DSM-5 Paraphilias and Paraphilic Disorders

This text-based course is an edited transcript of a live webinar presented by Giselle Levin, PsyD.

This material is for educational purposes and does not replace clinical judgment or local policy.

Course Overview

In this course, we will undertake a thorough and critical examination of the current classification of paraphilias and paraphilic disorders within the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). We will move beyond a simple recitation of diagnostic criteria to explore the historical evolution of these classifications, the ethical and legal implications of diagnosis, and the complexities of distinguishing between non-pathological sexual diversity and genuine psychological distress. Our analysis will be guided by central questions we must consider as clinicians, including the fundamental difference between a paraphilia and a paraphilic disorder and the role of classifications in the context of consent and criminal behavior. This discussion underscores the need for a nuanced, ethically-informed, and culturally competent approach to understanding paraphilic interests and behaviors.

Limitations/Risks

This presentation focuses on the fundamentals of DSM-5 Paraphilic Disorders. We discuss distinguishing paraphilias and paraphilic disorders, DSM-5 criteria, and an overview of treatment. This presentation does not provide in-depth training related to diagnosing and treating paraphilic disorders. Seek consultation or refer as needed.

This presentation provides a general overview of DSM-5 Paraphilic Disorders, but does not explore the cultural variations in how these disorders may be perceived, expressed, or diagnosed across different communities. Clinicians should apply culturally competent approaches and consider how societal norms, stigma, and access to care may influence assessment and treatment. Seeking culturally informed consultation or resources is recommended when working with diverse populations.
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Learning Outcomes

After this course, participants will be able to:

• Differentiate between non-disordered sexuality and DSM-5 paraphilias in two case studies.
• Describe ethical concerns related to the pathologizing of normal human sexual diversity within the DSM-5.
• Identify situations in which clients could benefit from diagnosis and treatment for DSM-5 paraphilias.

FAQs

• Are there guidelines for documentation that you recommend around paraphilic disorders?
• How do you treat patients who are invested in the idea that they have a paraphilia when there are no issues of nonconsensual behavior?
• Given that the DSM-5's paraphilic disorders have so many problems, what are your thoughts about what ideally DSM-6 should do with the chapter?
• How do we recommend we combat stigma among our coworkers about paraphilic disorders?
• Sexual offending is such a huge problem. Do you have different views on paraphilic disorders that involve sexual offenses compared with those that don't?

Guiding Questions:

• What is the difference between a paraphilia and a paraphilic disorder?
• How do we distinguish "normal" variations in human sexuality from a paraphilic disorder?
• Should psychological disorders be used as a mechanism for understanding criminal behavior and/or non-consensual sexual behavior?

Notice!

• What surprises you?
• What seems to be clinically relevant or irrelevant to your work?
• Which criteria feel helpful or unhelpful with regard to distinguishing "normal" sexual diversity and pathology?

History & DSM-5 Changes

The history of nosology—the way in which we classify diseases and disorders—is a journey that reveals as much about societal values and political landscapes as it does about scientific understanding. The evolution of the paraphilic disorders chapter within the DSM is a prime example of this.

When the first edition of the DSM was released in 1952, it included a category for "sexual deviation" under the broader heading of sociopathic personality disorder. This category was incredibly broad and encompassed a wide spectrum of behaviors that were not explicitly linked to procreation. This included homosexuality and what was then termed "transvestism," as well as other interests like pedophilia, fetishism, and sexual sadism.

The inclusion of these behaviors under a psychiatric label marked a significant shift from the previous view that these acts were sinful or evil. The perspective moved from one of morality to one of medicine, from seeing individuals as "bad" to seeing them as "mad". While some might argue that this medicalization was a step toward a more empathetic view, it also had severe negative consequences. The classification provided a seemingly scientific justification for the institutionalization of queer individuals, castration, and widespread discrimination. It gave society a scientific sanction to fire people from their jobs, to expel them from their families, and to deny them citizenship on the basis of their sexual orientation or gender expression. This period, therefore, highlights a crucial question that still resonates today: to what extent is the DSM a truly scientific document, and to what extent is it a reflection of social and political pressures? The scientific rigor behind the paraphilic disorders chapter has, in fact, been heavily questioned, and this lack of a strong evidence base has led to continued debate.

The landscape changed dramatically in 1973 with the removal of homosexuality from the DSM, an action driven largely by the tireless work of queer rights activists. This change was not without controversy and was met with strong resistance from many clinicians. The introduction of "paraphilias" in the DSM-III in 1980 was, in many ways, a compromise between these opposing factions. It also introduced a new, now-removed category of "ego dystonic homosexuality," which pathologized individuals who were distressed by their same-sex attractions, allowing a continued space for classification of same-sex attraction as a disorder under a new guise. This was a clear example of the DSM adapting to social pressures while still maintaining a degree of what some would consider a pathologizing stance.

