Essay on the diagnosis and nature of paraphilia
Other controversial proposals involved making significant changes to the criteria sets, including operationalizing the harm component by having it depend on the number of victims 17 and including the use of child pornography. Moreover, most of the other proposed criteria set changes were not implemented, so that the final criteria sets closely resemble their DSM-IV-TR counterparts.
Conceptually, the diagnostic criteria are split into two constructs, both of which are required for the diagnosis of a paraphilic disorder.
Criterion A is the paraphilia component of the disorder, which requires an atypical focus of sexual arousal and an arousal pattern that is recurrent, intense, and persists for at least six months. Criterion B is the harm component, which requires the presence of distress, impairment in functioning, or involvement of nonconsenting victims. Three different wording templates for the diagnostic criteria have been used: one for paraphilic disorders that may involve the participation of nonconsenting persons i.
As was the case with DSM-IV-TR, Criterion B for those paraphilic disorders in which the paraphilic interest potentially involves a nonconsenting victim requires that the individual act on the sexual urges or that the sexual urges or fantasies cause distress or impairment, whereas Criterion B for the other paraphilias requires only that the fantasies, urges, or behaviors cause distress or impairment.
The behavioral expression of pedophilic disorder often involves nonconsenting victims, since prepubescent children cannot legally give consent to sexual activity. However, the diagnostic criteria for pedophilic disorder have retained their DSM-IV-TR wording and thus differ from the DSM-5 diagnostic criteria for the other paraphilic disorders involving nonconsenting victims.
Although many of DSM-5's wording changes occurred for editorial purposes and are likely to be forensically inconsequential e.
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- DSM-5 and Paraphilic Disorders.
In fact, not every offender's sexually deviant behavior is driven by a paraphilic sexual arousal pattern, and sexually violent behavior, such as child molestation or rape, is not indicative that a paraphilic arousal pattern is the cause of the behavior. For example, in an analysis of the psychiatric diagnoses of a sample of male sex offenders, Dunsieth and colleagues 20 found that only 58 percent had a paraphilic disorder.
The change in the Criterion A wording places the presence of a persistent and intense atypical sexual arousal pattern at the center of the definition of a paraphilia, moving behaviors along with sexual urges and fantasies into subsidiary roles as possible manifestations of the deviant sexual arousal pattern.
In theory, behavioral data such as repeated sexual offenses should be considered indicative of a paraphilia only if it can be established that the behavior is being driven by a persistent and intense deviant sexual arousal pattern. In practice, however, given that individuals evaluated in forensic settings are likely to be less than forthcoming about their sexual proclivities, establishing the presence of a paraphilic sexual arousal preference can be challenging.
Forensic evaluators will by necessity sometimes have to infer its presence from the nature and pattern of the person's behaviors e. Nevertheless, given the explicit requirement that the behaviors be a manifestation of an atypical sexual arousal pattern, forensic evaluators should endeavor to provide additional support for their inference.
Acquiring such support requires attempts to establish that other explanations for the behaviors, such as substance intoxication or opportunistic behavior in a person with antisocial personality disorder, have been ruled out. Notably, these corrections to Criterion A have not been incorporated into the DSM-5 criteria for pedophilic disorder, thus perpetuating the risk that the diagnosis of pedophilic disorder will be made solely on the basis of criminal behavior. As a result of a quirk in the DSM-5 revision process, the ultimate rejection 21 of proposed changes in the pedophilia criteria set resulted in the default reversion to the DSM-IV-TR criteria.
This discrepancy in wording should not be construed as indicative of some fundamental difference between pedophilic disorder and the other paraphilic disorders in terms of the importance of establishing that the behavior is a manifestation of an atypical sexual arousal pattern.
In fact, compared with other paraphilic disorders, child molestation is even more likely to occur for nonparaphilic reasons. For example, a study by Seto and Lalumiere 22 of more than 1, child molesters, conducted with phallometric testing as a validator, demonstrated that less than one-third had an underlying pedophilic arousal pattern. Several other changes in the diagnostic criterion wording may also have forensic implications.
- DSM-5 and Paraphilic Disorders.
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Revisions of the definitions of the atypical focus for sexual sadism disorder, transvestic disorder, and fetishistic disorder may result in a more inclusive application of the diagnostic criteria. The DSM-IV-TR restriction for transvestic disorder that limited the diagnosis to heterosexual males has been removed, thus allowing the diagnosis to be made in females and homosexual males as well. The definition of fetishistic disorder has been expanded beyond a focus on nonliving objects to include a highly specific focus on nongenital body parts.
This paraphilic focus previously was identified as partialism and was diagnosed in previous DSM editions under paraphilia NOS. The extent to which these changes will in fact cause more individuals to be included in these categories is unclear. The wording of Criterion B, the harm component, for those paraphilic disorders that may involve nonconsenting participants has been changed in several ways. The criterion now clarifies that acting on paraphilic urges qualifies for the diagnosis only if the behavior involves a nonconsenting individual: for example, a diagnosis of frotteuristic disorder in which the individual's behavior involves rubbing against a person on a crowded subway car.
