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Chapter 20
Erotic Target Identity Inversions
Kevin J. Hsu and J. Michael Bailey
Abstract Sexual orientation is conventionally understood as relative attraction to
men versus women. It has recently been argued that male sexual orientation in
particular can be extended to include other dimensions of sexual attraction besides
gender. One such dimension is sexual maturity, or relative attraction to children
versus adults. A less familiar dimension is location, or relative attraction to other
individuals versus sexual arousal by the fantasy of being one of those individuals.
Erotic target identity inversions (ETIIs) refer to some men’s sexual arousal by the
fantasy of being the same kinds of individuals to whom they are sexually attracted.
Thus, ETIIs reflect the movement from external attraction to internal attraction on
the dimension of location. ETIIs can motivate men to change their appearance and
behavior to become more like the individuals to whom they are sexually attracted.
ETIIs also provide a compelling theoretical explanation for otherwise puzzling
phenomena, such as cross-dressing among heterosexual men, desire for limb ampu-
tation, and the furry phenomenon. Despite its scientific and clinical value, the
concept of ETIIs has been underappreciated and understudied. This chapter reviews
the ETIIs that have been previously identified in the literature, addresses important
issues related to ETIIs, discusses the causes and development of ETIIs, and proposes
future directions for research.
Keywords Erotic target identity inversion · Autogynephilia · Apotemnophilia ·
Autopedophilia · Paraphilia · Sexual orientation
K. J. Hsu (*)
Department of Psychology, Northwestern University, Evanston, IL, USA
Department of Psychological and Social Sciences, Pennsylvania State University, Abington,
Abington, PA, USA
e-mail: khsu@psu.edu
J. M. Bailey
Department of Psychology, Northwestern University, Evanston, IL, USA
©The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
D. P. VanderLaan, W. I. Wong (eds.), Gender and Sexuality Development, Focus on
Sexuality Research, https://doi.org/10.1007/978-3-030-84273-4_20
589
Most people understand sexual orientation to mean relative attraction to men versus
women. Some researchers (Blanchard, 2015; Hsu & Bailey, 2017; Seto, 2017) have
recently argued that the meaning of sexual orientation can be extended to include
other dimensions of sexual attraction besides gender, at least in men. For example,
men vary in the extent to which they are attracted to sexually mature adults
(teleiophilia) compared with prepubescent or pubescent children (pedohebephilia)
(Bailey et al., 2016; Seto, 2012,2017). It has been argued that important aspects of
this dimension of sexual attraction––early onset, strong arousal by some but not all
gender-age categories, and stability across time––are identical to the reasons why we
refer to relative attraction to men versus women as sexual orientation.
In addition to gender and sexual maturity, another dimension of men’s sexual
attraction may comprise sexual orientation. This dimension is likely to be less
familiar and more puzzling: the degree to which men are sexually attracted to
other individuals or instead sexually aroused by the fantasy of being one of those
individuals (Blanchard, 1991; Freund & Blanchard, 1993; Lawrence, 2009b).
Although most men are sexually attracted to other individuals (e.g., women) and
thus have external erotic targets, some men are sexually aroused by the fantasy that
they are one of those individuals and thus locate an erotic target within their own
body. In the latter case, their sexuality comprises an erotic target identity inversion
(ETII; Freund & Blanchard, 1993).
Men with ETIIs vary in the extent to which they retain attraction to other
individuals (Blanchard, 1989b,1992). Indeed, some men with ETIIs are
analloerotic, or exclusively sexually aroused by fantasizing about themselves as
another individual. Because they do not experience sexual attraction to others,
analloerotic men with ETIIs may report that they are asexual (Bogaert, 2012; Brotto
& Yule, 2017). Those unfamiliar with ETIIs may also assume that they lack any kind
of sexual attraction at all. Among men with ETIIs who retain sexual attraction to
others, the external and internal erotic targets are similar. For example, men sexually
aroused by the fantasy of being a woman are sexually attracted to actual women, if
they are attracted to other individuals at all. Thus, ETIIs reflect the extent to which
men’s sexual attraction is external versus internal on a dimension that may be
considered an erotic target’s location (Blanchard, 2015; Hsu & Bailey, 2017).
ETIIs can motivate men to change their appearance and behavior to become more
like their internalized erotic target (Bailey, 2003; Blanchard, 1989a,1991; Freund &
Blanchard, 1993; Lawrence, 2006,2009b,2013). For example, men sexually
aroused by the fantasy of being a woman are often motivated to cross-dress and to
act like women (Bailey, 2003; Blanchard, 1991; Blanchard et al., 1986; Brown et al.,
2020; Hsu et al., 2015; Hsu et al., 2017; Lawrence, 2013). Some men are so strongly
motivated by ETIIs that they seek expensive and irreversible medical procedures to
make their bodies more like their internalized erotic target. For example, some natal
males sexually aroused by the fantasy of being a woman are motivated to seek
gender confirmation surgery in order to make their bodies more like those of women
(Bailey, 2003; Blanchard, 1991; Freund & Blanchard, 1993; Lawrence, 2009b,
2013). Recently in Western countries, most natal males who have completed gender
confirmation surgery appear to be motivated by ETIIs (Lawrence, 2010a).
590 K. J. Hsu and J. M. Bailey
In the following sections, we review the ETIIs that have received scientificor
clinical attention thus far. We then address ETIIs as paraphilias, ETIIs in natal
females, and sexual masochism as an alternative explanation to ETIIs. Finally, we
discuss the causes and development of ETIIs and propose future directions for
research. In our proposal for future directions, we introduce a few more potential
ETIIs for consideration.
20.1 Autogynephilia
Autogynephilia is a natal male’s propensity to be sexually aroused by the thought or
image of being a woman (Blanchard, 1989a), and it is the best studied example of a
possible ETII (Blanchard, 2005; Lawrence, 2013). Autogynephilia occurs in natal
males who are sexually attracted to women (Blanchard, 1991,1993a; Freund &
Blanchard, 1993; Lawrence, 2007). However, autogynephilic males’attraction to
women has been internalized to some degree, such that they are also sexually
aroused by the fantasy of being a woman. Although autogynephilia usually coexists
with sexual attraction to women, sometimes the internalization is so complete that
the autogynephilic male does not experience sexual attraction to women. Because
women are the preferred erotic targets of most men, autogynephilia is likely to be the
most common form of ETII (Blanchard, 1993b).
