Paraphilic Disorders

In the ICD-11:

"Paraphilic disorders are characterised by persistent and intense patterns of atypical sexual arousal, manifested by sexual thoughts, fantasies, urges, or behaviours, the focus of which involves others whose age or status renders them unwilling or unable to consent and on which the person has acted or by which he or she is markedly distressed. Paraphilic disorders may include arousal patterns involving solitary behaviours or consenting individuals only when these are associated with marked distress that is not simply a result of rejection or feared rejection of the arousal pattern by others or with significant risk of injury or death."

In the DSM-5:

"A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention."

Both the ICD-11 & the DSM-5 stress that for a paraphilia to be considered disordered, it must either A) cause harm to others (without their consent) or B) cause harm or distress to the person themself.

Types of paraphilic disorders:

There are literally hundreds of named paraphilias, but the DSM-5 and ICD-11 only list eight. The DSM-5 states that:

"These disorders [are] in [the] DSM for two main reasons: they are relatively common, in relation to other paraphilic disorders, and some of them […] are classed as criminal offenses. The eight listed disorders do not exhaust the list of possible paraphilic disorders. Many dozens of distinct paraphilias have been identified and named, and almost any of them could, by virtue of its negative consequences for the individual or for others, rise to the level of a paraphilic disorder. The diagnoses of the other specified and unspecified paraphilic disorders are therefore indispensable and will be required in many cases."

The ICD-11 lists the following paraphilic disorders:

• Exhibitionistic Disorder
• Voyeuristic Disorder
• Pedophilic Disorder
• Coercive Sexual Sadism Disorder
• Frotteuristic Disorder

The DSM-5 adds the following:

• Sexual Masochism Disorder
• Fetishistic Disorder
• Transvestic Disorder

Both have an unspecified and other specified paraphilic disorder category, which the ICD-11 further divides into involving non-consenting individuals and involving solitary behaviour or consenting individuals.

General diagnostic criteria

In the DSM-5:

1. Over a period of at least 6 months, recurrent and intense sexual arousal from [acting on the paraphilia], as manifested by fantasies, urges, or behaviors.
2. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

In the ICD-11:

1. “Persistent and intense patterns of atypical sexual arousal, manifested by sexual thoughts, fantasies, urges, or behaviours, in which the focus of the arousal pattern involves others whose age or status renders them unwilling or unable to consent”;
2. OR, if involving consenting individuals or solitary behaviour, may be diagnosed if
   1. “the person is markedly distressed by the nature of the arousal pattern and the distress is not simply a consequence of rejection or feared rejection of the arousal pattern by others; or
   2. the nature of the paraphilic behaviour involves significant risk of injury or death.”

How do we separate paraphilic disorders from non-disordered paraphilias, sexual fantasies, and kinks?

This is a question that has been the topic of debate for decades. The wikipedia page on paraphilic disorders does a good job of discussing this.

The DSM-5 states:

"In keeping with the distinction between paraphilias and paraphilic disorders, the term diagnosis should be reserved for individuals who meet both Criteria A and B (i.e., individuals who have a paraphilic disorder). If an individual meets Criterion A but not Criterion B for a particular paraphilia […] then the individual may be said to have that paraphilia but not a paraphilic disorder."

In less clinical language, this PsychCentral article states:

"Kinks [are] nontraditional sexual behaviors that people sometimes use to spice things up, but that they can take or leave depending on their partner, their mood, etc. Fetishes are nontraditional sexual interests or behaviors (kinks) that are, for a particular individual, a deep and abiding (and possibly even necessary) element of sexual arousal and activity. Paraphilias are fetishes that have escalated in ways that have resulted in negative life consequences."

"A kink, a fetish, and a paraphilia can involve the same behavior, but the role that behavior plays and the effects it has can be very different depending on the person. Consider as an analogy the difference between a casual drinker, a heavy drinker, and an alcoholic. The basic behavior, consuming alcohol, is the same, but the underpinnings, impact, and long-term effects are quite different depending on the person. Moreover, it is only when the behavior is taken to an extreme that results in negative life consequences that its viewed as a disorder."

So: an unusual sexual desire (a kink) is a paraphilia if it causes distress to the person experiencing the desire. But it can also be a paraphilic disorder if acting on the desire would cause a violation of another’s consent, or if the person or object of desire is unable or unwilling to consent.

Voyeurism is a paraphilic disorder only if the person being spied on has not consented, and can be a non-paraphilic kink or fetish if they have consented. Pedophilia will always be a paraphilic disorder because children are unable to consent, regardless if the person with pedophilic disorder feels distress or not.