[1] The Paraphilias Subworkgroup is proposing two broad changes that affect all or several of the paraphilia diagnoses, in addition to various amendments to specific diagnoses. The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. 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. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.

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. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, Sexual Sadism would become Sexual Sadism Disorder; Sexual Masochism would become Sexual Masochism Disorder, and so on.

In general, the distinction between paraphilias and paraphilic disorders is reflected in the format of the diagnostic criteria for specific paraphilias. Paraphilias are ascertained according to the “A” criteria, and paraphilic disorders are diagnosed according to the “A” and “B” criteria. The distinction between paraphilias and paraphilic disorders is discussed in the context of specific diagnoses by Blanchard (2009b, 2009c).

The second broad change applies to paraphilias that involve nonconsenting persons (e.g., Voyeuristic Disorder, Exhibitionistic Disorder, and Sexual Sadism Disorder). We propose that the B criteria suggest a minimum number of separate victims for diagnosing the paraphilia in uncooperative patients. This was done to reflect the fact that a substantial proportion—perhaps a majority—of patients referred for assessment of paraphilias is referred after committing a criminal sexual offense. Such patients are not reliable historians, and they are typically not candid about their sexual urges and fantasies. The criteria have therefore been modified to lessen the dependence of diagnosis on patients’ self-reports regarding urges and fantasies. This change also addresses the past criticism that the word “recurrent” in the DSM-IV-TR A criteria says nothing beyond “more than once” and is too vague to be clinically useful. The reason for diagnosing specific paraphilic disorders from multiple, similar offenses in uncooperative patients is to achieve a level of diagnostic certitude closer to the certitude in diagnosing these disorders from self-reports in cooperative patients. It is not derived from legal theory or practice.       

The suggested minimum number of separate victims varies for different paraphilias. This represents an attempt to obtain similar rates of false positive and false negative diagnoses for all the paraphilias. The logic runs as follows: Paraphilias differ in the extent to which they resemble behaviors in the typical adult’s sexual repertoire. For example, sexual arousal from seeing unsuspecting people in the nude seems more probable, in a typical adult, than sexual arousal from hurting or maiming struggling, terrified strangers. It follows that the more closely a potentially paraphilic behavior resembles a potentially normophilic behavior, the more evidence should be required to conclude that the behavior is paraphilically motivated. We have therefore suggested, for example, three different victims for Voyeuristic Disorder but only two different victims for Sexual Sadism Disorder. We felt that fewer than three victims for Voyeuristic Disorder would result in too many false positives and more than two victims for Sexual Sadism Disorder would result in too many false negatives.

[23] Paraphilic Coercive Disorder has been proposed as a distinct syndrome, separate from Sexual Sadism, during previous revisions of the DSM. The present Paraphilias Subworkgroup is proposing it again.

Salient cues indicating that their partner is feeling coerced normally inhibit males’ sexual arousal, at least partially, whereas cues indicating mutual interest heighten arousal. However, for a minority of males—those with Paraphilic Coercive Disorder—this pattern reverses, with salient coercion cues leading to heightened arousal (Thornton, 2009; but see Knight, 2009; Quinsey, 2009).

Coercive sexual fantasy is commonly reported by rapists while participating in treatment (McKibben, Proulx, & Lusignan, 1994), and under optimal conditions in laboratory tests, about 60% of rapists demonstrate preferential arousal to saliently-coercive rape stimuli as compared to 10% of unconvicted individuals (Lalumière, Quinsey, Harris, Rice, & Trautrimas, 2003). Among convicted rapists it is those who have more persistently engaged in rape and assault who are more likely to show preferential arousal to saliently-coercive rape in laboratory tests (Willmot & Hart, 1996). Among individuals with no official record of sexual offending, preferential arousal to saliently-coercive rape as indicated by laboratory tests is found to be substantially correlated with self-report of engaging in sexually coercive behavior in the great majority of studies (Bernat, Calhoun, & Adams, 1999; Lalumière & Quinsey, 1996; Lohr, Adams, & Davis, 1997; Malamuth, 1986).

Under research conditions there is a good correspondence between self-report of engaging in coercive sexual fantasy and laboratory tests indicating preferential arousal to saliently-coercive rape (Malamuth, Check, & Briere, 1986). In clinical practice, especially under the adversarial conditions that commonly apply during forensic evaluations, convicted sexual offenders will commonly do their best to conceal coercive sexual interests. Consequently positive evidence from any source (self-report, laboratory tests, or patterns of behavior) may be taken as indicative.

There has been an unfortunate tendency to over-diagnose Paraphilic Coercive Disorder (usually under Paraphilia NOS) simply on the basis of repeated coercive sexual behavior. Care must be taken, in using patterns of behavior, that these are truly indicative of sexual coercion being a source of arousal (First & Hallon, 2008). The diagnostic criteria proposed here make this clearer and should lead to less frequent but more appropriate diagnosis.

[24] The reliance on “forcing sex on three or more nonconsenting persons on separate occasions” in indicating that the paraphilia rises to the level of a disorder will also likely have the effect of increasing the accuracy of the ascertainment of this paraphilic interest. It is probable that this degree of repetition is in itself partially indicative of a specific interest in coercive sexual behavior (as opposed, for example, to those rapes where situational or opportunistic factors play a larger role).

[25] Sexual sadism may sometimes lead to preferential arousal to saliently-coercive rape, and so should be diagnosed where it applies. However, the correlation between sexual sadism and preferential arousal to saliently-coercive rape is low and inconsistent (Barbaree, Seto, Serin, Amos, & Preston, 1994; Langevin et al., 1985; Marshall, Kennedy, & Yates, 2002; Preston, 1996; Proulx, 2001; Seto & Kuban, 1995) indicating that Paraphilic Coercive Disorder is not simply sadism.

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