Mapmedicalism

From MAP Wiki

Mapmedicalism is an ideological stance in MAP discourse. It denotes the belief that being a MAP is a mental disorder.

History

The first documented usage of the term or something adjacent was by the medicalist MAP Lo on nnia.space in February 2021. The conversation went as follows:

Lo[1]: I’m a MAPmed

Lecter[2]: does it mean you believe being a map is a medical condition, or..?

Lo[3]: I see it as a disordered sexual orientation.

Lecter[4]: why disordered?

Lo[5]: if acted on its inherently damaging. If not acted on it leaves the person with a lifetime of never truly being sexually or romantically satisfied. You can get laid elsewhere if course, and you can still find love (obvs I mean I’m married), but there will always be that lacking.

Lecter[6]: an unfortunate life situation is not inherently a medical issue.

A few other NNIA users have occasionally used the term in discussions about the medicalization of mapness as well. Unfortunately, records of these posts cannot be retrieved at this time. MAP blogger Ethan Edwards has expressed being favorable to classifying pedophilia as a mental disorder[7].

Other people have attempted to define mapness as a mental disorder both to justify stigmatizing MAPs[8][9][10][11] as well as to justify destigmatizing MAPs[12][13][14][15][16][17][18].

Roots

Presumably, the terms “mapmed,” “mapmedicalist,” and “mapmedicalism” were inspired by their parallels to transmedicalism[19], an ideology denoting the belief that being transgender[20] inherently constitutes a mental disorder (and thus a medical issue condition) because one must have a specific mental “disorder”[21] (gender dysphoria)[22] to be “actually trans.” The suffix -medicalism has been used to name other ideologies since then, such as system medicalism or “sysmedicalism”[23], an ideology in part centered around the belief that being a system[24] inherently constitutes a mental disorder because one must have a specific mental disorder (Dissociative Identity Disorder[25], Other Specified Dissociative Disorder subtype 1[26], or Unspecified Dissociative Disorder[27]) to be “actually a system.”

Academic precedents

The World Health Organization[28]’s International Statistical Classification of Diseases and Related Health Problems[29], Tenth Revision (ICD-10)[30] classified “paedophilia” (“a sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age“) as a “disorder of sexual preference”[31]. The ICD-11[32] changed the category to “paraphilic disorders”[33].

Paraphilic Disorders are characterized by 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 (e.g., pre-pubertal children, an unsuspecting individual being viewed through a window, an animal). Paraphilic Disorders may also involve other atypical sexual arousal patterns if they cause marked distress to the individual or involve significant risk of injury or death.


Paraphilic Disorders include the following:


6D30 Exhibitionistic Disorder
6D31 Voyeuristic Disorder
6D32 Pedophilic Disorder
6D33 Coercive Sexual Sadism Disorder
6D34 Frotteuristic Disorder
6D35 Other Paraphilic Disorder Involving Non-Consenting Individuals


In order for the above Paraphilic Disorders to be diagnosed, the individual must have acted on the arousal pattern or be markedly distressed by it.

In addition, the following diagnosis may be assigned to describe persistent and intense patterns of atypical sexual arousal—manifested by sexual thoughts, fantasies, urges, or behaviours—that involve consenting adults or solitary behaviours, as long as either: 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 (e.g., asphyxophilia or achieving sexual arousal by restriction of breathing).


6D36 Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals


Atypical patterns of sexual arousal that do not involve actions towards others whose age or status renders them unwilling or unable to consent or that are not associated with marked distress or significant risk of injury or death are not considered to be Paraphilic Disorders.

Many sexual crimes involve actions or behaviours that are not associated with a sustained underlying paraphilic arousal pattern. Rather, these behaviours may be transient and occur impulsively or opportunistically, or in relation to substance use or intoxication. A diagnosis of a Paraphilic Disorder should not be assigned in such cases.

Its entry on “Pedophilic disorder”[34]:

Pedophilic disorder is characterised by a sustained, focused, and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—involving pre-pubertal children. In addition, in order for Pedophilic Disorder to be diagnosed, the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. This diagnosis does not apply to sexual behaviours among pre- or post-pubertal children with peers who are close in age.


Diagnostic Requirements

Essential (Required) Features:


A sustained, focused, and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—involving pre-pubertal children. The individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them.

The diagnosis does not apply to sexual arousal and accompanying behaviour between pre- or post-pubertal children who are close in age.

The Diagnostic and Statistical Manual of Mental Disorders[35] (DSM), a publication by the American Psychiatric Association[36] (APA) for the classification of mental disorders, made similar changes which depathologized pedophilia and other paraphilias in recent versions. Malon (2012) gives a brief organized overview of the how the DSM’s diagnosis of pedophilia has evolved[37].

The first version of the DSM to discuss paraphilias was the DSM-III (1980)[38].

PARAPHILIAS


The essential feature of disorders in this subclass is that unusual or bizarre imagery or acts are necessary for sexual excitement. Such imagery or acts tend to be insistently and involuntarily repetitive and generally involve either: (1) preference for use of a nonhuman object for sexual arousal, (2) repetitive sexual activity with humans involving real or simulated suffering or humiliation, or (3) repetitive sexual activity with nonconsenting partners. In other classifications these disorders are referred to as Sexual Deviations. The term Paraphilia is preferable because it correctly emphasizes that the deviation (para) is in that to which the individual is attracted (philia).

The imagery in a Paraphilia, such as simulated bondage, may be playful and harmless and acted out with a mutually consenting partner. More likely it is not reciprocated by the partner, who consequently feels erotically excluded or superfluous to some degree. In more extreme form, paraphiliac imagery is acted out with a nonconsenting partner, and is noxious and injurious to the partner (as in severe Sexual Sadism) or to the self (as in Sexual Masochism).

Since paraphiliac imagery is necessary for erotic arousal, it must be included in masturbatory or coital fantasies, if not actually acted out alone or with a partner and supporting cast or paraphernalia. In the absence of paraphiliac imagery there is no relief from nonerotic tension, and sexual excitement or orgasm is not attained. The imagery in a paraphiliac fantasy or the object of sexual excitement in a Paraphilia is frequently the stimulus for sexual excitement in individuals without a Psychosexual Disorder. For example, women’s undergarments and imagery of sexual coercion are sexually exciting for many men; they are paraphiliac only when they become necessary for sexual excitement.

The Paraphilias included here are, by and large, conditions that traditionally have been specifically identified by previous classifications. Some of them are extremely rare; others are relatively common. Because some of these disorders are associated with nonconsenting partners, they are of legal and social significance. Individuals with these disorders tend not to regard themselves as ill, and usually come to the attention of mental health professionals only when their behavior has brought them into conflict with society. The specific Paraphilias described here are: (1) Fetishism, (2) Transvestism, (3) Zoophilia, (4) Pedophilia, (5) Exhibitionism, (6) Voyeurism, (7) Sexual Masochism, and (8) Sexual Sadism. Finally, there is a residual category, Atypical Paraphilia, for noting the many other Paraphilias that exist but that have not been sufficiently described to date to warrant inclusion as specific categories.

The DSM-III labeled attraction to children alone as sufficient to constitute a disorder, even without any additional specifiers of distress[39].

