DSM-5-TR Definition for 'Pedophilic Disorder - Changes and Commentary

[Chie]

Hey all.
I was able to acquire a digital copy of The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).

Changes are made to these books to be representative of the empirical consensus and serve as a base for practitioners, experts, researchers, for recognizing, understanding, and ultimately diagnosing mental disorders and other conditions. This is a standard and expected facet of the sciences, and psychological and psychiatric fields are no different.

The purpose of this thread is to document certain changes to their sections regarding ‘Pedophilic Disorder’ and provide personal commentary on it, as well as append commentary posted by others (whose commentary is ultimately more valuable than mine).

I’m not a researcher, but I read a lot and occasionally network with researchers and experts.

Here we go…

DSM-5 Definition

Pedophilic Disorder

Diagnostic Criteria 302.2 (F65.4)

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual
urges, or behaviors involving sexual activity with a prepubescent child or children
(generally age 13 years or younger).

B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause
marked distress or interpersonal difficulty.

C. The individual is at least age 16 years and at least 5 years older than the child or children
in Criterion A.
Note: Do not include an individual in late adolescence involved in an ongoing sexual
relationship with a 12- or 13-year-old.

Specify whether:

• Exclusive type (attracted only to children)
• Nonexclusive type

Specify if:

• Sexually attracted to males
• Sexually attracted to females
• Sexually attracted to both

Specify if:

• Limited to incest

Diagnostic Features

The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who
freely disclose this paraphilia and to individuals who deny any sexual attraction to prepubertal
children (generally age 13 years or younger), despite substantial objective evidence to the
contrary. Examples of disclosing this paraphilia include candidly acknowledging an intense
sexual interest in children and indicating that sexual interest in children is greater than or equal
to sexual interest in physically mature individuals. If individuals also complain that their sexual
attractions or preferences for children are causing psychosocial difficulties, they may be diagnosed
with pedophilic disorder. However, if they report an absence of feelings of guilt,
shame, or anxiety about these impulses and are not functionally limited by their paraphilic impulses
(according to self-report, objective assessment, or both), and their self-reported and legally
recorded histories indicate that they have never acted on their impulses, then these
individuals have a pedophilic sexual interest but not pedophilic disorder.

Examples of individuals who deny attraction to children include individuals who are
known to have sexually approached multiple children on separate occasions but who deny
any urges or fantasies about sexual behavior involving children, and who may further claim
that the known episodes of physical contact were all unintentional and nonsexual. Other individuals
may acknowledge past episodes of sexual behavior involving children but deny any
significant or sustained sexual interest in children. Since these individuals may deny experiences
impulses or fantasies involving children, they may also deny feeling subjectively distressed.
Such individuals may still be diagnosed with pedophilic disorder despite the absence
of self-reported distress, provided that there is evidence of recurrent behaviors persisting for
6 months (Criterion A) and evidence that the individual has acted on sexual urges or experienced
interpersonal difficulties as a consequence of the disorder (Criterion B).

Presence of multiple victims, as discussed above, is sufficient but not necessary for diagnosis;
that is, the individual can still meet Criterion A by merely acknowledging intense
or preferential sexual interest in children.

The Criterion A clause, indicating that the signs or symptoms of pedophilia have persisted
for 6 months or longer, is intended to ensure that the sexual attraction to children is
not merely transient. However, the diagnosis may be made if there is clinical evidence of
sustained persistence of the sexual attraction to children even if the 6-month duration cannot
be precisely determined.

Associated Features Supporting Diagnosis

The extensive use of pornography depicting prepubescent children is a useful diagnostic
indicator of pedophilic disorder. This is a specific instance of the general case that individuals
are likely to choose the kind of pornography that corresponds to their sexual interests.

Prevalence

The population prevalence of pedophilic disorder is unknown. The highest possible prevalence
for pedophilic disorder in the male population is approximately 3%–5%. The population
prevalence of pedophilic disorder in females is even more uncertain, but it is likely
a small fraction of the prevalence in males.

