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The Inclusion of Child Pornography in the DSM-5 Diagnostic Criteria for Pedophilia: Conceptual and Practical Problems

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The Inclusion of Child Pornography in the DSM-5 Diagnostic Criteria for Pedophilia: Conceptual and Practical Problems ANALYSIS AND COMMENTARY: SPECIAL SECTION The Inclusion of Child Pornography in the DSM-5 Diagnostic Criteria for Pedophilia: Conceptual and Practical Problems Michael B. First, MD The proposal to add use of child pornography to Criterion B of pedophilia is in direct conflict with the newly proposed distinction between paraphilia and paraphilic disorder, muddying rather than clarifying the diagnostic definition of pedophilia. The proposal to distinguish paraphilic disorder from paraphilia derives from the fact that the diagnostic criteria for the paraphilias have two components: Criterion A, defining the presence of a paraphilic erotic interest, and Criterion B, requiring clinically significant distress, impairment, or acting out the paraphilia with a nonconsenting person. Meeting Criteria A and B is necessary for a diagnosis of paraphilic disorder; meeting only Criterion A indicates a paraphilia. Use of pornography is better placed within Criterion A, perhaps as an example of a behavioral manifestation of pedophilia. If the Sexual and Gender Identity Disorders Work Group’s true intent was to add a third prong to Criterion B, then the criterion must be modified to restrict it to the use of illegal forms of pornography (i.e., visual depictions of real children), excluding written or aural forms or virtual images. J Am Acad Psychiatry Law 39:250–4, 2011 Among the proposals for paraphilias listed on the sociated with the proposal to include use of child DSM-5 website (www.dsm5.org) are those to create pornography in the diagnostic criteria for pedophilia. a categorical diagnostic distinction between a para- It concludes with a presentation of some options for philia and a paraphilic disorder and to incorporate rectifying the problem. the use of child pornography into the diagnostic cri- teria for pedophilia. While the proposal of the Sexual Conceptual Basis for the Distinction and Gender Identity Disorders Work Group to dis- Between Paraphilia and tinguish between paraphilia and paraphilic disorder Paraphilic Disorder has strong conceptual and practical advantages, add- The most significant change in the paraphilia sec- ing the use of child pornography to Criterion B of tion in Diagnostic and Statistical Manual of Mental pedophilia is in direct conflict with the distinction Disorders, Fourth Edition (DSM-IV)1 was the appli- between paraphilia and paraphilic disorder, muddy- cation of the DSM-IV-wide effort to add a clinical ing rather than clarifying the diagnostic definition of significance criterion (i.e., “. causes clinically sig- pedophilia. This commentary begins with a presen- nificant distress or impairment in social, occupa- tation of the conceptual basis for the distinction be- tional, or other important areas of functioning”) to tween paraphilia and paraphilic disorder and then the diagnostic criteria for each specified paraphilia. focuses on the conceptual and practical problems as- Reflecting concerns that nonpathological presenta- tions on the milder end of the severity spectrum were Dr. First is Professor of Clinical Psychiatry, Department of Psychiatry, 2 Columbia University and Department of Clinical Phenomenology, being inappropriately mislabeled as disorders, this New York State Psychiatric Institute, New York, NY. Address corre- criterion was added to most of the DSM-IV disorders spondence to: Michael B. First, MD, Department of Psychiatry, Co- to help “establish the threshold for a diagnosis of a lumbia University and Department of Clinical Phenomenology, New York State Psychiatric Institute, Unit 60, 1051 Riverside Drive, New disorder in those situations in which that symptom- York, NY 10032. E-mail: [email protected]. atic presentation by itself (particularly in its milder Disclosures of financial or other potential conflicts of interest: None. forms) is not inherently pathological and may be 250 The Journal of the American Academy of Psychiatry and the Law First encountered in individuals for whom a diagnosis of absurdities,” as noted in the work group’s rationale ‘mental disorder’ would be inappropriate” (Ref. 3, p for this proposal on the DSM-5 website: “In [DSM- 8). A clinical significance criterion was thus added to IV-TR] for example, a man cannot be classified as a the definitions of each of the paraphilias in DSM-IV transvestite—however much he cross-dresses and in recognition of the fact that the presence of a para- however sexually exciting that is to him—unless he is philic arousal pattern by itself may not be sufficient unhappy about this activity or impaired by it.”5 Ad- to justify a diagnosis of a clinical paraphilia. For ex- dressing this problem, the work group is proposing ample, individuals with a fetishistic sexual arousal that the DSM-5 make a distinction between para- pattern who are able to incorporate their fetish into philias and paraphilic disorders. According to the their sexual repertoire with a willing partner should