302.20 Pedophilia


The essential feature is the act or fantasy of engaging in sexual activity with prepubertal children as a repeatedly preferred or exclusive method of achieving sexual excitement. The difference in age between the adult with this disorder and the prepubertal child is arbitrarily set at ten years or more. For late adolescents with the disorder, no precise age difference is specified; and clinical judgment must be used, the sexual maturity of the child as well as the age difference being taken into account.

Isolated sexual acts with children do not warrant the diagnosis of Pedophilia. Such acts may be precipitated by marital discord, recent loss, or intense loneliness. In such instances the desire for sex with a child may be understood as a substitute for a preferred but unavailable adult.


Diagnostic criteria for Pedophilia

    1. The act or fantasy of engaging in sexual activity with prepuhertal children is a repeatedly preferred or exclusive method of achieving sexual excitement.
    2. If the individual is an adult, the prepubertal children are at least ten years younger than the individual. If the individual is a late adolescent, no precise age difference is required, and clinical judgment must take into account the age difference as well as the sexual maturity of the child.

The DSM-III-R (1987) added to the criteria distress and/or offending[40].

302.20 Pedophilia


The essential feature of this disorder is recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months’ duration, involving sexual activity with a prepubescent child. The person has acted on these urges, or is markedly distressed by them.


Diagnostic criteria for 302.20 Pedophilia

    1. Over a period of at least six months, recurrent intense sexual urges and sexually arousing fantasies involving sexual activity with a prepubescent child or children (generally age 13 or younger).
    2. The person has acted on these urges, or is markedly distressed by them.
    3. The person is at least 16 years old and at least 5 years older than the child or children in A.

The DSM-IV (1994) labeled “pedophilia” as a disorder, but its criteria technically excluded non-distressed pedophiles who had never offended[41].

Paraphilias

Diagnostic Features


The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons, that occur over a period of at least 6 months (Criterion A). For some individuals, paraphiliac fantasies or stimuli are obligatory for erotic arousal and are always included in sexual activity. In other cases, the paraphiliac preferences occur only episodically (e.g., perhaps during periods of stress), whereas at other times the person is able to function sexually without paraphiliac fantasies or stimuli. The behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B).


Differential Diagnosis


A Paraphilia must be distinguished from the nonpathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphiliac only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of nonconsenting individuals, lead to legal complications, interfere with social relationships).

Diagnostic criteria for 302.2 Pedophilia

    1. 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).
    2. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    3. The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.

Some slight changes in the DSM-IV-TR (2000)[42]:

Diagnostic criteria for 302.2 Pedophilia

    1. 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).
    2. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
    3. The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.

The DSM-V, however, distinguished between paraphilias and paraphilic disorders[43], and pedophilia and pedophilic disorder[44].

Paraphilic disorders included in this manual are voyeuristic disorder (spying on others in private activities), exhibitionistic disorder (exposing the genitals), frotteuristic disorder (touching or rubbing against a nonconsenting individual), sexual masochism disorder (undergoing humiliation, bondage, or suffering), sexual sadism disorder (inflict­ing humiliation, bondage, or suffering), pedophilic disorder (sexual focus on children), fetishistic disorder (using nonliving objects or having a highly specific focus on nongenital body parts), and transvestic disorder (engaging in sexually arousing cross-dressing). These disorders have traditionally been selected for specific listing and assignment of ex­plicit diagnostic criteria in DSM for two main reasons: they are relatively common, in re­lation to other paraphilic disorders, and some of them entail actions for their satisfaction that, because of their noxiousness or potential harm to others, 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.

In this chapter, the order of presentation of the listed paraphilic disorders generally corresponds to common classification schemes for these conditions. The first group of disorders is based on anomalous activity preferences. These disorders are subdivided into courtship disorders, which resemble distorted components of human courtship behavior (voyeuristic disorder, exhibitionistic disorder, and frotteuristic disorder), and algolagnic disorders, which involve pain and suffering (sexual masochism disorder and sexual sadism disorder). The second group of disorders is based on anomalous target preferences. These disorders include one directed at other humans (pedophilic disorder) and two directed elsewhere (fetishistic disorder and transvestic disorder).

The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, phys­ically mature, consenting human partners. In some circumstances, the criteria “intense and persistent” may be difficult to apply, such as in the assessment of persons who are very old or medically ill and who may not have “intense” sexual interests of any kind. In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests. There are also specific paraphilias that are gen­erally better described as preferential sexual interests than as intense sexual interests.

Some paraphilias primarily concern the individual’s erotic activities, and others pri­marily concern the individual’s erotic targets. Examples of the former would include in­tense and persistent interests in spanking, whipping, cutting, binding, or strangulating another person, or an interest in these activities that equals or exceeds the individual’s in­terest in copulation or equivalent interaction with another person. Examples of the latter would include intense or preferential sexual interest in children, corpses, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber.

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.

In the diagnostic criteria set for each of the listed paraphilic disorders. Criterion A specifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the gen­itals to strangers), and Criterion B specifies the negative consequences of the paraphilia (i.e., distress, impairment, or harm to others). 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—a circumstance that might arise when a benign paraphilia is discovered during the clinical investigation of some other condition—then the individual may be said to have that paraphilia but not a paraphilic disorder.

It is not rare for an individual to manifest two or more paraphilias. In some cases, the para­philic foci are closely related and the connection between the paraphilias is intuitively com­prehensible (e.g., foot fetishism and shoe fetishism). In other cases, the connection between the paraphilias is not obvious, and the presence of multiple paraphilias may be coincidental or else related to some generalized vulnerability to anomalies of psychosexual development. In any event, comorbid diagnoses of separate paraphilic disorders may be warranted if more than one paraphilia is causing suffering to the individual or harm to others.

Because of the two-pronged nature of diagnosing paraphilic disorders, clinician-rated or self-rated measures and severity assessments could address either the strength of the paraphilia itself or the seriousness of its consequences. Although the distress and impair­ment stipulated in the Criterion B are special in being the immediate or ultimate result of the paraphilia and not primarily the result of some other factor, the phenomena of reactive depression, anxiety, guilt, poor work history, impaired social relations, and so on are not unique in themselves and may be quantified with multipurpose measures of psychosocial functioning or quality of life.

The most widely applicable framework for assessing the strength of a paraphilia itself is one in which examines paraphilic sexual fantasies, urges, or behaviors are evaluated in relation to their normophilic sexual interests and behaviors. In a clinical interview or on self-administered questionnaires, examinees can be asked whether their paraphilic sexual fantasies, urges, or behaviors are weaker than, approximately equal to, or stronger than their normophilic sexual interests and behaviors. This same type of comparison can be, and usually is, employed in psychophysiological measures of sexual interest, such as pe­nile plethysmography in males or viewing time in males and females.

Pedophilic Disorder Diagnostic Criteria

    1. 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).
    2. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
    3. The individual is at least age 16 years and at least 5 years older than the child or chil­dren in Criterion A.

Diagnostic Features


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. Examples of disclosing this paraphilia include candidly acknowledging an intense sexual interest in children and indicating that sexual interest in children is greater than or equal to sexual interest in physically mature individuals. If individuals also complain that their sex­ual attractions or preferences for children are causing psychosocial difficulties, they may be di­agnosed with pedophilic disorder. 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.

