Is a diagnostic category for paraphilic coercive disorder defensible?

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.

Aggressive sexual fantasy frequency outperforms other characteristics in cross-sectionally predicting self-reported sexual aggression in 4 samples

BACKGROUND

Aggressive sexual fantasies (ASFs) have consistently been associated with sexual aggression measures. ASF frequency has mostly been used to indicate ASF, but other ASF characteristics may be important to explain the apparent gap between alleged high lifetime prevalence rates of ASF and lower sexual aggression rates-that is, why ASFs are only sometimes put into action.

AIM

The present study therefore examined whether additional ASF characteristics show associations with sexual aggression measures above and beyond ASF frequency to identify the most relevant ASF characteristics.

METHODS

The present study is based on cross-sectional survey data from 4 independent mostly community samples with 448, 131, 758, and 415 participants to examine whether ASF elaboration, intrusion, preoccupation, context, and consent were associated with self-reported sexual aggression measures beyond ASF frequency.

OUTCOMES

Self-reported sexual aggression measures included presumably consensual and nonconsensual sexual sadism, self-reports on acting on ASF, sexual harassment, use of coercive strategies, and rape proclivity.

RESULTS

The results showed positive correlations among all ASF characteristics. ASF frequency was the most consistent and often strongest predictor of sexual aggression across samples and outcome measures. ASF elaboration and/or its interaction with ASF frequency added to this prediction in study 1 but not in study 2. All other ASF characteristics in studies 1 to 4 either did not add to the predictions or yielded results contrary to expectations, mostly suggesting suppressor effects.

CLINICAL IMPLICATIONS

Sexual medicine and forensic sexology researchers may want to consider ASF frequency in diagnostics and develop and refine interventions to reduce it in cases of clearly elevated levels.

STRENGTHS AND LIMITATIONS

The strengths of the present study include considering 4 independent samples as well as a large number of ASF characteristics and sexual aggression measures. Its limitations include the reliance on cross-sectional data and not being able to examine the potential influences of all ASF characteristics in a single model.

CONCLUSION

ASF frequency seems the most valid and reliable indicator of ASF and the most important associate of sexual aggression. It should be considered the main indicator of ASF by future research and in prevention efforts and risk assessment.

Psychological and Developmental Correlates of Paraphilic and Normophilic Sexual Interests

The classification of sexual fantasies and behaviors (here referred to as 'sexual interests') has historically been divided into 'paraphilic' and 'normophilic'. However, studies on paraphilic interests are often limited to clinical or forensic samples and normophilic interests are rarely assessed in tandem. Previous research has found mixed results for psychological and other correlates of sexual interests, potentially due to inconsistency in operationalism and measurement of fantasies and behaviors. The aim of the current study was to quantify correlates of sexual interests via the Sexual Fantasies and Behaviors Inventory, containing factors related to general fantasies/behaviors, normophilia, power dynamics, sadomasochism, and courtship paraphilias, using a large (N = 4280) non-clinical sample. Psychological, developmental, sexual, and demographic correlates were investigated via bivariate correlations, mean difference testing, and multiple regression. Sexual interest domains were largely unrelated to psychopathology and developmental factors. Sociosexuality and more accepting attitudes towards sadomasochism was generally related to more arousal to/engagement in normophilic and paraphilic domains. More autism spectrum disorder traits were related to decreased normophilic interests. Psychopathic traits, sexual sensation seeking, and sexual compulsivity were related to paraphilia dimensions, especially courtship paraphilias and domination/sadism; the former was also associated with negative attitudes about establishing consent. Men, non-monogamous, and non-heterosexual participants indicated greater sexual fantasies and behaviors compared to women (except in the case of submission and masochism), monogamous, and heterosexual participants, respectively.

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.

Aggression-Related Sexual Fantasies: Prevalence Rates, Sex Differences, and Links With Personality, Attitudes, and Behavior

BACKGROUND

Aggression-related sexual fantasies (ASF) are considered an important risk factor for sexual aggression, but empirical knowledge is limited, in part because previous research has been based on predominantly male, North-American college samples, and limited numbers of questions.

AIM

The present study aimed to foster the knowledge about the frequency and correlates of ASF, while including a large sample of women and a broad range of ASF.

METHOD

A convenience sample of N = 664 participants from Germany including 508 (77%) women and 156 (23%) men with a median age of 25 (21-27) years answered an online questionnaire. Participants were mainly recruited via social networks (online and in person) and were mainly students. We examined the frequencies of (aggression-related) sexual fantasies and their expected factor structure (factors reflecting affective, experimental, masochistic, and aggression-related contents) via exploratory factor analysis. We investigated potential correlates (eg, psychopathic traits, attitudes towards sexual fantasies) as predictors of ASF using multiple regression analyses. Finally, we examined whether ASF would positively predict sexual aggression beyond other pertinent risk factors using multiple regression analysis.

