Paraphilic Coercive Disorder Research Articles

Sexual violence, deviance, and the paraphilias in American psychiatry, 1952–2013

ABSTRACT This article explores arguments within American psychiatry from the 1950s around whether rapists were mentally ill. It analyses debates in the lead-up to the various editions of the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM) from 1952 to the latest version in 2013, focussing particularly on a diagnostic category called ‘Paraphilic Coercive Disorder’ (PCD). Since the first DSM, American psychiatrists had routinely considered people who committed certain forms of sexual violence to be suffering from mental disorders. For example, ‘Paedophilia’ and ‘Sexual Sadism’ had always been considered valid diagnoses. However, the APA refused to pathologise non-sadistic sexual violence committed against adults. Opposition can be classified into four overlapping arguments: uncertainty about ‘normal’ male sexual aggression, feminist worries about ‘excusing’ harmful sexual behaviours, concerns about the misuse of psychiatry in courts, and the need to defend the psychiatric profession from encroachments on their ‘territory’ by non-medically trained psychologists, social workers, and anti-psychiatric activists.

Is paraphilic coercion a different construct from sadism or the lower end of an agonistic continuum?

PurposeIt has been hypothesized that paraphilic coercive disorder (PCD) constitutes a distinct preference for coercion that can be discriminated from a preference for sadism. Despite the repeated rejections of PCD as an acceptable diagnosis, it continues to be used. In 2013 Knight and colleagues reviewed the evidence that had been proffered to support the admission of PCD to the DSM-5 as a distinct diagnosis and proposed an alternative model that considers PCD and sadism as levels on a single dimension, called the Agonistic Continuum. They provided factor analytic data to support their argument for the unidimensionality of the proposed continuum, taxometrics to explore whether the construct was distributed categorically, and Item Response Theory to explore the ordinal structure of the dimension. MethodThe aim of the present study was to replicate the prior findings and to expand their analyses with latent profile analysis on 680 sexual offenders. ResultsThe results supported the viability of an Agonistic Continuum, challenging the hypothesis that PCD and sadism constitute distinct disorders and corroborating the reconceptualization of both paraphilic coercion and sadism. ConclusionThis dimension suggests important changes in the conceptualization and measurement of the construct of sadism. Implications are discussed.

Les troubles paraphiliques dans le DSM-5 : analyse critique et considérations médicolégales

IntroductionThe 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) aimed to improve the reliability of psychiatric diagnoses, to address problems identified in DSM-IV, and to improve its clinical and forensic utility. Some of the changes in the diagnostic criteria for the paraphilic disorders in the DSM-5 were guided by forensic concerns, since these are the ones of most interest to forensic psychiatrists. The aim of this paper is to describe and comment the changes made from DSM-IV to DSM-5 concerning paraphilic disorders, and to discuss their legal implications. MethodsPubMed and Medline search, Scopus, journal and textbook articles have been accessed for a detailed literature review on DSM-5 changes related to paraphilic disorders. We conducted the search using the following keywords: Paraphilia; DSM-5; Diagnosis; Diagnostic criteria. ResultsSeveral minor but important changes have been made to the paraphilic disorders diagnostic criteria in DSM-5. DSM-5 redefines the term “paraphilia” which now refers to non pathological, atypical sexual interests (Criterion A); and introduced the term “paraphilic disorder” which is reserved for individuals who meet both Criterion A and Criterion B (individuals who have clinically significant distress or impairment). The DSM-IV category of “paraphilia not otherwise specified” has been replaced with two disorders in DSM-5, “other specified paraphilic disorder” and “unspecified paraphilic disorder”. Both of these categories are considered to be residual. The decision to use one or other of the two disorders depends on whether the clinician wants to specify explicitly the type of atypical paraphilic focus. These residual categories don’t have the same degree of utility as the specific named categories, and can be misused in forensic contexts. In addition, for all of the paraphilic disorders except pedophilic disorder, there are two new course specifiers, “in full remission” and “in a controlled environment”. The decision to provide a specific duration threshold at which the individual must not have acted on his paraphilic urges nor have experienced any distress or impairment, was mainly motivated by forensic issues. Otherwise, three conditions were considered for inclusion in DSM-5: “hypersexual disorder”, “paraphilic coercive disorder”, and “pedophebophilic disorder”. Hypersexual disorder was defined as intense interest in normal sex that was causing problems. Paraphilic coercive disorder was defined as sexual arousal by coercive sex in men who do not meet the diagnostic criteria for sexual sadism. In pedophebophilic disorder, the range of pathologic sexual interest was extended to include adolescents. These proposed diagnosis have received considerable Criticism, and have been abandoned, largely due to a lack of empirical evidence. ConclusionChanges proposed in the DSM treatment of paraphilic disorders are relatively modest and the core of the DSM-IV diagnostic criteria is retained. Many of the changes that occur in paraphilic disorders diagnostic criteria increase the risk of false-positive diagnoses by making it easier to assign a specific paraphilia to an individual, and must be considered with caution. The classification of certain sexual behaviors as pathological, even in the absence of distress, reveals an underlying moral design. As a result, some authors question the validity and reliability of paraphilic disorders, and suggest revolutionary changes, depathologizing paraphilias and removing them from systems of mental disorder classification.