Examples of individuals who deny attraction to children include individuals who are known to have sexually approached multiple children on separate occasions but who deny any urges or fantasies about sexual behavior involving children, and who may further claim that the known episodes of physical contact were all unintentional and nonsexual. Other indi­viduals may acknowledge past episodes of sexual behavior involving children but deny any significant or sustained sexual interest in children. Since these individuals may deny experi­ences, impulses or fantasies involving children, they may also deny feeling subjectively dis­tressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence of self-reported distress, provided that there is evidence of recurrent behaviors persisting for 6 months (Criterion A) and evidence that the individual has acted on sexual urges or experi­enced interpersonal difficulties as a consequence of the disorder (Criterion B).

Presence of multiple victims, as discussed above, is sufficient but not necessary for di­agnosis; that is, the individual can still meet Criterion A by merely acknowledging intense or preferential sexual interest in children.

The Criterion A clause, indicating that the signs or symptoms of pedophilia have per­sisted for 6 months or longer, is intended to ensure that the sexual attraction to children is not merely transient. However, the diagnosis may be made if there is clinical evidence of sustained persistence of the sexual attraction to children even if the 6-month duration can­ not be precisely determined.


Associated Features Supporting Diagnosis


The extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of pedophilic disorder. This is a specific instance of the general case that individ­uals are likely to choose the kind of pornography that corresponds to their sexual interests.


Prevalence


The population prevalence of pedophilic disorder is unknown. The highest possible prev­alence for pedophilic disorder in the male population is approximately 3%-5%. The pop­ulation prevalence of pedophilic disorder in females is even more uncertain, but it is likely a small fraction of the prevalence in males.


Development and Course


Adult males with pedophilic disorder may indicate that they become aware of strong or preferential sexual interest in children around the time of puberty—the same time frame in which males who later prefer physically mature partners became aware of their sexual interest in women or men. Attempting to diagnose pedophilic disorder at the age at which it first manifests is problematic because of the difficulty during adolescent development in differentiating it from age-appropriate sexual interest in peers or from sexual curiosity. Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years older than the child or children in Criterion A.

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. Therefore, the course of pedophilic disorder may fluctuate, increase, or decrease with age. Adults with pedophilic disorder may report an awareness of sexual interest in children that preceded engaging in sexual behavior involving children or self-identification as a pedo­phile. Advanced age is as likely to similarly diminish the frequency of sexual behavior involv­ing children as it does other paraphilically motivated and normophilic sexual behavior.


Risk and Prognostic Factors


Temperamental. There appears to be an interaction between pedophilia and antisocial­ity, such that males with both traits are more likely to act out sexually with children. Thus, antisocial personality disorder may be considered a risk factor for pedophilic disorder in males with pedophilia.

Environmental. Adult males with pedophilia often report that they were sexually abused as children. It is unclear, however, whether this correlation reflects a causal influence of childhood sexual abuse on adult pedophilia.

Genetic and physiological. Since pedophilia is a necessary condition for pedophilic dis­order, any factor that increases the probability of pedophilia also increases the risk of pe­dophilic disorder. There is some evidence that neurodevelopmental perturbation in utero increases the probability of development of a pedophilic orientation.


Gender-Related Diagnostic Issues


Psychophysiological laboratory measures of sexual interest, which are sometimes useful in di­agnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in females, even when an identical procedure (e.g., viewing time) or analogous procedures (e.g., penile plethysmography and vaginal photoplethysmography) are available.


Diagnostic Markers


Psychophysiological measures of sexual interest may sometimes be useful when an indi­vidual’s history suggests the possible presence of pedophilic disorder but the individual denies strong or preferential attraction to children. The most thoroughly researched and longest used of such measures is penile plethysmography, although the sensitivity and spec­ificity of diagnosis may vary from one site to another. Viewing time, using photographs of nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic disorder, especially in combination with self-report measures. Mental health professionals in the United States, however, should be aware that possession of such visual stimuli, even for diagnostic purposes, may violate American law regarding possession of child pornog­raphy and leave the mental health professional susceptible to criminal prosecution.


Differential Diagnosis


Many of the conditions that could be differential diagnoses for pedophilic disorder also sometimes occur as comorbid diagnoses. It is therefore generally necessary to evaluate the evidence for pedophilic disorder and other possible conditions as separate questions.

Antisocial personality disorder. This disorder increases the likelihood that a person who is primarily attracted to the mature physique will approach a child, on one or a few occa­sions, on the basis of relative availability. The individual often shows other signs of this personality disorder, such as recurrent law-breaking.

Alcohol and substance use disorders. The disinhibiting effects of intoxication may also increase the likelihood that a person who is primarily attracted to the mature physique will sexually approach a child.

Obsessive-compulsive disorder. There are occasional individuals who complain about ego-dystonic thoughts and worries about possible attraction to children. Clinical inter­viewing usually reveals an absence of sexual thoughts about children during high states of sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality).


Comorbidity


Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depres­sive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic disorders. However, findings on comorbid disorders are largely among individuals con­victed for sexual offenses involving children (almost all males) and may not be generalizable to other individuals with pedophilic disorder (e.g., individuals who have never approached a child sexually but who qualify for the diagnosis of pedophilic disorder on the basis of subjective distress).

Several months later, the APA recanted their words after pressure from public outrage[45].

APA Statement on DSM-5 Text Error

Pedophilic disorder text error to be corrected


The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has recently been published after a comprehensive multi-year research and review of all of its diagnostic categories. In the case of pedophilic disorder, the diagnostic criteria essentially remained the same as in DSM-IV-TR. Only the disorder name was changed from “pedophilia” to “pedophilic disorder” to maintain consistency with the chapter’s other disorder listings.

“Sexual orientation” is not a term used in the diagnostic criteria for pedophilic disorder and its use in the DSM-5 text discussion is an error and should read “sexual interest.” In fact, APA considers pedophilic disorder a “paraphilia,” not a “sexual orientation.” This error will be corrected in the electronic version of DSM-5 and the next printing of the manual.

APA stands firmly behind efforts to criminally prosecute those who sexually abuse and exploit children and adolescents. We also support continued efforts to develop treatments for those with pedophilic disorder with the goal of preventing future acts of abuse.

A revised version of the statement remains on their website[46].

A news release sent Oct. 30 on behalf of the American Family Association mischaracterized the position of the American Psychological Association with respect to pedophilia. The American Psychological Association does not classify mental disorders or publish the Diagnostic and Statistical Manual, as the release incorrectly stated. The American Psychological Association maintains that pedophilia is a mental disorder; that sex between adults and children is always wrong; and that acting on pedophilic impulses is and should be a criminal act. The American Psychological Association has worked for many years to prevent child sexual abuse and will continue to do so.

The decision was criticized by Berlin (2014)[47].

In the face of significant criticism of its inclusion in the DSM-5, the American Psychiatric Association (APA) has stated its intention to remove the term Pedophilic Sexual Orientation from the diagnostic manual. Removing that term in response to public criticism would be a mistake. Experiencing ongoing sexual attractions to prepubescent children is, in essence, a form of sexual orientation, and acknowledging that reality can help to distinguish the mental makeup that is inherent to Pedophilia, from acts of child sexual abuse.

