In his commentary, Dr Frances (who was the editor of the DSM-IV) fails to mention the epistemological problems he created by clumsily implementing the requirement of distress and/or impairment to diagnosis a paraphilia. In the versions of the DSM prepared under Dr Frances’ supervision, a person cannot have a paraphilia unless he is distressed by that paraphilia or he is harming other people because of it. A distinct but harmless paraphilia cannot exist, by definition. A man cannot be a fetishist, for example, even if he masturbates into rubber boots on a regular basis, unless he is bothered by this behavior or is impaired in his psychosocial functioning. In DSM-IV-TR, there is no such thing as a well-adjusted paraphile; they are defined out of existence.
It is ironic that Dr Frances criticizes the wording of the proposed diagnostic criteria for the paraphilias, when the criteria prepared under his supervision contained such logical absurdities. He has often and ominously warned of future, possible “unintended consequences” of the wording details of the diagnostic criteria, but he has been strangely silent about clear errors in diagnostic criteria that should have been obvious in the DSM-IV. In order to correct this problem, the Paraphilias Subworkgroup has introduced the proposed distinction between ascertaining a Paraphilia versus diagnosing a Paraphilic Disorder. In my view, this is an extremely creative distinction that might do well in distinguishing people who have paraphilic behavior from those who have a paraphilic disorder. He had his kick at the paraphilic can and missed it.
Frances writes in his rebuttal:
I thank Dr Zucker for accurately stating my position and then illustrating it with a particularly vivid and well-chosen example. I continue to find no reason to label as mental disorder sexual urges, fantasies, or behaviors that are harmless to others and cause no distress or impairment to the individual. As psychiatrists, we have our hands full taking care of the suffering and distress caused by real mental disorders. There is no need for us to expand our purview to cover sexual thoughts and behaviors that are private and harmless.
The behaviors captured by “paraphilic coercion” and “hypersexuality” are anything but private or harmless—but that does not make them mental disorders. There is no infallible definition guiding what should, and what should not, be included in the official manual of mental disorders.
Many decisions can be tough calls. But it seems abundantly clear that these proposals from the Sexual Disorders Work Group have no place in DSM5. They offer little gain and would create significant problems. The construct “paraphilic coercion” has already contributed significantly to a grave misuse of psychiatry by the legal system in the handling of sexually violent predators—a misuse much opposed by the APA in a task force report and amicus brief to the Supreme Court.
Understanding Dr. Frances criticisms of the diagnosis "Paraphilic Coercive Disorder" requires a certain amount of background, which I intend to write about soon.