Most commonly, autogynephilia manifests as erotic cross-dressing, usually by
adolescence (Bailey, 2003; Blanchard, 1991; Blanchard et al., 1986; Brown et al.,
2020; Hsu et al., 2015,2017; Lawrence, 2013). The specific erotic interest in cross-
dressing is called transvestic fetishism (sometimes shortened to transvestism). Cross-
dressing is a relatively easy, impermanent, and inexpensive way for a man to make
himself look more like a woman. Thus, autogynephilic males often cross-dress to
satisfy their sexual fantasy of being a woman. Some find it erotic to fantasize about
having female-typical anatomy like breasts or a vagina. These anatomically
autogynephilic males are more likely to experience gender dysphoria, or recurrent
and intense feelings of discontent with being male (Blanchard, 1993a,1993c). For
some autogynephilic males, gender dysphoria and motivation to become a woman
are so strong that they pursue gender confirmation surgery (Blanchard, 1991;
Lawrence, 2004). The first row of Table 20.1 lists autogynephilia and its related
phenomena as they pertain to the concept of ETIIs.
Studies that have examined the co-occurrence of autogynephilia and sexual
attraction to women among gender dysphoric natal males or male-to-female trans-
gender women provide indirect evidence supporting the idea that autogynephilia is
an ETII. These studies have converged on the general finding that gender dysphoric
natal males (Blanchard, 1985,1989b,1992; Blanchard et al., 1987; Freund et al.,
1982; Zucker et al., 2012) and transgender women (Lawrence, 2005; Nuttbrock
et al., 2011; Smith et al., 2005; Veale et al., 2008) who are sexually attracted to
women report higher levels of autogynephilia or erotic cross-dressing, compared
with those who are exclusively sexually attracted to men. Conversely, men with
20 Erotic Target Identity Inversions 591
Table 20.1 Sexual attraction to erotic targets, erotic target identity inversions, and their related phenomena in men
Erotic targets
Sexual attraction to erotic
targets Erotic target identity inversion
Manifestation of erotic target identity
inversion
Related identity
dysphoria
Women Gynephilia Autogynephilia Cross-dressing (Transvestism) Gender dysphoria
Amputees Acrotomophilia Apotemnophilia Pretending Body integrity
dysphoria
Children Pedohebephilia Autopedophilia Dressing in children’s clothing
(Pedovestism)
Age dysphoria
Anthropomorphic
animals
Anthropomorphozoophilia Autoanthropomorphozoophilia Fursuiting Species dysphoria
Real animals Zoophilia Autozoophilia Unknown Species dysphoria
Men Androphilia Autoandrophilia Homeovestism Masculinity dysphoria
Corpses Necrophilia Autonecrophilia Unknown Unknown
592 K. J. Hsu and J. M. Bailey
transvestic fetishism overwhelmingly report at least some attraction to women, with
the majority identifying as heterosexual (Docter & Fleming, 2001; Docter & Prince,
1997; Långström & Zucker, 2005; Zucker et al., 2012).
An online study of 149 men who endorsed items explicitly assessing
autogynephilia found that 81% identified as heterosexual and 15% as bisexual,
further suggesting that this population is near exclusively comprised of men sexually
attracted to women (Hsu et al., 2015). A more recent online study, using a much
larger sample of 522 men who endorsed an item assessing autogynephilia, found that
63% identified as heterosexual and 30% as bisexual (Brown et al., 2020). Such
findings would be predicted if autogynephilia is an ETII involving the internalization
of sexual attraction to women. Although Brown et al.’s(2020) study required that
autogynephilic men also reported sexual arousal by the thought of having sex with a
woman, it did not appear to have inflated the combined prevalence of heterosexual
and bisexual identities, which was similar to that in Hsu et al.’s(2015) study.
Consistent with the concept of ETIIs, gender dysphoric natal males and trans-
gender women sexually attracted to women tend to report much more autogynephilia
than do those not attracted to women (e.g., Blanchard, 1992). There is also a strong
tendency for autogynephilic men to report sexual attraction to women (e.g., Hsu
et al., 2015). Because men have such a high base rate of sexual attraction to women,
these findings are neither entirely surprising nor strong evidence for the concept of
ETIIs. Indeed, some transgender women insist that they are “lesbians trapped in a
man’s body”and vehemently oppose the idea that their sexual attraction to women is
related to autogynephilia (Dreger, 2008). If these individuals admit to experiencing
autogynephilia, they argue that it is an expression of their latent feelings of being
female, rather than an ETII. There are other, less common but more perplexing
phenomena that provide more persuasive evidence for the concept of ETIIs. We
review the most compelling example next.
20.2 Apotemnophilia
Lawrence (2006) argued that men who desire limb amputation are motivated by an
ETII. Their desire is, according to Lawrence, analogous to some autogynephilic
men’s desire for gender confirmation surgery. For men who desire limb amputation,
the motivation is apotemnophilia, or sexual arousal by the thought or image of being
an amputee (Money et al., 1977), which can be conceptualized as the ETII that
occurs in men with acrotomophilia, or sexual attraction to amputees (Money, 1986).
In this case, their attraction to amputees has been internalized to some degree, such
that they are sexually aroused by the fantasy of being an amputee.
In a study conducted by First (2005), 67% of 52 participants who desired limb
amputation reported sexual arousal from the fantasy of being an amputee, and 87%
reported sexual attraction to amputees. More recent surveys of primarily men who
desire limb amputation have also found large percentages reporting sexual arousal
from the fantasy of being an amputee and sexual attraction to amputees (Blom et al.,
20 Erotic Target Identity Inversions 593
2012,2017; Pregartbauer et al., 2014). Thus, following the concept of ETIIs, men
who desire limb amputation tend to report both apotemnophilia and acrotomophilia.
The tendency for apotemnophilic men to be especially attracted to amputees cannot
plausibly be explained by high base rates, in contrast to the tendency for
autogynephilic males to be especially attracted to women.
There are other parallels between those with apotemnophilia and those with
autogynephilia (Lawrence, 2006). For example, in First’s(2005) study, 92% of
participants reported that they engaged in pretending, which is temporarily
presenting as an amputee through prosthetics or other means. Pretending may
involve binding or otherwise concealing a limb, and using crutches or a wheelchair
to impersonate an amputee. Similar to cross-dressing in autogynephilic males,
pretending is a relatively easy, impermanent, and inexpensive way for
apotemnophilic men to look more like amputees and to thus satisfy their sexual
fantasy of being an amputee. Some apotemnophilic men also experience body
integrity dysphoria,
1
or distress over having an intact body, which is often accom-
panied by a desire for limb amputation. Among participants in First’s study, 17%
successfully had a limb amputated. Similarly, some autogynephilic males experience
gender dysphoria and the desire for gender confirmation surgery. Taken together, the
parallels between apotemnophilia and autogynephilia provide evidence that both
belong to the same dimension of sexual orientation, one best explained by the
concept of ETIIs. The second row of Table 20.1 lists apotemnophilia and its related
phenomena as they pertain to the concept of ETIIs.