Changes in the DSM-V-TR[48] from the DSM-V in the paraphilic disorders category:

paragraph 1:

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.

paragraph 3:

In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests.

In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to nonparaphilic sexual interests.

paragraph 3:

Examples of the latter would include intense or preferential sexual interest in children, corpses, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber.

Examples of the latter would include intense or preferential sexual interest in children, corpses, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber. An individual’s pattern of paraphilic interests is often reflected in his or her choice of pornography.

paragraph 6:

If an individual meets

If an individual’s paraphilic interests or behaviors meet

paragraph 9:

The most widely applicable framework for assessing the strength of a paraphilia itself is one in which examinees’ paraphilic sexual fantasies, urges, or behaviors are evaluated in relation to their normophilic sexual interests and behaviors. In a clinical interview or on self-administered questionnaires, examinees can be asked whether their paraphilic sexual fantasies, urges, or behaviors are weaker than, approximately equal to, or stronger than their normophilic sexual interests and behaviors. This same type of comparison can be, and usually is, employed in psychophysiological measures of sexual interest, such as pe­nile plethysmography in males or viewing time in males and females.

Changes to the entry on pedophilic disorder:

Diagnostic Features

... (generally age 13 years or younger), despite substantial objective evidence to the contrary. Examples of disclosing...

... (generally age 13 years or younger), despite substantial objective evidence to the contrary. The age guideline of 13 or younger is approximate only, because the onset of puberty varies from person to person, and there is good evidence the average age at onset of puberty has been declining over time and differs across ethnicities and cultures. Examples of disclosing...

——————————————————————————————

greater than or equal to sexual interest in physically mature individuals.

greater than or equal to sexual interest in physically mature persons.

——————————————————————————————

pedophilic sexual orientation but not pedophilic disorder. Examples of...

pedophilic sexual interest but not pedophilic disorder. When trying to differentiate child offenders with pedophilic disorder from child offenders without pedophilic disorder, factors that suggest a diagnosis of pedophilic disorder in the offender include self-reported interest in children, use of child pornography, a history of multiple child victims, boy victims, and unrelated child victims (Seto 2018; Seto et al. 2016). Examples of...

——————————————————————————————

Since these individuals may deny...

Because these individuals may deny...

——————————————————————————————

... interpersonal difficulties as a consequence of the disorder (Criterion B). Presence of multiple victims...

... interpersonal difficulties as a consequence of the disorder (Criterion B).

Behaviors include sexual interactions with children, whether or not they involve physical contact (e.g., some pedophilic individuals expose themselves to children).

Although the use of sexually explicit content depicting prepubescent children is typical of individuals with pedophilic sexual interests and thus might contribute important information relevant to the evaluation of Criterion A, such behavior in the absence of the individual’s sexual interactions with children (i.e., acting on these sexual urges in person) is insufficient to conclude that Criterion B is met.

Presence of multiple victims...

——————————————————————————————

... acknowledging intense or preferential sexual interest in children.

The Criterion A clause, indicating that the signs or symptoms of pedophilia have per­sisted for 6 months or longer, is intended to ensure that the sexual attraction to children is not merely transient. However, the diagnosis may be made if there is clinical evidence of sustained persistence of the sexual attraction to children even if the 6-month duration can­ not be precisely determined.


Associated Features Supporting Diagnosis


The extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of pedophilic disorder. This is a specific instance of the general case that individ­uals are likely to choose the kind of pornography that corresponds to their sexual interests.

... acknowledging intense or preferential sexual interest in children.


Associated Features


Individuals with pedophilic disorder may experience an emotional and cognitive affinity with children, sometimes referred to as emotional congruence with children. Emotional congruence with children can manifest in different ways, including preferring social interactions with children over adults, feeling like one has more in common with children than with adults, and choosing occupations or volunteer roles in order to be around children more often (Seto 2019). Studies show that emotional congruence with children is related to both pedophilic sexual interest and the likelihood of sexually reoffending among individuals who have sexually offended (Hermann et al. 2017; McPhail et al. 2013).

Prevalence

The population prevalence of pedophilic disorder is unknown. The highest possible prev­alence for pedophilic disorder in the male population is approximately 3%-5%. The pop­ulation prevalence of pedophilic disorder in females is even more uncertain, but it is likely a small fraction of the prevalence in males.

The population prevalence of individuals whose presentations meet the full criteria for pedophilic disorder is unknown (Cohen and Galynker 2002; Hall and Hall 2007) but is likely less than 3% among men in international studies (Seto 2018). The population prevalence of pedophilic disorder in women is even more uncertain, but it is likely a small fraction of the prevalence in men (Cohen and Galynker 2002; Hall and Hall 2007; Seto 2009).

Development and Course

Adult males with pedophilic disorder may indicate...

Adult men with pedophilic disorder may indicate...

——————————————————————————————

Therefore, the course of pedophilic disorder may fluctuate, increase, or decrease with age. Adults with pedophilic disorder may report an awareness of sexual interest in children that preceded engaging in sexual behavior involving children or self-identification as a pedo­phile. Advanced age is as likely to similarly diminish the frequency of sexual behavior involv­ing children as it does other paraphilically motivated and normophilic sexual behavior.

Therefore, the course of pedophilic disorder may fluctuate, or the intensity might increase or decrease with age. Adults with pedophilic disorder may report an awareness of sexual interest in children that preceded engaging in sexual behavior involving children or self-identification as an individual with pedophilia (Seto 2018). Advanced age is as likely to similarly diminish the frequency of sexual behavior involving children as it does other paraphilically motivated and nonparaphilic sexual behavior (Barbaree and Blanchard 2008).

Risk and Prognostic Factors


Temperamental

There appears to be an interaction between pedophilia and antisocial­ity, such that males with both traits are more likely to act out sexually with children.

There appears to be an interaction between pedophilia and antisocial personality traits such as callousness, impulsivity, and a willingness to take risks without adequate regard for the consequences. Men with pedophilic interest and antisocial personality traits are more likely to act out sexually with children (Seto 2017) and thus qualify for a diagnosis of pedophilic disorder.

Environmental

Adult males with pedophilia often report that...

Adult men with pedophilia sometimes report that...

Genetic and physiological

... increases the probability of development of a pedophilic orientation.

... increases the probability of development of a pedophilic interest.



Gender-Related Diagnostic Issues


Psychophysiological laboratory measures of sexual interest, which are sometimes useful in di­agnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in females, even when an identical procedure (e.g., viewing time) or analogous procedures (e.g., penile plethysmography and vaginal photoplethysmography) are available.

Sex- and Gender-Related Diagnostic Issues

Laboratory measures of sexual interest, in terms of psychophysiological responses to sexual stimuli depicting children, which are sometimes useful in diagnosing pedophilic disorder in men, are not necessarily useful in diagnosing this disorder in women because there has been very limited research on the assessment of pedophilic sexual interest in women (Seto 2018).

Diagnostic Markers

... although the sensitivity and spec­ificity of diagnosis may vary from one site to another. Viewing time, using photographs of nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic disorder, especially in combination with self-report measures. Mental health professionals in the United States, however, should be aware that possession of such visual stimuli, even for diagnostic purposes, may violate American law regarding possession of child pornog­raphy and leave the mental health professional susceptible to criminal prosecution.

