DSM-V Options: Sexual Sadism, Sexual Masochism, and Paraphilic Coercive Disorder

By  Richard B. Krueger, M.D.

Disclaimer: There are no drug company or commercial interests associated with this presentation. I am employed by State of New York Office of Mental Health—these are my opinions only. I am presenting the current wording of our diagnostic suggestions for Sexual Sadism, Sexual Masochism, and Paraphilic Coercive Disorder. These formulations have been in a process of constant discussion and revision over the past two years. While some have complained that the DSM-V process has not been transparent or open, it is worth noting that previous DSMs were written in the pre-Internet era. The amount of discussion, exchange of ideas (in person or by email), or involvement of advisors has been much much greater in the preparation of this DSM as compared to earlier DSMs.

Summary

  • Sexual Sadism Disorder
  • Sexual Masochism Disorder
  • Paraphilias Coercive Disorder
  • Background, proposed changes, rationale for chnages
  • Literature reviews, advisor reports published
  • Actual criteria not available until ?

Diagnosis of Sexual Sadism

  • Included in all prior DSMs
  • Criticized for many years
  • Sweden in 2008 removed transvestism, fetishism and sadomasochism from its official list of mental disorders
  • important to note that this is the ICD-10 nomenclature Sadomasochism: A preference for sexual activity which involves the infliction of pain or humiliation, or bondage If the subject prefers to be the recipient of such stimulation this is called masochism; if the provider, sadism. Often an individual obtains sexual excitement from both sadistic and masochistic activities
  • Masochism
  • Sadism

It is important to note that in the DSM, Sexual Sadism and Sexual Masochism have been considered as separate diagnoses; whereas, in the ICD, they are parts of the same diagnosis. My review of forensic populations suggested that these diagnoses in these populations are indeed separate, with only a small fraction of individuals having both diagnoses. Thus, I think that they would best be kept separate.

Sexual Sadism Literature Review

–22 articles of chapters identified which presented criticisms
• Represent value judgements and should be removed
• Pathologizing socially deviant behavior
• Poor interrater reliability
• Little data to support current diagnoses
• Poorly operationalized
–Literature review disclosed 24 studies using DSM for forensic populations ; many had sexual sadism
–Only 4 for non-forensic populations
–Case survey of outpatient visits in the U.S. for diagnoses involving the sexual and gender identity disorders
–25,150,180 visits to psychiatrists. 18,306,540 to urologists
333.873,400 visits to general/family/internal medicine physicians &. 69,435,650 to obstetricians/gynecologist. no visits had diagnosis of sexual sadism or masochism
–Issue in child cuslody proceedings

Sexual Sadism Disorder
• DSM-IV-TR: Sexual Sadism
A. Over a period or at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiiliation) of the victim is sexually exciting to the person

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

•Proposed DSM-V: Sexual Sadism Disorder
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the physical or psychological suffering of another person.

B. The person is distressed or impaired by these attractions, or has sought sexual stimulation from behaviors involving the physical or psychological suffering or two or more nonconsenting persons on separate occasions.


It was not until after the review that I suggested the removal of the phrase “real, not simulated”. In fact, it can be difficult to determine if something is “real” and “not simulated”. Really, it is the actual behavior that is important. The B criterion was added because it was the consensus of our work-group that it was important to emphasize behavior and not just sexual urges or fantasies. The number of nonconsenting victims was added as a behavioral criterion, as many persons accused of sexual sadism will disavow any such motivation and behavior. The number of victims indicator allows diagnosticians to make a judgment in the absence of such endorsement of fantasy or interest by the individual being evaluated. The number “two” was chosen to reduce the likelihood of false positives. Also, it should be noted that the DSM-IV-TR text was based largely on evidence from forensic populations extending to all of those practicing S&M and that it did not include information about S&M in the community. It has been argued that the current DSM-IV-TR text adversely colors the behavior of non-forensic practitioners of S&M. Thus, we are suggesting criteria that will offer appropriate descriptions of both forensic and non-forensic populations.


