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Paraphilias and the DSM-V: General Diagnostic Issues and Options Exemplified with Pedohebephilic Disorder


Paper presented at 19th WAS World Congress for Sexual Health, June 25, 2009, Göteborg, Sweden



            Good afternoon and thank you for attending.



            As many people in this audience probably know, the American Psychiatric Association is currently conducting the fourth major revision of its Diagnostic and Statistical Manual of Mental Disorders. Thirteen Work Groups have been assembled to review the current diagnoses. One of these committees is the Sexual and Gender Identity Disorders Work Group. This comprises three subworkgroups, which focus on Sexual Dysfunctions, Gender Identity Disorders, and the Paraphilias. The Paraphilias Subworkgroup has four members, Richard Krueger and Martin Kafka from the United States, me from Canada, and Niklas Långström from the Karolinska Institute in Stockholm. I’ve been serving as the Chair of the Paraphilias Subworkgroup.


            I’m going to talk to you today about our some of work in progress. It is important for me to stress that the diagnostic options I will present are merely suggestions that I have made to the Subworkgroup. The Subworkgroup will make its final recommendations to the APA after considering feedback from various sources. The APA, in turn, might accept, reject, or modify the Subworkgroup’s recommendations. Thus, the diagnostic criteria and text that ultimately appear in print may bear little or no relation to the possibilities that I am about to show you.


            I’m going to begin my talk with certain matters pertaining to all the paraphilias. In the second part of my talk, I will present possible changes to the diagnostic criteria for Pedophilia.



            The first general matter I will address is the definition of the term paraphilia. The DSM-IV-TR really has no formal definition of paraphilia. I have proposed to add one, along these lines—any sexual interest other than that in petting or genital stimulation with consenting adults. At first glance, this definition seems to label everything outside a very narrow range of sexual behaviors as paraphilic. The next screen (Slide 4), however, shows that that is not really true.





            None of the things in the first list would be labeled as paraphilic—for example, cunnilingus, fellatio, or anal intercourse. All of the things in the second list would be labeled as paraphilic—for example, sexual interest in children, or a generalized interest in amputees. The qualifier “generalized” means, of course, that sexual attraction to a specific person who happens to have an amputated limb or a physical deformity would not be considered a paraphilia. The definition would apply only to patients who have a strong sexual attraction to amputees as a class.


            This option for supplying the missing definition of paraphilia would not change anything with regard to what is classified as paraphilic or not, and it clearly excludes homosexuality from the domain of paraphilias.



            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 the screen. 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 6 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 will be looking closely at feedback from multiple sources regarding this idea.



            I am now going to turn from matters that apply to all the paraphilias to my proposal for one specific paraphilia, which 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 7 shows that the A criterion—the ascertainment criterion—specifies the nature of the paraphilia, namely, strong sexual attraction to children under the age of 15. The B criterion is the distress and impairment criterion. Criminal sexual offenses against children are treated as de facto impairment.



            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 three reasons, which are shown on the screen: The two entities are not completely different, many patients are both pedophilic and hebephilic, and patients who are hebephilic are getting DSM diagnoses anyway—just not the most precise ones.




            Before I proposed this diagnostic option, I needed to demonstrate that men who say they are most attracted to pubescents could be shown in some objective way to respond most to pubescents. That is the meaning of the first bulleted point on the screen—that the concept would gain credibility from agreement between different methods of assessing sexual interest. I therefore carried out a study that was published earlier this year. I am now going to summarize that study for you.




            I used the data from 881 men who were assessed in my laboratory in Toronto. I divided these men into groups according to their self-reports. First I divided them into a heterosexual group and a homosexual group. Then I divided each of these groups into six age-preference groups, again according to their self-reports. The six age-preference groups are shown in Slide 13.




            The objective method that I chose to validate the subjects’ self-reports was phallometric testing, also known as penile plethysmography. The individual’s penile blood volume was monitored while he was presented with a standardized set of laboratory stimuli depicting persons of both sexes and different ages. As shown in the slide—and as must be obvious—penile blood volume increases during stimulus exposure were used as the measure of sexual attraction.




            Slide 15 shows a schematic drawing and a photograph of the device that fits over the subject’s penis. It allows us to measure blood volume changes indirectly but very accurately, by detecting air pressures changes inside the glass cylinder.




            The laboratory stimuli were photographic slides of nude models. The slides were accompanied by audiotaped narratives describing sexual interaction with a person of the same age and gender as the model being shown on the screen. The current screen (Slide 16) shows the six categories of persons depicted in the stimuli. There was also a “neutral” stimulus category, in which the slides showed landscapes and the auditory narratives described solitary and nonsexual activities, like rowing a boat on a lake.




            Here is a sample of a stimulus depicting a pubescent girl. All the models are posed in a manner resembling subjects in a medical textbook. I have whited out this model for the purposes of public presentation. The text on the right of the screen is an example of a narrative that the subject would hear while he looked at photographs of pubescent girls.


            Slide 18 shows the results for the six heterosexual groups. The penile response measures have been expressed as ipsative z-scores, but you can ignore that. Taller bars mean larger penile responses. The blue bars represent responses to prepubescent girls, the green bars represent responses to pubescent girls, and the tan bars represent responses to adult women.





