Explaining the pedophilic disorder in DSM-5

When writing about pedophilia, what does the majority of journalists referring to DSM-5 have in common? They haven’t read the DSM-5 entry on pedophilic disorder.

There is a lot of confusion about the diagnosis of pedophilic disorder in DSM-5. It seems that a lot of people who refer to DSM-5 regarding pedophilia or pedophilic disorder haven’t read the entry on the pedophilic disorder in it. It doesn’t surprise me that much in the case of mainstream media. However, it is a reason for concern in the case of articles written by mental health professionals. Therefore, I decided to write this article. I will include the key quotations from the DSM-5 for people who don’t have to access DSM-5 on their own. Hopefully it will help some people to understand certain issues better.

Definition and criteria

A mistake many people make is that they don’t make a difference between a definition of a disorder and diagnostic criteria for the disorder. While it is possible to define it such that people have a certain disorder when they fulfill certain diagnostic criteria, such a definition can be often problematic. A definition should be as simple as possible. In some cases it can be defined by a single characteristic. It may reflect a common mechanism behind the disorder. People with a certain disorder can show different signs because of variety of individual characteristics that aren’t considered a part of the disorder.

It is important to note that in many cases we don’t have any direct way how to find out whether someone has a certain disorder or not. If we want to diagnose such disorders, we need to use some diagnostic criteria. The role of DSM‑5 is to serve as a standard for diagnosing mental disorders and to provide evidence based criteria for such diagnoses. In the case of the pedophilic disorder, it is clear from the text in DSM-5 the criteria aren’t supposed by the authors to serve as a definition of the disorder:

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.

Diagnostic criteria for pedophilic disorder in DSM‑5 are designed as a pragmatic tool to diagnosing the disorder. Since they aren’t a definition of pedophilic disorder, they have a limited validity. They may be both over-inclusive and under-inclusive. I will get back to the problem of validity in more detail later in the article.

Difference between pedophilia and pedophilic disorder

One of the substantial differences DSM-5 brings is making a distinction between paraphilias (pedophilia is classified as paraphilia) and paraphilic disorders. Quoting 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.

I think this distinction is pragmatic rather than conceptual. Many people with paraphilias do well in their lives and don’t need help from mental health professionals. Also there have been cases in which the diagnoses of paraphilia have been abused against people with them in criminal and other cases. For example, they have been used to justify indefinite detentions of paraphilic sex offenders because paraphilias are believed to be life-long conditions. On the other hand, there were reasons to keep paraphilias in DSM‑5, such as to ensure people with them who need help with paraphilias get it covered by their health insurance.

As a result of this distinction, pedophilia is no longer listed among mental disorders in DSM‑5. Instead, a diagnosis of pedophilic disorder was introduced. The criteria for the pedophilic disorder in DSM‑5 are basically the same as the criteria for pedophilia in DSM-IV-TR. There are three criteria for pedophilic disorder in DSM-5:

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.

Criterion A pertains to the signs of pedophilia. Criterion B is the one that makes a distinction between pedophilia and pedophilic disorder, as can be seen from the accompanying text to the criteria:

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 orientation but not pedophilic disorder.

Another relevant part is:

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.

Criterion C limits the criteria to apply only to people who are old enough to ensure a reasonable validity of the criteria and to prevent diagnosing people based on activities that are quite common among their peers.

Problems with pedophilic disorder in DSM-5

The diagnostic criteria for pedophilic disorder have a limited validity. Unless those who are being diagnosed honestly admit their sexual fantasies and desires, the diagnosis rests on the behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger) being present over a period of 6 months. However, not every such person is necessarily a pedophile. Unfortunately, I couldn’t find any source dealing with exactly this problem. My non-expert estimate is that over 20 % of diagnoses based solely on behavior might be false positives.

The main problem I have with the criteria is, nonetheless in the criterion B. The key part is “The individual has acted on these sexual urges”. First, it is worth noticing that one can satisfy the criterion A without having (intense) sexual urges (specifically) towards children. In that case, what are the urges the criterion B refers to? Next, and more importantly, what does “acting on” mean? I find this term to be used frequently and it bothers me because of its vagueness. I kind of understand why it is used in media. What I can’t understand is how such a vague term got into a diagnostic criteria. I think it is supposed to mean engaging in sexual activities with children and possibly also viewing child pornography. But how about seeking out non-pornographic pictures of children (and eventually masturbating to them)? Or how about seeking out situations in which one is around children but without engaging in sexual activities with them?

A sexual orientation or sexual interest?

The original version of DSM-5 once uses the term “pedophilic sexual orientation” in it’s entry on pedophilic disorder. The goal is to make a distinction between pedophilia as an attraction pattern and pedophilic disorder as a mental disorder. There have been several papers using the term “sexual orientation” with respect to pedophilia. What is meant by it is simply that pedophilia is a pattern of erotic attraction that typically begins to manifest in puberty and is stable over life. It is a purely descriptive term.

Following a public outcry, APA decided announced a decision to change the wording from “sexual orientation” to “sexual interest”. In the context of DSM-5 this is a minor change. However, the way in which the change was announced was a pretty bad one. It completely failed to provide reasons why pedophilia should not be thought of as a sexual orientation. It claims that “In fact, APA considers pedophilic disorder a ‘paraphilia’, not a ‘sexual orientation.’” but this is a non-argument without also providing a justification for why a condition that is considered a paraphilia can’t be also considered a sexual orientation.

In my opinion APA should have explained how the term “sexual orientation” is used withing the context of sexology and stress that pedophilia can be thought of as a sexual orientation in a specific meaning of the term “sexual orientation”. It should state that the meaning of certain terms can be different in certain contexts. The position APA took failed to clarify the problematic and has shown its vulnerability to public pressure.

Resources on the topic

Diagnostic and Statistical Manual of Mental Disorders Fifth Edition by American Psychiatric Association

The DSM Diagnostic Criteria for Pedophilia by Ray Blanchard in Archives of Sexual Behavior (fulltext available on ResearchGate)

Commentary on Pedophilia Diagnostic Criteria in DSM-5 by Fred Berlin in The journal of the American Academy of Psychiatry and the Law (fulltext available on ResearchGate)

Pedophilia and DSM-5: The Importance of Clearly Defining the Nature of a Pedophilic Disorder, a commentary by Fred Berlin in The journal of the American Academy of Psychiatry and the Law (fulltext available)