Arch Sex Behav (2010) 39:1225-1227
L E T T E R T O T H E E D I T O R
Problems with Ascertainment
Published online: 23 July 2010
O Springer Science+Business Media, LLC 2010
The Paraphilias subworkgroup (PSWG; see Zucker, 2010) has
Homosexuality''(APA, 1980) referred to individuals who were
proposed a number of revisions for the fifth edition of the Diag-
distressed by their homosexual arousal pattern, but a homo-
nostic and Statistical Manual of Mental Disorders (DSM), to be
sexual arousal pattern was not (and is not) considered a mental
published by the American Psychiatric Association (APA). One
disorder. This diagnosis, which did not meet``the definition of a
supposedly new proposal is the recognition that the paraphilias are
disorder'' (Drescher, 2010, p. 435) was removed from the next
not ipso facto psychiatric disorders, but the existence of non-
edition of the DSM (see APA, 1987, p. 426), and thus``the APA
pathological unusual sexual interests was explicit and identical in
implicitly accepted a normal variant view of homosexuality''
both DSM-IV and DSM-IV-TR:
(Drescher, 2010, p. 435).
One of the arguments supporting the removal of Ego-
A Paraphilia must be distinguished from the nonpatho-
dystonic Homosexuality from the DSM was that its existence
logical use of sexual fantasies, behaviors, or objects as a
implied that other types of ego-dystonic characteristics were
stimulus for sexual excitement in individuals without a
also mental disorders. Distress or impairment related to one's
Paraphilia. Fantasies, behaviors, or objects are paraphilic
race, height, or normophilic sexual interests (e.g., ego-dys-
only when they lead to clinically significant distress or
tonic masturbation) could lead inappropriately to the creation
impairment (e.g., are obligatory, result in sexual dysfunc-
of new psychiatric disorders (see Drescher, 2010). It is not
tion, require participation of nonconsenting individuals,
clear why the DSM editors have not recognized that this argu-
lead to legal complications, interfere with social relation-
ment also applies to the Paraphilias.
ships). (APA, 1994, p. 525; APA, 2000, p. 568; boldfacing
Despite these problems, the PSWG seems intent on trying to
in both originals removed)
perpetuate the distinction between the interest versus the disorder
In practice, the distinction between pathological and non-
which results from the interest yet again. According to this pro-
pathological unusual sexual interests has been ignored.1 The
posal, individuals are to be ascertained with a paraphilia, which is
``pathological'' criteria often describe individuals with normo-
not a mental disorder. If the ascertained paraphilia ``causes'' dis-
philic sexual interests and do not distinguish normophilic indi-
tress or impairment, then the individual would be diagnosed with
viduals from individuals with a paraphilia (Moser & Kleinplatz,
a paraphilic disorder (see Blanchard, 2010), which would be
classified as a mental disorder.
The above differential diagnosis language was adopted after
The specific types of distress and impairment associated with
a similar attempt to distinguish a nonstandard sexual interest
paraphilic disorders have not been delineated (Moser, 2009).
from a mental disorder characterized by distress related to that
Apparently, the PSWG believes the distress must result from
interest was abandoned. The diagnosis of ``Ego-dystonic
the sexual interest itself. Classifying a disorder according to the
precipitant of the distress, rather than the characteristics of the
C. Moser (&)
Department of Sexual Medicine,
1 This Letter focuses on the non-criminal paraphilias (fetishism, partial-
Institute for Advanced Study of Human Sexuality,
ism, sexual masochism, consensual sexual sadism, and transvestism). The
45 Castro Street, #125, San Francisco, CA 94114, USA
reader should not construe the present Letter to support the decriminaliza-
tion of any sex crime.
Arch Sex Behav (2010) 39:1225-1227
distress produced, confuses the meaning of a mental disorder; it
inappropriate to diagnose both clinical depression and a para-
focuses the treatment away from the distress to whatever pre-
cipitated the distress. Becoming unemployed may result in dis-
Those with paraphilic interests could also be disadvantaged
tress for many individuals, but``unemployment disorder''is not a
even if they do not seek mental health treatment. For example, in
a child custody proceeding, an estranged spouse could expose
Assuming the distress or impairment resolves, would the
the other spouse's ascertained paraphilia to those evaluating
individual's status revert to paraphilic ascertainment, a para-
parental fitness. The distress from the exposure of one's sexual
philic disorder in remission, or continue with the paraphilic
interests, the impending divorce, or the fear of losing custody of
disorder diagnosis? An update on the DSM-5 website suggests
the child may now satisfy the distress or impairment criterion for
that the PSWG is leaning towards the ``In Remission'' option
a paraphilic disorder. An individual with a diagnosed paraphilic
(APA, 2010), which confuses the goals of treatment. Is it the
disorder, or even an ascertained paraphilia, can be seen as a less
remission of the ascertained paraphilia or remission of the
suitable parent and lose custody (Klein & Moser, 2006).
distress or impairment associated with the paraphilic disorder?