            Let’s look first at the Pedophile 1 group, at the extreme left of the figure. As one would expect, they responded more to prepubescent girls than to pubescent girls or adult women. Now let’s look at the Teleiophilic group, at the extreme right of the figure. They responded more to adult women than to pubescent or prepubescent girls. The crucial results are those for the two hebephilic groups in the centre of the figure. The results showed that they responded significantly more to pubescent girls than to prepubescent girls or to adult women. The results therefore supported the existence of a class of men—hebephiles—who are more attracted to pubescents than they are to older or younger persons.


            Slide 19 shows the results for the six groups of homosexual men. The results are generally similar to those for the heterosexual men. However, these groups were very much smaller, so the findings were not quite as orderly.







            I now want to move on to another topic. That is my reasons for the second major change that I have proposed regarding the diagnostic criteria for Pedohebephilic Disorder. Slide 20 emphasizes that Criterion A—which I showed you earlier—comprises two different ways of ascertaining pedophilic or hebephilic interest. The patient can be intensely aroused by children or else more aroused by children than by adults.




            Both approaches to ascertainment have been used in previous editions of the DSM. However, previous editions have used either one approach or the other—no previous edition has used both together. From DSM-III-R onward, the individual’s sexual interest in children has been evaluated without any reference to his sexual interest in adults. Take a look at the language quoted in the first bulleted point in Slide 21—recurrent, intense urges toward children; nothing said about adults. In other words, the strength of such interest is evaluated in absolute terms.


            The DSM-III had used a different approach. In that version, the strength of sexual interest in children was implicitly compared to the strength of sexual interest in adults. Take a look at the language quoted in the second bulleted point in Slide 21—preferred method, meaning preferred over adults. Thus, the magnitude of sexual interest in children was assessed in relative rather than absolute terms.



            My reasons for recommending the use of both approaches have to do with the clinical realities of ascertaining pedophilia or hebephilia in patients charged for sexual offenses against children. Many or most such patients are unreliable when it comes to reporting their erotic interests. Even those who are well aware that they have a pedophilic or hebephilic orientation may deny this. The examining clinician is forced to make an inference about the patient’s sexual interests, whether the clinician is looking for evidence that the patient’s interest in children is intense or evidence that the patient’s interest in children is greater than his interest in adults. Which type of inference is possible depends on the type of evidence available.


            Consider the hypothetical case of a man who is married and who claims to have regular intercourse with his wife. However, this man has sexually molested three girls outside of his home. He molested the third girl after having been charged and convicted of molesting the first two. It can be argued that the patient must have an intense sexual interest in girls to have behaved in this way, but there is no objective basis for concluding that his sexual interest in girls must be greater than his sexual interest in adult women. The opposite is generally true in the laboratory assessment of sexual offenders, where it is generally easier to conclude that a man’s sexual interest in children is greater than his sexual interest in adults than it is to conclude that his sexual interest in children is intense. In order to demonstrate this point as dramatically as possible, I worked up some data to present at this meeting.



            This study, like the previous one, used phallometric testing, but in this study the phallometric data were used in a different way. I selected two groups of subjects, as described on the screen. The first group responded substantially to depictions of prepubescent girls but even more to depictions of adult women, and the second group responded weakly to depictions of prepubescent girls but even less to depictions of adult women. This will seem much clearer when I show you the next screen (Slide 24).


            Slide 24 shows the full phallometric profiles for the two groups I selected. In this study, I am using untransformed data, that is, the height of a bar represents penile response measured in cubic centimeters of blood volume increase. Please pay special attention to the dark blue bars, which represent average responses to depictions of adult women, and the tan bars, which represent responses to prepubescent girls.





            Group 1—which I labeled the “teleiophilic profile” group—responded with about 13 cc of penile blood volume to prepubescent girls. That is a very substantial response in our laboratory—it represents about half of a full erection. However, these subjects responded even more—about 19 cc—to adult women. The second group—which I labeled the “pedophilic profile” group—had a much smaller response to prepubescent girls (only 2 to 3 cc), but their response to adult women was smaller yet (less than 2 cc).


            There are two key points to take away from this figure. The first point is that the second group’s penile responses to prepubescent girls were quite low, and there is no way that one could infer “intense” sexual attraction from them alone. The second point is that the second group, compared with the first group, had the smaller absolute response to prepubescent girls but the larger relative response.


            Slide 25 represents the sexual offense histories of the two groups. The height of a bar represents the number of victims in a given category. The dark blue bars represent the average number of adult female victims for the two groups. The tan bars represent the average number of female victims under the age of 12.





            The results showed that the second group had a significantly greater number of sexual offenses against prepubescent girls, even though they had a significantly smaller response to prepubescent girls in the laboratory. This represents strong evidence that the second group contained more pedophiles than the first. The key to understanding these results is that the second group’s laboratory response to prepubescent girls—as small as it may have been—was nevertheless greater than their response to adult women.


            These data demonstrate that there is a role for the relativistic approach to ascertaining pedophilia and hebephilia. I do not think that the usefulness of this approach is limited to phallometric testing. I think the same thing will prove true for other laboratory methods, such as the potential fMRI assessment of erotic preferences. In my view, it is important for the DSM-V to anticipate the advent of other laboratory methods of assessment in the foreseeable future.




            Since it turns out that we have more time for questions than expected, I’ll be happy to take them now. For people who might want to refer to this talk in the future, I plan to put the text on my Website after I get back to Toronto.