Most of the participants in First’s(2005) study were heterosexual men. The
concept of ETIIs raises the question of whether apotemnophilic men sexually
attracted to female amputees are also likely to have autogynephilia (Lawrence,
2006). After all, their preferred erotic targets are women as well as amputees. First
found elevated rates of various manifestations of autogynephilia in his sample,
including cross-dressing (29%), transvestic fetishism (15%), and desire for gender
confirmation surgery (12%). The rate of transvestic fetishism in First’s sample is five
times the rate of only 3% reported in the general male population by Långström and
Zucker (2005).
20.3 Autopedophilia
Until recently, no other putative ETII besides autogynephilia and apotemnophilia
had received systematic empirical study. Freund and Blanchard (1993) provided at
least one good lead by presenting several cases of pedohebephilic men who were
sexually aroused by fantasizing about being a child or dressing in children’s cloth-
ing. These men appear to have been motivated by an ETII involving sexual arousal
1
The condition has also been called body integrity identity disorder (First, 2005), but we refer to it
here as body integrity dysphoria to be consistent with gender dysphoria.
594 K. J. Hsu and J. M. Bailey
by the thought or image of being a child, which Lawrence (2006,2009b) has called
autopedophilia.
2
In this case, pedohebephilic men’s attraction to children has been
internalized to some degree, such that they are sexually aroused by the fantasy of
being a child.
Following the seminal publication by Freund and Blanchard (1993) and two other
case reports on autopedophilia (Dickey, 2007; Howitt, 1995), Hsu and Bailey (2017)
examined whether autopedophilia exists and can be conceptualized as an ETII in a
non-forensic, non-clinical sample of pedohebephilic men recruited anonymously
from the Internet. They found that a greater percentage of 475 pedohebephilic
participants reported some degree of autopedophilia (49%) than some degree of
autogynephilia (32%). Furthermore, pedohebephilic participants were more
intensely autopedophilic than they were autogynephilic, d¼1.50, based on contin-
uous measures that assessed both autopedophilia and autogynephilia. These results
were consistent with the concept of ETIIs: Because pedohebephilic men are prefer-
entially attracted to children rather than to women, they should be more
autopedophilic in prevalence and degree than autogynephilic, despite the fact that
autogynephilia is likely the more common ETII in general. Like the tendency for
apotemnophilic men to be especially attracted to amputees, the tendency for
pedohebephilic men to be especially autopedophilic cannot be explained by high
base rates.
Hsu and Bailey (2017) presented additional results that suggest parallels between
autopedophilia and autogynephilia. For example, the degree of autopedophilia was
related to the frequency of dressing in children’s clothing in their sample, and 13% of
their autopedophilic participants reported that they had dressed in children’s clothing
as an adult. The specific erotic interest in wearing children’s clothing is called
pedovestism (Lawrence, 2006,2009b). Dressing in children’s clothing is a relatively
easy, impermanent, and inexpensive way for autopedophilic men to look more like
children, and it appears analogous to both cross-dressing in autogynephilic males
and pretending in apotemnophilic men. In addition, just as some autogynephilic
males experience gender dysphoria and the desire for gender confirmation surgery,
and some apotemnophilic men experience body integrity dysphoria and the desire
for limb amputation, some autopedophilic men experience age dysphoria (distress
over being an adult) and the desire to physically become a child (Freund &
Blanchard, 1993; Hsu & Bailey, 2017). Although the desire to physically become
a child cannot be actualized, Freund and Blanchard described a pedohebephilic man
who wished to have his foreskin reconstructed to look like a young boy’s. The
parallels between autopedophilia and autogynephilia, in addition to those between
2
The term autopedohebephilia would be more accurate, but it is cumbersome and inconsistent with
existing terminology. Thus, we use the term autopedophilia to mean sexual arousal by the thought
or image of being either a prepubescent or a pubescent child.
20 Erotic Target Identity Inversions 595
both phenomena and apotemnophilia, suggest that all three share a common expla-
nation, and the concept of ETIIs is the best candidate. The third row of Table 20.1
lists autopedophilia and its related phenomena as they pertain to the concept of
ETIIs.
Consistent with the concept of ETIIs, autopedophilic men in the study by Hsu and
Bailey (2017) tended to be sexually aroused by the fantasy of being the same kinds
of children to whom they were sexually attracted, with respect to gender and age. For
instance, autopedophilic men sexually attracted to girls more commonly found it
sexually arousing to imagine themselves as a girl (58%), and autopedophilic men
sexually attracted to boys overwhelmingly found it sexually arousing to imagine
themselves as a boy (96%). In addition, sexual attraction to children of a particular
gender-age category (e.g., girls 4–10 years old) among autopedophilic men was most
strongly correlated with sexual arousal by the fantasy of being a child of the same
gender-age category.
The following narrative not only exemplifies autopedophilia as an ETII, but also
three dimensions of male sexual orientation––gender (attraction to females), sexual
maturity (attraction to children), and location (attraction to the fantasy of being
another individual):
Sometimes I fantasize about being with a child myself, but then I end up thinking about it
from the child’s perspective, being sexually active with an adult. Sometimes I fantasize
about spanking a child, and then I would think about being the child getting spanked. Other
times, I fantasize about being a little girl being sexually active with another little girl. (Hsu &
Bailey, 2017, p. 121).
20.4 Autoanthropomorphozoophilia
Freund and Blanchard (1993) presented a case report of a man who was sexually aroused
by imagining himself as an anthropomorphic dog named Puppy Smith. This man also
masturbated with plush animals that represented Puppy Smith and other anthropomor-
phic animals. Thus, this man appeared to have both sexual attraction to anthropomorphic
animals (anthropomorphozoophilia) and sexual arousal by the thought or image of being
an anthropomorphic animal (autoanthropomorphozoophilia)(Hsu&Bailey,2019).