OUTCOMES

The participants rated the frequency of a broad set of 56 aggression-related and other sexual fantasies, attitudes towards sexual fantasies, the Big Five (ie, broad personality dimensions including neuroticism and extraversion), sexual aggression, and other risk factors for sexual aggression.

RESULTS

All participants reported non-aggression-related sexual fantasies and 77% reported at least one ASF in their lives. Being male, frequent sexual fantasies, psychopathic traits, and negative attitudes towards sexual fantasies predicted more frequent ASF. ASF were the strongest predictor of sexual aggression beyond other risk factors, including general aggression, psychopathic traits, rape myth acceptance, and violent pornography consumption.

CLINICAL TRANSLATION

ASF may be an important risk factor for sexual aggression and should be more strongly considered in prevention and intervention efforts.

STRENGTHS AND LIMITATIONS

The strengths of the present study include using a large item pool and a large sample with a large proportion of women in order to examine ASF as a predictor of sexual aggression beyond important control variables. Its weaknesses include the reliance on cross-sectional data, that preclude causal inferences, and not continuously distinguishing between consensual and non-consensual acts.

CONCLUSION

ASF are a frequent phenomenon even in in the general population and among women and show strong associations with sexual aggression. Thus, they require more attention by research on sexual aggression and its prevention. Bondü R, Birke JB, Aggression-Related Sexual Fantasies: Prevalence Rates, Sex Differences, and Links With Personality, Attitudes, and Behavior. J Sex Med 2021;18:1383-1397.

What is a mental disorder? An exemplar-focused approach

The question of 'what is a mental disorder?' is central to the philosophy of psychiatry, and has crucial practical implications for psychiatric nosology. Rather than approaching the problem in terms of abstractions, we review a series of exemplars - real-world examples of problematic cases that emerged during work on and immediately after DSM-5, with the aim of developing practical guidelines for addressing future proposals. We consider cases where (1) there is harm but no clear dysfunction, (2) there is dysfunction but no clear harm, and (3) there is possible dysfunction and/or harm, but this is controversial for various reasons. We found no specific criteria to determine whether future proposals for new entities should be accepted or rejected; any such proposal will need to be assessed on its particular merits, using practical judgment. Nevertheless, several suggestions for the field emerged. First, while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation. Second, while dysfunction is useful for defining mental disorder, the field would benefit from more sharply defined indicators of dysfunction. Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments.

Altruistic (costly) punishment as motivation for vindictive rape

This paper presents a model of vindictive rape based on common mechanisms for maintaining cooperation among humans, namely altruistic (or costly) punishment, sex role expectations, and retributive (“eye for an eye”) justice. Vindictive rapes are characterized by high level of victim harm without explicit sadistic sexual interests. They are also distinguished from angry, reactive sexual aggression in response to personal insult or threats. In this model, vindictive rape is considered a form of retributive justice in which the perpetrator punishes the female victim for perceived transgressions against sexual norms. None of the specific psychological mechanisms are intrinsically problematic. Nevertheless, individuals who have committed vindictive rapes would still be expected to have risk-relevant schema worthy of interventions. For such individuals, the primary treatment targets would be loosening rigid sexual norm expectations for women, increasing confidence in conventional methods of maintaining social order, and decreasing willingness to hurt others at the cost of hurting oneself. A 15-item Vindictive Rape Attitude Questionnaire is presented in order to facilitate further research on the topic.

The admissibility of other specified paraphilic disorder (non-consent) in sexually violent predator proceedings

Following the advent of sexually violent predator (SVP) legislation in the early 1990s, forensic evaluators began to apply diagnostic labels related to a paraphilic interest in rape as a mental condition predisposing individuals convicted of sexual offenses to recidivate. The most recent iteration of the concept, other specified paraphilic disorder (non-consent) (OSPD (non-consent)), is a commonly utilized diagnostic entity in SVP proceedings. Research on paraphilic interest in coercive sex has failed to define a valid methodology or set of criteria to make a diagnosis of OSPD (non-consent) and has repeatedly demonstrated that the diagnostic construct has poor interrater reliability. The state of the science pertaining to OSPD (non-consent) thus raises serious concerns regarding its admissibility in SVP proceedings. Indeed, there are recent cases in which courts have deemed it inadmissible. The forensic expert involved in SVP proceedings should understand admissibility concerns related to OSPD (non-consent) and how to address them in court.

