Conference Coverage

Revisions proposed for sexual behaviors in ICD-11


 

AT WPA 2017

– A move to depathologize paraphilias that do not adversely affect self or others is at the heart of changes suggested for the eleventh revision of the International Classification of Diseases and Related Health Problems.

The upcoming version of the World Health Organization document, slated for release in 2018, would reduce the number of named F65 classifications from nine to five, Richard B. Krueger, MD, said at the meeting of the World Psychiatric Association.

Three behaviors now included – fetishism, fetishistic transvestitism, and sadomasochism – would be dropped altogether, said Dr. Krueger of Columbia University, New York. Others would be streamlined into four more general diagnostic groupings (exhibitionism, voyeurism, pedophilia, and coercive sexual sadism disorderA fifth diagnosis, frotteuristic disorder, would be added in light of its fairly common presentation in clinical practice. Two new general categories would address unspecified behaviors that potentially are criminal, or which cause distress or danger to the individual who performs them, Dr. Krueger said.

The proposed changes would bring the document more in line with the DSM-5, said Dr. Krueger, who also leads the Working Group on the Classification of Sexual Disorders and Sexual Health. WHO charged the committee with reviewing the evidence and making recommendations for categories related to sexuality that are contained in the chapter of Mental and Behavioral Disorders in ICD-10.

Dr. Richard Krueger
Dr. Richard Krueger
“The proposed guidelines for paraphilic disorders are now conceptually closer to DSM-5 in that they require a sustained, focused, and intense pattern of sexual arousal as manifested by persistent sexual thoughts, fantasies, urges, or behaviors,” he said. “Also, the individual must have acted on these thoughts, fantasies, or urges, or be markedly distressed by them.”

This definition parallels the A criterion in the paraphilic definitions in the DSM-5, which identifies a pattern of “recurrent and intense sexual arousal” as well as the B criterion, which specifies that the person “has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

The proposed revisions reflect a growing acceptance of the immense variation in human sexual behavior, and the depathologization of some of them, as long as they do not affect public health, said Dr. Krueger, a psychiatrist with expertise in forensic and sexual psychiatry.

“In a general sense, this is analogous to the situation that we faced with alcohol and drug users in the early 20th century, when the main treatment was incarceration. In the 1940s and 50s, if you admitted an alcoholic to the hospital for delirium tremens, you could risk losing your admitting privileges. This is similar to where we are now with the paraphilic disorders,” he said, with most of them still considered potentially criminal.

That paraphilic disorders will remain at all in ICD-11 is something of a compromise.

“At first, we considered outright deletion of this section. Many psychiatrists have suggested we have no business with these disorders, since paraphilias are largely dealt with in the legal system. Some feel that psychiatrists should not be involved with them at all. But there has been a lot of discussion about the public health impact of these behaviors. For example, about 50% of men incarcerated for crimes against children meet the diagnostic criteria for pedophilia, and about 10% of crimes that result in incarceration in the U.S. are sexual crimes. There is also forensic usage of these diagnoses in many countries in Europe, and in Great Britain, the U.S., and Canada, so we felt that it’s important to maintain them” as diagnosable disorders. Keeping official diagnostic codes alive also helps encourage research into epidemiology and potential treatments, he added.

The committee’s first recommendation is to change the name of the chapter from “Disorders of Sexual Preference” to “Paraphilic Disorders.”

“This better represents the content of the section, which involves atypical sexual interests,” Dr. Krueger said. “The word ‘disorders’ was added to clarify that these atypical interests have to be pathological. That is, they must result in action against a nonconsenting individual, or cause severe distress or significant risk of injury or death to the patient.”

This emphasis on a pathological aspect to the diagnoses leads directly to the elimination of the fetishism, transvestitism, and sadomasochism categories, which are considered largely benign. “These have no public health importance, generally no association with distress or functional impairment, and including them can result in stigmatization with no discernible health benefit,” Dr. Krueger said. “If you’re a sadomasochist and not bothered by it, and engage alone or with a consenting person, it’s not a problem. Why should these categories be retained if they are not associated with distress or dysfunction? If they are not, then clearly they are not disorders.”

The remaining diagnoses were not as cut-and-dried, he said. Voyeurism, exhibitionism, pedophilia, and frotteurism clearly can affect others who are either unwilling or unable to consent because of age or other circumstances – for example, children, unaware targets, and animals. These behaviors also present with different intensities, from solitary imaginings to well planned and executed acts.

Sadomasochism did retain an altered diagnostic code as a new entity: coercive sexual sadism disorder. While many practice sadomasochism with a willing partner and are not disturbed by it, the committee acknowledged that crimes of sexual sadism are a serious threat to public health and should be recognized as such.

The committee also added two general categories to cover unnamed paraphilias, of which there are many.

“Other paraphilic disorder involving nonconsenting individuals” may be used for a behavior in which the focus of arousal is unwilling or unable to consent, but not specified. Zoophilia would fall into this category, as would other potentially criminal acts. “We can capture a huge variety of paraphilic behaviors under this rubric,” Dr. Krueger said.

During discussion, some clinicians expressed concern that, in its effort to depathologize solitary behavior, the proposal shortchanges patients who suffer deeply from their sexual behaviors. An example, one British psychiatrist said, is the person who is distressed because he can’t experience sexual enjoyment without a particular object or behavior. The final diagnostic category, “Other paraphilic disorder involving solitary behavior or consenting individuals,” will serve that person’s needs, Dr. Krueger said.

“This is an attempt to address the concern if a behavior markedly distresses a person, outside of the rather normal fear of social rejection, or if the behavior poses a serious risk, such as asphyxiophilia.”

The draft proposal was published earlier this year in Archives of Sexual Behavior (2017 Jul;46[5]:1529-45).

Dr. Krueger had no financial disclosures.

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