In conceptualizing autoanthropomorphozoophilia as an ETII, men’s attraction to
anthropomorphic animals has been internalized to some degree, such that they are
sexually aroused by the fantasy of being an anthropomorphic animal. Because plush
animals are often representations of anthropomorphic animals, Lawrence (2009b)
suggested that sexual attraction to plush animals might actually reflect sexual
attraction to anthropomorphic animals.
Furries are individuals who are especially interested in anthropomorphic animals
(Gerbasi et al., 2008). Although furries have attracted the most media attention from their
large conventions where they socialize and share art, they tend to interact with each other
online rather than in person. For at least four reasons, furries are an increasingly visible
phenomenon relevant to the question of whether autoanthropomorphozoophilia is an
596 K. J. Hsu and J. M. Bailey
ETII. First, furries have been controversially portrayed as sexually motivated in the
media and popular culture (e.g., Gurley, 2001). Although their exact estimates differ,
recent surveys of furries have found that some degree of sexual motivation is not
uncommon, reported by at least 50% of their samples (Hsu & Bailey, 2019;Plante
et al., 2011;Schroyetal.,2016). Second, many furries identify with anthropomorphic
animals and create fursonas, versions of themselves as anthropomorphic animals
(Gerbasi et al., 2008). Third, some furries wear costumes resembling their fursonas,
which look similar to the costumes worn by mascots of athletic teams or theme parks.
This practice is called fursuiting, and it appears analogous to cross-dressing in
autogynephilic males and pretending in apotemnophilic men (Lawrence, 2009b).
Finally, some furries report species dysphoria, or distress over being a human (Gerbasi
et al., 2008). In their sample of 217 furries, Gerbasi et al. found that 24% indicated a
persistent feeling of discomfort with their human body, and 29% indicated a feeling that
they are a “non-human species trapped in a human body.”The species dysphoria
reported by some furries seems to parallel gender dysphoria in autogynephilic males,
and body integrity dysphoria in apotemnophilic men. Because furries tend to be sexually
motivated and change their appearance and behavior to become more like anthropomor-
phic animals, they may be especially likely to have ETIIs. The fourth row of Table 20.1
lists autoanthropomorphozoophilia and its related phenomena as they pertain to the
concept of ETIIs.
A recent study examined the extent to which 334 male furries were sexually
motivated, and if so, whether they were motivated by the ETII of
autoanthropomorphozoophilia (Hsu & Bailey, 2019). The vast majority (99%) of
the sample endorsed some degree of sexual motivation for being furries. As
predicted by the concept of ETIIs, more furry participants reported some degree of
sexual attraction to anthropomorphic animals (99%) than to real animals (47%) or
women (73%). Furry participants were also more likely to report some degree of
sexual arousal by the fantasy of being an anthropomorphic animal (93%) than by the
fantasy of being a real animal (44%) or a woman (37%), ds > 1.23. Furthermore,
autoanthropomorphozoophilic participants tended to be sexually aroused by the
fantasy of being the same kinds of anthropomorphic animals to whom they were
sexually attracted, with respect to gender and species. For instance, sexual attraction
to anthropomorphic animals of a particular species (e.g., wolves) was most strongly
correlated with sexual arousal by the fantasy of being an anthropomorphic animal of
the same species.
The following narrative exemplifies autoanthropomorphozoophilia as an ETII
and also suggests its confluence with another ETII involving sexual arousal by the
fantasy of being fat:
It was the early nineties. Garfield was still cool, and I was very interested in both fat people
and the idea of being fat. I imagined that I was Garfield, a tubby cat, and I became aroused. I
liked the idea of being a cartoon cat that was fat and fluffy. Later in my teenage years, I
would seek out other overweight cartoon animals and become aroused imagining that I was
them. (Hsu & Bailey, 2019, p. 1365).
20 Erotic Target Identity Inversions 597
20.5 Autozoophilia
There has been limited evidence for an ETII specific to men with zoophilia, or sexual
attraction to real animals as opposed to anthropomorphic animals. If there were such
an ETII, it would involve sexual arousal by the thought or image of being a real
animal, or autozoophilia (Lawrence, 2009b). In this case, zoophilic men’s attraction
to real animals would be internalized to some degree, such that they are sexually
aroused by the fantasy of being a real animal.
In a study of 82 zoophilic men, Miletski (2002) found that 40% reported at least
some identification with animals of their own gender. Similarly, Williams and
Weinberg (2003) reported that some zoophilic men in their study believed that
they had animal characteristics or felt like animals. Beetz (2004) also described
zoophilic men with species dysphoria and the desire to become an animal, usually of
the same species to which they were sexually attracted. As previously mentioned
with autoanthropomorphozoophilia, species dysphoria and the desire to become an
animal appear analogous to gender dysphoria and the desire to become a woman in
autogynephilic males (Lawrence, 2009b). However, like the desire to become a child
among autopedophilic men, the desire to become an animal cannot be actualized.
Casavant (2005) reported the case of a man who identified as a tiger and had
extensive body modifications in an attempt to achieve the physical appearance of
one. The fifth row of Table 20.1 lists autozoophilia and its related phenomena as they
pertain to the concept of ETIIs.
It is not clear whether zoophilic men are manifesting autozoophilia when they identify
with animals or experience species dysphoria, because the relevant studies have not asked
about sexual arousal by the fantasy of being an animal. Although these studies have been
unable to shed light on whether autozoophilia can be conceptualized as an ETII, they have
provided some important groundwork for future inquiry. In Hsu and Bailey’s(2019)
recent study of male furries, for example, participants who were sexually aroused by the
fantasy of being a real animal tended to also be sexually attracted to animals, consistent
with autozoophilia as an ETII. In addition, Brown et al. (2020) collected data on
286 participants who reported sexual arousal by the fantasy of being an animal, which
was erroneously called autoanthropomorphozoophilia instead of autozoophilia. In this
sample, autozoophilia was associated with dressing or behaving as an animal, feeling that
life would be better as an animal, and considering body modifications to look more like an
animal. Because participants were not asked about their sexual attraction to animals, it
could not be determined the extent to which this autozoophilic sample fit with the concept
of ETIIs.
598 K. J. Hsu and J. M. Bailey
20.6 Autoandrophilia
Freund and Blanchard (1993) speculated that there could be an ETII specific to men
sexually attracted to other men. If this ETII exists, it would involve sexual arousal by
the thought or image of being another man, which has been called autoandrophilia
(Dickey & Stephens, 1995; Lawrence, 2006,2009b). In this case, men’s attraction to
other men would be internalized to some degree, such that they are sexually aroused
by the fantasy of being another man.