website: not qualify for a diagnosis of a sexual disorder. It is A paraphilia by itself would not automatically justify or only when the fetishistic focus causes clinically sig- require psychiatric intervention. A paraphilic disorder is a nificant problems (e.g., rejection of an obligatory fe- paraphilia that causes distress or impairment to the individ- tish by an unwilling spouse resulting in significant ual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behav- strain in a marriage) that it should be considered iors) but diagnose a paraphilic disorder (on the basis of worthy of a psychiatric diagnosis. distress and impairment). In this conception, having a para- philia would be a necessary but not a sufficient condition Consequently, the criteria sets for the DSM-IV 5 paraphilias have two distinct components: Criterion for having a paraphilic disorder. A, which defines the presence of an abnormal sexual As noted by Blanchard,6 besides bringing the focus (i.e., “over a period of at least 6 months, recur- DSM terminology more in line with common usage, rent intense sexually arousing fantasies, sexual urges, the work group’s proposal to distinguish between a or behaviors involving...”(Ref. 3, p 569), and Cri- pattern of sexual arousal that is non-normative but terion B, which involves clinically significant distress yet is nondisordered (i.e., a paraphilia) and a pattern or impairment. Both criteria must be met to justify a of sexual arousal that is psychopathological (i.e., a diagnosis of a paraphilia. Fulfilling both criteria en- paraphilic disorder) is useful to researchers, as it sures that the DSM construct of paraphilia falls would “prevent a paraphilia from becoming invisible within the DSM-IV definition of mental disorder, to clinical science just because it lacks any secondary which requires that the psychological syndrome or effect of disturbing the individual or others” (Ref. 6, pattern be associated with “present distress (e.g., a p 307). Furthermore, by clarifying that cases of non- painful symptom), or disability (i.e., impairment in problematic paraphilic sexual arousal are not disor- one or more important areas of functioning) or with dered, this proposal at least partially addresses con- an increased risk of suffering, pain, disability or an cerns raised by advocacy groups for those with important loss of freedom” (Ref. 3, p xxxi). Confu- paraphilic sexual interests (e.g., sexual sadists and sion regarding what constitutes distress and impair- masochists), such as the National Coalition for Sex- ment in paraphilic individuals,4 however, led to a ual Freedom, who demand that paraphilias be re- revision of Criterion B in DSM-IV-TR,3 with vari- moved entirely from the DSM because of their con- ous wording, depending on whether acting out the tention that inclusion of their particular paraphilia in paraphilia involves the victimization of nonconsent- the DSM is inappropriately stigmatizing.7 The effort ing individuals. Specifically, the wording of the to destigmatize the paraphilias could be further DSM-IV-TR B Criteria for exhibitionism, frotteur- strengthened by listing the nondisordered para- ism, pedophilia, sexual sadism, and voyeurism indi- philias in the “Other Conditions That May Be a cates that the diagnosis is justified if “the person has Focus of Clinical Attention” chapter of DSM-5, acted on the sexual urges or the sexual urges or fan- which functions as a repository for conditions that tasies cause marked distress or interpersonal may be a focus of treatment but are not considered difficulty” (Ref. 3, p 569). mental disorders, such as normal grief. Thus, the The definitional requirement that the paraphilic Paraphilic Disorders would be listed in the front, pattern of sexual arousal cause distress and impair- mental disorder, section of the DSM-5 (with associ- ment, however, has resulted in the official DSM- ated F codes, indicating their status as mental disor- IV-TR terminology deviating from both common ders), whereas the nonpathological paraphilias, usage (and common sense), leading to some “logical which may be encountered by a clinician in the con- Volume 39, Number 2, 2011 251 Pornography and the Definition of Paraphilias Table 1 Proposed Criterion B Wording for the DSM-5 Paraphilias Exhibitionism B. The person has clinically significant distress or impairment in important areas of functioning or has sought sexual stimulation from exposing the genitals to unsuspecting strangers on three or more separate occasions. Fetishism B. The person has clinically significant distress or impairment in important areas of functioning. Frotteurism B. The person has clinically significant distress or impairment in important areas of functioning or has sought sexual stimulation from touching and rubbing against nonconsenting persons on three or more separate occasions. Pedohebephilia B. One or more of the following signs or symptoms: 1. The person has clinically significant distress or impairment in important areas of functioning, because of sexual attraction to children. 2. The person has sought sexual stimulation on separate occasions from either of the following: a. Two or more different children, if both are prepubescent.
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