When Is an Unusual Sexual Interest a Mental Disorder?

Abstract

Blanchard et al.’s (2008) excellent article distinguishing Hebephilia (erotic arousal to pubescent children) from Pedophilia (erotic arousal to prepubescent children) raises an important issue. In the article, Blanchard et al. specifically advocate incorporating Hebephilia into the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA). I am not challenging their conclusion that sexual interests in pubescent and prepubescent minors are distinct entities (albeit with some overlap) or that the distinction may have utility for research purposes, but it is not clear that a sexual interest in pubescent minors implies that the individual suffers from a mental disorder, specifically a Paraphilia. Blanchard et al. may assume that Hebephilia will meet the other criteria required for a Paraphilia diagnosis and a mental disorder, but that is neither obvious nor necessarily true. To be crystal clear, the following comments should not be construed as supportive of any sexual activity between adults and minors in any way. Having sex with a minor is a crime and should be punished as such, but it is not clear that this behavior constitutes a mental disorder. How we conceptualize a problem is important. Are the problems associated with an unusual sexual interest primarily sexual, related to another mental disorder, or are they social rather than psychiatric? There is no doubt that some people experience problems related to their sexual interests or behavior, but the sex can be a manifestation of another disorder rather than the cause of the problem. Compulsively washing one’s hands can be a symptom of Obsessive-Compulsive Disorder, but it is not a hand washing disorder. The treatment and conceptualization of unusual sexual interests as Paraphilias have not led to greater understanding of, or more effective treatment for, individuals with these interests; some would argue that pathologizing unusual sexual interests has led to more discrimination and discouraged individuals from seeking treatment for any problem (see Klein & Moser, 2006; Kleinplatz & Moser, 2004; Kolmes, Stock, & Moser, 2006). Paraphilia diagnoses have been misused in criminal and civil proceedings as an indication that these individuals cannot control their behavior. Although there is some indication in the DSM (see APA, 2000, p. 663) that the Paraphilias are Impulse Control Disorders, impulse control is not mentioned in the Paraphilia diagnostic criteria. At least from my experience, most individuals with unusual sexual interests are quite capable of controlling their behavior and, in fact, do so. Those individuals who cannot control their sexual impulses may qualify for another diagnosis based upon their inability to control their impulses, but not based upon the specific sexual behavior. The DSM specifically notes the ‘‘...Paraphilias... are not considered to be compulsions...’’ (APA, 2000, p. 462); ‘‘compulsive masturbators’’ and ‘‘compulsive homosexuals’’ began to disappear once those behaviors were no longer seen as signs or symptoms of psychopathology. I have been quite critical of the Paraphilias diagnostic category in the past (Kleinplatz & Moser, 2005; Moser, 2001, 2002; Moser & Kleinplatz, 2002, 2005a, 2005b) and will not repeat those criticisms here. I will question another aspect of Editor’s note: This letter was submitted to the Journal after Blanchard’s reply to the other letters about the Blanchard et al. (2008) article was in production; hence, the reply by Blanchard (2008) does not refer to the content of this letter.