... although the sensitivity and specificity of diagnosis may vary across sites, which frequently use different stimuli, procedures, and scoring (Lalumière and Harris 1998; McPhail et al. 2019). Viewing time, using photographs of nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic disorder, especially in combination with self-report measures (Camilleri and Quinsey 2008). U.S. clinicians, however, should be aware that possession of visual sexual stimuli depicting children, even for diagnostic purposes, may violate American law regarding possession of child pornography and leave the clinician susceptible to criminal prosecution. The option exists to use audio stimuli describing sexual interactions in penile plethysmography (Lalumière and Harris 1998; McPhail et al. 2019). Across psychophysiological methods, the diagnostic marker is relative sexual response to stimuli depicting children compared with stimuli depicting adults, rather than absolute response to child stimuli.

Differential Diagnosis

Many of the conditions that could be differential diagnoses for pedophilic disorder also sometimes occur as comorbid diagnoses. It is therefore generally necessary to evaluate the evidence for pedophilic disorder and other possible conditions as separate questions.

Pedophilia

Individuals with pedophilia experience recurrent, intense, sexually arousing fantasies or sexual urges involving sexual activity with a prepubescent child or children. Unless the individual has acted on these sexual urges with a prepubescent child or unless the sexual urges or fantasies cause marked distress or interpersonal difficulty, a diagnosis of pedophilic disorder is not warranted.


Other paraphilic disorders

Sometimes individuals present with a different paraphilic disorder but are referred for an evaluation regarding possible pedophilic disorder (e.g., when an individual with a diagnosis of exhibitionistic disorder exposes himself to children as well as adults). In some cases, both diagnoses may apply, whereas in others, it may be the case that one paraphilic disorder diagnosis is sufficient. For example, an individual who exposes himself exclusively to prepubescent children may have both exhibitionistic disorder and pedophilic disorder, whereas another individual who exposes himself to victims, irrespective of the victims’ age, may be considered to have only exhibitionistic disorder.

Antisocial personality disorder

This disorder increases the likelihood that a person who is primarily attracted to the mature physique will approach a child, on one or a few occa­sions, on the basis of relative availability. The individual often shows other signs of this personality disorder, such as recurrent law-breaking.

Some individuals with antisocial personality disorder sexually abuse children, reflecting the fact that the presence of antisocial personality disorder increases the likelihood that an individual who is primarily attracted to mature persons will approach a child sexually, on the basis of relative access to the child (Seto 2018). An additional diagnosis of pedophilic disorder should only be considered if there is evidence that over a period of at least 6 months, the individual has also had recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child.

——————————————————————————————

Alcohol and substance use disorders The disinhibiting effects of intoxication may also increase the likelihood that a person who is primarily attracted to the mature physique will sexually approach a child.

Substance intoxication The disinhibiting effects of substance intoxication may also increase the likelihood that an individual who is primarily attracted to mature persons will sexually approach a child.

Obsessive-compulsive disorder.

Clinical inter­viewing usually reveals an absence of sexual thoughts about children during high states of sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality).

Clinical interviewing usually reveals an absence of positive feelings about these thoughts, no connection between these thoughts and sexual behavior (e.g., masturbating to these thoughts), and sometimes additional ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality) (Vella-Zarb et al. 2017).

Other academics have also argued in favor of classifying pedophilia and/or hebephilia as mental disorders[49][50][51].

Implications

The diagnosis of pedophilia, paraphilias, or other associated disorders is used to justify involuntarily committing sex offenders to psychiatric facilities after their prison sentences have been served[52]. The belief that paraphilias such as biastophilia, pedophilia, or hebephilia constitute mental disorders leads to a belief that they can or should be “cured,” or that we should attempt to devise “cures” for them. The belief that paraphilias can be removed through conditioning has led to attempts at conversion therapy[53], physical assault and abusive psychotherapy[54], encouraging chemical castration as a necessity[55], sexual assault of adult sex offenders who are paraphilic[56][57] or perceived to be paraphilic[58], and sexual assault of minors who are paraphilic or perceived to be paraphilic at psychiatric facilities[59] by medical professionals.

Criticism in academia

Various academics have asserted that pedophilia, hebephilia, and/or paraphilias in general, should not be considered mental disorders[60][61][62][63], or otherwise criticized the DSM’s conceptualization of “pedophilic disorder”[64][65][47].

Münch et al (2020) argue for alterations to be made to the DSM-V criteria of Pedophilic Disorder[66].

Abstract


Generally, diseases are primarily harmful to the individual herself; harm to others may or may not be a secondary effect of diseases (e.g., in case of infectious diseases). This is also true for mental disorders. However, both ICD-10 and DSM-5 contain two diagnoses which are primarily defined by behavior harmful to others, namely Pedophilic Disorder and Antisocial (or Dissocial) Personality Disorder (ASPD or DPD). Both diagnoses have severe conceptual problems in the light of general definitions of mental disorder, like the definition in DSM-5 or Wakefield’s “harmful dysfunction” model. We argue that in the diagnoses of Pedophilic Disorder and ASPD the criterion of harm to the individual is substituted by the criterion of harm to others. Furthermore, the application of the criterion of dysfunction to these two diagnoses is problematic because both heavily depend on cultural and social norms. Therefore, these two diagnoses fall outside the general disease concept and even outside the general concept of mental disorders. We discuss whether diagnoses which primarily or exclusively ground on morally wrong, socially inacceptable, or criminal behavior should be eliminated from ICD and DSM. On the one side, if harming others is a sufficient criterion of a mental disorder, the “evil” is pathologized. On the other side, there are practical reasons for keeping these diagnoses: first for having an official research frame, second for organizing and financing treatment and prevention. We argue that the criteria set of Pedophilic Disorder should be reformulated in order to make it consistent with the general definition of mental disorder in DSM-5. This diagnosis should only be applicable to individuals that are distressed or impaired by it, but not solely based on behavior harmful to others.


Introduction


Generally, diseases are primarily harmful to the diseased individual herself either by being directly life-threatening or at least life-shortening, or by causing pain or suffering, or by impairing her ability to live in human symbiotic communities. Harm to others, however, may or may not be a secondary effect of diseases. A typical example are infectious diseases which harm the infected individual and possibly others as well. A mere infection, however, is not called a disease as long as it is not and will not be harmful to the infected individual herself, even if it poses a risk to others as a secondary effect. This is evident from the example of asymptomatic carriers of pathogens. Although they may transmit the pathogen to others and harm particularly vulnerable, e.g. immunosuppressed people, medicine does not regard them as ill. Therefore, such persons should be described as being ’disease-causing’ for others, rather than as being ’diseased’ themselves.

If this is true for diseases in general, that they are primarily harmful to the individual herself, it should also be true for mental disorders as long as they are viewed as a subset of diseases. This is reflected in frequently cited attempts to formulate a general definition of mental disorder, like the definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the “harmful dysfunction” model by Wakefield. Both definitions characterize a mental disorder by, broadly speaking, a dysfunction in mental processes that is associated with harm to the affected individual.