Paraphilias in the DSM-5.

This review summarizes and critically examines the changes in how the Diagnostic and Statistical Manual of Mental Disorders (DSM) characterizes paraphilias. Attention is paid to the diagnostic options that were included in DSM-5, the decision not to include criterion sets for two additional disorders (paraphilic coercive disorder and hypersexual behavior disorder), and the further decision not to modify the diagnosis of pedophilic to pedohebephilic disorder. The three most significant changes are (a) the move to distinguish paraphilias from paraphilic disorders (allowing unusual sexual interests to be studied by researchers but only regarded as disorders when they cause distress or dysfunction), (b) introducing criteria describing paraphilic disorders as being in remission (when they no longer cause distress or dysfunction), and (c) clarifying the relationship between behavior and paraphilias. Concerns are noted about the forensic use of diagnoses and the lack of funding for field trials in this revision of the DSM. Suggestions are given for future directions in order to further research efficacy and clinical diagnosis.

Paraphilic coercive disorder: an unresolved issue.

Nineteen years after the publication of DSM-IV, the DSM-5 was published (American Psychiatric Association, 2013). For the fourth time since DSM-III (American Psychiatric Association, 1980), Paraphilic Coercive Disorder (PCD) was excluded from the main body of the DSM as well as from Section III (in the section on Conditions for Further Study). The repeated rejection of PCD from DSM contributes greatly to maintaining unanswered questions regarding this putative condition (e.g., sexual preference vs. disinhibition hypothesis, categorical vs.dimensional structure ofPCD, lackofclear defining criteria). In this Commentary, we will focus on the B criteria that were proposed for PCD and we will look at the observed frequencies of PCD as well as behavioral markers (sexual acts) that may be characteristic of paraphilic sex offenders. We will conclude with our view on the matter.

DSM-5 and beyond: A critical feminist engagement with psychodiagnosis

The history of critical feminist engagement with psychiatry is a long one. It stretches at least to 1892, the year when Charlotte Perkins Gilman published her autobiographical novella, The Yellow Wallpaper. Gilman delivered a searing indictment of the ‘rest cure’ prescribed for her by Dr S Weir Mitchell. Some 70 years later, Friedan’s The Feminine Mystique (1963) blasted Freudian ideas about women and femininity, ideas that held sway among psychiatrists and many clinical psychologists in the US. Friedan’s book, described by one social critic as ‘pull[ing] the trigger on history,’ galvanized the Women’s Liberation Movement. It is now 50 years since The Feminine Mystique was published. Over those years, feminists have relentlessly challenged many psychiatric diagnoses, psychological theories, and clinical practices. Feminist psychologists like Chesler (1972) and Weisstein (1968/1993) argued that much of what was passed off as scientific knowledge was, as Ehrenreich and English (1978/2005: 5) put it, ‘the ideology of a masculinist society dressed up as objective truth.’ In the mid-1980s, feminists in the mental health professions organized a concerted protest against the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994; hereinafter, DSM), a protest that would stretch to the present day. They were spurred on by three new diagnostic categories proposed for the DSM-III-R: masochistic personality disorder (later renamed selfdefeating personality disorder), premenstrual dysphoric disorder (renamed many times over), and paraphilic rapism (later called paraphilic coercive disorder and sexual sadism disorder). To block the inclusion of these categories, prominent

Is a separate diagnostic category defensible for paraphilic coercion?

