Archives of Sexual Behavior

, Volume 39, Issue 2, pp 317–324

The DSM Diagnostic Criteria for Exhibitionism, Voyeurism, and Frotteurism

Authors

    • Centre for Violence Prevention, Karolinska Institutet
Original Paper

DOI: 10.1007/s10508-009-9577-4

Cite this article as:
Långström, N. Arch Sex Behav (2010) 39: 317. doi:10.1007/s10508-009-9577-4

Abstract

I reviewed the empirical literature for 1980–2008 on exhibitionism, voyeurism, and frotteurism for the American Psychiatric Association’s Sexual and Gender Identity Disorders Work Group in preparation for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Very limited empirical support was found for major changes of the current DSM-IV-TR criteria sets for these paraphilias. Some of the criticism of current criteria and the balancing of false negatives and false positive diagnoses are examined. The report concludes with suggestions for possible diagnostic criteria changes for the DSM-V.

Keywords

DSM-VParaphiliasExhibitionismVoyeurismFrotteurism

Exhibitionism

Method

In December 2008, I conducted computerized searches for exhibitionism, voyeurism, and frotteurism in literature databases Ovid MEDLINE, PsycINFO, CINAHL (nursing and allied health literature), Books@Ovid, and PsycBooks (scholarly books published by the American Psychological Association) for relevant publications published 1980–2008. The search strategy included the terms “exhibitionism,” “voyeurism,” or “frotteurism,” respectively, anywhere in title, abstract or keywords and English-only literature. I also surveyed the reference lists of publications identified this way and those of central textbooks in the field. Publications with relevant abstracts were studied in full text. Finally, I carefully read prior versions of the DSM diagnostic criteria for these paraphilias from the DSM-III to DSM-IV-TR.

Results from Literature Search

Most writers ascribe the introduction of the term exhibitionism to the French 19th century physician Lasègue (e.g., Murphy & Page, 2008). More widespread acknowledgement, however, came with the classic Psychopathia Sexualis by German psychiatrist Richard von Krafft-Ebing (1965). Following voyeuristic behavior, exhibitionistic acts are among the most common of potentially law-breaking sexual behaviors, judging from clinical (Abel, Becker, Cunningham-Rather, Mittelman, & Rouleau, 1988) and general population samples (Långström & Seto, 2006). Despite this, research is limited, perhaps reflecting a long-standing perception that exhibitionistic behaviors are merely a nuisance compared to other sexual offences (e.g., Morin & Levenson, 2008; Murphy & Page, 2008). However, the considerable overlap with other paraphilias in clinical samples, particularly voyeurism and sadomasochism (e.g., Abel et al., 1988; Bradford, Boulet, & Pawlak, 1992; Fedora et al., 1992; Freund, Seto, & Kuban, 1997; Gebhard, Gagnon, Pomeroy, & Christenson, 1965), seems to occur not only because of selection biases underlying referral to clinical and forensic settings. In fact, Långström and Seto (2006) found similar overlaps in their population survey of 18- to 60-year-old adults in Sweden of both genders.

Interestingly, Marshall and Fernandez (2003) reviewed 10 studies using penile plethysmography with exhibitionists. Nine of 10 suggested that exhibitionists in clinical settings did not have a preference for exposing themselves. Despite this counterintuitive finding, perhaps due to heterogeneity across studies and failure to ascertain exhibitionistic sexual arousal for technical and statistical power reasons, there are data to suggest that exhibitionists may be generally hypersexual (Kafka & Hennen, 1999; Långström & Seto, 2006).

In addition, unpublished data from my group suggest that, among all 16,000 men convicted of sexual offences in Sweden between 1973 and 2004, 15% of those convicted of sexual harassment offences (heavily dominated by exhibitionistic acts) had at least one independent prior or subsequent conviction of a contact sexual offence (rape, sexual coercion, or child molestation). Studying criminal recidivism among more than 200 convicted exhibitionists followed for an average of 13 years, Firestone, Kingston, Wexler, and Bradford (2006) found that hands-on compared to hands-off sexual recidivists more often had a criminal history of prior violent and criminal charges or convictions. This argues for continued attention to the important difference between the paraphilia exhibitionism (with or without exhibitionistic behavior) and criminal offending involving exhibitionistic acts. As with the other potentially criminal paraphilias (voyeurism, frotteurism, sadism, pedophilia, and “paraphilic rape”), it is likely that the criminal offending requires additional individual risk factors separate from the paraphilic interest per se.