For some psychiatric diagnoses, however, it is questionable whether the presupposition of harm to the individual really applies. We will show that several diagnoses essentially rely on behavior that is harmful to others, but not necessarily to the individual herself. This is especially true for the diagnoses “Antisocial Personality Disorder” (ASPD) in DSM-5 (or “Dissocial Personality Disorder” in ICD-10) and “Pedophilic Disorder” in DSM-5 and ICD-11. Instead, as we will show, another disease criterion comes in here: the criterion of “harm to others.”

In the case of Pedophilic Disorder, harm to others is a sufficient criterion. In the case of ASPD, it is a necessary one and, as we will argue, practically also a sufficient one. In addition to the harm criterion, getting another meaning, we will argue that the criterion of a mental dysfunction is unclear in these diagnoses. Thus, the diagnoses of ASPD and Pedophilic Disorder fall out of the general concept of diseases and even out of the general concept of mental disorders. Are they accordingly rather “moral disorders” than clinical disorders? If this is true, psychiatry contributes to a “medicalization” of morally wrong behavior. The conceptual problems of ASPD and Pedophilic Disorder lead to the fundamental question which criteria define a mental disorder.

The aim of this paper is to discuss whether behavior harmful to others should be a sufficient criterion of mental disorder as it is the case in the diagnoses of ASPD and Pedophilic Disorder. If we come to the conclusion that this should not be the case, the question arises whether ASPD and Pedophilic Disorder should be eliminated from the diagnostic manuals.


Dysfunction in Pedophilic Disorder


With regard to pedophilia, one could argue under an evolutionary account of dysfunction, that it is a form of a sexual dysfunction, assuming that the biologically defined function of sexual arousal (i.e. the reason the mechanism of sexual arousal was selected for) lies in its contribution to (potential) reproduction, which is clearly not the case in pedophilic sexual behavior. This, however, is an insufficient model of the function of human sexuality. Human sexuality has important functions beyond reproduction, particularly promoting pair bonding and fulfilling emotional needs. Many forms of sexuality that do not pursue reproduction are broadly accepted, e.g. sexual intercourse of infertile people, under birth control, or homosexuality. Furthermore, there is no reason not to use a certain function for other, possibly purely hedonistic purposes that have nothing to do with its evolutionary function. The fact that a function is used for other than the alleged evolutionary purposes does not mean that this is dysfunctional.

Some pedophilic men actually state that they are not only interested in sexual contact with children but also look for romantic relationships with them. The dysfunction in Pedophilic Disorder thus cannot simply stem from the fact that the sexual arousal is not associated with (potential) reproduction. The concept of a dysfunction in an evolutionary sense falls too short here.

According to DSM-5 and ICD-11, a pedophilic sexual interest is only deemed a mental disorder when it leads to subjective distress or impairment, or has been acted upon.

To assume that having certain sexual fantasies or urges is not pathological but acting according to them is, seems inconsistent. It might be explained by the implicit assumption that there is another dysfunction involved, namely an impaired ability to control one’s behavior. To illustrate this point: if a heterosexual teleiophilic man (i.e. a man sexually attracted to physically mature individuals) sexually assaults a woman, it is not generally supposed that he must be mentally disordered because he couldn’t control his sexual urges. For it is just as possible that he thought the assault was justified, e.g. because the woman dressed “lewdly“. There is no reason to regard the case of the heterosexual teleiophilic sexual offender differently from the case of a pedophilic sexual offender who is convinced that his behavior is morally justified, or who just does not respect the rights of children.


Conclusions
“Vice-Laden Disorders” in Psychiatry


Diagnoses that primarily rely on behavior harmful to others, like Pedophilic Disorder and ASPD, fall out of the general disease concept. They even do not meet the general criteria of mental disorders as defined by DSM-5 or the “harmful dysfunction” model by Wakefield. Neither the criterion of harm to the individual himself, nor the criterion of a dysfunction are met in these two diagnoses. Instead, they rely on another disease criterion: the criterion of harm to others. Psychiatry brings itself into great conceptual difficulties by making behavior harmful to others/criminal behavior a central part of the definition of some mental disorders, while at the same time lacking a clear concept of dysfunction in these cases. When diagnoses are formulated in a way that makes it possible to apply them to mere antisocial and criminal behavior, psychiatry is at risk of confounding the medical and the moral.


The Disorder-Status of Pedophilic Disorder


In the case of Pedophilic Disorder, we think that the diagnosis should be kept but reformulated in accordance with the general definition of mental disorder in DSM-5 in order to make it consistent with a medical model of mental disorder. This means it should only be applicable to individuals that are distressed or impaired by it so that they can get treatment within the health system. It should not be possible to make the diagnosis solely based on behavior harmful to others. Therefore, we suggest reformulating Criterion B of Pedophilic Disorder as follows: “The sexual urges or fantasies cause marked distress or interpersonal difficulty (e.g. in the context of occupation, family life, friendships, intimate life).” That means, the criterion “The individual has acted on these sexual urges” is cancelled.

Our suggested reformulation of Criterion B is indeed consistent with the form it already had in DSM-IV. As De Block et al. note, the DSM-IV diagnostic criteria were “by far the most consistent vis-à-vis the DSM’s own definition of mental disorder.” It was, however, criticized that this criteria set leads to the situation that someone acting on his pedophilic interests without feeling distressed would not be considered mentally ill. O’Donohoe et al. argue that rather the lack of experiencing subjective distress when being sexually attracted to children than the experience of distress is a sign of psychological problems. They do not accept that, according to DSM-IV, a “contended pedophile” does not meet the criteria of a mental disorder. They argue that a person sexually interested in children must be considered in some way socially impaired “because societal norms dictate that it is abnormal for a person to be sexually interested in children.” They clearly want to classify pedophilia as a mental disorder for social and forensic rather than for medical reasons. Their postulation that “a single instance of sexual behavior with a child should be sufficient to label someone as having a disorder” confounds criminal behavior with mental disorder.

If pedophilia by itself is not a mental disorder according to DSM-5, then acting according to it cannot be a mental disorder unless there is clear evidence of a dysfunction of volitional control. Impairment of volitional control, however, is not implied in the diagnosis of a paraphilic disorder. If we assume that sometimes such impairment is given, then it probably stems from another disease (like e.g. dementia, a brain tumor or mental retardation). If there is no such impairment, we have to assume that this person acted deliberately, and it is not clear why this should be a sign of a mental disorder rather than simply a criminal act.

The DSM-5 warns of the dangers of using a diagnostic manual developed for clinical purposes in the forensic context. For assigning mental disorder in the legal sense “additional information is usually required beyond that contained in the DSM-5 diagnosis, which might include information about the individual’s functional impairments and how these impairments affect the particular abilities in question.”

It is important to note that there is a difference between a mental disorder and the US-American legal concept of “mental abnormality.”

