As DSM-5 prepares to make important decisions on diagnostic criteria regarding the paraphilias, we are likely to see more and more articles published. Specifically, expect to see several articles each on Paraphilic Coercion, Pedohebephilia, and Hypersexuality.
Familiar civil commitment personalities Dr. Henry Richards (ex of the Washington SVP program) and Dr. Rebecca (Becky) Jackson (presently in the South Carolina SVP program) offer us an interesting article on “Behavioral discriminators of sexual sadism and paraphilia nonconsent in a sample of civilly committed sexual offenders,” just published in our stable-mate the
International Journal of Offender Therapy and Comparative Criminology (Volume 55, Issue 2, pp. 207-227).
Link to abstract.
Drs. Richards and Jackson examined the offense behaviors of 39 SVPs diagnosed with Sexual Sadism to a group of 39 SVPs diagnosed with Paraphilia Not Otherwise Specified—Nonconsent. As many readers will know, the Paraphilia NOS issue is quite contentious these days; particularly, in the run-up to DSM-5. On the one hand, we have many SVP evaluators who frequently use NOS to categorize coercive sexuality, while on the other we have those who claim this is a “made up” diagnosis with no basis in fact. Many on both sides point to the need for field trial research and some sort of scientific underpinning of the diagnostic frameworks for paraphilias in the DSM.
Interestingly, field trials have never been a big part of the establishment of diagnostic criteria for the paraphilias. Current Paraphilias Subworkgroup Chair Ray Blanchard tells me that in the entire history of the DSM, only three subjects have ever been put forward as “field trial subjects” regarding the paraphilias. This strikes me as odd, and I hope it does you as well. Here’s a selection of quotes from Dr. Blanchard’s recent Letter to the Editor of the
Archives of Sexual Behavior:
The field trials for DSM-III, which were sponsored by the National Institute of Mental Health, included three patients with paraphilias … That’s it … The implication of this brief history is simple: Any comparisons, made up to this time, of the DSM-IV-TR diagnostic criteria and the proposed DSM-5 criteria have been based, not only on speculations about how the proposed criteria would perform but also on speculations about how the existing criteria have performed.
In short, all bluster aside about what diagnoses belong and which ones don’t, there is little empirical support (by way of field trial research) for any of the paraphilia frameworks. Of course, that doesn’t take into consideration all the other fine research done looking at the epidemiological aspects of paraphilic presentations. However, this is what Dr. Blanchard has to say about that:
The amount of available information regarding the diagnostic criteria proposed for DSM-5 is already equal to, or perhaps greater than, the amount of information about the existing criteria.
A great deal of the aforementioned controversy in the lead-up to DSM-5 surrounds the apparent “over-use” of the Not Otherwise Specified qualifier regarding “nonconsent” and “adolescent victims” in civil commitment proceedings. In the absence of clear diagnostic frameworks, it would appear that SVP evaluators have used NOS as a way to diagnose difficult sexual behavior patterns not clearly described by existing diagnostic criteria. As noted above, it would appear that some of the literature supports this process, while other papers are condemning of the practice. As I understand it, the
DSM-5 Subworkgroup’s intent in revising the criteria is to increase diagnostic precision in all areas regarding paraphilias. This will, perhaps, also have a beneficial side-effect of clearing up some of the NOS grey space, but that is not what the Subworkgroup is specifically aiming to do.
Back to Drs. Richards and Jackson…
Specifically regarding the distinction between NOS Nonconsent and Sexual Sadism, these authors do a fine job of summarizing the existing literature. Very briefly, the existing literature suggests that reliable distinction between sadism and paraphilic coercion is difficult, except in extreme cases where the former is quite obvious. My understanding of all this is that there are “high specificity indicators” (e.g., mutilation, choking, gratuitous violence) that seem to resonate more with a diagnosis of Sexual Sadism, and then there are “low specificity indicators” (e.g., instrumental violence, degradation, confinement) that are, perhaps, more indicative of paraphilic coercion (sometimes referred to as “paraphilic rape”) referred to in this paper as Paraphilia Nonconsent. Admittedly, the research on this high/low specificity distinction is also less than clear.
In the Richards and Jackson study, factors that seemed to differentiate the NOS nonconsent and Sexual Sadism groups were:
+ careful planning of the offense (SS > NOS)
+ duration of at least 90 minutes (SS > NOS)**
+ manual masturbation of male victim (SS > NOS)
+ sexual dysfunction during the offense (NOS > SS)
+ forced oral sex (SS > NOS)
+ cutting/stabbing during sexual act (SS > NOS)
+ violence during sexual act (SS > NOS) **
+ use of physical restraints (SS > NOS) **
+ use of threats to evoke fear (SS > NOS)
+ attempts to verbally calm or comfort victim (SS > NOS)
+ any facial injury (NOS > SS)
These results seem to line up reasonably well with my high and low specificity idea, at least as far as the more significantly violent and “sadistic” elements seem to be more prevalent in those judged a priori as Sexual Sadists.
In the absence of reliable self-report and/or phallometric evidence, evaluators may misinterpret violence as being sexually motivated and hence incorrectly assign a diagnosis of sexual sadism.
Drs. Richards and Jackson note that the three noted above with ** were commonly associated with Sexual Sadism, both across studies and in the current one. They attempt to make distinctions between violence for violence’s sake and violence in the furtherance of another agenda (i.e., to facilitate a rape).
…it is likely that prolonged and excessive control, going beyond what is needed to effect the rape, is a means of inducing humiliation and displaying the power of the assailant and represents an important dimension of sadism that may not be present in nonsadistic rapes.
In the Conclusion of their paper, Drs. Richards and Jackson reiterate that certain factors appear to assist in discriminating between NOS nonconsent and Sexual Sadism:
Differences suggest that certain behaviors, particularly severe violence, efforts to exert control over one’s victim, and fear-provoking threats during a sexual assault, are especially characteristic of [Sexual Sadism].
They encourage evaluators to exercise caution, however, in equating any violence with sadism, noting that many of the non-sadists in their study also used a degree of violence. They suggest that it may be more profitable to look at the timing of the violence and the offender’s reaction to it.
In their closing statements, they issue an often-read caveat: The findings are hampered by small sample sizes; the implication being that further research is needed. Field trial research as to the utility of diagnostic frameworks is particularly needed, in light of the interesting revelations made by Dr. Blanchard in his letter, as highlighted above.
And, in some late breaking news ...
Dr. Blanchard just emailed me to say:
The updated DSM5 Website went live at midnight, announcing various updates and soliciting another round of public commentary. See
http://www.dsm5.orgThere were two changes concerning the paraphilias.
- Hypersexual Disorder and Paraphilic Coercive Disorder are described as being considered for the Appendix.
- Hypersexual Disorder is grouped with the Sexual Dysfunctions rather than the Paraphilias.
