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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, Virginia

 

SLIDE 1

 

 

††††††††††† 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.

SLIDE 2

 

 

††††††††††† 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. Iíll 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 NOSóNot Otherwise Specified. The second is that it is intellectually rather empty. Itís like defining dog by listing terriers, poodles, bloodhounds, Chihuahuas, and so on. For that reason, I have proposed an alternative definition, which I call the definition by exclusion.

SLIDE 3

 

 

††††††††††† Here is my proposal for a definition by exclusion, after extensive modifications by my subgroup. Iíll 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.

 

SLIDE 4

 

 

††††††††††† 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.

 

SLIDE 5

 

 

††††††††††† 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. Iíll give you a moment to read Slide 5 and then Iíll 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.

 

SLIDE 6

 

 

††††††††††† Slide 6 shows how the distinction would play out in DSM-V. Iíll 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.

SLIDE 7

 

 

††††††††††† 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 individualís 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 Toronto, because typical men show a slight but non-zero penile response to prepubescent girls when tested phallometrically. In Slide 8, I will show you a hybrid ascertainment criterion in which our subgroup has tried one possible way to combine both approaches.

 

SLIDE 8

 

 

††††††††††† 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. Iíll 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 pubescentsósay, ages 11 through 14óthan they are either to prepubescent children or to physically mature persons. The label hebephiles was invented for these men in the 1950ís. 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.

SLIDE 9

 

 

††††††††††† 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.

 

SLIDE 10

 

 

††††††††††† 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.

 

SLIDE 11

 

 

††††††††††† The second group of specifiers is identical to those in the current version of the DSM.

 

SLIDE 12

 

 

††††††††††† 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. Iíll wait a few seconds, for those of you who wish to refresh their memories.

 

SLIDE 13

 

 

††††††††††† The only change I have proposed is in the specifiers, which are shown on Slide 13. Iíll 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.