Coercive paraphilic disorder

Other Specified Paraphilic Disorder: Patterns of Use in Sexually Violent Predator Evaluations

"Sexually violent predator" (SVP) legislation requires, in part, that an individual has a mental abnormality that causes difficulty in controlling sexual behavior. Previous research has found paraphilia not otherwise specified (NOS) as one of the most prevalent diagnoses proffered in SVP evaluations. However, the fifth edition of the Diagnostic and Statistical Manual (DSM-5) modified paraphilia NOS diagnosis in two ways. First, this diagnosis was divided into two new diagnostic categories: other specified paraphilic disorder (OSPD) and unspecified paraphilic disorder. Second, OSPD required an added specifier to indicate the individual's source of sexual arousal. To date, no study has systematically explored how the revision to paraphilia NOS has affected diagnoses within SVP evaluations. The current study explored the frequency and diagnostic reliability of paraphilic disorders in a sample of 190 adult men evaluated for SVP civil commitment using the DSM-5. Results indicated that OSPD was the second most common paraphilic disorder, next to pedophilic disorder. However, there was poor to fair agreement (kappa = 0.21, p < .01) between independent evaluators in providing this diagnosis. Additionally, the two most common OSPD specifiers were non-consent and hebephilia, despite recent debate and rejection of these constructs from the DSM-5. While these constructs were the most prevalent, the specifiers contained quite varied terminology, suggesting vague diagnostic tendencies within these evaluations. Given that the presence of a mental abnormality is the cornerstone to the constitutionality of SVP commitment, diagnostic practices should be based in reliable and valid techniques.

Sexual Sadism Disorder and Coercive Paraphilic Disorder: A Scoping Review

BACKGROUND

Valid and reliable diagnostic criteria are essential in forensic psychiatry and sexual medicine due to the severe implications of potential misdiagnoses. One challenge in this field is the poor operationalization of sexual sadism disorder (SSD) and coercive paraphilic disorder (CP+) definitions.

AIM

The aim of this scoping literature review is to provide a comprehensive overview of the key conceptual differences between SSD and CP+, as well as consider pragmatic and clinically useful approaches to their diagnostic formulation.

METHODS

Arksey and O'Malley's methodological framework was followed. A literature search of Medline, PsychInfo, Web of Science, and Cumulative Index to Nursing and Allied Health Literature electronic databases was conducted. Publications in English describing the construct and/or operational definition of SSD or CP+ were included. Full-text studies were reviewed by 2 authors and data was charted and synthesized qualitatively.

RESULTS

The initial search provided 1,271 records, after which 120 full-text papers were considered for eligibility and 48 studies were ultimately included. The most common sources of definitions for SSD and CP+ were the Diagnostic and Statistical Manual of Mental Disorders (n = 53) and the International Classification of Disease (n = 12). There was more variation of terms used for CP+ than SSD. Both CP+ and SSD are critiqued by reviewed literature for having low validity, reliability, and consistency, as well as being conflated with sexual crime. SSD is better described due to having diagnostic criteria and validated diagnostic tools.

CLINICAL IMPLICATIONS

Currently, clinicians rely mostly on the DSM to diagnose SSD or CP+. As applications of SSD and CP+ definitions vary, interpretations may not be generalizable between clinicians. Furthermore, specific diagnoses may be practically unhelpful and unreliable. It may therefore be beneficial for treatment to be determined by risk of harm. In addition to these concerns, the stigma associated with SSD and CP+ may also impact treatment.

STRENGTHS & LIMITATIONS

Strengths of this study include duplicate review and charting to increase methodological rigor, transparent reporting to minimize publication bias, and encompassing a comprehensive scope. Limitations include the weaknesses of low strength of reviewed literature and risk of publication bias.

CONCLUSION

Despite their significant implications, the definitions of SSD and CP+ are inconsistent and lack reliability. Future research is necessary to develop stronger diagnostic criteria and tools. Liu A, Zhang E, Leroux EJ et al. Sexual Sadism Disorder and Coercive Paraphilic Disorder: A Scoping Review. J Sex Med 2022;000:1-11.