The DSM-IV introduced a key element that is still central today: the "distress criterion". This meant that an individual could be diagnosed with a paraphilic disorder based on the presence of distressing urges or fantasies, even without having acted on them or having any functional impairment. This was a significant development because it shifted the focus from behavior alone to the individual's internal experience.

The DSM-5, released in 2013, further refined this by making a crucial distinction between a paraphilia and a paraphilic disorder. The emphasis was placed on either personal distress, functional impairment, or the causing of harm or risk of harm to others. This distinction was a major step toward acknowledging that not all unusual sexual interests are pathological.

Paraphilias vs. Paraphilic Disorders

The distinction between a paraphilia and a paraphilic disorder is a cornerstone of the DSM-5's approach to this topic.

A paraphilia is defined by the DSM-5 as an "intense and persistent sexual interest other than genital stimulation or preparatory fondling with normal, physically mature, and consenting human partners" (American Psychiatric Association, 2022). This definition is complex and contains several key components that require careful unpacking. First, the sexual interest must be for a specific act or target, one that is outside of what the manual considers "normal" or "preparatory" sexual activity. The term "normal" itself is highly problematic and subjective. Second, the interest must be "intense and persistent," a qualitative measure that lacks a clear, research-supported definition, making it difficult to apply consistently. Finally, the "erotic target" must be other than what is considered a "normal, physically mature, and consenting human partner". This raises questions about what constitutes a "normal" partner and whether certain sexual interests, such as those for a particular body type, could technically be considered a paraphilia. The DSM-5 acknowledges that there are a vast number of potential paraphilias, many of which do not have a specific diagnosis in the manual.

The shift from the term "paraphilia" to "paraphilic disorder" in the DSM-5 was meant to clarify that not all paraphilic interests are pathological. For a paraphilia to become a paraphilic disorder, it must meet specific criteria. The individual's paraphilic interest, urges, or behaviors must either cause "distress or functional impairment to the individual" (Criterion B) OR have "caused harm or risk of harm to others" (Criterion B). This distinction is absolutely critical because it means that a person could have a paraphilia (meeting Criterion A) but not have a diagnosable disorder (by not meeting Criterion B). For example, a person with an intense and persistent fetishistic interest in feet would only be diagnosed with Fetishistic Disorder if that interest was causing them significant distress in their life or interfering with their daily functioning.

The distress and impairment criterion, however, is a point of significant contention. It is often challenging to determine whether an individual's distress stems from their sexual interest itself or from the societal stigma and internalized shame associated with that interest. We will explore this ethical dilemma further in later sections, but it is a fundamental problem with the current diagnostic framework.

Voyeuristic Disorder (F65.3)

Voyeuristic Disorder is defined as having "recurrent and intense sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months.

The diagnostic criteria (Criterion B) further specify that for a diagnosis to be made, the individual must have either acted on these urges with a non-consenting person, OR their urges or fantasies must cause them significant distress or functional impairment (American Psychiatric Association, 2022). This is a vital point to remember as it distinguishes a momentary impulse from a diagnosable disorder.

The criteria also include an age requirement (Criterion C), stating that the individual must be at least 18 years old (American Psychiatric Association, 2022). This is an attempt to avoid pathologizing what the DSM-5 considers to be "normative sexual exploration" in adolescence.

The manual provides specifiers for individuals "in a controlled environment" (e.g., a prison or psychiatric hospital) and for those "in full remission". To be in full remission, an individual must have not acted on the urges and must have experienced no distress or impairment for at least five years while in an uncontrolled environment (American Psychiatric Association, 2022). The long duration of the remission period is notably longer than for many other mental health conditions.

It is important to note that consensual voyeuristic behavior, such as a partner watching another undress with their knowledge and agreement, would not meet the diagnostic criteria unless the individual experienced significant distress or functional impairment that was not related to societal stigma.

Exhibitionistic Disorder (F65.2)

Exhibitionistic Disorder shares a similar structure to Voyeuristic Disorder. It is characterized by "recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person" (Criterion A) (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must persist for a period of at least six months.

As with other disorders, the individual must have (Criterion B) either acted on these urges with a non-consenting person, OR their fantasies and urges must cause them marked distress or functional impairment (American Psychiatric Association, 2022). Acts of exhibitionism are common, but the key to a diagnosis lies in the intensity and recurrence of the interest, which is much less common.

The specifiers for this disorder include whether the exposure is directed toward prepubertal children, physically mature individuals, or both. Additional specifiers exist for "in a controlled environment" and "in full remission" (American Psychiatric Association, 2022). Again, the element of a "non-consenting person" is central to the behavior, but the distress and impairment criteria can be met even in the absence of a non-consenting act, which is a point of confusion for some clinicians.

