated CSA or CPA were also significantly older compared to participants without CSA or CPA (M = 35.3 (SD 12.9) vs. M = 29.9 (SD 10.7) years for CSA, t(1902) = -8.21, p < 0.001 and M = 32.6 (SD 12.2) vs. M = 29.6 (SD 10.5) years for CPA, t(1902) = -5.75, p < 0.001 in independent t-tests), which was not found for the other types of abuse. A chi-square test revealed that participants who indicated any kind of abuse reported significantly more often that they had grown up without either their natural father or mother (χ² (1) = 80.51, p < 0.001). Moreover, CPA and CSA were negatively associated with education level and number of children (each p < 0.001 in non-parametric Mann-Whitney U Test).

To analyze associations between childhood abuse and pedophilic interests, we performed a further MANOVA with CTQ-scores as dependent and pedophilic interest (y/n) as independent variables, including age as covariate. In participants with pedophilic interests, we found significantly higher scores of CSA (7.5 ± 5.3 vs. 6.0 ± 3.2; F_{1, 1904} = 15.5; p < 0.001, partial eta² = 0.008), CPN (8.0 ± 3.5 vs. 7.0 ± 2.8; F_{1, 1904} = 12.4; p < 0.001, partial eta² = 0.007), CPA (7.7 ± 4.3 vs. 6.7 ± 3.2; F_{1, 1904} = 7.2; p = 0.007, partial eta² = 0.004) and a trend for CEN (12.2 ± 5.3 vs. 10.9 ± 4.9; F_{1, 1904} = 5.6; p = 0.018, partial eta² = 0.003) yet no significant effect for CEA (9.4 ± 5.3 vs. 8.9 ± 4.6; F_{1, 1904} = 1.1; p = 0.304, partial eta² = 0.001).

The prevalence for pedophilic interests was significantly higher in participants indicating CSA (7.9%) compared to those without self-reported CSA (4.3%; χ² (1) = 7.73, p = 0.005).

We were moreover interested in the association between adult fantasies about being a child suffering maltreatment or abuse, and pedophilic interest as well as self-reported childhood maltreatment. Participants who reported that they were at least rarely sexually aroused by imagining that they are a baby/child who is being sexually abused were significantly more likely to also report pedophilic interests (10.9% vs. 2.6%; χ2 (1) = 56.036, p < 0.001) or CSA (27.8% vs. 15%; χ2 = 41.449, p < 0.001).

Paraphilic infantilism-related role-play and fantasies

The mean age at which participants became interested in AB/DL fantasies or behaviors (or the earliest age they remember having these interests) was 10.18 years (SD 6.03) with a range from 1 to 55 years (mode = 5 years; 10%). The mean number of days participants wore diapers in a typical month was 13.75 (SD 10.41) with a mode of 31 (13.4%). The reasons for wearing diapers and situations in which diapers are worn are shown in Table 3. Relaxing was the most reported reason for wearing diapers, with 62% of regressers and 52% of non-regressers indicating that they always wore diapers to relax. The second most reported reason was sexual stimulation, with 28% of regressers and 45% of nonregressers always wearing diapers for sexual stimulation.

Identity and reasons for infant-like behaviors

Participants could agree to different statements on a 5-point Likert scale from 1 totally to 5 totally not. Most participants totally agreed with seeing themselves as an adult with an AB/DL interest while 10% of regressers and 0.5% of non-regressers totally identified as babies or children. Many participants also acknowledged that AB/DL behaviors were a coping mechanism for difficult feelings such as boredom, stress, frustration, guilt or shame or for difficult problems or responsibilities in life (Table 4).