PurposeIt has been hypothesized that paraphilic coercive disorder (PCD) constitutes a distinct sexual preference for the coercive elements of sexual interactions and that this preference can be discriminated from a sexual preference for violence, harm, and injury. This article critically reviews the evidence that has been marshaled to support this hypothesis in the recent debates about admission of PCD to the DSM-5. It then tests the validity of an alternative model—a single dimension Agonistic Continuum that encompasses both PCD and sadism. MethodsA critical, selective review of plethysmographic (PPG) and self-report studies attempting to differentiate coercion and harm is presented. The validity of the hypothesis that there is a single, Agonistic Continuum rather than distinct disorders was tested using exploratory factor analysis, Item Response Theory, and taxometrics. ResultsIt is argued that PPG studies that have purported to discriminate PCD from sadism have rather supported the linkage of the two constructs. The review and empirical analyses converge on a single dimension, anchored by coercive fantasies on the lower end and extreme sadism on the upper end and labeled the Agonistic Continuum. ConclusionsThe implications of these results for the DSM-5, legal decisions, and research strategies are discussed.

DSM-IV paraphilia: Descriptions, demographics and treatment interventions

Abstract An overview and demographic description of each of the current DSM-IV-TR paraphilias (i.e., Pedophilia, Transvestic Fetishism, Exhibitionism, Fetishism, Voyeurism, Sexual Masochism, Frotteurism, Paraphilia Not Otherwise Specified) are provided. Most of these are medical descriptions of sexual offenses. Discussion is provided regarding a paraphilic description of rape (i.e., Paraphilic Coercive Disorder) that may appear in DSM-5. The effectiveness of current treatments (behavioral, cognitive–behavioral therapy, chemical/physical castration; and the use of selective serotonin re-uptake inhibitors) for each of these paraphilias is examined. It was found that there are too few well-designed studies to provide support for evidence-based practice with any of the paraphilias, based on Chambless and Hollon (1998) criteria (i.e., evidence should be based on: two + well conducted studies/two + independent researchers, three + small experiments reporting data from at least nine participants). It is suggested that more high quality research studies need to be conducted into the treatment of paraphilias. This work is contrasted with the growing body of evidence for the effectiveness of sex offender treatment for child molesters and exhibitionists (typically without a paraphilic diagnosis); current evidence is equivocal regarding the efficacy of treatment for rapists.

