DSM-5 and the Paraphilic Disorders: Conceptual Issues.

TheAmericanPsychiatricAssociation (APA)haspublished the fifth edition of itsDiagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013a), which is considered to be a definitive reference for the diagnosis of psychiatric disorders. TheDSM-5revisionprocess involvedtheappointmentofWorkgroups (andsubworkgroups) foreachsection.Theparaphilias subworkgroup (PSWG) reviewedand recommendedchanges to the diagnostic criteria and text of the newly renamed ParaphilicDisorders section.Themembersof thePSWGpublished their initial reviews and recommendations in the Archives of Sexual Behavior and solicited comments fromboth thepublic and professionals on their proposals. Those comments were published in theArchives of Sexual Behavior, other professional publications, or were communicated directly to the PSWG. Presumably, the feedback to the PSWG (both published and unpublished)was considered and a final PSWGproposal was submitted for internalAPA review.The rest of the processwas shrouded in secrecy, because all participants in the revision processwere required to signconfidentiality pledges (formore details, seeAPA,2013b).Therationaleforwhyspecificchanges were includedor rejected is not knowndue to the confidentiality pledge.This commentary analyzes the conceptual issues raised bytheParaphilicDisorderssectionofDSM-5aspublished.Any criticism, actual or implied, of theDSM-5 is directedat the process that created it. There is ample reason to believe that PSWG members were not completely satisfied with or supportive of the final document (seeBlanchard, 2013). For simplicity, I will refer to the APA as the responsible party for problems with the DSM-5ParaphilicDisorders section.Asmuch as possible, repetition ofmypast criticisms of the paraphilias as diagnoseswill be minimized (Kleinplatz &Moser, 2005; Moser, 2001, 2002, 2009,2010,2011;Moser&Kleinplatz, 2002,2005a,b;Shindel & Moser, 2011). Nevertheless, all problems identified in this commentary were identified and discussed in earlier publications. The reasons the textwas not clarified, as per previous recommendations, are not clear. Field trials to test the usefulness andconsistencyofthenewdiagnosticcriteria(includingthenew paraphilia definition), surprisingly, were not undertaken. The rationale for the continued inclusion of the Paraphilic Disorders asmental disorders inexplicably is still lacking. The APA has never justified why it considers nonstandard sexual interests a typeofmentaldisorderor thespecificproblems these interests engender. It never explainswhy sex crimes are treated differently fromother crimes (e.g., Inwhatway does exposing one’s genitals to an unsuspecting stranger differ from brandishing a gun at an unsuspecting stranger during a robbery?). Despite the criticisms, the APA never seriously considered removing the paraphilias from DSM-5. Spitzer (2005), the EditorofDSM-III (APA,1980),stated,‘‘Firstofall it isnotgoing tohappen...’’(p. 115). InanAPAposition statement releasedon June 17, 2003 (APA, 2003), Regier, whowas then theDirector, American Psychiatric Association’s Division of Research and laterappointedVice-Chairof theDSM-5TaskForce,stated‘‘there are no plans or processes set up that would lead to the removal of the paraphilias from their consideration as legitimate mental disorders.’’It is reasonable to conclude that the APA’s insistence on the retention of these diagnoses is not based on an analysis of the latest scientific research (see Shindel &Moser, 2011). & Charles Moser [email protected]