Frotteuristic Disorder (F65.81)

Frotteuristic Disorder is defined by (Criterion A) a "recurrent and intense sexual arousal from touching or rubbing against a non-consenting person" (American Psychiatric Association, 2022). This must be present for a period of six months. The diagnostic criteria (Criterion B) require that the individual has acted on these urges OR that the fantasies and urges cause them significant distress or functional impairment (American Psychiatric Association, 2022).

This is an important distinction to make because frotteuristic acts—unwanted touching or rubbing against another person—are surprisingly common, occurring in up to 30 percent of adult men in the United States and Canada. However, a diagnosis of Frotteuristic Disorder is only made when there is a recurrent and intense sexual interest driving the behavior, which is a far less common occurrence. Statistics show that only 10 to 14 percent of men in outpatient settings with paraphilic disorders and hypersexuality meet the criteria for this disorder. Therefore, a single act of frotteurism would not warrant a diagnosis, as it does not meet the "recurrent and intense" criteria. The disorder, like others, also has specifiers for "in a controlled environment" and "in full remission" (American Psychiatric Association, 2022).

Sexual Masochism Disorder (F65.51)

Sexual Masochism Disorder stands apart from the previous disorders because it does not inherently involve a non-consenting partner. This disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months.

The diagnostic criteria (Criterion B) state that these behaviors, urges, or fantasies must be causing the individual significant distress or functional impairment (American Psychiatric Association, 2022). A diagnosis would not be made for a person who engages in consensual sexual masochism without experiencing distress. This distinction is critical because it separates consensual BDSM activities from a diagnosable disorder. Many people engage in consensual activities that fall under this umbrella, such as rope play or degradation, without any negative psychological consequences.

The disorder includes a specifier for "with asphyxiophilia," which is defined as deriving sexual arousal from choking (American Psychiatric Association, 2022). This is noted for its inherent dangers and the higher risk of death associated with such behavior. As with other disorders, there are specifiers for "in a controlled environment" and "in full remission".

The case study of Michael, an 80-year-old gay man who was distressed by his consensual masochistic interests due to his Mormon upbringing, perfectly illustrates the complexity of the "distress" criterion. While he technically meets the criteria for the disorder because he has distress, the root of his distress is not the behavior itself but the internalized shame from societal stigma.

Sexual Sadism Disorder (F65.51)

Sexual Sadism Disorder is the counterpart to masochism, defined as having (Criterion A) "recurrent and intense sexual arousal from the physical or psychological suffering of another person" (American Psychiatric Association, 2022). This must also be present for a period of six months.

The diagnostic criteria (Criterion B) require that the individual has either acted on these urges with a non-consenting person OR that their urges and fantasies cause them significant distress or functional impairment (American Psychiatric Association, 2022). A key point from the DSM-5 is that individuals who sadistically assault others but deny any sexual arousal or distress can still be diagnosed with this disorder. This is because the act itself, which has caused harm to another, is sufficient for the diagnosis. This is an important distinction, as it shows that harm to others can trump the individual's self-reported experience of distress or arousal.

It's also worth noting a striking statistic: less than 10 percent of sexual offenders in the United States meet the criteria for Sexual Sadism Disorder, which suggests that the vast majority of sexual offenders are not motivated by this specific type of paraphilic interest. This disorder, like the others, has specifiers for "in a controlled environment" and "in full remission" (American Psychiatric Association, 2022).

Pedophilic Disorder (F65.4)

Pedophilic Disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from sexual activity with a prepubescent child (under the age of 13)" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months. The diagnostic criteria (Criterion B) require that the individual has either acted on these urges OR that their urges and fantasies cause them significant distress or functional impairment (American Psychiatric Association, 2022).

A critical diagnostic criterion to emphasize is (Criterion C): the individual must be at least 16 years old AND at least five years older than the child (American Psychiatric Association, 2022). Therefore, a 13-year-old and a 17-year-old would not meet the criteria, as the five-year age gap is not met.

The DSM-5 also notes that individuals who repeatedly approach children can be diagnosed even if they deny sexual intent or distress, as their behavior itself is sufficient for the diagnosis (American Psychiatric Association, 2022).

Specifiers for this disorder include whether the attraction is "exclusive" or "non-exclusive" to prepubescent children, the gender of the children of interest ("attracted to males/females/both"), and whether the interest is "limited to incest" (American Psychiatric Association, 2022). It is also important to note that while pedophilia (the paraphilia) is often considered a lifelong condition, pedophilic disorder is not. An individual could stop meeting the criteria for the disorder if their urges no longer cause distress or functional impairment, though they would still be considered to have the paraphilia of pedophilia.

