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Proposals for Paraphilic Disorders in the International Classification Of Arch Sex Behav DOI 10.1007/s10508-017-0944-2 ORIGINAL PAPER Proposals for Paraphilic Disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11) 1,2,3 4,5 1 6 Richard B. Krueger • Geoffrey M. Reed • Michael B. First • Adele Marais • 7,8 9 Eszter Kismodi • Peer Briken Received: 1 December 2015 / Revised: 13 January 2017 / Accepted: 16 January 2017 Ó The Author(s) 2017. This article is published with open access at Springerlink.com Abstract The World Health Organization is currently devel- F65, Disorders of sexual preference, which describes condi- oping the 11th revision of the International Classifications of tions now widely referred to as Paraphilic Disorders. This arti- Diseases and Related Health Problems (ICD-11), with approval clereviewstheevidencebase,rationale,andrecommendations of the ICD-11 by the World Health Assembly anticipated in fortheproposedrevisionsinthisareaforICD-11andcompares 2018.TheWorkingGroupontheClassificationofSexualDisor- them with DSM-5. The WGSDSH recommended that the ders and Sexual Health (WGSDSH) was created and charged grouping, Disorders of sexual preference, be renamed to Para- with reviewing and making recommendations for categories philic Disorders and be limited to disorders that involve sexual related to sexuality that are contained in the chapter of Mental arousalpatternsthatfocusonnon-consentingothersorareasso- and Behavioural Disorders in ICD-10 (World Health Organiza- ciatedwithsubstantial distressordirectriskofinjuryordeath. tion1992a).Among thesecategorieswas the ICD-10 grouping Consistent with this framework, the WGSDSH also recom- mended that the ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism be removed from the clas- Electronic supplementary material The online version of this article (doi:10.1007/s10508-017-0944-2) contains supplementary material, sification and new categories of Coercive Sexual Sadism Disor- which is available to authorized users. der, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder & Richard B. Krueger Involving Solitary Behaviour or Consenting Individuals be [email protected] added. The WGSDSH’s proposals for Paraphilic Disorders in 1 Department of Psychiatry, College of Physicians and Surgeons, ICD-11 are based on the WHO’s role as a global public health New York State Psychiatric Institute, Columbia University, agencyandtheICD’sfunctionasapublichealthreportingtool. New York, NY, USA 2 Department of Psychiatry, New York Presbyterian Hospital, Keywords Paraphilic disorders Á ICD-11 Á Paraphilias Á New York, NY, USA ICD-10 Á DSM-5 Á Disorders of sexual preference 3 Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #45, New York, NY 10032, USA 4 Department of Mental Health and Substance Abuse, World Introduction Health Organization, Geneva, Switzerland 5 Global Mental Health Program, Columbia University Medical The World Health Organization (WHO) is the global public Center, New York, NY, USA health agency of the United Nations, whose mission is the attain- 6 Department of Psychiatry and Mental Health, Groote Schur ment of the highest possible level of health by all people. The Hospital, University of Cape Town, Observatory, South Africa WHO’s core responsibilities, ratifiedby international treatyby 7 Geneva, Switzerland the WHO’s 194 member states, include the development of 8 Global Health Justice Partnership, Yale Law School, international classification systems for health and the inter- New Haven, CT, USA national standardization of diagnostic procedures (WHO, 2014). 9 Institute for Sex Research and Forensic Psychiatry, University As an aspect of these responsibilities, the WHO is responsible for Medical Center Hamburg-Eppendorf, Hamburg, Germany the International Classification of Diseases and Related Health 123 Arch Sex Behav Problems (ICD), currently in its tenth revision (ICD-10) (WHO, ment of Reproductive Health and Research. This dual spon- 1992b),whichprovidesamandatoryframeworkfortheWHO sorship was seen as important because of potentially overlap- member states for the collection and reporting of health infor- ping areas of responsibility, knowledge, and expertise. The mation. The WHO is currently revising the ICD, with approval WGSDSH’s charge was informed by the public healthmission ofICD-11bytheWorldHealthAssemblyexpectedinMay2018. of the WHO and the primary public health purpose of the ICD. Inaddition tobeing the internationalstandardfor healthinfor- In addition to providing the global standard for the collection mation,theICDisusedbymanymemberstatesasaframework and reporting of information about morbidity and mortality, for defining their responsibilities to provide free or subsidized many WHO