Psychoanalytic principles as a heuristic framework to bridge the gap between psychology and the law in SVP evaluations: Assessing emotional and volitional impairment

The legal concepts of emotional and volitional impairment in SVP evaluations are vague and ill-defined. This article reviews the legal terms of emotional and volitional impairment as they have been contemplated in extant SVP statutes, SVP case law, logical constructions, and limited empirical studies. To bridge the gap between psychiatry and the law, a broad, theory-based heuristic framework is furnished for understanding emotional and volitional impairment at a deep psychological (and intra-psychic) level. Specifically discussed are the concepts of transference, repetition compulsion, fixation, cathexis, regression, identification with the aggressor, and the object-relations and self-psychology concepts related to a loss of possession of the self.

Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms

The simultaneous revision of the two major international classifications of disease, the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, serves as an opportunity to observe the dynamic processes through which social norms of sexuality are constructed and are subject to change in relation to social, political, and historical context. This article argues that the classifications of sexual disorders, which define pathological aspects of "sexually arousing fantasies, sexual urges or behaviors" are representations of contemporary sexual norms, gender identifications, and gender relations. It aims to demonstrate how changes in the medical treatment of sexual perversions/paraphilias passed, over the course of the 20th century, from a model of pathologization (and sometimes criminalization) of non-reproductive sexual behaviors to a model that reflects and privileges sexual well-being and responsibility, and pathologizes the absence or the limitation of consent in sexual relations.

Pornography, sex crime, and paraphilia

The current paper reviews research findings concerning the association of pornography with sexual violence and paraphilic interests. Little clarity concerning the causal impact of pornography on sexual aggression or child-oriented sexual behavior has been achieved in the scientific literature. Laboratory experimentation demonstrates that violent pornography may contribute to antiwoman aggression, but the artificiality and constraints of the experimental setting severely limit generalization of these findings to real-world situations, and observational studies in natural settings consistently find no association or an inverse association of pornography with sexual aggression. In addition, although pedophiles often use child pornography, the causal impact of child pornography on child sexual offending is not conclusive. The current analysis considers the confluence of predisposing factors and pornography use as issues requiring clinical judgment in the reduction of sexual aggression and management of paraphilic interest in children.

Pragmatic and Darwinian views of the paraphilias

In this article, I discuss the question of the pathological nature of various sexual orientations and paraphilias and provide arguments for and against the inclusion of various paraphilias in future versions of the DSM. Practically, it is proposed that most of the paraphilias can be usefully conceptualized as involving sexual behaviors directed toward non-consenting individuals. From a Darwinian standpoint, it seems clear that at least some of the paraphilias should not be considered to be pathological because they are potentially associated with enhanced fitness.

Explaining the erectile responses of rapists to rape stories: the contributions of sexual activity, non-consent, and violence with injury

In phallometric research, rapists have a unique pattern of erectile responses to stimuli depicting sexual activities involving coercion and violence. In this study, we attempted to determine the cues that control rapists' erectile responses to rape stories in the laboratory. A total of 12 rapists and 14 non-rapists were exposed to recorded audio scenarios that systematically varied with regard to the presence or absence of three orthogonally varied elements: sexual activity and nudity, violence and injury, and expression of non-consent. As expected from prior research, an index computed by subtracting participants' greatest mean responses to stories describing mutually consenting sexual activity from their greatest mean responses to stories describing rape was much higher among rapists than non-rapists. Both groups showed larger responses when stories involved sexual activity and nudity, but neither group exhibited a preference for cues of violence and serious injury, or for cues of non-consent. The element that produced the larger group difference, however, was the presence or absence of active consent. The results indicated that a sexual interest in (or indifference to) non-consent is at least as central to accounting for the unique sexual orientation of rapists as is sexual responding to violence and injury.

Paraphilic Coercive Disorder in the DSM: the right diagnosis for the right reasons

The recommendation to include a Paraphilic Coercive Disorder (PCD) diagnosis in the DSM-5 represents an improvement over current options and would lead to the shrinking of the pool of individuals considered for detention as Sexually Violent Predators. A precise description of the diagnostic criteria for PCD would permit psychologists and psychiatrists to use more specific and narrow criteria for those who seek sexual gratification by coercing others to engage in unwanted sexual behavior. This might permit mental health professionals to abandon the Paraphilia NOS designation in favor of the more defined PCD in appropriate cases. Various critics have attacked the proposal on what appears to be misplaced ideological grounds. Not only should ideological concerns not play a part in a scientific debate, but the critics' predictions of how the PCD diagnosis would play out in the legal arena are likely wrong. Paraphilic Coercive Disorder would give the judicial system the best opportunity to most accurately identify the small group of men who have previously committed, and are likely in the future to commit, this type of predatory sexual violence.