See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/327610422

Controversies in the Definition of Paraphilia

Article  in  Journal of Sexual Medicine · September 2018

DOI: 10.1016/j.jsxm.2018.08.005

CITATIONS READS
2 790

1 author:

Christian C Joyal
Université du Québec à Trois-Rivières
76 PUBLICATIONS   2,114 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Searching for an accessible neurobiological marker of empathy View project

All content following this page was uploaded by Christian C Joyal on 14 September 2018.

The user has requested enhancement of the downloaded file.

 Controversies in the Definition of Paraphilia

Christian C. Joyal

Invited comment in the Journal of Sexual Medicine (epub ahead of print September 2018)

D.O.I. https://doi.org/10.1016/j.jsxm.2018.08.005

The term paraphilia (from the Greek para, or “beside, aside”, and philia, “love”) is currently used in

psychiatry to define “anomalous” [1] or “atypical” [2] sexual interests. According to the latest edition of the

Diagnostic and Statistical Manual of Mental Disorders [1], a paraphilic sexual interest is any intense and

persistent (6 months or more) sexual interest (fantasies, urges or behaviors) not “normophilic” (i.e., “normal”

[1] p.685). A normophilic sexual interest refers to «genital stimulation or preparatory fondling with

phenotypically normal, physically mature, consenting human partners» ([1] p.685). The DSM-5 gives eight

descriptions of paraphilias (Criteria A): fetishism, exhibitionism, voyeurism, frotteurism, masochism, sexual

sadism, transvestism, and pedophilia. If these interests generate a “clinically significant” distress or impairment

to the person or if they were acted-out with non-consenting others, they become a paraphilic disorder (i.e., a

mental disorder, Criteria B). Determining what constitutes unhealthy sexual interests and behaviors is of utmost

importance, not only for clinical reasons (e.g., to provide adequate treatment to persons in need), but also for

forensic and legal purposes (e.g., child custody, criminal responsibility). However, these definitions of

“anomalous” or “atypical” sexual interests are recurrently debated, as they engender more problems than

solutions.

A first problem is that current psychiatric definitions of paraphilia derive more from historical, social,

cultural, and religious factors than medical or scientific evidences. It is well known, for instance, that interest

for non-coital behaviors, traditionally considered as deviant (if not illegal) in many eras and societies, are

mainstream today (e.g., masturbation, oral sex, anal sex), at least in the occident [3]. These influences (e.g.,

emphasis on procreation) are still tangible in the paraphilic section of the DSM-5, where interests for receptive

anal sex is “anomalous” (non-genital stimulation), whereas caressing the genitals of a physically mature,

phenotypically normal and consenting adolescent (age of consent varies between jurisdictions) is “normophilic”
with an adult partner. In addition, these definitions of “normality” are not based on normative statistical data. In

fact, several paraphilic interests are common in the general population [4]. Some of these sexual interests are

also as intense and persistent as “normolophilic” interests in significant non-clinical subgroups, so that

approximately half of the general population meet the DSM-5 criteria (A) for a paraphilic interest [5].

A second concern is the lack of proven validity for many paraphilic diagnoses. As any psychiatric

symptom, paraphilic interests should reflect an underlying mental disorder. According to the DSM-5, a mental

disorder is a “syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion

regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes

underlying mental functioning” ([1], p.20, italics added). Importantly, “socially deviant behavior (e.g., political,

religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders

unless the deviance or conflict results from a dysfunction in the individual” ([1], p.20, italics added).

Interestingly, the search for such underlying dysfunctions in psychological, biological or developmental process

among persons with certain paraphilic interests have been mostly negative so far, especially when no victim is

involved (i.e. fetishism, masochism, sadism, and transvestism). Baumeister and Butler [6], for instance, wrote a

classic (and forgotten) book chapter entitled: “Sexual masochism: Deviance without pathology” more than 20

years ago. More recently, Wismeijer and Assen [7] reported that Bondage-Domination/Submission-

Sadism/Masochism (BDSM) practices, many of which are included in the DSM-5 paraphilic symptoms, are

associated with significantly less neurotism, more extraversion, more openness to new experiences, more

conscientiousness, less fear of rejection, and higher subjective well-being than average. Thus, “non-

normophilic” interests are not necessarily symptoms of an underlying mental disorder. In fact, evidence-based

data are still lacking except, maybe, for apprehended pedophiles.