No systematic research has examined the extent to which autoandrophilia exists
in men sexually attracted to other men, and whether autoandrophilia can be concep-
tualized as an ETII. A few case studies, however, support the idea that
autoandrophilia is an ETII. For instance, Zavitzianos (1972) described a gay man
who appeared to be sexually attracted to male athletes with large penises, and who
masturbated wearing a jockstrap to help him imagine that he had a large penis
himself. Zavitzianos (1977) later summarized two other cases of gay men with
possible autoandrophilia. In the first case, a gay man reported sexual attraction to
men who wear boots and gabardine clothes, and he also reported masturbating in
front of a mirror while wearing boots and gabardine clothes himself. In the second
case, a gay man reported masturbating to the fantasy of being with an army man, as
well as masturbating to the fantasy of being an army man himself while wearing a
military uniform. Zavitzianos (1972) referred to the sexual interest in wearing
specific kinds of same-gender clothing (e.g., jockstrap, military uniform) as
homeovestism, and it seems analogous to transvestic fetishism in autogynephilic
males and pedovestism in autopedophilic men (Lawrence, 2006,2009b). Indeed, for
the men in these cases, their homeovestism was consistent with autoandrophilia.
Because these men masturbated wearing the same kinds of clothing worn by the men
they find attractive, their autoandrophilia was consistent with the concept of ETIIs.
They have internalized their sexual attraction to these other men, resulting in the
sexual desire to become more like them.
It may be difficult to detect autoandrophilia in men, because autoandrophilic men
are sexually aroused by the fantasy of being another man but are already men
themselves. The cases of autoandrophilic men reported by Zavitzianos (1972,
1977) might have been easier to detect because those men were attracted to the
more salient or stereotypical features of masculinity in other men (e.g., being in the
army), which they then found arousing to fantasize about having themselves. Thus,
if an autoandrophilic man became (or was already) as masculine as the men to whom
he is attracted, it would mean that he has actualized his desire to become another
man, much like autogynephilic males and apotemnophilic men have actualized their
desires to become a woman or an amputee through gender confirmation surgery or
limb amputation, respectively. Lawrence (2006) suggested that some gay men who
engage in bodybuilding might be attempting to make their bodies more like those of
the more muscular and thus more masculine men to whom they are attracted.
20 Erotic Target Identity Inversions 599
However, in gay men, it would be difficult to differentiate between bodybuilding that
is motivated by an ETII such as autoandrophilia and bodybuilding that is motivated
by the desire to look more attractive to potential sexual partners.
Lawrence (2009a) described a man who was both extremely dissatisfied with his
own male body and desired to have a more muscular, masculine body like those of
the men he found sexually attractive. This man’s most arousing sexual fantasy
involved having a muscular and attractive male body, being part of a group of
masculine heterosexual men who accept him as one of them, and masturbating
together with these other men. Consistent with conceptualizing his autoandrophilia
as an ETII, this man reported frequent sexual arousal by the fantasy of wearing the
bodies of other men and being masculine like them. In the absence of a term to
describe the distress that some autoandrophilic men experience from not being
muscular or masculine enough, we propose masculinity dysphoria, which would
be analogous to gender dysphoria in autogynephilic males. The sixth row of
Table 20.1 lists autoandrophilia and its related phenomena as they pertain to the
concept of ETIIs.
20.7 Autonecrophilia
Autonecrophilia refers to sexual arousal by the thought or image of being a corpse
(Aggrawal, 2009), and it might be conceptualized as the ETII that occurs in men
sexually attracted to corpses. In this case, their sexual attraction to corpses would be
internalized to some degree, such that they are sexually aroused by the fantasy of
being a corpse. Because it is likely to be extremely rare, autonecrophilia has not been
the subject of empirical research.
The infamous case of Dennis Rader (“BTK”) might be a vivid example of a
sexually sadistic serial killer with autonecrophilia. A large amount of evidence was
recovered after his arrest, including photographs that he took of his dead victims
placed in specific positions with their hands bound and with a cloth or mask covering
their faces (Knoll & Hazelwood, 2009). Photographs were also included that Rader
took of himself placed in specific positions with his hands bound and with a cloth or
mask covering his face, exactly as his dead victims were. He was cross-dressed in his
victims’clothing, and one photograph shows Rader lying on his back in a grave that
was meant for one of his victims. Based on this evidence, it seems that Rader
experienced necrophilia and autonecrophilia, and the similarity between the photo-
graphs of his victims and himself suggests that his autonecrophilia was an ETII. The
seventh row of Table 20.1 lists autonecrophilia and its related phenomena as they
pertain to the concept of ETIIs.
600 K. J. Hsu and J. M. Bailey
20.8 ETIIs as Paraphilias
Freund and Blanchard (1993) suggested that ETIIs may be considered paraphilias,
an ill-defined set of unusual sexual interests that include pedohebephilia,
acrotomophilia, zoophilia, exhibitionism, voyeurism, masochism, and sadism,
among others. Although paraphilias are not pathological by nature, they may
cause significant distress or impairment in an individual, or they may cause an
individual to harm others. Such instances of paraphilias have been called paraphilic
disorders in the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders (fifth ed. [DSM-5]; American Psychiatric Association, 2013).
Because they have not been clearly defined or understood, paraphilias have been
criticized as a scientifically vacuous concept that is based on value judgments
regarding which sexual interests are more or less socially desirable (e.g., Moser &
Kleinplatz, 2006). Two important observations, however, support the scientific
validity of paraphilias as a concept with limited but promising support: Paraphilias
are much more commonly found in natal males than in natal females, and paraphilias
tend to co-occur within the same individual (Abel & Osborn, 1992; Baur et al., 2016;
Dawson et al., 2016; Joyal & Carpentier, 2017; Långström & Seto, 2006; Långström
& Zucker, 2005). Both of these general findings suggest that classifying a sexual
interest as a paraphilia is more scientifically meaningful than a mere value judgment.
Paraphilias have typically been classified as sexual interests in either
non-normative erotic targets (e.g., pedohebephilia, zoophilia) or non-normative
sexual activities (e.g., masochism, sadism) (Freund et al., 1996). ETIIs may repre-
sent another class of paraphilias that consist of sexual interests in an erotic target’s
non-normative location within one’s own body (e.g., autogynephilia), resulting in
sexual arousal by the fantasy of being the erotic target (Freund & Blanchard, 1993).