The study by Långström and Seto (2006) used interview data from a national survey of 2,450 randomly selected 18- to 60-year-olds from the general population of Sweden. One item specifically addressed the core behavioral feature of exhibitionism—sexual arousal from exposing one’s genitals to a stranger. A total of 76 (3.1%, 4.1% among men, and 2.1% among women) participants reported at least one incident of being sexually aroused by exposing their genitals to a stranger. Although effects sizes were weak to moderate, exhibitionism was positively associated with being male and having more psychological problems, lower satisfaction with life, greater alcohol and drug use, and greater sexual interest and activity in general, including more sexual partners, greater sexual arousability, higher frequency of masturbation and pornography use, and greater likelihood of having had a same-sex sexual partner. Consistent with previous research from clinical samples of men with paraphilias, participants who reported any lifetime exhibitionistic behavior had substantially greater odds of reporting other atypical sexual behavior, voyeuristic, sadomasochistic, or cross-dressing behavior.

A well-known conceptual model of paraphilias that includes exhibitionism is Freund’s notion of courtship disorders (Freund & Blanchard, 1986; Freund et al., 1997), which includes exhibitionism, voyeurism, and frotteurism but also telephone scatologia and paraphilic rape. Very briefly, courtship disorder is conceptualized as disturbances in one or more phases of the statistically most common sequence of events in partner-based sexual interactions. The four stages of this process are typically described as finding an appropriate partner, approaching this potential partner, physical touching of the partner, and genital sexual intercourse. However, despite being theoretically interesting, the model does not account for possible mechanisms and seems difficult to test empirically. Based on clinical and preclinical data, Kafka (1997) introduced a new model that relates paraphilias to paraphilia-related disorders—often referred to as hypersexual, addictive, or compulsive—the primary difference being that the latter are non-deviant and legal. Comorbidity patterns seem similar across paraphilias and hypersexual disorders but there is currently no clear explanation as to why some individuals during certain circumstances actually offend against non-consenting partners. Swedish general population data (Långström & Hanson, 2006) corroborate a clear link between hypersexuality and paraphilic sexual behaviors (exhibitionism, voyeurism, sadism/masochism), equally strongly for both genders (odds ratios of 4–25 also when controlling for various covariates).

Without giving any specific references, Murphy and Page (2008) recently suggested that exhibitionists who expose themselves preferentially to adults and those who expose themselves to children might reflect different disorders. Murphy and Page also cited a critique of diagnostic criteria for pedophilia and other sexual disorders, such as their absence from DSM field trials (O’Donohue, Regev, & Hagstrom, 2000; see also Blanchard, 2009). O’Donohue et al. questioned the reliability and validity of paraphilic diagnoses, including how to interpret terms like “recurrent,” “intense,” and “marked distress.”

Review of Previous DSM Criteria Sets

DSM-III/DSM-III-R

In the DSM-III-R (American Psychiatric Association, 1987), the core criterion for Exhibitionism (Over a period of at least 6 months, recurrent, intense sexual urges and sexually arousing fantasies involving intense sexual arousal from exposing one’s genitals to an unsuspecting stranger) remained the same as in DSM-III (American Psychiatric Association, 1980). However, a qualifying diagnostic B criterion was added, as were true for all paraphilia diagnoses. This criterion was added to emphasize that psychiatric disorders or diagnoses had to include acting out against others or substantial distress:
  1. B.

    The person has acted on these urges, or is markedly distressed by them.

     

DSM-IV

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the exposure of one’s genitals to an unsuspecting stranger.

     
  2. B.

    The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

     

DSM-IV-TR

  1. A.

    The core defining criterion remained the same as in DSM-IV (American Psychiatric Association, 1994).

     
An unintended consequence of the removal of “the person has acted on these urges…”, from DSM-III-R to DSM-IV, was that many clinicians erroneously interpreted the DSM-IV B criterion to mean that those having paraphilias potentially hurting others (including Exhibitionism, Voyeurism, and Frotteurism) had to have or admit to “clinically significant distress or impairment” for each paraphilia to be diagnosed (First & Frances, 2008). Hence, the DSM-IV-TR (American Psychiatric Association, 2000) reinstated that these paraphilias could be diagnosed solely from the acting on the respective sexual urges.
  1. B.

    The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

     

Note that no specification of “acted on” was supplied in DSM-IV-TR. In an attempt to improve this, I propose a minimum number of three episodes needed for diagnosing each of the present Paraphilias/Paraphilic disorders in the uncooperative client.