Behavior that occurs with a consenting partner, such as sexually sadistic acts with a partner who has sexual masochism, is now explicitly excluded from the diagnosis. This change effectively broadens the diagnoses in two ways.
DSM-5 and Paraphilic Disorders | Journal of the American Academy of Psychiatry and the Law
First, it expands on the types of functioning that can be impaired as a result of the paraphilic urges or fantasies. A new Criterion C, which requires a minimum age of 18, has been added to the criteria set for voyeuristic disorder, restricting the diagnosis to adult individuals. Therefore, intense and persistent voyeuristic urges, fantasies, or behaviors can be considered indicative of a paraphilic disorder only if they persist into adulthood.
As noted by Federoff and colleagues, 15 however, it is not clear why adolescent curiosity involving voyeuristic acts should be treated differently from similar adolescent curiosity and activity about other sexual behaviors that would still be diagnosable as paraphilic disorders in DSM-5, even if they occurred before age For those individuals living in settings where there are no opportunities to act on their paraphilic urges, the specifier, in a controlled environment, would apply.
Of particular interest from a forensic perspective was the decision to provide a specific duration threshold indicating the minimum amount of time i. Although research suggests that the longer an individual in the community has not acted on his urges, the lower his risk of acting on them in the future, 23 there is in fact no empirical evidence that the five-year point represents an inflection point in decreased risk of relapse.
Nonetheless, because of the tendency in the legal system and elsewhere to reify the DSM criteria, 24 there is a strong likelihood that the five-year duration enshrined in the DSM-5 remission specifier will be used inappropriately to justify setting minimums for duration of commitment. Perhaps the clearest indication that some of the changes in the paraphilic disorders section of DSM-5 were guided by forensic concerns is the various additions to the text addressing the challenge of applying the diagnostic criteria to individuals who are not forthcoming about the presence or impact of sexual pathology.
Individuals, particularly in forensic settings, are motivated to deny or minimize deviant sexual urges or behaviors to avoid the negative forensic and social consequences of paraphilic disorder diagnoses. In contrast, DSM-5 contains numerous additions to the descriptive text for paraphilic disorders intended to provide guidance to evaluators in forensic contexts. Specifically, the texts for the voyeuristic, exhibitionistic, frotteuristic, sexual sadism, and pedophilic disorders were written using the same template and include similar statements regarding their application to nondisclosing individuals.
As discussed above, statements such as these that suggest that recurrent sexually offending behavior alone is sufficient to ascertain the presence of a paraphilia are in conflict with the evidence 20 , 22 that a substantial proportion of sex offenses are not a manifestation of a paraphilic arousal pattern. Moreover, such statements appear to run counter to the change in the Criterion A wording intended to clarify that the behaviors must be a manifestation of a paraphilic sexual arousal pattern.
However, much depends on whether one interprets phrases such as frotteuristic behavior to mean implicitly that the modifier frotteuristic requires the behavior to be a manifestation of a frotteuristic arousal pattern or whether it is simply descriptive of the type of behavior i. It is too soon to tell to what extent this subtle difference in interpretation will be used in forensic evaluations to argue for or against the necessity of establishing that the behavior is a manifestation of a paraphilic arousal pattern.
Victim count requirements were originally part of the proposed diagnostic criteria sets for these paraphilic disorders as well as for pedophilic disorder , but were ultimately rejected from inclusion in the criteria sets 25 because of the lack of broad clinical consensus. Moreover, the proposal to include victim count requirements in the diagnostic criteria was derived entirely from a single study 26 that examined the diagnostic sensitivity of phallometric testing for pedophilia.
Given that this study did not include any subjects with the four DSM-5 paraphilic disorders that actually include this victim count threshold in their descriptive texts, the validity of these thresholds should be considered questionable and raise concerns regarding both false-positive and false-negative diagnoses.
DSM-5, as did its predecessor DSM-IV-TR, includes eight specific paraphilic disorders: voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic. However, the range of stimuli that can form the basis of a persistent and intense sexual arousal pattern is potentially limitless, and some of these patterns can undoubtedly lead to negative consequences in some individuals. The question thus arises regarding the appropriate use of the residual other specified paraphilic disorder and unspecified paraphilic disorder categories for presentations that do not meet criteria for one of the eight specified paraphilic disorders.
Both other specified disorder and unspecified disorder categories are considered to be residual.
Sexual Addiction and Paraphilias
They are intended to be used for presentations that do not meet the criteria for any specific DSM-5 disorder; for presentations of uncertain etiology with respect to whether the condition is substance induced, due to another medical condition, or primary; and for presentations where there is insufficient information to make a more specific diagnosis. In the case of the paraphilic disorders, these residual categories are intended to be used when there is an atypical sexual focus that is not covered by one of the eight specific types of paraphilic disorders and the atypical sexual focus causes clinically significant distress in social, occupational, or other important areas of functioning.
