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Article Excerpt
Although the unusual erotic interests called paraphilias have been the subject of considerable attention by clinicians and researchers, a generally accepted classification scheme for paraphilic sexual interests has remained elusive. Attempts to classify the paraphilias have typically emphasized two principal dimensions: unusual erotic target preferences and unusual sexual activity preferences (Freund, Seto, & Kuban, 1996). For example, in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]; American Psychiatric Association [APA], 2000), the paraphilias are conceptualized in terms of either unusual objects of attraction (i.e., preferential attraction to children, nonconsenting persons, or inanimate objects vs. consenting adults) or unusual sexual activity preferences (i.e., attraction to experiencing the suffering or humiliation of oneself or one's partner vs. more conventional sexual activities).
In the early 1990s, Blanchard (1991; Freund & Blanchard, 1993) suggested the existence of yet another significant dimension of paraphilic sexuality: erotic target location errors (ETLEs), which involve the erroneous location of preferred erotic targets in the environment. Blanchard (1991) proposed that some persons with paraphilias erroneously direct their erotic interest toward peripheral or inessential parts of their preferred erotic targets (e.g., the clothing, hair, or feet of a target), which manifests as fetishism. Other persons with paraphilias erroneously locate their preferred targets in their own bodies, rather than in another person: They either desire to impersonate their preferred targets or desire to turn their bodies into facsimiles of those targets. ETLEs of the latter type manifest as transvestic fetishism, as one paraphilic variety of male-to-female (MtF) transsexualism, and as lesser known analogues of these two conditions. Freund and Blanchard (1993) coined the term erotic target identity inversion to describe ETLEs in which persons erroneously locate their preferred erotic targets in their own bodies and want to either impersonate or become facsimiles of those targets.
Blanchard's (1991; Freund and Blanchard, 1993) formulation, despite its potential clinical and heuristic value, has gone largely unnoticed and unappreciated. Recent searches of the Medline and PsycINFO databases, using the term "erotic target location error(s)" yielded only two articles: Freund and Blanchard's (1993) article and my extension of the ETLE concept to amputation-related phenomena (Lawrence, 2006). In this review, I advocate for wider appreciation of this paraphilic dimension, by discussing the following topics:
* How do the paraphilias that Freund and Blanchard (1993) called ETLEs manifest in men who are sexually attracted to women, and how prevalent are they?
* What is the basis for theorizing that these paraphilias define a single paraphilic dimension?
* What forms do ETLEs take in men who are sexually attracted to erotic targets other than women, or to women with unusual characteristics?
* What is known about the prevalence and manifestations of ETLEs in women?
* What theories have been proposed concerning the etiology of ETLEs?
* What are the implications of the ETLE concept for psychoanalytic theories of transvestism and MtF transsexualism?
* What are the implications of the ETLE concept for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-V]; APA, 2008)?
* Why have ETLEs been underappreciated?
* What might result if ETLEs became more widely appreciated?
Because paraphilias have been observed to occur almost exclusively in men and only rarely in women (G. G. Abel & Osborn, 1992; APA, 2000), most of the attention in this review is on ETLEs in men.
Before proceeding, I should briefly address the contemporary appropriateness of the word error in Freund and Blanchard's (1993) term, erotic target location error. Some readers may believe that the word error, used to describe uncommon patterns of sexual attraction, is inappropriately judgmental or moralistic and is incompatible with the objectivity that should characterize the scientific study of sexuality. I believe, however, that the word error, as used by Blanchard (1991), is both appropriate and conceptually useful.