Let's consider a quiz question: According to the DSM-5, which of the following individuals would meet criteria for pedophilic disorder? a) A 23-year-old man who has sexually arousing fantasies about young children but has never acted upon any urges and denies distress or interpersonal difficulty. b) An 18-year-old boy who is in a sexual relationship with a 13-year-old girl. c) A 16-year-old boy who has highly distressing sexual fantasies about a 9-year-old cousin. d) A 45-year-old woman who is sexually involved with a 16-year-old girl.

The correct answer is (c). The 16-year-old meets the age requirement (Criterion C) of being at least 16 and at least five years older than the nine-year-old. He is experiencing highly distressing fantasies, which meet the criteria for the disorder (Criterion B). The other options fail to meet the criteria: (a) lacks distress or action (Criterion B); (b) has an insufficient age gap (Criterion C); and (d) involves a child outside of the prepubescent definition (Criterion A).

Fetishistic Disorder (F65.0)

Fetishistic Disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from either non-living objects or a highly specific focus on non-genital body parts" (American Psychiatric Association, 2022). This must be present for at least six months. The diagnostic criteria (Criterion B) require that these behaviors, urges, or fantasies cause the individual significant distress or functional impairment (American Psychiatric Association, 2022).

It is important to note (Criterion C) that this diagnosis is not given if the interest is limited to cross-dressing or to sex toys that are designed to stimulate the genitals (American Psychiatric Association, 2022). An example would be an intense sexual interest in shoes, feet, or armpits, where these objects or body parts become the primary focus of sexual arousal.

While many people might enjoy incorporating a fetishized object or body part into their sexual activity, a person with this disorder would often have a preference for the fetishized object over traditional sexual acts. They would feel more sexually satisfied with the fetishized object present. Only a small number of people with this disorder would feel that they absolutely need the fetishized object to be present to experience sexual arousal. The disorder has specifiers for the type of fetish (body parts, nonliving objects, other), "in a controlled environment," and "in full remission" (American Psychiatric Association, 2022).

Transvestic Disorder (F65.1)

Transvestic Disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from cross-dressing" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months. The diagnostic criteria (Criterion B) require that these behaviors, urges, or fantasies cause the individual significant distress or functional impairment (American Psychiatric Association, 2022).

A key point to emphasize is that this diagnosis is not for people who cross-dress for reasons of gender affirmation, as in the case of a trans person. It is specifically tied to sexual excitement. The disorder is noted to be more prevalent in men than women and can be specified as "with fetishism," meaning the individual is aroused by specific garments or fabrics, or "with autogynephilia," which is defined by the DSM-5 as being aroused by the thought or image of oneself as a woman (American Psychiatric Association, 2022).

I want to highlight a troubling statement from the DSM-5 that suggests this behavior can "interfere with or detract from heterosexual relationships," implying a bias toward "conventional marriages" and a potential pathologization of behavior that is simply a departure from a narrow definition of normalcy (American Psychiatric Association, 2022). This phrasing in the manual itself underscores the ethical and political dimensions of these classifications.

Differential Diagnosis

When a person presents with symptoms or behaviors that may be related to a paraphilic disorder, it is crucial for a clinician to consider a differential diagnosis. Certain conditions can mimic or present with similar behaviors, but the underlying cause is different.

For example, if a sexual interest or behavior only occurs during a manic episode, a period of acute psychosis, while under the influence of substances, or in the context of a neurocognitive disorder, a paraphilic disorder diagnosis is not appropriate. The behavior is considered a symptom of the primary condition, not a stand-alone disorder. The case study of Robert, a 25-year-old man whose new and erratic behaviors, including assault, coincided with symptoms of a potential manic episode or substance use, illustrates this.

Similarly, a person with Conduct Disorder or Antisocial Personality Disorder might engage in norm-breaking behaviors, including assaultive behavior, but if there is no specific, recurrent, and intense sexual interest driving the behavior, a paraphilic disorder diagnosis is not warranted. I want to specifically mention that general sexual assault is not included as a paraphilic disorder.

Obsessive-Compulsive Disorder (OCD) is another important differential to consider. The case study of Mary, a 19-year-old with intense and distressing thoughts about touching a young child, perfectly illustrates this. Her thoughts are "ego-dystonic," meaning they are inconsistent with her self-concept and she finds them highly distressing. There are no positive feelings or sexual arousal associated with the thoughts, and she has no desire to act on them. The anxiety and rumination about being a pedophile are classic signs of OCD, not a paraphilic disorder. The DSM-5's distress criterion can be particularly challenging in such cases, as the distress may be a result of the intrusive thoughts rather than a paraphilic interest.

Finally, let's touch on the difference between Transvestic Disorder and Gender Dysphoria. While the DSM-5 suggests that a person with Transvestic Disorder does not have gender incongruence, it also confusingly states that a person can have both (American Psychiatric Association, 2022). This ambiguity highlights the need for clinicians to rely on a thorough assessment of the individual's full experience, rather than a superficial checklist of symptoms.