Alcool et inaptitude

Le DSM-5 s’écarte sur de nombreux points des éditions précédentes, apportant plusieurs changements concernant les paraphilies. Ces changements ont été principalement motivés par des considérations légales. Plusieurs modifications ont été apportées au texte descriptif de ces troubles, au détriment des critères diagnostiques qui étaient soumis à beaucoup moins de révision. L’Association Américaine de Psychiatrie a opté pour la conservation intégrale des huit catégories des troubles paraphiliques, en association avec deux catégories résiduelles : « autre trouble paraphilique spécifié » et « trouble paraphilique non spécifié ». Les différents changements ayant concerné les critères des troubles paraphiliques exigent principalement la considération des faux positifs potentiels, ayant comme risque notamment le fait d’assigner plus facilement des diagnostics psychiatriques aux prédateurs sexuellement violents. La classification de certains comportements sexuels comme pathologiques, même en l’absence de détresse, révèle une conception morale sous-jacente qui continue à sanctionner des comportements socialement répréhensibles. De ce fait, certains auteurs remettent en question la fiabilité diagnostique des paraphilies, et vont jusqu’à suggérer des changements révolutionnaires, dépathologisant les paraphilies et les supprimant des systèmes de classification des troubles mentaux.The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) aimed to improve the reliability of psychiatric diagnoses, to address problems identified in DSM-IV, and to improve its clinical and forensic utility. Some of the changes in the diagnostic criteria for the paraphilic disorders in the DSM-5 were guided by forensic concerns, since these are the ones of most interest to forensic psychiatrists. The aim of this paper is to describe and comment the changes made from DSM-IV to DSM-5 concerning paraphilic disorders, and to discuss their legal implications.PubMed and Medline search, Scopus, journal and textbook articles have been accessed for a detailed literature review on DSM-5 changes related to paraphilic disorders. We conducted the search using the following keywords: Paraphilia; DSM-5; Diagnosis; Diagnostic criteria.Several minor but important changes have been made to the paraphilic disorders diagnostic criteria in DSM-5. DSM-5 redefines the term “paraphilia” which now refers to non pathological, atypical sexual interests (Criterion A); and introduced the term “paraphilic disorder” which is reserved for individuals who meet both Criterion A and Criterion B (individuals who have clinically significant distress or impairment). The DSM-IV category of “paraphilia not otherwise specified” has been replaced with two disorders in DSM-5, “other specified paraphilic disorder” and “unspecified paraphilic disorder”. Both of these categories are considered to be residual. The decision to use one or other of the two disorders depends on whether the clinician wants to specify explicitly the type of atypical paraphilic focus. These residual categories don’t have the same degree of utility as the specific named categories, and can be misused in forensic contexts. In addition, for all of the paraphilic disorders except pedophilic disorder, there are two new course specifiers, “in full remission” and “in a controlled environment”. The decision to provide a specific duration threshold at which the individual must not have acted on his paraphilic urges nor have experienced any distress or impairment, was mainly motivated by forensic issues. Otherwise, three conditions were considered for inclusion in DSM-5: “hypersexual disorder”, “paraphilic coercive disorder”, and “pedophebophilic disorder”. Hypersexual disorder was defined as intense interest in normal sex that was causing problems. Paraphilic coercive disorder was defined as sexual arousal by coercive sex in men who do not meet the diagnostic criteria for sexual sadism. In pedophebophilic disorder, the range of pathologic sexual interest was extended to include adolescents. These proposed diagnosis have received considerable Criticism, and have been abandoned, largely due to a lack of empirical evidence.Changes proposed in the DSM treatment of paraphilic disorders are relatively modest and the core of the DSM-IV diagnostic criteria is retained. Many of the changes that occur in paraphilic disorders diagnostic criteria increase the risk of false-positive diagnoses by making it easier to assign a specific paraphilia to an individual, and must be considered with caution. The classification of certain sexual behaviors as pathological, even in the absence of distress, reveals an underlying moral design. As a result, some authors question the validity and reliability of paraphilic disorders, and suggest revolutionary changes, depathologizing paraphilias and removing them from systems of mental disorder classification.

The Debate About Paraphilic Coercive Disorder is Mostly Ideological and Going Nowhere

The Debate About Paraphilic Coercive Disorder is Mostly Ideological and Going Nowhere

AS01-01 - Recent controversies in diagnosis and management of paraphilias

Paraphilias are defined as sexually arousing fantasies, urges, or behaviors involving either nonhuman objects; suffering or humiliation of oneself or one's partner; or children or other non-consenting persons. In the DSM classification, paraphilias are subsumed under sexual disorders, while in the ICD paraphilias are classified as disorders of adult personality and behavior (disorders of sexual preference). Historically, some have advocated eliminating paraphilias or radically revising their definitions, while others suggested adhering to their traditional definitions. The classification and definition of paraphilias is complicated by cultural and societal underpinning, and the unclear boundaries between “normal” and “abnormal” sexuality. The diagnostic criteria of some paraphilias (e.g., pedophilia) are also complicated by the differences between the medical and the legal concepts of these entities. The recent attempts to introduce two new diagnoses, hypersexual disorder and paraphilic coercive disorder, into the DSM system stirred passionate scientific discussions about those two diagnoses and about paraphilias in general. This presentation reviews the pros and cons of classifying paraphilias as sexual disorders and of including the new diagnoses of hypersexual disorder (unclear borders with “normality”) and paraphillic coercive disorder (unclear distinction between this entity and sexual sadism). In addition, this presentation reviews some of the more and/or less accepted methods of paraphilia management, such as pharmacotherapy and castration (chemical, surgical). Several aspects of the classification and diagnosis of paraphilias remain controversial and some of the proposed changes seem unwarranted. Resolving diagnostic and management controversies could be helped by large multicenter and international field trials.