The ETLE concept assumes--correctly, I believe--that a person's erotic orientation nearly always involves an identifiable type of preferred erotic target, known or inferred, that is external to the self and that generally involves either other people or entities that are similar to people (e.g., animals). The ETLE concept further assumes that, as a result of some putative mental dysfunction, a person can metaphorically "miss" his known or inferred erotic target, mistakenly directing his erotic interest toward an inessential or peripheral part of the target, or toward creating a facsimile of the target in his own person. Consequently, the word error reflects an objective assessment, not a subjective or moralistic one. The ETLE concept makes no assumption about the correctness or moral acceptability of a person's preferred erotic target: As we shall see, ETLEs can involve conventional and morally unproblematic erotic targets (e.g., opposite-sex adults), unconventional and morally unacceptable erotic targets (e.g., prepubescent children), and erotic targets that are intermediate in their conventionality and moral valence. Implicit in the ETLE concept, however, is the assumption that ETLEs reflect putative mental dysfunctions that interfere with accurate erotic target location. Consequently, euphemistic alternatives, such as erotic target location variant, fail to capture the implication of mental dysfunction that is inherent in the ETLE concept. Consequently, in the interests of accuracy, as well as maintaining a consistent terminology, I employ Freund and Blanchard's (1993) original term, erotic target location error.
ETLEs in Men Who Are Sexually Attracted to Women
Blanchard (1991) proposed that three specific paraphilias constituted errors of erotic target location in men who are gynephilic (i.e., whose erotic target is women, or women's bodies). These paraphilias are listed in the first row of Table 1. Two of these paraphilias, fetishism and transvestism (also called transvestic fetishism), are widely recognized and are listed in both the DSM-IV-TR and the International Classification of Diseases (ICD-10; World Health Organization [WHO], 1992). The third of these paraphilias, anatomic autogynephilia, is less widely recognized; it is the unusual sexual interest that is thought to underlie one type of MtF transsexualism.
These paraphilic sexual interests compete with, and occasionally completely overshadow, sexual interest in adult female sexual partners (Blanchard, 1992). Physiological studies suggest, however, that these paraphilic interests are not always more sexually arousing than the bodies of female partners, and are sometimes less so (Freund et al., 1996).
Fetishism
The ICD-10 (WHO, 1992) describes fetishism as:
Reliance on some non-living object as a stimulus for sexual arousal and sexual gratification. Many fetishes are extensions of the human body, such as articles of clothing or footwear. Other common examples are characterized by some particular texture such as rubber, plastic or leather. Fetish objects vary in their importance to the individual. In some cases they simply serve to enhance sexual excitement achieved in ordinary ways (e.g., having the partner wear a particular garment). (p. 366)
Unlike the definition of fetishism in the DSM-IV-TR, the ICD 10 definition does not require the presence of clinically significant distress or impairment in functioning. Like its DSM-IV-TR counterpart, however, the ICD-10 definition specifies that fetish objects are necessarily inanimate, which excludes preferential attraction to specific parts of the body, an erotic interest called partialism (APA, 2000). Nevertheless, many authors consider nongenital body parts to be fetishes (Mason, 1997), and I adopt this more inclusive definition.
The developmental history of fetishism is incompletely understood. Freud (1927/1961) suggested that fetishism develops in response to castration anxiety during the oedipal phase of development, which typically begins at about age 5 or 6. More recently, psychoanalytically inclined theorists (e.g., Bak, 1953; Greenacre, 1968, 1979) have argued that fetishism typically develops in early childhood, prior to the oedipal period. Chalkley and Powell (1983) reported that the youngest of the 48 fetishistic patients they studied was age 12. Gosselin (1979) found that most rubber fetishists were aware of their paraphilic interest before puberty: Their mean age of awareness was 10, and about one fourth were aware of their interest by age 5. McConaghy (1993) observed that for many fetishists, strong pleasurable feelings toward the fetish object develop in childhood, with these feelings "becoming sexually arousing at puberty" (p. 320).
