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DSM-V Options: Paraphilias and Paraphilic Disorders, Pedohebephilic Disorder, and Transvestic Disorder


Paper presented at the 28th Annual Meeting of the Association for the Treatment of Sexual Abusers, October 1, 2009, Dallas, Texas




            Good afternoon. As the first speaker, I want to lead off with certain matters pertaining to all the paraphilias. After that, I will begin the discussion of specific paraphilias with my comments on pedophilia and transvestism. It is important for me to stress that I am presenting options for possible changes to the DSM. The diagnostic criteria and text that ultimately appear in print could bear little or no relation to the possibilities that I am about to show you.


            This presentation covers numerous wording issues. For people who want to study these issues at their leisure, I plan to put a verbatim copy of this talk on my Website after I return to Toronto. I will give the URL later.




            I will now start with the cross-cutting issues. The DSM-IV-TR does not give a precise definition of paraphilia, and it does not even consistently use a single loose definition. The first definition occurs on page 535.


            This definition has serious drawbacks. The only attribute that makes a sexual desire eligible for classification as a paraphilia is that it is unusual. This would include homosexuality, which is statistically unusual but is no longer considered a paraphilia. The definition also implies that one cannot have a paraphilia unless one is distressed or impaired by that paraphilia.




            A different definition occurs later on page 566. One might call this a definition by concatenation. It is really not so much a definition as a table of contents for the DSM’s section on paraphilias. This can be seen in Slide 4, where I have simply added to the list of numbered categories the coded DSM paraphilias to which they correspond.




            In practice, the definition by concatenation would be of limited use to clinicians or researchers in deciding whether a novel phenomenon is a paraphilia. I can illustrate this with klismaphilia, the erotic interest in having enemas, which is listed in the DSM-IV-TR as an example of a Paraphilia Not Otherwise Specified.


            Enemas do involve nonhuman objects, but these do not appear to be the focus of the experience. There is no reason to assume that enemas are experienced as painful or humiliating to the practitioners, and sexually motivated enemas do not involve nonconsenting persons. Thus, klismaphilia would not be identifiable as a paraphilia using the DSM’s second definition of paraphilia.


            In other words, a clinician using the definition on p. 566 would not be able to identify klismaphilia as a paraphilia, even though the DSM itself lists klismaphilia as an example of a Paraphilia NOS! 




            I have tried to avoid the problems with the DSM-IV-TR’s definitions of paraphilia with a formulation that I have called the definition by exclusion.


            This definition is not watertight. It has, for example, been misread as classifying masturbation as a paraphilia. I think it is better than no real definition, which is what the DSM-IV-TR currently has, but I am still listening to suggestions for improvements.




            The next question is equally or more important than the general definition of paraphilia. That is, are all paraphilias ipso facto psychiatric disorders? Our subgroup is taking the position that they are not.


            We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention.


            The general notion that we are considering is shown on Slide 6. The first bulleted sentence shows that only problematic paraphilias would be called paraphilic disorders. To underscore that point, we propose to use the verb ascertain when talking about paraphilias and the verb diagnose when talking about paraphilic disorders.



            Slide 7 shows how the distinction would play out in DSM-V. As the screen shows, a paraphilia would be a necessary but not a sufficient condition for a paraphilic disorder.


            The second bulleted point refers to the general layout of the diagnostic criteria for the various paraphilias in the DSM. The A criterion is about identifying the phenomenon and the B criterion is about distress and impairment.


            This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. As with the general definition of paraphilia, we have been looking closely at feedback from multiple sources regarding this idea.


            This change would also eliminate certain logical absurdities in the DSM-IV-TR. In this version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is he is unhappy about this activity or impaired by it.




            I am now going to turn from matters that apply to all the paraphilias to my proposals for two specific paraphilias. The first of these is presently called pedophilia. The first thing you will notice is that I have proposed changing the name of the entity from Pedophilia to Pedohebephilic Disorder. You will, of course, want to know the meaning of the word “Pedohebephilic.” This is a compound of two words: pedophilic and hebephilic. Pedophilia, as classically defined by Krafft-Ebing and as still defined in the DSM, denotes sexual attraction to prepubescent children.


            The word hebephilia, which was coined in the 1950’s, denotes sexual attraction to pubescent children. There are many men who appear sexually attracted to both pubescent and prepubescent children, and these have been called pedohebephiles. My suggested change in terminology, therefore, signals that I am proposing to expand the diagnostic category to include men who are sexually attracted to pubescent children as well as those attracted to prepubescent children. I will explain my reasons for this later. First, I want to go over the proposed diagnostic criteria.


            Slide 8 shows that the A criterion—the ascertainment criterion—specifies the nature of the paraphilia, namely, strong or preferential sexual attraction to prepubescent or pubescent children. The reference to “laboratory testing” is meant to include tests that might be developed in the future, such as fMRI ascertainment of pedohebephilia.




            The B criterion is the distress and impairment criterion. Criminal sexual offenses against children are treated as de facto impairment.


            The clauses pertaining to number of different victims may be understood as follows: Suppose that the patient is assigned 1 point for each pubescent victim and 1.5 points for each prepubescent victim. Then Criterion B is satisfied if the patient has accrued a total of 3 points or higher.




            Previous versions of the DSM have also included a C criterion, to avoid labeling peer-appropriate sexual interest as paraphilic. I have done the same, although the Subworkgroup has proposed increasing the age cut-off from 16 to 18 years.




            I am also proposing two groups of subtyping options. The first group of subtypes is shown on this screen—it would be used to record the ages of children who are most attractive to the patient. This would make it possible to identify classic pedophiles, through the use of the first subtype. In fact, I believe that the first subtype would do a better job of identifying classic pedophiles than the current DSM diagnostic criteria for pedophilia.




            The second group of subtypes is identical to that in the current version of the DSM. This group of subtypes would be used the record the gender of children who are most attractive to the patient.




            I promised earlier that I would explain why I have suggested replacing Pedophilia with Pedohebephilic Disorder. There are four reasons, which are shown on this slide and the next slide.


            The first and second reasons are that the two entities are not completely different, and that many patients are both pedophilic and hebephilic.




            The third reason is that patients who are hebephilic are getting DSM diagnoses anyway—just not the most precise ones.


            The fourth reason is that this modification would help to harmonize the DSM and the International Classification of Diseases published by the World Health Organization. The ICD-10 already implicitly recognizes the mismatch between the classical, narrow definition of pedophilia as sexual attraction to prepubescent children and the clinical reality.




            The other specific paraphilia that I will discuss was previously called Transvestic Fetishism. I have proposed changing its name to Transvestic Disorder. In this option, the A and B criteria are mostly similar to those in DSM-IV-TR.




            The main change I have proposed is in the specifiers, which are shown on Slide 16.


            I made this recommendation according to the results of research that I conducted specifically for the Paraphilias Subworkgroup.


            The results showed that transvestic patients who acknowledged autogynephilia had higher odds of reporting past or current desires for sex reassignment than transvestic patients who denied autogynephilia. The opposite result was found for fetishism, that is, transvestites who reported fetishism were less likely to report a desire for sex reassignment. It is noteworthy that these predictors were independent to a large extent.




            I realize that the amount of time allocated for this talk and questions was not enough for the topic. As I said earlier, I plan to put the text on my Website after I get back to Toronto. There will also be an interest group meeting this afternoon in which the four of us will be available for questions.