Whether a sexual arousal pattern should be considered atypical depends on the definition of the term paraphilia. In contrast, DSM-5 defines a paraphilia by exclusion by first defining normal foci of sexual arousal i. The decision to use other specified paraphilic disorder versus unspecified paraphilic disorder depends on whether the clinician wants to specify explicitly the type of atypical paraphilic focus.
If the other specified paraphilic disorder is used, the clinician is expected to add the name of the atypical paraphilic focus that is causing the clinically significant distress or impairment e. The unspecified paraphilic disorder diagnosis is used in situations in which the clinician knows but chooses not to specify the atypical paraphilic focus or in situations in which there is insufficient information available to indicate the precise nature of the atypical paraphilic focus.
The other specified and unspecified paraphilic disorders diagnoses are provided as are all of the residual other specified and unspecified categories in DSM-5 , to ensure that a diagnostic code is available for any conceivable psychiatric presentation that a clinician might encounter. When used in forensic settings, however, these residual categories do not carry with them the same degree of utility as the specific named categories and thus have the potential to be misused. Indeed, the paraphilia disorder NOS category, with the nonofficial addenda of the terms nonconsent or hebephilia, has been used in SVP evaluations as the basis for claiming that individuals convicted of rape or of having sexual relations with underage individuals have a paraphilia and thus qualify for civil commitment under SVP statutes.
By virtue of their residual and often idiosyncratic nature, cases diagnosed as other specified paraphilic disorder or unspecified paraphilic disorder are, by definition, outside of what is generally accepted by the field and thus should be used in forensic contexts only with great caution. Moreover, unlike the specific DSM paraphilic disorders categories that have an accompanying psychiatric body of literature indicating a range of likely courses and treatment responses, the paucity of such information for these residual categories greatly limits their forensic utility.
The provision for allowing the clinician to include the name of the atypical sexual focus within the other specified paraphilic disorder rubric may be misleading, especially to judges and juries who are not familiar with DSM-5 naming conventions. These residual specifiers may give the appearance that these categories are equivalent to the eight specific paraphilic disorders in terms of their acceptance by the field and their empirical backing and thus may appear to be equivalent in appropriateness for use in sexually violent predator commitment proceedings.
However, the ability to incorporate the name of the atypical sexual focus within the other specified paraphilic disorder rubric was intended only to facilitate clinical communication of the reason for the use of the residual category and not to provide quasi-legitimacy for the use of these as yet not officially accepted categories for forensic purposes. During the DSM-5 revision process, some of the most controversial proposals were those that would have expanded the pool of individuals who would qualify for a diagnosis of a specific paraphilic disorder. These included proposals to add a new paraphilic disorder for individuals who are sexually aroused by sexual coercion paraphilic coercive disorder and the expansion of pedophilic disorder to include attraction to pubescent children pedohebephilia.
Concerns about these proposals revolved around their impact on the evaluation of sex offenders charged with rape in the case of paraphilic coercive disorder and sexual offenses against adolescents in the case of pedohebephilia. Proponents argued that there are individuals with these foci of sexual arousal and that there is research and forensic utility in including the diagnoses as specific paraphilias in DSM The rejection of these proposed categories should cast doubt on the appropriateness of their use in forensic settings, especially for the purposes of qualifying individuals for sexually violent predator commitment.
However, the new paraphilia definition, which includes sexual interest in nonphysically mature and nonconsenting individuals, seems to suggest that such sexual interests could be included under the rubric of other specified paraphilic disorder. Whether it will now be easier or more difficult to make a convincing argument that a sexual offender charged with rape should have a diagnosis of other paraphilic disorder, nonconsent, as the qualifying mental disorder and thus be considered for civil commitment remains to be seen.
Paraphilic disorders, by virtue of their forensic import, exemplify the difficulty of integrating psychiatric concepts and concerns with those of the legal system and society in general. Although all DSM-5 changes require consideration of potential false positives and false negatives, the impact of the paraphilia diagnoses on such determinations as eligibility for SVP commitment, parental custodial and visitation rights, length of incarceration, and the risk category for community notification laws highlights the importance of achieving the right balance.
Even though virtually every change in the paraphilic disorder categories and criteria potentially has significant forensic ramifications, it is too soon to tell what their actual forensic impact will be. Will these changes make it easier to assign psychiatric diagnoses to sexually violent predators and therefore to commit them involuntarily after prison terms? Will it make a difference in treating them and reintegrating them into the community? Will the newly formalized distinction between paraphilias and paraphilic disorders reduce the stigma for those with atypical sexual interests who do not cause harm?
Their ultimate impact will depend on how the legal system incorporates these new definitions into statutes and case law. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.
We do not capture any email address. Skip to main content. Research Article Special Section. Michael B. Abstract Given that paraphilic disorders are diagnosed largely in forensic settings, virtually every significant change in the criteria has forensic implications. View this table: View inline View popup. Diagnosing Paraphilic Disorders in Nonforthcoming Individuals Perhaps the clearest indication that some of the changes in the paraphilic disorders section of DSM-5 were guided by forensic concerns is the various additions to the text addressing the challenge of applying the diagnostic criteria to individuals who are not forthcoming about the presence or impact of sexual pathology.