Paraphilic Coercive Disorder Does Not Belong in DSM-5 for Statistical, Historical, Conceptual, and Practical Reasons

Paraphilic Coercive Disorder Does Not Belong in DSM-5 for Statistical, Historical, Conceptual, and Practical Reasons

The medicalisation of rape: A discursive analysis of ‘Paraphilic Coercive Disorder’ and the psychiatrisation of sexuality

In 2010 the American Psychiatric Association (APA) proposed revisions for the fifth edition of the Diagnostic and Statistical Manual (DSM-5). These revisions included criteria for ‘Paraphilic Coercive Disorder’ (PCD), which state that the individual ‘…has sought sexual stimulation from forcing sex on three or more non-consenting persons on separate occasions’ (APA, 2010a). This proposed revision represents current attempts of psychiatry to medicalise ‘sadistic’ rape and normalise what the APA calls ‘opportunistic’ rape (APA, 2010b). Rape has always been a feature of the DSM nomenclature in various forms, however, this particular diagnosis has continually been proposed since the 1980s and the DSM-III. Despite vigorous protests from feminists, LGBTQ communities and forensic psychologists from the 1980s onwards, the DSM Work Group continues to push for its inclusion. This calls into question those positioned on the DSM Task Force, the lack of transparency in their selection (e.g. Zucker, 2009) and their own controversial work and ‘treatments’ (e.g. Zucker, 2006). This paper uses discourse analysis (Parker, 1992) to critically interrogate the construction of rape as a mental disorder using online texts. The APA encouraged comments on the proposed revisions on its website, but these were not accessible and the DSM Task Force criticised negative comments made outside of the APA (e.g. Zucker, 2010c; Aboraya, 2010). Therefore, data was collected from online blogs and the DSM-5 website regarding this proposed disorder and then analysed.

Professor Zucker’s invitation as a keynote speaker to the Division of Clinical Psychology Annual Conference: A response

The British Psychological Society’s Division of Clinical Psychology invited Professor Zucker as a keynote speaker at their Annual Conference (1–3 December 2010). Professor Zucker is considered an authoritative figure in the controversial diagnosis and ‘treatment’ of children with Gender Identity Disorder (GID). He is also the Chair for the American Psychiatric Association’s Sexual and Gender Identity Disorders Work Group for the DSM-5, which has proposed contentious revisions such as the inclusion of Paraphilic Coercive Disorder (PCD).Professor Zucker considers a diagnosis of GID when a child displays ‘gender incongruence’ such as rejecting toys or clothes considered to be associated with their gender (e.g. a girl’s rejection of feminine clothes).PCD is proposed as an addition, the diagnosis being suggested when an individual has ‘sought sexual stimulation from forcing sex on three or more non-consenting persons on separate occasions’. There are concerns that this pathologises rape, as well as the potential for misuse in the legal system.Professor Zucker’s invitation as a keynote speaker has presented concerns regarding the DCP and the Society’s position on GID and the other issues raised.Below is a copy of a joint statement by the Society’s Psychology of Women and Psychology of Sexualities Sections.

Paraphilic Coercive Disorder in the DSM: The Right Diagnosis for the Right Reasons

The recommendation to include a Paraphilic Coercive Disorder (PCD) diagnosis in the DSM-5 represents an improvement over current options and would lead to the shrinking of the pool of individuals considered for detention as Sexually Violent Predators. A precise description of the diagnostic criteria for PCD would permit psychologists and psychiatrists to use more specific and narrow criteria for those who seek sexual gratification by coercing others to engage in unwanted sexual behavior. This might permit mental health professionals to abandon the Paraphilia NOS designation in favor of the more defined PCD in appropriate cases. Various critics have attacked the proposal on what appears to be misplaced ideological grounds. Not only should ideological concerns not play a part in a scientific debate, but the critics' predictions of how the PCD diagnosis would play out in the legal arena are likely wrong. Paraphilic Coercive Disorder would give the judicial system the best opportunity to most accurately identify the small group of men who have previously committed, and are likely in the future to commit, this type of predatory sexual violence.

Evidence Regarding the Need for a Diagnostic Category for a Coercive Paraphilia

Evidence relevant to a potential diagnosis of Paraphilic Coercive Disorder is reviewed. Salient cues indicating that their partner is feeling coerced normally at least partially inhibit male sexual arousal while cues indicating mutual interest heighten arousal. However, for a minority of males, this pattern reverses with salient coercion cues leading to heightened arousal. This unusual pattern of arousal and fantasy is associated with a self-reported willingness to rape among non-convicted samples and is more common among convicted rapists than in other offender groups. It is inconsistently associated with Sadism as defined by the DSM-IV-TR and only weakly associated with psychopathy or general criminality. Evidence for it as an abnormal and persistent sexual interest comes from behavioral patterns, self-reported sexual fantasy, and laboratory tests. Two possible ways of incorporating it into a future version of the DSM are outlined.