We suggest that it should be possible to diagnose a “mental abnormality” in the forensic sense for a person with pedophilia who is neither distressed nor impaired by his pedophilic condition (i.e., who fulfills criterion A but not B according to our suggestion). Even though this person does not meet the criteria of a mental disorder as suggested by us, he might still meet the concept of “mental abnormality” if there is evidence of a high risk of reoffending. We thus suggest that this difference in clinical and forensic use is clearly annotated in the diagnostic criteria of Pedophilic Disorder in DSM. This suggestion is important with regard to other countries than the USA. The DSM is used worldwide for research, and therefore its diagnostic criteria should not be distorted in order to adapt them to the US legal system. In Germany, for example, no diagnosis of a mental disorder is required to order preventive detention after imprisonment; rather the assessment of danger and the prognosis of the probability of recidivism is decisive.

Our intention is not to protect the “contented pedophile,” as long as he is dangerous, from preventive detention or to downplay the harm that child molesters do to their victims in any sense. On the other hand, our suggestion is not meant to preclude the detained child molester from getting treatment if at some point he starts to show insight into his problems and wants to get treated. Rather, we want to separate the medical aspects of Pedophilic Disorder from the societal and forensic implications.

To summarize, our suggestion is as follows. We agree with the differentiation between Pedophilia and Pedophilic Disorder in DSM-5 and suggest adding a category “Pedophilia with mental abnormality” for forensic purposes. Thus, we suggest defining Pedophilia as pedophilic preference without distress/impairment; Pedophilic Disorder as pedophilic preference with distress/impairment; and Pedophilia with mental abnormality as pedophilic preference with sexual offending and high risk of re-offending with or without distress/impairment.

Malon (2012) calls to depathologize pedophilia entirely[37].

The past depathologization of homosexuality is the strongest argument available to those who take the position that pedophilia and other paraphilias should not be treated as mental disorders (Culver, & Gert, 2006; Moser, 2001). Culver and Gert and Moser both claim that the subject’s personal suffering is a necessary condition to define a mental disorder and their main argument is that paraphilias, including pedophilia, do not cause any particular distress in the majority of those who experience them. Where such distress is present, they add, it is better explained by the presence of a conflict with society (stigmatization, condemnation, persecution, etc.) than by the condition itself (Vogt, 2006). Indeed, some people are quite capable of integrating it into their lives and personalities with reasonably satisfactory results (Moser, 2001; Suppe, 1987; Wilson, & Cox, 1983). Moser (2001) asserted that homosexuality was not deleted from the DSM for scientific reasons but on political and social grounds, and other paraphilias should also have been eliminated. Bieber, an advocate of treating homosexuality as a pathology, once raised this question regarding the elimination of other paraphilias from the DSM with Spitzer. According to Bieber (1987), Spitzer replied to him that “...these conditions should perhaps also be removed from DSM-II, and that if the group so affected were to organize as did the gay activists, they, too, might find that their conditions would be removed as a diagnostic entity” (p. 433). This point was also made by others (e.g., Silverstein, 2009; Suppe, 1987), but it did not win much support. Any attempt to question the legitimacy of the psychiatric apparatus, including the DSM as a whole, was rejected as a political strategy by homosexual activists (see Silverstein, 2009, Footnote 3), because it would have jeopardized the goal of excluding homosexuality from the DSM.

Moser, & Kleinpatz (2005) argue for the removal of the DSM-IV-TR’s “paraphilias” category[67].

Although a radical solution, we now favor removal of the entire category from the DSM as the most appropriate remedy for the problems outlined. There are individuals now diagnosed with a paraphilia who seek psychotherapy. We believe that other psychological characteristics describe these individuals and their concerns more accurately than their sexual interests do. It is not their sexual interests, but the manner in which they are manifest that can be problematic at times and is a more appropriate focus for therapy. A guiding principle in medicine is the dictum “First, do no harm.” The confusion of variant sexual interests with psychopathology has led to discrimination against all “paraphiliacs.” Individuals have lost jobs, custody of their children, security clearances, become victims of assault, etc., at least partially due to the association of their sexual behavior with psychopathology. This is not a new problem for psychiatry. Within the last 100 years, the labeling of other sexual behaviors as pathological (e.g., masturbation, “nymphomania,” homosexuality) has caused untold misery. Judgments should be made on the basis of science, rather than the morality that is popular at the time of a given edition. It is time to reevaluate rigorously the Paraphilia section of the DSM.

Criticism from anti-MAPs

The position that mapness is a mental illness and thus worthy of stigmatization is popular among anti-MAPs who are more openly ableist[68]. Antis who claim to be supportive of destigmatizing mental illness, however, face a conundrum: either they betray their principles of all disorders being supposedly worthy of destigmatization, or they decide that mapness is in fact not an actual disorder. The latter proclaim that calling mapness a mental disorder is offensive to actually disordered individuals[69][70]. Some other antis, not necessarily mental illness activists, also loudly proclaim that mapness is not a mental illness and that saying it is one is deeply offensive[71][72][73][74][75]. This usually arises from a capitulation to the popular notion that mentally ill people should be offered help with kindness and compassion, something they do not wish to give to MAPs[76][77]. Another possibility is belief that a harmful behavior being caused by mental illness means that person is absolved of agency or responsibility, but they dislike the idea of letting off people who commit “actually harmful crimes,” so as a compromise they pick offending MAPs alone to ascribe self-aware evil and purposeful abuses to[78][79][80][81][82].

Criticism from MAPs and MAP allies

Pro-MAP activists such as Lecter[83][84], Fiction Is Not Reality[85], Virtuous Pedophiles[86], and B4U-ACT[87], among others, have also said that it is inaccurate to classify mapness as a mental illness or disorder.

Mentally ill MAP activist Iris takes a far more radical approach: that not only should pedophilia itself be demedicalized, but also that adjacent concepts such as “pedophilic disorder,” even when they do not claim pedophilia itself is a disorder, should nevertheless be abolished entirely as well. One such conversation, occurring on a suspended Tumblr account of theirs[88], went as follows:

smol-paw[89]:

As there is a post going around I want to clarify-

This blog DOES NOT support; beastiality, SA or CSA, “pro contact” zoo/map, those who engage in illegal/dangerous paraphilias, nor does it support the toxic “Zoo pride” community.

This blog DOES support; no-contact paraphiles, recovering zoos/maps, paraphiles who are seeking support and treatment, and the effort to understand and respect those with paraphilias.

Iris:

What if we aren’t seeking “support and treatment,” hmm? Our paraphilias aren’t something we need support or treatment for. Many of us are mentally ill (something that can actually be “recovered” from). But what if we don’t want to recover from our mental illnesses? What if we’re not actively trying to recover? Does that make us any less valid, any less deserving of community and support?

someone else:

You don’t have to chose treatment if you don’t want to it just helps as long as your non offending/non contact I don’t understand why “no contact” is an anti term it means the same thing as “non offending.”

harmful paraphilias are attractions but they can be harmful if acted upon such as zoophilia pedophilia that’s why it’s ADVISED to get help and treatment so that you find coping mechanism so that it’s easier to not bother the person who has it and so it’s easier for them to not act or get frustrated with it.

No one is saying that you have to as long as you are non offending you are fine.

paraphilia is something a lot people need help with bc it frustrates and or is hard for the user to deal with it and it benefits them to cope with their attraction but no you don’t have to seek treatment as long as you aren’t acting on it.

mental illness is not something to be cured but people DO need recovery anyone does not seeking to recover can literally be deadly for people with mental illness not seeking help is one thing not wanting to recover from your negative symptoms/symptoms that harm you is another that doesn’t mean you aren’t deserving of support but anyone should want to recover and learn to cope with their symptoms.

recover doesn’t mean “cure” or “treated” it means coping and trying not to fall into negative symptoms that harm you not wanting to get better is symptom of mental illness and these people DO need help and support like anyone else but it’s important that they do feel the need to recover and GET BETTER.