Consistent with their conceptualization as paraphilias, ETIIs have thus far been
observed almost exclusively in natal males rather than in natal females. For instance,
First’s(2005) study included only four women out of 52 participants who desired
limb amputation. We defer further discussion about the existence of ETIIs in natal
females to the next section. Also consistent with their conceptualization as
paraphilias, ETIIs tend to co-occur, such as autogynephilia most notably with
apotemnophilia (29%; First, 2005; Lawrence, 2006), autopedophilia (r¼0.48;
Hsu & Bailey, 2017), and autoanthropomorphozoophilia (r¼0.20; Hsu & Bailey,
2019). A recent study found that men who endorsed any degree of autogynephilia
were approximately three times more likely to have endorsed any degree of
autopedophilia and autozoophilia, compared with men who did not endorse any
degree of autogynephilia (Brown et al., 2020). In addition, at least two other unusual
sexual interests that might be classified as paraphilias but not ETIIs have been shown to
co-occur with autogynephilia: masochism (Blanchard & Hucker, 1991; Hsu et al.,
2015;Långström&Zucker,2005;Lawrence,2006,2013) and gynandromorphophilia
(sexual interest in transgender women with a penis; Blanchard & Collins, 1993;Hsu
et al., 2016; Rosenthal et al., 2017).
20 Erotic Target Identity Inversions 601
20.9 ETIIs in Natal Females
Conditions resembling ETIIs have been rarely observed in natal females, compared
with natal males. Indeed, female paraphilias are not well studied, and it is unclear
whether paraphilias occur in natal females at all. Although superficial similarities
seem to exist between some female sexual interests and male paraphilias, especially
masochism, no evidence has convincingly shown that the same phenomena in natal
females reflect paraphilias as in natal males. Evidence for female paraphilias would
require, at the very least, that they tend to co-occur in the same individual.
Because men are the preferred erotic targets of most women, autoandrophilia is
the most likely candidate for an ETII in natal females. In contrast to autogynephilia
in men, however, fewer cases of autoandrophilia in women have been reported.
Stoller (1982) reported on three women with transvestic fetishism, and several
population studies of paraphilias have found small numbers of women reporting
transvestic fetishism (Baur et al., 2016; Dawson et al., 2016; Joyal & Carpentier,
2017; Långström & Zucker, 2005). Despite these reports, it remains unclear whether
transvestic fetishism in women reflects autoandrophilia and a paraphilia, much less
an ETII. Some women and female-to-male transgender men have reported both
sexual attraction to men and autoandrophilia (Coleman et al., 1993; Dickey &
Stephens, 1995;O’Keefe, 2007; Stoller, 1982), consistent with the concept of
ETIIs. Notably, one recent study by Brown et al. (2020) reported on 328 women
who indicated sexual arousal by the fantasy of being a man, with a majority
identifying as heterosexual or bisexual (82%) and reporting sexual attraction to
men (84%). Although this pattern of sexual interests might appear to be consistent
with the concept of ETIIs, the authors also showed that women reported
autoandrophilia at a lower prevalence and intensity than men reported
autogynephilia.
More research is needed to clarify whether autoandrophilia in natal females is an
ETII. Autoandrophilia in natal females might instead be sexual arousal by the
specific fantasy of being a gay man and participating in gay male sex, rather than
internalization of sexual attraction to men. Bailey and Blanchard (2017) argued that
this kind of sexual arousal is responsible for a rare type of gender dysphoria in natal
females, called autohomoerotic gender dysphoria. In one of Stoller’s(1982) case
reports, a woman with transvestic fetishism described her autoandrophilia in this
manner:
Today my sex life is mostly satisfied by masturbation, with transvestite episodes occasion-
ally providing a pleasant stimulus to masturbation. I’ve dressed as a man, replete with
moustache, and had my partner call me by a man’s name. I take pleasure in being called by a
man’s name. Dressed as a man, I’ve sucked my partner’s penis. I felt myself, during the
experience, to be a gay male. (p. 103).
Besides autoandrophilia, no other putative ETII in natal females has received
much scientific or clinical attention. First’s(2005) study included only four women
with the desire for limb amputation, and Blom et al.’s(2012,2017) more recent
surveys included a total of 20 such women. Information about apotemnophilia
602 K. J. Hsu and J. M. Bailey
specific to these women was not presented, however. Money (1991) described a
woman who reported sexual attraction to amputees, pretending, and the desire for
limb amputation, suggesting an ETII presentation of apotemnophilia. In a study
attempting to examine autogynephilia in natal females, 93% of 29 women appeared
to report autogynephilia (Moser, 2009). Lawrence (2010b), however, raised serious
criticisms about its methodology and interpretation, especially the fact that many
items measured not autogynephilia but instead sexual arousal from the anticipation
of a romantic evening or sexual encounter.
Brown et al. (2020) recently studied ETIIs in natal female participants and found
that they were about half as likely as natal male participants to endorse more than one
of the four ETIIs assessed: autogynephilia (natal males), autoandrophilia (natal
females), autopedophilia, and autozoophilia. However, natal female participants
who endorsed one ETII were more than twice as likely to have endorsed another.
Both of these findings further support the conceptualization of ETIIs as paraphilias,
which are much less common in natal females than in natal males and also tend to
co-occur within the same individual. We previously summarized two recent studies
that examined whether autopedophilia and autoanthropomorphozoophilia can be
conceptualized as ETIIs among men (Hsu & Bailey, 2017,2019). These studies
also included a very small minority of natal female participants, whose results will be
detailed in a future article and compared with those from Brown et al.’s(2020) study.
20.10 Sexual Masochism as an Alternative to ETIIs
One plausible alternative to conceptualizing some phenomena as ETIIs is sexual
masochism (Freund & Blanchard, 1993). In particular, autogynephilic,
autopedophilic, and autozoophilic fantasies and behaviors can sometimes be viewed
as masochistic. Specifically, the idea of becoming a woman, a child, or an animal
may be humiliating or submissive to some men, as may cross-dressing, dressing in
children’s clothing, or pretending to be an animal. Thus, sexual arousal in these types
of fantasies and behaviors may be related to masochism instead of an ETII or the
internalization of sexual attraction to women, children, or animals. In support of this
alternative, autogynephilia tends to co-occur with masochism (Blanchard & Hucker,
1991; Hsu et al., 2015; Långström & Zucker, 2005; Lawrence, 2006,2013), and
some forms of animal role-play (e.g., pony play, pup play) have been associated with
masochism (Aggrawal, 2011; Wignall & McCormack, 2017). Fantasies and behav-
iors motivated by sexual masochism exaggerate differences between men and their
preferred erotic targets (e.g., women), increasing their feelings of submissiveness. In
contrast, fantasies and behaviors motivated by an ETII increase similarity between
men and their preferred erotic targets.