Qualitative Data

We asked participants to speculate in an open textbox about the origins and purpose of their AB/DL interests and most participants provided an answer (70.4%). The answers were coded into different categories and subsequently subsumed under the following groups:

Developmental factors: Negative or traumatic events during childhood

Several code s involved specific negative events during childhood such as childhood maltreatment. This included 8.8% (Cohen’s kappa ϰ = 0.87) of participants reporting a lack of a happy childhood because of problematic experiences such as upbringing in foster homes. For example: early parentification or

(26y): ”I never got a chance to experience my child hood so I am simply re living it and that’s because I have been in so many different group homes and foster homes from age 7 to 18”

(21 y): “I had to grow up quickly. I had to help take care of my younger brothers. I had to be in charge and make grown up decisions.”

Other participants (4.8%; ϰ = 0.89) reported a contrast between a positive early childhood and a less positive upbringing that followed it. Those participants indicated that they were wishing themselves back to an earlier time when practicing infant-related behaviors as adults. A participant (50 y) reported:

“It is just something that happened perhaps because that was the last time I really felt cared for”

Some participants indicated a medical condition in childhood (3.7%; ϰ = 0.76) as the reason for their adult AB/DL interest. For example, a participant (57 y) wrote:

“(…) having an overactive bladder and inflammatory bowel disease (Crohn) which caused also incontinence issues during daytime. I grew up in diapers, had my first orgasms in them. So wet and messy diapers are associated with sexual arousal”

Moreover, 5% (ϰ = 0.81) of participants related their interest to a traumatic event (such as physical or sexual abuse) during their childhood or particularly to punishment involving diapers and infant-like behaviors (2.5%; ϰ = 0.71). Two participants reported:

(20 y): “It started back when my grandpa molested me. I just started knowing and seeing what i was doing and they put me back in diapers because even though i was toilet trained i was wetting and messing myself because of my grandpa”

(47 y): “My parents divorced when I was 4. Mom worked and grandparents watched us. In second grade (8yrs old) I had a messy accident at school and was sent home. Mom cleaned me, spanked me, diapered me and treated me like a baby for the rest of the day. Negative attention was still attention from a mother I rarely saw. I loved it”

Furthermore, 3.7% (ϰ = 0.97) of participants hypothesized that losing or being separated from a parent at an early age was a possible reason for their paraphilic infantilism.

(21 y): “I know I have wanted to wear diapers since I was roughly 4 years old. I certainly believe that my interests have /become/ sexual as a result of growing up, but I believe that ultimately the core is nonsexual. My mother was paranoid schizophrenic and emotionally unstable and had custody of me until six months before my fourth birthday, at which point my father won sole custody. I have seen my mother for probably less than a total of a month since — this is largely my choice. However, I feel, based on my history and the history of other AB/DLs I know, that being separated from my mother permanently at a younger age than usual could have caused this”

(33 y): “Possibly just developed as a coping method after my mother passed away”

Others indicated a wish for more attention often combined with experienced neglect (6.1%, ϰ = 0.92) as a reason. This code included:

(33 y): “My little sister took the attention. I had lots of insecurities in my upbringing”

(22 y): “I think it comes down to the fact that my sister was born when I was only 3, and she had some serious health issues that required round the clock parental care. I was jealous that after 3 years of being the center of attention, I was basically left out in the cold. In my infinite 3 year old wisdom I thought that if I acted like the baby again, my parents would start babying me again. This included stealing my younger sisters diapers, wetting the bed on purpose, and having fake accidents to try and get them to diaper and baby me. It eventually developed into a fetish after I was caught multiple times and told to stop; like the forbidden fruit I wanted so desperately”

Developmental factors: Other events during childhood

Two codes were subsumed under this category. Firstly, 11.9% indicated prolonged continuation of infant-like behaviors into childhood or adolescence as a reason for their AB/DL interests. A typical example was late potty training and bedwetting. Two participants explained:

(24 y): “I was allowed the use of a pacifier up to the age of 7”

(22 y): “I was in diapers until about 4 years of age”

Secondly, 8.1% (ϰ = 0.72) hypothesized that a specific event or a few specific events induced their interest in AB/DL behaviors. Specifically, this code was only applied when events were neutral or positive. For example, one participant (22 y) wrote:

“Friend brought it up to me while talking about himself, I had never given it much thought and I became very interested in it”

Sexual interest

A group of participants (10.8%; ϰ = 0.79) argued that their paraphilic infantilism was primarily sexual. Often they also provided theories on why diapers and infant-like role play became sexual stimuli for them without referring to specific events during childhood, for example two participants explained:

(38 y): “My fetish is the sexualization of situations that subconsciously embarrassed and scared me as a child. My worst fears became my greatest desires, driven by an intense sense of taboo”

(26 y): “Generally, the arousal or excitement seems to stem from doing something considered forbidden, embarrassing, or naughty. Earlier everything was rather purely sexual and masturbation oriented, I could orgasm fast and rather frequently by using diapers as a catalyst, but lately (years) my diaper use has taken a direction towards relaxation rather than being purely sexual”

No theory or seeing it as inborn

A large group of participants (14.6%; ϰ = 0.82) indicated that paraphilic infantilism seems to be an inherent interest for them, which they had as long as they could remember. This code was applied when participants indicated that they were always interested in paraphilic infantilism or that the interest was inborn without providing a further theory. For example, one participant (26 y) reported:

“Not sure.. the interest in diapers has always been there. When I started to have sexual feelings, they were also applied onto diapers”

Others (16.3%; ϰ = 0.76) simply indicated that they have “no idea” about the reasons for their AB/DL interest.

Discussion

We here analyzed the data of 1904 male participants from the AB/DL online community with the aim of better understanding the underlying mechanisms of paraphilic infantilism. The finding that most participants did not self-report pedophilic interests argues against an underlying ETII in paraphilic infantilism. However, the prevalence of self-reported childhood maltreatment was high and in participants’ own opinions about causation, negative and traumatic experiences were commonly cited as an etiological factor. Self-reported childhood sexual abuse was associated with sexual arousal related to the thought of being a child who is abused. Moreover, the prevalence of CSA was high in those participants declaring sexual attraction to, or fantasies involving, prepubescent children. Our data thus indicate that paraphilic infantilism, in some participants, involves replaying (and/or sexualizing) traumatic and negative childhood experiences, or recreating an idealized childhood presumably to master traumatic memories or gain paternal devotion that was absent in childhood.

Pedophilia and Nepiophilia

In our sample, the 12-month incidence for sexual attraction or fantasies involving prepubescent children (under the age of 13) was 5% and 0.9% for fantasies involving babies (age 0–1). In comparison, the largest and most accurate online study to examine self-reported pedophilic interest in a community sample in the western world was recently published by Dombert et al. (2016). In an online sample of 8,718 German males, 5.5% reported any form of pedophilic interest (any report of fantasy, child pornography consumption, behavior or having paid a child for sexual services) and 4.1% indicated sexual fantasies involving children under the age of 13 in their lifetime. Thus, the 12-month incidence for pedophilic interest in men with paraphilic infantilism seems to be roughly comparable to the lifetime prevalence in the general male population. However, the degree to which 12-month incidence and lifetime prevalence differ is not clear. Seto (2009) stated that only some of the individuals acknowledging sexual fantasies involving prepubescent children in surveys might meet the diagnostic criteria for a pedophilic disorder in terms of persistence and intensity. Hence, the prevalence for pedophilic disorder is expected to be much lower in the present sample as well as in Dombert et al. (2016).

Of note, Hsu and Bailey (2017) reported that regressive interests may be highly prevalent in pedophilic men with almost half of their sample of pedophilic men feeling at least mildly sexually aroused when they imagined being a child or having a child’s body. Contrasted with the present data, this indicates a rather unidirectional connection between pedophilia and paraphilic infantilism: While fantasies of being a child seem to be common among pedophilic men according to Hsu and Bailey (2017), our data indicate that pedophilia and paraphilic infantilism might not be mutually exclusive, yet do not support any meaningful role of pedophilic sexual desire in paraphilic infantilism.