BDSM vs. Paraphilic Disorders?

The relationship between BDSM and the paraphilic disorders chapter in the DSM-5 is a contentious and often misunderstood topic. Drawing on my personal and professional experience, I want to emphasize that the fundamental distinction between consensual BDSM and a paraphilic disorder is the presence or absence of consent.

In BDSM, consent is not just assumed but is an active, ongoing, and fundamental part of the practice (Dunkley & Brotto, 2020). It involves detailed pre-scene negotiation, clear communication of desires and boundaries, and the use of safety mechanisms like safe words. Without consent, BDSM activities would be considered abuse or assault, not a consensual sexual practice.

Which Paraphilic Disorders Could Overlap with BDSM Behaviors?

Certain paraphilic disorders, specifically Sexual Sadism Disorder and Sexual Masochism Disorder, could potentially overlap with behaviors found in BDSM. However, the disorders that involve a non-consenting person, such as Voyeuristic Disorder, Exhibitionistic Disorder, and Frotteuristic Disorder, cannot be considered consensual BDSM. The very nature of the act is predicated on the lack of consent.

Can Overlap:

• Sexual Sadism Disorder
• Sexual Masochism Disorder

Cannot Overlap:

• Pedophilic Disorder
• Frotteuristic Disorder
• Voyeuristic Disorder
• Exhibitionistic Disorder

The case study of Michael, the 80-year-old gay man who was distressed by his consensual masochistic interests due to his religious upbringing, demonstrates the problematic nature of the distress criterion. While he technically meets the criteria for Sexual Masochism Disorder (due to distress), his distress is not about the behavior itself but the societal stigma and internalized shame associated with it. This is a powerful argument for the ethical concerns surrounding the DSM-5's classification.

ICD-11 Diagnoses

In contrast to the DSM-5's approach, the ICD-11, published in 2019, has taken a different path (World Health Organization, 2019). It has removed several diagnoses related to consensual behavior, including Fetishism, Fetishistic Transvestism, and Sadomasochism. Any consensual BDSM was removed.

The ICD-11 has shifted its focus to disorders that involve non-consensual behavior. For example, Sexual Sadism was changed to "Coercive Sexual Sadism Disorder" to focus specifically on non-consensual acts of sadism. What remains are disorders such as Exhibitionistic Disorder, Voyeuristic Disorder, Pedophilic Disorder, Coercive Sexual Sadism Disorder, and Frotteuristic Disorder. This move reflects a global effort to destigmatize consensual sexual interests and to concentrate diagnostic efforts on behaviors that cause genuine harm. This contrast between the DSM and ICD highlights the ongoing debate about the proper role of these diagnostic manuals in a diverse and evolving world.

Prevalence

Understanding the prevalence of various sexual interests and behaviors is essential for a clinician attempting to distinguish between a common variation in human sexuality and a statistically abnormal one.

A 2017 study found a surprisingly high prevalence of BDSM fantasies or practices, with almost 70 percent of people reporting at least one such fantasy or practice (Herbenick et al., 2017). However, a much smaller percentage, around 7 percent, actually identified as BDSM practitioners (Brown et al., 2020). This shows that a wide range of sexual interests exists, but most people do not organize their sexual identity around them.

Image Caption: Prevalence of BDSM fantasies versus BDSM practitioner identity in the general population. While nearly 70% of people report BDSM fantasies (Herbenick et al., 2017), only about 7% identify as practitioners (Brown et al., 2020). Data notes: Left Chart (BDSM Fantasies): Yes (red, ~69%), No (grey, ~31%) . Right Chart (BDSM Practitioners): Yes (red, ~7%), No (grey, ~93%).

Image Caption: Prevalence of various sexual interests in the general population (Herbenick et al., 2017). Rates include Public sex (43%), Spanking (30%), Role play (22%), Bondage (20%), Whipping (13%), and BDSM parties (8%). Data notes: Diagram shows six boxes with percentages: Public sex: 43%; Spanking: 30%; Role play: 22%; Bondage: 20%; Whipping: 13%; BDSM parties: 8%.

Another study found that 45 percent of people had a desire to engage in a paraphilia, and nearly 34 percent had actually engaged in a paraphilic behavior (Joyal & Carpentier, 2017). It's important to emphasize that many of the interests considered paraphilic by the DSM-5—such as voyeurism, fetishism, frotteurism, and masochism—are not, in fact, "statistically unusual" because they occur in more than 16 percent of the population (Joyal & Carpentier, 2017). The key difference between a common interest and a paraphilic disorder lies in the "recurrent or intense" nature of the interest, which is much less common, endorsed by less than 10 percent of people. This distinction is vital for clinicians to consider, as they must not mistake a common, if unconventional, sexual interest for a diagnosable disorder.

