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DSM-V work on paraphilias begins in earnest.

BALTIMORE--The work group developing definitions of various paraphilic disorders for the fifth edition of the Diagnostic and Statistical Manual has its job cut out for it.

"Distinguishing normal from abnormal sexual behaviors and fantasies is a challenging task," Dr. Howard Zonana, of Yale University, New Haven, Conn., said at the annual meeting of the American Academy of Psychiatry and the Law. He is not a member of the work group but commented on some of its proposals. Dr. Zonana, a past president of the academy as well as its current medical director, noted that in the case of paraphilias, there does not seem to be a guiding principle for what usually is or is not included in the definition. "The work group has an impossible task, and a lot of people are going to be unhappy with the product."

The proposed changes to the pedophilia definition sparked the most discussion. The new definition would change the name to pedohebephilic disorder and would include people attracted to pubescent children (aged 11-14).

Dr. Michael First had several problems with this change. "There's a major question about whether attraction to pubescent children is normal or abnormal," said Dr. First, who is professor of clinical psychiatry at Columbia University, New York. "For example, there have been sexualized media depictions of pubescent children for years. ... Based on certain definitions of what a mental disorder is, it doesn't appear to be a failure of an evolutionarily designed mechanism to be attracted to individuals who are, in fact, able to bear children."

Dr. First also objected to the idea that hebephilia needed to be added to the definition because many men do not differentiate between prepubescent and pubescent children, and offend against both. "Do men who don't differentiate ... actually have a paraphilia at all, or are they just antisocial and opportunistic, preying on children?" he asked.

Another proposed change to the definition, which Dr. First called "huge," is that the person must have offended against at least three victims (or at least two if both are prepubescent). "That is going to create false negatives. If you have two victims, you don't have a disorder? That makes no sense," he said.

Dr. J. Paul Fedoroff, forensic unit research director at the University of Ottawa, Ont., objected to the addition of the use of child pornography for at least 6 months as one criterion that could label someone as having pedohebephilic disorder. Under this definition, in addition to the "three or more" requirement, "a man with a single sex slave from infancy to 15 might not meet the criteria for pedohebephilia, whereas an intellectually disabled man who has cut out pictures from Vogue magazine and uses them to masturbate would," he said.

Dr. Richard B. Krueger, medical director of the sexual behavior clinic at the New York State Psychiatric Institute and the only presenter who was a member of the work group, presented the proposed definitions of several other paraphilic disorders:

* Sexual Sadism Disorder: The proposed definition reads, "Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the physical or psychological suffering of another person." In the current DSM-IV definition, the behaviors must "involve acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person."

* Exhibitonism Disorder: The proposed definition reads, "Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the exposure of one's genitals to an unsuspecting stranger. The person is distressed or impaired by these attractions, or has sought sexual stimulation from exposing the genitals to three or more unsuspecting strangers on separate occasions." The current definition of exhibitionism is very similar but does not include the "three or more" provision. The proposed definition also asks providers to specify the type of exhibitionism: whether the person is attracted to exposing himself to pubescent or prepubescent individuals, to mature adults, or to both.

Dr. Krueger also outlined the proposed definitions for fetishistic disorder, frotteuristic disorder, transvestic disorder, hypersexual disorder, and voyeuristic disorder, as well as sexual masochism disorder. Unlike the DSM-IV definition, the proposed DSM-V definition for sexual masochism disorder allows providers to note if the masochism includes asphyxiophilia.

When it comes to the terms being used in the new manual, Dr. Frederick Berlin, founder of the sexual disorders clinic and associate professor of psychiatry, both at Johns Hopkins University, Baltimore, said he was concerned about efforts to get the phrase "sexual preference" back into the DSM. "I'm worried a great deal about the connotation of that. I would very much argue against getting this term back into the DSM."

On the subject of conflicts of interest, Dr. First said he had provided expert declarations for the defense in sexually violent predator commitment hearings in California and Washington state. He and all of the other speakers said they had no financial conflicts related to their presentations.
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Title Annotation:ADULT PSYCHIATRY
Author:Frieden, Joyce
Publication:Clinical Psychiatry News
Date:Dec 1, 2009
Words:829
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