Alternatively, ETII hypothesis claim that internal identity follows from external erotic targets can be applied to sexual preferences for adults role-playing as prepubescent children. Arguably, this is a more liberal application of an ETII, since such attractions could be engaged in legally. According to the ETII hypothesis, a sub-group of those sexually attracted to adults who were role-playing as prepubescent children would develop the wish to role play as a prepubescent child. Such an application of ETII hypothesis would explain the etiology of paraphilic infantilism. However, we found that only a minority of those who role play as prepubescent children (31.7%) reported a sexual attraction toward people role playing as prepubescent children. Therefore, most childhood regressers did not report being attracted to other people who were regressing into childhood age ranges, arguing against a prominent role of this alternative application of an ETII.

The external erotic targets and internal identities thus seem to be dissimilar in the majority of people with paraphilic infantilism. Pedophilia and paraphilic infantilism appear to be two distinct conditions, which are not directly related in most participants even though they may share risk factors (such as childhood maltreatment) and can thus appear in one person, as one participant (29 y, male) reported:

“I have got into a program as a result of legal issues surrounding child pornography. This isn’t directly related to my AB/DL curiosity as I almost never combined the two, when looking online for AB/DL material I almost always looked at people around my age (…)”

Childhood maltreatment

Prevalence for self-reported childhood maltreatment ranged from 20.7% for child sexual abuse, 22.7% for physical abuse, 31.7% for physical neglect, 40.8% for emotional abuse, to 55.7% for child emotional neglect in our sample. In comparison, Thombs et al. (2006) found considerably lower levels of childhood maltreatment exploring a community sample of 775 US participants using the CTQ, however they only published results concerning abuse, not neglect (10% sexual abuse, 16% physical abuse and 31% emotional abuse). Another survey using the CTQ in 2500 German participants representative of the general population reported comparable prevalence rates for childhood maltreatment (12.7% sexual abuse, 12.2% physical abuse, 15.2% emotional abuse, 49.7% emotional neglect and 48.6% physical neglect) (Häuser, Schmutzer, Brähler & Glaesmer, 2011). Compared to these findings, individuals of the present study appear to have had a much higher burden of childhood physical abuse (almost double), sexual abuse (around double) and emotional abuse (around double) compared to the US and German populations, while the prevalence of emotional neglect was comparable and physical neglect was lower compared to the German population. We moreover found that participants who reported regressing to a prepubescent age were significantly more likely to report all forms of childhood maltreatment, though effect sizes were small. Participants who reported CSA and/or CPA were significantly older compared to participants with no history of childhood abuse. Two explanations for this older age could be that rates of childhood abuse are decreasing over time (Kloppen et al., 2016) and that a history of childhood abuse leads to more persistent AB/DL-related interests. If only severe to extreme childhood abuse was compared, values were even higher in our sample compared to the German population. In line, analyzing the qualitative data, a subgroup of participants suggested a relation between childhood maltreatment and the development of paraphilic infantilism. Notably, some participants even cited traumatic punishment involving diapers during childhood. Interestingly, significant associations between childhood maltreatment, especially childhood sexual abuse, and pedophilic interests as well as the fantasy of being a child who is sexually abused were found.