Criticisms of Paraphilic Disorders

The DSM-5's chapter on paraphilic disorders has been the subject of significant criticism from a number of experts in the field. I want to highlight an article by Moser (2019), who argued that the chapter would likely not pass a peer review process for publication in an academic journal. This scathing critique points to a number of fundamental problems with the chapter.

First, Moser (2019) noted a lack of transparency surrounding the development of the chapter, with committee members reportedly signing a confidentiality pledge and a lack of evidence that expert feedback was genuinely incorporated. The DSM-5 is a "consensus document," not a comprehensive literature review, and critics argue that this approach led to a chapter that is not rooted in quality research. No field trials were conducted to support the validity and reliability of the new diagnoses and criteria (Moser, 2019).

Other criticisms include the ambiguity of key terms. For instance, the manual lacks a clear definition for what constitutes an "intense" sexual interest, making it difficult to distinguish between a paraphilic and a "normophilic" interest (Moser, 2019). The term "preference," used by the APA, is also seen as problematic, as it can evoke the same kind of stigma that was historically used to pathologize homosexuality (Moser, 2019). This raises the question of whether a strong preference for a particular body type, such as redheads or curvy people, could technically be considered a paraphilia, a line of reasoning that, while absurd, highlights the flaws in the manual's language. For non-consensual disorders, Moser (2019) notes that "the crime is the disorder," questioning why this logic isn't applied to other crimes like embezzlement or even general sexual assault.

A major ethical and clinical criticism is the "distress criterion". I repeatedly voice a strong dislike for this criterion, noting that it is nearly impossible to distinguish between personal distress and distress that is a result of societal stigma and internalized shame. The APA's guidance that the distress should be personal, not from societal stigma, is seen as impractical and naive, as every individual is impacted by the society and culture in which they live. As Moser (2019) argues, it's unclear how a clinician could know where the distress truly originated, and most clinicians may not even be aware of this fine distinction from an APA fact sheet. This can lead to the pathologizing of people who are simply struggling with the shame and guilt of having a non-normative sexual interest, rather than a genuine psychological disorder. I argue that a psychiatric diagnosis should not be a reflection of what is "culturally or morally abhorrent" but should instead be based on a clear and evidence-based understanding of psychopathology.

How Do YOU Define Psychopathology?

Our discussion of the criticisms of the DSM-5's paraphilic disorders chapter culminates in a thought-provoking question about the very definition of psychopathology. This question forces clinicians to reflect on the foundations of their practice and the ethical implications of diagnosis.

Image Caption: Defining psychopathology is complex. It is often considered an intersection of what is statistically abnormal, culturally or morally abhorrent, and what causes clinical distress or functional impairment. Data notes: Central term: Psychopathology. Four surrounding terms: Statistically Abnormal, Culturally/Morally Abhorrent, Clinical Distress, Functional Impairment.

A diagnosis should not be made simply because a behavior is statistically abnormal, as many paraphilic interests are not. It should not be made simply because a behavior is culturally or morally abhorrent, as this opens the door to pathologizing any behavior that falls outside of a narrow societal norm. Diagnosis should also not be based solely on functional impairment or clinical distress without careful consideration of the source of that distress. As discussed in the case study of Michael, the source of distress was not his consensual BDSM activities but the internalized shame from his religious upbringing. A proper definition of psychopathology must be robust enough to withstand these challenges and must be rooted in a clear understanding of the individual's psychological experience, not just their behavior or the judgments of society.

Ethical Considerations

The diagnosis of a paraphilic disorder is not a neutral clinical act; it carries with it significant and potentially devastating ethical and legal consequences. It is important to highlight the fact that these diagnoses can be used in court to invoke sexually violent predator (SVP) statutes. This can lead to the involuntary commitment of individuals for life, sometimes preventatively, based on the presence of a diagnosis. This means that a person could be institutionalized without having committed a sexual crime, simply because they have a specific paraphilic disorder. This underscores the power and responsibility inherent in a diagnostic manual like the DSM-5.

Moser (2019) is quoted as saying that the APA should be held accountable for the harm its classifications cause, arguing that the DSM is a "policy and social document" as much as it is a scientific one, and that the APA should be clear when the science does not support its position.

The stigma associated with these diagnoses is immense and can lead to serious psychological harm. The DSM-5 itself acknowledges that suicidality is associated with the stigma-related shame and guilt experienced by some BDSM practitioners (American Psychiatric Association, 2022). This is a tragic consequence of a diagnostic system that has, in some cases, failed to adequately distinguish between unconventional sexual interests and genuine psychological pathology. The ethical obligation of clinicians is, therefore, to be extremely cautious and thoughtful in their application of these diagnoses, always considering the potential for harm to the individual.