Proposed DSM-V Diagnostic Criteria for Exhibitionistic Disorder

  1. A.

    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.

     
  2. B.

    (ad modum Blanchard’s [2009] reasoning for Pedohebephilic Disorder). 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.

     
Since DSM diagnoses can be refined by the use of specifiers, not necessarily mutually exclusive or cumulatively exhaustive categories (American Psychiatric Association, 2000), I suggest consideration of the following:
  • Specify if: Sexually attracted to exposing genitals to pubescent or prepubescent individuals (generally younger than age 15).

  • Sexually attracted to exposing genitals to physically mature individuals (generally age 15 or older).

  • Equally sexually attracted to exposing genitals to both age groups (non-specific age preference).

A concluding discussion at the end of this article contains commentaries on the proposed criteria. However, note that the DSM-V diagnostic criteria ultimately approved by the American Psychiatric Association may bear little or no resemblance to those suggested here.

Voyeurism

Method

See Exhibitionism.

Results from Literature Review

Acts of voyeurism are probably the most common of potentially law-breaking sexual behaviors, according to clinical studies (e.g., Abel et al., 1988; Bradford et al., 1992) and reports from general population samples (Långström & Seto, 2006; Templeman & Stinnet, 1991). Långström and Seto (2006) examined the prevalence of the defining characteristic of voyeurism—self-reported sexual arousal from spying on others having sex in a representative national sample in Sweden. A total of 2,450 randomly selected 18- to 60-year-olds were interviewed and 191 (8%; 12% of the men, and 4% of women) participants reported at least one incident of being sexually aroused by spying on others having sex. A much smaller study of 60 male non-convicted college students in a rural area of the U.S. suggested that 42% had secretly watched others in sexual situations (Templeman & Stinnet, 1991). When the students rank ordered their interest in less common sexual behaviors, voyeurism and frotteurism were the most popular. Similar high prevalences of voyeurism and frotteurism were also reported in a study of 61 adults of both genders in a small town in South India (Kar & Koola, 2007).

Despite these indications of considerable prevalence, research has been “extremely limited” (Mann, Ainsworth, Al-Attar, & Davies, 2008). Perhaps this is because voyeurism is relatively easy to relate to for many individuals and, therefore, does not elicit the same strong negative emotions as do some of the other paraphilias. Importantly, however, there is considerable overlap with other potentially criminal paraphilias in clinical samples, particularly exhibitionism and sadomasochism (Abel et al., 1988; Bradford et al., 1992; Fedora et al., 1992; Freund et al., 1997; Gebhard et al., 1965). This seems to occur not only because of selection biases to clinical and forensic settings. Långström and Seto (2006) found substantial overlaps in their non-clinical population survey of adults of both genders in Sweden.

Långström and Seto (2006) also investigated possible associations between voyeuristic behaviors and various risk factors and correlates. Voyeuristic behaviors were weakly to moderately but positively associated with being male and having more psychological problems, lower satisfaction with life, greater alcohol and drug use, and greater sexual interest and activity in general, including more sexual partners, greater sexual arousability, higher frequency of masturbation and pornography use, and greater likelihood of having had a same-sex sexual partner.

To examine whether non-clinical subjects would engage in voyeurism, Rye and Meaney (2007) asked university students about the likelihood (0–100%) that they would secretly watch an attractive person undress or two attractive people having sex. When the risk of being caught was manipulated from 0 to 25%, the mean likelihood fell from 84 to 61% among men and from 74 to 36% in women. This bears on the “incidental” vs. “patterned” subdivision suggested by Gebhard et al. (1965) in their study of 56 “peepers” or voyeurists. The former (43% of their sample) might be less planning and more opportunistic and may be less likely to fulfill DSM criteria for Voyeurism despite having been convicted in court for a voyeuristic act.

Review of Previous DSM Criteria Sets

DSM-III/DSM-III-R

  1. A.

    In the DSM-III-R, the core criterion for Voyeurism (Over a period of at least 6 months, recurrent, intense sexual urges and sexually arousing fantasies, involving the observation of an unsuspecting person who is naked, disrobing, or engaging in sexual activity) remained the same as in DSM-III.

     

A B Criterion was added:

  1. B.

    The person has acted on these urges, or is markedly distressed by them.

     

DSM-IV

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.

