A mental health primer on paraphilias in DSM-5

By John W. Addis, Ph.D.
January 21, 2014

A mental health primer on paraphilias in DSM-5Every 10 years or so, the American Psychiatric Association comes forth with a new or revised dictum on the right way to look at and ultimately diagnose mental disorders. This is a very exacerbating, costly and unpredictable task that makes the outsider question the mental stability and masochistic needs of this very respectable and highly educated group of men and women.

The end result is always affirmed by some, criticized by others and nullified by yet a third group who think the whole experiment of upgrading psychiatric nomenclature in lieu of the WHO’s ICD-9 and ICD-10 is unwarranted.

This article is not geared toward taking a stand on the DSM-5 but to take one segment and bring it into some cursory level of sensibility. The primary area of focus deals with paraphilias. As professionals, the legal statutes and paradigms are yours to seek out, assimilate and understand.

The DSM-IV-TR is and was a workable treatise, and the DSM-5, as far as paraphilic components are concerned, is an upgraded continuation of the same. The nomenclature, though, is slightly different and the clinician should be alert to this transitory jargon as well as the two group schema, including target preferences.

The DSM-5’s Paraphilic Disorders in Section II is many things, which will likely all be debated, with one special ingredient – cogency. It is clear and concise, but are there some divergences in terms of its research base?

Professionals dealing with cases of sexual assault and particularly Megan’s Law should make sure that they are au fait with, at a minimum, such terms/phrases as anomalous activity preferences, anomalous target preferences, algolagnic disorders, paraphilia, normal sexual behavior, intense, persistent, normophilic (sexual interest), orientation, benign paraphilia, other specified paraphilic disorder, unspecified paraphilic disorder, admitting individual and preferential.

Almost all the paraphilic disorders listed in the DSM-5 are likely criminal (when acted upon with nonconsenting persons) and in some states when adjudicated on a registered type sexual offense, violent (by statute). Some paraphilias relate to a person’s erotic actions while others relate to the focus or the “target.” The paraphilic disorders in the DSM-5 are the most common but there are many others. None of the listed paraphilic disorders actually require physical contact, contrary to the DSM-IV-TR where sexual sadism did. A paraphilic disorder is a paraphilia but the latter is “a necessary but not a sufficient condition for having a paraphilic disorder and a paraphilia by itself does not necessarily justify or require clinical intervention.” Simply put, some people identify with a paraphilia, e.g., transvestism, and have an intense and persistent interest in cross-dressing. But, a genetic male may be able to go to work on some days dressed as a woman and on other days as a man, be accepted by supervisors and coworkers, like to fondle his wife’s genitals and have her fondle his and have coitus with a playful and consenting wife while dressed as a woman.

Such a person may have had some distress about cross-dressing when younger but now is accepting of who he is and does not put himself or others in harm’s way (or at any risk). The “paraphilia” is the condition, the “paraphilic” is the disorder. There is a need for unusual sexual stimulation but there is not a need for “extreme or dangerous” practices “in order to achieve sexual arousal or orgasm.”

What is normal adult sexual behavior? The DSM-5 denotes “paraphilia” as “any intense and persistent sexual interest other than a sexual interest in general stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.” The interpretation of the DSM-5 definition leads one to believe that “normal” is sexual behavior that is age and maturity appropriate, consensual, humanly exchanged or in some way shared and geared to feeling and/or arousing oneself and/or another. The DSM-5 uses the term “phenotypically normal” as part of its definition of sexually normal interactions. Anything else is a paraphilia or “any intense and persistent sexual interest” other than normal sexual interests as described above. Nonetheless, and in special cases, “intense” can “be defined as any sexual interest greater than or equal to normophilic sexual interests.”

The paraphilias are divided into an “individual’s erotic activities” and an “individual’s erotic targets.” To have a paraphilic disorder the “paraphilia has to cause distress or impairment to the individual or where the paraphilia’s satisfaction has entailed personal harm, or risk of harm, to others.”

For a diagnosis of a paraphilic disorder (excluding certain age parameters and other factors in Criterion C) both Criterion A (in general persistent and troubling “fantasies, urges or behaviors over 6 months”) and Criterion B (broadly referring to stress and life “impairment” sequela due to the disorder and/or “acting on these sexual urges with a non-consenting person”) have to be met. In sum, the DSM-5 Paraphilic Disorders is an upgrade to the DSM-IV-TR’s Paraphilias Classification that has supposedly opened up the door to clearer diagnostic labeling. It seems to pardon certain behaviors of the past and gives societal parameters to accepting noncriminal intentions of sensual satisfaction and sharing.

Diagnosticians need to move to the next strata in this transition but with eyes open and an awareness of the implications of what they are doing. There is a lot of data and research available on paraphilias throughout the world, which for some reason the American Psychiatric Association has evidently forgone.

To receive more information on Dr. Addis’s analysis of paraphilic disorders in the DSM-5 contact him by email with the subject line “DSM-5 Request.” * DSM, DSM-IV, DSM-IV-TR and DSM-5 are registered trademarks of the American Psychiatric Association. The American Psychiatric Association is not affiliated with nor endorses this article.

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