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Paraphilias
vs. Paraphilic Disorders, Pedophilia vs. Pedo- And Hebephilia, and
Autogynephilic vs. Fetishistic Transvestism |
Paper
presented at the Annual Meeting of the Society for Sex Therapy and Research
(SSTAR), April
3, 2009, Arlington, |
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SLIDE 1
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Good
morning. As the first speaker from my subgroup, 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. We are just beginning the process of
soliciting feedback on these options, and the diagnostic criteria that
finally appear in print may bear little or no relation to the possibilities
that I am about to show you. I want to apologize in advance that I will ask the audience several times to read a passage of text from the screen. This talk is very much about precise wording, and there is little I can do to get around that or to make it more visually interesting. |
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SLIDE 2
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The
first issue I will address is the definition of paraphilia. There are at least two different ways that one can
define paraphilia. I have called them the definition by concatenation and the definition by exclusion. The current version of the DSM uses the definition by
concatenation, that is, it defines paraphilia by simply listing things that
have been called paraphilic. On
Slide 2 is one proposal for an extended version of the DSM-IV-TR definition.
I’ll give you a moment to read the screen. The first three clauses cover all
of the currently listed DSM paraphilias, and the fourth clause covers partialism, for example,
foot-fetishism. There
are two problems with this type of definition. The first is that it would
have to be even longer to cover all the phenomena that are currently
diagnosed as Paraphilia NOS—Not Otherwise Specified. The second is that it is
intellectually rather empty. It’s like defining dog by listing terriers, poodles, bloodhounds, |
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SLIDE 3
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Here
is my proposal for a definition by exclusion, after extensive modifications by
my subgroup. I’ll pause for a moment while you read Slide 3. Essentially,
it defines paraphilias as erotic interests that are not focused on copulatory or precopulatory behaviors, or the
equivalent behaviors in same-sex adult partners. At first glance, it seems to
label everything outside a very narrow range of sexual behaviors as
paraphilic. Slide 4, however, shows that that is not really true. |
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SLIDE 4
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None
of the things in the first list would be labeled as paraphilic. All of the
things in the second list would be labeled as paraphilic, even though some of
them, like erotic interest in enemas, are not clearly covered in the
definition by concatenation. We will consider input from our formal Advisors
as well as audiences like this one before deciding which type of definition
to support. |
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SLIDE 5
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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.
I’ll give you a moment to read Slide 5 and then I’ll elaborate on it. In
this formulation, 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. |
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SLIDE 6
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Slide
6 shows how the distinction would play out in DSM-V. I’ll give you a few
seconds to read and digest the screen before I comment on it. 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 will be looking closely at feedback from multiple sources regarding this idea. |
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SLIDE 7
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My
next topic concerns a relatively subtle point. Some sexual responses are
ascertained as paraphilic if their intensity is strong but not if their
intensity is weak. The question therefore arises: Strong compared to what? Strong compared to nonexistent,
or strong compared to normophilic
interest? This
distinction can be illustrated with the criteria for pedophilia in various
editions of the DSM. From DSM-III-R onward, the individual’s sexual interest
in children is evaluated without any reference to his sexual interest in
adults. Take a look at the language quoted in the second bulleted point in
Slide 7. In other words, the strength of such interest is evaluated in
absolute terms. The
DSM-III used a different approach. In that version, the strength of sexual
interest in children is implicitly compared to the strength of sexual
interest in adults. Take a look at the language quoted in the third bulleted
point in Slide 7. That is the conceptualization that has always been used in
our lab in |
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SLIDE 8
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Ignore, for
the moment, the change in the name of the disorder. Note that criterion A includes
both of the previous DSM approaches to ascertaining pedophilia. I’ll give you
a moment to spot them. Whether the DSM-V ends up with
this hybrid option, or anything like it, is one of many things that I cannot
answer as of today. The
most obvious innovation in this diagnosis is, of course, the proposal to
change the name of the phenomenon from pedophilia to pedohebephilia. The term pedophilia was introduced by
Krafft-Ebing to denote sexual interest in prepubescent children. Clinical
observation and my own formal research have shown, however, that there also
exist men who are more attracted to pubescents—say, ages 11 through 14—than
they are either to prepubescent children or to physically mature persons. The
label hebephiles was invented for
these men in the 1950’s. Some individuals are attracted both to prepubescent
and pubescent children, and they have been called pedohebephiles. I have
therefore proposed that the DSM be modified to reflect this clinical reality. In order to make a diagnosis, an individual must also meet a distress or impairment criterion, which is criterion B in this example, as it is for all of the paraphilias. |
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SLIDE 9
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Previous
versions of the DSM have also included a C criterion, to avoid labeling
peer-appropriate sexual interest as paraphilic. We have done the same,
although we propose increasing the age cut-off from 16 to 18 years. |
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SLIDE 10
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We
are also proposing two groups of specifiers. Please
take a moment to look at the first group of these. The
first group would make it possible to identify classic pedophiles, through
the use of the first specifier. In fact, I believe
that the first specifier would do a better job of
identifying classic pedophiles than the current DSM diagnostic criteria for
pedophilia. |
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SLIDE 11
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The
second group of specifiers is identical to those in
the current version of the DSM. |
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SLIDE 12
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The
last 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 unchanged from
DSM-IV-TR. I’ll wait a few seconds, for those of you who wish to refresh
their memories. |
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SLIDE 13
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The
only change I have proposed is in the specifiers,
which are shown on Slide 13. I’ll give you a moment to read them, before I
comment on them. I
made this recommendation according to the results of unpublished research,
which 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. Thank
you for your attention. I hope that we will have time for a few questions. |