Freund and Blanchard (1993) presented three cases of men who superficially
appeared to be motivated by ETIIs based on their fantasies and behaviors, which
included fantasizing about being either a baby or a young boy and wearing diapers.
One man described his sexual fantasy of being a baby put into the washing machine
20 Erotic Target Identity Inversions 603
by his mother, and he also reported a history of cross-dressing in order to feel
powerless or degraded. The men in all three cases reported that they were most
sexually attracted to adult women and fantasized about adult women spanking or
degrading them. Their fantasies thus exaggerated differences between them and their
preferred erotic targets (i.e., adult women) and did not increase similarity. As a
result, Freund and Blanchard concluded that these men were motivated by masoch-
istic fantasies of being a baby or child and wearing diapers, rather than by an ETII.
Among autopedophilic and autoanthropomorphozoophilic men, the correspon-
dence between their external and internal erotic targets with respect to gender and
either age or species suggests that they are more likely motivated by ETIIs than by
sexual masochism (Hsu & Bailey, 2017,2019). The finding that these men tended to
be sexually aroused by the fantasy of being the same kinds of children or anthropo-
morphic animals to whom they were sexually attracted is more consistent with the
concept of ETIIs, because there was increased similarity rather than differences
between the men and their preferred erotic targets. Future work to distinguish
ETIIs and sexual masochism may continue to benefit from examining the specificity
of a potential ETII at multiple levels, or whether sexual attraction to other individuals
matches sexual arousal by the fantasy of being one of those individuals in more than
one dimension of sexual attraction (e.g., gender and age). Lawrence (2013)
presented an especially compelling example of this specificity in an autogynephilic
individual: “In adolescence, I had a strong attraction to certain actresses (e.g., Dianna
Rigg from The Avengers and Mary Tyler Moore). I would get aroused by fantasies
involving having my appearance changed to match that of these actresses”(p. 113).
Further complicating the distinction between them, ETIIs and sexual masochism
are both paraphilias, and paraphilias tend to co-occur (Abel & Osborn, 1992; Baur
et al., 2016; Dawson et al., 2016; Joyal & Carpentier, 2017; Långström & Seto,
2006; Långström & Zucker, 2005). Thus, it is likely that the same individual might
fantasize or behave in ways that reflect an ETII, sexual masochism, or perhaps even
both simultaneously. Autogynephilic males, for example, are especially likely to be
masochistic (Blanchard & Hucker, 1991; Hsu et al., 2015; Långström & Zucker,
2005; Lawrence, 2006,2013). In theory, this might mean that autogynephilia is an
ETII that tends to co-occur with sexual masochism, that it is a form of sexual
masochism, or that it reflects both an ETII and sexual masochism. It seems possible
that these three interpretations of autogynephilia can be true to different degrees,
depending on the autogynephilic male.
20.11 Causes and Development of ETIIs
Little is known about the causes and development of ETIIs. Because paraphilias are
poorly understood in general, it is not surprising that most ETIIs are even less
so. Family co-occurrence of transvestic fetishism and gender dysphoria, both closely
related to autogynephilia, has been reported in several natal males, including a pair
of monozygotic twins (Green, 2000). Although this finding tentatively suggests a
604 K. J. Hsu and J. M. Bailey
familial contribution to autogynephilia, it is not clear the extent to which the
contribution is due to shared genes or shared environment. If there is a role for
environment in the causes and development of ETIIs, we suspect that it is a minor
one. Without knowledge of anthropomorphic animals and exposure to them, some-
one is unlikely to become a furry or to develop autoanthropomorphozoophilia.
Indeed, some furries recall that they became furries after discovering online pornog-
raphy of anthropomorphic animals, and others recall that they developed
autoanthropomorphozoophilia after watching cartoons featuring anthropomorphic
animals (Hsu & Bailey, 2019). Most people encounter anthropomorphic animals at
some point in their lives, however, and do not become furries or develop
autoanthropomorphozoophilia. Thus, environmental or learning factors may be
relevant to the causes and development of ETIIs, but they cannot explain why
some individuals develop ETIIs and others do not. Individual factors are more likely
to be relevant, especially in explaining the development within the same individual
of seemingly different but co-occurring ETIIs, such as autogynephilia and
apotemnophilia (First, 2005; Lawrence, 2006), or autogynephilia and autopedophilia
(Hsu & Bailey, 2017).
An underlying predisposition, perhaps genetic or inborn, could be one such
individual factor that leads some individuals and not others to develop ETIIs. Two
case reports have described boys younger than 3 years old who expressed a desire to
cross-dress and displayed penile erections when they did (Stoller, 1985; Zucker &
Blanchard, 1997). These cases suggest that individual factors relevant to the devel-
opment of autogynephilia and other ETIIs, if not genetic or inborn, have an early
onset. Given the overlap between autogynephilia and paraphilias that are not con-
sidered ETIIs, including masochism (Blanchard & Hucker, 1991; Hsu et al., 2015;
Långström & Zucker, 2005; Lawrence, 2006,2013) and gynandromorphophilia
(Blanchard & Collins, 1993; Hsu et al., 2016; Rosenthal et al., 2017), ETIIs might
even share the same causes as other paraphilias, which would suggest an underlying
predisposition to develop paraphilias in general and not ETIIs specifically.
A tendency to gravitate toward male-typical and “nerdy”occupations and
hobbies, especially those involving computers and technology, has been observed
in those with ETIIs, including autogynephilic individuals (Bailey, 2003; Lawrence,
2007,2013) and furries (Gerbasi et al., 2008). Consistent with this observation, a
former phone sex operator remarked that many who called her to role-play their
autogynephilic fantasies were “nerdy”and worked in Silicon Valley, a high-tech
sector in San Francisco (Culturally Bound Gender, 2013). According to Lawrence
and Bailey (2009), a study by Veale et al. (2008) showed that transgender women
who are active on the Internet are overwhelmingly autogynephilic. Furthermore, two
studies have found that autogynephilic transgender women score higher than
non-autogynephilic transgender women do on a measure of autistic traits (Jones
et al., 2012; Pasterski et al., 2014), which are closely associated with male-typical
and “nerdy”interests (Baron-Cohen, 2002). Consistent with autogynephilia being
correlated with both increased “nerdy”interests and autistic traits, an autogynephilic
individual who experienced gender dysphoria in one case study was described as
having strong interests in model building and anime, as well as Asperger’s syndrome
20 Erotic Target Identity Inversions 605
(Gallucci et al., 2005). Another study showed that furries are more likely to report
having been diagnosed with an autism spectrum disorder, compared with the general
population (Reysen et al., 2018). Finally, a recent study examined whether autistic
traits were related to four putative ETIIs (autogynephilia in men, autoandrophilia in
women, autopedophilia, and autozoophilia), finding limited evidence in this regard
(Brown et al., 2020).
