Paraphilias and the
DSM-V: General Diagnostic Issues and Options Exemplified with Pedohebephilic
presented at 19th WAS World Congress for Sexual Health, June 25,
Good afternoon and thank you for
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
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
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
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
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
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
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
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
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
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
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