Development and Course

Adult males with pedophilic disorder may indicate that they become aware of strong or
preferential sexual interest in children around the time of puberty—the same time frame
in which males who later prefer physically mature partners became aware of their sexual
interest in women or men. Attempting to diagnose pedophilic disorder at the age at which
it first manifests is problematic because of the difficulty during adolescent development in
differentiating it from age-appropriate sexual interest in peers or from sexual curiosity.
Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years
older than the child or children in Criterion A.

Pedophilia per se appears to be a lifelong condition. Pedophilic disorder, however,
necessarily includes other elements that may change over time with or without treatment:
subjective distress (e.g., guilt, shame, intense sexual frustration, or feelings of isolation) or
psychosocial impairment, or the propensity to act out sexually with children, or both.
Therefore, the course of pedophilic disorder may fluctuate, increase, or decrease with age.

Adults with pedophilic disorder may report an awareness of sexual interest in children
that preceded engaging in sexual behavior involving children or self-identification as a pedophile.
Advanced age is as likely to similarly diminish the frequency of sexual behavior involving
children as it does other paraphilically motivated and normophilic sexual behavior.

Risk and Prognostic Factors

Temperamental.
There appears to be an interaction between pedophilia and antisociality,
such that males with both traits are more likely to act out sexually with children. Thus,
antisocial personality disorder may be considered a risk factor for pedophilic disorder in
males with pedophilia.

Environmental.
Adult males with pedophilia often report that they were sexually abused
as children. It is unclear, however, whether this correlation reflects a causal influence of
childhood sexual abuse on adult pedophilia.

Genetic and physiological.
Since pedophilia is a necessary condition for pedophilic disorder,
any factor that increases the probability of pedophilia also increases the risk of pedophilic
disorder. There is some evidence that neurodevelopmental perturbation in utero
increases the probability of development of a pedophilic interest.

Gender-Related Diagnostic Issues

Psychophysiological laboratory measures of sexual interest, which are sometimes useful in diagnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in
females, even when an identical procedure (e.g., viewing time) or analogous procedures (e.g., penile plethysmography and vaginal photoplethysmography) are available.

Diagnostic Markers

Psychophysiological measures of sexual interest may sometimes be useful when an individual’s
history suggests the possible presence of pedophilic disorder but the individual
denies strong or preferential attraction to children. The most thoroughly researched and
longest used of such measures is penile plethysmography, although the sensitivity and specificity
of diagnosis may vary from one site to another. Viewing time, using photographs of
nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic
disorder, especially in combination with self-report measures. Mental health professionals
in the United States, however, should be aware that possession of such visual stimuli, even
for diagnostic purposes, may violate American law regarding possession of child pornography
and leave the mental health professional susceptible to criminal prosecution.

Differential Diagnosis

Many of the conditions that could be differential diagnoses for pedophilic disorder also
sometimes occur as comorbid diagnoses. It is therefore generally necessary to evaluate the
evidence for pedophilic disorder and other possible conditions as separate questions.

Antisocial personality disorder.
This disorder increases the likelihood that a person who
is primarily attracted to the mature physique will approach a child, on one or a few occasions,
on the basis of relative availability. The individual often shows other signs of this
personality disorder, such as recurrent law-breaking.

Alcohol and substance use disorders.
The disinhibiting effects of intoxication may also
increase the likelihood that a person who is primarily attracted to the mature physique will
sexually approach a child.

Obsessive-compulsive disorder.
There are occasional individuals who complain about
ego-dystonic thoughts and worries about possible attraction to children. Clinical interviewing
usually reveals an absence of sexual thoughts about children during high states of
sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional
ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality).

Comorbidity

Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depressive,
bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic
disorders. However, findings on comorbid disorders are largely among individuals convicted
for sexual offenses involving children (almost all males) and may not be generalizable
to other individuals with pedophilic disorder (e.g., individuals who have never
approached a child sexually but who qualify for the diagnosis of pedophilic disorder on
the basis of subjective distress).

[Chie]

DSM-5-TR

Pedophilic Disorder

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).

B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A.
(Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.)

