Erotic Target Location Errors (ETLEs): Implications for the DSM-V

An excerpt from:

Lawrence, A. A. (2009). Erotic target location errors: An underappreciated paraphilic dimension. Journal of Sex Research, 46, 194-215.

The [American Psychitric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders] is undergoing revision, a process that is expected to produce a new edition, the DSM-V, in 2012 (APA, 2008). Accordingly, I briefly address the implications of the [erotic target location error (ETLE)] concept for the DSM-V. I believe that the DSM-V should make explicit reference to the ETLE concept and to the clinical insights the concept has generated; this would make the DSM-V both a more useful clinical tool and a better educational resource. I will discuss three specific recommendations for the DSM-V:

  1. The general description of the paraphilias should set forth a dimensional classification system for paraphilias that includes ETLEs as an independent paraphilic dimension.
  2. The existing diagnosis of transvestic fetishism should be replaced by the broader and more conceptually useful diagnosis of autogynephilia.
  3. The text discussion of the diagnostic features of gender identity disorder (GID)*, or GID's replacement diagnosis in the DSM-V, should emphasize the importance of autogynephilia in accounting for the key symptoms of GID in nonhomosexual men.

The DSM-V should set forth and describe a dimensional classification system for the paraphilias as part of the general discussion that precedes the description of specific paraphilias. Ideally the listed dimensions would include (a) unusual erotic target preferences (e.g., pedophilia), (b) unusual sexual activity preferences (e.g., exhibitionism), and (c) ETLEs (e.g., fetishism). Such a dimensional classification system would increase the conceptual clarity of the term paraphilia and would constitute a significant improvement over the current DSM-IV-TR classification scheme, which includes only "1) nonhuman objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other nonconsenting persons" (APA, 2000, p. 566), categories that are disappointingly ad hoc. However, because the term ETLEs defines a paraphilic dimension and not a specific clinical entity, it would not be appropriate for ETLEs to become a named paraphilia in the DSM-V, even if individually described clinical subtypes, such as fetishism and autogynephilia, were specified. Instead, fetishism should be retained as a named paraphilia and transvestic fetishism should be replaced by the more comprehensive diagnosis of autogynephilia. Other ETLEs appear to have a very low prevalence and should continue to be categorized under "paraphilia not otherwise specified."

Autogynephilia should replace transvestic fetishism as a named paraphilia in the DSM-V. The term autogynephilia first appeared in the DSM in 2000, when it was mentioned in the DSM- IV-TR as a feature of most cases of transvestic fetishism and some forms of GID. As a named paraphilia, autogynephilia could easily be described using diagnostic criteria similar to those employed for existing named paraphilias in the DSM-IV-TR. For example, diagnostic criteria might include the following:

  1. Over a period of at least 6 months, in a nonhomosexual male, recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors in which the thought or image of being female is sexually exciting to the person.
  2. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
The specifier "with gender dysphoria," currently applicable to transvestic fetishism, should be retained as a specifier for autogynephilia as well. Autogynephilia is a superordinate paraphilic category that subsumes both fetishistic cross-dressing and related paraphilic manifestations that do not involve female clothing per se; as such, it could and logically should replace transvestic fetishism as a named paraphilia in the DSM-V. Admittedly, transvestic fetishism (or transvestism) has been a named paraphilia in the DSM since 1980, and a similar diagnosis, fetishistic transvestism, appears in the ICD-10 (WHO, 1992); these observations might argue for retention of transvestic fetishism in the interest of continuity (see APA, 2000, p. xxviii). On the other hand, it is impossible for clinicians to adequately understand fetishistic cross-dressing and the most prevalent form of MtF transsexualism without understanding the concept of autogynephilia. Making autogynephilia a named paraphilia would emphasize its conceptual importance and would promote wider appreciation of its significance.

Finally, the initial text discussion of the diagnostic features of GID, or whatever diagnosis replaces GID, should emphasize that, in nearly all cases, the key symptoms of GID in nonhomosexual men can be understood as manifestations or direct outgrowths of autogynephilia, a paraphilia of the ETLE type. In the DSM-IV-TR, autogynephilia is described as an "associated feature" of GID in nonhomosexual men, along with anxiety, depression, and personality disorders (APA, 2000). This is like describing elevated blood sugar as an "associated feature" of diabetes: It treats an essential element of the disorder as merely an associated phenomenon. Emphasizing that autogynephilia lies at the core of nearly all cases of GID in nonhomosexual men would make it clear to clinicians that GID in nonhomosexual men is best understood as a paraphilic phenomenon and that fetishistic transvestism and nonhomosexual MtF transsexualism can be understood as different manifestations of the same underlying dysfunction. This implies that nonhomosexual men diagnosed with GID, or whatever diagnosis replaces GID in the DSM-V, would nearly always receive the diagnosis of autogynephilia as well.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2008). DSM-V: The future manual. Retrieved June 15, 2008, from http://www.psych.org/dsmv.asp

World Health Organization. (1992). International statistical classification of diseases and related health problems (10th rev., Vol. 1). Geneva, Switzerland: Author.

* I consider GID to be a legitimate mental disorder and I support its continued inclusion in the DSM-V.

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© 2009 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.