490 CHAPTER 11
Self-reports of arousal (psychological factor) are also used to assess paraphilic
disorders: Men describe what they fi nd sexually arousing, either to a mental health
clinician or in response to a questionnaire. Finally, assessment of paraphilias may
rely on reports from partners or the criminal justice system (social factor), when
men are apprehended for engaging in illegal sexual activity such as exhibitionism or
pedophilia (McAnulty, Adams, & Dillon, 2001).Criticisms of the DSM-IV-TR Paraphilias
Critics of the set of paraphilic disorders identifi ed in DSM-IV-TR point out that
such disorders are, in essence, behaviors and fantasies that Western culture cur-
rently labels as “deviant”; such deviance is relative to the current cultural concept
of “normal” sexual behavior or fantasies (Moser & Kleinplatz, 2005). Normal sex-
ual behavior typically has been defi ned by the church, the government, or the medi-
cal community. Moreover, labeling certain sexual behaviors or urges as deviant has
been done throughout history, although the specifi c behaviors or urges have varied
across cultures and over time. For instance, homosexuality, masturbation, and oral
sex have at various points in time in various cultures been considered unaccept-
able deviations from normal sexuality. Sexual deviations have been considered sin-
ful, criminal, or sick, and the responses to such deviations have included penitence,
punishment, or “cure” (McAnulty, Adams, & Dillon, 2001; Moser, 2001).
However, we must stress that, according to DSM-IV-TR, the issue isn’t simply
having unusual sexual interests, but rather that these interests or their related be-
haviors cause signifi cant distress or signifi cantly impair functioning (Moser, 2009).
Another criticism is that some sex crimes are included as just another type of
paraphilia. Such crimes that may meet the criteria for a paraphilia include exhibi-
tionism, voyeurism, frotteurism, pedophilia, and sexual sadism. As one researcher
in the fi eld points out:
Some sex crimes are not diagnoses (e.g., rape) and some Paraphilia diagnoses are not
crimes (e.g., Fetishism, Sexual Masochism, consensual Sexual Sadism, and Transvestic
Fetishism). Some sexual interests were both crimes and diagnoses, but are no longer
(e.g., homosexuality).... Some sexual behaviors were psychiatric disorders and were
believed to cause a variety of physical disorders, but are now considered healthy (e.g.,
masturbation).... What is defi ned as ‘‘normal’’ sexual behavior, what is a mental dis-
order, what is a crime, and what constitutes a sex crime do change over time.
(Moser, 2009, p. 324)
Including such a large range of diverse disorders limits the kinds of generaliza-
tions that can be made about the paraphilias. Specifi cally, the diagnosis of some of
the paraphilias depends on the fact that the object of desire does not consent to the
sexual interaction, whereas others paraphilias do not involve coercion—and may
not involve another person at all.
And even among patients with paraphilias that are directed toward noncon-
senting victims, we can further distinguish distinct groups of patients. For instance,
some patients prefer normal sexual activity but have deviant fantasies of coercing
others, which cause them distress; in contrast, other patients meet the criteria solely
because of their behavior (that is, they may molest children or sadistically rape
someone), but they may not feel any distress about this behavior. Both types of indi-
viduals would be diagnosed with a paraphilic disorder directed toward nonconsent-
ing partners (McAnulty, Adams, & Dillon, 2001).
Similarly, DSM-IV-TR does not take into consideration how well an individual
can overcome his urges and not engage in a paraphilic behavior. The capacity to
restrain the behavior should be particularly important with paraphilias that involve
nonconsenting partners. A man may have fantasies of exposing himself or fondling a
child, but if he is always able to restrain himself from acting out those fantasies, he is
not a danger to anyone; nevertheless, if his fantasies and urges cause him distress or
impair his ability to function, he would be diagnosed with pedophilia.
Finally, as we discuss in the following section, some researchers have suggested
that paraphilias should be considered a type of obsessive-compulsive disorder (OCD).