Expanding Statistical Frontiers in Sexual Science: Taxometric, Invariance, and Equivalence Testing

Sexual scientists must choose from among myriad methodological and analytical approaches when investigating their research questions. How can scholars learn whether sexualities are discrete or continuous? How is sexuality constructed? And to what extent are sexuality-related groups similar to or different from one another? Though commonplace, quantitative attempts at addressing these research questions require users to possess an increasingly deep repertoire of statistical knowledge and programming skills. Recently developed open-source software offers powerful yet accessible capacity to researchers wishing to perform strong quantitative tests. Taking advantage of these new statistical opportunities will require sexual scientists to become familiar with new analyses, including taxometric analysis, tests of measurement variability and differential item functioning, and equivalence testing. In the current article, I discuss each of these analyses, providing conceptual and historical overviews. I also address common misunderstandings for each analysis that may discourage researchers from implementing them. Finally, I describe current best practices when using each analysis, providing reproducible coding examples and interpretations along the way, in an attempt to reduce barriers to the uptake of these analyses. By aspiring to explore these new statistical frontiers in sexual science, sexuality researchers will be better positioned to test their substantive theories of interest.

Convergent Validity of Three Measures of Sexual Sadism: Value of a Dimensional Measure

Sexual sadism can be described as the sexual pleasure produced by acts of cruelty and bodily punishment. The most common method for evaluating sexual sadism is clinical evaluation, that is, evaluation based on the diagnostic criteria of nosological instruments such as the Diagnostic and Statistical Manual of Mental Disorders ( DSM) or the International Classification of Diseases (ICD). It is also possible to evaluate sadistic sexual preferences by phallometry, which provides a physiological measure of sexual excitation by deviant and nondeviant scenarios. The most recently developed evaluation method is the Severe Sexual Sadism Scale (SESAS), a dimensional instrument that has been empirically validated. Despite the availability of all these measurement techniques, very little research has been conducted on their degree of convergence. Consequently, the aim of the current study was to assess the relationship between these three measures of sexual sadism. Our analyses were conducted on a sample of rapists ( N = 72), assessed in a maximum-security penitentiary. There was no significant relation between phallometric scores and other measures of sexual sadism. There was, however, an important correlation between SESAS scores and Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) sexual sadism diagnosis. Our results are consistent with other phallometric studies, which reported no difference in the penile responses of individuals diagnosed as sadists and those not diagnosed as sadists. Results and implications for future research are discussed.

Sadistic Offender or Sexual Sadism? Taxometric Evidence for a Dimensional Structure of Sexual Sadism

Severe sexual sadism is a disorder of sexual preferences that focuses on humiliation and domination of the victim, sometimes causing grievous injury or death. Because offenders with high levels of sadism represent a risk to both reoffend and cause considerable harm should they reoffend, a diagnosis of sexual sadism has serious implications. The actual diagnosis of sexual sadism is fraught with problems (i.e., low reliability and validity) and exhibits poor consistency across assessments and studies (Levenson, 2004; Marshall, Kennedy, & Yates, 2002a). Various authors have proposed that sadism should be reconceptualized and have suggested that a dimensional approach may be more effective than a classificatory one for diagnosing sexual sadism (e.g., Marshall & Kennedy, 2003; Nietschke, Osterheider, & Mokros, 2009b). The dimension versus taxon question also impacts debates about the etiology and treatment of sadism. We assessed the taxonicity of sexual sadism by conducting a taxometric analysis of the scores of 474 sex offenders from penitentiary settings on the MTC Sexual Sadism Scale, using Meehl's taxometric methods (Meehl & Yonce, 1994; Waller & Meehl, 1998). Findings indicated that sexual sadism presents a clear underlying dimensional structure. These results are consistent with earlier research supporting a dimensional assessment of sexual sadism and indicate that the diagnosis of sexual sadism should be reconceptualized. The theoretical and clinical implications of these findings are discussed.

MTC Sadism Scale: Toward a Dimensional Assessment of Severe Sexual Sadism With Behavioral Markers

Sadism was initially described as the experience of sexual pleasure produced by acts of cruelty and bodily punishment. Sadism was conceptualized as if sadists were fundamentally different from nonsadists. Recent studies have suggested that sadism is distributed as a dimension rather than as a category. The aim of the current study was to assess the psychometric properties the MTC Sexual Sadism Scale. Our analyses were conducted on a sample of 486 sexual offenders assessed at a correctional institution in Massachusetts. In summary, the results indicate that the MTC Sexual Sadism Scale possesses good psychometric properties for the dimensional assessment of severe sexual sadism with behavioral markers. Moreover, the scale captures a wide range of intensity of sadism among sexual offenders. These results are consistent with prior research and support the current consensus to move toward a dimensional interpretation of sadism. Implications both for clinical assessment and for research on the development of sadism are discussed.