Treatment: An Overview

Treatment for paraphilic disorders is a complex and multifaceted undertaking that typically involves a combination of pharmacological and behavioral therapies. The goal of treatment is not to change a person's sexual interest but to address the behaviors that are causing harm or distress.

Image Caption: An overview of common treatment modalities for paraphilic disorders includes pharmacological, behavioral, and cognitive-behavioral therapies.

Pharmacological treatments are often used to reduce sexual arousal and libido and are most commonly used with individuals who have a history of sexual offending. Behavioral therapies, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Schema-Focused Therapy (SFT), are also used to treat paraphilic disorders. These therapies are designed to address the cognitive distortions that maintain the behaviors, to help the individual recognize and correct maladaptive behaviors, and to address affective components such as a lack of empathy, which are often present in individuals with psychopathy or Antisocial Personality Disorder. The ultimate goal of these therapies, particularly in forensic settings, is to reduce recidivism. It is important to note that these treatments are most often used with sexual offenders.

Pharmacological Treatments

The use of pharmacological interventions for paraphilic disorders is a testament to the serious nature of the behaviors they are meant to address. The most common medications used are Selective Serotonin Reuptake Inhibitors (SSRIs), which can help to improve impulse control and reduce "deviant thoughts" in some individuals.

More aggressive treatments include anti-androgens and GnRH agonists, which work to reduce sexual arousal and libido by blocking testosterone. I use the stark phrase "akin to castration levels" to describe the effect of these medications. This highlights the severity of the treatment and the potentially life-altering side effects. The impact on bone health can be severe, with some individuals developing osteoporosis. Other side effects can include diabetes and high blood pressure. These medications are not a cure for the paraphilia itself but are intended to manage the intense urges and reduce the risk of re-offending. They are a tool used in a broader treatment plan that includes therapy and other behavioral interventions.

CBT & Other Therapies

Behavioral therapies are a cornerstone of treatment for paraphilic disorders, particularly for sexual offenders. Cognitive Behavioral Therapy (CBT) is a key modality used to identify and address the cognitive distortions that may maintain a person's paraphilic behaviors. The focus is on helping the individual recognize and correct maladaptive thoughts and behaviors.

I also want to mention the use of Dialectical Behavior Therapy (DBT) and Schema-Focused Therapy (SFT), which can be used to address broader psychological issues that may be present, such as psychopathy, Antisocial Personality Disorder, or a lack of empathy.

A comprehensive treatment plan might include psychoeducation about behavioral change, a functional behavioral analysis to understand what is perpetuating the behaviors, impulse control training, and the development of risk cards to help the individual identify situations that might lead to re-offending. Communication skills training and relapse prevention are also crucial components. Ultimately, the goal of these therapies is to reduce recidivism and to help individuals live a life that is in line with their values, even if they continue to have paraphilic interests. The discussion of an Internet-administered CBT protocol provides a detailed example of what such a treatment might look like, with a clear focus on education, skill-building, and relapse prevention.

Clinical Utility

A central question that must be asked of any psychiatric diagnosis is whether it has "clinical utility," a standard that the APA itself endorses. Citing Moser (2019), I would argue that the clinical utility for paraphilic disorders is questionable. While there may be a general link between paraphilias and other psychological disorders (Renaud, 2019), this does not automatically mean that all paraphilias should be pathologized.

The clinical utility of these diagnoses is most clear in forensic settings. Citing Shumate et al. (2023), I would argue that the focus of diagnosis and treatment should be on those who have a paraphilic disorder and have sexually offended, with the primary objective being to reduce recidivism.

For individuals who have paraphilic interests but have not acted on them and are not causing harm to others, the clinical utility of a diagnosis is far less clear. For people who engage in consensual BDSM or who have fantasies and arousal without a risk of offending, the focus of treatment should not be on eliminating their sexual interest. Instead, the focus should be on helping them manage any distress or functional impairment that they are experiencing, particularly if that distress is a result of societal stigma and internalized shame.

The case study of Michael perfectly illustrates this point. He was distressed by his consensual masochistic interests because of his religious upbringing, not because the interests themselves were inherently pathological. In such a case, the goal of therapy would be to help him process and manage his internalized shame, not to diagnose him with Sexual Masochism Disorder and attempt to "cure" his sexual interest. I also want to mention that there is very little data on what is considered "normal" sexual behavior, which further complicates the clinical utility of these diagnoses.

Who is the best candidate for treatment?

Our final question is a poll, designed to test the understanding of the key concepts discussed throughout this course.

Who is the best candidate for treatment for paraphilic disorders? a) A patient who is practicing sexual sadism with a consenting adult partner. b) A patient who is experiencing significant distress due to their addiction to pornography. c) A patient who crossdresses and experiences arousal while doing so. d) A patient who has exposed his genitals to a nonconsenting person.