Krafft-Ebing (1903/1965) proposed that the fetishistic objects and interests of heterosexual men could be divided into three main categories: (a) parts of the female body; (b) articles of female attire; and (c) "special materials" such as fur, velvet, and silk. Recent surveys of fetishistic interests, conducted among mostly heterosexual men, suggest that Krafft-Ebing's categories remain relevant, although rubber and leather have now become the most popular "special materials." Chalkley and Powell (1983), in a study of 47 men (most of whom were gynephilic) and 1 woman with sexual fetishism, found that the most frequent fetish categories, which were not mutually exclusive, involved clothing (58%), rubber items (23%), footwear (15%), and body parts (15%). Junginger (1997) observed that the most frequent categories of fetish objects mentioned in Internet alternative sex forums were underwear, rubber objects, body parts (especially feet), outer clothing, and leather objects (especially shoes and boots). In a more recent survey of fetish-related Internet groups and topics, Scorolli, Ghirlanda, Enquist, Zattoni, and Jannini (2007) reported that the most common fetishes involved body parts (especially feet) and objects associated with the body (especially underwear and shoes). Money (1986) noted that the materials that typically become the focus of fetishistic interest often bear a visual, tactile, or olfactory resemblance to human skin or hair (see also Freud, 1927/1961). These observations are consistent with Blanchard's (1991) idea that most fetish objects reflect a general erotic orientation toward the human body, but involve a misdirection of erotic interest toward body features that are peripheral (e.g., hair or feet) or inessential (e.g., clothing).
Persons who display fetishism for items of clothing typically are aroused by having these items worn by persons of their preferred sex. Beyond this, fetishistic persons often treat their fetish objects in the same ways that nonfetishistic persons would treat human sexual partners: They seek close physical contact with them (e.g., they wear them, or lie on or beneath them), gaze at them, fondle them, rub against them, suck on them, insert them into body cavities, cut them, and burn them (Chalkley & Powell, 1983; Epstein, 1969; Junginger, 1997). Activities that involve damaging the fetish object may be analogous to acts of sexual sadism directed toward human partners. McConaghy (1993)concluded that, "The caring and protective or destructive behaviors shown by some subjects in regard to the fetish suggests that they feel toward it as if it were a living object" (p. 320).
Gosselin and Wilson (1980) and Greenacre (1968) considered fetishism to be the prototypical paraphilia, in part because of its high prevalence in the general population. In studies of groups of men with paraphilic interests, using the Wilson Sex Questionnaire (WSQ; G. Wilson, 1978), Gosselin and Wilson (1980) found that 18% of their control group of 50 men reported engaging in fetish-related fantasies or activities (i.e., "being excited by material or clothing [e.g., rubber, leather, underwear]") with an intensity score at least two standard deviations above the participant's mean score for the 39 other WSQ items. In a survey of 94 men, Crepault and Couture (1980) observed that 15% had "often" engaged in erotic fantasies involving a "scene when you are with a woman wearing exciting clothing and accessories" during heterosexual activity. Person, Terestman, Myers, Goldberg, and Salvadori (1989) found, in a survey of more than 100 college men, that 7% reported recent sexual experience involving "dressing with erotic garments." In a replication study involving 54 college men, Hsu et al. (1994) observed that 15% reported recent sexual experience involving "dressing with erotic garments" and 37% reported lifetime sexual experience involving this activity.
Fetishism is often found in association with other paraphilias, reflecting the recognized tendency of the paraphilias to cluster or co-occur. G. G. Abel and Osborn (1992) reported the co-occurrence of 21 paraphilic diagnoses in a group of 859 persons with paraphilias seen in a forensic or treatment context; among 12 persons whose primary (most arousing) paraphilia was fetishism, the most frequent secondary paraphilias were pedophilia (5 cases, 42%), sexual masochism (4 cases, 33%), and transvestism (4 cases, 33%). There were also four other primary paraphilias in which 20% or more of involved persons reported fetishism as a secondary paraphilia: zoophilia (33% with fetishism), obscene phone calling (25%), pedophilia (22%), and transvestism (20%). Gosselin and Wilson (1980) observed a substantial overlap of paraphilic interests among members of organized groups for fetishists, transvestites, and sadomasochists: 64% of fetishists were also sadomasochists and 59% were also transvestites.