Specify whether:

• Exclusive type (attracted only to children)
• Nonexclusive type

Specify if:

• Sexually attracted to males
• Sexually attracted to females
• Sexually attracted to both

Specify if:

• Limited to incest

Diagnostic Features

The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who freely disclose this paraphilia and to individuals who deny any sexual attraction to prepubertal children (generally age 13 years or younger), despite substantial objective evidence to the contrary. The age guideline of 13 or younger is approximate only, because the onset of puberty varies from person to person, and there is good evidence the average age at onset of puberty has been declining over time and differs across ethnicities and cultures. Examples of disclosing this paraphilia include candidly acknowledging an intense sexual interest in children and indicating that sexual interest in children is greater than or equal to sexual interest in physically mature persons. If individuals also complain that their sexual attractions or preferences for children are causing marked distress or psychosocial difficulties, they may be diagnosed with pedophilic disorder. However, if they report an absence of feelings of guilt, shame, or anxiety about these impulses and are not functionally limited by their paraphilic impulses (according to self-report, objective assessment, or both), and their self-reported and legally recorded histories indicate that they have never acted on their impulses, then these individuals have a pedophilic sexual interest but not pedophilic disorder. When trying to differentiate child offenders with pedophilic disorder from child offenders without pedophilic disorder, factors that suggest a diagnosis of pedophilic disorder in the offender include self-reported interest in children, use of child pornography, a history of multiple child victims, boy victims, and unrelated child victims.

Examples of individuals who deny attraction to children include individuals who are known to have sexually approached multiple children on separate occasions but who deny any urges or fantasies about sexual behavior involving children, and who may further claim that the known episodes of physical contact were all unintentional and nonsexual. Other individuals may acknowledge past episodes of sexual behavior involving children but deny any significant or sustained sexual interest in children. Because these individuals may deny experiences, impulses, or fantasies involving children, they may also deny feeling subjectively distressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence of self-reported distress, provided that there is evidence of recurrent behaviors persisting for 6 months (Criterion A) and evidence that the individual has acted on sexual urges or experienced interpersonal difficulties as a consequence of the disorder (Criterion B). Behaviors include sexual interactions with children, whether or not they involve physical contact (e.g., some pedophilic individuals expose themselves to children). Although the use of sexually explicit content depicting prepubescent children is typical of individuals with pedophilic sexual interests and thus might contribute important information relevant to the evaluation of Criterion A, such behavior in the absence of the individual’s sexual interactions with children (i.e., acting on these sexual urges in person) is insufficient to conclude that Criterion B is met.

Presence of multiple victims, as discussed above, is sufficient but not necessary for diagnosis; that is, the individual can still meet Criterion A by merely acknowledging intense or preferential sexual interest in children.

Associated Features

Individuals with pedophilic disorder may experience an emotional and cognitive affinity with children, sometimes referred to as emotional congruencewith children. Emotional congruence with children can manifest in different ways, including preferring social interactions with children over adults, feeling like one has more in common with children than with adults, and choosing occupations or volunteer roles in order to be around children more often. Studies show that emotional congruence with children is related to both pedophilic sexual interest and the likelihood of sexually reoffending among individuals who have sexually offended.

Prevalence

The population prevalence of individuals whose presentations meet the full criteria for pedophilic disorder is unknown but is likely less than 3% among men in international studies. The population prevalence of pedophilic disorder in women is even more uncertain, but it is likely a small fraction of the prevalence in men.

Development and Course

Adult men with pedophilic disorder may indicate that they became aware of strong or preferential sexual interest in children around the time of puberty—the same time frame in which men who later prefer physically mature partners became aware of their sexual interest in women or men. Attempting to diagnose pedophilic disorder at the age at which it first manifests is problematic because of the difficulty during adolescent development in differentiating it from age-appropriate sexual interest in peers or from sexual curiosity. Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years older than the child or children in Criterion A.

Pedophilia per se appears to be a lifelong condition. Pedophilic disorder, however, necessarily includes other elements that may change over time with or without treatment: subjective distress (e.g., guilt, shame, intense sexual frustration, or feelings of isolation) or psychosocial impairment, or the propensity to act out sexually with children, or both. Therefore, the course of pedophilic disorder may fluctuate, or the intensity might increase or decrease with age.