Sadism and Violent Reoffending in Sexual Offenders

A diagnosis of sadism in sexual offenders is commonly regarded as indicative of high risk for violent reoffending. The purpose of the current two studies was to evaluate whether sadism is indeed associated with higher rates of violent (including sexual) reoffending. In Study 1 (meta-analysis), the rate of violent and sexual recidivism was assessed across seven samples of male sex offenders (total N = 2,169) as a function of diagnoses of sexual sadism. In Study 2 (N = 768) the outcome (violent recidivism yes/no) was regressed on sadism, along with behavioral indicators of sexually sadistic offending, and scores from violence risk assessment instruments. In Study 1 (meta-analysis), the overall risk of sadists compared with nonsadists with respect to violent (including sexual contact) reoffending was slightly elevated (by a factor of 1.18), yet not significantly increased. Similarly, the risk of sexual reoffending among sadists was slightly, but not significantly, higher than among nonsadists (factor 1.38). According to Study 2, only a measure of sadistic behavior, not the clinical diagnosis, was associated with violent reoffending. This association, however, was not present once age and customary risk assessment instruments for violence risk were included in the regression. A clinical diagnosis of sexual sadism and behavioral measures of sadism are related to the risk of violent reoffending in sexual offenders. These associations, however, are weak and do not hold once variables relevant for the prediction of violence are controlled for. At the individual level, the risk for future violence in sadists can therefore be adequately described by customary risk assessment instruments.

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.

Relating sexual sadism and psychopathy to one another, non-sexual violence, and sexual crime behaviors

Sexual sadism and psychopathy have been theoretically, clinically, and empirically linked to violence. Although both constructs are linked to predatory violence, few studies have sought to explore the covariation of the two constructs, and even fewer have sought to conceptualize the similarities of violence prediction in each. The current study considered all four Psychopathy Checklist-Revised (PCL-R) facets and employed well-defined, validated measures of sadism to elucidate the relation between sadism and psychopathy, as well as to determine the role of each in the prediction of non-sexual violence and sexual crime behaviors. Study 1 assessed 314 adult, male sex offenders using archival ratings, as well as the self-report Multidimensional Inventory of Development, Sex, and Aggression (the MIDSA). Study 2 used archival ratings to assess 599 adult, male sex offenders. Exploratory and confirmatory factor analyses of crime scene descriptions yielded four sexual crime behavior factors: Violence, Physical Control, Sexual Behavior, and Paraphilic. Sadism and psychopathy covaried, but were not coextensive; sadism correlated with Total PCL-R, Facet 1, and Facet 4 scores. The constructs predicted all non-sexual violence measures, but predicted different sexual crime behavior factors. The PCL-R facets collectively predicted the Violence and Paraphilic factors, whereas sadism only predicted the Violence factor.

Paraphilias: definition, diagnosis and treatment

There is a great deal of controversy concerning paraphilia, and defining what is normal versus deviant or disordered, given that this is to some degree dependent on cultural views of acceptability. In this article, we outline these issues and describe recent progress in diagnosing and treating paraphilias.

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.

Pedophilia: a diagnosis in search of a disorder

This article presents a critical review of the recent controversies concerning the diagnosis of pedophilia in the context of the preparation of the fifth edition of the DSM. The analysis focuses basically on the relationship between pedophilia and the current DSM-IV-TR's definition of mental disorder. Scholars appear not to share numerous basic assumptions ranging from their underlying ideas about what constitutes a mental disorder to the role of psychiatry in modern society, including irreconcilable theories about human sexuality, which interfere with reaching any kind of a consensus as to what the psychiatric status of pedophilia should be. It is questioned if the diagnosis of pedophilia contained in the DSM is more forensic than therapeutic, focusing rather on the dangers inherent in the condition of pedophilia (dangerous dysfunction) than on its negative effects for the subject (harmful dysfunction). The apparent necessity of the diagnosis of pedophilia in the DSM is supported, but the basis for this diagnosis is uncertain.

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.

Hebephilia: quintessence of diagnostic pretextuality

Hebephilia is an archaic term used to describe adult sexual attraction to adolescents. Prior to the advent of contemporary sexually violent predator laws, the term was not found in any dictionary or formal diagnostic system. Overnight, it is on the fast track toward recognition as a psychiatric condition meriting inclusion in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This article traces the sudden emergence and popularity of hebephilia to pressure from the legal arena and, specifically, to the legal mandate of a serious mental abnormality for civil commitment of sex offenders. Hebephilia is proposed as a quintessential example of pretextuality, in which special interests promote a pseudoscientific construct that furthers an implicit, instrumental goal. Inherent problems with the construct's reliability and validity are discussed. A warning is issued about unintended consequences if hebephilia or its relative, pedohebephilia, make their way into the DSM-5, due out in 2013.