Is a Diagnostic Category for Paraphilic Coercive Disorder Defensible?

There is a proposal to establish a paraphilic coercive disorder as a new paraphilia in the DSM-V. The empirical data do not, however, support the hypothesis that a distinct syndrome exists that comprises males who are sexually aroused by the coercive elements of rape per se. Purported evidence for this syndrome has centered on the results of phallometric studies. Higher plethysmographic responses of rapists to coercive rape scenarios may, however, be better explained by the failure of coercive elements to inhibit arousal to sexual aspects of the stimuli rather than by arousal specifically to the coercive elements. In addition, sexual fantasies about forcing sex and about struggling victims are highly correlated with sadistic fantasies and have not been shown to identify a syndrome that can be discriminated from sadism. Finally, taxometric evidence strongly supports the hypothesis that the underlying components of rape are distributed as dimensions and do not constitute a separate taxon. Consequently, the criteria purported to categorize rapists into the proposed syndrome would have to be arbitrarily determined. Not only does there seem to be little empirical justification for the creation of this new syndrome, the inclusion of this disorder among the paraphilias would have serious potential for misuse. It would imply endorsement of Paraphilia, NOS, nonconsent, which is currently inappropriately employed in civil commitment proceedings to justify commitment.

Preferential rape in the theory of courtship disorder.

The theory of courtship disorder suggests voyeurism, exhibitionism, frotteurism, and preferential rape (a paraphilic preference for coercive sex) are expressions of a common underlying disturbance. Previous research has demonstrated that voyeurism, exhibitionism, and frotteurism are relatively likely to co-occur; however, their associations with rape are weaker. One explanation is that rapists are more heterogeneous and may not always be motivated by a paraphilic interest in coercive sex. Paraphilic interests can be identified using phallometric testing, but the sensitivity of the test is attenuated by voluntary control over erectile responding. Another approach is to look for a behavioral marker associated with paraphilic rape-proneness. Freund (1990) has argued that exhibitionism may be the "hub" of courtship disorder because exposing one's genitals to a stranger is rare in control subjects. We predicted that rapists who also engaged in exhibitionistic activity would be more likely than other rapists to also engage in other expressions of courtship disorder, i.e., voyeurism and frotteurism. To rule out the possibility that rapists who report exhibitionistic activity only differ in their willingness to report anomalous sexual behavior, we also predicted no difference between the groups in their self-reported involvement in other paraphilic activities such as sadism or masochism, or paraphilic target preferences such as fetishism or transvestism. Finally, we predicted no difference between groups in their willingness to admit to attempting or committing rape. The results supported our predictions, and lend credence to the notion of preferential rape as an expression of courtship disorder. Moreover, these results suggest that the presence of another paraphilia, particularly exhibitionism, may be useful as a behavioral marker for paraphilic rape-proneness.

Successful Treatment of Paraphilic Coercive Disorder (a Rapist) with Fluoxetine Hydrochloride

A rape assailant with intrusive and persistent paraphilic rape fantasies was successfully treated with the antidepressant fluoxetine hydrochloride. Symptoms of impulsiveness, anxiety and depression were also markedly improved.

Mapping the boundaries of courtship disorder

The courtship disorder hypothesis maintains that voyeurism, exhibitionism, toucheurism‐frotteurism, and the preferential rape pattern are expressions of the same disorder (courtship disorder). Earlier studies had shown that with the exception of the preferential rape pattern these paraphilias co‐occur to a reasonably high degree. The present study (1) demonstrated that the preferential rape pattern co‐occurs with the above reasonably well established expressions of courtship disorder to a higher degree than other main paraphilic activity patterns do and (2) supported the conjecture that in addition to an erotic preference for unfamiliarity of target person‐or‐object (noted by earlier authors), three other paraphilic target‐person or object preferences may be connected with courtship disorder, though they are not at all virtually obligatory as is erotic unfamiliarity. These are choosing children and adults alike as target persons of the paraphilic activities, non‐gender dysphoric transvestism, and fetishism.