There are other conceptual and phenomenological problems with the DSM-5 definition of paraphilia,

which cannot all be addressed here due to space limitation (e.g., [8]). For example, diagnostic criteria for

paraphilia and paraphilic disorders such as an interest “equal or greater” than normophilic interests or an

“intense” sexual interest are difficult to assess because they are not operationalized and the DSM-5 provides no

instrument to evaluate them.

 Recently, the Working Group on Sexual Disorders and Sexual Health (WGSDSH) for the latest edition

of the International Classification of Diseases and Related Health Problems (ICD-11 [2]) addressed some of

these concerns and they took an important step in the right direction. They agreed to remove fetishism,

masochism, sadism (not to be confound with coercive sexual sadism), and transvestism from the list of

paraphilias, because: “The regulation of private behaviour without health consequences to the individual or to

others may be considered in different societies to be a matter for criminal laws, religious proscription, or public

morality, but is not a legitimate focus of public health or of health classification.” ([9], p.212). That decision,

reminiscent of a similar one made more than 40 years ago by the APA for the diagnosis of homosexuality

(DSM-II), should be applauded.

The WGSDSH further acknowledged that: “the diagnostic guidelines provided for ICD-10’s

classification of Disorders of sexual preference often merely describe the sexual behaviour involved.” [9]. That,

again, is progressive. However, because inter-personal criminality has public health implications, the WGSDSH

now propose focussing on illegality to define paraphilic disorders: (a) “a sustained, focused, and intense pattern

of [atypical] sexual arousal – as manifested by persistent sexual thoughts, fantasies, urge, or behaviours – that

involves others whose age or status renders them unwilling or unable to consent (e.g., pre-pubertal children, an

unsuspecting individual being viewed through a window, an animal); and b) that the individual has acted on

these thoughts, fantasies or urges or is markedly distressed by them.” ([9] p.213). Unfortunately, as for any

attempt to describe an atypical sexual interest, that definition remains problematic. First, sexual thoughts or

fantasies involving illegal acts are not necessarily atypical (e.g., voyeurism, coercion; [4,5]). Second,

fundamental diagnostic criteria such as “sustained”, “focused”, and “intense” are still not operationalized.

Third, although inter-personal criminality certainly has public health implications, it is not a sufficient indicator

of an underlying mental disorder. Not only this leaves open the possibility of adding rape in the list of mental

disorders (as soon as it is considered atypical and intense), but sexual behaviors involving victims are not

necessarily associated with mental illness. In fact, authors of books devoted to sexual deviance acknowledge

that evidence of psychopathology for persons with such paraphilic behaviors as voyeurism and exhibitionism is

scarce and mostly based on single clinical cases (e.g., [10]). Even for pedophilia, recent neuroimaging and
neuropsychological studies (assessing the biological and developmental process criteria of a mental disorder)

concluded that deficits are found among offending but not non-offending pedophiles (e.g., [11]). Therefore,

classic neuropsychiatric hypotheses of pedophilia might be more closely related with acting-out than pedophilia

per se. Clearly, further research is needed to demonstrate if (and which) illegal paraphilic behavior truly

indicate the presence of an underlying mental disorder.

Currently, the WGSDSH considers that paraphilic disorders represent an “underlying pattern of

persistent and intense atypical arousal, manifested by sexual thoughts, fantasies, urges, and/or behaviours” ([12]

p.7). Thus, we are dealing with a tautological definition in which symptoms (e.g., being sexually aroused by

committing voyeuristic behaviors) and syndromes (e.g., sexual arousal by voyeurism) are the same. Apparently,

the presence of an underlying mental disorder is no longer required. Following the same logic, one would affirm

that repetitive hand washing indicates an underlying need to wash hands. Scientific studies are warranted to

demonstrate that certain sexual proclivities are indeed indicative of a mental disorder.