The correct answer is (d). The rationale is that treatment for paraphilic disorders, particularly the forensic-focused treatments discussed, is most appropriate for individuals who have caused harm to others through non-consensual behavior.

Options (a) and (c) involve consensual behaviors and would not be the primary focus of treatment. While these individuals may be experiencing distress, the treatment would be focused on managing the effects of societal stigma and internalized shame, not on eliminating the paraphilic interest itself. Option (b) is not considered a paraphilic disorder in the DSM-5. I want to reiterate the central theme of this presentation: the diagnosis and treatment of paraphilic disorders should be reserved for those who are causing harm to others, with the goal of reducing recidivism, and should not be used to pathologize consensual sexual diversity.

Conclusion

I urge clinicians to think carefully and critically about when to diagnose and when to treat paraphilic disorders. I would like to reiterate that the "consequences can be huge" when it comes to the potential for legal ramifications like involuntary commitment and the profound psychological burden of stigma. It is important to underscore the inherent complexities of distinguishing between sexual diversity and genuine pathology, and careful consideration should be taken when reviewing the ethical concerns surrounding the DSM's role in potentially pathologizing consensual behaviors. The core message here is to prioritize treatment for individuals who have caused harm to others through non-consensual acts, with the primary goal of reducing recidivism. For individuals experiencing distress related to consensual sexual interests, the focus should shift to addressing the impact of societal stigma and internalized shame, rather than pathologizing their sexual preferences. I hope that the "crash course" has "changed the way you think about paraphilic disorders" and how to diagnose or treat, and when to diagnose or treat, if at all. Thank you for your time.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Brown, A., Barker, E. D., & Rahman, Q. (2020). A systematic scoping review of the prevalence, etiological, psychological, and interpersonal factors associated with BDSM. The Journal of Sex Research, 57(6), 781–811.

Herbenick, D., Bowling, J., Fu, T. C., Dodge, B., Guerra-Reyes, L., & Sanders, S. (2017). Sexual diversity in the United States: Results from a nationally representative probability sample of adult women and men. PloS one, 12(7), e0181198.

Dunkley, C. R., & Brotto, L. A. (2020). The role of consent in the context of BDSM. Sexual Abuse, 32(6), 657–678.

Joyal, C. C., & Carpentier, J. (2017). The prevalence of paraphilic interests and behaviors in the general population: A provincial survey. The Journal of Sex Research, 54(2), 161-171.

Moser, C. (2019). DSM-5, paraphilias, and the paraphilic disorders: Confusion reigns. Archives of Sexual Behavior, 48(3), 681-689.

Renaud, M. (2019). An examination of the relationship between the paraphilias and anxiety (Doctoral dissertation, Université d'Ottawa/University of Ottawa).

Sahoo, S., Pandiyan, S., & Chakravarty, R. (2023). Paraphilias: an update on nosology and diagnostic challenges. The Journal of Forensic Psychiatry & Psychology, 34(3-4), 371-385.

Shumate, J., Song, S. H., & Saleh, F. M. (2023). Paraphilic disorders, psychopathy, and those who sexually offend: a narrative review of treatment modalities. International Journal of Impotence Research, 1-7.

World Health Organization. (2019). International classification of diseases (11th ed.). https://icd.who.int/

Additional Current References

Please Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Abreu, R. L., Barrita, A. M., Sostre, J. P., Parmenter, J. G., & Watson, R. J. (2025). Interest in preexposure prophylaxis, cyberbullying, internalized stigma, and parental acceptance among Latinx sexual and gender diverse youth. Health Psychology, 44(3), 266–274. https://doi.org/10.1037/hea0001455

Hsu, K. J., Morandini, J. S., & Rudd, S. (2025). Cut from the same cloth? Comparing the sexuality of male cross-dressers and transfeminine individuals through the conceptual framework of autogynephilia. Archives of Sexual Behavior. Advance online publication. https://doi.org/10.1007/s10508-024-03053-7

Jabbour, J. (2025). Interest in BDSM: Structural, sexual, and personality factors. Dissertation Abstracts International: Section B: The Sciences and Engineering, 86(6-B).

Kirgios, E. L., Silver, I., & Chang, E. H. (2025). Does communicating measurable diversity goals attract or repel historically marginalized job applicants? Evidence from the lab and field. Journal of Experimental Psychology: General, 154(3), 624–643. https://doi.org/10.1037/xge0001699

McCauley, P. S., Eaton, L. A., Puhl, R. M., & Watson, R. J. (2025). Support from school personnel and in-school resources jointly moderate the association between identity-based harassment and depressive symptoms among sexual and gender diverse youth. Journal of Educational Psychology. Advance online publication. https://doi.org/10.1037/edu0000945