     
  2. B.

    The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

     

DSM-IV-TR

  1. A.

    The core defining criterion remained the same as in DSM-IV.

     
  2. B.

    The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

     

Proposed DSM-V Diagnostic Criteria for Voyeuristic Disorder

  1. A.

    Over a period of at least 6 months, recurrent and intense sexually arousing fantasies, sexual urges, or sexual behaviors involving the observing of an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.

     
  2. B.

    (Discussed in more detail by Blanchard [2009] and exemplified by Pedohebephilic Disorder). The person is distressed or impaired by these attractions, or has sought sexual stimulation from observing three or more unsuspecting persons who are naked, disrobing, or engaging in sexual activity on separate occasions.

     

A concluding discussion at the end of the article comments on the proposed criteria.

Frotteurism

Method

See Exhibitionism.

Results from Literature Review

The French verb “frotter” means “rubbing” or “friction,” and the associated nouns are “frottage” and “frotteur” (the person doing frottage). Krueger and Kaplan (2008) and others credit German psychiatrist von Krafft-Ebing for being the first mentioning frotteurism in Psychopathia Sexualis. However, frotteurism has not been a subject of much clinical or scientific interest. Prevalence-wise, data from Kafka and Hennen (2002), Bradford et al. (1992), and Abel et al. (1988) suggest that 10–14% of men in clinical outpatient settings for paraphilias and paraphilia-related disorders have committed frotteuristic acts. No representative survey has provided prevalence estimates of frotteurism in the general population. Two small studies suggested high rates among 61 unclearly recruited adult men and women in a little town in South India (Kar & Koola, 2007) and in a convenience sample of 60 male college students in a rural area of the U.S. (Templeman & Stinnet, 1991). Krueger and Kaplan (2008) further noted the lack of published accounts of female frotteurs. The relatively recent addition of Frotteurism by the American Psychiatric Association to DSM-III-R may have contributed to the lack of data. The disorder did not appear in the second edition (DSM-II; American Psychiatric Association, 1968) and was first introduced as an “atypical paraphilia” in the DSM-III.

Comorbidity is very common; among 144 frotteurs studied by Freund et al. (1997), 68% also had another paraphilic behavior, usually exhibitionism and voyeurism, two other courtship disorders. Templeman and Stinnet (1991) obtained similar results in their convenience sample of 60 male college students.

Lussier and Piché (2008) cited other researchers who argued that frotteurism is strongly reinforced behaviorally by immediate sexual gratification with very little cost and investment (albeit at the expense of another person). In addition, Lussier and Piché used developmental psychology references to suggest a specifier related to the age of onset of frotteurism: childhood or adolescence vs. young adulthood. Based on case studies, Horley (2001) argued that frotteurs could be seen as timid or nonassertive rapists, with the likelihood of committing a more serious sexual assault given the right set of circumstances (e.g., sufficient courage, a very submissive victim). However, we lack sufficient data to either support or refute this suggestion.

Review of Previous DSM Criteria Sets

DSM-III

Frotteurism was considered an atypical paraphilia.

DSM-III-R

In the DSM-III-R, Frotteurism was for the first time operationally defined as a specific paraphilia:
  1. A.

    Over a period of at least 6 months, recurrent, intense sexual urges and sexually arousing fantasies, involving touching and rubbing against a nonconsenting person. It is the touching, not the coercive nature of the act, that is sexually exciting.

     
  2. B.

    The person has acted on these urges, or is markedly distressed by them.

     

DSM-IV

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person.

     
  2. B.

    The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

     

DSM-IV-TR

  1. A.

    Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person.

     
  2. B.

    The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

     

Proposed DSM-V Diagnostic Criteria for Frotteuristic Disorder

I suggest that the diagnostic Criterion A for Frotteurism be preserved since there is very limited data to suggest otherwise. At the same time, it is not surprising that it was first with the DSM-III that Frotteurism was specified as a paraphilia on its own. It was probably its relevance to decision-making in criminal justice rather than in clinical settings that motivated its emergence as a specified paraphilia.
  1. A.

    Over a period of at least 6 months, recurrent and intense sexually arousing fantasies, sexual urges, or sexual behaviors involving touching or rubbing against a nonconsenting person.

     
  2. B.

    (Discussed in more detail by Blanchard [2009] and exemplified by Pedohebephilic Disorder). The person is distressed or impaired by these attractions, or has sought sexual stimulation from touching or rubbing against three or more nonconsenting persons on separate occasions.

