Proposed Changes for DSM-5 Diagnostic Criteria
Affecting Several or All Paraphilic Disorders
Ray Blanchard, Ph.D.
Toronto, ON Canada
The changes proposed by the DSM-5 Paraphilias Subworkgroup regarding the diagnostic criteria for Paraphilic Disorders may be divided into two categories: those that affect the diagnostic criteria for a single Paraphilic Disorder and those that affect the diagnostic criteria for all Paraphilic Disorders. This essay concerns proposed changes in the latter category.
Proposed Definitions, Labels, and Distinction between Paraphilias and Paraphilic Disorders
The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting human partners between the ages of physical maturity and physical decline. In some circumstances, the criteria “intense and persistent” may be difficult to apply; these include the assessment of persons who are very old or medically ill, and who may not have “intense” sexual interests of any kind. In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests (Blanchard et al., 2009).
Some paraphilias primarily concern the individual’s erotic activities, and others primarily concern the individual’s erotic targets (Cantor, Blanchard, & Barbaree, 2009). Examples of the former would include intense and persistent interests in spanking, whipping, cutting, immobilizing, or strangulating another person, or an interest in these activities that equals or exceeds the individual’s interest in copulation or equivalent interaction with another person. Examples of the latter would include intense or preferential sexual interest in children, the elderly, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber.
One of the first questions addressed by the Paraphilias Subworkgroup was whether all paraphilias are ipso facto mental disorders. We took the position that they are not. We therefore proposed that the DSM-5 make a distinction between paraphilias and Paraphilic Disorders, as described below.
A Paraphilic Disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.
It was possible to implement the distinction between paraphilias and Paraphilic Disorders without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. In the diagnostic criteria set for each of the listed Paraphilic Disorders, Criterion A specifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers), and Criterion B specifies the negative consequences of the paraphilia (distress, impairment, or harm—or risk of harm—to others). This format is exemplified by the proposed diagnostic criteria for Sexual Sadism Disorder:
A. Over a period of at least six months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.
B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.
The change proposed for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a Paraphilic Disorder. The word diagnosis would not be used in regard to individuals who meet Criterion A but not Criterion B, that is, individuals who have a paraphilia but not a Paraphilic Disorder. If an individual meets only Criterion A for a particular paraphilia—a circumstance that might arise when a benign paraphilia is discovered during the clinical investigation of some other condition—then the act of noting or reporting that the individual acknowledges the paraphilia should be referred to as ascertainment rather than diagnosis. Usage of the term ascertainment does not mean that an additional or a special step has been added to clinical assessment. It is simply a convenient way of avoiding the inappropriate word diagnosis when the individual has a paraphilia but not a Paraphilic Disorder.
The distinction between paraphilias and Paraphilic Disorders is one of the changes from DSM-IV-TR that applies to all atypical erotic interests. 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. An additional advantage of this approach is eliminating certain logical absurdities in the DSM-IV-TR. In that version, for example, a man could not be identified as having transvestism—however much he cross-dressed and however sexually exciting that was to him—unless he was unhappy about this activity or impaired by it (Blanchard, 2010b). This change in viewpoint is reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, DSM-IV-TR Fetishism becomes DSM-5 Fetishistic Disorder, Voyeurism becomes Voyeuristic Disorder, and so on.
Addition of Course Specifiers
The second overarching change from DSM-IV-TR is the addition of the course specifiers, “In a Controlled Environment” and “In Remission,” to the diagnostic criteria sets for all the Paraphilic Disorders. These specifiers were added in response to clinicians’ complaints that the DSM-IV-TR and earlier versions provided no mechanism for indicating important changes in the individual’s status. There is no expert consensus about whether a longstanding paraphilia can disappear spontaneously or be removed by therapy. There is less argument that consequent psychological distress, psychosocial impairment, or the propensity to do harm to others can be ameliorated by therapy or reduced to acceptable levels. Therefore, the “In Remission” course specifier was written so as to indicate remission from a Paraphilic Disorder. It is silent in regard to changes in the presence of the paraphilic interest per se. The intended meaning of remission is clarified in each of the diagnostic criteria sets with a parenthetical expression: “In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment).” The other course specifier, “In a Controlled Environment,” was included because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individual has no opportunity to act on such urges.
Changes and Continuities in Criterion A
The DSM-IV and DSM-IV-TR used the identical wording format in Criterion A for all Paraphilias: “Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving [the paraphilic focus].” Only the specification of the paraphilic focus varied from one paraphilia to another, for example, “nonliving objects” (Fetishism) and “exposure of one’s genitals” (Exhibitionism).
