Paraphilias and Paraphilic Disorders · Clinical Exercise

Atypical Is Not Disordered

The operative criteria are consent, distress and impairment, never how unusual the interest is. Six disclosures routed through the consent framework, and the presentation where the distress criterion is satisfied and assigning a diagnosis on that basis would be the wrong thing to do.

What this exercise practises

Applying the three questions of the consent framework in order, recognising that half of these disclosures require no diagnosis and no treatment at all, and scrutinising distress about a historically pathologised interest before acting on it.

Two of the six engage obligations that vary by province, territory, profession and context. The time to know yours is before a disclosure, not during one.

Estimated time to complete this exercise: 30 minutes

1Six disclosures
2The fantasy
3The criteria
4Close

Before you begin

How this one works

Three questions decide everything in this section. Does the interest involve or require the non-consent of others. Is it causing the individual distress or impairment. Is it consensual, adult-directed and causing no distress.
Part 1 routes six disclosures through those three questions. Three of the six require no diagnosis and no treatment at all, and recognising that is the main clinical skill here.
Part 2 is the presentation where the distress criterion is technically satisfied and assigning a diagnosis on that basis would be the wrong thing to do.
Part 3 is the criteria themselves, including the one obligation most likely to be skipped and the two places where a clinician oversteps.
Nothing is graded and nothing is recorded. Reloading starts it again.

The operative criteria are consent, distress and impairment. Never the atypical nature of the interest itself. A person whose sexual interests are atypical, who is not distressed by them, and who does not act on them in ways that harm others does not have a disorder, and pathologising atypical interests that meet none of those conditions is a clinical error with a long history behind it.

References

  1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
  2. Bayer, R. (1981). Homosexuality and American psychiatry: The politics of diagnosis. Basic Books.
  3. Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behavioral Sciences, 5(4), 565–575. https://doi.org/10.3390/bs5040565
  4. Haldeman, D. C. (1994). The practice and ethics of sexual orientation conversion therapy. Journal of Consulting and Clinical Psychology, 62(2), 221–227. https://doi.org/10.1037/0022-006X.62.2.221
  5. Hooker, E. (1957). The adjustment of the male overt homosexual. Journal of Projective Techniques, 21(1), 18–31. https://doi.org/10.1080/08853126.1957.10380742
  6. Krueger, R. B., Reed, G. M., First, M. B., Marais, A., Kismodi, E., & Briken, P. (2017). Proposals for paraphilic disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11). Archives of Sexual Behavior, 46(5), 1529–1545. https://doi.org/10.1007/s10508-017-0944-2
  7. Richters, J., de Visser, R. O., Rissel, C. E., Grulich, A. E., & Smith, A. M. A. (2008). Demographic and psychosocial features of participants in bondage and discipline, “sadomasochism” or dominance and submission (BDSM): Data from a national survey. Journal of Sexual Medicine, 5(7), 1660–1668. https://doi.org/10.1111/j.1743-6109.2008.00795.x
  8. World Health Organization. (2022). International classification of diseases for mortality and morbidity statistics (11th rev.). https://icd.who.int