It is reasonable to assume that those individuals whose
Usually, the``In Remission''specifier is applied to mental dis-
distress or impairment is associated with their paraphilic inter-
orders with characteristic relapsing courses, but which aspect
ests have a mental disorder or might benefit from treatment, but
of diagnosis is expected to relapse (the ascertained interest or
this reintroduces the problems associated with the Ego-dys-
the diagnosed distress or impairment)?
tonic Homosexuality diagnosis. There is no proposal to ascer-
The creation of the ascertainment category does not imply
tain homosexual (or heterosexual) interests. Individuals who
that the ascertained individual is healthy--only that the indi-
have distress or impairment related to normophilic interests
vidual does not meet the definition of a mental disorder yet.
can be diagnosed with the less stigmatizing Adjustment Dis-
Whether the ``patient'' indicates the sexual interest causes the
order, Identity Problem, or Sexual Disorder NOS, without speci-
distress or impairment is not germane to the diagnosis. It is the
fying the problematic interest. No empirical evidence or ratio-
mental health professional who``ascertains''the diagnosis. Most
nale is given to support the different treatment of distress or
people seek mental health treatment because they are experi-
impairment for normophilic versus paraphilic interests.
encing distress or impairment in some form. It is difficult to
It can be argued that the option of ascertainment represents
imagine that unusual sexual interests, denigrated by society,
a political compromise between the status quo and the formal
would not add to the distress or impairment resulting from an
removal of the paraphilias from DSM-5, analogous to the com-
unrelated problem. Thus, the distinction between ascertaining a
promise which replaced Homosexuality with Ego-dystonic
paraphilic interest and diagnosing a disorder could be mean-
Homosexuality (Drescher, 2010). Nevertheless, political com-
ingless in practice.
promises should not override the current state of the science.
Blanchard (2010) suggests that once an individual is ascer-
The DSM editors and PSWG should indicate clearly the data on
tained with a paraphilia, then that ascertainment can continue
which they base their decisions. If the data exist, they should be
even if the intense and recurrent sexual arousal is no longer
presented. If the data do not exist, that should be stated unam-
present. If one can have a paraphilia without the requisite intense
biguously. The lack of empirical data supporting the proposed
and recurrent sexual arousal, then a paraphilic disorder without
changes or the continued pathologizing of the paraphilias in the
current distress or impairment also may exist. The duration of
DSM is a glaring omission in a supposedly scientific document.
the distress or impairment is not indicated and it is common for
I object strongly to PSWG member Langstrom's (2010)
individuals with paraphilic (or homosexual) interests to expe-
statement,``I am not convinced that psychiatric nosology should
rience some distress as part of the ``coming out'' process. A
change primarily because of the potential or actual misuse of
moment of angst could label someone as mentally disordered
diagnoses in the judicial system'' (p. 323). It clearly is psychi-
atry's responsibility to minimize the misuse of its diagnoses; a
Societal discrimination against lesbians, gays, and bisexuals
basic dictum of all medicine is ``First, do no harm.'' The use-
is known to increase the incidence of non-sexual psychiatric
fulness of the paraphilic disorder diagnoses (or ascertainments)
disorders in these individuals (Hatzenbuehler, McLaughlin,
must be weighed against the damage from their misuse to justify
Keyes, & Hasin, 2010). Assuming societal discrimination has a
their continued listing in the DSM-5. Why should psychiatry be
similar effect on individuals ascertained with a paraphilia, one
exempt from these risk-benefit analyses?
should not diagnose a paraphilic disorder in addition to non-
It is clear that the paraphilic disorder diagnoses have been
sexual psychiatric diagnoses. If the revelation of someone's
misused (Klein & Moser, 2006; Kolmes, Stock, & Moser, 2006;
homosexual (or heterosexual) interests precipitates the disso-
Wright, 2006). The usefulness of these diagnoses is not apparent
lution of his or her primary relationship resulting in a clinical
and the arguments defending their usefulness are egregiously
depression, most mental health professionals would diagnose
absent. From a historical perspective, it is doubtful that the cre-
just the clinical depression. If the dissolution was precipitated
ation of the ascertainment category will prevent further misuse
by the revelation of his or her paraphilic interests, it seems
of these diagnoses. It appears the concept of ascertainment will
Arch Sex Behav (2010) 39:1225-1227
confuse rather than clarify the issues with these diagnoses. If
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