Adults with pedophilic disorder may report an awareness of sexual interest in children that preceded engaging in sexual behavior involving children or self-identification as an individual with pedophilia. Advanced age is as likely to similarly diminish the frequency of sexual behavior involving children as it does other paraphilically motivated and nonparaphilic sexual behavior.

Risk and Prognostic Factors

Temperamental.
There appears to be an interaction between pedophilia and antisocial personality traits such as callousness, impulsivity, and a willingness to take risks without adequate regard for the consequences. Men with pedophilic interest and antisocial personality traits are more likely to act out sexually with children and thus qualify for a diagnosis of pedophilic disorder. Thus, antisocial personality disorder may be considered a risk factor for pedophilic disorder in males with pedophilia.

Environmental.
Adult men with pedophilia sometimes report that they were sexually abused as children. It is unclear, however, whether this correlation reflects a causal influence of childhood sexual abuse on adult pedophilia.

Genetic and physiological.
Since pedophilia is a necessary condition for pedophilic disorder, any factor that increases the probability of pedophilia also increases the risk of pedophilic disorder. There is some evidence that neurodevelopmental perturbation in utero increases the probability of development of a pedophilic interest.

Sex- and Gender-Related Diagnostic Issues

Laboratory measures of sexual interest, in terms of psychophysiological responses to sexual stimuli depicting children, which are sometimes useful in diagnosing pedophilic disorder in men, are not necessarily useful in diagnosing this disorder in women because there has been very limited research on the assessment of pedophilic sexual interest in women.

Diagnostic Markers

Psychophysiological measures of sexual interest may sometimes be useful when an individual’s history suggests the possible presence of pedophilic disorder but the individual denies strong or preferential attraction to children. The most thoroughly researched and longest used of such measures is penile plethysmography, although the sensitivity and specificity of diagnosis may vary across sites, which frequently use different stimuli, procedures, and scoring. Viewing time, using photographs of nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic disorder, especially in combination with self-report measures. U.S. clinicians, however, should be aware that possession of visual sexual stimuli depicting children, even for diagnostic purposes, may violate American law regarding possession of child pornography and leave the clinician susceptible to criminal prosecution. The option exists to use audio stimuli describing sexual interactions in penile plethysmography. Across psychophysiological methods, the diagnostic marker is relative sexual response to stimuli depicting children compared with stimuli depicting adults, rather than absolute response to child stimuli.

Differential Diagnosis

Pedophilia.
Individuals with pedophilia experience recurrent, intense, sexually arousing fantasies or sexual urges involving sexual activity with a prepubescent child or children. Unless the individual has acted on these sexual urges with a prepubescent child or unless the sexual urges or fantasies cause marked distress or interpersonal difficulty, a diagnosis of pedophilic disorder is not warranted.

Other paraphilic disorders.
Sometimes individuals present with a different paraphilic disorder but are referred for an evaluation regarding possible pedophilic disorder (e.g., when an individual with a diagnosis of exhibitionistic disorder exposes himself to children as well as adults). In some cases, both diagnoses may apply, whereas in others, it may be the case that one paraphilic disorder diagnosis is sufficient. For example, an individual who exposes himself exclusively to prepubescent children may have both exhibitionistic disorder and pedophilic disorder, whereas another individual who exposes himself to victims, irrespective of the victims’ age, may be considered to have only exhibitionistic disorder.

Antisocial personality disorder.
Some individuals with antisocial personality disorder sexually abuse children, reflecting the fact that the presence of antisocial personality disorder increases the likelihood that an individual who is primarily attracted to mature persons will approach a child sexually, on the basis of relative access to the child. An additional diagnosis of pedophilic disorder should only be considered if there is evidence that over a period of at least 6 months, the individual has also had recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child.

Substance intoxication.
The disinhibiting effects of substance intoxication may also increase the likelihood that an individual who is primarily attracted to mature persons will sexually approach a child.

Obsessive-compulsive disorder.
There are occasional individuals who complain about ego-dystonic thoughts and worries about possible attraction to children. Clinical interviewing usually reveals an absence of positive feelings about these thoughts, no connection between these thoughts and sexual behavior (e.g., masturbating to these thoughts), and sometimes additional ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality).