     

Commentary on Proposed Criteria

Renaming the Diagnoses

In agreement with Blanchard (2009) and Kafka (2009), I find it idiosyncratic that Exhibitionism, Voyeurism, and Frotteurism are not followed by the term “Disorder” if the individual both admits to (or is indirectly observed to have) the respective core defining DSM-IV-TR characteristic (Criterion A) and has acted on these sexual urges, or is distressed or impaired interpersonally as a result of such urges and fantasies (according to Criterion B). Therefore, for reasons of conceptual clarity and consistency with other sections of the DSM, I suggest the introduction of the terms Exhibitionistic, Voyeuristic, and Frotteuristic Disorder, respectively, for those who also fulfill Criterion B (see also Cantor, Blanchard, & Barbaree, 2009).

The use of the present terms Exhibitionism, Voyeurism, and Frotteurism should be abandoned for diagnostic purposes. However, they might be used for research and development purposes, but only for those who do not fulfill Criterion B (and hence do not fulfill the full set of diagnostic criteria for a DSM-V Paraphilic Disorder).

Duration of Signs and Symptoms

Albeit somewhat arbitrary in character (cf. O’Donohue et al., 2000), there is no empirical support to suggest any alteration of the qualifying phrase “over a period of at least 6 months” for any of the three paraphilias reviewed here.

Altered Criterion B

I suggest consideration of similar attempts to quantify the extent of paraphilic behavior for those paraphilias that are potentially criminal (pedophilia, exhibitionism, voyeurism, frotteurism, and sadism) like those presented by Blanchard (2009) for non-cooperative individuals with possible Pedohebephilic Disorder (see also O’Donohue et al., 2000). To my knowledge, there are no published data that could directly advise on such behavioral determinants for the paraphilias reviewed here. However, the DSM-IV-TR used “has acted upon” as a vaguer behavioral indicator, and I suggest that three or more victims on separate occasions as a threshold for Exhibitionistic, Voyeuristic, and Frotteuristic Disorder. The rationale is to improve interrater reliability and validity. The exact number is chosen to balance false negatives (i.e., inaccurately diagnosing individuals not distressed or impaired by their attractions, or unwilling to report them, as not having a paraphilic disorder from behavior only, because of a too high threshold) against false positives (i.e., incorrectly diagnosing someone as having a paraphilic disorder from behavior only because of a too low threshold). Three or more victims on separate occasions is based on typical behaviors of individuals with these paraphilias (e.g., Abel et al., 1987), and base rates for core behaviors judged from epidemiological data (e.g., Långström & Seto, 2006; Templeman & Stinnet, 1991). However, importantly, the suggestion of these thresholds for DSM-V diagnostic purposes is not a comment on the varying ways used to define unlawful conduct in different judicial traditions. Nor does it imply that I want to minimize victim experiences of such acts.

Age Specifier for Targets of Exhibitionistic Fantasies, Urges, or Behaviors

Although not backed by any specific study, but suggested from some research (e.g., Gebhard et al., 1965), this specifier might have additional diagnostic value. Since several reports suggest frequent co-morbidity among the paraphilias (Abel et al., 1988, Bradford et al., 1992; Fedora et al., 1992; Freund et al., 1997; Gebhard et al., 1965), this specifier attempts to draw attention to possible underlying or comorbid pedophilia. However, the use of specifiers with Exhibitionistic Disorder should not prevent the clinician from independently considering possible co-occurring Pedohebephilic Disorder.

Further Reflections on Diagnostic Criteria

The similarities between “courtship disorder” paraphilias Exhibitionism/Exhibitionistic Disorder, Voyeurism/Voyeuristic Disorder, and Frotteurism/Frotteuristic Disorder and the little (new) empirical data there are for these entities particularly from community-based studies (for exceptions, see Långström & Seto, 2006; Templeman & Stinnet, 1991), but also from clinical, and convenience samples, led me to try to synthesize my impressions and to coordinate my suggestions for these three paraphilias.