memberstates usethe ICD as aframework fordefin- health service to their citizens (International Advisory Group ing their obligations to provide free or subsidized healthcare for the Revision ofICD-10 Mental and Behavioural Disorders, services to their citizens (International Advisory Group for the 2011). As an integral part of the global classification for all health RevisionofICD-10Mentaland BehaviouralDisorders,2011). conditions, the ICD chapter on Mental and Behavioural Disor- The WHO Departmentof Mental Health and Substance Abuse ders is by far the most widely used classification of mental disor- has indicated that developing a more effective tool for helping dersworldwide(Reed,Correia,Esparza,Saxena,&Maj,2011). WHO member countriestoreduce the disease burdenassociated Thecurrent revisionoftheICD—thefirst majorrevisioninmore with mental disorders is a central goal for ICD-11’s develop- than two decades—provides an important opportunity to improve mentand has identified improving the classification’sclinical thesystem,bringingitmoreinlinewithcurrentevidence,prac- utilityandglobal applicabilityas critical meansofachieving that tice, and human rights standards. goal. Theaimofthisarticleistopresentthebackground,evidence The specific tasks of the WGSDSH included the review of base, and rationale for the proposed revisions to the ICD-10 available evidence and the development of proposals for mod- grouping Disorders of sexual preference (F65), detailed diag- ification ofthe categories, definitions,and guidelinesfor disor- nostic guidelines which are found in the Clinical Descriptions ders related to sexual orientation, gender identity, sexual behav- and Diagnostic Guidelines for ICD-10 Mental and Behavioural iors, and sexual dysfunctions that had been included in the chap- Disorders (WHO, 1992a). The WHO Department of Mental ter on Mental and Behavioural Disorders in the ICD-10. The Health and Substance Abuse has technical responsibility for WGSDSH was also asked to evaluate the proposals in this area managing the activities involved in the current revision of the fortheAmericanPsychiatricAssociation’sDSM-5(American ICD-10 and in 2007 appointed an international advisory group Psychiatric Association, 2013), at that time in preparation, and to assist in this process. The advisory group has provided a to examine their clinical utility and global applicability. The description of the general principles underlying the develop- WGSDSH was further asked to draft diagnostic guidelines for mentoftheclassificationofMentaland Behavioural Disorders the proposed categories in line with specifications provided by in ICD-11 (International Advisory Group for the Revision of the WHODepartmentof Mental Health and Substance Abuse ICD-10 Mental and Behavioural Disorders, 2011). With the (First, Reed, Hyman, & Saxena, 2015). consultation of the advisory group, a series of working groups In taking up its charge, the WGSDSH considered multiple was appointed to review available evidence, to develop pro- sources of information. A literature search was completed in posals for changes to the ICD-10 Mental and Behavioural Ovid,MEDLINE,PubMed,PsychINFO,andScopusfrom1948 disorders categories, and to draft diagnostic guidelines for tothepresent.Relevantpolicydocumentsandrelatedliterature the categories within their area of responsibility. All working were provided by the World Health Organization, including groups were required to be multidisciplinary and to include theclassificationsofsexualdisordersinICDfromICD-6(WHO, representation of all WHO global regions, including a sub- 1948) to the present. In particular, the Working Group reviewed stantialrepresentation oflow-andmiddle-income countries.A the ICD-10 Clinical Descriptions and Diagnostic Guidelines in detailed description of the diagnostic guidance being developed the relevant areas for the purposes of identifying problematic by working groups has been provided (International Advisory elementsintermsofreliability,validity,andclinicalutilitythat Group for the Revision of ICD-10 Mental and Behavioural mightneed tobe revised. Inaddition, submission of proposals Disorders,2011),andarticles describingproposals inspecific for revisions to ICD-10 had been encouraged by WHO begin- disorder areashave been published elsewhere (e.g., Drescher, ning in 2008 and could be submitted in three languages. Pro- Cohen-Kettenis, & Reed, 2016;Maerckeretal.,2013;Reedetal. posals relevant to the areas of the WGSDSH’s responsibility 2016a, b; Stein et al., 2016). were received from a variety of scientific societies, professional In relation to the ICD-10 Mental and Behavioural Disorder associations, and advocacy organizations, as well as from sev- categories related to sexuality,
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