The wording format proposed for Criterion A for all DSM-5 paraphilias is essentially similar: “Over a period of at least six months, recurrent and intense sexual arousal from [the paraphilic focus], as manifested by fantasies, urges, or behaviors.” The purpose of this change was to clarify the relations of sexual fantasies, urges, and behaviors to each other and to the corresponding, underlying paraphilia. Fantasies, urges, and behaviors are (directly or indirectly) observable indicators of a psychological trait—a paraphilia—that cannot itself be observed using present technologies and perhaps cannot be observed in principle. The writer has previously expressed this conceptualization of paraphilias in somewhat different language: “I regard paraphilias . . . as erotic preferences or orientations that inhere in the individual and that have some existence independent of specific, observable actions” (Blanchard, 2010a, p. 310).
Changes and Continuities in Criterion B
In comparison with Criterion A, Criterion B (the distress and impairment criterion) has had a rather variable history. DSM-III-R used the identical wording format in Criterion B for all Paraphilias: “The person has acted on these urges, or is markedly distressed by them.” DSM-IV also used the identical format for all paraphilias, but it was completely different from the one applied in DSM-III-R: “The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
DSM-IV-TR used two different formats: One for Paraphilias whose satisfaction does not entail the involvement of nonconsenting others and one for Paraphilias that do involve nonconsenting others. Criterion B for Fetishism, Sexual Masochism, and Transvestic Fetishism remained exactly as it had been in DSM-IV. Criterion B for Exhibitionism, Frotteurism, Pedophilia, and Voyeurism reinstated a clause about acting on the basis of the paraphilia and thus returned to a formula very similar to that used in DSM-III-R: “The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.” Criterion B for Sadism was the same statement with an additional qualifier: “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.”
The B criteria proposed for DSM-5 follow the two-version pattern established in DSM-IV-TR. The version of Criterion B for Fetishistic Disorder, Sexual Masochism Disorder, and Transvestic Disorder reads: “The fantasies, sexual urges, or behaviors cause marked distress or impairment in social, occupational, or other important areas of functioning.” The version of Criterion B for Exhibitionistic Disorder, Frotteuristic Disorder, Sexual Sadism Disorder, and Voyeuristic Disorder reads: “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.” There is a slight variation of Criterion B for Pedophilic Disorder, because a nonconsenting person (in the common-language sense of unaware, unwilling, or resisting) is not inherent to the sexual objective. Thus: “The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.”
The crucial point of this section is that the proposed diagnostic criteria for DSM-5, exactly like the diagnostic criteria for DSM-IV-TR, make it possible to diagnose a patient with a specific paraphilia on the sole grounds that he has offended against multiple victims in a way characteristic of that paraphilia, whether he acknowledges that paraphilia or not. The recurrent behavior constitutes clinical grounds for inferring that the paraphilia is present (satisfying Criterion A) and, at the same time, it demonstrates that the paraphilically motivated behavior is causing distress, harm, or risk of harm to others (satisfying Criterion B).
The question of how much sexually offending behavior of the same type is necessary to diagnose the corresponding Paraphilic Disorder in a patient who verbally denies that disorder has traditionally been left to clinical judgment. The available research indicates that a threshold of three or more different victims age 14 or younger can be used to diagnose Pedophilic Disorder with a high degree of specificity, that is, 90% or more (Blanchard, 2010c, 2011). The writer knows of no published research investigating a diagnostic threshold based on a patient’s total number of sexual interactions with the same child or on the length of time (in weeks, months, or years) during which a patient interacted sexually with the same child.
Blanchard, R. (2010a). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior, 39, 304–316.
Blanchard, R. (2010b). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior, 39, 363–372.
Blanchard, R. (2010c). The specificity of victim count as a diagnostic indicator of pedohebephilia [Letter to the Editor]. Archives of Sexual Behavior, 39, 1245–1252.
Blanchard, R. (2011). Misdiagnoses of pedohebephilia using victim count: A reply to Wollert and Cramer (2011) paraphilias [Letter to the Editor]. Archives of Sexual Behavior, 40, 1081–1088.
Blanchard, R., Kuban, M. E., Blak, T., Cantor, J. M., Klassen, P. E., & Dickey, R. (2009). Absolute versus relative ascertainment of pedophilia in men. Sexual Abuse: A Journal of Research and Treatment, 21, 431–441.
Cantor, J. M., Blanchard, R., & Barbaree, H. E. (2009). Sexual disorders. In P. H. Blaney & T. Millon (Eds.), Oxford textbook of psychopathology (2nd ed., pp. 527–548). New York: Oxford University Press.