I entirely understand the mandate of the ICD, i.e., reporting behaviors that are relevant to public health,

including sexual criminal acts [9]. However, given the current lack of evidence-based data demonstrating that

paraphilic interests are truly symptoms of an underlying mental disorder, I would suggest using the International

Classification of Functioning, Disability, and Health (ICF, [2]) to classify and report criminal sexual behaviors

instead of the ICD-11. As specified by the WHO [2], the ICF is their framework for measuring health and

functioning/disability at both the individual and population levels. Until scientific evidence shows that

paraphilic interests are symptoms of a mental disorder, worldwide reporting of criminal sexual acts might be

achieved with the ICF. The ICF contains such categories as “Basic interpersonal interactions” (i.e., “Interacting

with people in a contextually and socially appropriate manner […]), “Physical contact in relationships” (i.e.,

“Making and responding to bodily contact with others, in a contextually and socially appropriate manner”),

“Regulating behaviours within interactions” (i.e., “Regulating emotions and impulses, verbal aggression and

physical aggression in interactions with others, in a contextually and socially appropriate manner”), and “Sexual

relationships” (i.e., “Creating and maintaining a relationship of a sexual nature […]), enabling the inclusion of
all criminal sexual behaviors (paraphilic or not) without the requirement of a psychiatric labels that are not yet

validated.

Paraphilic illegal behaviors might truly represent manifestations of an underlying dysfunction, although

this remains to be demonstrated empirically and assessed individually. Otherwise, I think paraphilic illegal

behaviors should be viewed as crimes and treated accordingly, just like most cases (i.e., non-psychotic) of rape

and interpersonal violence [13].

References

[1] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth edition.

American Psychiatric Association: Washington, 2013, 991 p.

[2] World Health Organization (2018). Classifications. http://www.who.int/classifications/en. Retrieved on June

22nd 2018.

[3] Joyal, C. C., Cossette, A., & Lapierre, V. (2015). What exactly is an unusual sexual fantasy? The Journal of

Sexual Medicine, 12, 328-340.

[4] Joyal, C. C., & Carpentier, J. (2017). The prevalence of paraphilic interests and behaviors in the general

population: A provincial survey. The Journal of Sex Research, 54, 161-171.

[5] Joyal, C. C. (2015). Defining “normophilic” and “paraphilic” sexual fantasies in a population‐based sample:

On the importance of considering subgroups. Sexual Medicine, 3, 321-330.

[6] Baumeister, R. F., & Butler, J. L. (1997). Sexual masochism: Deviance without pathology. In: D.R. Laws

and W. O’Donohue (Eds) Sexual Deviance: Theory, Assessment, and Treatment. NY, NY: Guilford Press

(pp.225-239).

[7] Wismeijer, A. A., & Assen, M. A. (2013). Psychological characteristics of BDSM practitioners. The Journal

of Sexual Medicine, 10, 1943-1952.

[8] Wakefield, J. C. (2011). DSM-5 proposed diagnostic criteria for sexual paraphilias: Tensions between

diagnostic validity and forensic utility. International Journal of Law and Psychiatry, 34, 195-209.

[9] Reed, G. M., Drescher, J., Krueger, R. B., Atalla, E., Cochran, S. D., First, M. B., ... & Briken, P. (2016).

Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on

current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry, 15,

205-221.

[10] Laws, D.R. and O’Donohue, W. (Eds). Sexual Deviance: Theory, Assessment, and Treatment. NY, NY:

Guilford Press.

[11] Kärgel, C., Massau, C., Weiß, S., Walter, M., Borchardt, V., Krueger, T. H., ... & Gerwinn, H. (2017).

Evidence for superior neurobiological and behavioral inhibitory control abilities in non‐offending as

compared to offending pedophiles. Human Brain Mapping, 38, 1092-1104. D.O.I: 10.1002/hbm.23443

[12] Krueger, R. B., Reed, G. M., First, M. B., Marais, A., Kismodi, E., & Briken, P. (2017). Proposals for

paraphilic disorders in the International Classification of Diseases and Related Health Problems, eleventh

revision (ICD-11). Archives of Sexual Behavior, 46, 1529-1545.

[13] Shindel, A. W., & Moser, C. A. (2011). Why are the paraphilias mental disorders? The Journal of Sexual

Medicine, 8, 927-929.

View publication stats