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DSM-5 and Paraphilias: What Psychiatrists Need to Know

DSM-5 and Paraphilias: What Psychiatrists Need to Know

Prevalence of Axis I comorbidity in paraphilic sexual offendersTABLE 1.
Medical conditions with hypersexual symptomsTABLE 2.
The psychosexual evaluationTABLE 3.

Paraphilic disorders are rarely part of the curriculum for psychiatry residents or fellows. As a result, there are few psychiatrists who work with individuals who have paraphilic disorders.

In the past few decades, research on sexual offenders has shown that those with paraphilic disorders are at high risk for committing future sexual offenses. Psychiatrists can serve a pivotal role in reducing sexual offender recidivism by treating individuals with paraphilic disorders.

DSM overview

DSM originally characterized sexual deviations with psychopathic personality disorders based on the belief that sexual deviations were criminal acts, and thereby those individuals who engaged in sexual deviations were unlawful or psychopathic. DSM-II defined sexual deviations in a broad category as “personality disorders and certain other nonpsychotic mental disorders.” DSM-II sexual deviations included sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestism, exhibitionism, voyeurism, sadism, masochism, and “other sexual deviation.”

The term paraphilias was introduced in DSM-III. The paraphilias were classified as psychosexual disorders, which included gender identity disorder, psychosexual dysfunctions, and ego-dystonic homosexuality. DSM-IV maintained the diagnostic classification of paraphilias. DSM-IV-TR moved transvestism from a disorder of gender identity to a paraphilia called transvestic fetishism.

The significant changes in DSM-5 include the change in nomenclature from “paraphilia” to “paraphilic disorder.” DSM-5 also introduced specifier terms such as “in remission,” and clarification between behavior and paraphilias.

DSM-5 classification

In DSM-5 the term paraphilia is defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physiologically mature, consenting human partners.” Paraphilias, however, may not necessarily classify as “intense and persistent” but rather preferential sexual interests or sexual interests that are greater than nonparaphilic sexual interests. The addition of the word “disorder” to the classification of paraphilias is new to DSM-5.

Previous DSM classifications did not include the word “disorder.” The term “disorder” was specifically added to DSM-5 to indicate a paraphilia that is causing distress or impairment to the individual or a paraphilia whereby satisfaction entailed personal harm, or risk of harm, to others. This distinction was made in an effort to identify those sexual behaviors and interests that are of clinical significance.


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