Sexual Masochism Literature Review

  • Much less literature than for sexual sadism
  • First mentioned In OSM-II
  • 16 articles/chaptersI identlfled as having criticisms relevant to sexual sadism
  • Criticisms very similar to those for sadism
  • 3 studies mention masochism using DSM criteria in forensic populations
  •  4 studies mention masochism using OSM criteria in non-forensic population
  • Hypoxophyia
  • Small number of other cases where masochism results in severe harm or even death
  • Diagnosis of sexual masochism does not apply to most practicing this behavior

Sexual Masochism Disorder

  • DSM-IV-TR: Sexual Masochism
    A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer
    B. The fantasies, sexual urges, or behaviors cause clinically significan distress or impairment in social, occupation, or other important areas of functioning.
  • Proposed DSM-V: Sexual Masochism Disorder
    A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving the act of being humiliated, beaten bound, or otherwise made to suffer.
    B. The fantasies, sexual urgs, or behaviors cause clinically significant distress or impairment insocial, occupational, or other important in social, occupational, or other important areas of functiong

Specify it With Asphyxiophilia (Sexually Aroused by asphyxiation)

Based on the literature review, I concluded that Sexual Masochism should be retained in the DSM. However, I recommended the removal of the phrase “real, not simulated”, for the same reasons I suggested it be deleted for sexual sadism.

Asphyxiophilia is a term originally described by John Money. For the purposes of our workgroup’s review, we asked Dr. Steven Hucker to prepare an analysis. He suggested that it was not anoxia or hypoxia, but the feeling of restriction of breathing that was sexually arousing. Asphyxiophilia was then included as a specifier.


Paraphilic Coercive Disorder

DSM-IV-TR and Prior DSMs: No Equivalent
A. Considered for DSM-III-R

Proposed DSM-V: Paraphilic Coercive Disorder
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies or sexual urges focused on sexual coercion, as indicated by self-report, laboratory testing, or behavior.
B. The person is distress or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occasions
C. The diagnosis of Paraphilic Coercive Disorder is not made if the patient meets criteria for a diagnosis for Sexual Sadism Disorder

Paraphilic coercive disorder (PCD) or paraphilic rape was considered for DSM-III-R. It was thought that there were a certain number of rapists or other individuals who could only be sexually aroused by coercive sexual behavior towards a victim. This was thought to be paraphilic behavior. However, there were objections based on the thought that such a diagnosis could be used by rapists to exculpate themselves. In fact, the opposite has occurred. In the sexual offender civil commitment domain, risk level determination based on a diagnosis of a paraphilia results in a more restrictive designation than for those who do not have a paraphilia. Our paraphilia workgroup decided that this diagnosis should be reexamined and, as such, we requested assistance from four advisors: Drs. Ray Knight, David Thornton, Vern Quinsey, and John Bradford. Three of these were able to provide reports. We reviewed these and concluded that there was sufficient evidence and sufficient need that this diagnosis should be suggested; perhaps, not for inclusion as a regular diagnosis in the DSM, but for inclusion in the appendix as a diagnosis worthy of further study.


 

Conclusions

  • Ratings of Change: 1 a minor revision to 4 a major revision
  • Sexual Sadism Disorder is a 2
  • Sexual Masochism Disorder is a 2
  • Paraphilic Coercive Disorder is a 4
  • Timetable and method for feedback
  • Field Trials

The rough rating scale in this slide represents the degree of change proposed for DSM-V, as compared to the existing diagnostic descriptions (DSM-IV-TR). A score of 1 represents minimal change, while a score of 4 indicates a very substantial degree of change. Overall, we are suggesting somewhat minor changes to most diagnostic frameworks, with the exception of PCD. It is our expectation that the workgroup’s diagnostic suggestions will be reviewed and that a decision will be made as to which formulations will be supported and which will not. These will then be posted on a public DSM-V page, where opinion and criticism will be solicited. Further, all of the literature reviews underlying our initial suggestions will be published in an upcoming issue of Archives of Sexual Behavior. Commentary on these literature reviews and our suggested diagnoses, as posted on the DSM-V website, will be solicited, with Dr. Zucker, the editor of Archives of Sexual Behavior, indicating that commentaries of up to 1,500 words (edited in a suitable academic fashion) will be considered for publication. At present, we understand that there will be field trials but, as yet, further details are unknown.

 

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