One common criticism of current conceptualizations of the paraphilias, particularly sadomasochism and fetishism, focuses on that the diagnostic criteria address sexual behavior which many people deem non-pathologic or normal, although not in a strict statistical sense. These critics often refer to the removal of homosexuality from the DSM-II in 1973, and argue that BDSM (Bondage, Dominance, Submission/Sadism, and Masochism) behaviors should be similarly depathologized (for a review, see Krueger, in press). Importantly, however, several other mental disorders in the DSM-IV-TR have criteria that are more or less statistically normal on their own (or at least not pathological) but without attracting similar criticism. For example, the DSM-IV-TR A Criterion “Recent use of alcohol” designates a quite common experience. However, it is first with the additional presence of B and C Criteria denoting distress or impairment that the necessary criteria for Alcohol Intoxication (303.00) are fulfilled. Likewise, although less common than recent use of alcohol, the A criterion “A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood” is not a DSM-IV-TR psychiatric disorder on its own. But when additional A Criterion-related symptoms and impairment (B, C, and D Criteria) are present, the necessary criteria for Hypomanic episode might be fulfilled. Using analogous reasoning as critics opposed to sexual behaviors perceived as normal being mentioned in diagnostic systems for mental disorders, a number of other diagnoses would have to be seriously considered for removal on similar grounds. In fact, recent lobbying from sexual rights organizations led the Swedish National Board of Health and Welfare to unilaterally delete paraphilias fetishism, sadomasochism, and transvestism from the latest Swedish version of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (World Health Organization, 1992) as of January 1, 2009 (Associated Press, 2008). Whereas clinicians in Sweden need to find other ways to diagnose and occasionally treat individuals with several of the deleted, but arguably still existing, disorders, another option could have been to strengthen distress and impairment criteria. DSM and ICD nosologies for the paraphilias are partly different and distress and impairment criteria undoubtedly much less pronounced in ICD-10 (cf. Reiersøl & Skeid, 2006).

Many individuals who practice variant sexual behaviors in a safe and consensual manner (typically recreational BDSM practitioners) appear to neither experience distress nor suffer significant psychosocial impairment (Långström & Hanson, 2006; Richters, de Visser, Rissel, Grulich, & Smith, 2008). In other words, this strongly indicates that they neither fulfill current DSM-IV-TR diagnostic criteria for paraphilias nor will do so with the current suggestions for DSM-V. One of the delicate challenges for revisions of the DSM (and ICD) diagnostic systems is to minimize false positives, by not diagnosing those who should not be diagnosed with potentially stigmatizing paraphilic diagnoses. In addition, introducing many false negatives by applying such strict criteria that minimizing or denying individuals with paraphilic disorders cannot be diagnosed should also be avoided. Seen from an overall perspective of DSM psychiatric nosology, this may be a particular problem for the potentially criminal paraphilias since shame, social stigma, and negative legal consequences prevent people from being open about their symptoms (in contrast to, for example, less stigmatizing conditions such as Major Depression or ADHD). Again, there are clearly non-pathological variants of paraphilic interest and attractions, such as those found among BDSM practitioners, but also highly destructive ones (typically found among pedophilic or sadistic sexual offenders). Optimally, criteria sets should allow the clinician to diagnose most of the latter individuals, overall more likely to truly have a Paraphilic Disorder, but prevent the diagnoses from being assigned to the absolute majority of the former.

I considered the introduction of “and” instead of “or” in “…fantasies, sexual urges, or behaviors” in the A criterion of these three paraphilias. I also considered the argument by First and Frances (2008) to delete the entire “or behaviors.” Both of these suggestions would decrease the rate of false positives at the expense of an increased rate of false negatives. An individual with repeated exhibitionistic behaviors that has become known to the criminal justice system but who denies any exhibitionistic fantasy or urge to expose himself or herself, or related distress or impairment related to these behaviors, will be more difficult to diagnose with such a change to the criteria. First and Frances (2008) might have overseen that the DSM-IV-TR contains at least two other mental disorders of significant importance in courts and/or civil commitment procedures. These are Conduct Disorder and Antisocial Personality Disorder; both are heavily based on behavioral criteria (for a related discussion, see Cauley, 2007). Should these two disorders be adjusted accordingly? Although this is, admittedly, a problematic issue, I am not convinced that psychiatric nosology should change primarily because of the potential or actual misuse of diagnoses in the judicial system. Therefore, I suggest keeping the current DSM-IV-TR wording “fantasies, sexual urges, or behaviors.”

Acknowledgments

Niklas Långström is funded by the Swedish Research Council-Medicine. The author is a member of the DSM-V Workgroup on Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker, Ph.D.). I wish to acknowledge the valuable input received from the other members of the Paraphilias subworkgroup (Ray Blanchard, Marty Kafka, and Richard Krueger) and Kenneth J. Zucker. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.

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© American Psychiatric Association 2009