Comorbidity

Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depressive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic disorders. However, findings on comorbid disorders are largely among individuals convicted for sexual offenses involving children (almost all males) and may not be generalizable to other individuals with pedophilic disorder (e.g., individuals who have never approached a child sexually but who qualify for the diagnosis of pedophilic disorder on the basis of subjective distress).

[Chie]

The most notable change that pops out to me is the expanded ‘Differential Diagnosis’, a modification that actually stood out to Dr. Michael Seto, who even wrote a paper voicing his criticisms and recommendations over it.

I personally think it’s fine?
Given the papers I’ve read and what I’ve been able to surmise after working with and associating with MAPs, I think it’s VERY helpful that they actually clarified what constituted ‘acting on’ with regard to diagnosing Pedophilic Disorder, but I will state that I agree with parts of Dr. Seto’s criticisms, wherein he clarifies that consumption of CSEM IS problematic, given that real children are exploited to create it, and drawing a line between real versus virtual materials is relevant when conceptualizing problematic behavior.

The only thing I disagree with here is whether consumption of virtual/simulated child pornography is relevant to diagnosing pedophilia, since not all consumers of this content are pedophilic, in addition to his use of the oxymoron “fictional CSEM” (but that’s bordering along pedantry).

He also rightfully clarifies that the manner in which virtual pornography is treated in the United States and Canada, whereby in the United States, the legal environment is much more lenient compared to that of Canada, so it’s not as problematic for people to engage with since it’s effectively legal in most states, and at worst in a grey area (even after what had happened to Arthur).
But this tangent requires a more context-friendly reading.

(If anyone is interested in Mr. Seto’s full commentary on this change, you can either purchase it via the link, email the author directly, or DM me directly and I can see about sharing it openly).

[Chie]

I can safely say that the consensus seems to be more welcoming than it was years prior, like in years prior to the DSM-5 where no distinction was drawn between paraphilias and paraphilic disorders. I always feel so relieved when I see level-headed individuals within the scientific arena.

Pedophilia and DSM-5: The Importance of Clearly Defining the Nature of a...

Viewing child pornography should not be considered a useful diagnostic indicator of a Pedophilic Disorder. DSM-5 states that the “extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of a Pedophilic Disorder” (Ref. 1, p 698). Any diagnosis simply constitutes a way of conveying information in shorthand. For example, when a diagnosis of Diabetes, Schizophrenia, or Anorexia Nervosa is made, that diagnosis conveys a great deal of useful information to a properly trained physician. For that reason, it is critical that the information conveyed not be misleading, particularly in a forensic setting. Under current circumstances, a diagnosis of Pedophilic Disorder can infer a risk of hands-on offending with children. If the diagnosis is made largely on the basis of the use of child pornography, the inference may be inaccurate, with potentially unwarranted negative consequences for the individual.

…

Clinically (as opposed to forensically), making distinctions between fantasies (e.g., voyeuristic fantasies) and real-life intentions is frequently not difficult. Many men in therapy have acknowledged feeling sexually aroused by images depicting rape, and some women have acknowledged being sexually aroused by fantasies of being raped. That does not mean that most such men are likely to become rapists or that most such women actually want to become rape victims. With the advent of the Internet, distinguishing between private fantasies and public intentions constitutes an ongoing forensic concern. Even though viewing sexualized images of children is illegal, privately viewing such images and fantasizing about them does not necessarily reflect a real-life intent or interest in being sexual with a child.

This is something that I agree with but also disagree with, in theory. I agree with Dr. Berlin’s commentary, even in the case of viewing CSEM, it may not reliably or consistently correspond with an underlying intent or motivation to actually perpetrate hands-on offenses against children, though, as I said with regard to the relevant portion of Michael Seto’s commentary, I would have loved to see this variance more properly discussed and explored, if not alluded to, in future prints of the DSM-5-TR.

Real children are exploited and abused with the creation of CSEM, and its continued existence and circulation constitutes a problematic economy that is contingent on the sexual abuse and exploitation of real children. Fantasies and fiction, on the other hand, is not CSEM, and therefore does not promote child sex abuse.

[Angel]

Honestly, I don’t think it should be a part of the DSM at all really lol

[Chie]

Bumping this thread because I think it’s interesting.