Transvestism
Used in its broad sense, the term transvestism denotes cross-dressing for any purpose. In its more specific sense, it denotes cross-dressing that is, or at one time was, associated with sexual arousal, and is synonymous with transvestic fetishism (DSM-IV-TR), fetishistic transvestism (ICD-10), and male heterosexual erotic cross-dressing (Stoller, 1971). I use transvestism in this second, more specific, sense. The ICD-10 describes fetishistic transvestism as "The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex" (WHO, 1992, p. 366). This definition, unlike that of the DSM-IV-TR, does not require the presence of clinically significant distress or functional impairment. In the DSM-IV-TR, transvestic fetishism is limited to heterosexual
males, a convention that is widely accepted.
Transvestism typically develops well before puberty. Stoller (1985) and Zucker and Blanchard (1997) provided case reports of boys younger than age 3 who expressed a desire to wear cross-sex clothing and who experienced penile erections when they did so. Doom, Poortinga, and Verschoor (1994), in a survey of 36 men with transvestism, found that 8 (22%) reported cross-dressing before age 7, and only 10 (28%) reported an onset after age 12. Schott (1995) observed that, among 85 transvestic men, 50% reported cross-dressing before age 7 and nearly all (97%) reported doing so before age 13. Docter and Prince (1997), in survey of 1,032 heterosexual cross-dressers, found that 66% reported cross-dressing before age 10. Prepubertal cross-dressing is not always explicitly erotic: Ovesey and Person (1976) noted that cross-dressing is sexually arousing from the beginning in some cases, but in other cases it is initially associated primarily with a sense of well-being and only later becomes sexualized.
It can be difficult to distinguish between transvestism and fetishism for items of female clothing, particularly in the case of fetishists who prefer to wear the fetish items. Docter (1988) argued that the desire to cross-dress fully was the crucial feature that distinguished transvestites from fetishists for female clothing: He noted that, although transvestism usually begins with single items of female clothing, often undergarments or stockings, there is almost always progression to complete cross-dressing when circumstances permit. This idea is consistent with the ICD-10 definition, which emphasizes that transvestism involves not just sexual excitement, but an attempt "to create the appearance of a person of the opposite sex" (WHO, 1992, p. 366). Docter and Prince (1997) found that 93% of their transvestite informants preferred to cross-dress completely when possible. Buhrich (1978) reported that all 33 of the transvestites he surveyed owned at least one complete female outfit. Moreover, cross-dressing by transvestites is usually accompanied by the fantasy of being a woman (Buhrich & McConaghy, 1977b); this fantasy may be more central to the phenomenon of transvestism than female clothing per se. S. B. Levine (1993) observed that "Cross-dressing reflects a deep, abiding wish to be a female.... I cannot ever recall speaking to or hearing about an adult cross-dresser who did not have a fantasy of himself as a female" (pp. 134-135).
Several researchers have examined the prevalence of transvestism, cross-gender sexual fantasies, and sexual arousal to images of cross-dressing among men; the results of these studies are summarized in Table 2. Although many of the studies listed have methodological limitations, taken together they suggest that roughly 2% to 3% of men have engaged in erotic cross-dressing at least occasionally, and perhaps twice that many have experienced sexual arousal with cross-gender fantasy.
Transvestism, like fetishism, is often associated with other paraphilias, again reflecting the recognized tendency of the paraphilias to co-occur. In a national probability survey of Swedish men, Langstrom and Zucker (2005) found that men who reported a history of sexual arousal with cross-dressing were significantly more likely to also report sexual arousal with exhibitionism, voyeurism, and sadomasochism than men who did not: 17% of men who had been sexually aroused by cross-dressing also had been aroused by exposing their genitals to a stranger, 33% had been aroused by spying on others engaged in sexual activity, and 14% had been aroused by using pain sexually. Gosselin and Wilson (1980) observed that, among members of a social group for transvestites, 59% had fetishistic interests and 39% were also interested in sadomasochism. Schott (1995) found that 78% of the 85 transvestic men he surveyed reported a history consistent with fetishism, in that "certain items of feminine clothing had a sexually-arousing attraction to them as children" (p. 316). Steiner, Sanders, and Langevin (1985) obtained sex histories from 18 transvestites: 6 (33%) reported voyeurism, 5 (28%) reported frotteurism (sexually rubbing against a nonconsenting person), 4 (22%)...
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