Repetition or replay of traumatic, dangerous or negative experiences in childhood as a means to reverse or master the trauma with its related emotions has long been proposed as an underlying etiology of paraphilias (Stoller, 1976). Stoller (1976) described the need for an illusion of risk in fantasy, as a source of excitement as well as an opportunity to reverse past trauma into triumph. This conceivably might extend to recreating one’s infancy – a time of maximum helplessness – under the controlled and self-supervised conditions of fantasy as an adult. Corradi (2009) argued that these compulsive repetitions can be characterized either as reparative (i.e., to master unresolved traumas), retributive (i.e., going back to be punished), or restorative (i.e., going back to get nurturant supplies). Scott (1983) writes of one person who was subjected to diaper-related punishment and humiliation in childhood, and in adulthood had a compulsion to subject himself to it again in fantasy. Similarly Money (1987) writes of a compulsion to repeat caning suffered in boarding school. As Money points out, this might be an application of an opponent process, as described by Solomon (1980). Per Solomon’s theory, negative sensations are followed by counterbalancing positive sensations. With repetition, habituation reduces the impact of the initial aversive sensation, eventually leading it to be overcome by the positive afterreaction of the opponent process. As a result, past trauma could be safely and enjoyably relived in fantasy. While speculative and clearly not the only possible explanation, this provides an explanation of why childhood maltreatment might result in a tendency to develop paraphilic infantilism.

Importantly, however, one-third of the present sample reported no or only minimal experiences of any form of childhood trauma or maltreatment. A recent meta-analysis found a poor agreement between prospective and retrospective measures of childhood maltreatment (Baldwin, Reuben, Newbury & Danese, 2019). Some people identified prospectively as having experienced childhood maltreatment do not report childhood maltreatment in adulthood. Thus, we cannot rule out that some of those reporting no or minimal childhood maltreatment may indeed have experienced childhood maltreatment

Etiological overlap with gender dysphoria?

Freund and Blanchard (1993) and Giles (2012) argued that paraphilic infantilism is comparable to gender dysphoria and suggested that the phenomenon should therefore be called age identity disorder. In the present study, a majority of participants reported that wearing diapers is always “relaxing” while a minority reported that it always leads to sexual stimulation. This might be the result of a transition described by one participant, where relaxation progressively replaces sexual excitation. A similar transition, except relating to cross-dressing, has been observed clinically in some transwomen (Burich, 1978). Also, similar to some people with gender dysphoria a younger participant in the present study described the sexualization of a core that he believed to be not sexual. The quantitative data did not differentiate among a lack of initial sexualization, a later fading, and other courses. Individually or collectively, these might have resulted in only a minority of participants reporting that their practices always lead to sexual stimulation.

However, data of the present study also show that only a small minority of the sample indicated that they totally want to be a baby for the rest of their life, while one third of the sample totally disagreed with this idea. Similarly, less than 10% see themselves as a baby or child but 71.7% see themselves as adults with AB/DL interests. This argues against an infant identity in most participants. Our findings therefore highlight significant differences between paraphilic infantilism and gender dysphoria.

Limitations

Due to the online approach, the present sample might not be representative of the group of people with paraphilic infantilism. Not all individuals interested in paraphilic infantilism might actively participate in the AB/DL online community. There was also no comparative sample from the general population or clinical control group. In addition, some of the questions regarding sexuality might have been difficult to answer for individuals who identify as asexual, as there was not always an alternative answer option for asexuality.

Conclusion

We found no empirical evidence that paraphilic infantilism is a pedophilic sexual interest with an erotic target identity inversion. In contrast, rates of childhood trauma were high in this sample, especially in those reporting regression to a prepubescent age. Many participants also saw a relation between childhood traumatic events and the development of paraphilic infantilism. We found tentative evidence indicating that repetition of traumatic childhood experiences or recreation of an idealized childhood as a means to reverse or master trauma could be a reason why some of the participants of the present study developed paraphilic infantilism. Notably, however, the expressions of desire among individuals with paraphilic infantilism were diverse – some reported purely sexual motives while others perceived their interest as an effective way to cope with traumatic memories or difficult feelings.

References

Table 2 Childhood maltreatment for childhood regresser (n = 1445) and non-regresser (n = 446) according to CTQ

Note. N = 1891; ^a absolute frequencies with (%); ^bn = 446; ^cn =1445; *** p < .001

Table 3 Situations and reasons for wearing diapers

Note. N = 1891; ^an =1445, ^bn = 446

Table 4 Agreement with statements

Note. N = 1891; ^an =1445, ^bn = 446