Iris:

There is no such thing as a “harmful paraphilia.” The thoughts themselves are never harmful to others. The potential actions being harmful doesn’t make the paraphilia itself harmful.

Iris followed with a screenshot of one of their NNIA posts:

“Pedophilic disorder” is arguably not a particularly useful diagnosis, even when eliminating distress caused purely by social stigma, and acts of offending.

Some people experience distress from their pedophilia only because pedophilic thoughts are a PTSD[90] trigger. But then the problem isn’t the pedophilia, it’s the PTSD. You don’t say someone’s suffering from [random object] disorder if [random object] is a PTSD trigger. The PTSD needs to be treated, not the connection between pedophilia and triggers, because by only treating the latter you’re not actually treating the root cause, only separating it from a current other factor/trait.

Some pedophiles (me, hello!) have ASPD[91], and thus experience violent urges + lack of impulse control when it comes to acting on those violent urges, and some of their violent urges manifest in the form of fantasizing about committing CSA. In treatment, we don’t try to cut the connection between our pedophilia and ASPD; we try to treat the ASPD as a whole.

Idk, I probably worded this very poorly, but this is an approximate reason for why I’m not going to claim pedophilic disorder as a label, because pedophilia is not inherently disordered nor is it causative of the listed related disordered factors (i.e. urges, & lack of control over those urges)[92].

I think the closet analogy is hypersexuality/sex addiction and why it was rejected as a diagnosis for the DSM-V[93]: for one, because sex [or sex-related behavior] isn’t inherently disordered nor more disordered than other [nonsexual] things [just because it is sexual][94], nor sexuality/porn [inherently, directly] causative of sex addiction; trauma[95][, religious guilt[96], and preexisting] predisposition for addiction[97] are.

Iris then attached a screenshot of a Reddit thread where they had discussed the topic:

Iris[98]:

Pedophilia is not a mental illness, as it does not inherently cause the individual distress.

un-lovable[99]:

Yeah if you want to get technical, the mental illness form of pedophilia is called “pedophilia disorder” or PD. In my comment I used the term mental illness loosely, as it tends to be an effective way of communicating the unchosen and subconscious nature of the attractions. Of course not all pedophiles agree with this usage, but I would at the very least argue that our attractions are not an optimal to find ourselves in. Given that we cannot fully express them and as such it often DOES cause us some degree of distress, I feel as though it is at the very least a dead end and unfortunate sexual orientation. I don’t personally have any qualms with using the term mental illness to describe it, though the dsm doesn’t classify it as such.

Iris[100]:

an effective way of communicating the unchosen and subconscious nature of the attractions

Of course not all pedophiles agree with this usage,

Of course we don’t. The entire community of neurodivergent, &/or mentally ill pedophiles will eat you alive for this.

but I would at the very least argue that our attractions are not an optimal to find ourselves in.

Because we are oppressed, not by any inherent factor in them.

Given that we cannot fully express them and as such it often DOES cause us some degree of distress, I feel as though it is at the very least a dead end and unfortunate sexual orientation.

It is almost equally unfortunate to be allo[101][102] then, because allos are often attracted to those who do not consent to them, and thus cannot fully express their attractions. But not every mildly unpleasant feeling constitutes a disorder. The aforementioned distress only comes from comorbidities, or societal stigma[103], not any inherent trait of the attraction itself. When the distress from not being able to engage in a relationship with the target of attraction becomes significant/severe as to be unmanageable, there is almost certainly a comorbidity (such as BPD or the like)[104].

I don’t personally have any qualms with using the term mental illness to describe it, though the dsm doesn’t classify it as such.

I do, as I am mentally ill with also some nondisordered neurodivergences and other traits, and I would greatly appreciate it if I could maintain accurate language to describe my separate experiences, thanks. It’s unfortunate that we’re not particularly familiar nor especially not off-platform, because everyone who knows me knows that I go with a “fuck the DSM” approach when it comes to neurodivergency or mental health. I do not personally believe that “pedophilic disorder” exists as an independent phenomenon in which disorder is caused by pedophilia itself, rather than separate comorbidities which happen to interfere and which coexisting pedophilia alters the presentation thereof.

Iris further elaborated on their arguments in a blog post[105].

According to the APA, a mental disorder is a “health condition involving significant changes in thinking, emotion and/or behavior, and distress and/or problems functioning in social, work or family activities”[106]. The connotation of the term “disorder” is that disorders are bad for us, that curing disorders or treating their symptoms is necessary for us to improve in certain ways health-wise, etc. I use “disorder” as synonymous with “illness,” as the APA agrees, and I have yet to see a source or convincing argument as to why they should be distinguished; connotation-wise they seem to carry similar meanings too.

Other marginalized people (POC[107], gay/lesbian/bi/aspec people[108], etc.) have argued against pathologizing our distress from society’s bigoted treatment of us as “disordered.” The connotation of the label “disorder” implies that we or something within us is the primary problem, rather than society. That to eliminate our distress activists should prioritize “treating” us rather than changing society to treat us better.

Are abuse victims “disordered” for experiencing distress from being abused? Similar to the previous paragraph’s example, I think not: claiming we are “disordered” implies it is optimal to try to minimize our currently experienced distress with medication or therapy, rather than simply removing our abusers.

Whereas if an abuse survivor has left their abusive situation, but still experiences PTSD (nightmares, flashbacks, now-excessive preemptive risk assessment, etc.), that distress is not going to go away just by environmental changes anymore. The symptoms themselves must be targeted for treatment.

This conversation becomes a bit more difficult when we consider that none of us, if we are marginalized, can truly (yet) escape the bigoted society, arguably the ultimate abuser. But like how abuse victims in ongoing abusive situations are capable of recognizing that we are experiencing PTSD which will continue even after we escape, so can marginalized people know that we are experiencing disorders because of society’s past treatment of us, which require treatment rather than merely social change to alleviate.

I think from this it is reasonable to conclude that a “disorder” is a condition (i.e. set of traits) which causes significantly severe and persistent (i.e. ongoing, not one-off) distress, the complete alleviation of which requires the removal of the condition’s traits, rather than merely accommodation which does not remove the traits themselves but rather makes it easier and less distressing to live with them by changing the way in which their environment interacts with them.


The problem with incorrect pathologization


Telling those of us with nondisordered neurodivergences, disabilities, and other divergent/non-normative characteristics that we are actually disordered is a denial of our agency. You are like every gaslighting psychiatrist who tells us we aren’t distressed when we actually are[109], except in reverse; you think you know better than us what we think and what we feel, as if we cannot know that for ourselves because we are too freaky, too insane[110]. You are speaking over us. You are implying that our feelings require “cures” rather than accommodation[111].

Pathologization also subjects us to misdirected anti-mental-illness stigma. It makes it easier for the psych industry to research how to “cure” us[112]; it lends further legitimacy to attempts at conversion therapy[113].

References

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