Future research is necessary to clarify the ways in which autogynephilia,
autoanthropomorphozoophilia, and other ETIIs are related to “nerdy”interests and
autistic traits, which have the potential to reveal more about the causes and devel-
opment of ETIIs. For instance, if ETIIs are correlated with increased autistic traits, it
might be that individuals with ETIIs have difficulty with distinguishing their own
mental states and experiences from those of others, which tends to show in the
cognitive representations and neural systems of individuals with autistic traits
(Gallese et al., 2013; Lombardo & Baron-Cohen, 2010). ETIIs might then reflect
the specific difficulty with distinguishing oneself from other individuals as an erotic
target, resulting in sexual arousal by the fantasy of being another individual. Several
neuroimaging studies have examined differences in brain structure and activity
between men who desire limb amputation and men who do not (see Brugger et al.,
2016, for a review). The results have implicated brain regions relevant to body
representation and the sensorimotor system in the desire for limb amputation.
We speculate that ETIIs and autistic traits might be related because both are
caused by difficulty with understanding mental representations of oneself versus
others, and ETIIs specifically represent this difficulty as it pertains to understanding
an erotic target as oneself versus others. But there is at least one other developmental
pathway through which ETIIs might be related to autistic traits, and it involves the
dysphoria that sometimes accompanies ETIIs. It is possible that increased autistic
traits cause some individuals with ETIIs to develop an intense and obsessional focus
on becoming more like their preferred erotic targets (e.g., women, anthropomorphic
animals), resulting in dysphoria related to their current identity (e.g., man, human).
In this scenario, ETIIs are related to autistic traits not because there is a direct
association between them, but rather because autistic traits cause dysphoria in
those with ETIIs.
Consistent with this explanation, the link between autogynephilia and “nerdy”
interests or autistic traits has mainly been observed in autogynephilic individuals
who were either experiencing gender dysphoria or transgender with a presumed
history of gender dysphoria (Bailey, 2003; Culturally Bound Gender, 2013; Gallucci
et al., 2005; Jones et al., 2012; Lawrence, 2007,2013; Pasterski et al., 2014). No
study has yet reported such a link controlling for gender dysphoria or in a sample of
autogynephilic males without gender dysphoria. Instead, recent studies have indi-
cated that prepubescent children with gender dysphoria are also elevated in autistic
traits (VanderLaan et al., 2015a,2015b; Zucker et al., 2017). Natal males who
experienced gender dysphoria as prepubescent children tend overwhelmingly to
become gay rather than autogynephilic men in adulthood (Zucker, 2014). Because
the evidence suggests increased autistic traits in both autogynephilic individuals and
prepubescent children with gender dysphoria, autistic traits might be related to the
606 K. J. Hsu and J. M. Bailey
dysphoria that these two different groups share and not autogynephilia or ETIIs more
generally. This developmental pathway might implicate autistic traits as causally
related to dysphoria in those with ETIIs, in contrast to a developmental pathway in
which ETIIs and autistic traits are both caused by difficulty with distinguishing
between mental representations of oneself and others.
20.12 Future Directions
It is unlikely that ETIIs are limited to those that were reviewed in this chapter. Two
promising approaches to studying ETIIs have been employed sparingly so far. The
first, used by Hsu and Bailey (2017) in their study of autopedophilia, is to recruit
participants sexually attracted to specific kinds of individuals (e.g., pedohebephilic
men) and examine whether a subset of them report sexual arousal by the fantasy of
being one of those individuals, consistent with the concept of ETIIs. The second,
used by Lawrence (2006) in her work on apotemnophilia and Hsu and Bailey (2019)
in their study of autoanthropomorphozoophilia, is to recruit participants who desire
to change their appearance or behavior to become more like a specific kind of
individual (e.g., men who desire limb amputation, furries), and to examine the extent
to which they are motivated by ETIIs. Individuals who might be sexually motivated
to change their appearance or behavior are especially promising candidates for this
second approach.
Regarding the first approach to studying ETIIs, there exist men sexually attracted
to overweight or obese individuals (Swami & Furnham, 2009) and to individuals of a
particular race/ethnicity that is different than their own (Phua & Kaufman, 2003).
Future research could investigate the putative ETIIs specific to these two populations
of men, which would involve sexual arousal by the fantasy of being overweight or
obese and by the fantasy of being a different race/ethnicity, respectively. Regarding
the second approach to studying ETIIs, there exist individuals known as adult baby/
diaper lovers, who are predominantly male and enjoy role-playing as babies and
wearing diapers (Hawkinson & Zamboni, 2014). It is possible that adult baby/diaper
lovers are motivated by an ETII involving sexual arousal by the fantasy of being a
baby, because they change their appearance and behavior to become more like
babies and appear to do so for sexual reasons. However, this interpretation would
require that they tend to experience both sexual attraction to babies and sexual
arousal by the fantasy of being a baby. Two recent studies found little evidence
that adult baby/diaper lovers tend to be sexually attracted to babies and thus
motivated by an ETII (Fuss et al., 2019; Hsu, 2019). Not all individuals who change
their appearance or behavior to become more like another kind of individual are
motivated by ETIIs, but we must study that possibility in order to know.
The concept of ETIIs has been controversial and difficult for many people to
appreciate and accept, despite its increasing empirical support and potential for
explaining otherwise puzzling phenomena, such as cross-dressing among heterosex-
ual men, desire for limb amputation, and the furry phenomenon. Some individuals
20 Erotic Target Identity Inversions 607
who might be characterized by ETIIs dislike and reject the notion that their changes
in appearance and behavior are sexually motivated by a paraphilia. For example,
some transgender women have been especially hostile to the idea that autogynephilia
can be a fundamental motivation for gender confirmation surgery in natal males
(Dreger, 2008). We hope this chapter helps researchers, clinicians, and other inter-
ested readers to better understand ETIIs. We also hope this chapter stimulates much
needed research on ETIIs, which may reflect an understudied but important dimen-
sion of sexual orientation.
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